Structural Brain Injury Research Articles

Ultrasonographic measurement of the optic nerve sheath diameter to detect intracranial hypertension: an observational study

ObjectivesTo evaluate the ultrasonographic measurement of optic nerve sheath diameter (ONSD) as a predictor of intracranial hypertension as compared to the invasive measurement of intracranial pressure (ICP).DesignCross-sectional observational study.SettingIntensive Care Unit (ICU) of two tertiary university hospitals in Montevideo, Uruguay.PatientsWe included 56 adult patients, over 18 years of age, who required sedation, mechanical ventilation, and invasive ICP monitoring as a result of a severe acute neurologic injury (traumatic or non-traumatic) and had a Glascow Coma Score (GCS) equal to or less than 8 on admission to the ICU.InterventionsUltrasonographic measurement of ONSD to detect intracranial hypertension.Measurements and main resultsIn our study, a logistic regression model was performed in which it was observed that the variable ONSD is statistically significant with a p value of 0.00803 (< 0.05). This model estimates and predicts the probability that a patient will have an ICP greater than 20 mmHg. From the analysis of the cut-off points, it is observed that a value of 5.7 mm of ONSD maximizes the sensitivity (92.9%) of the method (a greater number of individuals with ICP > 20 mmHg are correctly identified).ConclusionsIn sedated neurocritical patients, with structural Acute Brain Injury, the ONSD measurement correlates with the invasive measurement of ICP. It was observed that with ONSD values less than 5.7 mm, the probability of being in the presence of ICP above 20 mmHg is very low, while for ONSD values greater than 5.7 mm, said probability clearly increases.

Sport-related Structural Brain Injury in High School and College American Football Athletes, 2002-2020: Effect of Lystedt Law.

A previous report revealed an average of 7.2 (0.67 per 100,000 participants) sport-related structural brain injuries (SRSBIs) with macroscopic lesions per year in high school (HS) and college football players. The Lystedt law and other rule changes have been implemented with intent to reduce the risk of brain injury in football. To update the profile of SRSBIs in HS and college football players and evaluate the efficacy of legislation intended to reduce brain injuries. Descriptive epidemiology study. Level 4. We retrospectively reviewed 18 academic years (July 2002 through June 2020) of SRSBIs catalogued by the National Registry of Catastrophic Sports Injuries. The incidence of SRSBIs was assessed at the HS level during the pre (July 2002 through June 2009), transitional (July 2009 through June 2014), and post (July 2014 through June 2020) universal adoption time periods of the Lystedt law. In addition, the incidence of SRSBIs during the second half of the study (2011-2012 through 2019-2020) was compared with the first half of the study (2002-2003 through 2010-2011). During the study period, there was a total of 228 SRSBIs (12.7 per year, 1.01 per 100,000 participants): 212 (93%, 11.8 per year, 1.00 per 100,000) in HS athletes and 16 (7%, 0.89 per year, 1.17 per 100,000) in college athletes. There were 52 fatalities (2.9 per year, 0.22 per 100,000 participants) with 46 (2.56 per year, 0.22 per 100,000) in HS athletes and 6 (0.33 per year, 0.43/100,000) in college athletes. There was no significant difference in risk of HS total SRSBIs or fatalities during the 3 Lystedt periods. The risk of combined SRSBI cases [relative risk (RR) = 1.22, P = 0.13] and fatalities (RR = 1.20, P = 0.52) was similar in the second half of the study compared with the first half of the study. Despite implementation of rule changes intended to reduce head injury, in particular the Lystedt law, the incidence of SRSBIs has remained unchanged. Further research is necessary to develop effective prevention programs for SRSBIs. SRSBIs remain a persistent problem in HS and college American football. The recent head injury rule changes have not been effective at reducing SRSBIs.

