RESUMO
Traumatic subdural hemorrhage (TSH) is an injury between the meningeal membranes, caused by traumas, especially traffic accidents. OBJECTIVE: To describe the mortality rate (MR) due to TSH in the period 2018-2022 in Chile. MATERIALS AND METHODS: Descriptive, observational, and cross-sectional study on MR due to TSH in the period 2018-2022 in Chile, according to gender, age group, regional distribution, place of death, and month of death. Anonymous and public databases were used. No ethics committee approval was required. RESULTS: The average MR due to TSH in Chile from 2018 to 2022 was 0.45/100,000 inhabitants, with a peak in 2018 (0.75) and a minimum in 2021 (0.31). Men had higher rates. Mortality increased with age, especially in those over 80 years. The Metropolitan Region accounted for 35.2% of TSH-related deaths. Hospitals and clinics were the main places of death (67.1%), with more deaths in March, July, and August. DISCUSSION: The MR due to TSH progressively decreased due to medical improvements. Men have higher rates, possibly due to risk factors or biological differences. The reduction in MR in hospitals is linked to changes in the severity and categorization of the place of death. The connection with traffic accidents is significant, especially between March and August, due to the return to academic activities and weather conditions. Additionally, TSH-related deaths are concentrated in densely populated regions with more traffic accidents.
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Humanos , Masculino , Feminino , Recém-Nascido , Lactente , Pré-Escolar , Criança , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Hematoma Subdural Agudo/mortalidade , Hemorragia Subaracnoídea Traumática/mortalidade , Estudos Transversais , Mortalidade , Fatores Etários , Distribuição por Idade e SexoRESUMO
Introduction: Traumatic brain injury is a leading worldwide cause of death and disability in young people. Severity classification is based on the Glasgow Coma Scale. However, the neurological worsening in an acute setting does not always correspond to the initial severity suggesting an underestimation of the real magnitude of the injury. Objective: To study the correlation between the initial severity according to the Glasgow Coma Scale and the patient outcome in the context of different clinical and tomography variables. Materials and methods: We analyzed a retrospective cohort of 490 patients with closed traumatic brain injury requiring a stay in the intensive care unit of two third-level hospitals in Barranquilla. The risk was estimated by calculating the OR (95% CI). The significance level was established at an alpha value of 0.05. Results: Forty-one percent of all patients required orotracheal intubation; 51.2% were initially classified with moderate trauma and 6,0% as mild. The delay in the aggressive management of the traumas affected mainly those patients with traumas classified as moderate in whom lethality increased to 100% when there was delay in the detection of the neurological worsening and in the establishment of the aggressive treatment beyond 4 to 8 hours while the lethality in patients who received this treatment within the first hour reduced to <20%. Conclusions: The risk of lethality in traumatic brain injury increases with the delayed detection of neurological worsening in an acute setting, especially when aggressive management is performed after the first hour post-trauma.
Introducción. El trauma craneoencefálico es una de las principales causas de muerte y discapacidad en adultos jóvenes. Su gravedad se define según la escala de coma de Glasgow. Sin embargo, el deterioro neurológico agudo no siempre concuerda con la gravedad inicial indicada por la escala, lo que implica una subestimación de la magnitud real de la lesión. Objetivo. Estudiar la correlación entre la gravedad inicial del trauma craneoencefálico según la escala de coma de Glasgow y la condición final del paciente, en el contexto de diferentes variables clínicas y de los hallazgos de la tomografía. Materiales y métodos. Se analizó una cohorte retrospectiva de 490 pacientes con trauma craneoencefálico cerrado que requirieron atención en la unidad de cuidados intensivos de dos centros de tercer nivel de Barranquilla. La estimación del riesgo se estableció con la razón de momios (odds ratio, OR) y un intervalo de confianza (IC) del 95 %. Se utilizó un alfa de 0,05 como nivel de significación. Resultados. El 41,0 % de los pacientes requirió intubación endotraqueal; el 51,2 % había presentado traumas inicialmente clasificados como moderados y, el 6,0 %, como leves. El retraso en la implementación de un tratamiento agresivo afectó principalmente a aquellos con trauma craneoencefálico moderado, en quienes la letalidad aumentó al 100 % cuando no se detectó a tiempo el deterioro neurológico y, por lo tanto, el tratamiento agresivo se demoró más de 4 a 8 horas. Por el contrario, la letalidad fue de menos de 20 % cuando se brindó el tratamiento agresivo en el curso de la primera hora después del trauma. Conclusiones. El riesgo de letalidad del trauma craneoencefálico aumentó cuando el deterioro neurológico se detectó tardíamente y el tratamiento agresivo se inició después de transcurrida la primera hora a partir del trauma.
