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AIM: Accurate prognosis of diffuse axonal injury (DAI) is important in directing clinical care, allocating resources appropriately, and communicating with families and surrogate decision-makers. METHODS: A study was conducted on patients with clinical DAI due to closed-head traumatic brain injury treated at a trauma center in Brazil from July 2013 to September 2015. The objective efficacy of the Glasgow Coma Scale (GCS), Trauma and Injury Severity Scoring system (TRISS), New Trauma and Injury Severity Scoring system (NTRISS), Abbreviated Injury Scale (AIS)/head, Corticosteroid Randomization After Significant Head Injury (CRASH), and International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) models in the prediction of mortality at 14 days and 6-months and unfavorable outcomes at 6 months was tested. RESULTS: Our cohort comprised 95 prospectively recruited adults (85 males, 10 females, mean age 30.3 ± 10.9 years) admitted with DAI. Model efficacy was assessed through discrimination (area under the curve [AUC]), and Cox calibration. The AIS/head, TRISS, NTRISS, CRASH, and IMPACT models were able to discriminate both mortality and unfavorable outcomes (AUC 0.78-0.87). IMPACT models resulted in a statistically perfect calibration for both 6-month outcome variables; mortality and 6-month unfavorable outcome. Calibration also revealed that TRISS, NTRISS, and CRASH systematically overpredicted both outcomes, except for 6-month unfavorable outcome with TRISS. CONCLUSIONS: The results of this study suggest that TRISS, NTRISS, CRASH, and IMPACT models satisfactorily discriminate between mortality and unfavorable outcomes. However, only the TRISS and IMPACT models showed accurate calibration when predicting 6-month unfavorable outcome.
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Lesão Axonal Difusa , Humanos , Feminino , Masculino , Prognóstico , Adulto , Lesão Axonal Difusa/mortalidade , Estudos Prospectivos , Escala de Coma de Glasgow , Adulto Jovem , Brasil , Pessoa de Meia-Idade , Escala Resumida de FerimentosRESUMO
BACKGROUND: Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However, identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultrasound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates. METHODS: We conducted a survey among experienced professionals involved in researching and managing patients with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios. RESULTS: From October to December 2023, 109 professionals from the Americas and Europe participated in the survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18-22 mm Hg range, potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart and endorsing the use of NIM techniques and ICPW as ancillary information. CONCLUSIONS: Experienced clinicians tend to personalize ICP management, emphasizing the importance of considering various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to include these additional components for a more personalized approach to ICP management.
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Background: Patients with acute brain injury (ABI) are a peculiar population because ABI does not only affect the brain but also other organs such as the lungs, as theorized in brain-lung crosstalk models. ABI patients often require mechanical ventilation (MV) to avoid the complications of impaired respiratory function that can follow ABI; MV should be settled with meticulousness owing to its effects on the intracranial compartment, especially regarding positive end-expiratory pressure (PEEP). This scoping review aimed to (1) describe the physiological basis and mechanisms related to the effects of PEEP in ABI; (2) examine how clinical research is conducted on this topic; (3) identify methods for setting PEEP in ABI; and (4) investigate the impact of the application of PEEP in ABI on the outcome. Methods: The five-stage paradigm devised by Peters et al. and expanded by Arksey and O'Malley, Levac et al., and the Joanna Briggs Institute was used for methodology. We also adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension criteria. Inclusion criteria: we compiled all scientific data from peer-reviewed journals and studies that discussed the application of PEEP and its impact on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in adult patients with ABI. Exclusion criteria: studies that only examined a pediatric patient group (those under the age of 18), experiments conducted solely on animals; studies without intracranial pressure and/or cerebral perfusion pressure determinations, and studies with incomplete information. Two authors searched and screened for inclusion in papers published up to July 2023 using the PubMed-indexed online database. Data were presented in narrative and tubular form. Results: The initial search yielded 330 references on the application of PEEP in ABI, of which 36 met our inclusion criteria. PEEP has recognized beneficial effects on gas exchange, but it produces hemodynamic changes that should be predicted to avoid undesired consequences on cerebral blood flow and intracranial pressure. Moreover, the elastic properties of the lungs influence the transmission of the forces applied by MV over the brain so they should be taken into consideration. Currently, there are no specific tools that can predict the effect of PEEP on the brain, but there is an established need for a comprehensive monitoring approach for these patients, acknowledging the etiology of ABI and the measurable variables to personalize MV. Conclusion: PEEP can be safely used in patients with ABI to improve gas exchange keeping in mind its potentially harmful effects, which can be predicted with adequate monitoring supported by bedside non-invasive neuromonitoring tools.
