Secondary Brain Insults Research Articles

Machine Learning Based Prediction of Imminent ICP Insults During Neurocritical Care of Traumatic Brain Injury.

In neurointensive care, increased intracranial pressure (ICP) is a feared secondary brain insult in traumatic brain injury (TBI). A system that predicts ICP insults before they emerge may facilitate early optimization of the physiology, which may in turn lead to stopping the predicted ICP insult from occurring. The aim of this study was to evaluate the performance of different artificial intelligence models in predicting the risk of ICP insults. The models were trained to predict risk of ICP insults starting within 30min, using the Uppsala high frequency TBI dataset. A restricted dataset consisting of only monitoring data were used, and an unrestricted dataset using monitoring data as well as clinical data, demographic data, and radiological evaluations was used. Four different model classes were compared: Gaussian process regression, logistic regression, random forest classifier, and Extreme Gradient Boosted decision trees (XGBoost). Six hundred and two patients with TBI were included (total monitoring 138,411h). On the task of predicting upcoming ICP insults, the Gaussian process regression model performed similarly on the Uppsala high frequency TBI dataset (sensitivity 93.2%, specificity 93.9%, area under the receiver operating characteristic curve [AUROC] 98.3%), as in earlier smaller studies. Using a more flexible model (XGBoost) resulted in a comparable performance (sensitivity 93.8%, specificity 94.6%, AUROC 98.7%). Adding more clinical variables and features further improved the performance of the models slightly (XGBoost: sensitivity 94.1%, specificity of 94.6%, AUROC 98.8%). Artificial intelligence models have potential to become valuable tools for predicting ICP insults in advance during neurointensive care. The fact that common off-the-shelf models, such as XGBoost, performed well in predicting ICP insults opens new possibilities that can lead to faster advances in the field and earlier clinical implementations.

A Study of Efficacy and Outcomes of Two Techniques of Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract Background Endovascular mechanical thrombectomy (A Direct Aspiration First Pass Technique [ADAPT] and Solitaire stent retrieval techniques) as an emergency reperfusion therapy in acute ischemic stroke patients avoids secondary brain insult and thereby prevents permanent neurological deficits. As studies comparing the two thrombectomy procedures are scarce, we evaluated their efficacy. Methods In this prospective observational study done at Manipal Hospitals Bangalore, 75 patients were separated into two groups based on the final reperfusion technique employed: ADAPT group with 39 patients who underwent contact aspiration technique and Solitaire group with 36 patients who underwent stent retrieval thrombectomy. The rate of successful reperfusion (modified treatment in cerebral infarction scores [mTICI]); functional outcomes (modified Rankin scale [mRS] and National Institutes of Health Stroke Scale [NIHSS]) at 24 hours, 1 month and 3 months postintervention; and the adverse events were compared between the two groups. Results Successful reperfusion was significantly higher in the ADAPT group. Mean NIHSS and mRS scores reduced significantly postintervention for both groups, but was greater for the ADAPT group, while mortality and other adverse events were significantly greater in the solitaire group. Conclusion Mechanical thrombectomy is an effective reperfusion therapy for acute ischemic stroke patients. Comparing the two techniques revealed better outcomes for ADAPT, than stent retrieval technique.

Cerebral venous pathology and paediatric head injury

Cerebral venous thrombosis (CVT) is increasingly recognised in traumatic brain injury and carries a significant rate of complications leading to secondary brain insults. In general, the rate of complications is dependent on the anatomical location with midline and bilateral CVT associated with a significantly increased 30 day mortality in traumatic brain injury patients. Paediatric trauma related CVT is relatively uncommon (3%) and most cases of post-traumatic CVT in children involve a bone fracture along the adjacent dural sinus, but CVT can occur in the absence of a skull fracture. Older children are more likely to present with post-traumatic CVT and thrombosis occurs acutely, usually 1–5 days following head injury. Venous compromise may involve extrinsic sinus compression in addition to sinus thrombosis. Overlap in symptomology and descriptions of retinal and dural pathology associated with CVT has prompted some to advance CVT as a condition with a potential to mimic paediatric non-accidental head injury. CVT in the setting of NAHI is not uncommon (as much as a third of cases in the author’s experience). In this situation it though almost invariably represents a secondary, post-collapse complication due to venous stasis and a critically ill state with those rare cases showing evidence of CVT predating collapse typically associated with evidence of historic abusive injury. Careful scrutiny of the relevant scientific literature and due attention to clinicopathological features associated with CVT serve to further undermine CVT as a plausible alternative explanation for classic NAHI eye and intracranial pathology.

