Traumatic Brain-injured Patient Research Articles

Ageing is associated with maladaptive immune response and worse outcome after traumatic brain injury.

Traumatic brain injury is increasingly common in older individuals. Older age is one of the strongest predictors for poor prognosis after brain trauma, a phenomenon driven by the presence of extra-cranial comorbidities as well as pre-existent pathologies associated with cognitive impairment and brain volume loss (such as cerebrovascular disease or age-related neurodegeneration). Furthermore, ageing is associated with a dysregulated immune response, which includes attenuated responses to infection and vaccination, and a failure to resolve inflammation leading to chronic inflammatory states. In traumatic brain injury, where the immune response is imperative for the clearance of cellular debris and survey of the injured milieu, an appropriate self-limiting response is vital to promote recovery. Currently, our understanding of age-related factors that contribute to the outcome is limited; but a more complete understanding is essential for the development of tailored therapeutic strategies to mitigate the consequences of traumatic brain injury. Here we show greater functional deficits, white matter abnormalities and worse long-term outcomes in aged compared with young C57BL/6J mice after either moderate or severe traumatic brain injury. These effects are associated with altered systemic, meningeal and brain tissue immune response. Importantly, the impaired acute systemic immune response in the mice was similar to the findings observed in our clinical cohort. Traumatic brain-injured patient cohort over 70 years of age showed lower monocyte and lymphocyte counts compared with those under 45 years. In mice, traumatic brain injury was associated with alterations in peripheral immune subsets, which differed in aged compared with adult mice. There was a significant increase in transcription of immune and inflammatory genes in the meninges post-traumatic brain injury, including monocyte/leucocyte-recruiting chemokines. Immune cells were recruited to the region of the dural injury, with a significantly higher number of CD11b+ myeloid cells in aged compared with the adult mice. In brain tissue, when compared with the young adult mice, we observed a more pronounced and widespread reactive astrogliosis 1 month after trauma in aged mice, sustained by an early and persistent induction of proinflammatory astrocytic state. These findings provide important insights regarding age-related exacerbation of neurological damage after brain trauma.

Mourning, Bereavement and the Grief-Work of Traumatic Brain Injured Patients: Theory and Practice

Background: Grief, as a universal human experience, follows certain stages as described in different (at times overlapping) models, by various researchers. However, the completion of certain emotional tasks and processes is required for grief to be resolved, allowing us to return to full living. The dynamics and expression of grief and mourning in the traumatic brain-injured patient present specific challenges for therapeutic intervention since the mourner may be impaired both cognitively and emotionally by the sequelae of their injury and is often unable to work-through their grief in a coherent and continuous process. In these cases, the therapist should take a very active role in the process, eliciting memories and emotions, and then integrating them together with the patient’s associations and post-injury experiences, and grief reactions to the current loss. Moreover, when the loss occurs during, or after a rehabilitation program, the therapist’s memories of anecdotes previously recounted by the patient may be elicited and offered by the therapist, and incorporated into the present treatment. Procedure: A case will be presented illustrating the complexity of the mourning process in a traumatic brain injured patient. Conclusion: While keeping in mind the general reccomendations for the grief-work with traumatic brain injured persons, there is a clear need to “tailor” an individual approache for each and every single patient.

Epidemiology and Challenges of Neurotraumas Care in the Emergency Department of a Semi-Urban Hospital in Guinea, West Africa

Trauma is one of the most common surgical emergencies admitted in the acute care departments of hospitals in Guinea, West Africa. We carried a study to assess the epidemiological pattern and clinical care of neurotrauma in the emergency department of the Kindia regional hospital, a rural secondary hospital catering to the needs of western Guinea and nearby districts. Data were prospectively collected from December 2019 to March 2020 after receiving the required hospital authorization and informed consent from the patients or relatives. We recorded two hundred cases of neurotraumas (64.5% of traumatic brain injury cases and 14.5% of spinal cord injury). Neurotraumas represented 17.7% of all admitted patients in the department in the study period. The mean age was 25.34 ± 16.73, and the age range 16 to 30 was the most affected. The predominance was male, with a sex ratio of 3.43. Motor Vehicle Accident was the leading cause 68.5%, and 73.2% of them involved a motorcycle. Motorcycle-to-motorcycle collision was responsible for more than a third of neurotraumas. We classified the majority of the cases as mild and low risk neurotrauma representing 62.08%. All patients benefited from medical treatment, and 30.7% of patients received surgical treatment for associated abdominal, orthopedic, and minor procedures for scalp dilacerations. No patient was referred to a Neurosurgery department, and all living patients were discharged home during the study period with minimal disability. The mortality was 16.3%. Our results could be biased by the lack of interhospital networking and the fact that severe traumatic brain-injured patient dies before seeking medical attention.