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Transcranial ultrasonography is a non-invasive, bedside technique that has become a widely implemented tool in the evaluation and management of neurocritically ill patients. It constitutes a technique in continuous growth whose fundamentals (and limitations) must be known by the intensivist. This review provides a practical approach for the intensivist, including the different sonographic windows and planes of insonation and its role in different conditions of the neurocritical patients and in critical care patients of other etiologies.
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Ultrassonografia Doppler em Cores , Ultrassonografia Doppler Transcraniana , Humanos , Ultrassonografia Doppler Transcraniana/métodos , Ultrassonografia Doppler em Cores/métodos , Ultrassonografia , Cuidados CríticosRESUMO
Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.
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Lesões Encefálicas Traumáticas , Consenso , Humanos , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/classificação , Adulto , América Latina/epidemiologia , Técnica Delphi , Escala de Coma de Glasgow/normasRESUMO
Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.
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Lesões Encefálicas Traumáticas , Circulação Cerebrovascular , Escala de Coma de Glasgow , Hematoma Subdural Agudo , Tomografia Computadorizada por Raios X , Humanos , Pessoa de Meia-Idade , Masculino , Feminino , Adulto , Hematoma Subdural Agudo/diagnóstico por imagem , Hematoma Subdural Agudo/cirurgia , Tomografia Computadorizada por Raios X/métodos , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Lesões Encefálicas Traumáticas/cirurgia , Seguimentos , Hemodinâmica , Escala de Resultado de Glasgow , Encéfalo/diagnóstico por imagem , Encéfalo/irrigação sanguínea , Resultado do Tratamento , Volume Sanguíneo Cerebral , Imagem de Perfusão/métodos , PerfusãoRESUMO
BACKGROUND: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.
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Traumatismo Múltiplo , Traumatismos da Medula Espinal , Adulto , Humanos , Consenso , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/cirurgia , Traumatismo Múltiplo/cirurgiaRESUMO
Organ crosstalk is a complex biological communication between distal organs mediated via cellular, soluble, and neurohormonal actions, based on a two-way pathway. The communication between the central nervous system and peripheral organs involves nerves, endocrine, and immunity systems as well as the emotional and cognitive centers of the brain. Particularly, acute brain injury is complicated by neuroinflammation and neurodegeneration causing multiorgan inflammation, microbial dysbiosis, gastrointestinal dysfunction and dysmotility, liver dysfunction, acute kidney injury, and cardiac dysfunction. Organ crosstalk has become increasingly popular, although the information is still limited. The present narrative review provides an update on the crosstalk between the nervous system and systemic organs after acute brain injury. Future research might help to target this pathophysiological process, preventing the progression toward multiorgan dysfunction in critically ill patients with brain injury.
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Injúria Renal Aguda , Lesões Encefálicas , Gastroenteropatias , Humanos , Encéfalo , InflamaçãoAssuntos
Extubação , Lesões Encefálicas , Humanos , Lesões Encefálicas/terapia , Respiração ArtificialRESUMO
Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains a major challenge. Despite the recent publication of guidelines from the American Heart Association/American Stroke Association and the Neurocritical Care Society, there are many controversial questions in the intensive care unit (ICU) management of this population. The authors provide an analysis of common issues in the ICU and provide guidance on the daily management of this specific population of neurocritical care patients.
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Acidente Vascular Cerebral , Hemorragia Subaracnóidea , Estados Unidos , Humanos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/terapia , Cuidados Críticos , Unidades de Terapia IntensivaRESUMO
The brain-gut axis represents a bidirectional communication linking brain function with the gastrointestinal (GI) system. This interaction comprises a top-down communication from the brain to the gut, and a bottom-up communication from the gut to the brain, including neural, endocrine, immune, and humoral signaling. Acute brain injury (ABI) can lead to systemic complications including GI dysfunction. Techniques for monitoring GI function are currently few, neglected, and many under investigation. The use of ultrasound could provide a measure of gastric emptying, bowel peristalsis, bowel diameter, bowel wall thickness and tissue perfusion. Despite novel biomarkers represent a limitation in clinical practice, intra-abdominal pressure (IAP) is easy-to-use and measurable at bedside. Increased IAP can be both cause and consequence of GI dysfunction, and it can influence cerebral perfusion pressure and intracranial pressure via physiological mechanisms. Here, we address ten good reasons to consider GI function in patients with ABI, highlighting the importance of its assessment in neurocritical care.
