Traumatic Brain Injury

The incidence of traumatic brain injury in young people in the catchment area of the University Hospital Rotterdam, The Netherlands

Authors: Daniëlle van Pelt E, de Kloet A, Hilberink SR, Lambregts SA, Peeters E, Roebroeck ME, Catsman-Berrevoets CE.

BACKGROUND: Traumatic brain injury (TBI) is in the developed countries the most common cause of death and disability in childhood.

AIM: The purpose of this study is to estimate the incidence of TBI for children and young people in an urbanised region of the Netherlands and to describe relevant characteristics of this group.

METHODS: Patients, aged 1 month - 24 years who presented with traumatic brain injury at the Erasmus University Hospital (including the Sophia Children's Hospital) in 2007 and 2008 were included in a retrospective study. Data were collected by means of diagnosis codes and search terms for TBI in patient records. The incidence of TBI in the different referral areas of the hospital for standard, specialised and intensive patient care was estimated.

RESULTS: 472 patients met the inclusion criteria. The severity of the Injury was classified as mild in 342 patients, moderate in 50 patients and severe in 80 patients. The total incidence of traumatic brain injury in the referral area of the Erasmus University Hospital was estimated at 113.9 young people per 100.000. The incidence for mild traumatic brain injury was estimated at 104.4 young people, for moderate 6.1 and for severe 3.4 young people per 100.000.

CONCLUSION: The ratio for mild, moderate and severe traumatic brain injury in children and young people was 33.7-1.8-1.In the mild TBI group almost 17% of the patients reported sequelae. The finding that 42% of them had a normal brain CT scan at admission underwrites the necessity of careful follow up of children and young people with mild TBI.

Episodic disorders of behaviour and affect after acquired brain injury

Authors: Eames PE, Wood RL.

Psychological disorders that follow traumatic brain injury are possibly more complex and diverse than those associated with other forms of "brain damage". These may include organic aggressive, or organic affective syndromes that are episodic in nature and therefore require a more specific diagnosis, a different classification, and a different approach to treatment. Consequently, it is necessary for clinicians to learn to distinguish between "primary" psychiatric illnesses and those disorders of behavioural control and mood that stem specifically from brain injury. There is relatively little in the clinical literature that explains the relationship between variable states of behaviour, mood or temperament, and clinical disorders that may have long-term implications for patient management. This concept paper therefore addresses abnormalities of mood and behaviour that are episodic in character and are not recognisably included in the DSM and ICD classifications of psychological or psychiatric disorders.

Factors Affecting Blast Traumatic Brain Injury

Authors: Kamnaksh A, Kovesdi E, Kwon SK, Wingo DL, Ahmed F, Grunberg NE, Long JB, Agoston D.

The overlapping pathologies and functional outcomes of blast induced TBI (bTBI) and stress-related neurobehavioral disorders like PTSD are significant military health issues. Soldiers are exposed to multiple stressors with or without suffering bTBI, making diagnosis, treatment, as well as experimental modeling of bTBI a challenge. In this study we compared anxiety levels of Naïve rats to ones that were exposed to each of the following conditions daily for 4 consecutive days: C I: transportation alone; C II: transportation and anesthesia; C III: transportation, anesthesia, and blast sounds; Injured: all three variables plus mild blast overpressure. Following behavioral testing we analyzed sera and select brain regions for protein markers and cellular changes. C I through C III animals exhibited increased anxiety but serum CORT levels were only significantly elevated in C III and Injured rats. C III and Injured animals also had elevated IFNγ and IL-6 levels in their amygdala (AD) and ventral hippocampus (VHC). GFAP levels were only significantly elevated in the VHC, prefrontal cortex (PFC), and AD of Injured animals; they showed an apparent increase in Iba1 and GFAP immunoreactivities as well as increased numbers of TUNEL+ cells in their VHC. Our findings demonstrate that experimental conditions, particularly the exposure to blast acoustics, can increase anxiety and trigger specific behavioral and molecular changes without injury. These findings should be taken into consideration when designing bTBI studies, to better understand the role of stressors on the development of post-traumatic symptoms and to establish a differential diagnosis for PTSD and bTBI.

Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury

Authors: Stein DM, Hu PF, Brenner M, Sheth KN, Liu KH, Xiong W, Aarabi B, Scalea TM.

BACKGROUND: Management strategies after severe traumatic brain injury (TBI) target prevention and treatment of intracranial hypertension (ICH) and cerebral hypoperfusion (CH). We have previously established that continuous automated recordings of vital signs (VS) are more highly correlated with outcome than manual end-hour recordings. One potential benefit of automated vital sign data capture is the ability to detect brief episodes of ICH and CH. The purpose of this study was to establish whether a relationship exists between brief episodes of ICH and CH and outcome after severe TBI.

MATERIALS: Patients at the R Adams Cowley Shock Trauma Center were prospectively enrolled over a 2-year period. Inclusion criteria were as follows: age >14 years, admission within the first 6 hours after injury, Glasgow Coma Scale score <9 on admission, and placement of a clinically indicated ICP monitor. From high-resolution automated VS data recording system, we calculated the 5-minute means of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Brain Trauma Index (BTI = CPP/ICP). Patients were stratified by mortality and 6-month Extended Glasgow Outcome Score (GOSE).

