Traumatic Brain Injury Patients Research Articles

Predicting Progression of Intracranial Hemorrhage in the Prehospital TXA for TBI Trial.

Progression of intracranial hemorrhage is a common, potentially devastating complication after moderate/severe traumatic brain injury (TBI). Clinicians have few tools to predict which patients with traumatic intracranial hemorrhage on their initial head computed tomographic scan (hCT) scan will progress. The objective of this investigation was to identify clinical, imaging, and/or protein biomarkers associated with progression of intracranial hemorrhage (PICH) after moderate/severe TBI and to create an accurate predictive model of PICH based on clinical features available at presentation. We analyzed a subset of subjects from the phase II double-blind, multi-center randomized "Prehospital Tranexamic Acid Use for TBI" trial. This subset was limited to the placebo arm of the parent trial with evidence of hemorrhage on the initial head CT and a follow-up CT 6 hours after. PICH was defined as an increase in hemorrhage size by 30% or more, or the development of new hemorrhage in the intra- and extra-axial intracranial vault between the initial and the follow-up head CT. Two independent radiologists evaluated each head CT, and conflicts were adjudicated by a third. Clinical and radiographic characteristics were collected, along with plasma protein biomarkers at admission. Principal component analysis (PCA) was performed, and each principal component (PC) was interrogated for its association with PICH. Finally, expert opinion and recursive feature extraction (RFE) were used to select input features for the construction of several super- vised classification models. Their ability to predict PICH were quantified and compared. In this subset of subjects (n=104), 46% (n=48) demonstrated PICH. Univariate analyses showed no association between PICH and age, sex, admission Glasgow Coma Scale (GCS), GCS motor subscore, presence of midline shift, admission platelet count or admission INR. Radiographic severity scores (Marshall score [P=0.007], Rotterdam score [P=0.004]) and initial hematoma volume [P=0.005] were associated with PICH. Higher levels of admission GFAP (P<0.001) and MAP (P=0.011) were also associated with PICH. Of the PCs, PC1 was significantly associated with PICH (P=0.0125). Using multimodal data input, machine learning classifiers successfully discriminated patients with or without PICH. Models composed of machine selected features performed better than models composed of expert selected variables (reaching an average of 77% accuracy, AUC = 0.78 versus AUC = 0.68 for the expert selected variables). Predictive models utilizing variables measured at admission can accurately predict PICH, confirmed by the 6-hour follow-up head CT. Our best performing models must now be externally validated in a separate cohort of TBI patients with low GCS and initial head CT positive for hemorrhage.

Correlation between early computed tomography findings and neurological outcome in pediatric traumatic brain injury patients.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Head computed tomography (CT) is frequently utilized for evaluating trauma-related characteristics, selecting treatment options, and monitoring complications in the early stages. This study assessed the relationship between cranial CT findings and early and late neurological outcomes in pediatric TBI patients admitted to the pediatric intensive care unit (PICU). The study included children aged 1month to 18years who were admitted to the PICU due to TBI between 2014 and 2020. Sociodemographic data, clinical characteristics, and cranial CT findings were analyzed. Patients were categorized based on their Glasgow Coma Scale (GCS) score. Of the 129 patients, 83 (64%) were male, and 46 (36%) were female, with a mean age of 6.8years. Falls (n = 51, 39.5%) and in-vehicle traffic accidents (n = 35, 27.1%) were the most common trauma types observed. Normal brain imaging findings were found in 62.7% of the patients, while 37.3% exhibited intracranial pathology. Hemorrhage was the most frequent CT finding. Severe TBI (n = 26, p = 0.032) and mortality (n = 9, p = 0.017) were more prevalent in traffic accidents. The overall mortality rate in the study population was 10.1%. In children with TBI, cranial CT imaging serves as an essential initial method for patients with neurological manifestations. Particularly, a GCS score of ≤ 8, multiple hemorrhages, diffuse cerebral edema, and intraventricular bleeding are associated with sequelae and mortality.

