Predictors of neurosurgical intervention in complicated mild traumatic brain injury patients: a retrospective cohort study.

OBJECTIVES: To determine the predicting demographic, clinical and radiological factors for neurosurgical intervention in complicated mild traumatic brain injury (mTBI) patients. METHODS: Design: retrospective multicenter cohort study. Participants: patients aged ≥16 presenting to all level-I trauma centers in Quebec between 09/2016 and 12/2017 with mTBI(GCS 13-15) and complication on initial head CT (intracranial hemorrhage/skull fracture). Procedure: Consecutive medical records were reviewed and separated into two groups: no neurosurgical intervention and neurosurgical intervention (NSI). Main outcome: neurosurgical intervention. Analysis: multiple logistic regression model. RESULTS: Four hundred and seventy-eight patients were included and 40 underwent NSI. One patient had radiological deterioration but no clinical deterioration prior to surgery. Subdural hemorrhage ≥4 mm width (OR:3.755 [95% CI:1.290-10.928]) and midline shift (OR:7.507 [95% CI: 3.317-16.989]) increased the risk of NSI. Subarachnoid hemorrhage was associated with a lower risk of NSI (OR:0.312 [95% CI: 0.136-0.713]). All other intracranial hemorrhages were not associated with NSI. CONCLUSION: Radiological deterioration was not associated with the incidence of NSI. Subdural hemorrhage and midline shift should be predicting factors for neurosurgery. Some patients with isolated findings such as subarachnoid hemorrhage could be safely managed in their original center without being transferred to a level-I trauma center.

Can the "important brain injury criteria" predict neurosurgical intervention in mild traumatic brain injury? A validation study.

BACKGROUND: There is variability in the management of patients presenting to the emergency department (ED) with mild traumatic brain injury (MTBI) and abnormal findings on their initial head computed tomography (CT). The main objective of this study was to validate the value of the Important Brain Injury (IBI) criteria, introduced by the Canadian CT-Head Rule, in predicting the need for surgical intervention. The secondary objective was to identify independent predictors for neurosurgical intervention. METHODS: This is a post hoc analysis of a prospective cohort of adult patients presenting to the ED of one tertiary care, academic center, between 2008 and 2012, with MTBI and an abnormal initial head CT. Neurosurgical intervention was at the discretion of the treating physician. The sensitivity and specificity of the IBI criteria were calculated with 95% confidence intervals (CI95%). A multivariate logistic regression model was used to identify independent predictors for neurosurgical intervention with the direct entry method. RESULTS: A total of 678 patients (male = 65.9%, mean age = 62.5 years) were included, of whom 114 (16.8%) required neurosurgical intervention. All patients requiring neurosurgical intervention met IBI criteria on their initial head CT (sensitivity of 100% [CI95% 96.8-100]). However, 368 (65.2%) patients with findings of IBI did not require neurosurgical intervention (specificity of 34.8% [CI95% 30.8-38.8]). Age over 65 was independently associated with neurosurgical intervention in the IBI population. CONCLUSION: The IBI criteria for MTBI identified all patients who required neurosurgical intervention; however its specificity is low.

Intracranial pressure management and neurological outcome for patients with mild traumatic brain injury who required neurosurgical intervention: a Japanese database study.