Multimodal Neuromonitoring in Pediatric Neurocritical Care: Current Perspectives.

Children with neurological illness in the critical care unit are always at higher risk of developing secondary brain injury (SBI). Brain insult can lead to changes in cerebral autoregulation, intracranial pressure (ICP), cerebral oxygenation, and metabolism. This can cause a raised ICP, cerebral ischemia, hypoxia, excitotoxicity, cellular energy failure, and nonconvulsive status epilepticus. Simultaneous and continuous assessment of these parameters will help to improve patient care and neurological outcomes. Even thoughclinical examination and neuroimaging can help in the initial diagnosis of the neurological illness, they may not be helpful in continuous monitoring of cerebralpathophysiological changes. The ideal single neuromonitoring device to detect these real-time changes is currently unavailable. However, a range of invasive and noninvasive monitors are available to monitor these cerebral functional parameters. Invasive monitoring techniques include invasive ICP monitoring, cerebral autoregulation monitoring, brain tissue partial oxygen pressure, and cerebral microdialysis. Noninvasive-monitoring techniques include pupillometry, brain and ocular ultrasonography, near-infraredspectroscopy, and electrophysiological monitoring. Multimodal (MM) neuromonitoring involves incorporating these techniques and tools for the early identification and treatment of primary and secondary brain insults. The utility and feasibility of most of these techniques are well described in adult neurocritical care. Even though the evidence on their usage in children is primarily available in pediatric traumatic brain injury, the emerging data help to further expand their utility in pediatric nontraumatic coma. MM neuromonitoring aims to provide clinical and pathophysiological information to the intensivists to improve their understanding of the child's neurological status and to formulate patient-specific treatment approaches.

Epidemiological and Prognostic Aspects of Secondary Brain Insults of Systemic Origin in Patients Operated for Intracranial Tumor in Low-Resource Settings

Background: Secondary Brain Insults of Systemic Origin (SBISO) are factors that can aggravate a primary brain injury regardless of its origin (traumatic, vascular, infectious, tumoral, or surgical). The aim was to describe the type and frequency of SBISO occurring after intracranial surgery indicated for intracranial tumors, and to establish the prognosis of patients presenting with these SBISO. Methods: This was a prospective and descriptive study carried out at the ICU of the Yaoundé Central Hospital between January 1st, 2012 to December 31st, 2019. We enrolled patients operated for intracranial tumors and admitted in the ICU. The variables studied were data from the preoperative, intraoperative and postoperative periods. Data analysis was performed using Epi Info 3.5.4 software. The chi-square test was used, the p-value being considered significant if < 0.05. Results: 93 patients were included during the period of study. The mean age was 45 ± 17.1 years and a sex- ratio of 1.27. We found 604 SBISO in 70 patients (75.3%). The most common SBISO were hypoxia (44.7%) and hyperglycemia (30%). The risk factors for the occurrence of SBISO were age ≥ 60 years (p=0.02), history of hypertension (p=0.005), patients classified ASA II (p=0.007) and intraoperative complications (p ? 0.001). The occurrence of SBISO was associated with a high mortality risk. Conclusion: SBISO are common in patients operated for intracranial tumors. Mortality was increased by the presence of SBISO.

Intenzivno lečenje pacijenata sa kraniocerebralnom traumom - kako nam akronimi mogu pomoći?

Traumatic brain injury (TBI) is considered to be a "silent global epidemic" and is the leading cause of death in young males in developed countries, major cause of disability, morbidity, and mortality worldwide. The classification of TBI severity was performed using the Glasgow coma scale (GCS) into mild (GCS = 15-13), moderate (GCS = 12-9), and severe (GCS = 8-3). Despite developments in modern intensive care, improvements in resuscitation and vital organ support, the management of critically ill patients with traumatic brain injury presents a challenge to all members of the critical care team. Since severe head injury is often associated with poor functional outcomes due to secondary brain insults, the benefits of intensive treatment and care may not become apparent until months or years later during rehabilitation after injury. Due to the complexity and specificity of TBI, implementation of an easy-to-remember mnemonic can significantly help anesthesiologists and clinicians in conducting intensive therapy. Mnemonic GOST CAP was implementing to help with treatment of patients with primary craniocerebral trauma and prevention of secondary brain injury. GOST CAP acronym emphasizes the significance of glycemic control in neurotrauma, maintaining haemoglobin levels, oxygen support, sodium concentration, temperature maintenance, pain and agitation control, arterial blood pressure control in maintaining cerebral perfusion pressure, and partial pressure of CO2 control. The aim of this paper is to display acronyms that address the most important steps in treating patients with TBI.