The Effect of Probiotics on the Prognostication of the Neutrophil-to-Lymphocyte Ratio in Severe Multi-Trauma Patients

Background: The ratio of neutrophils to lymphocytes [NLR] is one of the most accepted prognostic indices and demonstrates a positive correlation with the severity of a disease. Given that probiotics exerted immunomodulatory properties and thus positively affected lymphocytopenia induction in severely ill patients, we performed a post hoc analysis in the ProVAP protocol to investigate whether probiotics affected the prognostication of NLR in respect to ventilator-associated pneumonia in multi-trauma patients. This cohort mandatorily involved severe traumatic brain injury patients. Methods: The white blood cell data of all patients, after being retrieved for the days 0 and 7, were statistically assessed in respect to neutrophils, lymphocytes and NLR among the 4 sub-groups of the study: placebo/no-VAP, placebo/VAP, probiotics/no-VAP, and probiotics/VAP. Results: Lymphopenia was dominant in placebo sub-groups, while an increased level of lymphocytes was prominent in probiotics sub-groups. This resulted in an increase [p = 0.018] in the NLR value in the probiotics/VAP group in relation to the probiotics/no-VAP cohort; this was an increase of half the value of the placebo/VAP [p &lt; 0.001], while the NLR value in placebo/no-VAP group increased almost four-fold in relation to probiotics/no-VAP [p &lt; 0.001]. Additionally, the ROC curve for probiotic-treated patients revealed a NLR7 cut-off value of 7.20 as a prognostic factor of VAP (AUC: 78.6%, p = 0.015, 95% CI: 62.6–94.5%), having a high specificity of 90.2% and a sensitivity of 42.9%. Conclusions: NLR may considered a credible prognostic biomarker in multi-trauma patients since it can evaluate the immunomodulatory benefits of probiotic treatment. However, the results of the present post hoc analysis should be interpreted meticulously until further evaluation, since they may be basically species- or strain-specific.

Evaluating olfactory function and quality of life in patients with traumatic brain injury.

Patients with traumatic brain injury (TBI) had worse olfactory quality of life (QoL) and Sino-Nasal Outcome Test-22 scores compared to a normal cohort. A worse olfactory QoL correlated with concussion symptom burden. Olfactory dysfunction among TBI patients should be addressed to improve overall outcomes.

An overview of preclinical models of traumatic brain injury (TBI): relevance to pathophysiological mechanisms

BackgroundTraumatic brain injury (TBI) is a major cause of morbidity and mortality, affecting millions annually worldwide. Although the majority of TBI patients return to premorbid baseline, a subset of patient can develop persistent and often debilitating neurocognitive and behavioral changes. The etiology of TBI within the clinical setting is inherently heterogenous, ranging from sport related injuries, fall related injuries and motor vehicle accidents in the civilian setting, to blast injuries in the military setting.ObjectiveAnimal models of TBI, offer the distinct advantage of controlling for injury modality, duration and severity. Furthermore, preclinical models of TBI have provided the necessary temporal opportunity to study the chronic neuropathological sequelae of TBI, including neurodegenerative sequelae such as tauopathy and neuroinflammation within the finite experimental timeline. Despite the high prevalence of TBI, there are currently no disease modifying regimen for TBI, and the current clinical treatments remain largely symptom based. The preclinical models have provided the necessary biological substrate to examine the disease modifying effect of various pharmacological agents and have imperative translational value.MethodsThe current review will include a comprehensive survey of well-established preclinical models, including classic preclinical models including weight drop, blast injury, fluid percussion injury, controlled cortical impact injury, as well as more novel injury models including closed-head impact model of engineered rotational acceleration (CHIMERA) models and closed-head projectile concussive impact model (PCI). In addition to rodent preclinical models, the review will include an overview of other species including large animal models and Drosophila.ResultsThere are major neuropathological perturbations post TBI captured in various preclinical models, which include neuroinflammation, calcium dysregulation, tauopathy, mitochondrial dysfunction and oxidative stress, axonopathy, as well as glymphatic system disruption.ConclusionThe preclinical models of TBI continue to offer valuable translational insight, as well as essential neurobiological basis to examine specific disease modifying therapeutic regimen.

