Mild Traumatic Brain Injury Patients Research Articles

Influence of concomitant injuries on post-concussion symptoms after a mild traumatic brain injury – a prospective multicentre cohort study

ABSTRACT Objectives: To compare post-concussion symptoms (PCS) and return to normal activities between mild Traumatic Brain Injury (mTBI) patients with or without concomitant injuries at 7-and 90 days post-mTBI.Methods: Design: Sub-analysis of a multicentre prospective cohort study. Participants and setting: patients with mTBI from 7 Canadian Emergency Departments. Procedure: Research assistants conducted telephone follow-ups using the Rivermead Postconcussion Symptoms Questionnaire (RPQ) at 7-, 30- and 90 days post-mTBI. Main outcome: Presence of PCS (RPQ: ≥3 symptoms) at 90 days. Secondary outcomes: RPQ score ≥21, prevalence of individual RPQ symptoms and patients’ return to normal activities, at 7- and 90-days. Adjusted risk ratios (RR) were calculated.Results: 1725 mTBI patients were included and 1055 (61.1%) had concomitant injuries. Patients with concomitant injuries were at higher risk of having ≥3 symptoms on the RPQ (RR:1.26 [95% CI 1.01–1.58]) at 90 days. They were also at higher risk of experiencing specific symptoms (dizziness, fatigue, headaches and taking longer to think) and of non-return to their normal activities (RR:2.11 [95% CI 1.30–3.45]).Conclusion: Patients with concomitant injuries have slightly more PCS and seemed to be at higher risk of non-return to their normal activities 90 days, compared to patients without concomitant injuries.

Use of diffusion tensor imaging to assess the vasogenic edema in traumatic pericontusional tissue

Background and objectiveCerebral edema is a frequent and serious complication of traumatic brain injury (TBI). Diffusion tensor imaging (DTI) is considered a useful technique to assess white matter integrity after TBI. The objective of this prospective, observational study was to assess the characteristics of the vasogenic edema in the traumatic pericontusional tissue and compare it to the vasogenic edema found in brain tumors. We also included a control group. MethodsUsing DTI, the Apparent diffusion coefficient (ADC) and Fractional anisotropy (FA) were measured in the area of vasogenic edema in both TBI and tumor patients. The measurements in the control group were done in the gray and white matter. We included 15 TBI patients, 18 tumor patients and 15 controls. ResultsADC and FA showed no differences between TBI and tumor patients (p=0.27 for AF; p=0.79 for ADC). Compared to healthy controls, TBI and tumor patients presented higher ADC values and lower FA values. The differences between TBI and controls were statistically significant (p<0.05). ConclusionsIn this prospective observational study using DTI-MRI in a selected group of mild and moderate TBI patients with vasogenic pericontusional edema we have shown that there were no significant differences of the ADC and FA values compared to brain tumor patients. Furthermore, healthy controls showed significant lower ADC values and higher FA values compared to TBI and tumor patients. Future studies, using DTI-MRI, should address whether any therapy has a favorable impact on the vasogenic edema of TBI patients with brain contusions.

Extracellular vesicles as distinct biomarker reservoirs for mild traumatic brain injury diagnosis.

Mild traumatic brain injury does not currently have a clear molecular diagnostic panel to either confirm the injury or to guide its treatment. Current biomarkers for traumatic brain injury rely mainly on detecting circulating proteins in blood that are associated with degenerating neurons, which are less common in mild traumatic brain injury, or with broad inflammatory cascades which are produced in multiple tissues and are thus not brain specific. To address this issue, we conducted an observational cohort study designed to measure a protein panel in two compartments—plasma and brain-derived extracellular vesicles—with the following hypotheses: (i) each compartment provides independent diagnostic information and (ii) algorithmically combining these compartments accurately classifies clinical mild traumatic brain injury. We evaluated this hypothesis using plasma samples from mild (Glasgow coma scale scores 13–15) traumatic brain injury patients (n = 47) and healthy and orthopaedic control subjects (n = 46) to evaluate biomarkers in brain-derived extracellular vesicles and plasma. We used our Track Etched Magnetic Nanopore technology to isolate brain-derived extracellular vesicles from plasma based on their expression of GluR2, combined with the ultrasensitive digital enzyme-linked immunosorbent assay technique, Single-Molecule Array. We quantified extracellular vesicle-packaged and plasma levels of biomarkers associated with two categories of traumatic brain injury pathology: neurodegeneration and neuronal/glial damage (ubiquitin C-terminal hydrolase L1, glial fibrillary acid protein, neurofilament light and Tau) and inflammation (interleukin-6, interleukin-10 and tumour necrosis factor alpha). We found that GluR2+ extracellular vesicles have distinct biomarker distributions than those present in the plasma. As a proof of concept, we showed that using a panel of biomarkers comprised of both plasma and GluR2+ extracellular vesicles, injured patients could be accurately classified versus non-injured patients.

Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury: A 6-Month Prospective Cohort Study

ObjectiveTo analyze fatigue after mild traumatic brain injury (TBI) with latent class growth analysis (LCGA) to determine distinct recovery trajectories and investigate influencing factors, including emotional distress and coping styles. DesignAn observational cohort study design with validated questionnaires assessing fatigue, anxiety, depression, posttraumatic stress, and coping at 2 weeks and 3 and 6 months postinjury. SettingThree level 1 trauma centers. ParticipantsPatients with mild TBI (N=456). InterventionsNot applicable. Main Outcome MeasuresFatigue was measured with the fatigue severity subscale of the Checklist Individual Strength, including 8 items (sum score, 8-56). Subsequently, 3 clinical categories were created: high (score, 40-56), moderate (score, 26-38), and low (score, 8-25). ResultsFrom the entire mild TBI group, 4 patient clusters with distinct patterns for fatigue, emotional distress, and coping styles were found with LCGA. Clusters 1 and 2 showed favorable recovery from fatigue over time, with low emotional distress and the predominant use of active coping in cluster 1 (30%) and low emotional distress and decreasing passive coping in cluster 2 (25%). Clusters 3 and 4 showed unfavorable recovery, with persistent high fatigue and increasing passive coping together with low emotional distress in cluster 3 (27%) and high emotional distress in cluster 4 (18%). Patients with adverse trajectories were more often women and more often experiencing sleep disturbances and pain. ConclusionsThe prognosis for recovery from posttraumatic fatigue is favorable for 55% of mild TBI patients. Patients at risk for chronic fatigue can be signaled in the acute phase postinjury based on the presence of high fatigue, high passive coping, and, for a subgroup of patients, high emotional distress. LCGA proved to be a highly valuable and multipurpose statistical method to map distinct courses of disease-related processes over time.

Discharge Education for Mild Traumatic Brain Injury Patients at Emergency Department

This study aims to review the literature on educational interventions for the discharge of mild traumatic brain injury (mTBI) patients in the Emergency Room (IGD). Database searches were performed based on PICO queries and keywords. using ProQuest, ScienceDirect, Scopus, and PubMed for the period 2012-2019. Ten studies were reviewed. The findings revealed the contents of discharge information for mTBI patients including diagnosis, signs and symptoms, treatment and medication, pain management, home care, and ED return instructions. Four methods of discharge intervention are commonly used in the ED; written, spoken, animated and moving videos, and printed instructions measured over two time periods, either pre-discharge in the ED or follow-up 1-2 weeks post-discharge at home. In conclusion, combined teaching was more effective in terms of level of knowledge, understanding, and ED repeat visits.&#x0D; &#x0D; Keywords: Discharge education, Emergency, Minor Traumatic Brain Injury

The detection of mild traumatic brain injury in paediatrics using artificial neural networks

