scholarly journals Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care—Indicative Observations and Future Perspectives

2021 ◽  
Vol 12 ◽  
Author(s):  
Teodor M. Svedung Wettervik ◽  
Anders Lewén ◽  
Per Enblad
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Fine Tuning ◽  
Neurointensive Care ◽  
Secondary Brain Injury ◽  
Brain Tissue Oxygenation ◽  
Treatment Protocols ◽  
Injury Mechanisms ◽  
Severe Tbi ◽  
Type Of Injury

Neurointensive care (NIC) has contributed to great improvements in clinical outcomes for patients with severe traumatic brain injury (TBI) by preventing, detecting, and treating secondary insults and thereby reducing secondary brain injury. Traditional NIC management has mainly focused on generally applicable escalated treatment protocols to avoid high intracranial pressure (ICP) and to keep the cerebral perfusion pressure (CPP) at sufficiently high levels. However, TBI is a very heterogeneous disease regarding the type of injury, age, comorbidity, secondary injury mechanisms, etc. In recent years, the introduction of multimodality monitoring, including, e.g., pressure autoregulation, brain tissue oxygenation, and cerebral energy metabolism, in addition to ICP and CPP, has increased the understanding of the complex pathophysiology and the physiological effects of treatments in this condition. In this article, we will present some potential future approaches for more individualized patient management and fine-tuning of NIC, taking advantage of multimodal monitoring to further improve outcome after severe TBI.

scholarly journals Decision-making for decompressive craniectomy in traumatic brain injury aided by multimodality monitoring: illustrative case

2021 ◽  
Vol 1 (25) ◽  
Author(s):  
Myranda B. Robinson ◽  
Peter Shin ◽  
Robert Alunday ◽  
Chad Cole ◽  
Michel T. Torbey ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Decision Making ◽  
Brain Injury ◽  
Decompressive Craniectomy ◽  
Pupillary Response ◽  
Illustrative Case ◽  
Secondary Brain Injury ◽  
Brain Tissue Oxygenation ◽  
Multimodality Monitoring ◽  
Severe Tbi

BACKGROUND Severe traumatic brain injury (TBI) requires individualized, physiology-based management to avoid secondary brain injury. Recent improvements in quantitative assessments of metabolism, oxygenation, and subtle examination changes may potentially allow for more targeted, rational approaches beyond simple intracranial pressure (ICP)-based management. The authors present a case in which multimodality monitoring assisted in decision-making for decompressive craniectomy. OBSERVATIONS This patient sustained a severe TBI without mass lesion and was monitored with a multimodality approach. Although imaging did not seem grossly worrisome, ICP, pressure reactivity, brain tissue oxygenation, and pupillary response all began worsening, pushing toward decompressive craniectomy. All parameters normalized after decompression, and the patient had a satisfactory clinical outcome. LESSONS Given recent conflicting randomized trials on the utility of decompressive craniectomy in severe TBI, precision, physiology-based approaches may offer an improved strategy to determine who is most likely to benefit from aggressive treatment. Trials are underway to test components of these strategies.

scholarly journals Predictors of recovery in moderate to severe traumatic brain injury

2019 ◽  
Vol 131 (5) ◽  
pp. 1648-1657
Author(s):  
Kadhaya David Muballe ◽  
Constance R. Sewani-Rusike ◽  
Benjamin Longo-Mbenza ◽  
Jehu Iputo
Keyword(s):  
Oxidative Stress ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Clinical Outcomes ◽  
Secondary Brain Injury ◽  
Coma Scale ◽  
Severity Of Injury ◽  
Severe Tbi

OBJECTIVETraumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. Clinical outcomes in TBI are determined by the severity of injury, which is dependent on the primary and secondary brain injury processes. Whereas primary brain injury lesions are related to the site of impact, secondary brain injury results from physiological changes caused by oxidative stress and inflammatory responses that occur after the primary insult. The aim of this study was to identify important clinical and biomarker profiles that were predictive of recovery after moderate to severe TBI. A good functional outcome was defined as a Glasgow Outcome Scale (GOS) score of ≥ 4.METHODSThis was a prospective study of patients with moderate to severe TBI managed at the Nelson Mandela Academic Hospital during the period between March 2014 and March 2016. Following admission and initial management, the patient demographic data (sex, age) and admission Glasgow Coma Scale score were recorded. Oxidative stress and inflammatory biomarkers in blood and CSF were sampled on days 1–7. On day 14, only blood was sampled for the same biomarkers. The primary outcome was the GOS score—due to its simplicity, the GOS was used to assess clinical outcomes at day 90. Because of difficulty in performing regular follow-up due to the vastness of the region, difficult terrain, and long travel distances, a 3-month follow-up period was used to avoid default.RESULTSSixty-four patients with Glasgow Coma Scale scores of ≤ 12 were seen and managed. Among the 56 patients who survived, 42 showed significant recovery (GOS score ≥ 4) at 3 months. Important predictors of recovery included antioxidant activity in the CSF (superoxide dismutase and total antioxidant capacity).CONCLUSIONSRecovery after TBI was dependent on the resolution of oxidative stress imbalance.

