Traumatic Brain Injured Patients Research Articles

Quantitative analysis of similarity between cerebral arterial blood volume and intracranial pressure pulse waveforms during intracranial pressure plateau waves

IntroductionBoth intracranial pressure (ICP) and cerebral arterial blood volume (CaBV) have a pulsatile character related to the cardiac cycle. The evolution of the shape of ICP pulses under increasing ICP or decreasing intracranial compliance is well documented. Nevertheless, the exact origin of the alterations in the ICP morphology remains unclear. Research questionDoes ICP pulse waveform become similar to non-invasively estimated CaBV pulse during ICP plateau waves. Material and methodsA total of 15 plateau waves recorded in 15 traumatic brain injured patients were analyzed. CaBV pulse waveforms were calculated using global cerebral blood flow model from transcranial Doppler cerebral blood flow velocity (CBFV) signals. The difference index (DI) was used to quantify the similarity between ICP and CaBV waveforms. DI was calculated as the sum of absolute sample-by-sample differences between ICP and CaBV waveforms, representing the area between the pulses. ResultsICP increased (19.4 mm Hg [Q1–Q3: 18.2–23.4 mm Hg] vs. 42.7 mm Hg [Q1–Q3: 36.5–45.1 mm Hg], p < 0.001) while CBFV decreased (44.2 cm/s [Q1–Q3: 34.8–69.5 cm/s] vs. 32.9 cm/s [Q1–Q3: 24.7–68.2 cm/s], p = 0.002) during plateau waves. DI was smaller during the plateau waves (20.4 [Q1–Q3: 15.74–23.0]) compared to the baselines (26.3 [Q1–Q3: 24.2–34.7], p < 0.001). Discussion and conclusionThe area between corresponding ICP and CaBV pulse waveforms decreased during the plateau waves which suggests they became similar in shape. CaBV may play a significant role in determining the shape of ICP pulses during the plateau waves and might be a driving force in formulating ICP elevation.

Functional hub disruption emphasizes consciousness recovery in severe traumatic brain injury.

Severe traumatic brain injury can lead to transient or even chronic disorder of consciousness. To increase diagnosis and prognosis accuracy of disorder of consciousness, functional neuroimaging is recommended 1 month post-injury. Here, we investigated brain networks remodelling on longitudinal data between 1 and 3 months post severe traumatic brain injury related to change of consciousness. Thirty-four severe traumatic brain-injured patients were included in a cross-sectional and longitudinal clinical study, and their MRI data were compared to those of 20 healthy subjects. Long duration resting-state functional MRI were acquired in minimally conscious and conscious patients at two time points after their brain injury. The first time corresponds to the exit from intensive care unit and the second one to the discharge from post-intensive care rehabilitation ward. Brain networks data were extracted using graph analysis and metrics at each node quantifying local (clustering) and global (degree) connectivity characteristics. Comparison with brain networks of healthy subjects revealed patterns of hyper- and hypo-connectivity that characterize brain networks reorganization through the hub disruption index, a value quantifying the functional disruption in each individual severe traumatic brain injury graph. At discharge from intensive care unit, 24 patients' graphs (9 minimally conscious and 15 conscious) were fully analysed and demonstrated significant network disruption. Clustering and degree nodal metrics, respectively, related to segregation and integration properties of the network, were relevant to distinguish minimally conscious and conscious groups. At discharge from post-intensive care rehabilitation unit, 15 patients' graphs (2 minimally conscious, 13 conscious) were fully analysed. The conscious group still presented a significant difference with healthy subjects. Using mixed effects models, we showed that consciousness state, rather than time, explained the hub disruption index differences between minimally conscious and conscious groups. While severe traumatic brain-injured patients recovered full consciousness, regional functional connectivity evolved towards a healthy pattern. More specifically, the restoration of a healthy brain functional segregation could be necessary for consciousness recovery after severe traumatic brain injury. For the first time, extracting the hub disruption index directly from each patient's graph, we were able to track the clinical alteration and subsequent recovery of consciousness during the first 3 months following a severe traumatic brain injury.