Head computed tomography (CT) is the gold standard in emergency departments (EDs) to evaluate mild traumatic brain injury (mTBI) patients, especially for paediatrics. Data-driven models for successfully classifying head CT scans that have mTBI will be valuable in terms of timeliness and cost-effectiveness for TBI diagnosis. This study applied two different machine learning (ML) models to diagnose mTBI in a paediatric population collected as part of the paediatric emergency care applied research network (PECARN) study between 2004 and 2006. The models were conducted using 15,271 patients under the age of 18 years with mTBI and had a head CT report. In the conventional model, random forest (RF) ranked the features to reduce data dimensionality and the top ranked features were used to train a shallow artificial neural network (ANN) model. In the second model, a deep ANN applied to classify positive and negative mTBI patients using the entirety of the features available. The dataset was divided into two subsets: 80% for training and 20% for testing using five-fold cross-validation. Accuracy, sensitivity, precision, and specificity were calculated by comparing the model's prediction outcome to the actual diagnosis for each patient. RF ranked ten clinical demographic features and twelve CT-findings; the hybrid RF-ANN model achieved an average specificity of 99.96%, sensitivity of 95.98%, precision of 99.25%, and accuracy of 99.74% in identifying positive mTBI from negative mTBI subjects. The deep ANN proved its ability to carry out the task efficiently with an average specificity of 99.9%, sensitivity of 99.2%, precision of 99.9%, and accuracy of 99.9%. The performance of the two proposed models demonstrated the feasibility of using ANN to diagnose mTBI in a paediatric population. This is the first study to investigate deep ANN in a paediatric cohort with mTBI using clinical and non-imaging data and diagnose mTBI with balanced sensitivity and specificity using shallow and deep ML models. This method, if validated, would have the potential to reduce the burden of TBI evaluation in EDs and aide clinicians in the decision-making process.

Comparison of the effects of transcranial direct current stimulation and mindfulness-based stress reduction on mental fatigue, quality of life and aggression in mild traumatic brain injury patients: a randomized clinical trial

BackgroundThe rate of traumatic brain injuries (TBIs) due to the accidents is high around the world. Patients with mild TBIs may suffer from some psychological disorders, including aggression, and mental fatigue, and thus their quality of life decreased. Among different treatments for TBI, two treatments, namely transcranial direct current stimulation (tDCS), and mindfulness-based stress reduction (MBSR) have shown to be effective. Therefore, this study aimed to compare the effects of these two treatments on mental fatigue, aggression and quality of life in mTBI patients.Materials and methodsThis randomized controlled trial study was conducted on 48 TBI patients referred to emergency and neurosurgery departments of Shahid Beheshti Hospital, Kashan, Iran. They were selected using the convenience sampling method. Data were collected using the mental fatigue scale, the World Health Organization Quality of Life-BREF (short version), and the Buss–Perry Aggression Questionnaires. Then, the data were analyzed using a Mixed Repeated Measures ANOVAs, and the Levene and Kolmogorov–Smirnov tests by SPSS-23 software.ResultsThe mean age of patients in the three groups of MBSR, tDCS and control were 69.38 + 6.11 (25% male), 25.40 + 12.11 (25% male) and 69.37 + 0.2 (18.8% male), respectively. There was no significant difference between the three groups in terms of mental fatigue, quality of life and aggression (P < 0.05). In addition, the results showed that there was a significant difference between the main effect of time and the interaction between time and group (P < 0.001).ConclusionsBoth MBSR and tDCS methods are effective in reducing the mental fatigue and aggression and increasing quality of life of mTBI patients; MBSR treatment, as indicated in the present study, can be more effective than tDCS in patients with mTBI.Trial registration : Thailand Registry of Clinical Trials, TCTR20180827003 Registered on August 24, 2018.

White matter degeneration in diffuse axonal injury and mild traumatic brain injury observed with automatic tractography.

A better understanding of white matter tract damage in patients with diffuse axonal injury (DAI) and mild traumatic brain injury (MTBI) is important to obtain an objective basis for sequelae. The purpose of this study was to clarify the characteristics of white matter tract degeneration in DAI and MTBI using automated tractography. T1-weighted and diffusion tensor imaging (DTI) was performed on seven DAI and seven MTBI patients as well as on nine healthy subjects. Automated probabilistic tractography analysis was performed using FreeSurfer and TRACULA (tracts constrained by underlying anatomy) for the reconstruction of major nerve fibers. We investigated the difference between DTI quantitative values in each white matter nerve fiber between groups and attempted to evaluate the classification accuracy of DAI and MTBI using receiver operator curve analysis. Both DAI and MTBI appeared to exhibit axonal degeneration along the nerve fiber tract in a scattered manner. The mean diffusivity of the ampulla of the corpus callosum was significantly higher in DAI than that in MTBI patients, suggesting axonal degeneration of the corpus callosum in DAI patients. Using mean diffusivity of the right cingulum-angular bundle, DAI and MTBI could be discriminated with an area under the curve of 94%. Both DAI and MTBI exhibited scattered axonal degeneration; however, DAI appeared to exhibit more pronounced axonal degeneration in the ampulla of the corpus callosum than MTBI. Our results suggest that DAI and MTBI can be accurately distinguished using DTI.

