Homocysteine Plasmatic Concentration in Brain-Injured Neurocritical Care Patients: Systematic Review of Clinical Evidence

Background: Hyperhomocysteinemia (HHcy) is considered as an independent risk factor for several diseases, such as cardiovascular, neurological and autoimmune conditions. Atherothrombotic events, as a result of endothelial dysfunction and increased inflammation, are the main mechanisms involved in vascular damage. This review article reports clinical evidence on the relationship between the concentration of plasmatic homocysteine (Hcy) and acute brain injury (ABI) in neurocritical care patients. Materials and methods: a systematic search of articles in the PubMed and EMBASE databases was conducted, of which only complete studies, published in English in peer-reviewed journals, were included. Results: A total of 33 articles, which can be divided into the following 3 subchapters, are present: homocysteine and acute ischemic stroke (AIS); homocysteine and traumatic brain injury (TBI); homocysteine and intracranial hemorrhage (ICH)/subarachnoid hemorrhage (SAH). This confirms that HHcy is an independent risk factor for ABI and a marker of poor prognosis in the case of stroke, ICH, SAH and TBI. Conclusions: Several studies elucidate that Hcy levels influence the patient’s prognosis in ABI and, in some cases, the risk of recurrence. Hcy appears as biochemical marker that can be used by neuro-intensivists as an indicator for risk stratification. Moreover, a nutraceutical approach, including folic acid, the vitamins B6 and B12, reduces the risk of thrombosis, cardiovascular and neurological dysfunction in patients with severe HHcy that were admitted for neurocritical care.

Bedside detection of intracranial midline shift using portable magnetic resonance imaging

Neuroimaging is crucial for assessing mass effect in brain-injured patients. Transport to an imaging suite, however, is challenging for critically ill patients. We evaluated the use of a low magnetic field, portable MRI (pMRI) for assessing midline shift (MLS). In this observational study, 0.064 T pMRI exams were performed on stroke patients admitted to the neuroscience intensive care unit at Yale New Haven Hospital. Dichotomous (present or absent) and continuous MLS measurements were obtained on pMRI exams and locally available and accessible standard-of-care imaging exams (CT or MRI). We evaluated the agreement between pMRI and standard-of-care measurements. Additionally, we assessed the relationship between pMRI-based MLS and functional outcome (modified Rankin Scale). A total of 102 patients were included in the final study (48 ischemic stroke; 54 intracranial hemorrhage). There was significant concordance between pMRI and standard-of-care measurements (dichotomous, κ = 0.87; continuous, ICC = 0.94). Low-field pMRI identified MLS with a sensitivity of 0.93 and specificity of 0.96. Moreover, pMRI MLS assessments predicted poor clinical outcome at discharge (dichotomous: adjusted OR 7.98, 95% CI 2.07–40.04, p = 0.005; continuous: adjusted OR 1.59, 95% CI 1.11–2.49, p = 0.021). Low-field pMRI may serve as a valuable bedside tool for detecting mass effect.

Effectiveness of Standard Oral Care Plan During Hospital Stay in Individuals With Brain Injury

Objective: To investigate the effectiveness of an existing standard oral care program (SOCP) and factors associated with it during hospitalization in individuals with acquired brain injury (ABI).Material and Methods: A total of 61 individuals underwent a SOCP for 4 weeks in a longitudinal observational study. Rapidly noticeable changes in oral health were evaluated by performing plaque, calculus, bleeding on probing (BOP) and bedside oral examination (BOE) at weeks 1 and 5. Individuals' brushing habits, eating difficulties, and the onset of pneumonia were retrieved from their medical records. Association between oral-health outcomes to systemic variables were investigated through multilevel regression models.Results: Dental plaque (P = 0.01) and total BOE score (P < 0.05) decreased over time but not the proportion of dental calculus (P = 0.30), BOP (P = 0.06), and tooth brushing frequency (P = 0.06). Reduction in plaque and BOE over time were negatively associated with higher periodontitis scores at baseline (coef. −6.8; −1.0), respectively, which in turn were associated with an increased proportion of BOP (coef. ≈ 15.0). An increased proportion of calculus was associated with eating difficulties (coef. 2.3) and the onset of pneumonia (coef. 6.2).Conclusions: Nursing care has been fundamental in improving oral health, especially reducing dental plaque and BOE scores. However, our findings indicate a need for improving the existing SOCP through academic-clinical partnerships.Clinical Relevance: Early introduction of oral care program to brain-injured individuals is beneficial in reducing plaque accumulation and improving oral health.