Assuntos
Lesões Encefálicas Traumáticas/complicações , Transtornos da Consciência/etiologia , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/terapia , Criança , Colômbia/epidemiologia , Coma/etiologia , Terapia Combinada , Intervalos de Confiança , Craniectomia Descompressiva , Feminino , Fundações , Escala de Coma de Glasgow , Hospitais Universitários , Humanos , Soluções Hipertônicas/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Hemorragia Subaracnoídea Traumática/complicações , Hemorragia Subaracnoídea Traumática/mortalidade , Hemorragia Subaracnoídea Traumática/terapia , Adulto JovemRESUMO
OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. METHODS: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. CONCLUSION: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.
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Procedimentos Neurocirúrgicos/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Hemorragia Subaracnoídea Traumática/cirurgia , Centros de Traumatologia/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Escala Resumida de Ferimentos , Idoso , Idoso de 80 Anos ou mais , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Hemorragia Subaracnoídea Traumática/mortalidadeRESUMO
In this study, the roles of exosomes (Exo) from bone marrow mesenchymal stem cells (BMSCs) in attenuating early brain injury (EBI) in rat brain after subarachnoid hemorrhage (SAH) had been investigated. The male Sprague-Dawley rats (300-350 g) were used to establish the SAH model using endovascular perforation method. The animals were randomly divided into three groups: sham (n = 25), SAH+PBS (n = 42), and SAH+Exo groups (n = 33). At 1 h after SAH, Exo or phosphate-buffered saline (PBS) was administered by femoral vein injection. The effects of Exo on the mortality, neurological function, brain water content, and blood-brain barrier (BBB) were explored. Furthermore, the expressions of miRNA129-5p and high-mobility group box 1 protein (HMGB1) after Exo treatment were also detected. In addition, immunohistochemistry and western blot were applied to investigate the mechanism of Exo's effects. The results indicated that Exo could improve the neurological functions, reduce brain water content and maintain BBB integrity after SAH. After Exo treatment, the expression of miRNA129-5p was significantly increased, whereas the RNA level of HMGB1 was decreased. The protein levels of proinflammatory and proapoptosis factors, such as HMGB1, Toll-like receptor-4 (TLR4), tumor necrosis factor-α, and p53, were increased after SAH, which were significantly declined after Exo application. The results indicated that Exo from BMSCs could alleviate EBI after SAH through miRNA129-5p's anti-inflammation and antiapoptosis effects through quenching the activity of HMGB1-TLR4 pathway.
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Células da Medula Óssea/metabolismo , Lesões Encefálicas/terapia , Exossomos/transplante , Proteína HMGB1/genética , Células-Tronco Mesenquimais/metabolismo , MicroRNAs/genética , Hemorragia Subaracnoídea Traumática/terapia , Animais , Barreira Hematoencefálica/metabolismo , Células da Medula Óssea/citologia , Lesões Encefálicas/genética , Lesões Encefálicas/mortalidade , Lesões Encefálicas/patologia , Meios de Cultivo Condicionados/química , Meios de Cultivo Condicionados/metabolismo , Exossomos/metabolismo , Regulação da Expressão Gênica , Proteína HMGB1/metabolismo , Masculino , Células-Tronco Mesenquimais/citologia , MicroRNAs/metabolismo , Permeabilidade , Cultura Primária de Células , Ratos , Ratos Sprague-Dawley , Transdução de Sinais , Hemorragia Subaracnoídea Traumática/genética , Hemorragia Subaracnoídea Traumática/mortalidade , Hemorragia Subaracnoídea Traumática/patologia , Análise de Sobrevida , Receptor 4 Toll-Like/genética , Receptor 4 Toll-Like/metabolismoRESUMO
Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.
