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1.
Sci Rep ; 11(1): 2745, 2021 02 02.
Artigo em Inglês | MEDLINE | ID: mdl-33531533

RESUMO

This study aimed to compare gait analysis and balance function measurements, such as the Berg balance scale (BBS) score to seek specific measurements that can represent the balance functions of patients with brain lesions. Additionally, we also compared other different gait function scale scores with gait analysis measurements. This study included 77 patients with brain lesions admitted to our institution between January 2017 and August 2020. Their gait analysis parameters and clinical data, including personal data; clinical diagnosis; duration of the disease; cognition, ambulation, and stair-climbing sub-scores of the modified Barthel index (MBI); manual muscle test (MMT) findings of both lower extremities; functional ambulation category (FAC); and BBS score, were retrospectively analyzed. A multiple linear regression analysis was performed to identify the gait analysis parameters that would significantly correlate with the balance function and other physical performances. In the results, the BBS scores were significantly correlated with the gait speed and step width/height2. However, the other gait function measurements, such as the FAC and ambulation and stair-climbing sub-scores of the MBI, were correlated only with the gait speed. Additionally, both the summations of the lower extremity MMT findings and anti-gravity lower extremity MMT findings were correlated with the average swing phase time. Therefore, in the gait analysis, the gait speed may be an important factor in determining the balance and gait functions of the patients with brain lesions. Moreover, the step width/height2 may be a significant factor in determining their balance function. However, further studies with larger sample sizes should be performed to confirm this relationship.


Assuntos
Análise da Marcha/métodos , Transtornos Neurológicos da Marcha/diagnóstico , Hemorragia Intracraniana Traumática/complicações , Acidente Vascular Cerebral/complicações , Hemorragia Subaracnóidea/complicações , Adulto , Idoso , Encéfalo/irrigação sanguínea , Encéfalo/fisiopatologia , Feminino , Transtornos Neurológicos da Marcha/etiologia , Transtornos Neurológicos da Marcha/fisiopatologia , Humanos , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Equilíbrio Postural/fisiologia , Estudos Retrospectivos , Análise Espaço-Temporal , Acidente Vascular Cerebral/fisiopatologia , Hemorragia Subaracnóidea/fisiopatologia , Caminhada/fisiologia , Adulto Jovem
2.
World Neurosurg ; 144: e421-e427, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32890849

RESUMO

BACKGROUND: Traumatic intracranial hemorrhage (TICH) is one of the commonest indications for neurosurgical consultation after trauma. Worsening neurologic examination results, size of initial TICH, presence of displaced skull fracture, and concomitant anticoagulant use at the time of injury drive the recommendations for repeat computed tomography of head (RCTH), to assess for stability of intracranial hemorrhage. Chronic alcohol use is not generally considered an indication for repeat head computed tomography (CT). METHODS: A retrospective study of 423 patients with TICH with normal admission platelet (PLT) counts was reviewed for this study, taken as a subset of 1330 patients with TICH admitted to Lahey Hospital and Medical Center over a 3-year period. Of these 423 patients, 330 were classified as nonalcoholics and 93 were classified as alcoholics, based on whether alcohol use disorder was documented in the patient's medical record, present before injury. The normal PLT level was defined as ≥100,000 µ/L. Patients were excluded from review if they had comorbid conditions that could cause PLT dysfunction or coagulopathy. Continuous and categorical variables were compared using independent t test and χ2, respectively. Binary logistic regression was used to predict outcome: stable versus worsening of TICH on RCTH. Statistical analysis was conducted using SPSS version 25. RESULTS: The mean age of the nonalcoholic and alcoholic cohorts were 71.9 years and 54.8 years, respectively. A significantly higher percentage of alcoholics were male. There was a statistically significant difference (χ2 = 8.14; P < 0.004) in radiologic progression of TICH between the 2 groups, with the alcoholics having a worsening RCTH 16.1% of the time compared with only 6.7% in nonalcoholics. Chronic alcohol use was an independent predictor of radiologic progression in patients with normal PLT level (odds ratio, 2.69; confidence interval, 1.34-5.43; P < 0.006). CONCLUSIONS: Chronic alcohol use was an independent predictor of radiologic progression of TICH in the setting of normal PLT level. Modification of this risk of progression with transfusion of fresh PLTs in chronic alcoholic patients with TICH needs to be investigated in a prospective trial.


Assuntos
Alcoolismo/complicações , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/patologia , Idoso , Doença Crônica , Progressão da Doença , Feminino , Humanos , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
3.
World Neurosurg ; 142: e95-e100, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32561488

