Marshall Classification Research Articles

Ultrasound Measurement of Optic Nerve Sheath Diameter as Non-Invasive Detector of Raised Intracranial Pressure in Adult Traumatic and Non-Traumatic Neurocritical Patients in ICU

Abstract Background Measurement of intracranial pressure (ICP) is crucial in the management of many neurological conditions. However, due to the invasiveness, high cost, and required expertise of available ICP monitoring techniques, many patients who could benefit from ICP monitoring do not receive it. As a result, there has been a substantial effort to explore and develop novel non-invasive ICP monitoring techniques to improve the overall clinical care of patients who may be suffering from ICP disorders. Objective Assessment of the role of ultrasound as a non-invasive method (bedside) to measure the raising of intracranial pressure by measuring the optic nerve sheath diameter in traumatic and nontraumatic neurocritical patients. Patients and Methods: A total of 100 patients of both sexes above 18 years old diagnosed with traumatic & non-traumatic brain injury with high intracranial pressure (ICP) which suspected by the initial CT brain and Marshall Classification were enrolled. Patients were divided into control group that included 50 patients with no evidence of any intracranial abnormality or severe head injury. Mean ONSD in the control group was considered to be normal. Study group subjects included 50 patients aged above 18 years old who sustained a severe traumatic or non-traumatic brain injury (GCS <8) All patients had a non-contrast CT head b efore any surgical or non-surgical i ntervention. The CT head was used to determine the Marshall score. Results Optic nerve sheath diameter was statistically significant higher in all periods 0-24 hours among cases with high intracranial tension compared with control ones with statistically significant positive correlations between it and age at 6hrs. and 24hrs and Marshal score at Ohr. and 24hrs and negative correlation between it and GCS score at Ohr. and 24hrs. The best cut off value for detector of raised intracranial pressure was 4.9 with sensitivity 94.7%, specificity 83.3%, positive predictive value 94.7% and negative predictive value 83.3%. Conclusion The evaluation of the optic nerve sheath diameter is a simple non-invasive procedure, which is a potentially useful tool in the assessment and monitoring of traumatic and nontraumatic neurocritical patients suspected of having raised intracranial pressure.

Contusion expansion, low platelet count andbifrontal contusions are associated with worse patient outcome following traumatic brain injury-a retrospective single-center study.

Cortical contusions are common in moderate-severe traumatic brain injury (TBI). Cortical contusions often expand, potentially causing neuro-worsening several hours to days post-trauma. While contusion expansion (CE) may affect outcome, potential clinical and radiological markers that can predict CE have been insufficiently explored. In the present single-center retrospective observational cohort study, we evaluated clinical outcome by the Glasgow Outcome Scale extended (GOSE) scale and evaluated risk factor for CE. Adult TBI patients > 18years of age, and of all injury severities, were included. Main variables of interest were low platelet count, defined as < 150 × 109/L, presence of bifrontal contusions and CE, defined as absolute contusion volume increase in cm3. Factors associated with CE and clinical outcome according to GOSE were analyzed. Between 2012-2022, 272 patients were included. Contusion size on admission correlated positively with CE, as did the Marshall and Rotterdam radiological classification scores. Bifrontal contusions were significantly larger at admission, experienced larger CE, and had a worse outcome than contusions in other locations. Patients with a platelet count < 150 × 109/L experienced a greater volume CE and had a worse outcome when compared to patients with a normal platelet count. In a multivariate analysis, CE remained significantly associated with a poor outcome six months post- injury. Contusion volume at admission, Marshall CT classification and Rotterdam CT score, positively correlated to CE. Bifrontal contusions and a platelet count < 150 × 109/L were associated with CE, and a poor clinical outcome. Large CE volumes were associated with a worse clinical outcome, and CE was per se associated with outcome in a multivariate analysis. Management of these risk factors for CE in the acute post-injury setting may be needed to attenuate contusion expansion and to improve clinical outcome in TBI patients suffering from cortical contusion injuries.

External lumbar drainage for the management of refractory intracranial hypertension in pediatric severe traumatic brain injury: a retrospective single-center case series.