Multi-Modal Analysis of Resting-State fMRI Data in mTBI Patients and Association With Neuropsychological Outcomes.

Various cognitive disorders have been reported for mild traumatic brain injury (mTBI) patients during the acute stage. This acute stage provides an opportunity for clinicians to optimize treatment protocols, which are based on the evaluation of brain structural connectivity. So far, most brain functional magnetic resonance imaging studies are focused on moderate to severe traumatic brain injuries (TBIs). In this study, we prospectively collected resting state data on 50 mTBI within 3 days of injury and 50 healthy volunteers and analyzed them using Amplitude of low-frequency fluctuation (ALFF), Regional Homogeneity (ReHo), graph theory methods and behavior measure, to explore the dysfunctional brain regions in acute mTBI. In our study, a total of 50 patients suffering <3 days mTBI and 50 healthy subjects were tested in rs-fMRI, as well as under neuropsychological examinations including the Wechsler Intelligence Scale and Stroop Color and Word Test. The correlation analysis was conducted between graph theoretic parameters and neuropsychological results. For the mTBI group, the ReHo of the inferior temporal gyrus and the cerebellum superior are significantly lower than in the control group, and the ALFF of the left insula, the cerebellum inferior, and the middle occipital gyrus were significantly higher than in the control group, which implies the dysfunctionality usually observed in Parkinson's disease. Executive function disorder was significantly correlated with the global efficiencies of the dorsolateral superior frontal gyrus and the anterior cingulate cortex, which is consistent with the literature: the acute mTBI patients demonstrate abnormality in terms of motor speed, association, information processing speed, attention, and short-term memory function. Correlation analysis between the neuropsychological outcomes and the network efficiency for the mTBI group indicates that executive dysfunction might be caused by local brain changes. Our data support the idea that the cerebral internal network has compensatory reactions in response to sudden pathological and neurophysiological changes. In the future, multimode rs-fMRI analysis could be a valuable tool for evaluating dysfunctional brain regions after mTBI.

To determine the outcome of isolated hemorrhagic TBI in a large tertiary care center in Karachi, Pakistan.

Objective: To assess the outcome of mild traumatic brain injury patients who have isolated intracranial hemorrhages. Study Design: Cross-sectional, Setting: Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi. Period: 1st January 2018 to 31st January 2020. Material &amp; Methods: The inclusion criteria were that all the patients have to be above the age of 18 years, presented to us with mild TBI cases and had observable intracranial hemorrhage on computer tomography (CT) scan. Patient demographics and the various types of interventions were recorded. Results: A total of n= 300 patients were included in the study, The average age was 50.5 +/- 20.6 years. There were n= 180 males and n= 120 females. We performed a total of n= 45 (15%) neurosurgical interventions, the most common intervention being craniotomies performed in n= 31 (68.66%) patients. Of all the patients who underwent an intervention 64.44% had immediate intervention 20% had planned intervention as non-emergency cases, and 15.55% had delayed intervention. A one point increment in the GCS score is associated with 50% lower odds of surgical intervention having a p value of &lt;0.001. The mortality rate in our study population was 6%. Conclusion: We found that the length of stay and mortality are associated with an increased age and lower GCS score of the patients, care should be taken when evaluating the patients as some cases require delayed intervention hence monitoring is of prime importance.