RESUMO

BACKGROUND: Andexanet alfa, a novel anticoagulation reversal agent for factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors study established the efficacy of andexanet alfa in reversing factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood. The objective of this study was to determine progression rates of patients with traumatic intracranial hemorrhage on factor Xa inhibitors prior to hospitalization who were managed without the use of andexanet alfa. METHODS: A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans. RESULTS: We identified 25 patients meeting the inclusion criteria. Two patients were excluded because of a lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 were (48%) on rivaroxaban. On admission CT scan, 14 patients had subdural hematoma, 6 had traumatic intraparenchymal hemorrhage, and 3 had subarachnoid hemorrhage. Anticoagulation reversal was attempted in 17 patients (74%), primarily using 4-factor prothrombin complex concentrate. Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging. CONCLUSIONS: Our results indicate that patients on factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after andexanet alfa administration.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Fator Xa/uso terapêutico , Hemorragia Intracraniana Traumática/tratamento farmacológico , Proteínas Recombinantes/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/tratamento farmacológico , Hemorragia Cerebral Traumática/diagnóstico por imagem , Hemorragia Cerebral Traumática/tratamento farmacológico , Hemorragia Cerebral Traumática/fisiopatologia , Estudos de Coortes , Progressão da Doença , Inibidores do Fator Xa/uso terapêutico , Feminino , Escala de Coma de Glasgow , Hematoma Subdural Intracraniano/diagnóstico por imagem , Hematoma Subdural Intracraniano/tratamento farmacológico , Hematoma Subdural Intracraniano/fisiopatologia , Hemostasia , Humanos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Plasma , Transfusão de Plaquetas , Pirazóis/efeitos adversos , Pirazóis/uso terapêutico , Piridonas/efeitos adversos , Piridonas/uso terapêutico , Estudos Retrospectivos , Risco , Fatores de Risco , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico , Hemorragia Subaracnoídea Traumática/diagnóstico por imagem , Hemorragia Subaracnoídea Traumática/tratamento farmacológico , Hemorragia Subaracnoídea Traumática/fisiopatologia , Tomografia Computadorizada por Raios X , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle
4.
Neurocrit Care ; 32(2): 407-418, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32034657

RESUMO

BACKGROUND: With increasing use of direct oral anticoagulants (DOACs) and availability of new reversal agents, the risk of traumatic intracranial hemorrhage (tICH) requires better understanding. We compared hemorrhage expansion rates, mortality, and morbidity following tICH in patients treated with vitamin k antagonists (VKA: warfarin) and DOACs (apixaban, rivaroxaban, dabigatran). METHODS: Retrospective chart review of patients from 2010 to 2017 was performed to identify patients with imaging diagnosis of acute traumatic intraparenchymal, subdural, subarachnoid, and epidural hemorrhage with preadmission use of DOACs or VKAs. We identified 39 patients on DOACs and 97 patients on VKAs. Demographic information, comorbidities, hemorrhage size, and expansion over time, as well as discharge disposition and Glasgow Outcome Scale (GOS) were collected. Primary outcome was development of new or enlargement of tICH within the first 48 h of initial CT imaging. RESULTS: Of 136 patients with mean (SD) age 78.7 (13.2) years, most common tICH subtype was subdural hematoma (N = 102/136; 75%), and most common mechanism was a fall (N = 130/136; 95.6%). Majority of patients in the DOAC group did not receive reversal agents (66.7%). Hemorrhage expansion or new hemorrhage occurred in 11.1% in DOAC group vs. 14.6% in VKA group (p = 0.77) at a median of 8 and 11 h from initial ED admission, respectively (p = 0.82). Patients in the DOAC group compared to VKA group had higher median discharge GOS (4 vs. 3 respectively, p = 0.03), higher percentage of patients with good outcome (GOS 4-5, 66.7% vs. 40.2% respectively, p = 0.005), and higher rate of discharge to home or rehabilitation (p = 0.04). CONCLUSIONS: We report anticoagulation-associated tICH outcomes predominantly due to fall-related subdural hematomas. Patients on DOACs had lower tICH expansion rates although not statistically significantly different from VKA-treated patients. DOAC-treated patients had favorable outcomes versus VKA group following tICH despite low use of reversal strategies. DOAC use may be a safer alternative to VKA in patients at risk of traumatic brain hemorrhage.


Assuntos
Anticoagulantes/efeitos adversos , Inibidores do Fator Xa/efeitos adversos , Hemorragia Intracraniana Traumática/fisiopatologia , Varfarina/efeitos adversos , Acidentes por Quedas , Idoso , Idoso de 80 Anos ou mais , Antifibrinolíticos/uso terapêutico , Antitrombinas/efeitos adversos , Fatores de Coagulação Sanguínea/uso terapêutico , Coagulantes/uso terapêutico , Dabigatrana/efeitos adversos , Progressão da Doença , Feminino , Escala de Resultado de Glasgow , Humanos , Hemorragia Intracraniana Traumática/induzido quimicamente , Hemorragia Intracraniana Traumática/terapia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Mortalidade , Procedimentos Neurocirúrgicos , Plasma , Transfusão de Plaquetas , Pirazóis/efeitos adversos , Piridinas/efeitos adversos , Piridonas/efeitos adversos , Estudos Retrospectivos , Rivaroxabana/efeitos adversos , Tiazóis/efeitos adversos , Vitamina K/uso terapêutico
5.
Neurocrit Care ; 32(2): 373-382, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31797278