RESULTS: Sixty subjects were enrolled with a mean admission Glasgow Coma Scale score of 6.4 ± 3.1, a mean Head Abbreviated Injury Severity Scale score of 4.2 ± 0.7, and a mean Marshall CT score of 2.5 ± 0.9. Significant differences in the mean number of brief episodes of CPP <50 and BTI <2 in patients with a GOSE 1-4 versus GOSE 5-8 (9.4 vs. 4.7, p = 0.02 and 9.3 vs. 4.9, p = 0.03) were found. There were significantly more mean brief episodes per day of ICP >30 (0.52 vs. 0.29, p = 0.02), CPP <50 (0.65 vs. 0.28, p < 0.001), CPP <60 (1.09 vs. 0.7, p = 0.03), BTI <2 (0.66 vs. 0.31, p = 0.002), and BTI <3 (1.1 vs. 0.64, p = 0.01) in those patients with GOSE 1-4. Number of brief episodes of CPP <50, CPP <60, BTI <2, and BTI <3 all demonstrated high predictive power for unfavorable functional outcome (area under the curve = 0.65-0.75, p < 0.05).

CONCLUSIONS: This study demonstrates that the number of brief 5-minute episodes of ICH and CH is predictive of poor outcome after severe TBI. This finding has important implications for management paradigms which are currently targeted to treatment rather than prevention of ICH and CH. This study demonstrates that these brief episodes may play a significant role in outcome after severe TBI.

Pulsatile Intracranial Pressure and Cerebral Autoregulation After Traumatic Brain Injury

Authors: Radolovich DK, Aries MJ, Castellani G, Corona A, Lavinio A, Smielewski P, Pickard JD, Czosnyka M.

BACKGROUND: Strong correlation between mean intracranial pressure (ICP) and its pulse wave amplitude (AMP) has been demonstrated in different clinical scenarios. We investigated the relationship between invasive mean arterial blood pressure (ABP) and AMP to explore its potential role as a descriptor of cerebrovascular pressure reactivity after traumatic brain injury (TBI).

METHODS:
We retrospectively analyzed data of patients suffering from TBI with brain monitoring. Transcranial Doppler blood flow velocity, ABP, ICP were recorded digitally. Cerebral perfusion pressure (CPP) and AMP were derived. A new index-pressure-amplitude index (PAx)-was calculated as the Pearson correlation between (averaged over 10 s intervals) ABP and AMP with a 5 min long moving average window. The previously introduced transcranial Doppler-based autoregulation index Mx was evaluated in a similar way, as the moving correlation between blood flow velocity and CPP. The clinical outcome was assessed after 6 months using the Glasgow outcome score.

RESULTS:
293 patients were studied. The mean PAx was -0.09 (standard deviation 0.21). This negative value indicates that, on average, an increase in ABP causes a decrease in AMP and vice versa. PAx correlated strong with Mx (R (2) = 0.46, P < 0.0002). PAx also correlated with age (R (2) = 0.18, P < 0.05). PAx was found to have as good predictive outcome value (area under curve 0.71, P < 0.001) as Mx (area under curve 0.69, P < 0.001).

CONCLUSIONS:
We demonstrated significant correlation between the known cerebral autoregulation index Mx and PAx. This new index of cerebrovascular pressure reactivity using ICP pulse wave information showed to have a strong association with outcome in TBI patients.

Monitoring and Prediction of Intracranial Hypertension in Pediatric Traumatic Brain Injury: Clinical Factors and Initial Head Computed Tomography

Authors: Bailey BM, Liesemer K, Statler KD, Riva-Cambrin J, Bratton SL

BACKGROUND: Control of intracranial hypertension (ICH) in patients with traumatic brain injury (TBI) is standard care. However, predicting risk for ICH is essential to balance risks and benefits of intracranial pressure (ICP) monitoring. Current recommendations for ICP monitoring in pediatric trauma patients are extrapolated from adult studies.

METHODS: This retrospective study evaluated 299 children admitted to Primary Children's Medical Center with moderate to severe TBI. ICP monitors were used in 120. Demographic, injury, and admission computed tomography (CT) scan characteristics were compared with determine factors associated with monitoring among those with less severe head CT findings. Among all monitored patients, clinical and radiographic features were compared for early ICH defined as any sustained ICP ≥20 mm Hg in the first 24 hours.

RESULTS: Factors independently associated with monitoring children with Marshall I or II scores included presence of intraventricular hemorrhage (odds ratio , 21.4; 95% confidence interval , 4.0-114.7) and greater injury severity scores (ISS) (OR, 9.5 for ISS 21 to 29 and OR, 14.3 for ISS >29 compared with ISS <21). Among those with a normal head CT, 9 of 68 had an ICP monitor placed because of the inability to localize pain. Of these, 78% (7 of 9) had early ICH. Among monitored patients radiologic and clinical features of injury severity were not useful to distinguish risk for early ICH.

CONCLUSIONS: Among children with severe TBI, a normal head CT does not exclude ICH. Need for ICP monitoring should be determined by depth of coma in addition to radiographic imaging.

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