Treatment Of Traumatic Brain Injury Patients Research Articles

Influence of Concomitant Injuries on Outcome of Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extra cranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. We retrospectively enrolled 129 patients with head injury Total patients were dichotomized into isolated TBI (n = 90) and TBI associated with SEI (n = 39). The differences in severity and outcome between these two groups were analyzed. Mortality was 8.89 % in the isolated TBI group and 20.28 % in TBI with SEI group (P = 0.0719), but the Glasgow Outcome Scale (GOS) in terms of Good Recovery (GR) was more in the isolated TBI group (P = 0.0004). Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.
 Bangladesh Crit Care J March 2020; 8(1): 24-28

Determinants affecting the prognosis of decompressive craniectomy for traumatic brain injury.

Objective:This research was designed to investigate the prognostic determinants of patients with traumatic brain injury (TBI) undergoing decompressive craniectomy (DC).Methods:The present study was a retrospective single center research including a total of 112 patients undergoing DC for TBI in Liaocheng People’s Hospital between January 2017 and December 2018. The results were measured by Extended Glasgow Outcome Sale (GOSE). The prognostic determinants were identified by univariate and binary logistic regression analysis between the deaths and survivors or favorable and unfavorable outcomes.Results:At the six-month follow-up, the mortality was 45.5% including 37 (33.0%) patients died within 30 days. The independent prognostic factors of 30-day mortality were age (p=0.033), D-dimer level at admission (p=0.032) and postoperative hypernatremia (p=0.014). Seventy five patients survived more than 30 days after DC, among which 27 (36.0%) patients had unfavorable prognosis (GOSE 1-4) and 48 (64.0%) patients presented favorable prognosis (GOSE 5-8). After 30 days from DC, the occurrence of post-traumatic hydrocephalus(PTH) (p= 0.008) was associated with unfavorable prognosis.Conclusions:Although DC is an effective treatment for TBI patients, the mortality and morbidity risk remain high. A combination of age, D-dimer level at admission and postoperative hypernatremia may be a good prognostic factor for 30-day mortality. Developing an accurate therapy strategy to prevent and control PTH may be beneficial to the 6-month prognosis for TBI patients undergoing DC.

Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries.

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≥ 3. SEI was defined as AIS ≥ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≤ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.

Beta-blockers and Traumatic Brain Injury: A Systematic Review, Meta-analysis, and Eastern Association for the Surgery of Trauma Guideline.

To determine if beta-(β)-blockers improve outcomes after acute traumatic brain injury (TBI). There have been no new inpatient pharmacologic therapies to improve TBI outcomes in a half-century. Treatment of TBI patients with β-blockers offers a potentially beneficial approach. Using MEDLINE, EMBASE, and CENTRAL databases, eligible articles for our systematic review and meta-analysis (PROSPERO CRD42016048547) included adult (age ≥ 16 years) blunt trauma patients admitted with TBI. The exposure of interest was β-blocker administration initiated during the hospitalization. Outcomes were mortality, functional measures, quality of life, cardiopulmonary morbidity (e.g., hypotension, bradycardia, bronchospasm, and/or congestive heart failure). Data were analyzed using a random-effects model, and represented by pooled odds ratio (OR) with 95% confidence intervals (CI) and statistical heterogeneity (I). Data were extracted from 9 included studies encompassing 2005 unique TBI patients with β-blocker treatment and 6240 unique controls. Exposure to β-blockers after TBI was associated with a reduction of in-hospital mortality (pooled OR 0.39, 95% CI: 0.27-0.56; I = 65%, P < 0.00001). None of the included studies examined functional outcome or quality of life measures, and cardiopulmonary adverse events were rarely reported. No clear evidence of reporting bias was identified. In adults with acute TBI, observational studies reveal a significant mortality advantage with β-blockers; however, quality of evidence is very low. We conditionally recommend the use of in-hospital β-blockers. However, we recommend further high-quality trials to answer questions about the mechanisms of action, effectiveness on subgroups, dose-response, length of therapy, functional outcome, and quality of life after β-blocker use for TBI.

An Integration of Decision Tree and Visual Analysis to Analyze Intracranial Pressure.

In Traumatic Brain Injury (TBI), elevated Intracranial Pressure (ICP) causes severe brain damages due to hemorrhage and swelling. Monitoring ICP plays an important role in the treatment of TBI patients because ICP is considered a strong predictor of neurological outcome and a potentially amenable method to treat patients. However, it is difficult to predict and measure accurate ICP due to the complex nature of patients' clinical conditions. ICP monitoring for severe TBI patient is a challenging problem for clinicians because traditionally known ICP monitoring is an invasive procedure by placing a device inside the brain to measure pressure. Therefore, ICP monitoring might have a high infection risk and cause medical complications. In here, an ICP monitoring using texture features is proposed to overcome this limitation. The combination of image processing methods and a decision tree algorithm is utilized to estimate ICP of TBI patients noninvasively. In addition, a visual analytics tool is used to conduct an interactive visual factor analysis and outlier detection.