Protective down-regulated states in the human brain: A possible lesson from COVID-19

The COVID-19 pandemic has created a large population of patients who are slow to recover consciousness following mechanical ventilation and sedation in the intensive care unit. Few clinical scenarios are comparable. Possible exceptions are the rare patients in post-cardiac arrest coma with minimal to no structural brain injuries who recovered cognitive and motor functions after prolonged delays. A common electroencephalogram (EEG) signature seen in these patients is burst suppression [8]. Biophysical modeling has shown that burst suppression is likely a signature of a neurometabolic state that preserves basic cellular function "during states of lowered energy availability." These states likely act as a brain protective mechanism [9]. Similar EEG patterns are observed in the anoxia resistant painted turtle [24]. We present a conceptual analysis to interpret the brain state of COVID-19 patients suffering prolonged recovery of consciousness. We begin with the Ching model and integrate findings from other clinical scenarios and studies of the anoxia-tolerant physiology of the painted turtle. We postulate that prolonged recovery of consciousness in COVID-19 patients could reflect the effects of modest hypoxic injury to neurons and the unmasking of latent neuroprotective mechanisms in the human brain. This putative protective down-regulated state appears similar to that observed in the painted turtle and suggests new approaches to enhancing coma recovery [12].

A-42 Emotional Health and Recovery in Adolescent and Young Adult Athletes Who Experienced a Sports-Related Concussion

Abstract Purpose: This quantitative study explored the relation between mood and recovery time in. athletes with sports-related concussion. Methods: Deidentified data were extracted from an existing database of an outpatient concussion clinic. Subjects (n = 89; 39.3% female; mean age = 15.57) were included if they were ages 13 to 25, sustained concussion while participating in sport, were assessed within 10 days of injury, and had no evidence of structural brain injury. Total scores from the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) were predictor variables. Recovery time was defined as time from injury to return-to-play. Results: Mean recovery time was consistent with prior research (24.41 days, SD = 16.36). Anxiety and depression total scores considered together predicted recovery time (multiple linear regression; F(2,86) = 8.84, p &amp;lt; 0.001). Anxiety did not predict recovery time when controlling for depression. Depression (mean total = 3.78, SD = 3.41) predicted recovery time when controlling for anxiety, (standardized ß = 0.44, t = 3.34, p = 0.001). Conclusions: The GAD-7 and PHQ-9 are easy-to-use mood screening instruments that do not require a considerable amount of time to administer. Higher scores on the PHQ-9 and the combination of both instruments when administered within 10 days of injury were related to longer recovery times in athletes. For every 3.41 points that the total PHQ-9 score increased, recovery time increased by approximately 7 days. This underscores the importance of examining mood state as part of a comprehensive assessment after sport-related concussion.

Functional and Prognostic Assessment in Comatose Patients: A Study Using Somatosensory Evoked Potentials.

AimThe functional prognosis of patients after coma following either cardiac arrest (CA) or acute structural brain injury (ABI) is often uncertain. These patients are associated with high mortality and disability. N20 and N70 somatosensory evoked potentials (SSEP) are used to predict prognosis. We evaluated the utility of SSEP (N20–N70) as an early indicator of long-term prognosis in these patients.MethodsThis was a retrospective cohort study of patients (n = 120) admitted to the intensive care unit (ICU) with a diagnosis of coma after CA (n = 60) or ABI (n = 60). An SSEP study was performed, including N20 and N70 at 24–72 h, after coma onset. Functional recovery was assessed 6–12 months later using the modified Glasgow scale (mGS). The study was approved by our local research ethics committee.ResultsIn the CA and ABI groups, the absence of N20 (36% of CA patients and 41% of ABI patients; specificity = 100%) or N70 (68% of CA patients and 78% of ABI patients) was a strong indicator of poor outcome. Conversely, the presence of N70 was an indicator of a good outcome (AC: specificity = 84.2%, sensitivity = 92.7%; ABI: specificity = 64.2% sensitivity = 91.3%).ConclusionSomatosensory evoked potentials are useful early prognostic markers with high specificity (N20) and sensitivity (N70). Moreover, N70 has additional potential value for improving the prediction of good long-term functional outcomes.Clinical Trial Registration:[https://clinicaltrials.gov/], identifier [2018/01/001].

Prolonged Unconsciousness is Common in COVID-19 and Associated with Hypoxemia.