Monitoring and Neurocritical Care of Severe Traumatic Brain Injury

The main objectives of critical care of severe traumatic brain injury(TBI)are the prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure, and optimization of cerebral oxygenation. The critical care management of severe TBI will be discussed with a focus on the monitoring and avoidance or minimization of secondary brain insults, with emphasis on understanding the underlying physiology and pathophysiology. The evolution of critical care of severe traumatic brain injury will also be discussed along with the accumulating knowledge and experience.

Incidence and predictors of mortality among patients with head injury admitted to Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: A retrospective follow-up study.

Head injury is the leading cause of morbidity and mortality throughout the world, especially in resource-limited countries including Ethiopia. However, little is known about the mortality rate and its predictors among these patients in Ethiopia. Thus, the study aims to assess the incidence rate of mortality and its predictors among patients with head injury admitted at Hawassa University Comprehensive Specialized Hospital. Institutional based retrospective follow-up study was conducted among 1220 randomly selected head injury patients admitted from July 2017 to July 2019. Bivariable and multivariable Cox regression models were fitted to identify the predictors of mortality. Proportionality assumption was tested by a global test based on the Schoenfeld residuals test. The incidence of the mortality rate was 2.26 (95%CI: 1.9-2.6) per 100-person day observation. The independent predictors of time to death were age above 65 years (AHR:3.49, 95%CI:1.63, 7.48), severe TBI (AHR: 8.8, 95%CI:5.13, 15.0), moderate TBI (AHR:3, 95%CI:1.73,5.31), hypotension (AHR:1.72, 95%CI: 1.11,2.66), hypoxia (AHR:1.92, 95%CI: 1.33,2.76), hyperthermia (AHR:1.8, 95%CI: 1.23,2.63) and hypoglycemic (AHR:1.94, 95%CI: 1.34, 2.81) positively associated with mortality, while underwent neurosurgery was negatively associated with mortality (AHR: 0.25, 95% CI: 0.11,0.53). The incidence of mortality rate among head injury patients was high. Older age, moderate and severe TBI, hypotension and hypoxia at admission, neurosurgical procedure, and the episode of hyperthermia and hypoglycemia during hospitalization were the independent predictors of mortality among head injury patients. Therefore, intervention to reduce earlier deaths should focus on the prevention of secondary brain insults.

Retinal Haemorrhages in Childhood Encephalopathies: Review of a Prospective Research Programme

One important cause of retinal haemorrhages (RHs) in children is abusive head trauma (AHT). Our programme of research was conducted on children admitted to hospital over a seven‐year period who had RHs as part of their clinical presentation. This paper summarises important findings from previous publications. As a prerequisite, two basic studies were necessary: (i) a method of reporting the precise location of the RH in the retina; and (ii) defining a simple clinical classification of RHs based on the appearance of the retinal layer involved. Because raised intracranial pressure (RICP) is a frequent secondary brain insult following serious adult head injury, causing hypoxic‐ischaemic injury with a resultant poor outcome, it was considered whether such RICP might also cause RHs in children. Detailed, state‐of‐the‐art monitoring methods were used to investigate this relationship along with retinal imaging. Methodical documentation of the type, area and lifespan of RHs meant that it was possible to address the question of predicting AHT from RH numbers and characteristics, and to describe not only the duration of different layer haemorrhages, but also a previously unreported observation that some RHs transiently enlarge over two to three days before resolving normally.‘One important cause of retinal haemorrhages (RHs) in children is abusive head trauma’Key Practitioner Messages A new retinal zone classification for research and legal purposes has been developed, as well as a simplified five‐point working classification of RHs, based on existing fundoscopic descriptions. In this cohort study, a young age and a high ‘dot‐blot’ count (>25 intraretinal haemorrhages) are strong predictors of AHT. There is a complex association between the burden of intracranial pressure insult and RHs. Time to resolution of different RHs has been calculated using two‐dimensional RH area pixel counts from sequential retinal imaging. Two patterns of resolution are reported.