Treatments and outcome, the point in head trauma

When a severe traumatic brain-injured patient arrives to hospital, fear of failure and definite opinions about the outcome modify early care and provoke self-fulfilling prophecies. It is obvious that working on prognosis is not only useful to inform relatives but also permits to maintain a high level of care, key for a better outcome. Mortality is high (40–50%) if deaths in the first days are not excluded. Following guidelines in all cases will permit to decrease the number of preventable death and a decrease in morbidity. Well-defined networks of care leading to specialized centres with multimodal monitoring give best results. However, only 20% of living patients return to their previous life with mild handicap. These unsatisfactory results require intensifying research, notably in early rehabilitation in intensive care unit. Ethic issues should be discussed after few days of care and dialogue with relatives in a defined “window of opportunity”. Ideally, we need to find strong and early indicators of outcome to limit fears on presumed handicap. A magnetic resonance imaging (MRI) sequence called diffusion tensor imaging (TDI) permits to visualise traumatic axonal injury. Studies with complex statistical methodology give a good estimated probability of bad outcome but must be confirmed by more validation studies. Progress will come from a better understanding of physiopathology. Focuses on processing chain, rapid multi-monitoring, biomarkers, and investigations in MRI and TDI will help to establish opportunities for treatments and to determine limits.

Traumatic brain injuries: Continuing dilemmas in the pre-hospital care arena

This article examines the clinical assessment, diagnosis and management of an agitated traumatic brain-injured patient in the pre-hospital setting by a UK Helicopter Emergency Medical (HEMS) Team. Using a case study from clinical practice, the signs and symptoms, aetiology and clinical management options are discussed and compared against current best evidence, with the specific aims of improving mortality and morbity in critically-ill traumatic brain-injured patients.

Lipid Mediators in Cerebral Spinal Fluid of Traumatic Brain Injured Patients

Enzymatic and nonenzymatic oxidation of polyunsaturated fatty acids leads to the formation of biologically active products known as lipid mediators. In the brain, lipid mediators play an important role in supporting homeostasis and normal function. Thus, levels of these metabolites in normal and pathologic conditions in the brain are particularly relevant in understanding the transition to disease. In this study, liquid chromatography tandem mass spectrometry was used to analyze lipid mediators in cerebrospinal fluid (CSF) of controls and traumatic brain injured (TBI) patients. Our results showed that the levels of arachidonic acid (AA), docosahexaenoic acid (DHA), 5- and 12- eicosatetraenoic acid (HETE) were significantly increased in the CSF of TBI patients. The magnitude of increase was 10-fold for AA, DHA, and 5-HETE and 17-fold for 12-HETE. Prostaglandins and leukotrienes were not detected in CSF of either control or brain injured patients. Furthermore, this study found that isoprostanes and thromboxanes are present in CSF of brain injured patients. This study clearly shows that certain lipid mediators accumulate in the CSF of TBI patient. This study also suggests the potential use of DHA, AA, 5- and 12-HETE as biochemical markers of brain injury and to monitor the impact of interventions.

Advances in brain tissue oxygen monitoring: Using the Licox system in neurointensive care

The care and management of a traumatic brain-injured patient continues to present many challenges to the bedside practitioner. As technology is integrated into intensive care management it has become clear that maintaining conventional intracranial pressure and cerebral perfusion pressure levels will not always prevent cerebral ischaemia. The Licox Brain Tissue Oxygen Monitoring System offers a direct, accurate, real-time, regional partial pressure measurement of oxygen levels in brain tissue. The information gained from this monitoring system will provide an early warning of oxygenation problems that can contribute to secondary injury. When Licox is used in combination with other neurointensive care monitoring parameters it can help inform the bedside practitioner in making decisions about the choice of interventions and in assessing their effectiveness.

Poster 9: An Intermittent “Blown Pupil” in a Severe Traumatic Brain-Injured Patient Undergoing Rehabilitation: A Case Report