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Lesões Encefálicas Traumáticas/fisiopatologia , Escala de Resultado de Glasgow , Mortalidade Hospitalar , Escala Resumida de Ferimentos , Acidentes por Quedas , Acidentes de Trânsito , Atividades Cotidianas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Contusão Encefálica/mortalidade , Contusão Encefálica/fisiopatologia , Contusão Encefálica/terapia , Lesões Encefálicas Difusas/fisiopatologia , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/terapia , Hemorragia Cerebral Traumática/mortalidade , Hemorragia Cerebral Traumática/fisiopatologia , Hemorragia Cerebral Traumática/terapia , Hemorragia Cerebral Intraventricular/mortalidade , Hemorragia Cerebral Intraventricular/fisiopatologia , Hemorragia Cerebral Intraventricular/terapia , Estudos de Coortes , Feminino , Hematoma Subdural/mortalidade , Hematoma Subdural/fisiopatologia , Hematoma Subdural/terapia , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Masculino , Mortalidade , Procedimentos Neurocirúrgicos , Razão de Chances , Sistema de Registros , Respiração Artificial , Fraturas Cranianas/mortalidade , Fraturas Cranianas/fisiopatologia , Fraturas Cranianas/terapia , Hemorragia Subaracnoídea Traumática/mortalidade , Hemorragia Subaracnoídea Traumática/fisiopatologia , Hemorragia Subaracnoídea Traumática/terapia , Traqueostomia , VitóriaRESUMO
Traumatic subarachnoid hemorrhage (SAH) is the second most frequent intracranial hemorrhage and a common radiologic finding in computed tomography. This study aimed to estimate the risk of mortality in adult trauma patients with traumatic SAH concurrent with other types of intracranial hemorrhage, such as subdural hematoma (SDH), epidural hematoma (EDH), and intracerebral hemorrhage (ICH), compared to the risk in patients with isolated traumatic SAH. We searched our hospital's trauma database from 1 January, 2009 to 31 December, 2018 to identify hospitalized adult patients ≥20 years old who presented with a trauma abbreviated injury scale (AIS) of ≥3 in the head region. Polytrauma patients with an AIS of ≥3 in any other region of the body were excluded. A total of 1856 patients who had SAH were allocated into four exclusive groups: (Group I) isolated traumatic SAH, n = 788; (Group II) SAH and one diagnosis, n = 509; (Group III) SAH and two diagnoses, n = 493; and (Group IV) SAH and three diagnoses, n = 66. One, two, and three diagnoses indicated occurrences of one, two, or three other types of intracranial hemorrhage (SDH, EDH, or ICH). The adjusted odds ratio with a 95% confidence interval (CI) of the level of mortality was calculated with logistic regression, controlling for sex, age, and pre-existing comorbidities. Patients with isolated traumatic SAH had a lower rate of mortality (1.8%) compared to the other three groups (Group II: 7.9%, Group III: 12.4%, and Group IV: 27.3%, all p < 0.001). When controlling for sex, age, and pre-existing comorbidities, we found that Group II, Group III, and Group IV patients had a 4.0 (95% CI 2.4-6.5), 8.9 (95% CI 4.8-16.5), and 21.1 (95% CI 9.4-47.7) times higher adjusted odds ratio for mortality, respectively, than the patients with isolated traumatic SAH. In this study, we demonstrated that compared to patients with isolated traumatic SAH, traumatic SAH patients with concurrent types of intracranial hemorrhage have a higher adjusted odds ratio for mortality.
Assuntos
Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Estudos Transversais , Feminino , Humanos , Hemorragias Intracranianas/classificação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Hemorragia Subaracnoídea Traumática/etiologia , Hemorragia Subaracnoídea Traumática/mortalidade , Taiwan/epidemiologiaRESUMO
BACKGROUND: Acute subdural hemorrhage often occurs in those ≥65 years of age after trauma and tends to yield poor clinical outcomes. Previous studies have demonstrated a propensity toward high in-hospital mortality rates in this population; however, postdischarge mortality data are limited. The objective of the present study was to analyze short- and long-term mortality data after acute traumatic subdural hemorrhage in the geriatric population as well as review the impact of associated clinical variables including mechanism of injury, pre-morbid antithrombotic use, and need for surgical decompression on mortality rates. METHODS: We retrospectively reviewed 455 patients who presented with an isolated traumatic acute subdural hemorrhage to our level-1 trauma center over a 5 year period using our data registry. Patients were then cross-referenced in the National Social Security Death Index for postdischarge mortality rates. United States life tables were used for peer-controlled actuarial comparisons. RESULTS: Acute traumatic subdural hemorrhage is often a fatal injury in the geriatric population, especially if taking antithrombotics or requiring surgical decompression. Specifically, they have greater in-hospital mortality rates than adults with similar injuries and have significantly lower survival rates for several years following discharge compared with their peer-matched controls. CONCLUSIONS: Here, we found that age is a significant predictor of both short- and long-term survival after acute traumatic subdural hemorrhage. Moreover, the present study corroborates that the need for surgical decompression or the use of pre-morbid antithrombotic medications is associated with increased overall mortality.