ObjectiveThe purpose of this study was to estimate the time to recovery of command‐following and associations between hypoxemia with time to recovery of command‐following.MethodsIn this multicenter, retrospective, cohort study during the initial surge of the United Statesʼ pandemic (March–July 2020) we estimate the time from intubation to recovery of command‐following, using Kaplan Meier cumulative‐incidence curves and Cox proportional hazard models. Patients were included if they were admitted to 1 of 3 hospitals because of severe coronavirus disease 2019 (COVID‐19), required endotracheal intubation for at least 7 days, and experienced impairment of consciousness (Glasgow Coma Scale motor score <6).ResultsFive hundred seventy‐one patients of the 795 patients recovered command‐following. The median time to recovery of command‐following was 30 days (95% confidence interval [CI] = 27–32 days). Median time to recovery of command‐following increased by 16 days for patients with at least one episode of an arterial partial pressure of oxygen (PaO2) value ≤55 mmHg (p < 0.001), and 25% recovered ≥10 days after cessation of mechanical ventilation. The time to recovery of command‐following was associated with hypoxemia (PaO2 ≤55 mmHg hazard ratio [HR] = 0.56, 95% CI = 0.46–0.68; PaO2 ≤70 HR = 0.88, 95% CI = 0.85–0.91), and each additional day of hypoxemia decreased the likelihood of recovery, accounting for confounders including sedation. These findings were confirmed among patients without any imagining evidence of structural brain injury (n = 199), and in a non‐overlapping second surge cohort (N = 427, October 2020 to April 2021).InterpretationSurvivors of severe COVID‐19 commonly recover consciousness weeks after cessation of mechanical ventilation. Long recovery periods are associated with more severe hypoxemia. This relationship is not explained by sedation or brain injury identified on clinical imaging and should inform decisions about life‐sustaining therapies. ANN NEUROL 2022;91:740–755

Association of Carotid Intima-Media Thickness with Brain MRI Markers in the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS)

ObjectiveElevated carotid intima-media thickness (cIMT) and carotid plaque are markers of arterial injury and may be linked to structural brain injury. We hypothesized cIMT or presence of carotid plaque at midlife are associated with presence of infarcts and cerebral microbleeds, greater white matter hyperintensity (WMH) volume, and smaller regional brain volumes in late-life. MethodsWe included 1,795 Atherosclerosis Risk in Communities (ARIC) Study participants (aged 57±6 years, 57% female, 23% Black) with carotid ultrasounds in 1990-1992 and brain MRI scans in 2011-2013. Weighted linear regression was used for brain volume outcomes, while logistic regression was used for infarcts and cerebral microbleeds. ResultsAfter multivariable adjustments, the highest cIMT quintile was associated with smaller deep gray matter (β [95% CI]: -0.11 [-0.22, -0.01]) and cortical volume in a temporal-parietal meta region of interest (ROI) (β [95% CI]: -0.10 [-0.20, -0.01]) in late-life. Similarly, those with carotid plaque had smaller regional brain volumes than those without (βs [95% CIs]: -0.05 [-0.12, 0.03] and -0.06 [-0.13, 0.01] for deep gray matter and temporal-parietal meta ROI). No significant relations were observed with WMH volume, infarcts, or cerebral microbleeds. ConclusionOver a median follow-up of 21 years, greater midlife cIMT and presence of carotid plaque were associated with smaller deep gray matter volume and cortical volume in a meta ROI involving temporal and parietal lobe regions typically involved in neurodegeneration, including Alzheimer's disease, in later life. Contrary to our hypothesis, associations between measures of arterial injury and markers of vascular brain injury were null.

Blood Biomarkers and Structural Imaging Correlations Post-Traumatic Brain Injury: A Systematic Review.

Blood biomarkers are of increasing importance in the diagnosis and assessment of traumatic brain injury (TBI). However, the relationship between them and lesions seen on imaging remains unclear. To perform a systematic review of the relationship between blood biomarkers and intracranial lesion types, intracranial lesion injury patterns, volume/number of intracranial lesions, and imaging classification systems. We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, and Cumulative Index to Nursing and Allied Health Literature from inception to May 2021, and the references of included studies were also screened. Heterogeneity in study design, biomarker types, imaging modalities, and analyses inhibited quantitative analysis, with a qualitative synthesis presented. Fifty-nine papers were included assessing one or more biomarker to imaging comparisons per paper: 30 assessed imaging classifications or injury patterns, 28 assessed lesion type, and 11 assessed lesion volume or number. Biomarker concentrations were associated with the burden of brain injury, as assessed by increasing intracranial lesion volume, increasing numbers of traumatic intracranial lesions, and positive correlations with imaging classification scores. There were inconsistent findings associating different biomarkers with specific imaging phenotypes including diffuse axonal injury, cerebral edema, and intracranial hemorrhage. Blood-based biomarker concentrations after TBI are consistently demonstrated to correlate burden of intracranial disease. The relation with specific injury types is unclear suggesting a lack of diagnostic specificity and/or is the result of the complex and heterogeneous nature of TBI.