Nghiên cứu đặc điểm lâm sàng, cận lâm sàng và đánh giá kết quả điều trị ở bệnh nhân động kinh sau chấn thương sọ não

Background: Post-traumatic epilepsy (PTE) results in a huge burden and reduces patients' quality of life. Understanding clinical, subclinical characteristics and assessing treatment results helps to improve management strategies for epilepsy after traumatic brain injury (TBI). Objectives: 1. To describe clinical and subclinical characteristics of patients with PTE at Vietnam - Cuba Friendship Dong Hoi Hospital. 2. To evaluate initial results of the treatment of PTE after 3 months. Methods: A cross-sectional descriptive study with follow-up on 58 patients with PTE receiving examination and treatment at Vietnam - Cuba Friendship Dong Hoi Hospital from April 2022 to June 2023. Results: Clinical: Late PTE (occurring &gt; 1 week after TBI) accounted for 69% with 6.9% of first seizures occurred from 1 week - 6 months after TBI while 3.4% happened between 6 months - 1 year. Most seizures lasting less than 5 minutes (86.2%); 37.9% had ³ 1 seizure per month; 32.8% had 1 seizure weekly and daily attacks accounted for 24.1%. Focal seizure registered the majority (89.6%) while generalized seizures accounted for 10.4%; there was a difference in type of seizure between early PTE and late PTE. Subclinical: Abnormal electroencephalogram (EEG) was recorded in 24.1% of cases with following characteristics: diffuse slowing in both hemispheres (6.9%), localized slow waves (17.2%). Lesion location on CT/MRI: temple 53.4% and forehead 46.6%. Treatment results: 87.9% of TBI cases were treated conservatively and 12.1% were treated surgically. Antiepileptic medications: Depakin (62.5%), Tegretol (13.8%), Phenytoin (13.8%), Keppra (8.6%); treatment adherence rate was very high (89.7%). The recurrence rate was 37.9%, this was lower in the group of early PTE compared with late PTE (22.2% versus 45%). During 3 months of treatment, the majority had 1 - 4 seizures (72.2%) and 19.0% needed re-hospitalization. Neurological complications were recorded in 12.1% of cases. Aura happened in 43.1% of cases, more frequently in late PTE when compared with early PTE (50.0% and 27.8%, respectively). Conclusion: Prophylaxis of PTE should be considered in TBI patients having seizures without EEG abnormalities or in elderly patients with temporal and frontal lobe lesions. 

Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review.

Intracranial pressure (ICP) monitoring is necessary for managing patients with traumatic brain injury (TBI). Although gold-standard methods include intraventricular or intraparenchymal transducers, these systems cannot be used in patients with coagulopathies or in those who are at high risk of catheter-related infections, nor can they be used in resource-constrained settings. Therefore, a non-invasive modality that is more widely available, cost effective, and safe would have tremendous impact. Among such non-invasive choices, transcranial Doppler (TCD) provides indirect ICP estimates through waveform analysis of cerebral hemodynamic changes. The objective of this scoping review is to describe the existing evidence for the use of TCD-derived methods in estimating ICP in adult TBI patients as compared with gold-standard invasive methods. This review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, with a main search of PubMed and Embase. The search was limited to studies conducted in adult TBI patients published in any language between 2012 and 2022. Twenty-two studies were included for analysis, with most being prospective studies conducted in high-income countries. TCD-derived non-invasive ICP (nICP) methods are either mathematical or non-mathematical, with the former having slightly better correlation with invasive methods, especially when using time-trending ICP dynamics over one-time estimated values. Nevertheless, mathematical methods are associated with greater cost and complexity in their application. Formula-based methods showed promise in excluding elevated ICP, exhibiting a high negative predictive value. Therefore, TCD-derived methods could be useful in assessing ICP changes instead of absolute ICP values for high-risk patients, especially in low-resource settings.

Socioeconomic Determinants of Long-term Disability Outcomes in Traumatic Brain Injury Patients (P2-14.010)

Socioeconomic Determinants of Long-term Disability Outcomes in Traumatic Brain Injury Patients (P2-14.010)

Low-field, Portable Magnetic Resonance Imaging to Assess Hematoma Volume in Traumatic Brain Injury Patients (P10-5.008)

Low-field, Portable Magnetic Resonance Imaging to Assess Hematoma Volume in Traumatic Brain Injury Patients (P10-5.008)

IPad-Based Neurocognitive Testing (ImPACT-QT) in Acute Adult Mild Traumatic Brain Injury/Concussion: Study on Practicality and Bedside Cognitive Scores in a Level-1 Trauma Center.