FMRI findings in MTBI patients with headaches following rTMS

Mild Traumatic Brain Injury (MTBI) patients with persistent headaches are known to have diminished supraspinal modulatory connectivity from their prefrontal cortices. Repetitive transcranial magnetic stimulation (rTMS) is able to alleviate MTBI-related headache (MTBI-HA). This functional magnetic resonance imaging (fMRI) study assessed supraspinal correlates associated with the headache analgesic effect of rTMS at left prefrontal cortex (LPFC), hypothesizing real rTMS would significantly increase modulatory functions at LPFC in comparison to sham treatment. Subjects with MTBI-HA were randomized to receive either real or sham rTMS treatments and subjected to pre- and post-treatment resting state and evoked heat-pain fMRI as described in a prior study. Real rTMS consisted of 2000 pulses delivered at 10 Hz and 80% of the resting motor threshold at left dorsolateral prefrontal cortex, whereas sham treatment was delivered with same figure-of-eight coil turned 180 degrees. Follow-up fMRI was performed one-week post-treatment. All fMRI data was processed using BrainVoyager QX Software. 14 subjects receiving real and 12 subjects receiving sham treatments completed the study. The REAL group demonstrated significant (P < 0.02) decreases in headache frequency and intensity at one week following treatment. fMRI scans in the REAL group showed increased evoked heat pain activity (P < 0.002) and resting functional connectivity (P < 0.0001) at the LPFC after rTMS. Neither this significant analgesic effect nor these fMRI findings were seen in the sham group. Sham treatment was, however, associated with a decrease in resting state activity at the LPFC (P < 0.0001). This study correlates the demonstrated analgesic effect of rTMS in the treatment of MTBI-HA with enhanced supraspinal functional connectivity in the left prefrontal cortex, which is known to be involved in “top-down” pain inhibition along the descending midbrain-thalamic-cingulate pathway.Trial Registration: This study was registered on September 24, 2013, on ClinicalTrials.gov with the identifier: NCT01948947. https://clinicaltrials.gov/ct2/show/NCT01948947.

Does Pituitary Dysfunction Always Occur Following Penetrating Head Trauma?

Background: Pituitary dysfunction and panhypopituitarism remain underdiagnosed in penetrating and blunt head trauma and can occur in both acute and chronic settings. Case: A 56 years old male with no significant PMH was admitted with a gunshot wound to the left T9 rib paraspinally with bullet deflection cranially along the left lung, left sternocleidomastoid, and resting anterior to the suprasellar cistern just above the midline of the sphenoid sinus close to the pituitary gland. Moderate volume pneumocephalus, chest hemopneumothorax, and sudden loss of right-sided vision required neurosurgical and pulmonary intervention. Endocrinology was consulted to evaluate pituitary function in the context of the bullet within the cranium. Physical examination showed intact mental status, non-focal exam, right-sided blindness, and foley catheter with normal urine output. Laboratory hormonal assessment for hypothalamic-pituitary axis (HPA) was performed consistent with normal sodium, potassium, FSH of 14.2 mIU/ml (1.0-13.0 mIU/ml), LH of 4.5 mIU/ml (1.0-9.0 mIU/ml), AM cortisol of 13.6 ug/dl (5-25 ug/dl), free cortisol of 2.06, ACTH of 10 pg/ml (10-60 pg/ml), IGF-1 of 80 ng/ml (78-220 ng/ml), TSH 1.93 mIU/L (0.5-5.0 mIU/L), FT4 1.05 ng/dl (0.8-1.8 ng/dl), Prolactin of 14.2 ng/ml (4-23 ng/ml) and HbA1c 5.1%. He reported no symptoms of adrenal insufficiency and remained hemodynamically stable. He was monitored for symptoms of pituitary insufficiency and suppression of the HPA axis along with urine output which remained normal and reassuring for the absence of central DI. The patient will continue outpatient endocrine surveillance. Discussion: The development of hormone deficiencies is directly related to the severity of head trauma. Mild traumatic brain injury (TBI) patients discharged from the ED, without loss of consciousness or post-traumatic amnesia less than 30 minutes do not require endocrine surveillance. Pituitary dysfunction occurs in 20-40% of patients with moderate to severe TBI. Pituitary ischemia leads to pituitary injury, due to changes in cerebral blood flow, cerebral hypoxia, and increased intracranial pressure. Compressive effects on the stalk from increased intracranial pressure is another indirect mechanism for pituitary dysfunction. Hospitalizations longer than 48 hours following TBI, require pituitary screening at 3-6 months. Chronic hypopituitarism develops in 15-20% of patients within 2-3 years with ACTH and GH deficiencies. Other changes in LH, FSH, TSH, and development of central diabetes insipidus can occur. However, despite severe TBI, acute pituitary hormonal involvement may not always occur, as in our patient.

