Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study.

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.

Predictors and Time-Based Hospital Mortality in Patients with Isolated and Polytrauma Brain Injuries.

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.

Is Impaired Autoregulation Associated with Mortality in Patients with Severe Cerebral Diseases?

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.

Acute ischaemia after subarachnoid haemorrhage, relationship with early brain injury and impact on outcome: a prospective quantitative MRI study.

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 0-3 days of ictus (prior to vasospasm) and a repeat MRI (median 7 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 3 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.

Subarachnoid hemorrhage prevalence and its association with short-term outcome in pediatric severe traumatic brain injury.

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.

[Relation between expression of cerebral beta-APP in the chronic alcoholism rats and death caused by TSAH].

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.

Traumatic brain injury in the elderly: considerations in a series of 103 patients older than 70.

AIM: Mortality and morbidity due to brain injury in the elderly population is a growing clinical problem: among older patients, those >70 years have a considerably higher risk both in terms of mortality and morbidity. Thereafter, the reasons influencing outcome have not been clearly examined: in the present study we addressed these questions considering the main clinical characteristics exerting a significant impact on the outcome of patients aged > 70, with emphasis for the severity of brain injury and anticoagulant (CAW) treatments. METHODS: We performed a retrospective analysis of 103 consecutive isolated head injury patients older than 70, admitted at our Department in the period November 2004-November 2009. The clinical variables considered were as follow: age, sex, type of TBI, GCS, pre-TBI use of anti-coagulants (aspirin, warfarin, clopidogrel), INR at admission (INR values were subdivided in values >1.25 as at risk for hemorrhagic events and <1.25 as normal), initial CT scan classification looking at the presence of subarachnoid hemorrhage (t-SAH) or mass lesions; the main outcome measure was the Glasgow Outcome Scale. RESULTS: The most frequent cause of TBI was accidental fall (65%): 39 were in CAW therapies and in 36 cases the cause of falling down injury was recorded due to a sincopal event (arterial hypotension, atrial fibrillation); in the older patients an accidental fall is significantly related to the TBI, while in the patients aged 70-75 years, TBI is related to a traffic accident (P=0.002). Moreover the cause of TBI correlates with the CAW treatment, the accidental fall being significantly more frequent in patients in CAW treatment (P=0.003). Overall mortality rate is significantly related to an elevated INR class, to presence of t-SAH (16/50 patients) and subdural hematoma (26/46). CONCLUSION: The results of the present study show that in a population of patients aged > 70, TBI is a high risk event if patient has concurrent treatment with CAW therapies and if an accidental fall is the cause of TBI. In these cases the finding of t-SAH represents a high-risk parameter for mortality but not for morbidity.

Should the management of isolated traumatic subarachnoid hemorrhage differ from concussion in the setting of mild traumatic brain injury?

BACKGROUND: In the setting of mild traumatic brain injury (TBI), the clinical significance of a traumatic subarachnoid hemorrhage (tSAH) has not been sufficiently studied. We examined the impact of an isolated tSAH on patient outcomes in the mild TBI population. METHODS: We retrospectively identified all mild TBI patients (Glasgow Coma Scale score ≥13) who presented to a Level I trauma center over a 10-year period. We compared isolated tSAH patients with isolated concussion patients. χ(2) and logistic regression analyses were used to compare intensive care unit (ICU) admission, ICU length of stay (LOS), hospital LOS, progression of tSAH, in-hospital mortality, and disposition to rehabilitation. RESULTS: There were 1,144 concussion and 117 tSAH patients included in our study. After adjustment, tSAH patients had increased odds of admission to the ICU (odds ratio, [OR] = 8.87; p < 0.0001), yet their ICU LOS was significantly shorter (OR = 0.29; p = 0.01). The overall hospital LOS and mortality rate were not significantly different between the TBI groups. When stratified by age, only the 40-year to 69-year-old tSAH patients had significantly increased adjusted odds of disposition to rehabilitation compared with concussion patients, independent of ICU admission (OR = 7.96; p = 0.004). None of the patients required any neurosurgical interventions. CONCLUSIONS: We encourage healthcare facilities to consider revising or creating ICU admission criteria for the mild TBI population to help optimize the utilization of their ICUs. We believe clinicians should place more emphasis on variables such as age, comorbidities, and neurologic condition rather than the presence of a small volume of blood in the subarachnoid space when admitting mild isolated TBI patients to the ICU.