Assuntos
Hematoma Subdural Agudo/mortalidade , Hemorragia Subaracnoídea Traumática/mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Fall with head injury is a pervasive challenge, especially in the aging population. Contributing factors for mortality include the development of cerebral contusions and delayed traumatic intracerebral hematoma. Currently, there is no established specific treatment for these conditions. OBJECT: This study aimed to investigate the impact of independent factors on the mortality rate of traumatic brain injury with contusions or traumatic subarachnoid hemorrhage. METHODS: Data were collected from consecutive patients admitted for cerebral contusions or traumatic subarachnoid hemorrhage at an academic trauma center from 2010 to 2016. The primary outcome was the 30-day mortality rate. Independent factors for analysis included patient factors and treatment modalities. Univariate and multivariate analyses were conducted to identify independent factors related to mortality. Secondary outcomes included thromboembolic complication rates associated with the use of tranexamic acid. RESULTS: In total, 651 consecutive patients were identified. For the patient factors, low Glasgow Coma Scale on admission, history of renal impairment, and use of warfarin were identified as independent factors associated with higher mortality from univariate and multivariate analyses. For the treatment modalities, univariate analysis identified tranexamic acid as an independent factor associated with lower mortality (P = 0.021). Thromboembolic events were comparable in patients with or without tranexamic acid. CONCLUSION: Tranexamic acid was identified by univariate analysis as an independent factor associated with lower mortality in cerebral contusions or traumatic subarachnoid hemorrhage. Further prospective studies are needed to validate this finding.
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Contusão Encefálica/tratamento farmacológico , Contusão Encefálica/mortalidade , Hemorragia Subaracnoídea Traumática/mortalidade , Ácido Tranexâmico/farmacologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral Traumática/tratamento farmacológico , Hemorragia Cerebral Traumática/mortalidade , Feminino , Humanos , Hemorragia Intracraniana Traumática/tratamento farmacológico , Hemorragia Intracraniana Traumática/mortalidade , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Hemorragia Subaracnoídea Traumática/cirurgia , Adulto JovemRESUMO
BACKGROUND: Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. We studied the predictors and time-based mortality in patients with isolated and polytrauma brain injuries in a rapidly developing country. We hypothesized that TBI-related 30-day mortality is decreasing over time. METHODS: A retrospective analysis was conducted for all patients with moderate-to-severe TBI who were admitted directly to a level 1 trauma center between 2010 and 2014. Patient's data were analyzed and compared according to survival (survived vs. not survived), time (early death [2 days], intermediate [3-7 days] versus late [>7 days]) post-injury, and type (polytrauma vs. isolated TBI). Cox proportional hazards models were performed for the predictors of mortality. RESULTS: A total of 810 patients were admitted with moderate-to-severe TBI with a median age of 27 years. Traffic-related injury was the main mechanism of TBI (65%). Isolated TBIs represented 22.6% of cases and 56% had head AIS >3. The overall mortality rate was 27%, and most of deaths occurred in the intermediate (40%) and early period (38%). The incidence of TBI was greater in patients aged 21-30 years but the mortality was proportionately higher among elderly. The average annual incidence was 8.43 per 100,000 population with an overall mortality of 2.28 per 100,000 population. Kaplan-Meier curves showed that polytrauma had greater mortality than isolated TBI. However, Cox survival analysis showed that age [Hazard ratio (HR) 1.02], scene GCS (HR 0.86),subarachnoid hemorrhage (HR 1.7), and blood transfusion amount (HR 1.03) were the predictors of mortality regardless of being polytrauma or isolated TBI after controlling for 14 relevant covariates. CONCLUSIONS: The 30-day survival in patients with TBI is improving over the years in Qatar; however, the mortality remains high in the elderly males. The majority of deaths occurred within a week after the injury. Further studies are needed to assess the long-term survival in patients with moderate-to-severe TBI.
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Lesões Encefálicas/mortalidade , Mortalidade Hospitalar , Traumatismo Múltiplo/mortalidade , Escala Resumida de Ferimentos , Adolescente , Adulto , Fatores Etários , Idoso , Transfusão de Sangue/estatística & dados numéricos , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Catar/epidemiologia , Estudos Retrospectivos , Hemorragia Subaracnoídea Traumática/mortalidade , Fatores de Tempo , Centros de Traumatologia , Adulto JovemRESUMO
Background: In contrast to patients with traumatic subarachnoid hemorrhage (tSAH) in the presence of other types of intracranial hemorrhage, the prognosis of patients with isolated tSAH is good. The incidence of mortality in these patients ranges from 0-2.5%. However, few data or predictive models are available for the identification of patients with a high mortality risk. In this study, we aimed to construct a model for mortality prediction using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry, in a Level 1 trauma center. Methods: Five hundred and forty-five patients with isolated tSAH, including 533 patients who survived and 12 who died, between January 2009 and December 2016, were allocated to training (n = 377) or test (n = 168) sets. Using the data on demographics and injury characteristics, as well as laboratory data of the patients, classification and regression tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. Results: In this established DT model, three nodes (head Abbreviated Injury Scale (AIS) score ≤4, creatinine (Cr) <1.4 mg/dL, and age <76 years) were identified as important determinative variables in the prediction of mortality. Of the patients with isolated tSAH, 60% of those with a head AIS >4 died, as did the 57% of those with an AIS score ≤4, but Cr ≥1.4 and age ≥76 years. All patients who did not meet the above-mentioned criteria survived. With all the variables in the model, the DT achieved an accuracy of 97.9% (sensitivity of 90.9% and specificity of 98.1%) and 97.7% (sensitivity of 100% and specificity of 97.7%), for the training set and test set, respectively. Conclusions: The study established a DT model with three nodes (head AIS score ≤4, Cr <1.4, and age <76 years) to predict fatal outcomes in patients with isolated tSAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.
