[Progress in application of adult endogenous neurogenesis in brain injury repair].

Persistent neurogenesis exists in the subventricular zone (SVZ) of the ventricles and the subgranular zone (SGZ) of the dentate gyrus of the hippocampus in the adult mammalian brain. Adult endogenous neurogenesis not only plays an important role in the normal brain function, but also has important significance in the repair and treatment of brain injury or brain diseases. This article reviews the process of adult endogenous neurogenesis and its application in the repair of traumatic brain injury (TBI) or ischemic stroke, and discusses the strategies of activating adult endogenous neurogenesis to repair brain injury and its practical significance in promoting functional recovery after brain injury.

Extracorporeal membrane oxygenation use in patients with traumatic brain injury.

Venovenous extracorporeal membrane oxygenation (ECMO) is used for patients with severe, potentially reversible, respiratory failure unresponsive to conventional management. It is relatively contraindicated in patients with traumatic brain injury (TBI) due to bleeding complications and use of anticoagulation. We report two cases of TBI patients treated with ECMO.

Bilateral remote cerebellar haemorrhage after spinal surgery: a case study and review of the literature.

BACKGROUND: Remote cerebellar haemorrhage is a rare and unpredictable complication after intracranial and spinal surgery, although less frequently found in the latter. The physiopathology of this phenomenon has not been definitely explained. OBJECTIVES: To describe and discuss the potential implications and pathomechanism of a bilateral remote cerebellar haemorrhage case after spinal surgery and review the literature related to this rare phenomenon. CASE REPORT: A 75 year-old man developed bilateral remote cerebellar haemorrhage after a lumbar laminectomy. Brain CT and MRI examinations showed chronic bilateral remote cerebellar haemorrhage, right haemoventricle and bilateral supratentorial subarachnoid haemorrhage. Subsequently, the patient underwent rehabilitation therapy with improvement of symptoms. CONCLUSION: When large cerebrospinal fluid loss is observed during spinal surgery, brain imaging study should be carried out. The pathogenetic hypothesis of microcirculation vessels tearing, the role of previous spinal surgery and of cerebellar atrophy should be considered and validated with further investigation.

Traumatic brain injury and its effect on coagulopathy.

Polytraumatic injury results in tissue factor (TF) release from damaged cells. The acute coagulopathy of trauma (ACT) occurs early and results from significant tissue injury and tissue hypoperfusion. ACT is augmented by therapies resulting in acidemia, hypothermia, and hemodilution contributing to trauma-induced coagulopathy. Coagulopathy associated with traumatic brain injury (TBI) results from the interplay of numerous variables. Because of the high concentration of TF in brain tissue, TBI has been believed to be associated with a greater degree of coagulopathy compared with injury in other body systems. TBI has also recently been shown to cause platelet dysfunction. Platelet receptor inhibition prevents cellular initiation and amplification of the clotting cascade, limiting thrombin incorporation, and stabilization of clot to stop hemorrhage. Therefore, head injury in the presence of polytrauma does appear to augment ACT and warrants close monitoring and appropriate intervention.

Ethics, choices, and decisions in acute medicine: a national survey of Norwegian physicians' attitudes.

OBJECTIVE: To study the attitudes of Norwegian physicians to resuscitation of hypothetical patients all at risk of neurological sequelae. DESIGN: Mail-based survey. SETTING: A cohort of Norwegian physicians who are representative of the national physician corps. INTERVENTIONS: A total of 1650 Norwegian physicians (7% of practicing physicians in Norway) received a written questionnaire describing six scenarios of patients all in need of emergency life-saving intervention. Respondents were asked whether they would resuscitate; whether such resuscitation was in the patient's best interest; whether a surrogate's refusal of intervention would be accepted; and whether they would have wanted resuscitation if the patient were their own child, their spouse, or themselves. Positive or negative responses on a four-point Likert scale were recorded. MEASUREMENTS AND MAIN RESULTS: A total of 1,069 respondents (response rate, 65%). Physicians responding to these scenarios were a) more inclined to resuscitate an anonymous patient than if the patient were themselves or their kin; b) willing to resuscitate although they do not consider this intervention to be in the patient's best interest; c) willing to refrain from resuscitation on surrogate request in spite of a reasonably good prognosis; d) willing to accept surrogate's refusal of resuscitation in spite of a stated opinion that such intervention would be in the patient's best interest; and e) less willing to resuscitate newborn infants compared with older children and adults (except the aged) with similar prognoses. CONCLUSION: There appear to be differences in medical thinking about best interest, surrogate decision making, and the relative value of lives as far as these are applied to acute, life-saving treatment.

Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature.