Guidelines for the management of pediatric severe traumatic brain injury (TBI) recommend external ventricular drainage for CSF drainage as a first-tier treatment in the intracranial pressure (ICP) pathway. However, ventriculostomy in children can sometimes be challenging because of the small size of the lateral ventricles. External lumbar drainage (ELD) may be a useful alternative; therefore, the authors analyzed the outcome of a cohort of pediatric patients who underwent ELD to manage intracranial hypertension (ICH). This study retrospectively enrolled pediatric patients with ICH following severe TBI who underwent ELD. Radiological and clinical severity scores (Marshall classification, Rotterdam score, Injury Severity Score, and Pediatric Trauma Score) were noted. ICP and cerebral perfusion pressure (CPP) curves were analyzed 12 hours before and after the procedure. Any change in medical therapy was recorded, as well as the total volume and duration of drainage. Cerebellar tonsillar position according to the McRae line was noted before and after ELD. Glasgow Outcome Scale-Extended score at follow-up was also noted. Thirty patients were included, with a mean age of 8 ± 4.4 years, and a median admission Glasgow Coma Scale score of 7 ± 4 (range 3-13). ELD was performed after a median delay of 1 day (range 0-7 days), mean drainage volume/day was 296 ± 129 ml, and median duration of drainage was 7 ± 5 (range 2-12) days. Forty-three percent of the patients underwent ELD as a part of the first-tier therapy. ICP decreased after ELD (mean difference 13.4 ± 6.2 mm Hg, p < 0.001), whereas CPP increased (mean difference 10.6 ± 6.4 mm Hg, p < 0.001). Fifty-three percent of the cohort did not need any further second-tier therapy after ELD. The study found 1 case of drain revision and 3 cases of cerebellar tonsil herniation. These preliminary data suggest ELD is a valuable option to treat ICH in severely head-injured children, limiting the use of second-tier treatments. This pilot study should lay the foundation for a multicenter prospective trial.

Evaluation of Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 Using a Rapid Point of Care Test for Predicting Head Computed Tomography Lesions After Mild Traumatic Brain Injury in a Dutch Multi-Center Cohort.

Mild traumatic brain injury (mTBI) is a common condition seen in emergency departments worldwide. Blood-based biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) are recently U.S. Food and Drug Administration-approved for the prediction of intracranial lesions on head computed tomography (CT) scans in mTBI. We evaluated the diagnostic performance of GFAP and UCH-L1 in a Dutch cohort using the i-STAT TBI assay. In a multi-center observational study, we enrolled 253 mTBI patients. Head CT scans were scored using the Marshall classification system. Logistic regression models were used to assess the contribution of biomarkers and clinical parameters to diagnostic performance. Detection of UCH-L1 and GFAP resulted in a sensitivity of 97% and specificity of 19% for CT positivity in mTBI patients, along with a negative predictive value of 95% (88-100%) and a positive predictive value of 27% (21-33%). Combining biomarker testing with loss of consciousness and time to sample increased specificity to 46%. Combined testing of UCH-L1 and GFAP testing resulted in possibly more unnecessary CT scans compared with GFAP testing alone, with only limited increase in sensitivity. This study confirmed high sensitivity of GFAP and UCH-L1 for CT abnormalities in mTBI patients using the i-STAT TBI test. The results support the potential use of GFAP and UCH-L1 as tools for determining the indication for CT scanning in mTBI patients, possibly offering a cost- and time-effective approach to management of patients with mTBI. Prospective studies in larger cohorts are warranted to validate our findings.

A New Algorithm to Treat Chronic Combined ACL/MCL Injuries: Let's Come Back to the “Rotatory Instability Test”

Background: Chronic combined medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injuries are frequent. Medial residual laxity is a risk factor for ACL rerupture. It should be treated at the same time as the ACL reconstruction (ACLR) if necessary, but there are still questions surrounding the indications for abstention or surgery of the medial plan, especially for grade 2 MCL injuries of the Fetto and Marshall classification. Indications: The purpose is to come back to a simple test, the “Rotatory Instability Test” as described by Slocum and Larson in 1968 for systematic clinical examination of the knee to improve the sensitivity and accuracy of the deep MCL (dMCL) and superficial MCL (sMCL) examination and to propose a decision-making algorithm for the treatment of the chronic combined ACL/MCL injuries based on the assessment of anteromedial rotatory instability (AMRI). Technique Description: Examination of the ACL with Lachman test, anterior drawer in neutral rotation, and pivot shift test confirm the ACL injury. Valgus laxity is tested in extension and at 20° of flexion. Then, an anterior drawer test at 90° of flexion with external rotation is done (the anterior drawer in external rotation [ADER] test) allowing to identify isolated dMCL, dMCL + sMCL, or MCL + posterior oblique ligament (POL) injuries. Discussion: As persistent medial laxity is a risk factor for ACL graft failure and there is no reliable method of instrumented laxity assessment, careful clinical examination remains essential. Systematic examination of the medial side with valgus laxity testing at 0° and 20° flexion combined with the ADER test assessment of AMRI can guide treatment of the MCL injury component. Where there is no valgus laxity and the ADER test is negative, isolated ACLR is indicated. If there is significant medial laxity at 0°, this suggests combining sMCL and POL reconstruction with ACLR. Where the knee is stable at 0° but there is valgus laxity at 20° and a positive ADER test, the dMCL can be reconstructed using a gracilis graft or a combined sMCL and dMCL reconstruction can be added to the ACLR depending on the degree of laxity. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Prediction of In-Hospital Mortality in Patients With Traumatic Brain Injury Using the Rotterdam and Marshall CT Scores: A Retrospective Study From Western India.

