Confronting the grey zone after severe brain injury

2019 ◽  
Vol 3 (6) ◽  
pp. 707-711 ◽  
Author(s):  
Andrew Peterson ◽  
Adrian M. Owen
Keyword(s):  
Brain Injury ◽  
Ethical Issues ◽  
Vegetative State ◽  
Clinical Care ◽  
Grey Zone ◽  
Severe Brain Injury ◽  
New Methods ◽  
Legal Decision Making ◽  
Technological Developments ◽  
The Brain

In recent years, rapid technological developments in the field of neuroimaging have provided several new methods for revealing thoughts, actions and intentions based solely on the pattern of activity that is observed in the brain. In specialized centres, these methods are now being employed routinely to assess residual cognition, detect consciousness and even communicate with some behaviorally non-responsive patients who clinically appear to be comatose or in a vegetative state. In this article, we consider some of the ethical issues raised by these developments and the profound implications they have for clinical care, diagnosis, prognosis and medical-legal decision-making after severe brain injury.

scholarly journals Post-Operative Outcome of Traumatic Extradural Haematoma in HOSHAS

2019 ◽  
Vol 18 (1) ◽  
Author(s):  
Lim CY ◽  
Baharuddin OB ◽  
Xavier RG
Keyword(s):  
Brain Injury ◽  
General Surgery ◽  
Emergency Surgery ◽  
Road Traffic ◽  
Vegetative State ◽  
Extradural Haematoma ◽  
Severe Brain Injury ◽  
Operative Outcome ◽  
General Surgeons ◽  
Operative Recovery

Introduction: Traumatic extradural haematoma (EDH) is a common surgical emergency with huge socio-economic impact. Prompt diagnosis and management are key for patient survival and good outcome. Considering that neurosurgical units are mostly only available in tertiary centres, it is a challenge for non-neurosurgical centres to transport patient to the nearest neurosurgical unit for emergency surgery, which may be of significant distance away, hence, a delay in surgery. General surgery units are more widely available and general surgeons are trained to competently manage patients with EDH. Referring to the nearest general surgery unit for emergency surgery for EDH can be life-saving and avoid delay in surgery. There is a lack of study regarding outcome of patients with EDH operated by general surgeons, hence the aim of this study to investigate in this regard. To determine the post-operative functional outcome of patients with extradural haematoma in a nonneurosurgical centre, and compare the outcome with other centres. Materials and Methods: This study was a retrospective review of records of all post-operative patients operated in HOSHAS for traumatic EDH in year 2017. Sample were obtained from 2017 General Surgery Department operative census in HOSHAS. Data were obtained from patient admission records using a proforma. Documented patient post-operative functional status was classified as per Glasgow Outcome Scale (GOS). Data were analysed using SPSS version 22. Results: A total of 11 patient data were collected. Mean age of the study population is 27. All samples were male patients. Road traffic accident was the main mode of injury (82%). Seven patients had GCS on arrival of 9 to 12 (64%), while 4 patients had severe brain injury on arrival (36%). All except 1 patient with moderate brain injury (GCS on arrival 9-12) recovered well post-operatively. As for patients with severe brain injury on arrival (GCS 3-8), only half of the patients had complete recovery post operatively. Most of the patients (73%) had good post-operative recovery (GOS 4-5). One patient died (GOS 1) and another ended up in vegetative state (GOS 2). The post-operative outcome in this study is comparable to other studies done in neurosurgical unit. Conclusion: The functional outcomes of traumatic EDH patients operated by general surgeons in HOSHAS are similar to those in neurosurgical centre.

scholarly journals FEATURES OF DEVELOPMENT OF THE BRAIN OEDEMA IN THE ACUTE PERIOD OF THE SEVERE BRAIN INJURY

2016 ◽  
Vol 2 (1) ◽  
pp. 18-20
Author(s):  
S. M. Karpov ◽  
A. B. Kopylov ◽  
N. I. Malchenko ◽  
I. A. Vyshlova ◽  
K. S. Gandylayn ◽  
...  
Keyword(s):  
Brain Injury ◽  
Brain Oedema ◽  
Severe Brain Injury ◽  
Acute Period ◽  
The Brain

scholarly journals A surveillance study to determine the accuracy of mild traumatic brain injury diagnosis in an emergency department: protocol for a retrospective cohort study

BMJ Open ◽  
2017 ◽  
Vol 7 (8) ◽  
pp. e016222 ◽  
Author(s):  
Ilaria Pozzato ◽  
Ian D Cameron ◽  
Susanne Meares ◽  
Annette Kifley ◽  
Kim Van Vu ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Emergency Department ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Ethical Issues ◽  
Clinical Care ◽  
Local Health ◽  
South Wales ◽  
Operational Criteria ◽  
Clinical Records

