Therapeutic temperature modulation in severe or moderate traumatic brain injury: a propensity score analysis of data from the Nationwide Japan Neurotrauma Data Bank

OBJECT In patients with severe traumatic brain injury (TBI), a randomized controlled trial revealed that outcomes did not significantly improve after therapeutic hypothermia (TH) or normothermia (TN). However, avoiding pyrexia, which is often associated with intracranial disorders, might improve clinical outcomes. The objective of this study was to compare neurological outcomes among patients with moderate and severe TBI after therapeutic temperature modulation (TTM) in the absence of other interventions. METHODS Data from 1091 patients were obtained from the Japan Neurotrauma Data Bank Project 2009, a cohort observational study. Patients with cardiac arrest, those with a Glasgow Coma Scale score of 3 and dilated fixed pupils, and those whose cause of death was injury to another area of the body were excluded, leaving 687 patients aged 16 years or older in this study. The patients were divided into 2 groups: the TTM group underwent TN (213 patients) or TH (82 patients), and the control group (392 patients) did not receive TTM. The primary end point for this study was the rate of poor outcome at hospital discharge, and the secondary end point was in-hospital death. Out of the 208 total items in the database, 29 variables that could potentially affect outcome were matched using the propensity score (PS) method in order to reduce selection bias and balance the baseline characteristics. RESULTS From each group, 141 patients were extracted using the PS-matching process. Among the patients in the TTM group, 29 had undergone TH and 112 had undergone TN. In a log-rank test using Kaplan-Meier survival curves, no significant differences in patient outcome or death were observed between the 2 groups (poor outcome, p = 0.83; death, p = 0.18). A Cox proportional-hazards regression analysis established the HR for poor outcome and mortality at 1.03 (95% CI 0.78–1.36, p = 0.83) and 1.34 (95% CI 0.87–2.07, p = 0.18), respectively. CONCLUSIONS There was no clear improvement in neurological outcomes after TTM in patients with moderate or severe TBI. To elucidate the role of TTM in patients with these injuries, a prospective study is needed with long-term follow-up using specific target temperatures.

Download Full-text

Early and persistent impaired percent alpha variability on continuous electroencephalography monitoring as predictive of poor outcome after traumatic brain injury

Journal of Neurosurgery ◽

10.3171/jns.2002.97.1.0084 ◽

2002 ◽

Vol 97 (1) ◽

pp. 84-92 ◽

Cited By ~ 81

Author(s):

Paul M. Vespa ◽

W. John Boscardin ◽

David A. Hovda ◽

David L. McArthur ◽

Marc R. Nuwer ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Eeg Monitoring ◽

Content Type ◽

Poor Outcome ◽

Continuous Electroencephalography ◽

Continuous Eeg ◽

Continuous Eeg Monitoring ◽

Severe Tbi ◽

Fine Print

Object. Early prediction of outcomes in patients after they suffer traumatic brain injury (TBI) is often nonspecific and based on initial imaging and clinical findings alone, without direct physiological testing. Improved outcome prediction is desirable for ethical, social, and financial reasons. The goal of this study was to determine the usefulness of continuous electroencephalography (EEG) monitoring in determining prognosis early after TBI, while the patient is in the intensive care unit. Methods. The authors hypothesized that the reduced percentage of alpha variability (PAV) in continuous EEG tracings indicates a poor prognosis. Prospective continuous EEG monitoring was performed in 89 consecutive patients with moderate to severe TBI (Glasgow Coma Scale [GCS] Scores 3–12) from 0 to 10 days after injury. The PAV was calculated daily, and the time course and trends of the PAV were analyzed in comparison with the patient's Glasgow Outcome Scale (GOS) score at the time of discharge. In patients with GCS scores of 8 or lower, a PAV value of 0.1 or lower is highly predictive of a poor outcome or death (positive predictive value 86%). The determinant PAV value was obtained by Day 3 after injury. Persistent PAV values of 0.1 or lower over several days or worsening of the PAV to a value of 0.1 or lower indicated a high likelihood of poor outcome (GOS Scores 1 and 2). In comparison with the combination of traditional initial clinical indicators of outcome (GCS score, pupillary response to light, patient age, results of computerized tomography scanning, and early hypotension or hypoxemia), the early PAV value during the initial 3 days after injury independently improved prognostic ability (p < 0.01). Conclusions. Continuous EEG monitoring performed with particular attention paid to the PAV is a sensitive and specific method of prognosis that can indicate outcomes in patients with moderate to severe TBI within 3 days postinjury.