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Árvores de Decisões , Sistema de Registros/estatística & dados numéricos , Hemorragia Subaracnoídea Traumática/mortalidade , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos , Tomografia Computadorizada por Raios X , Índices de Gravidade do TraumaRESUMO
BACKGROUND: Cerebral autoregulation (CA) is a mechanism that compensates for variations in cerebral perfusion pressure (CPP) by changes in cerebral blood flow resistance to keep the cerebral blood flow constant. In this study, the relationship between lethal outcome during hospitalisation and the autoregulation-related indices PRx and Mx was investigated. MATERIALS AND METHODS: Thirty patients (aged 18-77 years, mean 53 ± 16 years) with severe cerebral diseases were studied. Cerebral blood flow velocity (CBFV), arterial blood pressure (ABP) and intracranial pressure (ICP) were repeatedly recorded. CA indices were calculated as the averaged correlation between CBFV and CPP (Mx) and between ABP and ICP (PRx). Positive index values indicated impairment of CA. RESULTS: Six patients died in hospital. In this group both PRx and Mx were significantly higher than in the group of survivors (PRx: 0.41 ± 0.33 vs 0.09 ± 0.25; Mx: 0.28 ± 0.40 vs 0.03 ± 0.21; p = 0.01 and 0.04, respectively). PRx and Mx correlated significantly with Glasgow Outcome Scale (GOS) score (PRx: R = -0.40, p < 0.05; Mx: R = -0.54, p < 0.005). PRx was the only significant risk factor for mortality (p < 0.05, logistic regression). CONCLUSION: Increased PRx and Mx were associated with risk of death in patients with severe cerebral diseases. The relationship with mortality was more pronounced in PRx, whereas Mx showed a better correlation with GOS score.
Assuntos
Encefalopatias/fisiopatologia , Circulação Cerebrovascular/fisiologia , Homeostase , Pressão Intracraniana/fisiologia , Adolescente , Adulto , Idoso , Encefalopatias/mortalidade , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/fisiopatologia , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Encefalite/mortalidade , Encefalite/fisiopatologia , Feminino , Humanos , Hipóxia Encefálica/mortalidade , Hipóxia Encefálica/fisiopatologia , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/fisiopatologia , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/fisiopatologia , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/fisiopatologia , Monitorização Fisiológica , Prognóstico , Estudos Retrospectivos , Trombose dos Seios Intracranianos/mortalidade , Trombose dos Seios Intracranianos/fisiopatologia , Hemorragia Subaracnóidea/mortalidade , Hemorragia Subaracnóidea/fisiopatologia , Hemorragia Subaracnoídea Traumática/mortalidade , Hemorragia Subaracnoídea Traumática/fisiopatologia , Ultrassonografia Doppler Transcraniana , Adulto JovemRESUMO
Traumatic subarachnoid hemorrhage (SAH) has an annual incidence of 9 per 100 000 people. It is a rare but serious event, with an estimated mortality rate of 40% within the first 48hours. In 85% of cases, it is due to rupture of an intracranial aneurysm. In the early phase, during the first 24hours, cerebral CT, combined with intracranial CT angiography is recommended to make a positive diagnosis of SAH, to identify the cause and to investigate for an intracranial aneurysm. Cerebral MRI may be proposed if the patient's clinical condition allows it. FLAIR imaging is more sensitive than CT to demonstrate a subarachnoid hemorrhage and offers greater degrees of sensitivity for the diagnosis of restricted subarachnoid hemorrhage in cortical sulcus. A lumbar puncture should be performed if these investigations are normal while clinical suspicion is high.