Levomepromazine and Weaning from Sedation in Traumatic Brain Injured Patients

Background: Sedation is a key for the management of patients with traumatic brain injuries. However, in some of the brain injured patients, weaning from sedation is a real challenge. In this work, we aim to evaluate the use of Levomepromazine as a safe strategy for weaning from sedation in mechanically ventilated brain injured patients. Patients and Method: This is a prospective randomized controlled monocentric study carried out on patients admitted to the surgical ICU of the university hospital Ibn Rochd of Casablanca, between January 2022 and April 2022. The study included all mechanically ventilated patients over 18 years old admitted for traumatic brain injury. The patients were divided in two groups. The primary endpoint assessed was the need to resume sedation. Results: In our study, the average age was 30 years ± 10.9. 97% were men. Resumption of sedation was 73.3% in the control group compared to only 37,5% in the group who took levomepromazine. Agitation was significantly lower in the levomepromazine group 18.7% compared to 73,3% in the control group. The reasons of re-sedation in both groups were accidental extubation due to the agitation of the patient and also patient-ventilator asynchrony. The length of stay was reduced in the control group with 18,4 days versus 28,7 days in the levomepromazine group. Concerning the impact on ICU deaths, there was no significant difference. Conclusion: Levomepromazine has been shown through this work to reduce agitation in traumatic brain injured patients. ICU Death may not be influenced by the use of this molecule but it would reduce the need for prolonged or re-sedation.

Which risk factors significantly influence the outcome of traumatic brain injured patients with alcohol use disorder?

Every year, approximately 10 million people worldwide suffer a traumatic brain injury that leads to hospitalization or mortality. Chronic and acute alcohol intoxication increase the risk of developing traumatic brain injury. Alcohol use disorder (AUD) as a predictor of outcome in neurosurgical patients and the definition of risk factors have been sparsely addressed so far. This study aims to improve the understanding of the effects of alcohol use disorder in the context of neurosurgical therapy. This study included patients admitted to Münster University Hospital with a traumatic brain injury and alcohol use disorder from January 1, 2010, to December 31, 2018. Univariate and multivariate analyses were performed to identify risk factors for a poorer outcome, assessed by the Glasgow Outcome Score. Of the 197 patients included, 156 (79%) were male, and 41 (21%) were female, with a median age of 49 years (IQR 38-58 years). In multivariate analyses, age (p < 0.001), the occurrence of a new neurologic deficit (p < 0.001), the development of hydrocephalus (p = 0.005), and CT-graphic midline shift due to intracerebral hemorrhage (p = 0.008) emerged as significant predictors of a worse outcome (GOS 1-3). In addition, the level of blood alcohol concentration correlated significantly with the occurrence of seizures (p = 0.009). Early identification of risk factors in patients with alcohol use disorder and traumatic brain injury is crucial to improve the outcome. In this regard, the occurrence of hydrocephalus or seizures during the inpatient stay should be considered as cause of neurological deterioration in this patient group.

Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

BackgroundSevere traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care.MethodsA multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted.ResultsA total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided.ConclusionsThis consensus provides practical recommendations to support clinician’s decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

Eight rules for the haemodynamic management of traumatic brain-injured patients

Traumatic brain injury (TBI), a leading cause of death and poor neurological outcomes in trauma patients, is a primary cause of severe disability among survivors and a major public health burden globally. Optimal haemodynamic management is a keystone of care in avoiding secondary brain injury, and contributes to minimising mortality and morbidity. Although some important progress has been achieved, a paucity of high-quality recommendations still exists. The purpose of this article is to review the current knowledge on TBI-associated haemodynamic tenets, in order to summarise the most important aspects of this heterogeneous and complex field.

Effect of continuous infusion of hypertonic saline solution on survival of patients with brain injury: a systematic review and meta-analysis