Download Full-text

Early enteral nutrition in patients with severe traumatic brain injury: a propensity score–matched analysis using a nationwide inpatient database in Japan

American Journal of Clinical Nutrition ◽

10.1093/ajcn/nqz290 ◽

2019 ◽

Vol 111 (2) ◽

pp. 378-384 ◽

Cited By ~ 1

Author(s):

Hiroyuki Ohbe ◽

Taisuke Jo ◽

Hiroki Matsui ◽

Kiyohide Fushimi ◽

Hideo Yasunaga

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Propensity Score ◽

Enteral Nutrition ◽

Hospital Mortality ◽

Nosocomial Pneumonia ◽

Severe Traumatic Brain Injury ◽

Scale Scores ◽

Severe Tbi ◽

Inpatient Database

ABSTRACT Background Whether enteral nutrition (EN) should be administered early in severe traumatic brain injury (TBI) patients has not been fully addressed. Objective The present study aimed to evaluate whether early EN can reduce mortality or nosocomial pneumonia among severe TBI patients. Methods Using the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2017 linked with the Survey for Medical Institutions, we identified patients admitted for intracranial injury with Japan Coma Scale scores ≥30 (corresponding to Glasgow Coma Scale scores ≤8) at admission. We designated patients who started EN within 2 d of admission as the early EN group, and those who started EN at 3–5 d after admission as the delayed EN group. The primary outcome was in-hospital mortality. The secondary outcome was nosocomial pneumonia. Propensity score–matched analyses were performed to compare the outcomes between the 2 groups. Results We identified 3080 eligible patients during the 36-mo study period, comprising 1100 (36%) in the early EN group and 1980 (64%) in the delayed EN group. After propensity score matching, there was no significant difference in in-hospital mortality (difference: −0.3%; 95% CI: −3.7%, 3.1%) between the 2 groups. The proportion of nosocomial pneumonia was significantly lower in the early EN group than in the delayed EN group (difference: −3.2%; 95% CI: −5.9%, −0.4%). Conclusions Early EN may not reduce mortality, but may reduce nosocomial pneumonia in patients with severe TBI.

Download Full-text

Use of Vasopressors Increases the Risk of Mortality in Severe Traumatic Brain Injury: A Nationwide Retrospective Cohort Study in Japan

10.21203/rs.3.rs-140000/v1 ◽

2021 ◽

Author(s):

Sanae Hosomi ◽

Tomotaka Sobue ◽

Tetsuhisa Kitamura ◽

Atsushi Hirayama ◽

Hiroshi Ogura ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Emergency Department ◽

Cohort Study ◽

Brain Injury ◽

Propensity Score ◽

Hospital Discharge ◽

Severe Traumatic Brain Injury ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Severe Tbi

Abstract Background: Pharmacological elevation of blood pressure is frequently incorporated in severe traumatic brain injury (TBI) management algorithms. However, there is limited evidence on prevalent clinical practices regarding resuscitation for severe TBI using vasopressors. We conducted a nationwide retrospective cohort study to determine the association between the use of vasopressors and mortality following discharge from hospital in patients with severe TBI, and to determine whether the use of vasopressors affects emergency department mortality or the occurrence of cognitive dysfunction.Methods: Data were collected between January 2004 and December 2018 by the Japanese Trauma Data Bank, which includes data from 272 emergency hospitals in Japan. Adults aged ≥ 16 years with severe TBI, without other major injuries, were examined. A severe TBI was defined based on the Abbreviated Injury Scale code and a Glasgow Coma Scale score of 3–8 on admission. Multivariable and propensity score matching analyses were performed. Statistical significance was assessed using a 95% CI.Results: In total, 10,284 patients were eligible for analysis, with 650 patients (6.32%) included in the vasopressor group and 9,634 patients (93.68%) included in the non-vasopressor group. The proportion of deaths on hospital discharge was higher in the vasopressor group than in the non-vasopressor group (81.69% [531/650] vs. 40.21% [3,874/9,634]). This finding was confirmed by multivariable logistic regression analysis (adjusted odds ratio [OR], 5.71; 95% confidence interval [CI]: 4.56–7.16). Regarding propensity score-matched patients, the proportion of deaths on hospital discharge remained higher in the vasopressor group than in the non-vasopressor group (81.66% [530/649] vs. 50.69% [329/649]) (OR, 4.33; 95% CI: 3.37–5.57). The vasopressor group had a higher emergency department mortality rate than the non-vasopressor group (8.01% [52/649] vs. 2.77% [18/649]) (OR, 3.05; 95% CI: 1.77–5.28). There was no reduction in complications of cognitive disorders in the vasopressor group (5.39% [35/649] vs. 5.55% [36/649]) (OR, 0.97; 95% CI: 0.60–1.57).Conclusions: In this population, the use of vasopressors for severe TBI was associated with higher mortality on hospital discharge. Our results suggest that vasopressors should be avoided in most cases of severe TBI.