Incidence and Clinical Impact of Myocardial Injury Following Traumatic Brain Injury: A Pilot TRACK-TBI Study.

Traumatic brain injury (TBI) is a major global health problem. Little research has addressed extracranial organ dysfunction following TBI, particularly myocardial injury. Using a sensitive marker of myocardial injury-high sensitivity troponin (hsTn)-we examined the incidence of early myocardial injury following TBI and explored its association with neurological outcomes following moderate-severe TBI. We conducted a pilot cohort study of 133 adult (age above 17 y) subjects enrolled in the TRACK-TBI 18-center prospective cohort study. Descriptive statistics were used to examine the incidence of myocardial injury (defined as hsTn >99th percentile for a standardized reference population) across TBI severities, and to explore the association of myocardial injury with a 6-month extended Glasgow Outcome Score among patients with moderate-severe TBI. The mean (SD) age of the participants was 44 (17) years, and 87 (65%) were male. Twenty-six patients (20%) developed myocardial injury following TBI; myocardial injury was present in 15% of mild TBI patients and 29% of moderate-severe TBI patients (P=0.13). Median (interquartile range) hsTn values were 3.8 ng/L (2.1, 9.0), 5.8 ng/L (4.5, 34.6), and 10.2 ng/L (3.0, 34.0) in mild, moderate, and severe TBI participants, respectively (P=0.04). Overall, 11% of participants with moderate-severe TBI and myocardial injury experienced a good outcome (6-mo extended Glasgow Outcome Score≥5) at 6 months, compared with 65% in the group that did not experience myocardial injury (P=0.01). Myocardial injury is common following TBI, with a likely dose-response relationship with TBI severity. Early myocardial injury was associated with poor 6-month clinical outcomes following moderate-severe TBI.

Delayed intracranial hemorrhage after mild traumatic brain injury in patients on oral anticoagulants: is the juice worth the squeeze?

Mild Traumatic Brain Injury (MTBI) in anticoagulated patients is a common challenge for Emergency Department (ED) Physicians. Anticoagulation is considered a risk factor for developing delayed intracranial hemorrhage (ICH) after MTBI. The occurrence of this event in patients on Vitamin K Antagonists (VKA) or Direct Oral Anticoagulants (DOACs) remains unclear. Primary endpoint: to analyze the role of anticoagulants as risk factors for developing delayed ICH after MTBI and evaluate the indications to repeat a cranial computed tomography (CT) after a period of observation. Secondary endpoint: to assess the difference in the prevalence rate of delayed ICH in patients on VKA versus those on DOACs. We evaluated all consecutive patients admitted to our ED for MTBI, which had a control CT for late ICH after a negative CT at admission. We used a propensity score match (PSM) on factors affecting the need for oral anticoagulation to adjust the comparison between anticoagulated vs. non-anticoagulated patients for the baseline clinical characteristics. Among 685 patients enrolled, 15 (2.2%) developed ICH at control CT. After PSM, the incidence of ICH, although slightly higher, was not statistically different in anticoagulated patients vs. non-anticoagulated (2.3% vs. 0.6%, p=0.371). Among the 111 patients on VKA, 5 (4.5%) had a late ICH, compared to 4 out of 99 (4.0%) on DOACs; the difference was not statistically significant (p=0.868). The risk of developing delayed ICH after MTBI in patients on anticoagulation therapy is low. After correction for baseline covariates, the risk does not appear higher compared to non-anticoagulated patients. Thus, a routine control CT scan seems advisable only for patients presenting a clinical deterioration. Larger, prospective trials are required to clarify the safety profile of DOACs vs. VKA in MTBI.

Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes.

Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population. To report our experience with protocol implications and patient outcome. Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed. Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations. Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.

18F-FDG PET Combined With MR Spectroscopy Elucidates the Progressive Metabolic Cerebral Alterations After Blast-Induced Mild Traumatic Brain Injury in Rats.