OBJECTIVE: To evaluate the efficacy of routine follow-up CT scans of the head after complicated mild traumatic brain injury (TBI). METHODS: 74 English language studies published from 1999 to February 2011 were reviewed. The papers were found by searching the PubMed database using a combination of keywords according to Cochrane guidelines. Excluding studies with missing or inappropriate data, 1630 patients in 19 studies met the inclusion criteria: complicated mild TBI, defined as a GCS score 13-15 with abnormal initial CT findings and the presence of follow-up CT scans. For these studies, the progression and type of intracranial haemorrhage, time from trauma to first scan, time between first and second scans, whether second scans were obtained routinely or for neurological decline and the number of patients who had a neurosurgical intervention were recorded. RESULTS: Routine follow-up CT scans showed hemorrhagic progression in 324 patients (19.9%). Routine follow-up head CT scans did not predict the need for neurosurgical intervention (p=0.10) but a CT scan of the head performed for decline in status did (p=0.00046). For the 56 patients (3.4%) who declined neurologically, findings on the second CT scan were worse in 38 subjects (67%) and unchanged in the rest. Overall, 39 patients (2.4%) underwent neurosurgical intervention. CONCLUSION: Routine follow-up CT scans rarely alter treatment for patients with complicated mild TBI. Follow-up CT scans based on neurological decline alter treatment five times more often than routine follow-up CT scans.

Does ventricular opening promote remote cerebellar haemorrhage?

Cerebellar haemorrhage after supratentorial craniotomy is a rare complication Because of its significant morbidity and mortality rates, being aware of this complication is important for early diagnosis. In a 30-year-old male with multiple intracranial cavernomas, remote cerebellar haemorrhage (RCH) was observed after removal of symptomatic left temporal lesion. The lateral wall of the temporal horn that was tightly attached to the cavernoma was also opened and excessive drainage of the CSF occurred. The haemorrhage is attributed to opening of the ventricle wall and excessive drainage of cerebrospinal fluid (CSF) during the procedure.

[Factors indicative of differentiated approach to the treatment of severe focal lesions of the brain].

The article is devoted the study of complex research 126 patients with a heavy craniocerebral trauma, accompanied vnutrimozgovoy traumatic haematoma and hearth crushing of cerebrum, passing treatment in the clinic of neuro-surgery. The use of modern diagnostic methods of research considerably changed the informative providing of diagnostic and medical process at the different hearth defeats of cerebrum, including traumatic hearth injuries of cerebrum. The long-term looking after intracraneal haematomas allowed to mark that haematomas suffer successive changes which are expressly traced on computer tomography researches in course of time.

Relationships among hematoma diameter, location categorized by vascular territory, and 1-year outcome in patients with cerebellar hemorrhage.

OBJECTIVE: Some studies have investigated the relationship between anatomic location and outcome in patients with cerebellar hemorrhage (CH), but not as yet the relationship between location of CH, as categorized according to vascular territory, and outcome. Furthermore, other studies have shown that taking antithrombotics was related to having CH; however, there have been no studies assessing the relationship between antithrombotics and the location of CH. The aim of this study was to determine whether the outcome of patients with CH at 1-year after onset differed depending on antithrombotic use and lesion location. METHODS: A retrospective, single-institution study involving 53 patients with CH was conducted. Location of the CH, categorized by vascular territory, was classified as either superior cerebellar artery hemorrhage (SCAH), anterior inferior cerebellar artery hemorrhage, or posterior inferior cerebellar artery hemorrhage. Outcome was evaluated using the modified Rankin scale (mRS) and mRS was divided into good (mRS ≤2) or poor (mRS ≥3). RESULTS: Thirty-four patients had SCAH, 5 had anterior inferior cerebellar artery hemorrhage, and 14 had posterior inferior cerebellar artery hemorrhage. Patients with poor outcome had higher proportions of Glasgow coma scale score ≤8, SCAH, intraventricular bleeding, hydrocephalus, and maximal transverse diameter ≥30 mm by univariate analysis. After multivariate analysis, Glasgow coma scale score ≤8 and SCAH showed a significant association with poor outcome. CONCLUSIONS: Outcome at 1-year after onset differed by location of the CH lesion as categorized according to vascular territory. SCAH was related to poor outcome by a larger maximal transverse diameter of hematoma and hydrocephalus.

[Special aspects of the emergency medical care of head and neck injuries]. / Besonderheiten der notärztlichen Versorgung von Kopf-/Halsverletzten.

The overall incidence of severe head, face and neck injuries as seen from the German Trauma Registry of the National Association of German Trauma Surgeons is 81.3%. The leading causes of death among these patients are hemorrhage and severe traumatic brain injury. The aim of prehospital emergency medical care is to stabilize vital functions in order to ensure primary survival and to reduce morbidity with appropriate prehospital treatment of the individual injuries within the overall injury pattern. In this review, special aspects as well as pitfalls of the prehospital management of patients with head, face and neck injuries are demonstrated. Prehospital airway management concepts as well as concepts for stopping bleeding in the head, face and neck region are discussed in detail.

Predictors of functional recovery in African patients with traumatic intracranial hematomas.