Commentary: Blood Biomarkers and Structural Imaging Correlations Post-Traumatic Brain Injury: A Systematic Review.

Department of Neurological Surgery, University of California, Irvine, Orange, California, USA Correspondence: Jeferson W. Chen, MD, PhD, Department of Neurological Surgery, University of California, Irvine, 200S. Manchester # 210, Orange, CA92868, USA. Email: [email protected]

Disorders of Consciousness Associated With COVID-19: A Prospective Multimodal Study of Recovery and Brain Connectivity.

Background and ObjectivesIn patients with severe coronavirus disease 2019 (COVID-19), disorders of consciousness (DoC) have emerged as a serious complication. The prognosis and pathophysiology of COVID-DoC remain unclear, complicating decisions about continuing life-sustaining treatment. We describe the natural history of COVID-DoC and investigate its associated brain connectivity profile.MethodsIn a prospective longitudinal study, we screened consecutive patients with COVID-19 at our institution. We enrolled critically ill adult patients with a DoC unexplained by sedation or structural brain injury and who were planned to undergo a brain MRI. We performed resting-state fMRI and diffusion MRI to evaluate functional and structural connectivity compared to healthy controls and patients with DoC resulting from severe traumatic brain injury (TBI). We assessed the recovery of consciousness (command following) and functional outcomes (Glasgow Outcome Scale Extended [GOSE] and the Disability Rating Scale [DRS]) at hospital discharge and 3 and 6 months after discharge. We also explored whether clinical variables were associated with recovery from COVID-DoC.ResultsAfter screening 1,105 patients with COVID-19, we enrolled 12 with COVID-DoC. The median age was 63.5 years (interquartile range 55–76.3 years). After the exclusion of 1 patient who died shortly after enrollment, all of the remaining 11 patients recovered consciousness 0 to 25 days (median 7 [5–14.5] days) after the cessation of continuous IV sedation. At discharge, all surviving patients remained dependent: median GOSE score 3 (1–3) and median DRS score 23 (16–30). Ultimately, however, except for 2 patients with severe polyneuropathy, all returned home with normal cognition and minimal disability: at 3 months, median GOSE score 3 (3–3) and median DRS score 7 (5–13); at 6 months, median GOSE score 4 (4–5), median DRS score 3 (3–5). Ten patients with COVID-DoC underwent advanced neuroimaging; functional and structural brain connectivity in those with COVID-DoC was diminished compared to healthy controls, and structural connectivity was comparable to that in patients with severe TBI.DiscussionPatients who survived invariably recovered consciousness after COVID-DoC. Although disability was common after hospitalization, functional status improved over the ensuing months. While future research is necessary, these prospective findings inform the prognosis and pathophysiology of COVID-DoC.Trial Registration InformationClinicalTrials.gov identifier: NCT04476589.

83. DAMAGING RARE CODING VARIANTS IDENTIFIED BY EXOME SEQUENCING ARE ASSOCIATED WITH REDUCED COGNITIVE FUNCTION IN SCHIZOPHRENIA

Disorders of consciousness (DOC) following severe structural brain injuries globally affect the conscious state and the expression of goal-directed behaviors. In some subjects, neuromodulation with medications or electrical stimulation can markedly improve the impaired conscious state present in DOC. We briefly review recent studies and provide an organizing framework for considering the apparently widely disparate collection of medications and approaches that may modulate the conscious state in subjects with DOC. We focus on neuromodulation of the anterior forebrain mesocircuit in DOC and briefly compare mechanisms supporting recovery from structural brain injuries to those underlying facilitated emergence from unconsciousness produced by anesthesia. We derive some general principles for approaching the problem of restoration of consciousness after severe structural brain injuries, and suggest directions for future research.

Organizing a Rational Approach to Treatments of Disorders of Consciousness Using the Anterior Forebrain Mesocircuit Model.