A majority of blast-induced mild traumatic brain injury (mTBI) patients experience persistent neurological dysfunction with no findings on conventional structural MR imaging. It is urgent to develop advanced imaging modalities to detect and understand the pathophysiology of blast-induced mTBI. Fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) could detect neuronal function and activity of the injured brain, while MR spectroscopy provides complementary information and assesses metabolic irregularities following injury. This study aims to investigate the effectiveness of combining 18F-FDG PET with MR spectroscopy to evaluate acute and subacute metabolic cerebral alterations caused by blast-induced mTBI. Thirty-two adult male Sprague–Dawley rats were exposed to a single blast (mTBI group) and 32 rats were not exposed to the blast (sham group), followed by 18F-FDG PET, MRI, and histological evaluation at baseline, 1–3 h, 1 day, and 7 days post-injury in three separate cohorts. 18F-FDG uptake showed a transient increase in the amygdala and somatosensory cortex, followed by a gradual return to baseline from day 1 to 7 days post-injury and a continuous rise in the motor cortex. In contrast, decreased 18F-FDG uptake was seen in the midbrain structures (inferior and superior colliculus). Analysis of MR spectroscopy showed that inflammation marker myo-inositol (Ins), oxidative stress marker glutamine + glutamate (Glx), and hypoxia marker lactate (Lac) levels markedly elevated over time in the somatosensory cortex, while the major osmolyte taurine (Tau) level immediately increased at 1–3 h and 1 day, and then returned to sham level on 7 days post-injury, which could be due to the disruption of the blood–brain barrier. Increased 18F-FDG uptake and elevated Ins and Glx levels over time were confirmed by histology analysis which showed increased microglial activation and gliosis in the frontal cortex. These results suggest that 18F-FDG PET and MR spectroscopy can be used together to reflect more comprehensive neuropathological alterations in vivo, which could improve our understanding of the complex alterations in the brain after blast-induced mTBI.

Serum netrin-1 as a potential biomarker for functional outcome of traumatic brain injury

BackgroundDecreased serum netrin-1 concentrations have been found after acute brain injury. We investigated the role of serum netrin in prognosis of traumatic brain injury (TBI). MethodsIn this prospective and observational study, enzyme-linked immunosorbent assay was used to detect serum netrin-1 concentrations in 50 mild TBI patients (Glasgow coma scale (GCS) score, 13–15), 83 moderate TBI patients (GCS score, 9–12), 69 severe TBI patients (GCS score, 3–8) and 50 healthy controls. Glasgow outcome scale score of 1–3 at 6 months after trauma was defined as poor outcome. ResultsSerum netrin-1 concentrations were significantly lower in moderate or severe TBI patients than in controls and in severe TBI patients than in moderate TBI patients, while not in mild TBI patients than in controls. GCS score and Rotterdam computed tomography classification were closely correlated with serum netrin-1 concentrations among TBI patients. Forty-two (20.8%) patients had poor outcome. Receiver operating characteristic curve analysis revealed that serum netrin-1 concentrations could distinguish patients with poor outcome from the other remainders significantly. In addition, serum netrin-1 concentrations were independently associated with poor outcome. ConclusionsSerum netrin-1 might serve as a potential biomarker for prognosis of TBI.

Post-concussion symptoms in sports-related mild traumatic brain injury compared to non-sports-related mild traumatic brain injury.