Objective Head trauma of any severity, including concussions and skull fractures, can cause a traumatic brain injury (TBI). Prognostication plays a vital role in the scenario of urgency put forth by TBI. The application of CT-based scoring systems developed by the Rotterdam CT score and Marshall classification system appears to be appropriate for the early and precise prediction of clinical outcomes in TBI patients. The present study was designed to determine the predictive value of the Rotterdam CT score and Marshall classification system for in-hospital mortality in patients with TBI. Methods All adult patients (≥ 18 years) with acute traumatic brain injury presented over a period from February 2019 to November 2022 were included. Only those patients who had undergone a plain CT scan of the brain during the initial presentation at the emergency department (ED) were considered. Patients who presented with penetrating brain injury as well as those who died on arrival or who died prior to the initial CT scan of the brain were excluded. A total of 127 patients were included in the final data analysis. Based on initial CT-scan findings, the Rotterdam CT scoreand Marshall classification system were calculated in order to predict in-hospital mortality. Results The study was dominated by male patients (85.8%) as compared to female patients (14.2%). The overall mortality rate was 32.3% (n = 41). The mortality rate among males and females was 30.3% (33/109) and 44.4% (8/18), respectively. As per the Glasgow Coma Scale (GCS) classification, the severity of the injury was mild in 12.6% of the study subjects, moderate in 22%, and severe in 65.4%. The mortality rate among the patients with mild severity was 12.5% (2/16), while it was 28.6% in moderate (8/28) and 37.3% (31/83) in the severe category group. The best cut-off point of the Rotterdam score for predicting mortality was >4 (as per the Youden Index), which had a sensitivity and specificity of 60.98% and 90.70%, respectively, while the cut-off point of the Marshall CT classificationfor predicting mortality was >3 (as per the Youden Index), which had a sensitivity of 82.93% and a specificity of 75.58%. There was only a minor difference in the area under the curve (AUC) value of the receiver operating characteristic curve (ROC) curve between the Rotterdam CT score (0.827) and the Marshall classification system (0.833). Conclusion The Rotterdam and Marshall CT scores have demonstrated significant independent prognostic value and may serve as a useful initial evaluation tool for risk stratification of in-hospital mortality among patients with TBI.

Abstract WP53: The Assessment Of Brain Water Content At Posttraumatic Ischemia: Ct Perfusion Study

Background: The influence of cerebral edema and secondary insults on the clinical outcome of traumatic brain injury (TBI) is well known. The studies of the brain water homeostasis dynamics at TBI remain rare, which determines the relevance of our work. The purpose is to study the changes in brain water homeostasis after TBI of varying severity compared to the cerebral microcirculation parameters. Materials: This non-randomized retrospective single-center study complies with the Helsinki Declaration. One hundred twenty-eight patients with posttraumatic ischemia (PCI) after moderate-to-severe TBI in the middle cerebral artery territory who presented between July 2015 and February 2022 to our hospital were included. PCI was determined using perfusion computed tomography (CT), and brain edema was determined using net water uptake (NWU) on baseline CT images. The patients were divided according to Marshall’s classification. Multivariate linear regression models were performed to analyze data. Results: NWU in PCI zones was significantly higher than in non-ischemic zones (8.1% versus 4.2%; P &lt;0.001). In the multivariable regression analysis, the mean transit time increase was significantly and independently associated with higher NWU ( R 2 = 0,089, P &lt;0.01). In the PCI zone, cerebral blood flow (CBF), volume (CBV), and time to peak (TTP) were not significantly associated with NWU values ( P &gt;0.05). No significant differences existed between the NWU values in PCI foci in different Marshall groups ( P =0.308). Conclusion: The Marshall classification does not seem to be able to predict the progression of posttraumatic ischemia. The blood passage delay through the cerebral microvascular bed was significantly accompanied by brain tissue water uptake increase in the PCI focus.