Traumatic subarachnoid hemorrhage and the COL3A1 gene: emergence of a potential causal link.

We describe two previously unreported associations in four cases. The first two cases demonstrate an association between segmental mediolytic arteriopathy and vascular Ehlers-Danlos syndrome. The second two cases illustrate an association between vascular Ehlers-Danlos syndrome and traumatic subarachnoid hemorrhage. In case 1, there was acute subarachnoid hemorrhage and mesenteric artery dissection. In case 2, there was an acute mesenteric artery dissection with intestinal infarction. In both cases 1 and 2, segmental mediolytic arteriopathy was found in the vertebral arteries. Cases 3 and 4 were sudden deaths from traumatic subarachnoid hemorrhage with intracranial vertebral artery rupture. Genetic testing in all four cases revealed point mutations in the type 3 procollagen gene (COL3A1), as observed in vascular Ehlers-Danlos syndrome. Based on the first two cases, we propose that segmental mediolytic arteriopathy may be a marker for this disease. We further suggest that vascular Ehlers-Danlos syndrome may be related to the pathogenesis of traumatic vertebral artery injury, in some cases. We recommend that cases of segmental mediolytic arteriopathy and traumatic subarachnoid hemorrhage undergo genetic testing for COL3A1 mutations.

Cardiac injury in traumatic subarachnoid hemorrhagea: prospective study in 35 patients.

BACKGROUND: Various electrocardiographic abnormalities have been noted since 1954 in patients with head trauma complicated by subarachnoid hemorrhage (SAH). However, very few studies have interested to these ECG modifications in the case of post traumatic SAH (t-SAH) AIM: To assess the incidence of ECG abnormalities during the first five days after admission and the predictive value of these cardiac complications on the mortality in t-SAH. METHODS: This prospective study included 35 patients out of 125 with traumatic SAH diagnosed in the emergency unit in Rabta's hospital (2001-2009). Patients with cardio vascular history, thoracic trauma, non neurological coma and vascular-related neurological coma were excluded. An electrocardiogram monitoring was performed. A brain CT scan was performed in admission, 48 h after and case of neurological aggravation. Serum cardiac troponin IC levels were determined on hospital admission and then on the third and fifth days of hospitalization. The statistical analysis was based on the non-parametric variance test of Kruskal-Wallis to compare the means; on the chi 2 and Fisher tests to compare percentage, with a significant result at 0.05 percentile and on the Odds ratio nonparametric factors for death. Association between 2 quantitative variables have been analyzed by Pearson coefficient of correlation. RESULTS: Mean age of the 35 patients was 39 ± 17 years. Sex ratio was 4 in favor of men. The prevalence of electrocardiographic changes was of 57% (20 patients). Serum Troponin I level showed a peak on the 3rd day then it decreased. The majority of electrical abnormalities occurred during the third after admission and are associated to a markedly increased Troponin I plasma level and to the highest rate of mortality. Statistical analysis showed a significant correlation between T wave changes and the increase of serum Tn IC level (p= 0; 0002). The relative risk of mortality was higher than 7.2 times in cases with increase serum TnIc level. CONCLUSION: We demonstrated that ECG changes were common in patients with t SAH and the major predictive factors of mortality were the increase of serum TnIC and T wave changes.

Systemic glucose and brain energy metabolism after subarachnoid hemorrhage.