Download Full-text

A Novel Histological Technique to Assess Severity of Traumatic Brain Injury in Rodents: Comparisons to Neuroimaging and Neurological Outcomes

Frontiers in Neuroscience ◽

10.3389/fnins.2021.733115 ◽

2021 ◽

Vol 15 ◽

Author(s):

Dmitry Frank ◽

Benjamin F. Gruenbaum ◽

Ilan Shelef ◽

Vladislav Zvenigorodsky ◽

Yair Benjamin ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Brain Edema ◽

Histological Evaluation ◽

Lesion Volume ◽

Histological Techniques ◽

Histological Technique ◽

Neurological Outcomes ◽

Severe Tbi ◽

Magnetic Resonance Imaging Mri

Here we evaluate an alternative protocol to histologically examine blood-brain barrier (BBB) breakdown, brain edema, and lesion volume following traumatic brain injury (TBI) in the same set of rodent brain samples. We further compare this novel histological technique to measurements determined by magnetic resonance imaging (MRI) and a neurological severity score (NSS). Sixty-six rats were randomly assigned to a sham-operated, mild TBI, moderate TBI, or severe TBI group. 48 h after TBI, NSS, MRI and histological techniques were performed to measure TBI severity outcome. Both the histological and MRI techniques were able to detect measurements of severity outcome, but histologically determined outcomes were more sensitive. The two most sensitive techniques for determining the degree of injury following TBI were NSS and histologically determined BBB breakdown. Our results demonstrate that BBB breakdown, brain edema, and lesion volume following TBI can be accurately measured by histological evaluation of the same set of brain samples.

Download Full-text

A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients

BioMed Research International ◽

10.1155/2015/529580 ◽

2015 ◽

Vol 2015 ◽

pp. 1-8 ◽

Cited By ~ 8

Author(s):

Chien-Min Lin ◽

Ming-Chin Lin ◽

Sheng-Jean Huang ◽

Cheng-Kuei Chang ◽

Dan-Ping Chao ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Randomized Study ◽

Survival Rates ◽

Therapeutic Interventions ◽

Neurological Outcomes ◽

Severe Tbi ◽

Brain Tissue Oxygen Pressure ◽

Guided Therapy

The purpose of this study was to compare the effect of PbtO2-guided therapy with traditional intracranial pressure- (ICP-) guided treatment on the management of cerebral variables, therapeutic interventions, survival rates, and neurological outcomes of moderate and severe traumatic brain injury (TBI) patients. From 2009 to 2010, TBI patients with a Glasgow coma scale <12 were recruited from 6 collaborative hospitals in northern Taiwan, excluding patients with severe systemic injuries, fixed and dilated pupils, and other major diseases. In total, 23 patients were treated with PbtO2-guided management (PbtO2> 20 mmHg), and 27 patients were treated with ICP-guided therapy (ICP < 20 mmHg and CPP > 60 mmHg) in the neurosurgical intensive care unit (NICU); demographic characteristics were similar across groups. The survival rate in the PbtO2-guided group was also significantly increased at 3 and 6 months after injury. Moreover, there was a significant correlation between the PbtO2signal and Glasgow outcome scale-extended in patients from 1 to 6 months after injury. This finding demonstrates that therapy directed by PbtO2monitoring is valuable for the treatment of patients with moderate and severe TBI and that increasing PaO2to 150 mmHg may be efficacious for preventing cerebral hypoxic events after brain trauma.

Download Full-text

DOES ADHERENCE TO TREATMENT TARGETS IN CHILDREN WITH SEVERE TRAUMATIC BRAIN INJURY AVOID BRAIN HYPOXIA? A BRAIN TISSUE OXYGENATION STUDY

Neurosurgery ◽

10.1227/01.neu.0000335074.39728.00 ◽

2008 ◽

Vol 63 (1) ◽

pp. 83-92 ◽

Cited By ~ 39

Author(s):

Anthony A. Figaji ◽

A. Graham Fieggen ◽

Andrew C. Argent ◽

Peter D. LeRoux ◽

Jonathan C. Peter

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Brain Tissue ◽

Cerebral Perfusion Pressure ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Treatment Targets ◽