IntroductionPrevious literature confirms that a mild traumatic brain injury (mTBI) may result in long-term emotional impacts and, in vulnerable subgroups, cognitive deficits. The accurate diagnosis of mTBI and its written documentation is an important first step towards providing appropriate and timely clinical care. Surveillance studies involving emergency department (ED) and hospital-based data need to be prioritised as these provide incident mTBI estimates. This project will advance existing research findings by estimating the occurrence of mTBI among those attending an ED and quantifying the accuracy of mTBI diagnoses recorded by ED staff through a comprehensive audit of ED records.Methods and analysisRetrospective chart reviews (between June 2015 and June 2016) of electronic clinical records from an ED in Sydney (New South Wales, Australia) will be conducted. The study population will include persons aged 18–65 years who attended the ED with any clinical features potentially indicative of mTBI. The WHO operational criteria for the clinical identification of mTBI cases is the presence of: (1) a Glasgow Coma Scale (GCS) of 13–15 after 30 min postinjury or on presentation to hospital; (2) one or more of the following: post-traumatic amnesia (PTA) of less than 24 hours’ duration, confusion or disorientation, a witnessed loss of consciousness for ≤30 min and/or a positive CT brain scan. We estimate that 30 000 ED attendances will be screened and that a sample size of 500 cases with mTBI will be identified during this 1-year period, which will provide reliable estimates of mTBI occurrence in the ED setting.Ethics and disseminationThe study was approved by the Northern Sydney Local Health District Ethics Committee. The committee deemed this study as low risk in terms of ethical issues. The written papers from this study will be submitted for publication in quality peer-reviewed medical and health journals. Study findings will be disseminated via presentations at national/international conferences and peer-reviewed journals.

Assessment of P3a and P3b after Moderate to Severe Brain Injury

2002 ◽  
Vol 33 (3) ◽  
pp. 102-110 ◽  
Author(s):  
Anne-Kristin Solbakk ◽  
Ivar Reinvang ◽  
Stein Andersson
Keyword(s):  
Brain Injury ◽  
Reaction Times ◽  
Duration Discrimination ◽  
Severe Brain Injury ◽  
Tone Duration ◽  
Attentional Resources ◽  
Injury Group ◽  
Brain Injured ◽  
Healthy Control ◽  
The Brain

The purpose of the study was to examine the P3a and P3b components of the event-related brain potential (ERP) in patients sustaining moderate to severe brain injury. Electrophysiological and behavioral responses were recorded in brain injured (N = 18) and healthy control (N = 21) participants during performance of an auditory 3-stimulus distractor paradigm. Auditory stimuli consisted of a series of repetitive standard tones (75 ms), occasionally interrupted by equiprobable target (25 ms) and distractor sounds (white noise). Tone duration discrimination accuracy was similar in patients and controls, but patients had prolonged reaction times to targets. The reaction time delay was paralleled by a prolongation of P3b latency to targets in the patient group relative to controls. The stimulus and task dependent modulation of ERP responses in the brain injury group was similar to that of controls in terms of the spatial distribution of ERPs over the scalp. However, the brain injury group had attenuated P3a and P3b amplitudes to distractor and target stimuli, respectively. The electrophysiological data suggest a deficit in the allocation of attentional resources to the processing of deviant stimuli in the brain injury group.

scholarly journals Informed consent for functional MRI research on comatose patients following severe brain injury: balancing the social benefits of research against patient autonomy

2019 ◽  
Vol 45 (5) ◽  
pp. 299-303 ◽  
Author(s):  
Tommaso Bruni ◽  
Mackenzie Graham ◽  
Loretta Norton ◽  
Teneille Gofton ◽  
Adrian M Owen ◽  
...  
Keyword(s):  
Informed Consent ◽  
Brain Injury ◽  
Functional Mri ◽  
Ethical Issues ◽  
Proxy Consent ◽  
Severe Brain Injury ◽  
Related Factors ◽  
The Social ◽  
Alternative Approaches ◽  
The Impact

Functional MRI shows promise as a candidate prognostication method in acutely comatose patients following severe brain injury. However, further research is needed before this technique becomes appropriate for clinical practice. Drawing on a clinical case, we investigate the process of obtaining informed consent for this kind of research and identify four ethical issues. After describing each issue, we propose potential solutions which would make a patient’s participation in research compatible with her rights and interests. First, we defend the need for traditional proxy consent against two alternative approaches. Second, we examine the impact of the intensive care unit environment on the informed consent process. Third, we discuss the therapeutic misconception and its potential influence on informed consent. Finally, we deal with issues of timing in recruiting participants and related factors which may affect the risks of participation.