Visible Markers of Traumatic Brain Injury and their Influence on Affective Reactions and Discriminatory Behaviour: A Comparison of Two Models

<p>Two studies examined the influence visible markers of Traumatic Brain Injury (TBI) have on two mental health models. The two models examined were The Model of Helping Behaviour (Weiner, 1980) and The Danger Appraisal Model (Corrigan, 2000). A total of 305 participants across two experiments were invited and participated in an online survey to investigate the impact visible markers of brain injury have on their emotional and behavioural responses. Participants were recruited via a link on social media or via the intranet at three New Zealand workplaces. The findings of this study found support for visible markers of TBI influencing both The Model of Helping Behaviour and The Danger Appraisal Model. This study suggested that a higher level of perceived dangerousness and social distance is associated with visible markers of TBI and that TBI markers can significantly increase the level of support participants are willing to provide to brain injured individuals within the workplace. Further findings suggested that participants who reported having familiarity of brain injury had lower negative affective reactions, reduced social distance but less willingness to support TBI individuals within the workplace. Due to the limited research relevant to this field, further studies will need to investigate these findings to ascertain whether this is a true replica of the publics’ emotional and behavioural response towards visible markers of brain injury.</p>

Visible Markers of Traumatic Brain Injury and their Influence on Affective Reactions and Discriminatory Behaviour: A Comparison of Two Models

<p>Two studies examined the influence visible markers of Traumatic Brain Injury (TBI) have on two mental health models. The two models examined were The Model of Helping Behaviour (Weiner, 1980) and The Danger Appraisal Model (Corrigan, 2000). A total of 305 participants across two experiments were invited and participated in an online survey to investigate the impact visible markers of brain injury have on their emotional and behavioural responses. Participants were recruited via a link on social media or via the intranet at three New Zealand workplaces. The findings of this study found support for visible markers of TBI influencing both The Model of Helping Behaviour and The Danger Appraisal Model. This study suggested that a higher level of perceived dangerousness and social distance is associated with visible markers of TBI and that TBI markers can significantly increase the level of support participants are willing to provide to brain injured individuals within the workplace. Further findings suggested that participants who reported having familiarity of brain injury had lower negative affective reactions, reduced social distance but less willingness to support TBI individuals within the workplace. Due to the limited research relevant to this field, further studies will need to investigate these findings to ascertain whether this is a true replica of the publics’ emotional and behavioural response towards visible markers of brain injury.</p>

Selective activation of central thalamic fiber pathway facilitates behavioral performance in healthy non-human primates

Central thalamic deep brain stimulation (CT-DBS) is an investigational therapy to treat enduring cognitive dysfunctions in structurally brain injured (SBI) patients. However, the mechanisms of CT-DBS that promote restoration of cognitive functions are unknown, and the heterogeneous etiology and recovery profiles of SBI patients contribute to variable outcomes when using conventional DBS strategies,which may result in off-target effects due to activation of multiple pathways. To disambiguate the effects of stimulation of two adjacent thalamic pathways, we modeled and experimentally compared conventional and novel ‘field-shaping’ methods of CT-DBS within the central thalamus of healthy non-human primates (NHP) as they performed visuomotor tasks. We show that selective activation of the medial dorsal thalamic tegmental tract (DTTm), but not of the adjacent centromedian-parafascicularis (CM-Pf) pathway, results in robust behavioral facilitation. Our predictive modeling approach in healthy NHPs directly informs ongoing and future clinical investigations of conventional and novel methods of CT-DBS for treating cognitive dysfunctions in SBI patients, for whom no therapy currently exists.