RESUMO

BACKGROUND: Failure of cerebral autoregulation and progression of intracranial lesion have both been shown to contribute to poor outcome in patients with acute traumatic brain injury (TBI), but the interplay between the two phenomena has not been investigated. Preliminary evidence leads us to hypothesize that brain tissue adjacent to primary injury foci may be more vulnerable to large fluctuations in blood flow in the absence of intact autoregulatory mechanisms. The goal of this study was therefore to assess the influence of cerebrovascular reactivity measures on radiological lesion expansion in a cohort of patients with acute TBI. METHODS: We conducted a retrospective cohort analysis on 50 TBI patients who had undergone high-frequency multimodal intracranial monitoring and for which at least two brain computed tomography (CT) scans had been performed in the acute phase of injury. We first performed univariate analyses on the full cohort to identify non-neurophysiological factors (i.e., initial lesion volume, timing of scan, coagulopathy) associated with traumatic lesion growth in this population. In a subset analysis of 23 patients who had intracranial recording data covering the period between the initial and repeat CT scan, we then correlated changes in serial volumetric lesion measurements with cerebrovascular reactivity metrics derived from the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC (correlation coefficient between the pulse amplitude of intracranial pressure and cerebral perfusion pressure). Using multivariate methods, these results were subsequently adjusted for the non-neurophysiological confounders identified in the univariate analyses. RESULTS: We observed significant positive linear associations between the degree of cerebrovascular reactivity impairment and progression of pericontusional edema. The strongest correlations were observed between edema progression and the following indices of cerebrovascular reactivity between sequential scans: % time PRx > 0.25 (r = 0.69, p = 0.002) and % time PAx > 0.25 (r = 0.64, p = 0.006). These associations remained significant after adjusting for initial lesion volume and mean cerebral perfusion pressure. In contrast, progression of the hemorrhagic core and extra-axial hemorrhage volume did not appear to be strongly influenced by autoregulatory status. CONCLUSIONS: Our preliminary findings suggest a possible link between autoregulatory failure and traumatic edema progression, which warrants re-evaluation in larger-scale prospective studies.


Assuntos
Pressão Arterial/fisiologia , Edema Encefálico/fisiopatologia , Lesões Encefálicas Traumáticas/fisiopatologia , Circulação Cerebrovascular/fisiologia , Hemorragia Intracraniana Traumática/fisiopatologia , Pressão Intracraniana/fisiologia , Adulto , Contusão Encefálica/diagnóstico por imagem , Contusão Encefálica/fisiopatologia , Edema Encefálico/diagnóstico por imagem , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Progressão da Doença , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Homeostase/fisiologia , Humanos , Unidades de Terapia Intensiva , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Adulto Jovem
6.
Arq Neuropsiquiatr ; 77(6): 381-386, 2019 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-31314839

RESUMO

OBJECTIVE: To investigate the expressions of plasma cystatin C (Cys-C), D-dimer (D-D) and hypersensitive C-reactive protein (hs-CRP) in patients with intracranial progressive hemorrhagic injury (IPHI) after craniocerebral injury, and their clinical significance. METHODS: Forty-two IPHI patients and 20 healthy participants (control) were enrolled. The severity and outcome of IPHI were determined according to the Glasgow Coma Scale and Glasgow Outcome Scale, and the plasma Cys-C, hs-CRP and D-D levels were measured. RESULTS: The plasma Cys-C, D-D and hs-CRP levels in the IPHI group were significantly higher than those in the control group (p < 0.01). There were significant differences of plasma Cys-C, D-D and hs-CRP levels among different IPHI patients according to the Glasgow Coma Scale and according to the Glasgow Outcome Scale (all p < 0.05). In the IPHI patients, the plasma Cys-C, D-D and hs-CRP levels were positively correlated with each other (p < 0.001). CONCLUSION: The increase of plasma Cys-C, D-D and hs-CRP levels may be involved in IPHI after craniocerebral injury. The early detection of these indexes may help to understand the severity and outcome of IPHI.


Assuntos
Proteína C-Reativa/análise , Cistatina C/sangue , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hemorragia Intracraniana Traumática/sangue , Adolescente , Adulto , Estudos de Casos e Controles , Criança , Feminino , Escala de Resultado de Glasgow , Humanos , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valores de Referência , Fatores de Risco , Índices de Gravidade do Trauma , Adulto Jovem
7.
Arq. neuropsiquiatr ; 77(6): 381-386, June 2019. tab
Artigo em Inglês | LILACS | ID: biblio-1011358

RESUMO

ABSTRACT Objective To investigate the expressions of plasma cystatin C (Cys-C), D-dimer (D-D) and hypersensitive C-reactive protein (hs-CRP) in patients with intracranial progressive hemorrhagic injury (IPHI) after craniocerebral injury, and their clinical significance. Methods Forty-two IPHI patients and 20 healthy participants (control) were enrolled. The severity and outcome of IPHI were determined according to the Glasgow Coma Scale and Glasgow Outcome Scale, and the plasma Cys-C, hs-CRP and D-D levels were measured. Results The plasma Cys-C, D-D and hs-CRP levels in the IPHI group were significantly higher than those in the control group (p < 0.01). There were significant differences of plasma Cys-C, D-D and hs-CRP levels among different IPHI patients according to the Glasgow Coma Scale and according to the Glasgow Outcome Scale (all p < 0.05). In the IPHI patients, the plasma Cys-C, D-D and hs-CRP levels were positively correlated with each other (p < 0.001). Conclusion The increase of plasma Cys-C, D-D and hs-CRP levels may be involved in IPHI after craniocerebral injury. The early detection of these indexes may help to understand the severity and outcome of IPHI.