Poor Outcome ◽

Severe Tbi

ABSTRACT OBJECTIVE Most physicians rely on conventional treatment targets for intracranial pressure, cerebral perfusion pressure, systemic oxygenation, and hemoglobin to direct management of traumatic brain injury (TBI) in children. In this study, we used brain tissue oxygen tension (PbtO2) monitoring to examine the association between PbtO2 values and outcome in pediatric severe TBI and to determine the incidence of compromised PbtO2 in patients for whom acceptable treatment targets had been achieved. METHODS In this prospective observational study, 26 children with severe TBI and a median postresuscitation Glasgow Coma Scale score of 5 were managed with continuous PbtO2 monitoring. The relationships between outcome and the 6-hour period of lowest PbtO2 values and the length of time that PbtO2 was less than 20, 15, 10, and 5 mmHg were examined. The incidence of reduced PbtO2 for each threshold was evaluated where the following targets were met: intracranial pressure less than 20 mmHg, cerebral perfusion pressure greater than 50 mmHg, arterial oxygen tension greater than 60 mmHg (and peripheral oxygen saturation > 90%), and hemoglobin greater than 8 g/dl. RESULTS There was a significant association between poor outcome and the 6-hour period of lowest PbtO2 and length of time that PbtO2 was less than 15 and 10 mmHg. Multiple logistic regression analysis showed that low PbtO2 had an independent association with poor outcome. Despite achieving the management targets described above, 80% of patients experienced one or more episodes of compromised PbtO2 (< 20 mmHg), and almost one-third experienced episodes of brain hypoxia (PbtO2 < 10 mmHg). CONCLUSION Reduced PbtO2 is associated with poor outcome in pediatric severe TBI. In addition, many patients experience episodes of compromised PbtO2 despite achieving acceptable treatment targets.

Download Full-text

An evaluation of outcomes in patients with traumatic brain injury at a referral hospital in Tanzania: evidence from a survival analysis

Neurosurgical FOCUS ◽

10.3171/2019.7.focus19316 ◽

2019 ◽

Vol 47 (5) ◽

pp. E6 ◽

Cited By ~ 1

Author(s):

Cyrus Elahi ◽

Thiago Augusto Hernandes Rocha ◽

Núbia Cristina da Silva ◽

Francis M. Sakita ◽

Ansbert Sweetbert Ndebea ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Road Traffic ◽

Referral Hospital ◽

Middle Income ◽

Middle Income Countries ◽

Poor Outcome ◽

Severity Of Injury ◽

Severe Tbi ◽

Low And Middle Income

OBJECTIVEThe purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury.METHODSThe authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9–13), or severe (3–8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale–Extended, categorized as poor outcome (1–4) and good outcome (5–8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania.RESULTSOf the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06–0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06–0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24–0.89; p = 0.02) for those with severe TBI.CONCLUSIONSThose who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI—a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

Download Full-text

Survival outcomes after traumatic brain injury during national academic meeting days in Japan

Scientific Reports ◽

10.1038/s41598-021-94759-4 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Sanae Hosomi ◽

Tetsuhisa Kitamura ◽

Tomotaka Sobue ◽

Hiroshi Ogura ◽

Takeshi Shimazu

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Hospital Mortality ◽

Data Bank ◽

Hospital Death ◽

National Meeting ◽

Japanese Association ◽

Neurosurgical Society ◽

Before And After ◽

Japan Trauma Data Bank

AbstractSurgeons and medical staff attend academic meetings several times a year. However, there is insufficient evidence on the influence of the “meeting effect” on traumatic brain injury (TBI) treatments and outcomes. Using the Japan Trauma Data Bank, we analyzed the data of TBI patients admitted to the hospital from 2004 to 2018 during the national academic meeting days of the Japanese Association for Acute Medicine, the Japanese Society of Intensive Care Medicine, the Japanese Association for the surgery of trauma, the Japan Society of Neurotraumatology and the Japan Neurosurgical Society. The data of these patients were compared with those of TBI patients admitted 1 week before and after the meetings. The primary outcome was in-hospital death. We included 7320 patients in our analyses, with 5139 and 2181 patients admitted during the non-meeting and meeting days, respectively; their in-hospital mortality rates were 15.7% and 14.5%, respectively. No significant differences in in-hospital mortality were found (adjusted odds ratio, 0.93; 95% confidence interval, 0.78–1.11). In addition, there were no significant differences in in-hospital mortality during the meeting and non-meeting days by the type of national meeting. In Japan, it is acceptable for medical professionals involved in TBI treatments to attend national academic meetings without impacting the outcomes of TBI patients.