On Net Water Uptake in Posttraumatic Ischemia Foci.

The influence of cerebral edema and resultant secondary complications on the clinical outcome of traumatic brain injury (TBI) is well known. Clinical studies of brain water homeostasis dynamics in TBI are limited, which determines the relevance of our work. The purpose is to study changes in brain water homeostasis after TBI of varying severity compared to corresponding cerebral microcirculation parameters. This non-randomized retrospective single-center study complies with the Helsinki Declaration for patient's studies. The study included 128 patients with posttraumatic ischemia (PCI) after moderate-to-severe TBI in the middle cerebral artery territory who were admitted to the hospital between July 2015 and February 2022. PCI was evaluated by perfusion computed tomography (CT), and brain edema was determined using net water uptake (NWU) on baseline CT images. The patients were allocated according to Marshall's classification. Multivariate linear regression models were performed to analyze data. NWU in PCI areas were significantly higher than in patients with its absence (8.1% vs. 4.2%, accordingly; p<0.001). In the multivariable regression analysis, the mean transit time increase was significantly and independently associated with higher NWU (R2=0.089, p<0.01). In the PCI zone, cerebral blood flow, cerebral blood volume, and time to peak were not significantly associated with NWU values (p>0.05). No significant differences were observed between the NWU values in PCI foci in different Marshall groups (p=0.308). Marshall's classification does not predict the progression of posttraumatic ischemia. The blood passage delays through the cerebral microvascular bed is associated with brain tissue water content increase in the PCI focus.

Cerebral Net Water Uptake in Posttraumatic Cerebral Ischemia.

128 moderate-to-severe traumatic brain injury patients (44 women, 84 men, age: 37±12years) were stratified into 3 groups: Marshall 2-3: 48 patients, Marshall 4: 44 patients, Marshall 5: 36 patients. The groups were matched by sex and age. Patients received multiphase perfusion computed tomography (PCT) 1-5days after admission. Net water uptake was calculated from non-contrast computed tomography. Data are shown as a median [interquartile range]. P<0.05 was considered statistically significant. Cerebral blood flow in posttraumatic ischemia foci in Marshall 4 group was significantly higher than that in the Marshall 5 group (p=0.027). Net water uptake in posttraumatic ischemia zones was significantly higher than in zones without posttraumatic ischemia (8.1% versus 4.2%, p<0.001). Mean transit time in posttraumatic ischemia zones was inversely and significantly correlated with higher net water uptake (R2=0,089, p<0.01). Delay of blood flow through the cerebral microvascular bed was significantly correlated with the increased net water uptake in posttraumatic ischemia foci. Marshall's classification did not predict the progression of posttraumatic ischemia.

183 Predicting Vasospasm and Mortality in Early Severe TBI: A Model Using Serum Cytokines and Clinical Data

INTRODUCTION: It is difficult to predict outcomes in patients with severe traumatic brain injury (sTBI) using current clinical tools. METHODS: Adult civilian patients were prospectively enrolled in the sTBI arm of the Surgical Critical Care Initiative (SC2i). Patient clinical and serum inflammatory and neuronal protein data were combined and evaluated using the machine learning methods of LASSO and CART to construct parsimonious models for predicting development of post-traumatic vasospasm and mortality. Cross validations were performed to assess the robustness of conclusions. Missing data were imputed with random forest techniques; only variables with less than 10% missingness were included. RESULTS: There were 53 patients, of whom 36 (67.9%) developed vasospasm and 10 (18.9%) died. The mean age was 39.2; 22.6% were female. There were an equal number of white (25) and black (25) patients. For vasospasm, LASSO identified Eotaxin and Marshall classification of traumatic brain injury as predictors (XV AUC = 0.77). CART identified S100B as a predictor (full data AUC = 0.75). For mortality, LASSO identified S100B and sRAGE (XV AUC = 0.97), while CART identified S100B (full data AUC = 0.912). CONCLUSION: Inflammatory and glial-specific protein levels following sTBI may have predictive value that exceeds conventional clinical variables for certain outcomes. Eotaxin, S100B and radiographic findings highly predict development of post-traumatic vasospasm. S100B and sRAGE highly predict mortality. These results warrant validation in a prospective cohort.