RESUMO Objetivo Investigar as expressões da cistatina C plasmática (Cys-C), dímero-D (D-D) e proteína C-reativa hipersensível (hs-CRP) em pacientes com lesão hemorrágica progressiva intracraniana (IPHI) após lesão craniocerebral e seus significados clínicos. Métodos Quarenta e dois pacientes com IPHI e 20 indivíduos saudáveis (controle) foram incluídos. A gravidade e o resultado do IPHI foram determinados de acordo com a Escala de Coma de Glasgow (GCS) e Escala de Resultados de Glasgow (GOS), e os níveis plasmáticos Cys-C, hs-CRP e D-D foram detectados. Resultados Os níveis plasmáticos de Cys-C, D-D e hs-CRP no grupo IPHI foram significativamente maiores do que no grupo controle (P <0,01). Houve diferença significativa entre os níveis plasmáticos de Cys-C, D-D e hs-CRP entre os diferentes pacientes com IPHI de acordo com a GCS e entre os diferentes pacientes com IPHI de acordo com o GOS, respectivamente (todos P <0,05). Em pacientes com IPHI, os níveis plasmáticos de Cys-C, D-D e hs-CRP foram positivamente correlacionados entre si (P <0,001). Conclusão O aumento dos níveis plasmáticos de Cys-C, D-D e hs-CRP pode estar envolvido no IPHI após trauma crânio-encefálico. A detecção precoce desses índices pode ajudar a entender a gravidade e o resultado do IPHI.


Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Proteína C-Reativa/análise , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hemorragia Intracraniana Traumática/sangue , Cistatina C/sangue , Valores de Referência , Estudos de Casos e Controles , Índices de Gravidade do Trauma , Fatores de Risco , Hemorragia Intracraniana Traumática/fisiopatologia , Escala de Resultado de Glasgow
8.
J Med Case Rep ; 13(1): 44, 2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30803441

RESUMO

BACKGROUND: Atlanto-occipital dislocation is a rare and severe injury of the upper spine associated with a very poor prognosis. CASE PRESENTATION: We report the case of a 59-year-old European man who suffered from out-of-hospital cardiac arrest following a motor vehicle accident. Cardiopulmonary resuscitation was initiated immediately by bystanders and continued by emergency medical services. After 30 minutes of cardiopulmonary resuscitation with a total of five shocks following initial ventricular fibrillation, return of spontaneous circulation was achieved. An electrocardiogram recorded after return of spontaneous circulation at the scene showed signs of myocardial ischemia as a possible cause for the cardiac arrest. No visible signs of injury were found. He was transferred to the regional academic trauma center. Following an extended diagnostic and therapeutic workup in the emergency room, including extended focused assessment with sonography for trauma ultrasound, whole-body computed tomography, and magnetic resonance imaging (of his head and neck), a diagnosis of major trauma (atlanto-occipital dislocation, bilateral serial rip fractures and pneumothoraces, several severe intracranial bleedings, and other injuries) was made. An unfavorable outcome was initially expected due to suspected tetraplegia and his inability to breathe following atlanto-occipital dislocation. Contrary to initial prognostication, after 22 days of intensive care treatment and four surgical interventions (halo fixation, tracheostomy, intracranial pressure probe, chest drains) he was awake and oriented, spontaneously breathing, and moving his arms and legs. Six weeks after the event he was able to walk without aid. After 2 months of clinical treatment he was able to manage all the activities of daily life on his own. It remains unclear, whether cardiac arrest due to a cardiac cause resulted in complete atony of the paravertebral muscles and caused this extremely severe lesion (atlanto-occipital dislocation) or whether cardiac arrest was caused by apnea due the paraplegia following the spinal injury of the trauma. CONCLUSIONS: A plausible cause for the trauma was myocardial infarction which led to the car accident and the major trauma in relation to the obviously minor trauma mechanism. With this case report we aim to familiarize clinicians with the mechanism of injury that will assist in the diagnosis of atlanto-occipital dislocation. Furthermore, we seek to emphasize that patients presenting with electrocardiographic signs of myocardial ischemia after high-energy trauma should primarily be transported to a trauma facility in a percutaneous coronary intervention-capable center rather than the catheterization laboratory directly.


Assuntos
Acidentes de Trânsito , Articulação Atlantoccipital/lesões , Hemorragia Intracraniana Traumática/fisiopatologia , Luxações Articulares/fisiopatologia , Parada Cardíaca Extra-Hospitalar/terapia , Recuperação de Função Fisiológica/fisiologia , Traumatismos da Coluna Vertebral/fisiopatologia , Articulação Atlantoccipital/diagnóstico por imagem , Vértebras Cervicais/diagnóstico por imagem , Cuidados Críticos , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Luxações Articulares/complicações , Luxações Articulares/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Ressuscitação , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento
10.
Eur J Trauma Emerg Surg ; 45(5): 901-907, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29550926

