RESUMEN
Studies show conflicting results regarding the prognostic significance of traumatic axonal injuries (TAI) in patients with traumatic brain injury (TBI). Therefore, we documented the presence of TAI in several brain regions, using different magnetic resonance imaging (MRI) sequences, and assessed their association to patient outcomes using machine learning. Further, we created a novel MRI-based TAI grading system with the goal of improving outcome prediction in TBI. We subsequently evaluated the performance of several TAI grading systems. We used a genetic algorithm to identify TAI that distinguish favorable from unfavorable outcomes. We assessed the discriminatory performance (area under the curve [AUC]) and goodness-of-fit (Nagelkerke pseudo-R2) of the novel Stockholm MRI grading system and the TAI grading systems of Adams and associates, Firsching and coworkers. and Abu Hamdeh and colleagues, using both univariate and multi-variate logistic regression. The dichotomized Glasgow Outcome Scale was considered the primary outcome. We examined the MRI scans of 351 critically ill patients with TBI. The TAI in several brain regions, such as the midbrain tegmentum, were strongly associated with unfavorable outcomes. The Stockholm MRI grading system exhibited the highest AUC (0.72 vs. 0.68-0.69) and Nagelkerke pseudo-R2 (0.21 vs. 0.14-0.15) values of all TAI grading systems. These differences in model performance, however, were not statistically significant (DeLong test, p > 0.05). Further, all included TAI grading systems improved outcome prediction relative to established outcome predictors of TBI, such as the Glasgow Coma Scale (likelihood-ratio test, p < 0.001). Our findings suggest that the detection of TAI using MRI is a valuable addition to prognostication in TBI.
Asunto(s)
Lesiones Traumáticas del Encéfalo , Lesión Axonal Difusa , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Enfermedad Crítica , Lesión Axonal Difusa/diagnóstico por imagen , Lesión Axonal Difusa/patología , Escala de Consecuencias de Glasgow , Humanos , Imagen por Resonancia Magnética , PronósticoRESUMEN
Brain-enriched protein biomarkers of tissue fate are being introduced clinically to aid in traumatic brain injury (TBI) management. The aim of this study was to determine how concentrations of six different protein biomarkers, measured in samples collected during the first weeks after TBI, relate to injury severity and outcome. We included neurocritical care TBI patients that were prospectively enrolled from 2007 to 2013, all having one to three blood samples drawn during the first 2 weeks. The biomarkers analyzed were S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1), tau, and neurofilament-light (NF-L). Glasgow Outcome Score (GOS) was assessed at 12 months. In total, 172 patients were included. All serum markers were associated with injury severity as classified on computed tomography scans at admission. Almost all biomarkers outperformed other known outcome predictors with higher levels the first 5 days, correlating with unfavorable outcomes, and UCH-L1 (0.260, pseduo-R2) displaying the best discrimination in univariate analyses. After adjusting for acknowledged TBI outcome predictors, GFAP and NF-L added most independent information to predict favorable/unfavorable GOS, improving the model from 0.38 to 0.51 pseudo-R2. A correlation matrix indicated substantial covariance, with the strongest correlation between UCH-L1, GFAP, and tau (r = 0.827-0.880). Additionally, the principal component analysis exhibited clustering of UCH-L1 and tau, as well as GFAP, S100B, and NSE, which was separate from NF-L. In summary, a panel of several different protein biomarkers, all associated with injury severity, with different cellular origin and temporal trajectories, improve outcome prediction models.
Asunto(s)
Lesiones Traumáticas del Encéfalo/sangre , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Proteína Ácida Fibrilar de la Glía/sangre , Subunidad beta de la Proteína de Unión al Calcio S100/sangre , Ubiquitina Tiolesterasa/sangre , Proteínas tau/sangre , Adulto , Biomarcadores/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fosfopiruvato Hidratasa/sangre , Valor Predictivo de las Pruebas , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Cerebral air embolism should be considered in case of stroke symptoms during any invasive procedure. Transport to a hospital with neurosurgical/hyperbaric oxygen treatment (HBOT) facility could improve the outcome for the patient. Absence of air on computed tomography (CT) scan should not disqualify a patient from HBOT if air embolism is suspected.