Colchicine Effectiveness and Safety in Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis.

Introduction: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is the most common fever syndrome in childhood. High disease activity (DA) dramatically impacts the health-related quality of life. Thus, effective and safe treatment is crucial. Colchicine might be effective, but data are still lacking. Study aimed to assess colchicine safety and effectiveness in PFAPA.Methods: This single center study was conducted between 03/2012 and 05/2021 in PFAPA patients without variants in genetic panel testing aged ≤ 18 years fulfilling Marshall criteria and classification criteria of Gattorno et al. Exclusion criteria were elevated liver enzymes, impaired kidney function, celiac disease, lactose intolerance, previous/ongoing biologics, known colchicine-intolerance. Demographics, clinical characteristics, treatment, DA, colchicine effectiveness and safety were recorded at baseline, first and last visit. Colchicine was started at 0.5–1.0 mg/day. DA was captured by physician (PGA) and patient/parent (PPGA) global assessment on a 10 cm visual analog scale, categorized as mild (<2), moderate (2–4), and high (≥5). Adverse event (AE) monitoring included gastrointestinal symptoms, liver enzyme/creatinine elevation, leukopenia, neutropenia. Primary outcome included response (R; composite of PPGA + PGA decrease ≥2) at last follow-up. Secondary outcomes were partial response (PR; PGA decrease = 1 + PPGA decrease ≥1), no response (NR; unchanged/worsened PGA/PPGA), colchicine safety, flare characteristics.Results: Twenty-seven PFAPA patients were included, 52% were female, median age was 5.8 years (1–10.75), median follow-up time was 13 months. At baseline, median PPGA was high; median PGA moderate. All patients had febrile flares. Median flare frequency was every 4–5 weeks; median duration 5–6 days. Nine patients were pre-treated with corticosteroids, increasing flare frequency in 8/9. Primary Outcome: 17 patients (63%) were responders. Secondary outcomes: PR was achieved in 15%; NR in 22% at last follow-up. DA decreased significantly (p <0.0001). At last follow-up, 52% reported no flares, median flare duration decreased to 1–2 days. At first follow-up, 22% reported mild abdominal pain/diarrhea. Moderate abdominal pain/diarrhea occurred with ≥1 mg/day. Mild asymptomatic liver enzyme elevation or leucopenia were rare; no severe AE or colchicine discontinuation were observed.Conclusion: Colchicine seems to be safe, well-tolerated, and effective in PFAPA patients. It can be considered in children with moderate/high DA even those without corticosteroid-benefit.

Selection of CT variables and prognostic models for outcome prediction in patients with traumatic brain injury

BackgroundTraumatic brain injuries (TBI) are associated with high risk of morbidity and mortality. Early outcome prediction in patients with TBI require reliable data input and stable prognostic models. The aim of this investigation was to analyze different CT classification systems and prognostic calculators in a representative population of TBI-patients, with known outcomes, in a neurointensive care unit (NICU), to identify the most suitable CT scoring system for continued research.Materials and methodsWe retrospectively included 158 consecutive patients with TBI admitted to the NICU at a level 1 trauma center in Sweden from 2012 to 2016. Baseline data on admission was recorded, CT scans were reviewed, and patient outcome one year after trauma was assessed according to Glasgow Outcome Scale (GOS). The Marshall classification, Rotterdam scoring system, Helsinki CT score and Stockholm CT score were tested, in addition to the IMPACT and CRASH prognostic calculators. The results were then compared with the actual outcomes.ResultsGlasgow Coma Scale score on admission was 3–8 in 38%, 9–13 in 27.2%, and 14–15 in 34.8% of the patients. GOS after one year showed good recovery in 15.8%, moderate disability in 27.2%, severe disability in 24.7%, vegetative state in 1.3% and death in 29.7%. When adding the variables from the IMPACT base model to the CT scoring systems, the Stockholm CT score yielded the strongest relationship to actual outcome. The results from the prognostic calculators IMPACT and CRASH were divided into two subgroups of mortality (percentages); ≤50% (favorable outcome) and > 50% (unfavorable outcome). This yielded favorable IMPACT and CRASH scores in 54.4 and 38.0% respectively.ConclusionThe Stockholm CT score and the Helsinki score yielded the closest relationship between the models and the actual outcomes in this consecutive patient series, representative of a NICU TBI-population. Furthermore, the Stockholm CT score yielded the strongest overall relationship when adding variables from the IMPACT base model and would be our method of choice for continued research when using any of the current available CT score models.