scholarly journals Comparison of strategies for monitoring and treating patients at the early phase of severe traumatic brain injury: the multicentre randomised controlled OXY-TC trial study protocol

BMJ Open ◽  
2020 ◽  
Vol 10 (8) ◽  
pp. e040550
Author(s):  
Jean-Francois Payen ◽  
Marion Richard ◽  
Gilles Francony ◽  
Gérard Audibert ◽  
Emmanuel L Barbier ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Life Assessment ◽  
Secondary Outcome ◽  
Trauma Patients ◽  
Brain Tissue Oxygenation ◽  
Severe Tbi ◽  
Randomised Controlled ◽  
The Impact

IntroductionIntracranial hypertension is considered as an independent risk factor of mortality and neurological disabilities after severe traumatic brain injury (TBI). However, clinical studies have demonstrated that episodes of brain ischaemia/hypoxia are common despite normalisation of intracranial pressure (ICP). This study assesses the impact on neurological outcome of guiding therapeutic strategies based on the monitoring of both brain tissue oxygenation pressure (PbtO2) and ICP during the first 5 days following severe TBI.Methods and analysisMulticentre, open-labelled, randomised controlled superiority trial with two parallel groups in 300 patients with severe TBI. Intracerebral monitoring must be in place within the first 16 hours post-trauma. Patients are randomly assigned to the ICP group or to the ICP + PbtO2 group. The ICP group is managed according to the international guidelines to maintain ICP≤20 mm Hg. The ICP + PbtO2 group is managed to maintain PbtO2 ≥20 mm Hg in addition to the conventional optimisation of ICP. The primary outcome measure is the neurological status at 6 months as assessed using the extended Glasgow Outcome Scale. Secondary outcome measures include quality-of-life assessment, mortality rate, therapeutic intensity and incidence of critical events during the first 5 days. Analysis will be performed according to the intention-to-treat principle and full statistical analysis plan developed prior to database freeze.Ethics and disseminationThis study has been approved by the Institutional Review Board of Sud-Est V (14-CHUG-48) and from the National Agency for Medicines and Health Products Safety (Agence Nationale de Sécurité du Médicament et des produits de santé) (141 435B-31). Results will be presented at scientific meetings and published in peer-reviewed publications.The study was registered with ClinTrials NCT02754063 on 28 April 2016 (pre-results).

scholarly journals Pathophysiology of severe traumatic brain injury and management of intracranial hypertension

2019 ◽  
Vol 18 (2) ◽  
pp. 62-71
Author(s):  
Raimondas Juškys ◽  
Vaiva Hendrixson
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Hypertension ◽  
Severe Traumatic Brain Injury ◽  
Current Treatment ◽  
Secondary Brain Injury ◽  
Management Options ◽  
Treatment Protocols ◽  
Improved Outcomes ◽  
The Brain

It is well recognized that severe traumatic brain injury causes major health and socioeconomic burdens for patients their families and society itself. Over the past decade, understanding of secondary brain injury processes has increased tremendously, permitting implementation of new neurocritical methods of care that substantially contribute to improved outcomes of such patients. The main objective of current treatment protocols is to optimize different physiological measurements that prevent secondary insults and reinforce the ability of the brain to heal. The aim of this literature review is to uncover the pathophysiological mechanisms of severe traumatic brain injury and their interrelationship, including cerebral metabolic crisis, disturbances of blood flow to the brain and development of edema, putting emphasis on intracranial hypertension and its current management options.

scholarly journals Co-Expression Network Analysis of MicroRNAs and Proteins in Severe Traumatic Brain Injury: A Systematic Review

Cells ◽  
2021 ◽  
Vol 10 (9) ◽  
pp. 2425
Author(s):  
Claire Osgood ◽  
Zubair Ahmed ◽  
Valentina Di Pietro
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Therapeutic Potential ◽  
Psychosocial Problems ◽  
Bioinformatic Analysis ◽  
Healthcare Services ◽  
Secondary Brain Injury ◽  
Mortality And Morbidity ◽  
Severe Tbi ◽  
Novel Target