RESUMO

PURPOSE: Head trauma is common in the emergency department. Identifying the few patients with serious injuries is time consuming and leads to many computerized tomographies (CTs). Reducing the number of CTs would reduce cost and radiation. The aim of this study was to evaluate the characteristics of adults with head trauma over a 1-year period to identify clinical features predicting intracranial hemorrhage. METHODS: Medical record data have been collected retrospectively in adult patients with traumatic brain injury. A total of 1638 patients over a period of 384 days were reviewed, and 33 parameters were extracted. Patients with high-energy multitrauma managed with ATLS™ were excluded. The analysis was done with emphasis on patient history, clinical findings, and epidemiological traits. Logistic regression and descriptive statistics were applied. RESULTS: Median age was 58 years (18-101, IQR 35-77). High age, minor head injury, new neurological deficits, and low trauma energy level correlated with intracranial hemorrhage. Patients younger than 59 years, without anticoagulation or antiplatelet therapy who suffered low-energy trauma, had no intracranial hemorrhages. The hemorrhage frequency in the entire cohort was 4.3% (70/1638). In subgroup taking anticoagulants, the frequency of intracranial hemorrhage was 8.6% (10/116), and in the platelet-inhibitor subgroup, it was 11.8% (20/169). CONCLUSION: This study demonstrates that patients younger than 59 years with low-energy head trauma, who were not on anticoagulants or platelet inhibitors could possibly be discharged based on patient history. Maybe, there is no need for as extensive medical examination as currently recommended. These findings merit further studies.


Assuntos
Concussão Encefálica/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hemorragia Intracraniana Traumática/prevenção & controle , Centros de Traumatologia/estatística & dados numéricos , Adulto , Idoso , Anticoagulantes/uso terapêutico , Concussão Encefálica/diagnóstico , Concussão Encefálica/fisiopatologia , Feminino , Escala de Coma de Glasgow , Humanos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Neuroimagem , Guias de Prática Clínica como Assunto , Estudos Retrospectivos
11.
Pediatr Crit Care Med ; 20(4): 372-378, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30575699

RESUMO

OBJECTIVES: To examine cerebral autoregulation in children with complex mild traumatic brain injury. DESIGN: Prospective observational convenience sample. SETTING: PICU at a level I trauma center. PATIENTS: Children with complex mild traumatic brain injury (trauma, admission Glasgow Coma Scale score 13-15 with either abnormal head CT, or history of loss of consciousness). INTERVENTIONS: Cerebral autoregulation was tested using transcranial Doppler ultrasound between admission day 1 and 8. MEASUREMENTS AND MAIN RESULTS: The primary outcome was prevalence of impaired cerebral autoregulation (autoregulation index < 0.4),determined using transcranial Doppler ultrasonography and tilt testing. Secondary outcomes examined factors associated with and evolution and extent of impairment. Cerebral autoregulation testing occurred in 31 children 10 years (SD, 5.2 yr), mostly male (59%) with isolated traumatic brain injury (91%), median admission Glasgow Coma Scale 15, Injury Severity Scores 14.2 (SD, 7.7), traumatic brain injury due to fall (50%), preadmission loss of consciousness (48%), and abnormal head CT scan (97%). Thirty-one children underwent 56 autoregulation tests. Impaired cerebral autoregulation occurred in 15 children (48.4%) who underwent 19 tests; 68% and 32% of tests demonstrated unilateral and bilateral impairment, respectively. Compared with children on median day 6 of admission after traumatic brain injury, impaired autoregulation was most common in the first 5 days after traumatic brain injury (day 1: relative risk, 3.7; 95% CI, 1.9-7.3 vs day 2: relative risk, 2.7; 95% CI, 1.1-6.5 vs day 5: relative risk, 1.33; 95% CI, 0.7-2.3). Children with impaired autoregulation were older (12.3 yr [SD, 1.3 yr] vs 8.7 yr [SD, 1.1 yr]; p = 0.04) and tended to have subdural hematoma (64% vs 44%), epidural hematoma (29% vs 17%), and subarachnoid hemorrhage (36% vs 28%). Eight children (53%) were discharged home with ongoing impaired cerebral autoregulation. CONCLUSIONS: Impaired cerebral autoregulation is common in children with complex mild traumatic brain injury, despite reassuring admission Glasgow Coma Scale 13-15. Children with complex mild traumatic brain injury have abnormal cerebrovascular hemodynamics, mostly during the first 5 days. Impairment commonly extends to the contralateral hemisphere and discharge of children with ongoing impaired cerebral autoregulation is common.


Assuntos
Concussão Encefálica/fisiopatologia , Homeostase/fisiologia , Unidades de Terapia Intensiva Pediátrica , Adolescente , Fatores Etários , Encéfalo/irrigação sanguínea , Concussão Encefálica/diagnóstico por imagem , Concussão Encefálica/epidemiologia , Circulação Cerebrovascular/fisiologia , Criança , Pré-Escolar , Feminino , Escala de Coma de Glasgow , Humanos , Hemorragia Intracraniana Traumática/epidemiologia , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Prevalência , Estudos Prospectivos , Centros de Traumatologia , Ultrassonografia Doppler Transcraniana
12.
Am J Emerg Med ; 37(9): 1694-1698, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30559018

RESUMO

BACKGROUND: Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. METHODS: This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. RESULTS: Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. CONCLUSIONS: RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.