Utility of the Marshall & Rotterdam Classification Scores in Predicting Outcomes in Trauma Patients

Traumatic Brain Injury (TBI) is a leading cause of mortality in the trauma population. Accurate prognosis remains a challenge. Two common Computed Tomography (CT)-based prognostic models include the Marshall Classification and the Rotterdam CT Score. This study aims to determine the utility of the Marshall and Rotterdam scores in predicting mortality for adult patients in coma with severe TBI. Retrospective review of our Level 1 Trauma Center's registry for patients ≥ 18 years of age with blunt TBI and a Glasgow Coma Scale (GCS) of 3-5, with no other significant injuries. Admission Head CT was evaluated for the presence of extra-axial blood (SDH, EDH, SAH, IVH), intra-axial blood (contusions, diffuse axonal injury), midline shift and mass effect on basilar cisterns. Rotterdam and Marshall scores were calculated for all patients; subsequently patients were divided into two groups according to their score (< 4, ≥ 4). 106 patients met inclusion criteria; 75.5% were males (n=80) and 24.5% females (n=26). The mean age was 52. The odds ratio (OR) of dying from severe TBI for patients in coma with a Rotterdam score of ≥ 4 compared to < 4 was OR=17 (P < 0.05). The odds of dying from severe TBI for patients in coma with a Marshall score of ≥ 4 versus < 4 was OR=11 (P < 0.05). Higher scores in the Marshall classification and the Rotterdam system are associated with increased odds of mortality in adult patients in come from severe TBI after blunt injury. The results of our study support these scoring systems and revealed that a cutoff score of < 4 was associated with improved survival.

Delayed intracranial hemorrhage after trauma

ABSTRACT Introduction: Delayed Intracranial Hemorrhage (D-ICH), defined as finding of ICH on subsequent imaging after a normal computed tomography of the brain (CTB), is a feared complication after head trauma. The aim of this study was to determine the incidence and severity of D-ICH. Methods: This retrospective cohort study included patients that presented directly from the scene of injury to an adult major trauma center from Jan 2013 to Dec 2018. Results: There were 6536 patients who had an initial normal CTB and 23 (0.3%; 95%CI: 0.20–0.47) had D-ICH. There were 653 patients who had a repeat CTB (incidence of D-ICH 3.5%; 95%CI: 2.2–5.2). There was no significant association of D-ICH with age>65 years (OR 1.33; 95%CI: 0.54–3.29), presenting GCS <15 (OR 1.21; 95% CI: 0.52–2.80) and anti-platelet medications (OR 0.68; 95%CI: 0.26–1.74). Exposure to anti-coagulant medications was associated with lower odds of D-ICH (OR 0.23; 95%CI: 0.05–0.99). All cases of D-ICH were diffuse injury type II lesions on the Marshall classification. There were no cases that underwent neurosurgical intervention and no deaths were attributed to D-ICH. Conclusions: These results question observation of patients with head injury in hospital after a normal CTB for the sole purpose of excluding D-ICH.

Relationship between YKL-40, neuron-specific enolase, tumor necrosis factor-a, interleukin-6, and clinical assessment scores in traumatic brain injury

Background and Objectives: The aim of the present study is to determine plasma and cerebrospinal levels of YKL-40, in combination with neuron-specific enolase (NSE), interleukin (IL)-6, tumor necrosis factor (TNF)-α, and the clinical scales such as Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation a III, and MARSHALL classification in traumatic brain injury (TBI). Materials and Methods: This was a prospective study conducted on patient cohort of 27 patients with isolated severe TBI. Cerebrospinal fluid (CSF) and plasma were collected on the 24th and 96th h after trauma. CSF samples were obtained also from forensic autopsies of 29 adult healthy cadavers. Results: The CSF level of YKL-40 in TBI patients was higher compared to controls, while no significant change between CSF NSE levels in patients and controls was found. We determined a strong correlation between YKL-40 and NSE levels and TBI clinical assessment scores. The analysis of the influence of independent prognostic factors on the outcome of TBI patients showed that plasma NSE concentrations are the major independent variable which is associated with the survival of TBI patients. Still, changes in IL-6 and TNF-α levels could not be considered as reliable predictors of mortality. Conclusion: We present data for correlation of YKL-40 and NSE levels with clinical scores for assessment of trauma severity and the outcome of TBI patients. Even though further large-scale investigations are required to clarify and evaluate the clinical significance of both biomarkers, our findings suggest that YKL-40 and NSE might be implicated in the pathogenesis of TBI and could indicate the degree of neuroinflammation and brain damage.