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Lesões Encefálicas , Gastroenteropatias , Humanos , Gastroenteropatias/etiologia , Encéfalo , Lesões Encefálicas/complicaçõesRESUMO
Introduction: Coagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication. Methods: A narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device. Results and conclusion: Eleven factors were identified: cerebral computed tomography, oral anticoagulant & antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid-base status, forming the acronym "Coagulation." This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis.
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Transtornos da Coagulação Sanguínea , Lesões Encefálicas Traumáticas , Humanos , Fibrinolíticos , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/terapia , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/terapia , Coagulação Sanguínea , Anticoagulantes/uso terapêutico , Unidades de Terapia IntensivaRESUMO
Rationale: Noninvasive respiratory support using a high-flow nasal cannula (HFNC) or noninvasive positive pressure ventilation (NIPPV) can decrease the risk of reintubation in patients being liberated from mechanical ventilation, but effects in patients with acute brain injury (ABI) are unknown. Objectives: To evaluate the association between postextubation noninvasive respiratory support and reintubation in patients with ABI being liberated from mechanical ventilation. Methods: This was a secondary analysis of a prospective, observational study of mechanically ventilated patients with ABI (clinicaltrials.gov identifier NCT03400904). The primary endpoint was reintubation during ICU admission. We used mixed-effects logistic regression models with patient-level covariates and random intercepts for hospital and country to evaluate the association between prophylactic (i.e., planned) HFNC or NIPPV and reintubation. Measurements and Main Results: 1,115 patients were included from 62 hospitals and 19 countries, of whom 267 received HFNC or NIPPV following extubation (23.9%). Compared with conventional oxygen therapy, neither prophylactic HFNC nor NIPPV was associated with decreased odds of reintubation (respectively, odds ratios of 0.97 [95% confidence interval, 0.54-1.73] and 0.63 [0.30-1.32]). Findings remained consistent in sensitivity analyses accounting for alternate adjustment procedures, missing data, shorter time frames of the primary endpoint, and competing risks precluding reintubation. In a Bayesian analysis using skeptical and data-driven priors, the probabilities of reduced reintubation ranged from 17% to 34% for HFNC and from 46% to 74% for NIPPV. Conclusions: In a large cohort of brain-injured patients undergoing liberation from mechanical ventilation, prophylactic use of HFNC and NIPPV were not associated with reintubation. Prospective trials are needed to confirm treatment effects in this population. Primary study registered with www.clinicaltrials.gov (NCT03400904).
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Lesões Encefálicas , Ventilação não Invasiva , Insuficiência Respiratória , Humanos , Respiração Artificial , Extubação , Teorema de Bayes , Estudos Prospectivos , Oxigenoterapia/métodos , Cânula , Lesões Encefálicas/complicações , Lesões Encefálicas/terapia , Encéfalo , Insuficiência Respiratória/terapiaRESUMO
For decades, one of the main targets in the management of severe acute brain injury (ABI) has been intracranial hypertension (IH) control. However, the determination of IH has suffered variations in its thresholds over time without clear evidence for it. Meanwhile, progress in the understanding of intracranial content (brain, blood and cerebrospinal fluid) dynamics and recent development in monitoring techniques suggest that targeting intracranial compliance (ICC) could be a more reliable approach rather than guiding actions by predetermined intracranial pressure values. It is known that ICC impairment forecasts IH, as intracranial volume may rapidly increase inside the skull, a closed bony box with derisory expansibility. Therefore, an intracranial compartmental syndrome (ICCS) can occur with deleterious brain effects, precipitating a reduction in brain perfusion, thereby inducing brain ischemia. The present perspective review aims to discuss the ICCS concept and suggest an integrative model for the combination of modern invasive and noninvasive techniques for IH and ICC assessment. The theory and logic suggest that the combination of multiple ancillary methods may enhance ICC impairment prediction, pointing proactive actions and improving patient outcomes.