BACKGROUND: Brain energy metabolic crisis (MC) and lactate-pyruvate ratio (LPR) elevations have been linked to poor outcome in comatose patients. We sought to determine if MC and LPR elevations after subarachnoid hemorrhage (SAH) are associated with acute reductions in serum glucose. METHODS: Twenty-eight consecutive comatose SAH patients that underwent multimodality monitoring with intracranial pressure and microdialysis were studied. MC was defined as lactate/pyruvate ratio (LPR) > or = 40 and brain glucose < 0.7 mmol/l. Time-series data were analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes. RESULTS: Multimodality monitoring included 3,178 h of observation (mean 114 +/- 65 h per patient). In exploratory analysis, serum glucose significantly decreased from 8.2 +/- 1.8 mmol/l (148 mg/dl) 2 h before to 6.9 +/- 1.9 mmol/l (124 mg/dl) at the onset of MC (P < 0.001). Reductions in serum glucose of 25% or more were significantly associated with new onset MC (adjusted odds ratio [OR] 3.6, 95% confidence interval [CI] 2.2-6.0). Acute reductions in serum glucose of 25% or more were also significantly associated with an LPR rise of 25% or more (adjusted OR 1.6, 95% CI 1.1-2.4). All analyses were adjusted for significant covariates including Glasgow Coma Scale and cerebral perfusion pressure. CONCLUSIONS: Acute reductions in serum glucose, even to levels within the normal range, may be associated with brain energy metabolic crisis and LPR elevation in poor-grade SAH patients.

Head injury caused by tear gas cartridge in teenage population.

OBJECTIVES: The aim of this study was to assess the head injury in children caused by an unusual projectile, a tear gas cartridge. The study is the only one on this subject which has been done in a teenage population. METHOD: This was a prospective study conducted over a period of 4 years in which all the patients aged less than or equal to 18 years and who had a head injury due to a tear gas cartridge were included. RESULTS: We had 5 patients in our study group. All the patients were males. Commonest CT scan finding was brain contusion with skull fracture. One of our patients died. One patient continues to be in vegetative state whereas 3 had a good outcome. CONCLUSION: Tear gas cartridge, though considered as one of the benign modalities of controlling agitated crowds, is not really benign. It can cause serious injuries and mortality. The personnel using them might be trained in a better way so that the people do not receive direct hits. In addition some changes in the design of tear gas cartridge can be done to decrease the impact to the skull.

The prognosis of the traumatic subarachnoid hemorrhage: a prospective report of 121 patients.

Recent investigations have shown the significance of subarachnoid bleeding on computed tomography scans first taken after admission for head injuries. In our study, we describe a prospective follow-up of 121 patients with traumatic subarachnoid hemorrhage (tSAH). From January 2004 to January 2007 we collected data prospectively from 121 patients admitted with diagnosis of tSAH to our trauma intensive care unit, on the basis of admission with a computed tomography scan. The classification of tSAH was performed using the Fisher scale with modification, and the follow-up was performed using the Glasgow Outcome Scale (GOS). The minimum period for a follow-up was established 6 months after the injury. Traffic accident was the main cause of head injuries (72% in total; 48% involving cars and 24% involving motorcycles), followed by falls (23%) and aggression (5%). Twenty-eight percent of patients sustained major multiple injuries, with spinal injury as the main associated trauma. The outcome was favorable (GOS score 4 or 5) in 54 patients (45%) and unfavorable (GOS score 1, 2, or 3) in 67 patients (55%). The mortality rate was proportionally greater in patients who had cisternal clots >1 mm (P < 0.001), assessed by the Fisher scale with modification. When functional recovery was evaluated using the GOS, the recovery rate and the daily life activities were lower in patients with intraventricular bleeding (P = 0.001). Our results showed that patients with severe tSAH had the worst prognosis.

Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

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.

The delayed detection of an acute neurological worsening increases traumatic brain injury lethality / [La detección tardía del deterioro neurológico agudo incrementa la letalidad por trauma craneoencefálico.]

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.

Exosomes from Bone Marrow Mesenchymal Stem Cells Can Alleviate Early Brain Injury After Subarachnoid Hemorrhage Through miRNA129-5p-HMGB1 Pathway.

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.

Short- and Long-Term Geriatric Mortality After Acute Traumatic Subdural Hemorrhage.

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.

Concurrent Types of Intracranial Hemorrhage are Associated with a Higher Mortality Rate in Adult Patients with Traumatic Subarachnoid Hemorrhage: A Cross-Sectional Retrospective Study.

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.

Improving Survival with Tranexamic Acid in Cerebral Contusions or Traumatic Subarachnoid Hemorrhage: Univariate and Multivariate Analysis of Independent Factors Associated with Lower Mortality.

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.

Actualización epidemiológica: tasa de mortalidad por Hemorragia Subdural Traumática entre los años 2018-2022 en Chile / Epidemiological update: traumatic Subdural Hemorrhage mortality rate between 2018-2022 in Chile

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.