BackgroundThe objective was to determine the effects of continuous infusion of hypertonic saline solutions on outcomes of patients with brain injury. MethodsPreferred Reported Items for Systemic Reviews and Meta-Analysis guidelines were followed. We searched the MEDLINE and COCHRANE clinical trials register (through December 2021) and reference lists of articles. We included all clinical trials conducted in brain-injured patients hospitalized in intensive care units evaluating continuous infusion of hypertonic saline solution (osmolarity above 308 mOsm/L). Two reviewers extracted data that were checked by two others. The primary outcome was the in-hospital mortality rate. The main secondary outcomes were the rates of intracranial hypertension, an unfavorable neurological outcome at day 90, and adverse events. ResultsWe identified 23 clinical trials reporting the use of continuous infusion of hypertonic saline solution in brain-injured patients. The primary outcome was available in 10 studies (n = 1883 patients). The odds ratio (OR) for in-hospital death with the intervention was 0.68 (95% confidence interval (CI), 0.54−0.85, I2 = 0%). In the subgroup of studies including only traumatic brain-injured patients (7 studies, n = 1521 patients), the OR for the primary outcome was 0.74 (95%CI 0.57−0.95) with the intervention. The OR for intracranial hypertension and unfavorable neurological outcome at day 90 were 0.66 (95%CI 0.49−0.88, I2 = 42%, n = 787 patients) and 0.61 (95%CI 0.46−0.81, I2 = 15%, n = 956 patients), respectively. Regarding safety, the OR of acute kidney injury and severe hypernatremia were 0.82 (95%CI 0.47–1.44, I2 = 0%) and 3.38 (95%CI 2.16–5.27, I2 = 24%). ConclusionsContinuous hypertonic saline solution infusion reduced in-hospital mortality without increasing the risk of unfavorable neurological outcome at day 90 in brain-injured patients hospitalized in intensive care units. Given the inclusion of observational and heterogeneous studies, further randomized studies are needed before developing recommendations for implementation at the bedside. Systematic review registrationPROSPERO CRD42021221367. Registered 13 May 2021.

Outcomes of family-centred auditory and tactile stimulation implementation on traumatic brain injured patients.

To determine the outcomes of Family-centred Auditory and Tactile Stimulation Implementation on Traumatic Brain Injured Patients in Egypt. Family engagement in the care of their relatives in the Intensive care units is limited due to patients' life-threatening conditions, in addition to the use of high technology in these settings. Auditory and tactile sensory stimulations are among the diverse sensory stimulations that have received more attention in brain injured patients than other senses as being considered safe, and effective measures. A Quasi-experimental design was used to test the hypotheses of this study. A convenience sample of 60 adult patients suffering from Traumatic Brain Injury and admitted to the intensive care units of two University Hospitals in Egypt was included in the study. Patients were assigned into two equal groups: control and study groups (30 patients each). The auditory and tactile stimulations were provided by trained family members, once daily for 2 weeks for the study group. Whereas routine communication was provided by the family of traumatic brain injured patients in the ICU for the control group. Two tools were used for data collection; tool one, the "Glasgow Coma Scale" to assess patient's level of consciousness, and tool two the "Physiological Adverse Events Assessment" to monitor patients for the occurrence of physiological adverse events. January to October 2019. The implementation of an organized auditory and tactile stimulation by trained family members is associated with highly statistically significant positive effects . Patients in the study group showed a higher mean of consciousness, lower incidence rate of physiological adverse events, and a lower mean duration of ICU stay. Implementation of an organized auditory and tactile stimulation by trained family members enhanced the consciousness level of comatose Traumatic Brain Injured patients, decreased the occurrence of physiological adverse events, and ICU length of stay. Thus, it is recommended for use in the daily routine nursing care of comatose Traumatic Brain Injured patients. This study gives a deeper understanding of how family engagement in the care of their critically ill relative enhances their recovery and improve their level of consciousness.

Application of a Near-infrared Spectroscope by an Extreme Forward Medical Team for the Triage of Casualties With Traumatic Brain Injury.

During deployment of military medical teams similarly to prehospital practice, without immediate computed tomography scan access, identifying patients requiring neuro-specific care to manage pragmatic triage proves crucial. We assessed the contribution of this portable near-infrared spectroscope (NIRS) handheld device, Infrascanner Model 2000 (InfraScan Inc.; Philadelphia, PA), to screen patients suspected to require specific neurosurgical care. This single-center retrospective analysis was based on the data from the medical records of the traumatic brain injured patients. We analyzed all the patients strictly over 18 years old presenting a clinical history of traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) < 15. Thirty-seven medical records of patients admitted for TBI met the inclusion criteria for our analysis. The median GCS was 9 [3-14]. Eight patients (21.6%) underwent neurosurgery and 25 (67.6%) required intensive care unit (ICU) admission, after initial assessment and resuscitation. The NIRS was the most sensible to detect intracranial hematoma (n = 21), intracranial hematoma leading to surgery (n = 8), and intracranial hematoma leading to admission in ICU (n = 25). Its negative predictive value was 100% regarding hematomas leading to surgery. False-positive results were encountered in 10 cases (27.0%). Excluding cases harboring confounding extracranial hematomas, parietal area was still the most represented (n = 3). The NIRS was relevant to detect hematoma leading to prompt surgery in our study. The lack of specificity in a nonselected cohort of patients underlines the need to associate simple clinical feature such as neurological deficit and NIRS results to perform rational triage.