Association Between Serum Sodium Abnormalities and Clinicoradiologic Parameters in Severe Traumatic Brain Injury

Background: Secondary brain insults after traumatic brain injury such as electrolyte dysfunctions are associated with poor outcomes. This study aimed at determining the incidence of serum sodium ion abnormalities and their association with clinicoradiological parameters.
 Methods: A prospective crosssectional study of one hundred and seventeen patients with severe head injury. Data collected included patient demographics, prehospital interventions, clinical examination findings, computed tomography (CT) scan head findings, serum sodium ion levels (at admission and 48 h later), and outcome (30 days).
 Results: At admission, 93(79.5%) patients had normal serum sodium ion levels. However, 48 h post-admission, hypernatremia was prevalent in 56(63.6%) patients (p < 0.001). Hypernatremia was significantly associated with the use of mannitol (p = 0.036), lower Glasgow Coma Score (p = 0.047), higher Injury Severity Score (p = 0.015), presence of subdural hematoma (p = 0.044), midline shift >5 mm (p = 0.048), compressed/absent basal cistern (p = 0.010), and higher Rotterdam CT Score (p = 0.003). Hypernatremia reported 48 h postadmission was associated with a high 30-day mortality rate [odds ratio (OR) 3.55, p = 0.0095]. Risk of mortality associated with hyponatremia and hypernatremia at admission was not statistically significant.
 Conclusion: While both hyponatremia and hypernatremia can occur in serious TBI patients, hypernatremia predominates 48 hours post- admission and is associated with statistically significant increased risk of death.

Systematic review and Meta-analysis on efficacy and safety of Naoxueshu Oral Liquid in treatment of hypertensive intracerebral hemorrhage

To systematically review the efficacy and safety of Naoxueshu Oral Liquid in treatment of hypertensive intracerebral hemorrhage, four Chinese databases, four English databases, clinical trials registration center(ClinicalTrials.gov) and Chinese clinical trial registry were retrieved. The retrieval time was from the establishment of each database to September 9, 2020. According to the set criteria, the randomized controlled trial(RCT) of Naoxueshu Oral Liquid combined with conventional Western medicine was selected. The "Cochrane bias risk assessment" tool was used to evaluate the quality of the included studies. RevMan 5.4.1 was used to conduct Meta-analysis of the included studies and GRADE system was used to evaluate the evidence quality of the outcome indicators. Eleven studies were finally included, with a total sample size of 1 221 cases, 612 cases in the treatment group and 609 cases in the control group. Meta-analysis showed that Naoxueshu Oral Liquid combined with conventional Western medicine had no significant difference compare with conventional Western medicine in reducing National Institute of health stroke scale(NIHSS) after 2 weeks of treatment for hypertensive intracerebral hemorrhage(MD=-1.59,95%CI[-3.46,0.29],P=0.10), but was superior to conventional Western medicine after 30 d of treatment(MD=-1.16,95%CI [-1.39,-0.94],P<0.000 01). Naoxueshu Oral Liquid combined with conventional Western medicine was superior to conventional Western medicine in improving Glasgow coma scale(MD=1.00,95%CI[0,2.00],P=0.05) and reducing the incidence of secondary brain insults(RR=0.38,95%CI[0.24,0.59],P<0.000 1), but there was no significant difference in increasing Barthel index(MD=1.00,95%CI[-0.30,2.30],P=0.13). In terms of effective rate, studies using Guideline for clinical trials of new patent Chinese medicines, NHISS or Glasgow outcome scale(GOS) had shown that Naoxueshu Oral Liquid combined with conventional Western medicine was superior to conventional Western medicine(RR_(Guideline for clinical trials of new patent Chinese medicines)=1.27,95%CI[1.10,1.46],P=0.001;RR_(NHISS)=1.26,95%CI[1.13,1.40],P<0.000 1;RR_(GOS)=1.54,95%CI[1.22,1.93],P=0.000 2). In reduction of hematoma volume, Naoxueshu Oral Liquid combined with conventional Western medicine was superior to conventional Western medicine after 2 and 4 weeks of treatment(MD_(2 week)=-2.31,95%CI[-3.12,-1.49],P<0.000 01;MD_(4 week)=-2.04,95%CI[-2.41,-1.68],P<0.000 01). GRADE system showed that the evidence level of the above outcome indicators was low and extremely low. In terms of adverse reactions, two of the included studies reported mild adverse reactions, and the rest of studies were not mentioned, so this study was not able to make a positive evaluation of the safety of Naoxueshu Oral Liquid. This study showed that compared with conventional Western medicine, combined Naoxueshu Oral Liquid may be better for hypertensive intracerebral hemorrhage. However, due to the high bias risk in the included studies, more large-sample and high-quality RCTs are still needed in the future.