To compare post-concussion symptoms in patients who sustained a sports-related mild traumatic brain injury (TBI) to those with non-sports-related mild TBIat 7 and 90 days post-injury. This prospective multicentre cohort study took place in seven Canadian Emergency Departments (ED). Non-hospitalized patients aged ≥ 14years with a documented mild TBI that occurred ≤ 24h of ED visit and a Glasgow Coma Scale score ≥ 13 were included. Main outcome measure was the presence of ≥ 3 symptoms on the Rivermead Post-concussion Questionnaire at 90days post-injury. Secondary outcomes were the prevalence of (1) individual Rivermead Post-concussion Questionnaire symptom, (2) total Rivermead Post-concussion Questionnaire score ≥ 21 and (3) return to normal daily activities. Adjusted risk ratios (RR) were calculated. 1727 patients were included, 363 (21.0%) sustained a sports-related mild TBI. Similar proportions of patients with ≥ 3 symptoms, a Rivermead Post-concussion Questionnaire score ≥ 21 and those who returned to their normal daily activities were observed at 7 and 90days post-injury. Sports-related mild TBI patients were at higher risk of poor concentration [RR: 1.3 (95% CI 1.05-1.54)] and non-return to sports activities [RR: 2.2 (95% CI 1.69-2.94)] at 7days post-injury. At 90days, sports-relate -mild TBI patients reported less fatigue [RR: 0.7 (95% CI 0.51-0.98)] and feeling of dizziness [RR: 0.6 (95% CI 0.35-0.99)]. Patients who sustained sports-related mild TBI could be at lower risk of experiencing symptoms such as fatigue and dizziness 90days post-injury. Clinicians should be mindful that non-sports-related mild TBI patients may experience more post-concussion symptoms and that the level of physical activity may influence the patient's rehabilitation.

Neurocognitive and Affective Sequelae Following Complicated Mild and Moderate Traumatic Brain Injury: A Case Series.

Traumatic brain injury (TBI) leads to various sequelae that affect the day-to-day functioning of patients. However, there is a dearth of studies investigating these sequelae in complicated mild TBI and moderate TBI patients. The prime objective of the present study was to present the neurocognitive and affective profile of complicated mild and moderate TBI patients along with to compare the neurocognitive and affective sequelae in patients with complicated mild and moderate TBI. Twenty-two patients with complicated mild TBI and 17 patients with Moderate TBI, each with an intracranial lesion were recruited from level 1 trauma center in Varanasi. All patients were assessed with neurocognitive measures, Rivermead Post Concussive Symptoms Questionnaire, and Hospital Anxiety and Depression Scale. The patients' profiles were presented as clinical series using descriptive analysis. Further, comparison was done by using the Chi-square test and Fisher's exact test. Findings revealed that complicated mild TBI patients reported significantly higher psychological distress and post head injury symptoms in comparison to patients with moderate TBI. Further, the complicated mild TBI and moderate TBI groups showed differences with respect to verbal fluency, mental speed, and flexibility tasks. Complicated mild TBI and moderate TBI groups have not differed significantly on most of the cognitive tasks. Furthermore, affective symptoms were found more prominent in complicated mild TBI group as compared to the moderate TBI group.

Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs

Although mild traumatic brain injury (MTBI) in people on oral anticoagulant treatment (OAT) is a frequent challenge for Emergency Department (ED), strong guidelines recommendations are lacking. In the attempt to assess the safety profile of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs), we have recruited 473 patients with a MTBI on OAT (43.6% males; age 81.8 ± 8.7 years), admitted to the Pisa’s University Hospital ED (Jan 2016—Oct 2018). All patients underwent a head CT scan with those with no sign of acute bleedings remaining under clinical observation for the ensuing 24 h. Fifty patients (10.6%, 95% CI: 8.1–13.7%) had immediate intracranial hemorrhage (ICH), with a prevalence of patient-important outcomes due to immediate ICH of 1.1% (95% CI 0.4–2.4%); 3 patients died (0.6%, 95% CI 0.2–1.8) and 2 required neurosurgical intervention. Immediate ICHs were more frequent in VKA-treated than in DOAC-treated patients (15.9 vs. 6.4%. RR 2.5. 95%CI 1.4–4.4. p < 0.05). Multivariate analysis identified that post-traumatic amnesia, evidence of trauma above clavicles, high blood glucose, high blood pressure (BP) at arrival, and low prothrombin activity were predictors of immediate ICH. The prevalence of delayed ICH was 1.0% (95%CI 0.4–2.5%) without differences between DOACs and VKAs. Despite ICH being a frequent complication of MTBI in patients on OAT, immediate and delayed patient-important outcomes are rare. DOACs have a better safety profile than VKAs. Simple clinical parameters such as blood pressure at arrival or blood glucose might provide useful predictors of immediate ICH. Trial registration number: 11924_CIPRIANO. Local ethics committee approval number 33096.