Setting: Inpatient rehabilitation unit. Patient: A 16-year-old male undergoing rehabilitation after severe traumatic brain injury. Case Description: The patient was transferred to the rehabilitation unit 4 months after a motor vehicle accident in which he sustained a splenic rupture, bilateral femoral, tibial, and multiple cranial fractures with a right cranial nerve VII injury. His previous hospital course was complicated by intracranial and subdural hematoma, multiple infections, bilateral pneumothoraces, hydrocephalus, and several ventriculoperitoneal (VP) shunt revisions and shunt-related complications. On admission to the rehabilitation unit the patient was unable to communicate or follow directions due to the severity of his brain injury. On the third day of rehabilitation the on-call resident was called to investigate the concerns of the nurse and parents about a new right “blown pupil.” Examination confirmed an extremely dilated and unresponsive right pupil. A stat computerized tomography (CT) of the head showed no significant changes when compared with previous CTs. No other mental status or neurologic changes were noted on exam, although he was severely cognitively impaired from his accident. Neurosurgery suggested close monitoring. 6 hours later his pupils were again symmetric. The next morning the rehabilitation residents were called again to the bedside for a right “blown pupil;” it was at this time that the cause of the intermittent mydriasis was identified. Assessment/Results: The patient's intermittent unilateral mydriasis, or “blown pupil,” was induced by the ipratropium contained in his nebulizer administered by a loose-fitting face mask. Due to a right sided seventh cranial nerve injury the patient was unable to blink his right eye (lagophthalmos), which then led to the this unilateral exposure to the nebulized anticholinergic. The nebulizers were discontinued and his pupils remained symmetric during the remainder of his rehabilitation. Conclusions: Once serious complications, such as VP shunt complication, are excluded, it is important to consider medications and other iatrogenic causes of new symptoms. To our knowledge, this is the first reported case of mydriasis from nebulized ipratropium.

Bilateral Sciatic Nerve Entrapment Due to Heterotopic Ossification in a Traumatic Brain-Injured Patient

We report a 22-yr-old man who was admitted to our inpatient rehabilitation center 17 mos after a traumatic brain injury (TBI). He was also diagnosed to have bilateral sciatic nerve entrapment attributable to hip heterotopic ossification (HO). Presenting the first report of a sciatic nerve entrapment secondary to a HO in TBI, we herein discuss the concurrence of a lower-motor nerve problem in a patient with an upper-motor nerve injury.

Évaluation écologique des fonctions exécutives chez un patient traumatisé crânien

Dysexecutive syndrome is one of the most frequent sequel of severe traumatic brain injury. It causes severe disabilities and it is incompletely assessed by the classical “paper and pencil” neuropsychological tests. We developed an ecological assessment conducted in a naturalistic situation, consisting of a cooking task, and we described a classification of errors. This assessment is very sensitive, even to a mild dysexecutive syndrome. Objective To describe the disabilities in activities of daily living of a traumatic brain-injured patient and to demonstrate the sensitivity of an ill-structured ecological assessment. Method We report a single case study illustrating how the ecological assessment by the cooking task helped better understand and characterize the patient's disabilities. Results The patient presented severe disabilities in daily life activities, which were well described by his family. His cognitive disorders were mild in the cognitive tests, even those supposed to be more ecological, such as the Six Elements Task or script generation. He exhibited very severe disorders in the cooking task, with a very high number of errors. Moreover, duration of the cooking task was very long; he did not achieve the goal and exhibited dangerous behaviour. Discussion and conclusion The cooking task involves abilities to deal with multitasking, which particularly involve executive functions. The most severe disorders were observed during the patient's interaction with the environment while conducting a complex goal-directed action plan, indicating control disorders. This type of naturalistic assessment provides very useful information to help patients organise their familial, social or professional reintegration.

Respiratory support of the head-injured child.

Meticulous care of the head-injured child revolves around the prevention of secondary injury. In no arena is this more crucial than in the respiratory support of the pediatric traumatic brain-injured patient. Careful attention to intubation techniques, maintenance of adequate oxygen delivery, avoidance of hypoxia, and judicious use of PEEP and other respiratory therapeutics all can be invaluable in the care of the pediatric traumatic brain-injured patient and may ultimately enhance outcome in this sometimes devastating disease.

Application of technology in the treatment of traumatic brain injury.

The goal of care of the traumatic brain-injured patient is to prevent secondary injury. Technology gives the caregivers information as to the cause and severity of injury and can guide appropriate management of the patient. Use of multimodality monitoring increases the complexity of care but may allow for better targeted therapy. This article will discuss the current state of technology, the physiology and pathophysiology that it assesses, the normal and abnormal values obtained, and how care will be impacted.

Diagnosis and Treatment of Addictions in Traumatic Brain Injury

The prevalence of alcohol and drug disorders is greater than 50% of all patients experiencing traumatic brain injury. The diagnosis of addictive disorders often goes unmade in this patients despite having sustained traumatic brain injury under the influence of alcohol/drugs. The treatment of addictive disorders is not yet integrated in the overall management of the traumatic brain injured patient. Special considerations must be taken in the treatment of addiction in traumatic brain injured patients because of cognitive and emotional problems arising from the brain damage. Integrated programs with special attention to the needs of the addicted brain injured patients can be developed. Various suggestions and directions that can be incorporated in treatment settings for the traumatic brain injured patient are described. Specific recommendations are provided for clinical application and long term recovery for the addicted traumatic brain injured patient.