Early induction of hypothermia for evacuated intracranial hematomas: a post hoc analysis of two clinical trials

2012 ◽  
Vol 117 (4) ◽  
pp. 714-720 ◽  
Author(s):  
Guy L. Clifton ◽  
Christopher S. Coffey ◽  
Sierra Fourwinds ◽  
David Zygun ◽  
Alex Valadka ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Relative Risk ◽  
Brain Injury ◽  
Vegetative State ◽  
Acute Brain Injury ◽  
Multicenter Clinical Trial ◽  
Severe Brain Injury ◽  
Start Time ◽  
Clinical Trial Registration ◽  
Intracranial Hematomas

Object The authors hypothesized that cooling before evacuation of traumatic intracranial hematomas protects the brain from reperfusion injury and, if so, further hypothesized that hypothermia induction before or soon after craniotomy should be associated with improved outcomes. Methods The National Acute Brain Injury Study: Hypothermia I (NABIS:H I) was a randomized multicenter clinical trial of 392 patients with severe brain injury treated using normothermia or hypothermia for 48 hours with patients reaching 33°C at 8.4 ± 3 hours after injury. The National Acute Brain Injury Study: Hypothermia II (NABIS:H II) was a randomized, multicenter clinical trial of 97 patients with severe brain injury treated with normothermia or hypothermia for 48 hours with patients reaching 35°C within 2.6 ± 1.2 hours and 33°C within 4.4 ± 1.5 hours of injury. Entry and exclusion criteria, management, and outcome measures in the 2 trials were similar. Results In NABIS:H II among the patients with evacuated intracranial hematomas, outcome was poor (severe disability, vegetative state, or death) in 5 of 15 patients in the hypothermia group and in 9 of 13 patients in the normothermia group (relative risk 0.44, 95% CI 0.22–0.88; p = 0.02). All patients randomized to hypothermia reached 35°C within 1.5 hours after surgery start and 33°C within 5.55 hours. Applying these criteria to NABIS:H I, 31 of 54 hypothermia-treated patients reached a temperature of 35°C or lower within 1.5 hours after surgery start time, and the remaining 23 patients reached 35°C at later time points. Outcome was poor in 14 (45%) of 31 patients reaching 35°C within 1.5 hours of surgery, in 14 (61%) of 23 patients reaching 35°C more than 1.5 hours of surgery, and in 35 (60%) of 58 patients in the normothermia group (relative risk 0.74, 95%, CI 0.49–1.13; p = 0.16). A meta-analysis of 46 patients with hematomas in both trials who reached 35°C within 1.5 hours of surgery start showed a significantly reduced rate of poor outcomes (41%) compared with 94 patients treated with hypothermia who did not reach 35°C within that time and patients treated at normothermia (62%, p = 0.009). Conclusions Induction of hypothermia to 35°C before or soon after craniotomy with maintenance at 33°C for 48 hours thereafter may improve outcome of patients with hematomas and severe traumatic brain injury. Clinical trial registration no.: NCT00178711.

Hypotension and Brain Injury in Asphyxiated Newborns Treated with Hypothermia

2017 ◽  
Vol 35 (01) ◽  
pp. 031-038 ◽  
Author(s):  
Asim Al Balushi ◽  
Stephanie Barbosa Vargas ◽  
Julie Maluorni ◽  
Priscille-Nice Sanon ◽  
Emmanouil Rampakakis ◽  
...  
Keyword(s):  
Brain Injury ◽  
Brain Magnetic Resonance Imaging ◽  
Severe Brain Injury ◽  
Resonance Imaging ◽  
Increased Risk ◽  
Blood Pressures ◽  
Magnetic Resonance Imaging Mri ◽  
Lactate Levels ◽  
The Impact ◽  
The Brain

Objective This study aimed to assess the incidence of hypotension in asphyxiated newborns treated with hypothermia, the variability in treatments for hypotension, and the impact of hypotension on the pattern of brain injury. Study Design We conducted a retrospective cohort study of asphyxiated newborns treated with hypothermia. Mean blood pressures, lactate levels, and inotropic support medications were recorded during the hospitalization. Presence and severity of brain injury were scored using the brain magnetic resonance imaging (MRI) obtained after the hypothermia treatment was completed. Results One hundred and ninety term asphyxiated newborns were treated with hypothermia. Eighty-one percent developed hypotension. Fifty-five percent of the newborns in the hypotensive group developed brain injury compared with 35% of the newborns in the normotensive group (p = 0.04). Twenty-nine percent of the newborns in the hypotensive group developed severe brain injury, compared with only 15% in the normotensive group. Nineteen percent of the newborns presenting with volume- and/or catecholamine-resistant hypotension had near-total injury, compared with 6% in the normotensive group and 8% in the group responding to volume and/or catecholamines. Conclusion Hypotension was common in asphyxiated newborns treated with hypothermia and was associated with an increased risk of (severe) brain injury in these newborns.

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