Characteristics, management and outcomes of patients with severe traumatic brain injury in Victoria, Australia compared to United Kingdom and Europe: A comparison between two harmonised prospective cohort studies

ObjectiveThe aim of this manuscript is to compare characteristics, management, and outcomes of patients with severe Traumatic Brain Injury (TBI) between Australia, the United Kingdom (UK) and Europe. MethodsWe enrolled patients with severe TBI in Victoria, Australia (OzENTER-TBI), in the UK and Europe (CENTER-TBI) from 2015 to 2017. Main outcome measures were mortality and unfavourable outcome (Glasgow Outcome Scale Extended <5) 6 months after injury. Expected outcomes were compared according to the IMPACT-CT prognostic model, with observed to expected (O/E) ratios and 95% confidence intervals. ResultsWe included 107 patients from Australia, 171 from UK, and 596 from Europe. Compared to the UK and Europe, patients in Australia were younger (median 32 vs 44 vs 44 years), a larger proportion had secondary brain insults including hypotension (30% vs 17% vs 21%) and a larger proportion received ICP monitoring (75% vs 74% vs 58%). Hospital length of stay was shorter in Australia than in the UK (median: 17 vs 23 vs 16 days), and a higher proportion of patients were discharged to a rehabilitation unit in Australia than in the UK and Europe (64% vs 26% vs 28%). Mortality overall was lower than expected (27% vs 35%, O/E ratio 0.77 [95% CI: 0.64 – 0.87]. O/E ratios were comparable between regions for mortality in Australia 0.86 [95% CI: 0.49–1.23] vs UK 0.82 [0.51–1.15] vs Europe 0.76 [0.60–0.87]). Unfavourable outcome rates overall were in line with historic expectations (O/E ratio 1.32 [0.96-1.68] vs 1.13 [0.84-1.42] vs 0.96 [0.85-1.09]). ConclusionsThere are major differences in case-mix between Australia, UK, and Europe; Australian patients are younger and have a higher rate of secondary brain insults. Despite some differences in management and discharge policies, mortality was less than expected overall, and did not differ between regions. Functional outcomes were similar between regions, but worse than expected, emphasizing the need to improve treatment for patients with severe TBI.

Predictive value of magnetic resonance spectroscopy combined with diffusion weighted imaging in patients with secondary brain insult after spontaneous intra-cerebral hemorrhage

To investigate the correlations between the changes of N-acetylaspartate/creatine (NAA/Cr) detected by magnetic resonance spectroscopy (MRS), and of the relative apparent diffusion coefficient (rADC) detected by diffusion weighted imaging (DWI) and the occurrence and outcome of secondary brain injury (SBI) in patients with spontaneous intra-cerebral hemorrhage (SICH). One hundred and eight SICH patients diagnosed by CT from January 2014 to December 2019 in the First People's Hospital of Huzhou were selected as the research objects. MRS and DWI examinations were performed on day 2 after admission. The body temperature, blood pressure, blood glucose, blood sodium, arterial oxygen partial pressure (PaO2) and other indexes were continuously monitored. The patients were divided into two groups: SBI group (46 cases) and control group (62 cases) according to whether there were secondary brain injury factors (SBIF). The differences in NAA/Cr and rADC of the edema area and Glasgow outcome score (GOS) after 6 months were compared between the two groups; multivariate Logistic regression analysis was used to analyze the risk factors of SBI. The NAA/Cr and rADC of perihematoma edema area and GOS after 6 months in SBI group were significantly lower than those in control group [NAA/Cr: 1.64±0.35 vs. 1.87±0.41, rADC: 2.57±0.39 vs. 2.75±0.45, GOS after 6 months (points): 3.47±0.59 vs. 3.76±0.65], with significant differences (all P < 0.05). Logistic regression analysis showed that NAA/Cr and rADC were the risk factors for the occurrence of SBI [odds ratio (OR) values were 0.172, 0.343, 95% confidence intervals (95%CI) were 0.048-0.609 and 0.118-0.996, respectively, both P < 0.05]. MRS combined with DWI has a certain value in predicting SBI after SICH. SBI can aggravate brain injury and affect the prognosis of patients. SBI should be actively prevented and intervention, carried out.