Assuntos
Aneurisma Roto/diagnóstico , Emergências , Hemorragia Subaracnoídea Traumática/diagnóstico , Hemorragia Subaracnóidea/diagnóstico , Aneurisma Roto/mortalidade , Artefatos , Angiografia Cerebral , Meios de Contraste , Diagnóstico Diferencial , Humanos , Hidrocefalia/diagnóstico , Hidrocefalia/mortalidade , Aumento da Imagem , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Sensibilidade e Especificidade , Punção Espinal , Hemorragia Subaracnóidea/mortalidade , Hemorragia Subaracnoídea Traumática/mortalidade , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To determine if ischaemia is a mechanism of early brain injury at the time of aneurysm rupture in subarachnoid haemorrhage (SAH) and if early MRI ischaemia correlates with admission clinical status and functional outcome. METHODS: In a prospective, hypothesis-driven study patients with SAH underwent MRI within 0-3â days of ictus (prior to vasospasm) and a repeat MRI (median 7â days). The volume and number of diffusion weighted imaging (DWI) positive/apparent diffusion coefficient (ADC) dark lesions on acute MRI were quantitatively assessed. The association of early ischaemia, admission clinical status, risk factors and 3-month outcome were analysed. RESULTS: In 61 patients with SAH, 131 MRI were performed. Early ischaemia occurred in 40 (66%) with a mean DWI/ADC volume 8.6 mL (0-198 mL) and lesion number 4.3 (0-25). The presence of any early DWI/ADC lesion and increasing lesion volume were associated with worse Hunt-Hess grade, Glasgow Coma Scale score and Acute Physiology and Chronic Health Evaluation II physiological subscores (all p<0.05). Early DWI/ADC lesions significantly predicted increased number and volume of infarcts on follow-up MRI (p<0.005). At 3â months, early DWI/ADC lesion volume was significantly associated with higher rates of death (21% vs. 3%, p=0.031), death/severe disability (modified Rankin Scale 4-6; 53% vs. 15%, p=0.003) and worse Barthel Index (70 vs. 100, p=0.004). After adjusting for age, Hunt-Hess grade and aneurysm size, early infarct volume correlated with death/severe disability (adjusted OR 1.7, 95% CI 1.0 to 3.2, p=0.066). CONCLUSIONS: Early ischaemia is related to poor acute neurological status after SAH and predicts future ischaemia and worse functional outcomes. Treatments addressing acute ischaemia should be evaluated for their effect on outcome.
Assuntos
Lesões Encefálicas/patologia , Isquemia Encefálica/patologia , Hemorragia Subaracnoídea Traumática/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas/complicações , Isquemia Encefálica/complicações , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/patologia , Masculino , Pessoa de Meia-Idade , Neuroimagem , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Hemorragia Subaracnoídea Traumática/complicações , Hemorragia Subaracnoídea Traumática/mortalidadeRESUMO
Evidence is emerging that isolated traumatic subarachnoid hemorrhage (ITSAH) may be a milder form of traumatic brain injury (TBI). If true, ITSAH may not benefit from intensive care unit (ICU) admission, which would, in turn, decrease resource utilization. We conducted a retrospective review of all TBI admissions to our institution between February 2010 and November 2012 to compare the presentation and clinical course of subjects with ITSAH to all other TBI. We then performed descriptive statistics on the subset of ITSAH subjects presenting with a Glasgow Coma Score (GCS) of 13-15. Of 698 subjects, 102 had ITSAH and 596 had any other intracranial hemorrhage pattern. Compared to all other TBI, ITSAH had significantly lower injury severity scores (p<0.0001), lower head abbreviated injury scores (p<0.0001), higher emergency department GCS (p<0.0001), shorter ICU stays (p=0.007), higher discharge GCS (p=0.005), lower mortality (p=0.003), and significantly fewer head computed tomography scans (p<0.0001). Of those ITSAH subjects presenting with a GCS of 13-15 (n=77), none underwent placement of an intracranial monitor or craniotomy. One subject (1.3%) demonstrated a change in exam (worsened headache and dizziness) concomitant with a progression of his intracranial injury. His symptoms resolved with readmission to the ICU and continued observation. Our results suggest that ITSAH are less-severe brain injuries than other TBI. ITSAH patients with GCS scores of 13-15 demonstrate low rates of clinical progression, and when progression occurs, it resolves without further intervention. This subset of TBI patients does not appear to benefit from ICU admission.