Inflammatory neuroprotection following traumatic brain injury.

Traumatic brain injury (TBI) elicits an inflammatory response in the central nervous system (CNS) that involves both resident and peripheral immune cells. Neuroinflammation can persist for years following a single TBI and may contribute to neurodegeneration. However, administration of anti-inflammatory drugs shortly after injury was not effective in the treatment of TBI patients. Some components of the neuroinflammatory response seem to play a beneficial role in the acute phase of TBI. Indeed, following CNS injury, early inflammation can set the stage for proper tissue regeneration and recovery, which can, perhaps, explain why general immunosuppression in TBI patients is disadvantageous. Here, we discuss some positive attributes of neuroinflammation and propose that inflammation be therapeutically guided in TBI patients rather than globally suppressed.

Current practice in neurocritical care of patients withsubarachnoid haemorrhage and severe traumatic braininjury : Results of the Austrian Neurosurvey Study.

The task force Neuroanaesthesia of the Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is aiming to develop and provide recommendations in order to improve neurocritical care in Austria. Thus, a survey on neurocritical care concepts in Austria regarding intensive care of subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI) was performed to assess the current status. An online internet questionnaire comprising 59items on current concepts of SAH and TBI critical care was sent to 117 anaesthesiology departments. The survey was answered by 30 (25.6 %) of the hospitals, 24 (80 %) of them treating patients with SAH and/or TBI. Data from ten SAH centres reveal that definitive care was achieved within 24h in all hospitals; a case load >50per year is noted in 70 % of intensive care units (ICU). In all, 50 % of departments employ written protocols for treatment. Regarding the treatment of TBI patients, 14answers were received, indicating that 42.9 % of departments provide care for >50patients per year. Time between arrival and CT scan is <30min in all hospitals, and 28.6 % of departments rely on written protocols. Only 14.3 % of hospitals report about routine morbidity and mortality rounds. While the neurologic status is assessed at discharge from the ICU, there is no evaluation of 1‑year outcome. Definitive care of SAH and TBI patients is achieved timely in Austria. When compared with SAH, more hospitals with lower case loads take care of TBI patients. Written guidelines and protocols at institutional level are often missing. Since routine morbidity and mortality conferences are sparse, and long-term outcome is not assessed, there is room for improvement.

Continuous Renal Replacement Therapy for Acute Renal Failure in Patients with Traumatic Brain Injury.

ObjectiveThe purpose of this study was to investigate the impact of continuous renal replacement therapy (CRRT) on survival and relevant factors in patients who underwent CRRT after traumatic brain injury (TBI).MethodsWe retrospectively reviewed the laboratory, clinical, and radiological data of 29 patients who underwent CRRT among 1,190 TBI patients treated at our institution between April 2011 and June 2015. There were 20 men and 9 women, and the mean age was 60.2 years. The mean initial Glasgow Coma Scale score was 9.2, and the mean injury severity score was 24. Kaplan-Meier method and Cox regression were used for analysis of survival and relevant factors.ResultsThe actuarial median survival time of the 29 patients was 163 days (range, 3-317). Among the above 29 patients, 22 died with a median survival time of 8 days (range, 3-55). The causes of death were TBI-related in 8, sepsis due to pneumonia or acute respiratory distress syndrome (ARDS) in 4, and multi-organ failure in 10. Among the various factors, urine quantity of more than 500 mL for 24-hours before receiving CRRT was a significant and favorable factor for survival in the multivariate analysis (p=0.026).ConclusionAccording to our results, we suggest that early intervention with CRRT may be beneficial in the treatment of TBI patients with impending acute renal failure (ARF). To define the therapeutic advantages of early CRRT in the TBI patients with ARF, a well-designed and controlled study with more cases is required.

Neuroprotection after traumatic brain injury in heat-acclimated mice involves induced neurogenesis and activation of angiotensin receptor type 2 signaling.