Association of systemic secondary brain insults and outcome in patients with convulsive status epilepticus: A post hoc study of a randomized controlled trial.

To evaluate the association between systemic factors (mean arterial blood pressure, arterial partial pressures of carbon dioxide and oxygen, body temperature, natremia, and glycemia) on day 1 and neurologic outcomes 90 days after convulsive status epilepticus. This was a post hoc analysis of the Evaluation of Therapeutic Hypothermia in Convulsive Status Epilepticus in Adults in Intensive Care (HYBERNATUS) multicenter open-label controlled trial, which randomized 270 critically ill patients with convulsive status epilepticus requiring mechanical ventilation to therapeutic hypothermia (32°C-34°C for 24 hours) plus standard care or standard care alone between March 2011 and January 2015. The primary endpoint was a Glasgow Outcome Scale score of 5, defining a favorable outcome, 90 days after convulsive status epilepticus. The 172 men and 93 women had a median age of 57 years (45-68 years). Among them, 130 (49%) had a history of epilepsy, and 59 (29%) had a primary brain insult. Convulsive status epilepticus was refractory in 86 (32%) patients, and total seizure duration was 67 minutes (35-120 minutes). The 90-day outcome was unfavorable in 126 (48%) patients. In multivariate analysis, none of the systemic secondary brain insults were associated with outcome; achieving an unfavorable outcome was associated with age >65 years (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.20-3.85; p = 0.01), refractory convulsive status epilepticus (OR 2.00, 95% CI 1.04-3.85; p = 0.04), primary brain insult (OR 2.00, 95% CI 1.02-4.00; p = 0.047), and no bystander-witnessed seizure onset (OR 2.49, 95% CI 1.05-5.59; p = 0.04). In our population, systemic secondary brain insults were not associated with outcome in critically ill patients with convulsive status epilepticus. NCT01359332.

Establishment and validation of a model for brain injury state evaluation and prognosis prediction

PurposeTraumatic brain injury (TBI) is one of the leading causes of disability and death in modern times, whose evaluation and prognosis prediction have been one of the most critical issues in TBI management. However, the existed models for the abovementioned purposes were defective to varying degrees. This study aims to establish an ideal brain injury state clinical prediction model (BISCPM). MethodsThis study was a retrospective design. The six-month outcomes of patients were selected as the end point event. BISCPM was established by using the split-sample technology, and externally validated via different tests of comparison between the observed and predicted six-month mortality in validating group. TBI patients admitted from July 2006 to June 2012 were recruited and randomly divided into establishing model group and validating model group. Twenty-one scoring indicators were included in BISCPM and divided into three parts, A, B, and C. Part A included movement, pupillary reflex and diameter, CT parameters, and secondary brain insult factors, etc. Part B was age and part C was medical history of the patients. The total score of part A, B and C was final score of BISCPM. ResultsAltogether 1156 TBI patients were included with 578 cases in each group. The score of BISCPM from validating group ranged from 2.75 to 31.94, averaging 13.64 ± 5.59. There was not statistical difference between observed and predicted mortality for validating group. The discrimination validation showed that the BISCPM is superior to international mission for prognosis and analysis of clinical trials (IMPACT) lab model. ConclusionBISCPM is an effective model for state evaluation and prognosis prediction of TBI patients. The use of BISCPM could be of great significance for decision-making in management of TBI.

The Role of Secondary Brain Insults in Status Epilepticus: A Systematic Review.