Validity of Glasgow Coma Scale - Pupil Age Charts in Predicting The Outcome for Patients with Traumatic Brain Injury

Context: Glasgow Coma Scale (GCS) is considered a cornerstone of neurological assessment to distinguish the prognosis of traumatic brain injury patients.&#x0D; Aim: This study aimed to examine the validity of the Glasgow coma scale - Pupil Age charts in predicting outcomes for patients with traumatic brain injury.&#x0D; Methods: Descriptive exploratory research design was utilized to conduct this study at El-Fayoum University Hospitals and EL-Nabawi Mohandas General hospital in the Neurosurgical intensive care unit and neurosurgical inpatients ward. This research included a purposive sample of 100 adult patients with Traumatic Brain Injury using three tools for assessment. They were the patient's profile data form, the Glasgow Coma Scale - Pupil Age Charts, and the Glasgow outcome scale. Criterion validity with its two types of predictive validity and concurrent validity was used to validate GCS-Pupil Age charts.&#x0D; Results: The study shows that the Glasgow Coma Scale-Pupil Age Chart is valid in predicting outcomes in patients with traumatic brain injury patient with the best cut-off value of &lt;10.50, a sensitivity of 91.5%, and a specificity of 98.1%, while the Glasgow Coma Scale with the best cut off value &lt;9.50, sensitivity 87.2%, and specificity of 94.3%. Glasgow Coma Scale-Pupil Age Charts and Computed tomography findings are valid in predicting outcomes following traumatic brain injury.&#x0D; Conclusion: Glasgow Coma Scale-Pupil Age Charts and computed tomography finding chart are valid in predicting outcomes following traumatic brain injury. The current study recommended developing an educational program for nurses working in intensive care units about GCS and GCS- PA charts to assess traumatic brain injured patients. Besides, encouraging the use of GCS- PA charts in the emergency unit and neurosurgical intensive care unit to predict patient outcomes and plan the care for traumatic brain injury patients. Designing the clinical pathway for traumatic brain-injured patients from admission until discharge considering age, pupil reactivity response, and CT findings.

Head Injury and Pregnancy—Does the Outcome Differ? A Descriptive Analysis of 15 Years from a Single Tertiary Care Center

There are conflicting data about the outcome of head injury in pregnant patients. Since they comprise a small proportion of the traumatic brain-injured (TBI) patients, the literature is sparse on true evidence on this issue. A 15-year observational study to analyze the outcome of TBI in pregnant women admitted to a level 1 trauma center from 2005-2020 was carried out with the approval of institutional review board. Female patients aged 18-50 years admitted with TBI were included. Patients with polytrauma or dead-on arrival to the emergency department were excluded from the study. The vital parameters, Glasgow Coma Scale (GCS) score at admission, Rotterdam computed tomography (CT) scan, severity score, and Glasgow Outcome Score (GOS) at 3 months were collected from the trauma database, discharge summaries, and patient records. During the study period, 5071 patients with head injury were admitted. Among the 228 patients who met inclusion criteria, 31 (13.6%) were pregnant with a mean age of 24.2 ± 3.8 years. The Rotterdam CT severity score, which moderately correlated with outcome in the control group, was found to be a poor predictor in the pregnant group. The outcome measures were compared using GCS score at discharge for immediate and GOS at 3 months for long-term periods. A better functional outcome was observed at 3 months among pregnant patients (P= 0.02). Pregnant TBI patients have better long-term outcomes than their similar-aged counterparts. However, radiologic severity of injury does not seem to predict outcome in this cohort.

A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation.

The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries. We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation. Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6months. The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.

Development and validation of a prediction nomogram for a 6-month unfavorable prognosis in traumatic brain-injured patients undergoing primary decompressive craniectomy: An observational study.