There lacks rapid standardized bedside testing to screen cognitive deficits following mild traumatic brain injury (mTBI). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT) is an abbreviated-iPad form of computerized cognitive testing. The aim of this study is to test ImPACT-QT utility in inpatient settings. We hypothesize ImPACT-QT is feasible in the acute trauma setting. Trauma patients ages 12-70 were administered ImPACT-QT (09/2022-09/2023). Encephalopathic/medically unstable patients were excluded. Mild traumatic brain injury was defined as documented-head trauma with loss-of-consciousness <30 minutes and arrival Glasgow Coma Scale 13-15. Patients answered Likert-scale surveys. Bivariate analyses compared demographics, attention, motor speed, and memory scores between mTBI and non-TBI controls. Multivariable logistic regression assessed memory score as a predictor of mTBI diagnosis. Of 233 patients evaluated (36 years [IQR 23-50], 71% [166/233] female), 179 (76%) were mTBI patients. For all patients, mean test-time was 9.3 ± 2 minutes with 93% (73/76) finding the test "easy to understand." Mild traumatic brain injury patients than non-TBI control had lower memory scores (25 [IQR 7-100] vs 43 [26-100], P = .001) while attention (5 [1-23] vs 11 [1-32]) and motor score (14 [3-28] vs 13 [4-32]) showed no significant differences. Multivariable-regression (adjustment: age, sex, race, education level, ISS, and time to test) demonstrated memory score predicted mTBI positive status (OR .96, CI .94-.98, P = .004). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test is feasible in trauma patients. Preliminary findings suggest acute mTBIs have lower memory but not attention/motor scores vs non-TBI trauma controls.

Evaluation of activities and instrumental activities of daily living and correlated factors of traumatic brain injury patients in Vietnam

Traumatic brain injury (TBI) is among the leading causes of death in Vietnam. Survivors of TBI suffer from functional and cognitive deficits. Understanding that Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) are crucial in measuring the treatment and health-related quality of life among patients with TBI. This study aims to evaluate ADLs and IADLs among the TBI population in Vietnam and determine the correlated factors to these two indices. A cross-sectional study was conducted on 212 patients with TBI in Vietnam from February to September 2020. ADLs and IADLs scales were applied. Depression, quality of sleep, and social support scales were used. Multivariate Tobit regression was adopted to identify factors associated with ADLs and IADLs. Patients who received first aid had higher ADLs scores than those who had not, by a statistical difference with a p value = 0.04. The mean ADLs score was 5.4 (SD = 1.4). The mean score of IADLs was 7.3 (SD = 1.7). Female patients (Mean = 7.6, SD = 1.1) performed better in IADLs than male patients (Mean = 7.1, SD = 1.9). Both ADLs and IADLs were affected strongly by depression and Injury Severity scores (p < 0.01), whereas IADLs were significantly correlated to caregiver types and quality of sleep (p < 0.01). Family support was observed as a negatively correlated factor to IADLs. Findings from the study provided evidence for authorities to adjust the health strategies among patients with TBI. Proper prehospital care, a basic low-cost hospital care model, and mental health counseling services should be considered when developing health interventions in Vietnam.

DREADD-mediated activation of the periaqueductal gray restores nociceptive descending inhibition after traumatic brain injury in rats.