Assuntos
Hemorragia Intracraniana Traumática/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Progressão da Doença , Serviço Hospitalar de Emergência , Feminino , Escala de Coma de Glasgow , Hematoma Epidural Craniano/diagnóstico por imagem , Hematoma Epidural Craniano/fisiopatologia , Hematoma Epidural Craniano/cirurgia , Hematoma Subdural Intracraniano/diagnóstico por imagem , Hematoma Subdural Intracraniano/fisiopatologia , Hematoma Subdural Intracraniano/cirurgia , Humanos , Hemorragia Intracraniana Traumática/fisiopatologia , Hemorragia Intracraniana Traumática/cirurgia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Estudos Retrospectivos , Índice de Gravidade de Doença , Hemorragia Subaracnoídea Traumática/diagnóstico por imagem , Hemorragia Subaracnoídea Traumática/fisiopatologia , Hemorragia Subaracnoídea Traumática/cirurgia
13.
Epileptic Disord ; 20(6): 551-556, 2018 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-30530419

RESUMO

Seizures and other electrophysiological disturbances are an under-recognized cause of coma, focal deficits, and prolonged encephalopathy following subdural hematoma evacuation. In these patients, it is possible that seizures remain unrecognized on scalp EEG. It has been shown that a high burden of seizures and other electrophysiological disturbances exist following surgical evacuation and underlie the encephalopathy commonly seen in this patient population, predisposing them to medical complications and confounding estimates of prognosis. As part of a research protocol, we are performing intraoperative placement of cortical surface (non-parenchyma penetrating) intracranial EEG on patients who present after trauma and require emergent decompressive hemicraniectomy. In this case report of a patient with high-velocity traumatic epidural, subdural, and subarachnoid hemorrhages, we identified frequent non-convulsive seizures or seizure-like SIRPIDs with intracranial cortical surface monitoring that were not identified on simultaneous scalp EEG. Stimulation consistently triggered these electrographic seizures in addition to rhythmic lateralized periodic discharges. His mental status improved rapidly after resolution of these electrographic seizures shortly after increasing antiseizure medications, suggesting that they may have been contributing to his encephalopathy. More research is needed to determine the frequency of this phenomenon and determine whether treatment of such seizures improves patient outcomes.


Assuntos
Córtex Cerebral/fisiopatologia , Hemorragia Intracraniana Traumática/complicações , Convulsões/diagnóstico , Adulto , Eletroencefalografia , Humanos , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Couro Cabeludo/fisiopatologia , Convulsões/etiologia , Convulsões/fisiopatologia
14.
World Neurosurg ; 120: e68-e71, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30055364

RESUMO

BACKGROUND: The exact mechanism, incidence, and risk factors for cerebral vasospasm after traumatic intracranial hemorrhage (ICH) continue to be poorly characterized. The incidence of post-traumatic vasospasm (PTV) varies depending on the detection modality. OBJECTIVE: We aimed to shed light on the predictors, associations, and true incidence of cerebral vasospasm after traumatic ICH using digital subtraction angiography (DSA) as the gold standard. METHODS: We examined a prospectively maintained database of traumatic brain injury (TBI) patients to identify patients with ICH secondary to TBI enrolled between 2002 and 2015 at our trauma center. Patients with TBI-associated ICH and evidence of elevated velocities on transcranial Doppler and computed tomography angiograms, confirmed with DSA were included. The diagnostic cerebral angiograms were evaluated by 2 blinded neurointerventionalists for cerebral vasospasm. Statistical analyses were conducted to determine predictors of PTV. RESULTS: Twenty patients with ICH secondary to TBI and evidence of vasospasm underwent DSAs. Seven patients (7/20; 35%) with traumatic ICH developed cerebral vasospasm and of those, 1 developed delayed cerebral ischemia (1/7; 14%). Of these 7 patients, 6 presented with subarachnoid hemorrhage (6/7; 85%). Vasospasm was substantially more common in patients with a Glasgow Coma Scale <9 (P = 0.017) than in all other groups. CONCLUSIONS: PTV as demonstrated by DCA may be more common than previously reported. Patients who exhibit PTV were more likely to have a Glasgow Coma Scale <9. This subgroup of patients may benefit from more systematic screening for the development of PTV, and earlier monitoring for signs of delayed cerebral ischemia.


Assuntos
Hemorragia Encefálica Traumática/epidemiologia , Hemorragia Cerebral Traumática/epidemiologia , Hemorragia Cerebral Intraventricular/epidemiologia , Escala de Coma de Glasgow , Hematoma Subdural/epidemiologia , Hemorragia Subaracnoídea Traumática/epidemiologia , Vasoespasmo Intracraniano/epidemiologia , Adulto , Angiografia Digital , Hemorragia Encefálica Traumática/diagnóstico por imagem , Hemorragia Encefálica Traumática/fisiopatologia , Angiografia Cerebral , Hemorragia Cerebral Traumática/diagnóstico por imagem , Hemorragia Cerebral Traumática/fisiopatologia , Hemorragia Cerebral Intraventricular/diagnóstico por imagem , Hemorragia Cerebral Intraventricular/fisiopatologia , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Feminino , Hematoma Subdural/diagnóstico por imagem , Hematoma Subdural/fisiopatologia , Humanos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/epidemiologia , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Medição de Risco , Fatores de Risco , Hemorragia Subaracnoídea Traumática/diagnóstico por imagem , Hemorragia Subaracnoídea Traumática/fisiopatologia , Ultrassonografia Doppler Transcraniana , Vasoespasmo Intracraniano/diagnóstico por imagem
15.
Acta Neurochir Suppl ; 126: 21-24, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29492525