Assuntos
Lesões Encefálicas/diagnóstico , Hemorragia Subaracnoídea Traumática/diagnóstico , Adulto , Idoso , Lesões Encefálicas/mortalidade , Estudos de Coortes , Transtornos da Consciência/diagnóstico , Transtornos da Consciência/etiologia , Progressão da Doença , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Hemorragia Subaracnoídea Traumática/mortalidade , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Traumatic brain injury (TBI) is a common cause of morbidity and mortality worldwide. It is difficult to estimate the real incidence of traumatic subarachnoid hemorrhage (TSAH). Although TSAH after trauma is associated with poor prognoses, the impact of mechanism of injury (MOI) and the pathophysiology remains unknown. We hypothesized that outcome of TSAH caused by motor vehicle crash (MVC) or fall from height (FFH) varies based on the MOI. METHODS: Data were collected retrospectively from a prospectively created database registry in the section of Trauma Surgery at Hamad General Hospital between January 2008 and July 2012. All patients presented with head trauma and TSAH were included. Patient data included age, gender, nationality, mechanism of injury, injury severity score (ISS), types of head injuries, and associated injuries. Ventilator days, intensive care unit length of stay, pneumonia, and mortality were also studied. RESULTS: A total of 1665 patients with TBI were identified, of them 403 had TSAH with a mean age of 35 ± 15 years. Of them 93% were male patients and 86% were expatriates. MVC (53%) and FFH (35%) were the major mechanisms of injury. The overall mean ISS and head abbreviated injury score were 19 ± 10.6 and 3.4 ± 0.96, respectively. Patients in MVC group sustained severe TSAH, had significantly greater head abbreviated injury score (3.5 ± 0.9 vs. 3.2 ± 0.9; P = 0.009) and ISS (21.6 ± 10.6 vs. 15.9 ± 9.5; P = 0.001), and lower scene Glasgow coma scale (10.8 ± 4.8 vs. 13.2 ± 3.4; P = 0.001) compared with the FFH group. In addition, the MVC group sustained more intraventricular hemorrhage (4.7 vs. 0.7; P = 0.001) and diffuse axonal injury (4.2 vs. 2.9; P = 0.001). In contrast, extradural hemorrhage (14.3% vs. 11.6%; P = 0.008) was higher in the FFH group. Lower extremities (14% vs. 4.3%; P = 0.004) injury was mainly associated with the MVC group. The overall mortality was 19 % among patients with TSAH. The mortality rate was higher in the MVC group when compared with the FFH group (24% vs. 10%; P = 0.001). In both groups, ISS and Glasgow coma scale at the scene were independent predictors of mortality. CONCLUSIONS: Patients with TSAH have a higher mortality rate. In this population, MVCs are associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can reduce the incidence and severity of TBI in Qatar.
Assuntos
Acidentes por Quedas/mortalidade , Acidentes de Trânsito/mortalidade , Veículos Automotores , Hemorragia Subaracnoídea Traumática/mortalidade , Adulto , Lesões Encefálicas/mortalidade , Feminino , Hematoma Epidural Craniano/mortalidade , Hematoma Subdural/mortalidade , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Catar/epidemiologia , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Subarachnoid hemorrhage (SAH) is an independent prognostic indicator of outcome in adult severe traumatic brain injury (sTBI). There is a paucity of investigations on SAH in pediatric sTBI. The goal of this study was to determine in pediatric sTBI patients SAH prevalence, associated factors, and its relationship to short-term outcome. METHODS: We retrospectively analyzed 171 sTBI patients (pre-sedation GCS ≤8 and head MAIS ≥4) who underwent CT head imaging within the first 24 h of hospital admission. Data were analyzed with both univariate and multivariate techniques. RESULTS: SAH was found in 42 % of sTBI patients (n = 71/171), and it was more frequently associated with skull fractures, cerebral edema, diffuse axonal injury, contusion, and intraventricular hemorrhage (p < 0.05). Patients with SAH had higher Injury Severity Scores (p = 0.032) and a greater frequency of fixed pupil(s) on admission (p = 0.001). There were no significant differences in etiologies between sTBI patients with and without SAH. Worse disposition occurred in sTBI patients with SAH, including increased mortality (p = 0.009), increased episodes of central diabetes insipidus (p = 0.002), greater infection rates (p = 0.002), and fewer ventilator-free days (p = 0.001). In sTBI survivors, SAH was associated with increased lengths of stay (p < 0.001) and a higher level of care required on discharge (p = 0.004). Despite evidence that SAH is linked to poorer outcomes on univariate analyses, multivariate analysis failed to demonstrate an independent association between SAH and mortality (p = 0.969). CONCLUSION: SAH was present in almost half of pediatric sTBI patients, and it was indicative of TBI severity and a higher level of care on discharge. SAH in pediatric patients was not independently associated with increased risk of mortality.