Traumatic Brain Injury (TBI) patients frequently experience chronic pain that can enhance their suffering and significantly impair rehabilitative efforts. Clinical studies suggest that damage to the periaqueductal grey matter (PAG) following TBI, a principal center involved in endogenous pain control, may underlie the development of chronic pain. We hypothesized that TBI would diminish the usual pain control functions of the PAG, but that directly stimulating this center using a chemogenetic approach would restore descending pain modulation. We used a well-characterized lateral fluid percussion model (1.3 ±0.1 atm) of TBI in male rats (n=271) and measured hindpaw mechanical nociceptive withdrawal thresholds using von Frey filaments. To investigate the role of the PAG in pain both before and after TBI we activated the neurons of the PAG using a Designer Receptor Exclusively Activated by Designer Drug (DREADD) viral construct. Immunohistochemical analysis of brain tissue was used to assess the location, and confirm the appropriate expression of the viral constructs in the PAG. Activation of the PAG DREADD using clozapine N-oxide (CNO) caused hindpaw analgesia that could be blocked using opioid receptor antagonist, naloxone, in uninjured but not TBI rats. Due to the importance of descending serotonergic signaling in modulating nociception, we ablated spinal serotonin signaling using 5,7-DHT. This treatment strongly reduced CNO-mediated anti-nociceptive effects in TBI but not uninjured rats. To define the serotonergic receptor(s) required for the CNO-stimulated effects in TBI rats we administered 5-HT7 (SB-269970) and 5-HT1A (WAY-100635) receptor antagonists but observed no effects. The selective 5-HT2A receptor antagonist ketanserin, however, blocked CNO's effects in the DREADD expressing TBI but not DREADD expressing sham TBI animals. Blockade of alpha-1 adrenergic receptors with prazosin also had no effect after TBI. Descending pain control originating in the PAG is mediated through opioid receptors in uninjured rats. TBI, however, fundamentally alters the descending nociceptive control circuitry such that serotonergic influences predominate, and those are mediated by the 5-HT2A receptor. These results provide further evidence that the PAG is a key target for anti-nociception after TBI.

Lesion Frequency Distribution Maps of Traumatic Axonal Injury on Early Magnetic Resonance Imaging after Moderate and Severe Traumatic Brain Injury and Associations to 12 Months Outcome.

Traumatic axonal injury (TAI) is a common finding on MRI in patients with moderate - severe traumatic brain injury (TBI), and the burden of TAI is associated with outcome in this patient group. Lesion mapping offers a way to combine imaging findings from numerous individual patients into common lesion maps where the findings from a whole patient cohort can be assessed. The aim of this study was to evaluate the spatial distribution of traumatic axonal injury (TAI) lesions on different MRI sequences and its associations to outcome with use of lesion mapping. 269 patients (8-70 years) with moderate or severe TBI traumatic brain injury and magnetic resonance imaging (MRI) within six weeks after injury were prospectively included. TAI lesions were evaluated and manually segmented on fluid-attenuated inversed recovery (FLAIR), diffusion weighted imaging (DWI) and either T2* gradient echo (T2*GRE) or susceptibility weighted imaging (SWI). The segmentations were registered to the Montreal Neurological Institute space and combined to lesion frequency distribution maps. Outcome was assessed with Glasgow Outcome Scale Extended (GOSE) score at 12 months. The frequency and distribution of TAI was assessed qualitatively by evaluated visually reading. Univariable associations to outcome was assessed qualitatively by visual reading evaluated visually and also quantitatively with use of voxel-based lesion-symptom mapping (VLSM). The highest frequency of TAI was found in the posterior half of corpus callosum. The frequency of TAI was higher in the frontal- and temporal lobes than in the parietal- and occipital lobes, and in the upper parts of the brainstem than in the lower. On At the group level, all the voxels in mesencephalon had TAI on FLAIR. The patients with poorest outcome (GOSE scores ≤ 4) had higher frequencies of TAI. On VLSM, poor outcome was associated with TAI lesions univariable associations to outcome was found bilaterally in the splenium, and in the right side of tectum, tegmental mesencephalon and pons. With this study, we present lesion frequency distribution maps of TAI in a large cohort of patients with moderate and severe TBI. In conclusion, we found the highest higher frequency of TAI in posterior corpus callosum, and TAI in splenium, mesencephalon and pons were associated to with poor outcome. In the future, integration into picture archiving systems would enable comparison of individual patient maps with If lesion frequency distribution maps containing outcome information based on imaging findings from numerous patients in the future can be compared to the imaging findings from individual patients, it would offer a new tool in the clinical work-up and outcome prediction of TBI patient. Key Words: Brain injuries, traumatic; Diffuse axonal injury; Neuroimaging; Brain mapping; Artificial intelligence.

Visualization of Cerebral Pressure Autoregulatory Insults in Traumatic Brain Injury.