RESUMEN
BACKGROUND: Traumatic brain injury (TBI) is a major contributor to morbidity and mortality. Computerized tomography (CT) scanning of the brain is essential for diagnostic screening of intracranial injuries in need of neurosurgical intervention, but may also provide information concerning patient prognosis and enable baseline risk stratification in clinical trials. Novel CT scoring systems have been developed to improve current prognostic models, including the Stockholm and Helsinki CT scores, but so far have not been extensively validated. The primary aim of this study was to evaluate the Stockholm and Helsinki CT scores for predicting functional outcome, in comparison with the Rotterdam CT score and Marshall CT classification. The secondary aims were to assess which individual components of the CT scores best predict outcome and what additional prognostic value the CT scoring systems contribute to a clinical prognostic model. METHODS AND FINDINGS: TBI patients requiring neuro-intensive care and not included in the initial creation of the Stockholm and Helsinki CT scoring systems were retrospectively included from prospectively collected data at the Karolinska University Hospital (n = 720 from 1 January 2005 to 31 December 2014) and Helsinki University Hospital (n = 395 from 1 January 2013 to 31 December 2014), totaling 1,115 patients. The Marshall CT classification and the Rotterdam, Stockholm, and Helsinki CT scores were assessed using the admission CT scans. Known outcome predictors at admission were acquired (age, pupil responsiveness, admission Glasgow Coma Scale, glucose level, and hemoglobin level) and used in univariate, and multivariable, regression models to predict long-term functional outcome (dichotomizations of the Glasgow Outcome Scale [GOS]). In total, 478 patients (43%) had an unfavorable outcome (GOS 1-3). In the combined cohort, overall prognostic performance was more accurate for the Stockholm CT score (Nagelkerke's pseudo-R2 range 0.24-0.28) and the Helsinki CT score (0.18-0.22) than for the Rotterdam CT score (0.13-0.15) and Marshall CT classification (0.03-0.05). Moreover, the Stockholm and Helsinki CT scores added the most independent prognostic value in the presence of other known clinical outcome predictors in TBI (6% and 4%, respectively). The aggregate traumatic subarachnoid hemorrhage (tSAH) component of the Stockholm CT score was the strongest predictor of unfavorable outcome. The main limitations were the retrospective nature of the study, missing patient information, and the varying follow-up time between the centers. CONCLUSIONS: The Stockholm and Helsinki CT scores provide more information on the damage sustained, and give a more accurate outcome prediction, than earlier classification systems. The strong independent predictive value of tSAH may reflect an underrated component of TBI pathophysiology. A change to these newer CT scoring systems may be warranted.
Asunto(s)
Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Tomografía Computarizada por Rayos X/normas , Adulto , Anciano , Lesiones Traumáticas del Encéfalo/epidemiología , Femenino , Finlandia/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Prevalencia , Pronóstico , Estudios Retrospectivos , Suecia/epidemiologíaRESUMEN
Traumatic brain injury (TBI) is a common cause of death and disability, worldwide. Early determination of injury severity is essential to improve care. Neurofilament light (NF-L) has been introduced as a marker of neuroaxonal injury in neuroinflammatory/-degenerative diseases. In this study we determined the predictive power of serum (s-) and cerebrospinal fluid (CSF-) NF-L levels towards outcome, and explored their potential correlation to diffuse axonal injury (DAI). A total of 182 patients suffering from TBI admitted to the neurointensive care unit at a level 1 trauma center were included. S-NF-L levels were acquired, together with S100B and neuron-specific enolase (NSE). CSF-NF-L was measured in a subcohort (n = 84) with ventriculostomies. Clinical and neuro-radiological parameters, including computerized tomography (CT) and magnetic resonance imaging, were included in the analyses. Outcome was assessed 6 to 12 months after injury using the Glasgow Outcome Score (1-5). In univariate proportional odds analyses mean s-NF-L, -S100B and -NSE levels presented a pseudo-R2 Nagelkerke of 0.062, 0.214 and 0.074 in correlation to outcome, respectively. In a multivariate analysis, in addition to a model including core parameters (pseudo-R2 0.33 towards outcome; Age, Glasgow Coma Scale, pupil response, Stockholm CT score, abbreviated injury severity score, S100B), S-NF-L yielded an extra 0.023 pseudo-R2 and a significantly better model (p = 0.006) No correlation between DAI or CT assessed-intracranial damage and NF-L was found. Our study thus demonstrates that S-NF-L correlates to TBI outcome, even if used in models with S100B, indicating an independent contribution to the prediction, perhaps by reflecting different pathophysiological processes, not possible to monitor using conventional neuroradiology. Although we did not find a predictive value of NF-L for DAI, this cannot be completely excluded. We suggest further studies, with volume quantification of axonal injury, and a prolonged sampling time, in order to better determine the connection between NF-L and DAI.