Long-term exposure of mice to mild heat (34°C±1°C) confers neuroprotection against traumatic brain injury (TBI); however, the underling mechanisms are not fully understood. Heat acclimation (HA) increases hypothalamic angiotensin II receptor type 2 (AT2) expression and hypothalamic neurogenesis. Accumulating data suggest that activation of the brain AT2 receptor confers protection against several types of brain pathologies, including ischemia, a hallmark of the secondary injury occurring following TBI. As AT2 activates the same pro-survival pathways involved in HA-mediated neuroprotection (e.g., Akt phosphorylation, hypoxia-inducible factor 1α (HIF-1α), and brain-derived neurotrophic factor (BDNF)), we examined the role of AT2 in HA-mediated neuroprotection after TBI. Using an AT2-specific antagonist PD123319, we found that the improvements in motor and cognitive recovery as well as reduced lesion volume and neurogenesis seen in HA mice were all diminished by AT2 inhibition, whereas no significant alternations were observed in control mice. We also found that nerve growth factor/tropomyosin-related kinase receptor A (TrkA), BDNF/TrkB, and HIF-1α pathways are upregulated by HA and inhibited on PD123319 administration, suggesting that these pathways play a role in AT2 signaling in HA mice. In conclusion, AT2 is involved in HA-mediated neuroprotection, and AT2 activation may be protective and should be considered a novel drug target in the treatment of TBI patients.

Combining Functional and Psychoanalytic Techniques, Using Rhythmic Auditory Stimulation (RAS) and Songwriting to Treat a Man with a Traumatic Brain Injury

A common dilemma for music therapists, particularly when treating the symptoms of neurological damage, is deciding whether to employ functional or psychotherapeutic treatment techniques (Jochims 2004). This paper discusses the process and outcomes of combining two different techniques as a short-term treatment with a man with a traumatic brain injury (TBI) who is transitioning from post acute into the community stage of rehabilitation. Beginning with a brief review of examples where other music therapists have used a combination of techniques in the treatment of TBI patients, I will continue with a case study describing the referral, assessment and treatment plan for the client, including the outcomes of the two main techniques and concluding with a discussion of the process, outcomes and some interpretation of the client’s responses within the six week period. Working with Will, a 35-year-old man with a TBI, sessions began using several techniques in order to assess his condition, establish goals and begin treatment. Following an initial four months of weekly music therapy we planned to employ two different techniques over a six week period with two different aims: 1. RAS to improve gait parameters, 2. song writing to help sustain motivation for RAS and to address adjustment, self-expression, identity and communication difficulties. This resulted in a highly motivating, holistic treatment plan that was structured, with clear goals and timescales. Sessions lasted for 70 minutes, with 50 minutes of RAS and pregait exercises, followed by 20 minutes spent working on a song: ‘Life After a Bike Crash (that I can’t remember having)’. The RAS programme was set up conjointly with a privately employed physiotherapist and also supported with a daily home programme of RAS and pregait exercises.

Genetic Polymorphisms Influence Recovery from Traumatic Brain Injury

Traumatic brain injury (TBI) is a major public health concern in both civilian and military populations. Recently, genetics studies have begun to identify individual differences in polymorphisms that could affect recovery and outcome of cognitive and social processes following TBI. This review considers the potential for polymorphisms to influence six specific cognitive and social functions, which represent the most prominent domains of impairment following TBI: working memory, executive function, decision making, inhibition and impulsivity, aggression, and social and emotional function. Examining the influence of polymorphisms on TBI outcome has the potential to contribute to an understanding of variations in TBI outcome, aid in the triaging and treatment of TBI patients, and ultimately lead to targeted interventions based on genetic profiles.

Penetrating- and rotatonal traumatic brain injury; differentiation of the underlying pathobiology

Event Abstract Back to Event Penetrating- and rotatonal traumatic brain injury; differentiation of the underlying pathobiology Elham Rostami1* 1 Karolinska Institutet, Department of neuroscience, Sweden Traumatic Brain Injury (TBI) is a complex disease involving multiple pathological processes depending on the type of the primary injury. Regardless of the type of injury, the primary injury initiates complex secondary biochemical and physiological processes. The secondary process proceeds over hours and days and involve both harmful and compensatory events. The major secondary events include inflammation, alteration of cytoskeleton, neuronal- and glial cell death and also repair and regeneration. In order to better understand the pathobiologies of TBI we use the two animal models developed in our lab that mimics distinct injury processes. The first model is a rotational TBI (rot-TBI) animal model that mimics the physical forces of sagittal acceleration-deceleration that produces traumatic diffuse axonal injury. The second model is a penetration TBI (pen-TBI) animal model that produces a direct focal injury on the parenchyma with disruption of dura. We have analyzed the temporal pattern of expression of complement factors and other selected protein biomarkers in these two models, both in brain and serum. Our results show that the two models have different local- and temporal pattern of expression for complement factors and release of different biomarkers. Although, we have not indentified any biomarker that is unique for rot-TBI or pen-TBI, our findings suggests that there are patterns of different biomarkers that can be used to define a more specific fingerprint of each TBI. This would contribute in the diagnosis of various forms of TBI and also in evaluation and treatment of TBI patients and may even provide prediction of outcome of the future impairments of the patients. Keywords: biomarkers, complement, DAI Conference: Karolinska Institutet 200 years anniversary Symposium on Traumatic Injuries in the Nervous System, Stockholm, Sweden, 15 Sep - 16 Sep, 2010. Presentation Type: Presentation Topic: Traumatic Injuries in the Nervous System Citation: Rostami E (2010). Penetrating- and rotatonal traumatic brain injury; differentiation of the underlying pathobiology. Front. Neurol. Conference Abstract: Karolinska Institutet 200 years anniversary Symposium on Traumatic Injuries in the Nervous System. doi: 10.3389/conf.fneur.2010.56.00004 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 16 Sep 2010; Published Online: 21 Sep 2010. * Correspondence: Dr. Elham Rostami, Karolinska Institutet, Department of neuroscience, Stockholm, Sweden, elham.rostami@neuro.uu.se Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Elham Rostami Google Elham Rostami Google Scholar Elham Rostami PubMed Elham Rostami Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Resuscitation of traumatic brain injury and hemorrhagic shock with polynitroxylated albumin, hextend, hypertonic saline, and lactated Ringer's: Effects on acute hemodynamics, survival, and neuronal death in mice.