Purpose: Among mild traumatic brain injuries (mTBI; a Glasgow Coma Scale score ≥13 on arrival), few result in severe neurological deficit, especially when they needed neurosurgical intervention. We investigated the association of intracranial pressure (ICP) control management with neurological outcome in patients with mTBI who needed neurosurgical intervention. Methods: From 1,092 records of the Japan Neurotrauma Data Bank during 2009-2011, we retrospectively identified 195 patients with neurosurgical intervention for mTBI. Using the Glasgow Outcome Scale, we grouped records into two: favorable and poor outcome. We analyzed neurological outcomes using a logistic regression analysis adjusted for ICP control managements. Results: Seventy patients had a poor outcome. Logistic regression analysis revealed that sedatives, hyperosmotic agents, and hyperventilation therapy were significantly associated with poor outcome (odds ratio [OR]: 2.36, 95% confidence interval [CI]: 1.31-4.26; OR: 2.81, 95% CI: 1.17-6.75; OR: 9.36, 95% CI: 1.81-48.35). However, temperature management was significantly related with favorable outcome (OR: 0.26, 95% CI: 0.10-0.66). Conclusions: Our study, using a Japanese multicenter brain trauma registry, suggested that requirement of sedatives, hyperosmotic agents, and hyperventilation is associated with poor neurological outcome for patients with mTBI who underwent neurosurgical intervention, although temperature management was associated with favorable neurological outcome.

Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis.

OBJECTIVE Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis. METHODS Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non-sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed. RESULTS After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4-75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45-0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03-0.88]). CONCLUSIONS This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.

[CRANIO­CEREBRAL TRAUMA WITH ESTIMATED SEVERITY OF 13­15 POINTS IN ACCORDANCE TO GLASGOW SCALE ­ A LIGHT TRAUMA].

Retrospective analysis of cranio­cerebral trauma (CCT) in 141 injured persons, ageing (38.3 ± 14.3) yrs at average, severity of which in accordance to Glasgow scale was estimated in 13 ­ 15 points, was performed. The injured persons were managed in accordance to actual recommendations of Ministry of Health of Ukraine. In accordance to CT data, the brain commotion was noted in 40 patients, the brain contusion type І ­ in 25, the brain contusion type ІІ with the skull fornix fracture ­ in 30, with linear fracture of the skull bones and traumatic hematomas into the brain­tunics ­ in 30, with fracture of the temporal bone pyramid ­ in 16. In indices 14 points and less (in accordance to Glasgow scale) in terms up to 24 h after CCT and absence of alcohol intoxication in 76.9% injured persons in accordance to CT data the intracranial traumatic affections were revealed. In indices of 15 points in 21% of injured persons false­negative results were determined, witnessing disparity of CCT signs with a CT data.

[Repeated head injury during judo practice].

Mild traumatic brain injuries, if repeated, can cause permanent brain damage, or even death. I examined five published documents(three judicial decisions, one official injury report, and one book)to analyze incidents in which high school students who, while practicing judo, experienced acute subdural hematoma(ASDH)with grave outcomes, despite the fact that they had been examined by neurosurgeons. The five students, first-grade boy and girl of junior high school and two first-grade boys and one second-grade girl of senior high school, were hit on the head during extracurricular judo practice and were taken to the neurosurgery department of different hospitals. They were all novices or unskilled players. The initial diagnoses were ASDH in three cases, concussion in one, and headache in one. Although the surgeons, except in one case, prohibited the students from returning to play, the juveniles resumed judo practice soon. Some of them complained of continued headaches, but they kept practicing. Between 17 and 82 days after the first injury, they received the fateful hits to their heads, and they were brought to the emergency rooms. MRI and CT revealed ASDH in all;two of them died, and the other three remain in persistent vegetative state. Neurosurgeons should take the initiative to prevent severe brain injury of young athletes through collaborations with the athletes themselves, fellow athletes, family members, coaches, teachers, athletic directors, and other physicians. They should pay close attention to headaches and other signs and symptoms of concussion and prohibit the athletes from returning to play until they are confirmed to be symptom free for recommended periods, insisting that safety comes first.

A mismatch between the abnormalities in diffusion- and susceptibility-weighted magnetic resonance imaging may represent an acute ischemic penumbra with misery perfusion.