Traumatic brain injury (TBI) represents one of the leading causes of mortality and morbidity worldwide, placing an enormous socioeconomic burden on healthcare services and communities around the world. Survivors of TBI can experience complications ranging from temporary neurological and psychosocial problems to long-term, severe disability and neurodegenerative disease. The current lack of therapeutic agents able to mitigate the effects of secondary brain injury highlights the urgent need for novel target discovery. This study comprises two independent systematic reviews, investigating both microRNA (miRNA) and proteomic expression in rat models of severe TBI (sTBI). The results were combined to perform integrated miRNA-protein co-expression analyses with the aim of uncovering the potential roles of miRNAs in sTBI and to ultimately identify new targets for therapy. Thirty-four studies were included in total. Bioinformatic analysis was performed to identify any miRNA–protein associations. Endocytosis and TNF signalling pathways were highlighted as common pathways involving both miRNAs and proteins found to be differentially expressed in rat brain tissue following sTBI, suggesting efforts to find novel therapeutic targets that should be focused here. Further high-quality investigations are required to ascertain the involvement of these pathways and their miRNAs in the pathogenesis of TBI and other CNS diseases and to therefore uncover those targets with the greatest therapeutic potential.

Management and Challenges of Severe Traumatic Brain Injury

2020 ◽  
Author(s):  
Shayan Rakhit ◽  
Mina F. Nordness ◽  
Sarah R. Lombardo ◽  
Madison Cook ◽  
Laney Smith ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Great Promise ◽  
Secondary Brain Injury ◽  
Trauma Patients ◽  
Barbiturate Coma ◽  
High Quality Research ◽  
Paroxysmal Sympathetic Hyperactivity ◽  
Vte Prophylaxis ◽  
Severe Tbi

AbstractTraumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro–Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.

The Aetiology of Reduced Cardiorespiratory Fitness Among Adults with Severe Traumatic Brain Injury and the Relationship with Physical Activity: A Narrative Review

2015 ◽  
Vol 17 (1) ◽  
pp. 43-54 ◽  
Author(s):  
Leanne Hassett ◽  
Anne Moseley ◽  
Alison Harmer
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Cardiorespiratory Fitness ◽  
Bed Rest ◽  
Peak Oxygen Uptake ◽  
Physiological Factors ◽  
Fitness Level ◽  
Severe Tbi ◽  
Short And Long Term ◽  
Type Of Injury

Reduced cardiorespiratory fitness or cardiorespiratory deconditioning is a secondary physical impairment commonly reported to affect people after traumatic brain injury (TBI), both in the short- and long-term. Eleven studies have measured peak oxygen uptake${\rm ({\dot V}O}_{{\rm 2peak}} )$to evaluate fitness in this population. The mean (SD)${\rm \dot VO}_{{\rm 2peak}}$from these studies was 27.2 (6.7) mL.kg−1·min−1, which is markedly below the average fitness level of age-matched healthy individuals. The aetiology of cardiorespiratory deconditioning has not been well evaluated among people with TBI; however, studies on prolonged bed rest and studies on the acute consequences of TBI inform our current understanding. The primary aim of this paper is to present a model to describe the physiological factors contributing to the development of cardiorespiratory deconditioning among people with severe TBI. We propose that both central and peripheral factors contribute to reduced fitness, and that these changes occur because of both the initial brain damage and trauma sustained and the prolonged and initially extreme physical inactivity that is commonly experienced after this type of injury. Reduced fitness can significantly affect the ability to return to pre-injury activities. Given that reintegration into the community is a key goal of rehabilitation among people with TBI, interventions that can prevent or reverse reduced fitness need to be implemented.

scholarly journals Recent advances in traumatic brain injury

2019 ◽  
Vol 266 (11) ◽  
pp. 2878-2889 ◽  
Author(s):  
Abdelhakim Khellaf ◽  
Danyal Zaman Khan ◽  
Adel Helmy
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Low Income ◽  
Health And Safety ◽  
Evidence Base ◽  
Neurointensive Care ◽  
Workplace Health ◽  
Middle Income ◽  
Severe Tbi ◽  
The Uk

Abstract Traumatic brain injury (TBI) is the most common cause of death and disability in those aged under 40 years in the UK. Higher rates of morbidity and mortality are seen in low-income and middle-income countries making it a global health challenge. There has been a secular trend towards reduced incidence of severe TBI in the first world, driven by public health interventions such as seatbelt legislation, helmet use, and workplace health and safety regulations. This has paralleled improved outcomes following TBI delivered in a large part by the widespread establishment of specialised neurointensive care. This update will focus on three key areas of advances in TBI management and research in moderate and severe TBI: refining neurointensive care protocolized therapies, the recent evidence base for decompressive craniectomy and novel pharmacological therapies. In each section, we review the developing evidence base as well as exploring future trajectories of TBI research.