BACKGROUND: Head injury is a critical public health problem responsible for up to 50% of fatalities among trauma patients and for a large component of continuing care among survivors. Intracranial hematomas are among the most common clinical entities encountered by any neurosurgical service and have a very high mortality rate and extremely poor prognosis among traumatic brain injuries. OBJECTIVE: The purpose of this study was to investigate reliable factors influencing the functional outcome of the patients with traumatic intracranial hematomas (ICHs). METHODS: A retrospective analysis was conducted of consecutive patients presenting at the Kenyatta National Hospital between January 2000 and December 2009. Following ethical approval, the records of patients admitted to the neurosurgical unit and diagnosed with traumatic ICH were retrieved and reviewed. The outcome measure was the Glasgow Outcome Scale (GOS) score at discharge. Data were collected in preformed questionnaires, and the coding and analysis were carried out using SPSS, version 11.5. RESULTS: Of the 608 patients diagnosed with intracranial hematomas during the study period, there was a clear male predominance, with 89.3% male and 10.7% female patients. Majority of the patients (49%) were aged between 26 and 45 years, whereas 5.6% and 9.4% were younger than age 13 years and older than age 61 years, respectively. The most common cause of injury was assault (48%). Good functional recovery was achieved by 280 (46.1%) of the patients in our series, whereas moderate and severe disability accounted for 27% and 6.9%, respectively. Males were more likely to have functional recovery (46.4%) than were females (43.1%), though this finding was not statistically significant (P = 0.069). The proportion of patients who achieved functional recovery seemed to decrease with increasing age. Patients who were involved in motor vehicle accidents were less likely to have functional recovery (33.7%, P = 0.003) than those who fell (53.6%). There was a statistically significant difference in the proportion of patients who achieved functional recovery, with 65.2% of those who had mild head injury as compared to 46% and 15.1% (P ≤ 0.001) for those with moderate and severe head injury, respectively. Patients who had surgical intervention were more likely to achieve functional outcome (51.2%) as compared to 31.7% in those managed conservatively. Furthermore, the time elapsed from initial trauma to surgery significantly influenced outcome. The type of surgery done was not found to significantly influence patient outcome (P = 0.095). CONCLUSION: An increased risk of poor outcome occurs in patients who are older than age 61 years, have lower preoperative GCS scores, pupillary abnormalities, and a long interval between trauma and decompression. The findings would help clinicians determine management criteria and improve survival.

Neuroanesthesiology review--2006.

In this article, we will provide a review of the 2006 literature of interest to those readers who provide perioperative care to patients with neurologic disease. This evaluation of the literature is not intended to be comprehensive, nor were systematic criteria used to include or exclude articles. Instead, the authors attempted to highlight those articles of greatest clinical relevance or those that provided unique insights into the physiology, pharmacology, and pathomechanisms of neurologic function for practicing clinicians and clinician-investigators. This article focuses on intracranial hemorrhage, anesthetic considerations in neurosurgical patients, cerebral hemodynamics, electrophysiologic monitoring, neuroprotection, and traumatic brain injury.

[Uncontrollable bleeding in a patient with head trauma treated with blood component therapy guided by thromboelastography]. / Ukontrollabel blødning hos en patient med hovedtraume behandlet med blodkomponentterapi vejledt af tromboelastografi.

This is a case report concerning a patient with traumatic uncontrolled bleeding. The patient was admitted with a severe head injury and facial fractures. During neurosurgery, the bleeding became life-threatening and there was a request for recombinant factor VIIa therapy (NovoSeven). Before the treatment, thromboelastography was performed. This showed platelet insufficiency, and after infusion of platelets, the bleeding was under control and there was no longer a need for recombinant factor VIIa therapy. We therefore recommend thromboelastography to evaluate coagulation status before treatment with recombinant factor VIIa.

[Cerebral circulatory autoregulation as a guide for controlling the parameters of assisted ventilation in acute severe brain injury].

The paper presents the results of cerebral circulation (CC) in 17 ventilated patients with severe brain injury in its acute phase. All the patients developed traumatic subarachnoidal hemorrhage, which was accompanied with angiospasm in the majority of cases. Doppler transcranial study (DTCS) was performed, by using the carotid compression test; the findings correlated with paCO2 and CV parameters. A dynamic study was performed every two days starting from their admission to an intensive care unit to the recovery from coma or normalization of CC parameters. The dilation and constriction components of the CC reserve were assessed from the results of this test and continued to be controlled during therapy. Thus, this paper shows the possibility of goal-oriented correction of CC autoregulation and optimization by selecting the parameters of assisted ventilation and by changing paCO2 under the guidance of Doppler transcranial study.

Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation.

BACKGROUND: Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. METHODS: Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. RESULTS: Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1). CONCLUSIONS: Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.

Cutaneous stimulation improves function of a chronic patient with cerebellar damage.

The prognosis of cerebellar hemorrhage with brain stem compression is known to be poor, and patients who can usually survive are severely disabled with limited benefit from conventional rehabilitation. An innovative cutaneous stimulation was administered to a chronic patient (2 years after the incidence) who has severe ataxia, gait imbalance and limb spasticity caused by cerebellar hemorrhage. After 8 months of intervention, patient's function as evaluated by two functional measures has improved by 40%. In addition, the patient's ataxia and hypotonia have improved significantly in which he has regained the abilities to grasp objects, sit upright, control his equilibrium, and monitor an electric wheelchair. The present case study demonstrated a significant improvement of a chronic severely disabled patient who received the intervention 2 years after the accident, suggesting that the cutaneous stimulation may be a possible effective neurologic intervention.