Assuntos
Lesões Encefálicas/complicações , Lesão Axonal Difusa/complicações , Mortalidade Hospitalar , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Fraturas Cranianas/complicações , Hemorragia Subaracnoídea Traumática/complicações , Adolescente , Lesões Encefálicas/diagnóstico por imagem , Lesões Encefálicas/mortalidade , Hemorragia Cerebral/complicações , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/mortalidade , Ventrículos Cerebrais , Criança , Pré-Escolar , Lesão Axonal Difusa/diagnóstico por imagem , Lesão Axonal Difusa/mortalidade , Feminino , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Fraturas Cranianas/diagnóstico por imagem , Fraturas Cranianas/mortalidade , Hemorragia Subaracnoídea Traumática/diagnóstico por imagem , Hemorragia Subaracnoídea Traumática/mortalidade , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: By observing the cerebral beta-amyloid precursor protein (beta-APP) expression in the chronic alcoholism rats with slight cerebral injury, to discuss the correlation of chronic alcoholism and death caused by traumatic subarachnoid haemorrhage (TSAH). METHODS: Sixty male SD rats were randomly divided into watering group, watering group with strike, alcoholism group and alcoholism group with strike. Among them, the alcohol was used for continuous 4 weeks in alcoholism groups and the concussion was made in groups with strike. In each group, HE staining and immunohistochemical staining of the cerebral tissues were done and the results were analyzed by the histopathologic image system. RESULTS: In watering group, there was no abnormal. In watering group with strike, mild neuronic congestion was found. In alcoholism group, vascular texture on cerebral surface was found. And the neurons arranged in disorder with dilated intercellular space. In alcoholism group with strike, diffuse congestion on cerebral surface was found. And there was TSAH with thick-layer patches around brainstem following irregular axonotmesis. The quantity of beta-APP IOD in alcoholism group was significantly higher in the frontal lobe, hippocampus, cerebellum, brainstem than those in watering group with strike and alcoholism group with strike. CONCLUSION: The cerebral tissues with chronic alcoholism, due to the decreasing tolerance, could cause fatal TSAH and pathological changes in cerebral tissues of rats under slight cerebral injury.
Assuntos
Alcoolismo/complicações , Precursor de Proteína beta-Amiloide/metabolismo , Concussão Encefálica/complicações , Encéfalo/metabolismo , Hemorragia Subaracnoídea Traumática/etiologia , Alcoolismo/metabolismo , Alcoolismo/patologia , Animais , Encéfalo/patologia , Concussão Encefálica/metabolismo , Concussão Encefálica/patologia , Modelos Animais de Doenças , Etanol/efeitos adversos , Masculino , Neurônios/metabolismo , Neurônios/patologia , Distribuição Aleatória , Ratos , Ratos Sprague-Dawley , Hemorragia Subaracnoídea Traumática/mortalidade , Hemorragia Subaracnoídea Traumática/patologiaRESUMO
OBJECT: The authors conducted a study to review outcomes and management in patients in whom intracranial hemorrhage (ICH) develops during left ventricular assist device (LVAD) therapy. METHODS: This retrospective cohort study included all adult patients (18 years of age or older) at a single institution who underwent placement of an LVAD between January 1, 2003, and March 1, 2012. The authors conducted a detailed medical chart review, and data were abstracted to assess outcomes in patients in whom ICH developed compared to those in patients in whom ICH did not develop; to compare management of antiplatelet agents and anticoagulation with outcomes; to describe surgical management employed and outcomes achieved; to compare subtypes of ICH (intraparenchymal, subdural, and subarachnoid hemorrhage) and their outcomes; and to determine any predictors of outcome. RESULTS: During the study period, 330 LVADs were placed and 36 patients developed an ICH (traumatic subarachnoid hemorrhage in 10, traumatic subdural hematoma in 8, spontaneous intraventricular hemorrhage in 1, and spontaneous intraparenchymal hemorrhage in 17). All patients were treated with aspirin and warfarin at the time of presentation. With suspension of these agents, no thromboembolic events or pump failures were seen and no delayed rehemorrhages occurred after resuming these medications. Intraparenchymal hemorrhages had the worst outcomes, with a 30-day mortality rate in 59% compared with a 30-day mortality rate of 0% in patients with traumatic subarachnoid hemorrhages and 13% in those with traumatic subdural hematomas. Five patients with intraparenchymal hemorrhages were managed with surgical intervention, 4 of whom died within 60 days. The only factor found to be predictive of outcome was initial Glasgow Coma Scale score. No patients with a Glasgow Coma Scale score less than 11 survived beyond 30 days. Overall, the development of an ICH significantly reduced survival compared with the natural history of patients on LVAD therapy. CONCLUSIONS: The authors' data suggest that withholding aspirin for 1 week and warfarin for 10 days is sufficient to reduce the risk of hemorrhage expansion or rehemorrhage while minimizing the risk of thromboembolic events and pump failure. Patients with intraparenchymal hemorrhage have poor outcomes, whereas patients with traumatic subarachnoid hemorrhage or subdural hematoma have better outcomes.