Organizing a rational treatment strategy for patients with multifocal structural brain injuries and disorders of consciousness (DOC) is an important and challenging clinical goal. Among potential clinical end points, restoring elements of communication to DOC patients can support improved patient care, caregiver satisfaction, and patients' quality of life. Over the past decade, several studies have considered the use of the anterior forebrain mesocircuit model to approach this problem because this model proposes a supervening circuit-level impairment arising across DOC of varying etiologies. We review both the conceptual foundation of the mesocircuit model and studies of mechanisms underlying DOC that test predictions of this model. We consider how this model can guide therapeutic interventions and discuss a proposed treatment algorithm based on these ideas. Although the approach reviewed originates in the evaluation of patients with chronic DOC, we consider some emerging implications for patients in acute and subacute settings.

Do we need neuroimaging in every case of near-hanging?: experience from a level 1 trauma center and analysis of the National Trauma Data Bank.

Our study analyzes imaging results in near-hanging to determine what neuroimaging workup is necessary. We evaluate GCS as a clinical predictor to help guide imaging choice. This is a retrospective study of patients from a level one trauma center and from the National Trauma Data Bank (NTDB). We classified injuries into categories based on the likelihood that CT played an important role in their diagnosis and management. We assessed whether a normal Glasgow Coma Scale (GCS) could exclude clinically important injuries. Chi square was used to test for significance for categorical variables. Multivariate logistic regression was used for multivariate analysis. CT showed structural brain findings in 0% of patients from our facility (local patients) and 11.7% of NTDB patients. Of local patients and NTDB patients, 1.4% and 6.6% had blunt cerebral vascular injury (BCVI) respectively. Of local patients and NTDB patients, 1.4% and 3.3% had a cervical spine fracture or dislocation, respectively. Mortality for patients with GCS 15 versus GCS < 15 was 0 versus 26.9% for local patients (p = 0.004) and 0 versus 43.8% for NTDB (p < 0.001). Structural brain injury for patients with GCS 15 versus GCS < 15 for isolated hanging was 0 versus 14.9% for NTDB (p < 0.001). GCS 15 was an independent predictor of survival and freedom from brain injury (p < 0.001), but not neck injury. GCS 15 is a significant independent predictor of survival and freedom from brain injury in near-hanging. GCS 15 rules out intracranial injury likely to require intervention with negative predictive value of 100%. GCS of 15 does not rule out critical neck injury.

Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight.

Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI. To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions. A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted. Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size>10mm(52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P=.033). RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

Abstract P120: Association Of Carotid Intima-Media Thickness With Brain MRI Markers In The Atherosclerosis Risk In Communities Neurocognitive Study (ARIC-NCS)

Background: Elevated carotid intima-media thickness (cIMT) and presence of carotid plaque are markers of atherosclerosis, which may be linked to structural brain injury. Using data from the ARIC-NCS cohort, we tested the hypotheses that greater cIMT and presence of carotid plaque at late midlife were each associated with presence of infarcts (lacunar and cortical) and cerebral microbleeds (lobar and subcortical), greater white matter hyperintensity (WMH) volume, and smaller regional brain volumes in late life. Methods: We included 1,795 ARIC participants who had carotid ultrasounds in 1990-92 and brain MRI scans in 2011-13. Weighted linear regression was used for continuous (brain volume) outcomes, and weighted logistic regression for dichotomous outcomes (infarcts and cerebral microbleeds). Results: Participants were aged 57±6 years at baseline, 57% were female, and 23% were Black. Mean ± SD follow-up was 21±1 years. After multivariable adjustments, the highest quintile of cIMT in late midlife was associated with smaller deep grey matter volume (β [95% CI]: -0.11 [-0.22, -0.01]) and cortical volume in a temporal-parietal meta region of interest (ROI) (β [95% CI]: -0.10 [-0.20, -0.01]) in late life (Table). At baseline, 473 (26%) participants had carotid plaque present on their carotid ultrasound. Similar to cIMT, those with carotid plaque had smaller regional brain volumes than those without carotid plaque present (βs [95% CIs]: -0.05 [-0.12, 0.03] and -0.06 [-0.13, 0.01] for deep grey matter and temporal-parietal meta ROI volumes, respectively). No significant relations were observed with WMH volume, or the presence of any infarcts or cerebral microbleeds. Conclusion: Greater midlife cIMT and presence of carotid plaque were associated with smaller deep grey matter volume and cortical volume in a temporal-parietal meta ROI in later life. Contrary to our hypothesis, associations between midlife subclinical atherosclerosis and markers of vascular brain injury in later life were null.