Download Full-text

Challenges and Opportunities for Neuroimaging in Young Patients with Traumatic Brain Injury: a Coordinated Effort towards Advancing Discovery from the ENIGMA Pediatric Moderate/Severe TBI Group

10.31234/osf.io/y2txh ◽

2019 ◽

Cited By ~ 4

Author(s):

Emily L. Dennis ◽

Karen Caeyenberghs ◽

Robert F. Asarnow ◽

Talin Babikian ◽

Brenda Bartnik-Olson ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Meta Analysis ◽

Young Patients ◽

Future Research ◽

Childhood And Adolescence ◽

Developmental Issues ◽

Challenges And Opportunities ◽

Severe Tbi ◽

Advance Research

Traumatic brain injury (TBI) is a major cause of death and disability in children in both developed and developing nations. Children and adolescents suffer from TBI at a higher rate than the general population; however, research in this population lags behind research in adults. This may be due, in part, to the smaller number of investigators engaged in research with this population and may also be related to changes in safety laws and clinical practice that have altered length of hospital stays, treatment, and access to this population. Specific developmental issues also warrant attention in studies of children, and the ever-changing context of childhood and adolescence may require larger sample sizes than are commonly available to adequately address remaining questions related to TBI. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric Moderate-Severe TBI (msTBI) group aims to advance research in this area through global collaborative meta-analysis. In this paper we discuss important challenges in pediatric TBI research and opportunities that we believe the ENIGMA Pediatric msTBI group can provide to address them. We conclude with recommendations for future research in this field of study.

Download Full-text

IMPACT probability of poor outcome and plasma cytokine concentrations are associated with multiple organ dysfunction syndrome following traumatic brain injury

Journal of Neurosurgery ◽

10.3171/2018.8.jns18676 ◽

2019 ◽

Vol 131 (6) ◽

pp. 1931-1937 ◽

Cited By ~ 2

Author(s):

Sungho Lee ◽

Hyunsoo Hwang ◽

Jose-Miguel Yamal ◽

J. Clay Goodman ◽

Imoigele P. Aisiku ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Organ Dysfunction ◽

Multiple Organ Dysfunction Syndrome ◽

Sofa Score ◽

Plasma Concentrations ◽

Multiple Organ ◽

Multiple Organ Dysfunction ◽

Poor Outcome ◽

Initial Plasma

OBJECTIVETraumatic brain injury (TBI) is a major cause of morbidity and mortality. Multiple organ dysfunction syndrome (MODS) occurs frequently after TBI and independently worsens outcome. The present study aimed to identify potential admission characteristics associated with post-TBI MODS.METHODSThe authors performed a secondary analysis of a recent randomized clinical trial studying the effects of erythropoietin and blood transfusion threshold on neurological recovery after TBI. Admission clinical, demographic, laboratory, and imaging parameters were used in a multivariable Cox regression analysis to identify independent risk factors for MODS following TBI, defined as maximum total Sequential Organ Failure Assessment (SOFA) score > 7 within 10 days of TBI.RESULTSTwo hundred patients were initially recruited and 166 were included in the final analysis. Respiratory dysfunction was the most common nonneurological organ system dysfunction, occurring in 62% of the patients. International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) probability of poor outcome at admission was significantly associated with MODS following TBI (odds ratio [OR] 8.88, 95% confidence interval [CI] 1.94–42.68, p < 0.05). However, more commonly used measures of TBI severity, such as the Glasgow Coma Scale, Injury Severity Scale, and Marshall classification, were not associated with post-TBI MODS. In addition, initial plasma concentrations of interleukin (IL)–6, IL-8, and IL-10 were significantly associated with the development of MODS (OR 1.47, 95% CI 1.20–1.80, p < 0.001 for IL-6; OR 1.26, 95% CI 1.01–1.58, p = 0.042 for IL-8; OR 1.77, 95% CI 1.24–2.53, p = 0.002 for IL-10) as well as individual organ dysfunction (SOFA component score ≥ 1). Finally, MODS following TBI was significantly associated with mortality (OR 5.95, 95% CI 2.18–19.14, p = 0.001), and SOFA score was significantly associated with poor outcome at 6 months (Glasgow Outcome Scale score < 4) when analyzed as a continuous variable (OR 1.21, 95% CI 1.06–1.40, p = 0.006).CONCLUSIONSAdmission IMPACT probability of poor outcome and initial plasma concentrations of IL-6, IL-8, and IL-10 were associated with MODS following TBI.

Download Full-text