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Lesiones Encefálicas/sangre , Lesiones Encefálicas/líquido cefalorraquídeo , Proteínas del Líquido Cefalorraquídeo/análisis , Proteínas de Neurofilamentos/sangre , Proteínas de Neurofilamentos/líquido cefalorraquídeo , Adulto , Anciano , Anciano de 80 o más Años , Axones/patología , Daño Encefálico Crónico/epidemiología , Daño Encefálico Crónico/etiología , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/diagnóstico por imagen , Lesiones Encefálicas/mortalidad , Femenino , Estudios de Seguimiento , Escala de Coma de Glasgow , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Fosfopiruvato Hidratasa/sangre , Pronóstico , Reflejo Pupilar , Estudios Retrospectivos , Subunidad beta de la Proteína de Unión al Calcio S100/sangre , Tomografía Computarizada por Rayos X , Índices de Gravedad del TraumaRESUMEN
We report a patient with intracranial hemorrhage secondary to venous hypertension as a result of a giant aortic pseudoaneurysm that compressed the superior vena cava and caused obstruction of the venous return from the brain. To our knowledge, this is the first patient reported to have an intracranial hemorrhage secondary to a superior vena cava syndrome. The condition appears to be caused by a reversible transient rise in intracranial pressure, as a result of compression of the venous return from the brain. Treatment consisted of surgery for the aortic pseudoaneurysm, which led to normalization of the intracranial pressure and resorption of the intracranial hemorrhage.
Asunto(s)
Aneurisma Falso/complicaciones , Hemorragias Intracraneales/etiología , Hipertensión Intracraneal/etiología , Síndrome de la Vena Cava Superior/complicaciones , Enfermedades de la Aorta/complicaciones , Femenino , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: Patients presenting unconscious may reasonably be categorized as suffering from a metabolic or structural condition. STUDY OBJECTIVE: The objective was to investigate if some routinely recorded clinical features may help to distinguish between these 2 main forms of coma in the emergency department (ED). METHODS: Adults admitted to an ED in Stockholm between February 2003 and May 2005 with a Glasgow Coma Scale (GCS) score less than 11 were enrolled prospectively. The GCS score was entered into a protocol that was complemented with available data within 1 month. RESULTS: The study population of 875 patients was classified into 2 main groups: one with a metabolic (n = 633; 72%) and one with a structural disorder (n = 242; 28%). Among the clinical features recorded in the ED, 3 were found to be strongly associated with a metabolic disorder, namely, young age, low or normal blood pressure, and absence of focal signs in the neurological examination. Patients younger than 51 years with a systolic blood pressure less than 151 mm Hg who did not display signs of focal pathology had a probability of 96% for having a metabolic coma. The mean GCS score on admission was identical in the groups. Hospital mortality was 14% in the metabolic and 56% in the structural group. CONCLUSIONS: These findings indicate that unconscious young adults who present without a traumatic incident with a low or normal blood pressure and without signs of focal pathology most probably suffer from a metabolic disorder, wherefore computed tomography of the brain may be postponed and often avoided.
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Coma/diagnóstico , Servicio de Urgencia en Hospital , Factores de Edad , Anciano , Presión Sanguínea/fisiología , Coma/clasificación , Coma/etiología , Coma/fisiopatología , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Enfermedades Metabólicas/complicaciones , Enfermedades Metabólicas/diagnóstico , Persona de Mediana Edad , Estudios Prospectivos , Factores SexualesRESUMEN
BACKGROUND: Cerebral microdialysis (MD) is used to monitor local brain chemistry of patients with traumatic brain injury (TBI). Despite an extensive literature on cerebral MD in the clinical setting, it remains unclear how individual levels of real-time MD data are to be interpreted. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are important continuous brain monitors in neurointensive care. They are used as surrogate monitors of cerebral blood flow and have an established relation to outcome. The purpose of this study was to investigate the relations between MD parameters and ICP and/or CPP in patients with TBI. METHODS: Cerebral MD, ICP and CPP were monitored in 90 patients with TBI. Data were extensively analyzed, using over 7,350 samples of complete (hourly) MD data sets (glucose, lactate, pyruvate and glycerol) to seek representations of ICP, CPP and MD that were best correlated. MD catheter positions were located on computed tomography scans as pericontusional or nonpericontusional. MD markers were analyzed for correlations to ICP and CPP using time series regression analysis, mixed effects models and nonlinear (artificial neural networks) computer-based pattern recognition methods. RESULTS: Despite much data indicating highly perturbed metabolism, MD shows weak correlations to ICP and CPP. In contrast, the autocorrelation of MD is high for all markers, even at up to 30 future hours. Consequently, subject identity alone explains 52% to 75% of MD marker variance. This indicates that the dominant metabolic processes monitored with MD are long-term, spanning days or longer. In comparison, short-term (differenced or Δ) changes of MD vs. CPP are significantly correlated in pericontusional locations, but with less than 1% explained variance. Moreover, CPP and ICP were significantly related to outcome based on Glasgow Outcome Scale scores, while no significant relations were found between outcome and MD. CONCLUSIONS: The multitude of highly perturbed local chemistry seen with MD in patients with TBI predominately represents long-term metabolic patterns and is weakly correlated to ICP and CPP. This suggests that disturbances other than pressure and/or flow have a dominant influence on MD levels in patients with TBI.