ObjectiveThis study was designed to develop and validate a risk-prediction nomogram to predict a 6-month unfavorable prognosis in patients with traumatic brain-injured (TBI) undergoing primary decompressive craniectomy (DC).MethodsThe clinical data of 391 TBI patients with primary DC who were admitted from 2012 to 2020 were reviewed, from which 274 patients were enrolled in the training group, while 117 were enrolled in the internal validation group, randomly. The external data sets containing 80 patients were obtained from another hospital. Independent predictors of the 6-month unfavorable prognosis were analyzed using multivariate logistic regression. Furthermore, a nomogram prediction model was constructed using R software. After evaluation of the model, internal and external validations were performed to verify the efficiency of the model using the area under the receiver operating characteristic curves and the calibration plots.ResultsIn multivariate analysis, age(p = 0.001), Glasgow Score Scale (GCS) (p < 0.001), operative blood loss of >750 ml (p = 0.045), completely effaced basal cisterns (p < 0.001), intraoperative hypotension(p = 0.001), and activated partial thromboplastin time (APTT) of >36 (p = 0.012) were the early independent predictors for 6-month unfavorable prognosis in patients with TBI after primary DC. The AUC for the training, internal, and external validation cohorts was 0.93 (95%CI, 0.89–0.96, p < 0.0001), 0.89 (95%CI, 0.82–0.94, p < 0.0001), and 0.90 (95%CI, 0.84–0.97, p < 0.0001), respectively, which indicated that the prediction model had an excellent capability of discrimination. Calibration of the model was exhibited by the calibration plots, which showed an optimal concordance between the predicted 6-month unfavorable prognosis probability and actual probability in both training and validation cohorts.ConclusionThis prediction model for a 6-month unfavorable prognosis in patients with TBI undergoing primary DC can evaluate the prognosis accurately and enhance the early identification of high-risk patients.

An Overview of the Quality of Life of Post Severe Brain Injury Patients within 2018-2020 Period of Time in Dr. Soetomo General Academic Hospital based on Short Form-36

Highlight: Until today, Traumatic Brain Injury is still a major cause of death, disability, and a serious health issue Traumatic Brain Injury patients have a good quality of life if they get adequate therapy and on time interventions ABSTRACT Introduction: Approximately 90 million traumatic brain injury (TBI) cases worldwide exist yearly. TBI pathophysiology varies, which may cause diverse complications. These complications may decrease the patients’ quality of life. Objective: Describing the quality of life of traumatic brain-injured patients after being treated at Dr. Soetomo General Academic Hospital Period 2018-2020. Methods: This research is a descriptive cross-sectional study using SF-36 questionnaire data from patients with post-severe brain injury at Dr. Soetomo General Academic Hospital in 2018-2020. Results: The value of the physical component (59.9) and mental component (68.6) in patients with severe brain injury at Dr. Soetomo General Academic Hospital showed a good quality of life, with values ​​in the SF-36 domains, namely physical function (58.2), physical limitations (46.7), body pain (73.6), general health (61.3), vitality (65.3), social functioning (72.5), emotional limitations (60), and mental health (76.5) is above the threshold value (50) except for physical limitations (46.7).Conclusion: Patients with severe brain injury had a good quality of life after receiving treatment in Dr. Soetomo General Academic Hospital.

Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis.

Introduction. Tracheostomy can help weaning in long-term ventilated patients, reducing the duration of mechanical ventilation and intensive care unit length of stay, and decreasing complications from prolonged tracheal intubation. In traumatic brain injury (TBI), ideal timing for tracheostomy is still debated. We performed a systematic review and meta-analysis to evaluate the effects of timing (early vs. late) of tracheostomy on mortality and incidence of VAP in traumatic brain-injured patients. Methods. This study was conducted in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a search in PubMed, using an association between heading terms: early, tracheostomy, TBI, prognosis, recovery, impact, mortality, morbidity, and brain trauma OR brain injury. Two reviewers independently assessed the methodological quality of eligible studies using the Newcastle–Ottawa Scale (NOS). Comparative analyses were made among Early Tracheostomy (ET) and late tracheostomy (LT) groups. Our primary outcome was the odds ratio of mortality and incidence of VAP between the ET and LT groups in acute brain injury patients. Secondary outcomes included the standardized mean difference (MD) of the duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS. Results. We included two randomized controlled trials, three observational trials, one cross-sectional study, and three retrospective cohort studies. The total number of participants in the ET group was 2509, while in the LT group it was 2597. Early tracheostomy reduced risk for incidence of pneumonia, ICU length of stay, hospital length of stay and duration of mechanical ventilation, but not mortality. Conclusions. In TBI patients, early tracheostomy compared with late tracheostomy might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, but increase the risk of mortality.