Susceptibility-weighted imaging (SWI) has recently attracted attention for its ability to investigate acute stroke pathophysiology. SWI detects an increased ratio of deoxyhemoglobin to oxyhemoglobin in cerebral venous compartments, which can illustrate cerebral misery perfusion with a compensatory increase of oxygen extraction fraction in the hypoperfused brain. In this study we make the first case report of blunt cervical trauma leading to a stroke, demonstrating the disparity between diffusion-weighted imaging (DWI) and SWI changes, or DWI-SWI mismatch, in the acute ischemic brain. The area of mismatch between a smaller DWI cytotoxic edema and a larger SWI misery perfusion in our patient matured into a complete infarction with time. The DWI-SWI mismatch may signify the presence of an ischemic penumbra, and provide information about viability of the brain tissue at risk of potential infarction if without early reperfusion.

Is delayed fixation worthwhile in patients with long bone fracture concomitant with mild traumatic brain injury? A propensity score-matched study.

INTRODUCTION: Early definite treatment for orthopedic patients is strongly advocated. However, a consensus has not been reached on the optimal timing of long bone fracture fixation for patients with associated mild traumatic brain injury (TBI). Surgeons lack evidence on the basis on which they should decide on the operation timing. METHODS: We retrospectively reviewed the data of patients with mild TBI and lower extremity long bone fractures from 2010 to 2020. The patients receiving internal fixation within and after 24 h were defined as the early- and delayed-fixation groups. We compared the discharge Glasgow Coma Scale (GCS) scores, lengths of stay, and in-hospital complications. Propensity score matching (PSM) with multiple adjusted variables and a 1:1 matching ratio was applied to reduce selection bias. RESULTS: In total, 181 patients were enrolled; 78 (43.1%) and 103 (56.9%) patients received early and delayed fracture fixation, respectively. After matching, each group had 61 participants and were statistically identical. The delayed group did not have better discharge GCS scores (early vs. delayed: 15.0 ± 0 vs. 15.0 ± 0.1; p = 0.158). The groups did not differ in their lengths of hospital stay (15.3 ± 10.6 vs. 14.8 ± 7.9; p = 0.789), intensive care unit stay (2.7 ± 4.3 vs. 2.7 ± 3.8; p = 0.947), or incidence of complications (23.0% vs. 16.4%; p = 0.494). CONCLUSIONS: Delayed fixation for patients with lower extremity long bone fractures concurrent with mild TBI does not result in fewer complications or improved neurologic outcomes compared with early fixation. Delaying fixation may not be necessary to prevent the second hit phenomenon and has not demonstrated any clear benefits.

Toward rational use of repeat imaging in children with mild traumatic brain injuries and intracranial injuries.

OBJECTIVE: Limited evidence exists on the utility of repeat neuroimaging in children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs). Here, the authors identified factors associated with repeat neuroimaging and predictors of hemorrhage progression and/or neurosurgical intervention. METHODS: The authors performed a multicenter, retrospective cohort study of children at four centers of the Pediatric TBI Research Consortium. All patients were ≤ 18 years and presented within 24 hours of injury with a Glasgow Coma Scale score of 13-15 and evidence of ICI on neuroimaging. The outcomes of interest were 1) whether patients underwent repeat neuroimaging during index admission, and 2) a composite outcome of progression of previously identified hemorrhage ≥ 25% and/or repeat imaging as an indication for subsequent neurosurgical intervention. The authors performed multivariable logistic regression and report odds ratios and 95% confidence intervals. RESULTS: A total of 1324 patients met inclusion criteria; 41.3% of patients underwent repeat imaging. Repeat imaging was associated with clinical change in 4.8% of patients; the remainder of the imaging tests were for routine surveillance (90.9%) or of unclear prompting (4.4%). In 2.6% of patients, repeat imaging findings were reported as an indication for neurosurgical intervention. While many factors were associated with repeat neuroimaging, only epidural hematoma (OR 3.99, 95% CI 2.22-7.15), posttraumatic seizures (OR 2.95, 95% CI 1.22-7.41), and age ≥ 2 years (OR 2.25, 95% CI 1.16-4.36) were significant predictors of hemorrhage progression and/or neurosurgery. Of patients without any of these risk factors, none underwent neurosurgical intervention. CONCLUSIONS: Repeat neuroimaging was commonly used but uncommonly associated with clinical deterioration. Although several factors were associated with repeat neuroimaging, only posttraumatic seizures, age ≥ 2 years, and epidural hematoma were significant predictors of hemorrhage progression and/or neurosurgery. These results provide the foundation for evidence-based repeat neuroimaging practices in children with mTBI and ICI.