RESUMO

OBJECTIVE: The main role of the cerebral arterial compliance (cAC) is to maintain the stiffness of vessels and protect downstream vessels when changing cerebral perfusion pressure. The aim was to examine the flexibility of the cerebral arterial bed based on the assessment of the cAC in patients with traumatic brain injury (TBI) in groups with and without intracranial hematomas (IHs). MATERIALS AND METHODS: We examined 80 patients with TBI (mean age, 35.7 ± 12.8 years; 42 men, 38 women). Group 1 included 41 patients without IH and group 2 included 39 polytraumatized patients with brain compression by IH. Dynamic electrocardiography (ECG)-gated computed tomography angiography (DHCTA) was performed 1-14 days after trauma in group 1 and 2-8 days after surgical evacuation of the hematoma in group 2. Amplitude of arterial blood pressure (ABP), as well as systole and diastole duration were measured noninvasively. Transcranial Doppler was measured simultaneously with DHCTA. The cAC was calculated by the formula proposed by Avezaat. RESULTS: The cAC was significantly decreased (p < 0.001) in both groups 1 and 2 compared with normal data. The cAC in group 2 was significantly decreased compared with group 1, both on the side of the former hematoma (р = 0.017). CONCLUSION: The cAC in TBI gets significantly lower compared with the conditional norm (p < 0.001). After removal of the intracranial hematomas, compliance in the perifocal zone remains much lower (р = 0.017) compared with compliance of the other brain hemisphere.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Artérias Cerebrais/fisiopatologia , Hemorragia Intracraniana Traumática/fisiopatologia , Rigidez Vascular/fisiologia , Adulto , Pressão Arterial , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Estudos de Casos e Controles , Angiografia Cerebral , Artérias Cerebrais/diagnóstico por imagem , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Eletrocardiografia , Feminino , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Ultrassonografia Doppler Transcraniana , Adulto Jovem
16.
Acta Neurochir Suppl ; 126: 25-28, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29492526

RESUMO

OBJECTIVE: The aim was to evaluate changes in cerebrovascular resistance (CVR) in combined traumatic brain injury (CTBI) in groups with and without intracranial hematomas (IH). MATERIALS AND METHODS: Treatment outcomes in 70 patients with CTBI (42 males and 28 females) were studied. Mean age was 35.5 ± 14.8 years (range, 15-73). The patients were divided into two groups: group 1 included 34 CTBI patients without hematomas; group 2 comprised 36 patients with CTBI and IH. The severity according to the Glasgow Coma Scale averaged 10.4 ± 2.6 in group 1, and 10.6 ± 2.8 in group 2. All patients underwent perfusion computed tomography (CT) and transcranial Doppler of both middle cerebral arteries. Cerebral perfusion pressure and CVR were calculated. RESULTS: The mean CVR values in each group (both with and without hematomas) appeared to be statistically significantly higher than the mean normal value. Intergroup comparison of CVR values showed statistically significant increase in the CVR level in group 2 on the side of the removed hematoma (р = 0.037). CVR in the perifocal zone of the removed hematoma remained significantly higher compared with the symmetrical zone in the contralateral hemisphere (p = 0.0009). CONCLUSION: CVR in patients with CTBI is significantly increased compared to the normal value and remains elevated after evacuation of hematoma in the perifocal zone compared to the symmetrical zone in the contralateral hemisphere. This is indicative of certain correlation between the mechanisms of cerebral blood flow autoregulation and maintaining CVR.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Circulação Cerebrovascular/fisiologia , Hemorragia Intracraniana Traumática/fisiopatologia , Artéria Cerebral Média/fisiopatologia , Resistência Vascular/fisiologia , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Estudos de Casos e Controles , Feminino , Escala de Coma de Glasgow , Homeostase , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Imagem de Perfusão , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler Transcraniana , Adulto Jovem
17.
J Pak Med Assoc ; 68(2): 268-271, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29479105

RESUMO

Optic nerve sheath diameter measurement (ONSD) has been associated with identifying the prognosis of traumatic brain injury (TBI) patients. The study was planned to evaluate the prognostic value of ONSD measured on the initial brain computed tomography (CT) scan performed on patients with blunt TBI in the emergency department(ED). This retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of moderate and severe TBI patients from January to December 2014. ONSD for each eye on the initial CT scan and Glasgow Coma Scale (GCS) was measured upon patient presentation. Correlation between presentation GCS and ONSD was done through Pearson's correlation. Receiver operator curve (ROC) analysis was done to measure the predictive values of ONSD for mortality. Of the 276 patients, 211(76%) were males and 65(23%) females. ONSD was measured on 160(58%) patients. The mean ONSD measured on CT scan was 3.8±1. The Pearson's correlation between the severity of brain injury as per GCS at presentation and ONSD was not significant (-0.182). We concluded that ONSD measured on the initial CT brain scan had good association with the severity of blunt TBI in patients presenting to the ED.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Hipertensão Intracraniana/diagnóstico por imagem , Bainha de Mielina/patologia , Nervo Óptico/diagnóstico por imagem , Ferimentos não Penetrantes/diagnóstico por imagem , Acidentes de Trânsito , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/fisiopatologia , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Escala de Coma de Glasgow , Hematoma Epidural Craniano/diagnóstico por imagem , Hematoma Epidural Craniano/mortalidade , Hematoma Epidural Craniano/fisiopatologia , Hematoma Subdural/diagnóstico por imagem , Hematoma Subdural/mortalidade , Hematoma Subdural/fisiopatologia , Humanos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/mortalidade , Hemorragia Intracraniana Traumática/fisiopatologia , Pressão Intracraniana , Masculino , Pessoa de Meia-Idade , Nervo Óptico/patologia , Tamanho do Órgão , Paquistão , Pedestres , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Hemorragia Subaracnoídea Traumática/diagnóstico por imagem , Tomografia Computadorizada por Raios X
18.
Neurol Med Chir (Tokyo) ; 57(8): 418-425, 2017 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-28679968