The Expanding Role of Quantitative Pupillometry in the Evaluation and Management of Traumatic Brain Injury.

Traumatic brain injury is a rapidly increasing source of morbidity and mortality across the world. As such, the evaluation and management of traumatic brain injuries ranging from mild to severe are under active investigation. Over the last two decades, quantitative pupillometry has been increasingly found to be useful in both the immediate evaluation and ongoing management of traumatic brain injured patients. Given these findings and the portability and ease of use of modern pupillometers, further adoption and deployment of quantitative pupillometers into the preclinical and hospital settings of both resource rich and medically austere environments.

Brain Protection after Anoxic Brain Injury: Is Lactate Supplementation Helpful?

While sudden loss of perfusion is responsible for ischemia, failure to supply the required amount of oxygen to the tissues is defined as hypoxia. Among several pathological conditions that can impair brain perfusion and oxygenation, cardiocirculatory arrest is characterized by a complete loss of perfusion to the brain, determining a whole brain ischemic-anoxic injury. Differently from other threatening situations of reduced cerebral perfusion, i.e., caused by increased intracranial pressure or circulatory shock, resuscitated patients after a cardiac arrest experience a sudden restoration of cerebral blood flow and are exposed to a massive reperfusion injury, which could significantly alter cellular metabolism. Current evidence suggests that cell populations in the central nervous system might use alternative metabolic pathways to glucose and that neurons may rely on a lactate-centered metabolism. Indeed, lactate does not require adenosine triphosphate (ATP) to be oxidated and it could therefore serve as an alternative substrate in condition of depleted energy reserves, i.e., reperfusion injury, even in presence of adequate tissue oxygen delivery. Lactate enriched solutions were studied in recent years in healthy subjects, acute heart failure, and severe traumatic brain injured patients, showing possible benefits that extend beyond the role as alternative energetic substrates. In this manuscript, we addressed some key aspects of the cellular metabolic derangements occurring after cerebral ischemia-reperfusion injury and examined the possible rationale for the administration of lactate enriched solutions in resuscitated patients after cardiac arrest.

Outcomes of Traumatic Brain-Injured Patients With Glasgow Coma Scale < 5 and Bilateral Dilated Pupils Undergoing Decompressive Craniectomy.

Objective: Decompressive craniectomy (DC) plays an important role in the treatment of patients with severe traumatic brain injury (sTBI) with mass lesions and intractably elevated intracranial hypertension (ICP). However, whether DC should be performed in patients with bilateral dilated pupils and a low Glasgow Coma Scale (GCS) score is still controversial. This retrospective study explored the clinical outcomes and risk factors for an unfavorable prognosis in sTBI patients undergoing emergency DC with bilateral dilated pupils and a GCS score <5.Methods: The authors reviewed the data from patients who underwent emergency DC from January 2012 to March 2019 in a medical center in China. All data, such as patient demographics, radiological findings, clinical parameters, and preoperative laboratory variables, were extracted. Multivariate logistic regression analysis was performed to determine the factors associated with 30-day mortality and 6-month negative neurological outcome {defined as death or vegetative state [Glasgow Outcome Scale (GOS) score 1–2]}.Results: A total of 94 sTBI patients with bilateral dilated pupils and a GCS score lower than five who underwent emergency DC were enrolled. In total, 74 patients (78.7%) died within 30 days, and 84 (89.4%) had a poor 6-month outcome (GOS 1–2). In multivariate analysis, advanced age (OR: 7.741, CI: 2.288–26.189), prolonged preoperative activated partial thromboplastin time (aPTT) (OR: 7.263, CI: 1.323–39.890), and low GCS (OR: 6.162, CI: 1.478–25.684) were associated with a higher risk of 30-day mortality, while advanced age (OR: 8.812, CI: 1.817–42.729) was the only independent predictor of a poor 6-month prognosis in patients undergoing DC with preoperative bilateral dilated pupils and a GCS score <5.Conclusions: The mortality and disability rates are extremely high in severe TBI patients undergoing emergency DC with bilateral fixed pupils and a GCS score <5. DC is more valuable for younger patients.

Effects on traumatic brain injured patients of COVID pandemia: which responses from neurosurgical departments?

Effects on traumatic brain injured patients of COVID pandemia: which responses from neurosurgical departments?

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.