The first aim was to investigate the combined effect of insult intensity and duration of the pressure reactivity index (PRx) and deviation from the autoregulatory cerebral perfusion pressure target (∆CPPopt = actual CPP - optimal CPP [CPPopt]) on outcome in traumatic brain injury. The second aim was to determine if PRx influenced the association between intracranial pressure (ICP), CPP, and ∆CPPopt with outcome. Observational cohort study. Neurocritical care unit, Cambridge, United Kingdom. Five hundred fifty-three traumatic brain injury patients with ICP and arterial blood pressure monitoring and 6-month outcome data (Glasgow Outcome Scale [GOS]). None. The insult intensity (mm Hg or PRx coefficient) and duration (minutes) of ICP, PRx, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In these plots, there was a transition from favorable to unfavorable outcome when PRx remained positive for 30 minutes and this was also the case for shorter durations when the intensity was higher. In a similar plot of ∆CPPopt, there was a gradual transition from favorable to unfavorable outcome when ∆CPPopt went below -5 mm Hg for 30-minute episodes of time and for shorter durations for more negative ∆CPPopt. Furthermore, the percentage of monitoring time with certain combinations of PRx with ICP, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In the combined PRx/ICP heatmap, ICP above 20 mm Hg together with PRx above 0 correlated with unfavorable outcome. In a PRx/CPP heatmap, CPP below 70 mm Hg together with PRx above 0.2-0.4 correlated with unfavorable outcome. In the PRx-/∆CPPopt heatmap, ∆CPPopt below 0 together with PRx above 0.2-0.4 correlated with unfavorable outcome. Higher intensities for longer durations of positive PRx and negative ∆CPPopt correlated with worse outcome. Elevated ICP, low CPP, and negative ∆CPPopt were particularly associated with worse outcomes when the cerebral pressure autoregulation was concurrently impaired.

Neuromonitoring in neurocritical care for traumatic brain injury in the Thai context

The purposes of this review were to identify the incidence and types of traumatic brain injury (TBI) in Thailand, and recommend neuro-monitoring for limited resources in Thai patients. The monitoring methods focus on the targeted and personalized management in severe TBI such as intracranial pressure (ICP), pressure reactivity index (PRx), regional cerebral saturation (rSO2), cerebral autoregulation (CA), as well as noninvasive methods for example near-infrared spectroscopy (NIRS) and optic nerve sheath diameter (ONSD). These monitors are aimed to optimize brain oxygen delivery and prevent further neurologic deterioration in terms of increased ICP and decreased cerebral perfusion pressure (CPP). Some of these were implemented in neurological monitoring protocol and clinical practice guidelines for severe TBI. However, cost - effectiveness is concerned. Even though considering CA and the advance monitoring methods in continuous assessment are widely used, current therapeutic interventions which appear entirely to bedside approach for correct dysregulated CA are limited. In addition, understanding of basic molecular and cellular pathways involved in cerebral homeostasis ( brain oxygen delivery, cerebral blood flow, CA and cerebral vascular reactivity to oxygen and carbon dioxide) as well as secondary brain injury prevention are still necessary for improving TBI outcomes. In summary, further study in Thailand is required to determine optimal cerebral physiologic-based technology, monitoring parameters, and individualized thresholds to optimize CA and potentially improve neurologic outcomes across a spectrum of TBI patients, which focus in Thai rural areas where invasive monitoring is not routinely performed due to resources limitation. Encourage and training of non invasive methods might solve these issues.

224 Artificial Intelligence-based Decision Support Predicts Requirement for Neurosurgical Intervention in Acute Traumatic Brain Injury: Automated Surgical Intervention Support Tool (ASIST-TBI) Development, Validation and Simulated Prospective Deployment