(1) Background: Little is known about the impact of pathophysiological mechanisms that underlie the enhancement of excitotoxicity and the neuronal consequences of status epilepticus (SE), as well as the clinical consequences of secondary brain insults (SBI) in patients with SE on outcome; (2) Methods: Electronic searches were conducted in May 2020 using Medline via PubMed, Embase, and Google Scholar (#CRD42019139092). Experimental studies of animals or randomized, observational, controlled trials of patients with SE in indexed journals were included. There were no language or date restrictions for the published literature included in this review. Information was extracted on study design, sample size, SBI characteristics, and primary and secondary outcomes, including the timing of evaluation; (3) Results: Among the 2209 articles responding to our inclusion criteria, 56 were included in this systematic review. There are numerous experimental data reporting the deleterious effects associated with each of the SBI in animals exposed to SE. In humans, only the effect of target temperature management in hypothermia (32–34 °C) has been explored. (4) Conclusions: There is little experimental evidence that favors the control of secondary brain insult after SE. Further studies are required to assess the neuroprotective interest of secondary brain insult control after SE in humans.

Arterial Oxygenation in Traumatic Brain Injury-Relation to Cerebral Energy Metabolism, Autoregulation, and Clinical Outcome.

Background:Ischemic and hypoxic secondary brain insults are common and detrimental in traumatic brain injury (TBI). Treatment aims to maintain an adequate cerebral blood flow with sufficient arterial oxygen content. It has been suggested that arterial hyperoxia may be beneficial to the injured brain to compensate for cerebral ischemia, overcome diffusion barriers, and improve mitochondrial function. In this study, we investigated the relation between arterial oxygen levels and cerebral energy metabolism, pressure autoregulation, and clinical outcome.Methods:This retrospective study was based on 115 patients with severe TBI treated in the neurointensive care unit, Uppsala university hospital, Sweden, 2008 to 2018. Data from cerebral microdialysis (MD), arterial blood gases, hemodynamics, and intracranial pressure were analyzed the first 10 days post-injury. The first day post-injury was studied in particular.Results:Arterial oxygen levels were higher and with greater variability on the first day post-injury, whereas it was more stable the following 9 days. Normal-to-high mean pO2 was significantly associated with better pressure autoregulation/lower pressure reactivity index (P = .02) and lower cerebral MD-lactate (P = .04) on day 1. Patients with limited cerebral energy metabolic substrate supply (MD-pyruvate below 120 µM) and metabolic disturbances with MD-lactate-/pyruvate ratio (LPR) above 25 had significantly lower arterial oxygen levels than those with limited MD-pyruvate supply and normal MD-LPR (P = .001) this day. Arterial oxygenation was not associated with clinical outcome.Conclusions:Maintaining a pO2 above 12 kPa and higher may improve oxidative cerebral energy metabolism and pressure autoregulation, particularly in cases of limited energy substrate supply in the early phase of TBI. Evaluating the cerebral energy metabolic profile could yield a better patient selection for hyperoxic treatment in future trials.

Cerebral venous thrombosis in traumatic brain injury: a cause of secondary insults and added mortality.

Cerebral venous thrombosis (CVT) is increasingly recognized in traumatic brain injury (TBI), but its complications and effect on outcome remain undetermined. In this study, the authors characterize the complications and outcome effect of CVT in TBI patients. In a retrospective, case-control study of patients included in the Oslo University Hospital trauma registry and radiology registry from 2008 to 2014, the authors identified TBI patients with CVT (cases) and without CVT (controls). The groups were matched regarding Abbreviated Injury Scale 1990, update 1998 (AIS'98) head region severity score 3-6. Cases were identified by AIS'98 or ICD-10 code for CVT and CT or MR venography findings confirmed to be positive for CVT, whereas controls had no AIS'98 or ICD-10 code for CVT and CT venography or MR venography findings confirmed to be negative for CVT. All images were reviewed by a neuroradiologist. Rates of complications due to CVT were recorded, and mortality was assessed both unadjusted and in a multivariable logistic regression analysis adjusting for initial Glasgow Coma Scale score, Rotterdam CT score, and Injury Severity Score. Complications and mortality were also assessed in prespecified subgroup analysis according to CVT location and degree of occlusion from CVT. Lastly, mortality was assessed in an exploratory subgroup analysis according to the presence of complications from CVT. The CVT group (73 patients) and control group (120 patients) were well matched regarding baseline characteristics. In the CVT group, 18% developed venous infarction, 11% developed intracerebral hemorrhage, and 19% developed edema, all representing complications secondary to CVT. Unadjusted 30-day mortality was 16% in the CVT group and 4% in the no-CVT group (p = 0.004); however, the difference was no longer significant in the adjusted analysis (OR 2.24, 95% CI 0.63-8.03; p = 0.215). Subgroup analysis by CVT location showed an association between CVT location and rate of complications and an unadjusted 30-day mortality of 50% for midline or bilateral CVT and 8% for unilateral CVT compared with 4% for no CVT (p < 0.001). The adjusted analysis showed a significantly higher mortality in the midline/bilateral CVT group than in the no-CVT group (OR 8.41, 95% CI 1.56-45.25; p = 0.032). There is a significant rate of complications from CVT in TBI patients, leading to secondary brain insults. The rate of complications is dependent on the anatomical location of the CVT, and midline and bilateral CVT is associated with an increased 30-day mortality in TBI patients.