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Lesões Encefálicas , Hipertensão Intracraniana , Humanos , Lesões Encefálicas/complicações , Pressão Intracraniana , Hipertensão Intracraniana/diagnóstico , Circulação Cerebrovascular , Monitorização Fisiológica/métodosRESUMO
BACKGROUND: Stroke patients requiring mechanical ventilation often have a poor prognosis. The optimal timing of tracheostomy and its impact on mortality in stroke patients remains uncertain. We performed a systematic review and meta-analysis of tracheostomy timing and its association with reported all-cause overall mortality. Secondary outcomes were the effect of tracheostomy timing on neurological outcome (modified Rankin Scale, mRS), hospital length of stay (LOS), and intensive care unit (ICU) LOS. METHODS: We searched 5 databases for entries related to acute stroke and tracheostomy from inception to 25 November 2022. We adhered to PRISMA guidance for reporting systematic reviews and meta-analyses. Selected studies included (1) ICU-admitted patients who had stroke (either acute ischaemic stroke, AIS or intracerebral haemorrhage, ICH) and received a tracheostomy (with known timing) during their stay and (2) > 20 tracheotomised. Studies primarily reporting sub-arachnoid haemorrhage (SAH) were excluded. Where this was not possible, adjusted meta-analysis and meta-regression with study-level moderators were performed. Tracheostomy timing was analysed continuously and categorically, where early (< 5 days from initiation of mechanical ventilation to tracheostomy) and late (> 10 days) timing was defined per the protocol of SETPOINT2, the largest and most recent randomised controlled trial on tracheostomy timing in stroke patients. RESULTS: Thirteen studies involving 17,346 patients (mean age = 59.8 years, female 44%) met the inclusion criteria. ICH, AIS, and SAH comprised 83%, 12%, and 5% of known strokes, respectively. The mean time to tracheostomy was 9.7 days. Overall reported all-cause mortality (adjusted for follow-up) was 15.7%. One in five patients had good neurological outcome (mRS 0-3; median follow-up duration was 180 days). Overall, patients were ventilated for approximately 12 days and had an ICU LOS of 16 days and a hospital LOS of 28 days. A meta-regression analysis using tracheostomy time as a continuous variable showed no statistically significant association between tracheostomy timing and mortality (ß = - 0.3, 95% CI = - 2.3 to 1.74, p = 0.8). Early tracheostomy conferred no mortality benefit when compared to late tracheostomy (7.8% vs. 16.4%, p = 0.7). Tracheostomy timing was not associated with secondary outcomes (good neurological outcome, ICU LOS and hospital LOS). CONCLUSIONS: In this meta-analysis of over 17,000 critically ill stroke patients, the timing of tracheostomy was not associated with mortality, neurological outcomes, or ICU/hospital LOS. TRIAL REGISTRATION: PROSPERO-CRD42022351732 registered on 17th of August 2022.
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Isquemia Encefálica , Acidente Vascular Cerebral , Humanos , Feminino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/cirurgia , Estado Terminal , Hemorragia Cerebral , Cuidados Críticos , Unidades de Terapia Intensiva , Respiração Artificial , Tempo de InternaçãoRESUMO
Cerebral oxygenation represents the balance between oxygen delivery, consumption and utilization by the brain, and therefore reflects the adequacy of cerebral perfusion. Different factors can influence the amount of oxygen to the brain including arterial blood pressure, hemoglobin levels, systemic oxygenation, and transfer of oxygen from blood to the cerebral microcirculation. A mismatch between cerebral oxygen supply and demand results in cerebral hypoxia/ischemia, and is associated with secondary brain damage and worsened outcome after acute brain injury. Therefore, monitoring and prompt treatment of cerebral oxygenation compromise is warranted in both neuro and general intensive care unit populations. Several tools have been proposed for the assessment of cerebral oxygenation, including non-invasive/invasive or indirect/direct methods, including Jugular Venous Oxygen Saturation (SjO2), Partial Brain Tissue Oxygen Tension (PtiO2), Near infrared spectroscopy (NIRS), Transcranial Doppler, electroencephalography and Computed Tomography. In this manuscript, we aim to review the pathophysiology of cerebral oxygenation, describe monitoring technics, and generate recommendations for avoiding brain hypoxia in settings with low availability of resources for direct brain oxygen monitoring.