Outcome after traumatic brain injury (TBI) is worsened by hemorrhagic shock (HS), but the optimal resuscitation approach is unclear. In particular, treatment of TBI patients with colloids remains controversial. We hypothesized that resuscitation with the colloids polynitroxylated albumin (PNA) or Hextend (HEX) is equal or superior to resuscitation with the crystalloids hypertonic (3%) saline (HTS) or lactated Ringer's solution (LR) after TBI plus HS in mice. C57/BL6 mice (n = 30) underwent controlled cortical impact (CCI) and 90 min of volume-controlled HS (2 mL/100 g). The mice were randomized to resuscitation with LR, HEX, HTS, or PNA, followed by 30 min of test fluid administration targeting a mean arterial pressure (MAP) of >50 mm Hg. Shed blood was re-infused to target a MAP >70 mm Hg. At 7 days post-insult, hippocampal neuron counts were assessed in hematoxylin and eosin-stained sections to quantify neuronal damage. Prehospital MAP was higher, and prehospital and total fluid requirements were lower in the PNA and HEX groups (p < 0.05 versus HTS or LR). Also, 7-day survival was highest in the PNA group, but was not significantly different than the other groups. Ipsilateral hippocampal CA1 and CA3 neuron loss did not differ between groups. We conclude that the colloids PNA and HEX exhibited more favorable effects on acute resuscitation parameters than HTS or LR, and did not increase hippocampal neuronal death in this model.

SURGERY OF CEREBRAL TRAUMA AND ASSOCIATED CRITICAL CARE

The last 30 years have been both exciting and frustrating for those in the field of traumatic brain injury (TBI). Much has been learned, but no new treatment has been shown to improve patient outcomes despite the execution of many clinical trials. The overall incidence of TBI has decreased, probably because of intensive efforts toward prevention and education. Rigorous assessment of available research has produced several evidence-based guidelines for the management of neurotrauma patients. The creation of organized emergency medical services systems in many regions has improved prehospital care. Computed tomographic scans have become the gold standard for obtaining immediate images of patients with TBI, and ongoing advances in visualizing cerebral metabolism continue to be remarkable. The major current question regarding surgical treatment for TBI involves the role of decompressive craniectomy, an operation that first fell out of favor and has since (in the last three decades) enjoyed a resurgence of interest. Growing interest in the intensive care management of TBI patients helped to establish the new field of neurocritical care. Prophylactic hyperventilation is no longer recommended, and earlier recommendations for aggressive elevation of blood pressure have been softened to endorsement of a cerebral perfusion pressure of 60 mmHg. Recombinant factor VIIa is increasingly used for minimizing complications related to coagulopathy. Intracranial pressure monitoring is now recommended for the majority of TBI patients. At present, available technologies allow measurement of other aspects of cerebral metabolism including cerebral blood flow, brain oxygen tension, biochemistry, and electrical activity. Therapeutic interventions that are growing in popularity or are presently under investigation include administration of hypertonic saline, hyperoxygenation, decompressive craniectomy, and hypothermia. Rehabilitation has become accepted as an important part of the TBI recovery process, and additional work is needed to identify optimal interventions in this area. Socioeconomic factors will play a growing role in our treatment of TBI patients. Although much progress has been made in the last 30 years, the challenge now is to find ways to translate that progress into improved care and outcomes for TBI patients.