Functional Outcome After Primary Decompressive Craniectomy for Acute Subdural Hematoma in Severe Traumatic Brain Injury.

To evaluate the impact of primary decompressive craniectomy (DC) on the functional outcome in patients with post traumatic acute subdural hematoma (SDH). A retrospective cohort analysis of 92 patients with post traumatic acute SDH who underwent primary DC and evacuation of SDH. The primary outcome variable is Glasgow outcome scale at 6 months follow up, while exposure variables are demographic data (age and gender), initial Glasgow coma scale, Marshall Classification Score of traumatic brain injury, midline shift, side of the lesion, surgery related complications and time of cranioplasty. Out of the 92 patients in this study, 89.1% were males and the mean age was 30.2 ± 14.4 years. At admission, the mean Glasgow Coma Scale (GCS) was 5.8 ± 2 and mean Marshall score was 4.7 ± 0.7, while the average midline shift was 8.8 ± 3.5 mm. Right decompressive craniectomy was performed in 46 (50%) patients, while in 2 (2.1%) cases, bi-frontal craniectomy was performed and left decompressive craniectomy was performed in 44 (47.8%) patients. Mortality was reported in 38 patients (41.3%) and poor outcome was reported in 24 patients (26.1%), while 30 patients (32.6%) showed good outcome. During the follow up period, cranioplasty for restoration of the bone defect was completed in 52 patients. Primary decompressive craniectomy after STBI for post-traumatic acute subdural hematoma improved the favorable outcome whenever the initial GCS > 4 among adult patients.

Apoptosis in cerebrospinal fluid as outcome predictors in severe traumatic brain injury: An observational study.

Traumatic brain injury (TBI), due to its high mortality and morbidity, is an important research topic. Apoptosis plays a pathogenic role in a series of neurological disorders, from neurodegenerative diseases to acute neurological lesions.In this study, we analyzed the association between apoptosis and the Glasgow Outcome Scale (GOS), to examine the potential of apoptosis as a biomarker for a TBI outcome. Patients with severe TBI were recruited at the Department of Neurosurgery, Wujin Hospital Affiliated with Jiangsu University, between January 2018 and December 2019. As a control group, healthy subjects were recruited. The concentrations of caspase-3, cytochrome c, sFas, and caspase-9 in the cerebrospinal fluid (CSF) were analyzed by enzyme-linked immunosorbent assay (ELISA). The association between the GOS and the clinical variables age, sex, initial Glasgow Coma Scale (GCS) score, intracranial pressure (ICP), cerebral perfusion pressure (CPP), initial computed tomography (CT) findings, and apoptotic factors was determined using logistic regression. The area under the receiver operator characteristic (ROC) curve (AUC), and thus the sensitivity and specificity of each risk factor, were obtained.The levels of caspase-3, cytochrome c, sFas, and caspase-9 in the TBI group were significantly higher than those in the control group (P < .05). The logistic regression results showed that ICP and caspase-3 were significant predictors of outcome at 6 months post-TBI (P < .05). The AUC was 0.925 and 0.888 for ICP and caspase-3, respectively. However, the AUC for their combined prediction was 0.978, with a specificity and sensitivity of 96.0% and 95.2%, respectively, showing that the combined prediction was more reliable than that of the 2 separate factors.We demonstrated that caspase-3, cytochrome C, sFas, and caspase-9 were significantly increased in the CSF of patients following severe TBI. Furthermore, we found that ICP and caspase-3 were more reliable for outcome prediction in combination, rather than separately.

Risk factors of clinical deterioration in cerebral contusions

Evaluation of the relationship between radiological progression of cerebral contusion and clinical course is the object of many recent studies.The aim of the study is to identify factors that are associated with clinical deterioration in patients with brain contusions.Materials and methods. The study included 148 patients with brain injuries, who were treated at the Kiev City Clinical Emergency Hospital in 2016–2017.Results. 43.9 % patients were in conscious or obtunded, 31.8 % were in stupor and 24.3 % in a coma. The average time to computed tomography was 4.3 ± 3.3 hours. Brain damage according to Marshall classification: type II – 60.8 %, type III – 26.4 %, IV – 8.8 %, type VI – 4.1 % patients, types I and V belonged to exclusion criteria. In the first 24 hours, clinical deterioration was found in 18.9 %, improvement in 16.2 % and stable neurological status in 64.8 % patients. Another 5.4 % patients worsened after the first day (on days 2–8). The cause of the clinical deterioration was the hemorrhagic progression of contusion, the increase of the epi-subdural hematoma, and brain edema. An analysis of treatment outcomes in patients with clinical deterioration revealed a higher risk of adverse outcome (1–3 points on the Glasgow outcome scale at discharge) compared to patients without clinical deterioration.Conclusions. Low Glasgow coma scale score at admission, the size of the contusion more than 25 ml, midline shift, basal cisterns compression and epidural hematoma were the risk factors of the clinical deterioration. The early determination of secondary hemorrhagic progression of contusion and clinical deterioration with modification of treatment strategy are important in improving the prognosis after traumatic brain injury.