RESUMO

In recent years, instances of neurotrauma in the elderly have been increasing. This article addresses the clinical characteristics, management strategy, and outcome in elderly patients with traumatic brain injury (TBI). Falls to the ground either from standing or from heights are the most common causes of TBI in the elderly, since both motor and physiological functions are degraded in the elderly. Subdural, contusional and intracerebral hematomas are more common in the elderly than the young as the acute traumatic intracranial lesion. High frequency of those lesions has been proposed to be associated with increased volume of the subdural space resulting from the atrophy of the brain in the elderly. The delayed aggravation of intracranial hematomas has been also explained by such anatomical and physiological changes present in the elderly. Delayed hyperemia/hyperperfusion may also be a characteristic of the elderly TBI, although its mechanisms are not fully understood. In addition, widely used pre-injury anticoagulant and antiplatelet therapies may be associated with delayed aggravation, making the management difficult for elderly TBI. It is an urgent issue to establish preventions and treatments for elderly TBI, since its outcome has been remained poor for more than 40 years.


Assuntos
Lesões Encefálicas Traumáticas/epidemiologia , Acidentes por Quedas/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Atrofia , Encéfalo/patologia , Encéfalo/fisiopatologia , Dano Encefálico Crônico/epidemiologia , Dano Encefálico Crônico/etiologia , Dano Encefálico Crônico/prevenção & controle , Edema Encefálico/etiologia , Edema Encefálico/fisiopatologia , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/terapia , Comorbidade , Gerenciamento Clínico , Progressão da Doença , Humanos , Hiperemia/fisiopatologia , Hemorragia Intracraniana Traumática/etiologia , Hemorragia Intracraniana Traumática/fisiopatologia , Inibidores da Agregação Plaquetária/efeitos adversos , Guias de Prática Clínica como Assunto , Espaço Subdural/patologia , Resultado do Tratamento
19.
Sci Rep ; 6: 37620, 2016 11 29.
Artigo em Inglês | MEDLINE | ID: mdl-27897197

RESUMO

Rapid, on-the-spot diagnostic and monitoring systems are vital for the survival of patients with intracranial hematoma, as their conditions drastically deteriorate with time. To address the limited accessibility, high costs and static structure of currently used MRI and CT scanners, a portable non-invasive multi-slice microwave imaging system is presented for accurate 3D localization of hematoma inside human head. This diagnostic system provides fast data acquisition and imaging compared to the existing systems by means of a compact array of low-profile, unidirectional antennas with wideband operation. The 3D printed low-cost and portable system can be installed in an ambulance for rapid on-site diagnosis by paramedics. In this paper, the multi-slice head imaging system's operating principle is numerically analysed and experimentally validated on realistic head phantoms. Quantitative analyses demonstrate that the multi-slice head imaging system is able to generate better quality reconstructed images providing 70% higher average signal to clutter ratio, 25% enhanced maximum signal to clutter ratio and with around 60% hematoma target localization compared to the previous head imaging systems. Nevertheless, numerical and experimental results demonstrate that previous reported 2D imaging systems are vulnerable to localization error, which is overcome in the presented multi-slice 3D imaging system. The non-ionizing system, which uses safe levels of very low microwave power, is also tested on human subjects. Results of realistic phantom and subjects demonstrate the feasibility of the system in future preclinical trials.


Assuntos
Hemorragia Cerebral/diagnóstico , Imageamento Tridimensional/métodos , Hemorragia Intracraniana Traumática/diagnóstico , Micro-Ondas , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/fisiopatologia , Desenho de Equipamento , Humanos , Processamento de Imagem Assistida por Computador/métodos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/fisiopatologia , Imageamento por Ressonância Magnética
20.
Biomed Res Int ; 2015: 261825, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26457298

RESUMO

Intracranial hemorrhage (ICH) after traumatic brain injury (TBI) commonly increases in size and coagulopathy has been implicated in such progression. Our aim is to perform a meta-analysis to assess their relationship. Cochrane library, PubMed, and EMBASE were searched for literatures. Pooled effect sizes and 95% confidential intervals (CIs) were calculated using random-effects model. We included six studies, involving 1700 participants with 540 progressive hemorrhagic injuries (PHIs). Our findings indicate that PT, D-dimer level, and INR value are positively associated with the risk of PHI. Higher level of PLT and Fg seemed to suggest a lower risk of PHI. Among these parameters, higher D-dimer level and INR value would possess more powerful strength in predicting PHI.


Assuntos
Coagulação Sanguínea , Lesões Encefálicas/sangue , Lesões Encefálicas/fisiopatologia , Hemorragia Intracraniana Traumática/sangue , Hemorragia Intracraniana Traumática/fisiopatologia , Modelos Cardiovasculares , Lesões Encefálicas/complicações , Feminino , Humanos , Hemorragia Intracraniana Traumática/etiologia , Masculino
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