Abstract 16144: Association Between Elevated Initial Trauma Center Body Temperature and Non-mortality Outcomes Following Major Traumatic Brain Injury

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Joshua B Gaither ◽  
Vatsal Chikani ◽  
Daniel W Spaite ◽  
Jennifer J Smith ◽  
Merlin Curry ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Body Temperature ◽  
Trauma Center ◽  
Hospital Charges ◽  
Secondary Brain Injury ◽  
Continuous Variables ◽  
Severe Tbi ◽  
Future Work ◽  
Center Body

Introduction: During prolonged hospitalization for Traumatic Brain Injury (TBI), fever has been identified as a possible cause of secondary brain injury and previous reports have identified an association between elevated body temperature and increased mortality following TBI. However, little is known about the relationship between an elevated initial trauma center body temperature (ITCT), measured immediately after EMS transport, and non-mortality outcomes. The purpose of this study was to determine if a correlation exists between elevated ITCT and various important patient outcomes. Methods: All moderate/severe TBI cases (CDC Barell Matrix Type 1) in the Arizona State Trauma Registry (ASTR; 1/1/07-12/31/12) were analyzed by the following ITCT categories: 36.5-37.9°C (normal-NT), 38.0-38.9°C (elevated-ET) and ≥39.0°C (very elevated-VET). Outcomes included: Trauma Center (TC) length-of-stay (LOS), Intensive Care Unit (ICU) LOS, and total TC charges. For continuous variables, non-parametric Kruskal-Wallis test was used to assess the median difference between the ET and VET cohorts and the NT group (reference). Wilcoxon two-sample tests identified groups with significant differences (alpha = 0.05). Results: 22,925 cases met inclusion criteria (exclusions: missing ITCT-2,885; missing demographics-700; ITCT <36.5°C - 8953). Both ET and VET had significantly longer TC LOS/ICU LOS and higher total hospital charges compared to the NBT group (all p values <0.0001; Figure 1). Conclusion: In this statewide study, ET or VET were associated with longer ICU LOS, longer hospital LOS and increased hospital charges. Future work is needed to identify the causes of temperature elevations that occur during prehospital TBI care (e.g., environmental factors versus autonomic dysregulation) and whether initiation of in-field measures to prevent temperature elevation might improve outcome.

scholarly journals Surgical Outcome Following Early Decompressive Hemicraniectomy in Patients of Severe Traumatic Brain Injury: A Retrospective Study

2021 ◽  
Author(s):  
Srikanta Das ◽  
Acharya Suryakant Pattajoshi ◽  
Pratyusha Ranjan Bishi ◽  
Kulwant Lakra ◽  
Biswajeet Bedbak ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Retrospective Study ◽  
Brain Injury ◽  
Surgical Outcome ◽  
Road Traffic ◽  
Secondary Brain Injury ◽  
Basal Cistern ◽  
Decompressive Hemicraniectomy ◽  
Novel Technique ◽  
Severe Tbi

Introduction: Traumatic Brain Injury (TBI) has become an epidemic and remains the leading cause of death and disability in people of 2nd to 4th decade. Road Traffic Accidents (RTA) are responsible for the majority of cases. Primary brain injury sustained on impact and secondary brain injury that develops in following hours and days contribute together to overall injury and decides ultimate outcome. The goal of management in any TBI patient aims to prevent secondary brain injury. Understanding the importance of Intracranial Pressure (ICP) is key to minimise secondary injury. Decompressive hemicraniectomy is a novel technique of reducing ICP in patients of severe brain injury. It’s judicious and timely performance not only saves life but also prevents the dreaded consequences of raised ICP. Aim: To evaluate the role of early decompressive hemicraniectomy in improving the survival rate among patients of severe TBI and analysing the important factors (glasgow coma scale, airway status, timing of surgery) affecting the surgical outcome. Materials and Methods: It was a retrospective study conducted at the Department of Neurosurgery, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India between September 2016 to March 2020. Case records of 60 patients of TBI who had undergone unilateral Decompressive Craniectomy (DECRA) were analysed. The decision for decompressive hemicraniectomy was purely based upon Glasgow Coma Scale GCS) and Computed Topography (CT) findings. The presence of an evacuable mass lesion, diffuse oedema and obliteration of basal cistern in CT was considered to be the most important criteria for the early decompressive procedure. Patients were assessed until their discharge from ward. Statistical analysis was performed by statistical package for science version 12. Results: A total of 60 patients with severe TBI, who underwent DECRA were analysed. Road Traffic Accident (RTA) was the predominant mechanism of injury. All had presence of a surgically evacuable mass lesion along with compression/obliteration of the basal cistern. The majority of mass lesions (n=42) were frontotemporal contusions (70%). Forty patients of total achieved good surgical outcome (66.67%) and rest 20 patients (33.33%) had poor outcomes. Overall incidence of complications was around 40%. The most important factors associated with good outcomes were GCS of 7 and and above, patent airway, and early surgery. Conclusion: Decompressive hemicraniectomy is a novel technique of reducing ICP which acts by directly breaking the rigid box phenomenon of Monro-Kellie doctrine. However patient selection, prompt decision, earliest intervention, adoption of standard technique of DECRA and post operative critical care management are important aspects behind the successful outcome.

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