Hubungan Kadar Natrium Serum dengan Outcome Klinis pada Pasien Cedera Kepala Berat di RSUD Abdul Wahab Sjahranie Samarinda

Recently, Traumatic Brain Injury (TBI) has high mortality in the world. In severe TBI, secondary brain injury can occur. ElectrSolyte disorders are the most common in secondary brain insult especially sodium disorders. It remains unclear whether hyponatremia or hypernatremia can cause worse clinical outcome in TBI patients. This study aimed to determine association between serum sodium level with clinical outcome in severe TBI patients at RSUD Abdul Wahab Sjahranie Samarinda. A cross sectional analytical study by taking samples to the patients with diagnosed severe TBI (GCS ≤ 8) which were hospitalized at RSUD Abdul Wahab Sjahranie Samarinda in the period of January-December 2018 that complied inclusion and exclusion criteria. Research variables are sodium serum level and clinical outcome that was assessed by structured interviews for Glasgow Outcome Scale (GOS). The relationship between variables was done using the Fisher's Exact test. A total of 41 severe TBI patients were administered. The characteristics of the sample were the most patients in 20s-40s (46.3%), patients were dominated by male (82.9%) and the most common CT scan characteristic were epidural hematoma (29.3%). The most of patients showed normonatremia in 25 patients (61%), 9 patients (22%) had hypernatremia and 7 patients (17.1%) had hyponatremia. The most clinical outcome on severe TBI patients were worse outcome with 70.7% while good outcome with 29.3%. Statistical result showed there’s no association between serum sodium level (hyponatremia and hypernatremia) with clinical outcome in severe TBI patients with p values, 1.000 and 0.225, respectively. There’s no association between serum sodium level with clinical outcome in severe TBI patients.

Optic Nerve Sheath Diameter is not Related to Intracranial Pressure in Subarachnoid Hemorrhage Patients.

Intracranial pressure (ICP) monitoring is essential after subarachnoid hemorrhage (SAH) to prevent secondary brain insults and to tailor individualized treatments. Optic nerve sheath diameter (ONSD), measured using ultrasound (US), could serve as a noninvasive bedside tool to estimate ICP, avoiding the risks of hemorrhage or infection related to intracranial catheters. The aims of this study were twofold: first, to explore the reliability of US for measuring ONSD; second, to establish whether the US-ONSD can be considered a proxy for ICP in SAH patients early after bleeding. For the first aim, we compared the ONSD measurements given by magnetic resonance imaging (MRI-ONSD) with the US-ONSD findings. For the second aim, we analyzed the relationship between US-ONSD measurements and ICP values. Adult patients with diagnosis of aneurysmal SAH and external ventricular drainage system (EVD) were included. Ten patients were examined by MRI to assess ONSD, and the results were compared to the diameter given by US. In 20 patients, the US-ONSD values were related to ICP measured simultaneously through EVD. In ten of these patients, we explored the changes in the US-ONSD at the time of controlled and fairly rapid changes in ICP after cerebrospinal fluid (CSF) drainage. US-ONSD measurements at the bedside were accurate, very similar to the diameters measured by MRI (the mean difference in the Bland-Altman plot was 0.08mm, 95% limits of agreement: - 1.13; + 1.23mm). No clear relationship was detectable between the ICP and US-ONSD, and a linear regression model showed an angular coefficient very close to 0 (p > 0.05). US-ONSD and ICP values were in agreement after CSF drainage and shifts in ICP in a limited number of patients. US-ONSD measurement does not accurately estimate ICP in SAH patients in the intensive care unit.