Improvement of quality of life (QOL) between 1 and 3-4years after traumatic brain injury (TBI) in ICU patients.

Evaluation of changes in quality of life (QOL) in ICU patients several years after traumatic brain injury (TBI) is not well documented. A prospective cohort study was conducted in all patients with TBI admitted between 2004 and 2008 to the ICU of Regional Hospital of Malaga (Spain). Functional status was evaluated by Glasgow Outcome Scale (GOS) and QOL by PAECC (Project for the Epidemiologic Analysis of Critical Care patients) questionnaire between 0 (normal QOL) to 29 points (worst QOL). A total of 531 patients. Median(Quartile1,Quartile 3) age: 35 (22, 56) years. After 3-4years, 175 died (33%). Survivor QOL was deteriorated (median total PAECC score: 5 (0, 11) points) although 75.76% of patients who survived showed good functional situation (GOS normal or mild dysfunction). An improvement in QOL scores between 1 and 3-4years was observed (median PAECC score differences between 3-4years and 1 year: - 1(- 4, 0) points). QOL score improved during this interval of time: 62.6%of patients. Change in QOL was related by multivariate analysis to admission cranial-computed tomography scan (Marshall's classification), age, and Injury Severity Score (ISS), with the biggest improvement seen in younger patients and with more severe ISS. Basic physiological activities were maintained in the majority of patients. Subjective aspects and working activities improved between 1 and 3-4years but with a high proportion still impaired in these items after 3-4years. ICU patients with TBI after 1year show improvement in QOL between 1 and 3-4years, with the biggest improvement in QOL seen in younger patients and in those with more severe ISS.

IMPACT probability of poor outcome and plasma cytokine concentrations are associated with multiple organ dysfunction syndrome following traumatic brain injury.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality. Multiple organ dysfunction syndrome (MODS) occurs frequently after TBI and independently worsens outcome. The present study aimed to identify potential admission characteristics associated with post-TBI MODS. The authors performed a secondary analysis of a recent randomized clinical trial studying the effects of erythropoietin and blood transfusion threshold on neurological recovery after TBI. Admission clinical, demographic, laboratory, and imaging parameters were used in a multivariable Cox regression analysis to identify independent risk factors for MODS following TBI, defined as maximum total Sequential Organ Failure Assessment (SOFA) score > 7 within 10 days of TBI. Two hundred patients were initially recruited and 166 were included in the final analysis. Respiratory dysfunction was the most common nonneurological organ system dysfunction, occurring in 62% of the patients. International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) probability of poor outcome at admission was significantly associated with MODS following TBI (odds ratio [OR] 8.88, 95% confidence interval [CI] 1.94-42.68, p < 0.05). However, more commonly used measures of TBI severity, such as the Glasgow Coma Scale, Injury Severity Scale, and Marshall classification, were not associated with post-TBI MODS. In addition, initial plasma concentrations of interleukin (IL)-6, IL-8, and IL-10 were significantly associated with the development of MODS (OR 1.47, 95% CI 1.20-1.80, p < 0.001 for IL-6; OR 1.26, 95% CI 1.01-1.58, p = 0.042 for IL-8; OR 1.77, 95% CI 1.24-2.53, p = 0.002 for IL-10) as well as individual organ dysfunction (SOFA component score ≥ 1). Finally, MODS following TBI was significantly associated with mortality (OR 5.95, 95% CI 2.18-19.14, p = 0.001), and SOFA score was significantly associated with poor outcome at 6 months (Glasgow Outcome Scale score < 4) when analyzed as a continuous variable (OR 1.21, 95% CI 1.06-1.40, p = 0.006). Admission IMPACT probability of poor outcome and initial plasma concentrations of IL-6, IL-8, and IL-10 were associated with MODS following TBI.