Cerebral Autoregulation in Non-Brain Injured Patients: A Systematic Review

Introduction: Cerebral autoregulation (CA) plays a fundamental role in the maintenance of adequate cerebral blood flow (CBF). CA monitoring, through direct and indirect techniques, may guide an appropriate therapeutic approach aimed at improving CBF and reducing neurological complications; so far, the role of CA has been investigated mainly in brain-injured patients. The aim of this study is to investigate the role of CA in non-brain injured patients.Methods: A systematic consultation of literature was carried out. Search terms included: “CA and sepsis,” “CA and surgery,” and “CA and non-brain injury.”Results: Our research individualized 294 studies and after screening, 22 studies were analyzed in this study. Studies were divided in three groups: CA in sepsis and septic shock, CA during surgery, and CA in the pediatric population. Studies in sepsis and intraoperative setting highlighted a relationship between the incidence of sepsis-associated delirium and impaired CA. The most investigated setting in the pediatric population is cardiac surgery, but the role and measurement of CA need to be further elucidated.Conclusion: In non-brain injured patients, impaired CA may result in cognitive dysfunction, neurological damage, worst outcome, and increased mortality. Monitoring CA might be a useful tool for the bedside optimization and individualization of the clinical management in this group of patients.

Acquired brain injury and serious criminal offenders: An argument to expand the court's therapeutic jurisdiction

<p>Brain injury is a debilitating mental impairment. It can cause aggression, impulsivity, and other socially challenging behaviours, including criminal offending. This is largely a consequence of damage to the frontal lobes, the part of the brain that facilitates selfregulation and emotional control. Remedying this requires specialist rehabilitation, preferably in dedicated facilities. However, rather than being in such facilities, a disproportionate number of brain injured New Zealanders are in prison, often for violent or sexual offences. By contrast, other mentally impaired offenders, such as the intellectually disabled and mentally ill, are not kept in prison but instead transferred to the health jurisdiction to receive treatment or care. This raises a question as to why brain injured offenders do not receive the same therapeutic response by our criminal justice system. This paper explores that question by examining the current legislative framework for diverting mentally impaired offenders into healthcare through therapeutic dispositions on sentencing. It demonstrates the inadequacy of this framework for violent or sexual offenders with brain injury by showing how the gateway definitions of “intellectual disability” and “mental disorder” exclude that condition. It then explores the appropriateness of imprisoning serious offenders with brain injury by examining whether their detention breaches the state’s statutory obligations, and argues that the status quo violates both the Corrections Act 2004 and the New Zealand Bill of Rights Act 1990. Finally, in recognition of the current exclusion of brain injured offenders from therapeutic dispositions, and the potential illegality of their detention in prison, this paper argues for an expansion of the court’s therapeutic jurisdiction and examines mechanisms to achieve this.</p>

Acquired brain injury and serious criminal offenders: An argument to expand the court's therapeutic jurisdiction

<p>Brain injury is a debilitating mental impairment. It can cause aggression, impulsivity, and other socially challenging behaviours, including criminal offending. This is largely a consequence of damage to the frontal lobes, the part of the brain that facilitates selfregulation and emotional control. Remedying this requires specialist rehabilitation, preferably in dedicated facilities. However, rather than being in such facilities, a disproportionate number of brain injured New Zealanders are in prison, often for violent or sexual offences. By contrast, other mentally impaired offenders, such as the intellectually disabled and mentally ill, are not kept in prison but instead transferred to the health jurisdiction to receive treatment or care. This raises a question as to why brain injured offenders do not receive the same therapeutic response by our criminal justice system. This paper explores that question by examining the current legislative framework for diverting mentally impaired offenders into healthcare through therapeutic dispositions on sentencing. It demonstrates the inadequacy of this framework for violent or sexual offenders with brain injury by showing how the gateway definitions of “intellectual disability” and “mental disorder” exclude that condition. It then explores the appropriateness of imprisoning serious offenders with brain injury by examining whether their detention breaches the state’s statutory obligations, and argues that the status quo violates both the Corrections Act 2004 and the New Zealand Bill of Rights Act 1990. Finally, in recognition of the current exclusion of brain injured offenders from therapeutic dispositions, and the potential illegality of their detention in prison, this paper argues for an expansion of the court’s therapeutic jurisdiction and examines mechanisms to achieve this.</p>