INTRODUCTION: Artificial intelligence (AI) model integration into clinical workflow offers potential to optimize decision-support for transfer of acute traumatic brain injury (TBI) patients to appropriate trauma centers. METHODS: We retrospectively identified TBI patients from 2005-2021 treated at a quaternary Canadian trauma center. We employed various modeling techniques including principal component analysis, three-dimensional convolutional neural networks, and a transformer-based approach using Vision Transformer (ViT) architecture. Model training, validation, and testing was performed using head CT scans with binary ground truth labels corresponding to whether the patient received neurosurgical intervention witin 72 hours. The finalized model, termed Automated Surgical Intervention Support Tool for TBI (ASIST-TBI), was then deployed in a simulated prospective fashion on consecutive TBI patients at our center between March 2021 - September 2022. RESULTS: A dataset of 2,806 trauma patients with acute head CT scans were divided into training, validation, and testing groups; the ViT model exhibited optimal performance. There was accurate prediction of requirement for neurosurgical intervention with an area under the receiver operating curve (AUC) of 0·92, accuracy of 0·87, sensitivity of 0·87, and specificity of 0·88 on the testing cohort. In simulated 18-month prospective deployment, an additional 612 consecutive scans were used to assess the performance of ASIST-TBI. Classification accuracy remained robust with AUC of 0·89, 0·85 sensitivity, 0·84 specificity, and 0·84 accuracy. We manually reviewed false positive and false negative cases to identify reasons for misclassification. CONCLUSIONS: We developed a novel deep learning model that accurately predicts requirement for acute neurosurgical intervention using unlabeled TBI scans. ASIST-TBI has potential application to optimize state-wide triage efficiency and care pathways for brain-injured patients.

255 Frailty Is Associated With Decreased 365-day Survival in Adult Patients With Operative and Nonoperative Traumatic Subdural Hemorrhage

INTRODUCTION: Traumatic subdural hematoma (tSDH) is observed frequently in traumatic brain injury (TBI) patients and is one of the commonest neurosurgical emergencies. tSDH patients require rapid evaluation and treatment in order to achieve the best possible results. There is a paucity of literature on frailty’s impact in TBI patients. METHODS: We performed a retrospective review of tSDH patients in the ACS-TQIP® database between 2007-2020. We employed multivariable regression models to examine the independent relationship of frailty, identified by the modified frailty index-5 (mFI-5) with the endpoints of major complications, length of stay (LOS), mortality, and discharge to a higher level of care. Additionally, we employ Kaplan-Meier (K-M) plots to examine the probability of survival following tSDH across the various mFI-5 frailty risk strata. RESULTS: 340,096 patients were managed nonoperatively and 41,658 operatively. The median age of the patients was 70.0 (IQR: 54.0, 81.0) nonoperative, and 71.0 (57.0, 80.0) operative cohorts. Multivariate analysis demonstrates a stepwise dose response relationship with outcomes p &lt; 0.001. In both cohorts, there was an 18-86% in mortality i.e. nonoperative: frail (OR: 1.18 [95% CI 1.13, 1.23]), very frail (OR: 1.75 [95% CI 1.65, 1.86]); and operative: frail (OR: 1.21 [95% CI 1.12, 1.32]), very frail (OR: 1.86 [95% CI 1.66, 2.09]). Survival probability markedly decreased across frailty strata within the first 100 days. CONCLUSIONS: Frailty was associated with major complications, LOS, mortality, and discharge to a higher-level care facility in patients with tSDH. Rapid deployment of point of care frailty risk-assessment allows clinicians to improve prognostication for patients and their families and allocate resources more precisely in order to try to achieve better outcomes.

440 Retrospective Assessment of the Clinical Timeline and Predictors for Vasospasm Severity in Traumatic Brain Injury Within a Safety-Net Hospital Population

INTRODUCTION: Unlike aneurysmal subarachnoid hemorrhage, vasospasm following traumatic brain injury (TBI) is poorly understood and no guidelines-based recommendations for surveillance exist. METHODS: TBI patients admitted to the surgical ICU 11/2014-12/2020 with 2+ instances of TCD-diagnosed vasospasm were included. Clinical timelines, TBI severity by Glasgow Coma Score (GCS) (mild = 13-15, moderate = 9-12, severe = 3-8), presence of subarachnoid hemorrhage (tSAH), and vasospasm severity (mild, moderate, or severe) were extracted from records. One-way ANOVA analysis compared the highest severity of vasospasm noted with date of onset and total days of vasospasm. Significant differences in means were further analyzed with Games-Howell post-hoc test. Stata® determined the dependence of vasospasm severity upon imaging findings or the GCS via Chi2 analysis. RESULTS: Forty-four patients were identified (31 male, 13 female, median age 40 (15-92) years). Amongst mild TBIs (13), vasospasm was mild (9), moderate (1), and severe (3). For moderate TBIs (2), vasospasm was mild (1), moderate (0), and severe (1). For severe TBIs (29), vasospasm was mild (16), moderate (6), and severe (7). Thirty-two patients had tSAH, 19 with mild, 6 moderate, and 7 with severe vasospasm. Of the 12 patients without tSAH, 7 had mild, 1 moderate, and 4 with severe vasospasm. Median time to onset did not differ between mild (Hospital Day (HD) 3), moderate (HD 4), and severe (HD 3) vasospasm (p = 0.47). Mean duration of mild vasospasm (2.35 days) differed from severe vasospasm (6.73 days), (p &lt; 0.05). Neither presence of tSAH nor severity of TBI was related to severity of vasospasm (p = 0.11 and p = 0.61). CONCLUSIONS: Our study found that post-traumatic vasospasm can impact TBI patients, early, regardless of TBI severity or the presence of tSAH, suggesting early and routine surveillance for PTV may be warranted in all critically ill TBI patients.