Use of the levels of cognitive functioning assessment scale (LOCFAS) by acute care nurses

W ITH MORE than 1.5 million traumatic brain-injured (TBI) persons hospitalized annually for extended periods, nurses in acute care settings have the opportunity to make a difference in the rehabilitation of these patients' cognitive functioning (National Institute of Neurological and Communicative Disorder and Stroke, 1989). Although nurses are at the bedsides of patients with brain injuries and have the greatest opportunity for ongoing direct observation, nurses generally do not assess the cognitive level of these patients in the acute care setting. The data routinely collected as the basis for nursing care provide the necessary baseline to make such an assessment, but nurses who are not rehabilitative specialists may not know how to interpret these data to make a cognitive level diagnosis. The assessment of cognitive functioning for rehabilitation programming is more routinely done by neuropsychologists. For this type of evaluation to be administered, the patient must be able to comprehend, cooperate, and participate. Many weeks may elapse after trauma before the patient reaches this level. Because early intervention provides greater success for the patient's achieving maximum potential than later intervention, nurses caring for the TBI patient at an early stage of recovery are in a position to evaluate the patient's level of cognitive functioning and initiate rehabilitative measures before the patient is at the level appropriate for a neuropsychological evaluation (Hagen, 1982; Miller, 1984). The Levels of Cognitive Functioning Assessment Scale (LOCFAS) was developed from the Rancho Los Amigos Levels by author Jeanne Flannery using only Levels I through V of the eight original levels (Malkmus, Booth, & Kodimer, 1980). These selected levels include behaviors more commonly seen in the earliest stages of recovery, when the TBI patient is more likely to be in an inpatient acute care setting. For example, a Level I patient is in the deepest possible stage of coma. Six behaviors are assessed in the LOCFAS for this level and include items such as unresponsive to auditory, tactile, and painful stimuli. In contrast, a Level V patient is no longer comatose but remains disoriented to time and place. The patient can respond to simple commands but is unable to learn new tasks. Ten behaviors are included at this level to assess the TBI patient. For more detailed information or a copy of the instrument, please contact Dr. Jeanne Flannery. On the LOCFAS, a grid beside each behavior allows the nurse simply to make a check to indicate the presence of that behavior. Once completed, a summary grid allows the nurse to designate the cognitive level in which most behaviors were observed. The outcome shows the patient's maximum capacity at the time of each observation. Repeated use of the instrument also provides a common interdisciplinary language to describe a patient's progress in recovery. More important, by identifying the patient's current level of cognitive functioning, the tool can serve as a basis for the development of an appropriate plan of care to facilitate cognitive recovery. Initial psychometric data with the LOCFAS was reported by Flannery (1993). Construct and content validity were established by expert opinion. Three reliability studies were conducted using five written vignettes developed to represent each of the five LOCFAS levels. Interrater reliability, with raters experienced in assessing cognitive functioning for care-planning purposes, was supported with high agreement among cognitive levels (coefficient kappa = 1.00) and individual items (M coefficient kappa = .871). A second interrater re-

Role of ground reaction torque and other dynamic measures in postural stability

To compare the sensitivity of different balance parameters of movement of the center of pressure (COP) and ground reaction torque (GRT) measurements, data from balance tests are presented. To examine dynamic parameters and possible quantitative interpretations, data are presented for an identical test condition (feet tandem, eyes closed) for a traumatic brain-injured patient and a norm. It is shown that the plot of the COP position during a balance test, the stabilogram, was a less sensitive measure of balance than dynamic parameters of radial velocity or GRT.< <ETX xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">&gt;</ETX>

THE USE OF TRANSDERMAL SCOPOLAMINE TO CONTROL DROOLING

Drooling is a serious social handicap experienced by some neurologically impaired patients. No one method has been identified to control drooling for all patients, however, anticholinergic drugs recently have been utilized. In the case study described, transdermal scopolamine patches were found to be effective for controlling drooling in a traumatic brain-injured patient for whom more conservative methods failed. From a baseline saliva flow rate, saliva flow decreased an average of 30% with one-patch and 59% with two-patch dosing. No significant side effects were observed with treatment, and the decrease in drooling was maintained for a 4-month period. Although transdermal scopolamine may represent one acceptable facet of long-term treatment, it must be stressed that efficacy is variable across patient populations and that treatment approaches must be individualized.