Donor Transient Myocardial Dysfunction - Structural versus Hypoxic Brain Injury

<h3>Purpose</h3> We theorized that transient myocardial dysfunction in donors with hypoxic brain injury will have different markers, risk factors and prognosis in comparison to donors with structural brain injury. <h3>Methods</h3> All heart transplant recipients between 2010 - 2017 were categorized according to whether they received an organ from donor with structural (traumatic + stroke) versus hypoxic brain injury. Baseline donor characteristics were evaluated for association with transient myocardial dysfunction and post-transplantation outcomes (PGD, survival, freedom from rejection, and CAV) of grafts recovered from donors with transient dysfunction were compared to those without dysfunction. <h3>Results</h3> Altogether 248 donor hearts were transplanted during a study period (222 heart-alone, 12 re-do, 11 heart-kidney, 2 heart-liver and 1 heart-lung). Pre-donation transient myocardial dysfunction was detected in 14 out of 177 donors with structural brain injury (8%) and 9 out of 71 donors with hypoxic brain injury (13%). Myocardial dysfunction in donors with structural brain injury was associated with low BMI (P = .002) and elevated serum troponin (P = .032). Myocardial dysfunction in donors with hypoxic brain injury was associated with the number of blood products received before donation (P = .032). Post-transplantation outcomes of recipients who received an organ with and without transient pre-recovery dysfunction stratified by the donor cause of death are summarized in Table 1. <h3>Conclusion</h3> Transient myocardial dysfunction in donors with hypoxic brain death is quite common and is associated with different variables than in donors with structural brain death. Pre-donation transient graft dysfunction is not associated with inferior post-transplantation outcome in neither donors after structural nor hypoxic brain injury group. Organs recovered from donors after hypoxic brain death with transient dysfunction showed a trend towards less freedom from graft vasculopathy in comparison to non-dysfunctional organs.

AN OVERVIEW OF THE CAUSATIVE RISK FACTORS OF ATTENTION DEFICIT HYPERACTIVITY DISORDER AMONG CHILDREN

Attention deficit hyperactivity disorder is a complicated disorder that affects childrens cognition and behavior. The exact cause of ADHD is not known however, multiple risk factors may be involved. This study aims to provide an overview of the different risk factors involved in the development of ADHD through reviewing and summarizing all recently published researches in this respect. Multiple factors were evaluated to find out their relation to ADHD. Various genetic loci and mutations were found to be linked to ADHD susceptibility. Environmental factors as prenatal smoking, maternal obesity, vitamin D and minerals deficiencies, birth-related problems, pesticides, and lead exposure, artificial food coloring, and sugar consumption were investigated and proven to increase ADHD. Structural brain abnormalities and traumatic brain injury were also involved as risk factors of ADHD. Although the exact causes of ADHD are not discovered, multiple genetic, environmental and structural brain abnormalities proved to play a role in ADHD development. Mutations in Latrophilin 3 (LPHN3) gene linked with increase ADHD susceptibility. Reduced gray matter volume may contribute to ADHD development. Sugar consumption and artificial food colorings increase hyperactivity in both ADHD and normal children.

Relationship Between Early Functional and Structural Brain Developments and Brain Injury in Preterm Infants