Optimal Range of Systolic Blood Pressure in the Emergent Phase that Reduces the Negative Outcomes of Traumatic Brain Injury Surgery

BackgroundBlood pressure management is critical for the treatment of traumatic brain injury (TBI). The purpose of this study was to determine the safe systolic blood pressure (SBP) range during the emergent phase that reduces negative outcomes after TBI surgery. MethodsPatients with isolated TBI who received surgical treatment were enrolled. We retrospectively analyzed the outcomes of the TBI patients with different admission SBP (mmHg) ranges. In addition, the safe SBP ranges for patients in different age groups (<50 or ≥50 years old) were identified. ResultsAmong the TBI patients, those with an admission SBP ranging from 100 to 140 mmHg had the lowest mortality rate: 18.97% for the 100–120-mmHg group and 19.52% for the 120–140-mmHg group. Among the patients with an admission SBP of ≥140 mmHg, the mortality rate decreased dramatically when the SBP was controlled to 100–140 mmHg during the emergent phase (22.22% vs. 37.542%, p = 0.022). However, this control had no effect on the extended Glasgow outcome scale (GOSE) score of the survivals (p = 0.920). Multivariate regression analysis further revealed that an admission SBP of 100–140 mmHg is an independent factor for favorable outcomes, but only in patients who are ≥50 years old (p = 0.017). ConclusionsThis study identified the optimal range of SBP during the emergent phase for isolated TBI patients. We emphasize the beneficial effects of reducing blood pressure before surgery in TBI, especially for patients who are ≥50 years old. The study provides new evidence for a blood pressure management target in TBI.

A prospective study on the incidence and outcome of cranial nerve injuries in patients with traumatic brain injuries

Background: The worldwide mortality and morbidity rates are highest for traumatic brain injury (TBI), which frequently involves damage to the cranial nerves (CNs). The occurrence of CN injury (CNI) in craniocerebral trauma ranges from 5 to 23%. Aims and Objectives: The objective of this study is to evaluate the occurrence of CNI in TBI patients within our population and determine the association between CN involvement and the severity of head injuries. In addition, we aim to assess the outcomes of patients who experience CNI in cases of head trauma. Materials and Methods: In our institution, a prospective observational analytical study was conducted from July 2022 to June 2023. The study included 100 patients aged over 1 year who had sustained head injuries. These patients were followed up for a period of 6 months. Results: Our study included a total of 100 patients, revealing that the highest number of head injuries occurred within the age range of 20–60 years, with an average age of 46 years. Among the study population, males accounted for 74%. Of these patients, 66 had mild head injuries, 22 had moderate head injuries, and 12 were admitted with severe head injuries. We discovered that 15% of TBI patients experienced CNIs. Specifically, five patients had a single CN palsy, while three patients had multiple CN palsies. Road traffic accidents accounted for 78% of the cases, making them the most common cause of injury, while low-velocity injuries only made up 22% of the cases. The facial nerve was the CN most frequently affected, followed by the olfactory nerve, optic nerve, and vestibulocochlear nerve. Among the 15 patients with CNI, seven had delayed symptoms, whereas eight patients presented with immediate symptoms. Conclusion: A substantial proportion of patients experience a delayed onset of CNI symptoms. Therefore, it is essential to perform a comprehensive neurological examination of all CNs during follow-up for all TBI patients.