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Química Encefálica , Lesiones Encefálicas/diagnóstico , Encéfalo/fisiopatología , Cuidados Críticos/métodos , Microdiálisis/métodos , Adolescente , Adulto , Anciano , Cateterismo/métodos , Humanos , Presión Intracraneal , Persona de Mediana Edad , Perfusión , Adulto JovenRESUMEN
Traumatic brain injury (TBI) is responsible for up to 45% of in-hospital trauma mortality. Computed tomography (CT) is central to acute TBI diagnostics, and millions of brain CT scans are conducted yearly worldwide. Though many studies have addressed individual predictors of outcome from findings on CT scans, few have done so from a multivariate perspective. As these parameters are interrelated in a complex manner, there is a need for a better understanding of them in this context. CT scans from 861 TBI patients were reviewed according to an extensive protocol. An extended analysis of CT parameters with respect to outcome was performed using linear and non-linear methods. We identified complex interactions and mutual information in many of the parameters. Variables predicting death differ from those predicting unfavorable versus favorable outcomes (Glasgow Outcome Scale scores of 1-3 versus 4-5 [GOS]). The most important parameter for prediction of unfavorable outcome is the magnitude of midline shift. In fact, this parameter, as a continuous variable, is by itself a better predictor and is better calibrated than the Marshall CT score, even for predicting death. In addition, hematoma volumes are nearly co-linear with midline shift and can be substituted for it. A score of traumatic subarachnoid/intraventricular blood components adds substantially to model calibration. A CT scoring system geared toward dichotomous GOS scores is suggested. CT parameters were found to add 6-10% additional estimated explained variance in the presence of the important clinical variables of age, Glasgow Coma Scale score, and pupillary response. Finally we present a practical clinical "rule of thumb" to help predict the probability of unfavorable outcome using clinical and CT variables.
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Lesiones Encefálicas/diagnóstico por imagen , Lesiones Encefálicas/patología , Encéfalo/diagnóstico por imagen , Encéfalo/patología , Procesamiento de Imagen Asistido por Computador/métodos , Tomografía Computarizada por Rayos X/métodos , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Encéfalo/fisiopatología , Lesiones Encefálicas/terapia , Hemorragia Cerebral Traumática/diagnóstico por imagen , Hemorragia Cerebral Traumática/patología , Hemorragia Cerebral Traumática/terapia , Interpretación Estadística de Datos , Progresión de la Enfermedad , Femenino , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Evaluación de Resultado en la Atención de Salud/métodos , Valor Predictivo de las Pruebas , Pronóstico , Trastornos de la Pupila/diagnóstico , Trastornos de la Pupila/etiología , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea Traumática/diagnóstico por imagen , Hemorragia Subaracnoidea Traumática/patología , Hemorragia Subaracnoidea Traumática/terapia , Adulto JovenRESUMEN
Functional Magnetic Resonance Imaging, fMRI, is a method for the study of neuronal circuits underlying cognitive, sensory, emotional and motor activities in the living human brain. An important question is whether elderly persons and patients with cognitive deficits differ from others as regards neuronal activation. Not many studies have been published but some of them have shown surprising results. This new research has shown some very interesting new facts about the vascular response and the regulation of the microvasculature in the brain. Most fMRI studies have been performed on healthy young males, but in our opinion this method could reveal new findings to complete the picture of human cognition if studies were to be performed involving elderly people and patients with dementia.