BackgroundRecent studies explored the relationship between early brain function and brain morphology, based on the hypothesis that increased brain activity can positively affect structural brain development and that excitatory neuronal activity stimulates myelination.ObjectiveTo investigate the relationship between maturational features from early and serial aEEGs after premature birth and MRI metrics characterizing structural brain development and injury, measured around 30weeks postmenstrual age (PMA) and at term. Moreover, we aimed to verify whether previously developed maturational EEG features are related with PMA.Design/MethodsOne hundred six extremely preterm infants received bedside aEEGs during the first 72h and weekly until week 5. 3T-MRIs were performed at 30weeks PMA and at term. Specific features were extracted to assess EEG maturation: (1) the spectral content, (2) the continuity [percentage of spontaneous activity transients (SAT%) and the interburst interval (IBI)], and (3) the complexity. Automatic MRI segmentation to assess volumes and MRI score was performed. The relationship between the maturational EEG features and MRI measures was investigated.ResultsBoth SAT% and EEG complexity were correlated with PMA. IBI was inversely associated with PMA. Complexity features had a positive correlation with the cerebellar size at 30weeks, while event-based measures were related to the cerebellar size at term. Cerebellar width, cortical grey matter, and total brain volume at term were inversely correlated with the relative power in the higher frequency bands.ConclusionsThe continuity and complexity of the EEG steadily increase with increasing postnatal age. Increasing complexity and event-based features are associated with cerebellar size, a structure with enormous development during preterm life. Brain activity is important for later structural brain development.

An Observation of Application of Structural Brain Injury Devices for Traumatic Brain Injury Evaluation in Austere Military Prehospital Settings.

Military units lack the ability to quickly, objectively, and accurately assess individuals that have suffered a closed head injury for structural brain injury and functional brain impairments in forward settings, where neurological assessment equipment and expertise may be lacking. With acute traumatic brain injury patients, detached medical providers are often faced with a decision to wait and observe or medically evacuate, both of which have cascading consequences. Structural brain injury assessment devices, when employed in forward environments, have the potential to reduce the risk of undiagnosed and/or mismanaged traumatic brain injuries given their high negative predictive value and suggested increased specificity compared to common subjective clinical decision rules. These handheld devices are portable and have an ease of use, from combat medic to physician, allowing for use in austere environments, safely keeping soldiers with their teams when able and suggesting further evaluation via computed tomography (CT) scan when warranted. Data collected on 13 encounters at 5 locations were retrospectively analyzed using descriptive statistics. A total number of 13 examinations were performed using the BrainScope One device during the 9-month deployment. The Structural Injury Classification was negative for 11 of the patients. Two of the 11 patients underwent head CT scans, which confirmed the absence of intracranial hemorrhage. Of the two positive Structural Injury Classification exams, one was CT negative and no CT was performed for the other based on clinical judgment. The data from this study suggest that structural brain injury devices may provide value by ruling out serious brain injury pathology while limiting excessive medical evacuations from austere settings, where neurological assessment equipment and expertise may be lacking, reducing unnecessary head CT scans.

Glial Fibrillary Acidic Protein (GFAP) and Cleaved Tau Protein (CTP) Biomarkers as a Forensic Tool for Detection and Assessement of Traumatic Brain Injury

Traumatic brain injury (TBI) is defined as a traumatically-induced structural brain injury or physiologicaldisruption of brain function caused by an external force. Traumatic brain injury is a neuropsychiatric disorderthat breaks down the remaining barriers between neurology and psychiatry. Several biomarkers have beendeveloped to directly determine the pathology of the nerve cells in the central nervous system (CNS) whenit is injured. This review recent research on brain injury biomarkers could be used for rapid and accuratediagnostics of TBI in easily accessible fluid.Objectives: The purpose of this study was to assess utility of GFAP-BDP for the diagnosis of intracranialinjury in patients with a positive clinical screen for head injury across the spectrum of TBI typicallypresenting to ED in Kasr- Alainy hospital.Subjects & Methods: This prospective cohort study was based on the data collected from 90 cases presentedto Kasr Al-Aini Hospitals Emergency Department, Cairo University, with history of traumatic brain injurythrough the period from April 2017 to Mars 2019. According to age, they were classified into 3 age groups;age group A (18-35 years), age group B (36-50 years) and age group C (> 50 years). Data were analyzed withrespect to socio-demographic data, type of head injury, clinical presentations, radiological investigation, andmanagement of TBI in relation to serum specific biomarkers level (GFAP, C-tau).Results: The most common age group was age group B (18-35 years) (70%). Males were more commonthan females (71.1% and 28.9% respectively). The most common cause of trauma was fall from height(33.3%). Serum GFAP level and C-tau levels in studied groups show high significant correlation betweenthem (p value <0.001).Conclusion and Recommendations: The combination of the two biomarkers or more may be more usefulthan either biomarker in isolation for predicting intracranial lesions on CT scanning therefor decreasesunwanted CT head scanning and radiological bad effect especially in young ages.