Structural brain injury in sports-related concussion.

OBJECT: Sports-related concussions (SRCs) represent a significant and growing public health concern. The vast majority of SRCs produce mild symptoms that resolve within 1-2 weeks and are not associated with imaging-documented changes. On occasion, however, structural brain injury occurs, and neurosurgical management and intervention is appropriate. METHODS: A literature review was performed to address the epidemiology of SRC with a targeted focus on structural brain injury in the last half decade. MEDLINE and PubMed databases were searched to identify all studies pertaining to structural head injury in sports-related head injuries. RESULTS: The literature review yielded a variety of case reports, several small series, and no prospective cohort studies. CONCLUSIONS: The authors conclude that reliable incidence and prevalence data related to structural brain injuries in SRC cannot be offered at present. A prospective registry collecting incidence, management, and follow-up data after structural brain injuries in the setting of SRC would be of great benefit to the neurosurgical community.

Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature.

BACKGROUND: Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed. METHODS: A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020. RESULTS: Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs. CONCLUSIONS: An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Therapeutic Effect of Aerobic Exercise for Adolescents After Mild Traumatic Brain Injury and Sport-Related Concussion: A Meta-Analysis from Randomized Controlled Trials.

BACKGROUND: We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials from January 1980 to April 2018 for adolescents with mild traumatic brain injury (mTBI) to explore the value of aerobic exercise in sport-related concussion (SRC) and mTBI treatment. METHODS: A meta-analysis for the postconcussion symptom scale (PCSS) score and time to recovery was performed with STATA software. RESULTS: We found that aerobic exercise versus usual treatment significantly decreased the PCSS score (weighted mean difference = 6.51, 95% confidence interval: 0.29, 12.72; P = 0.040), as well as the time to recovery (weighted mean difference = -3.87; 95% confidence interval: -6.50, -1.23; P = 0.004). However, aerobic exercise showed no significant improvement in immediate postconcussion assessment and cognitive testing (P = 0.471/0.129/0.648/0.800, respectively, in verbal memory, visual memory, visual motor speed, and reaction time). CONCLUSIONS: Compared with usual treatment, aerobic exercise promoted mTBI adolescents' recovery, assessed by PCSS and time to recovery. However, aerobic exercise may not help with neurocognitive function recovery.

Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury.

OBJECT: Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need. METHODS: The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded. RESULTS: During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6-131.8; OR 9.7 for SDH, 95% CI 2.4-39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15. CONCLUSIONS: Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.

Development of clinical decision rules for traumatic intracranial injuries in patients with mild traumatic brain injury in a developing country.

BACKGROUND: The majority of clinical decision rules for prediction of intracranial injury in patients with mild traumatic brain injury (TBI) were developed from high-income countries. The application of these rules in low or middle-income countries, where the primary mechanism of injury was traffic accidents, is questionable. METHODS: We developed two practical decision rules from a secondary analysis of a multicenter, prospective cohort of 1,164 patients with mild TBI who visited the emergency departments from 2013 to 2016. The clinical endpoints were the presence of any intracranial injury on CT scans and the requirement of neurosurgical interventions within seven days of onset. RESULTS: Thirteen predictors were included in both models, which were age ≥60 years, dangerous mechanism of injury, diffuse headache, vomiting >2 episodes, loss of consciousness, posttraumatic amnesia, posttraumatic seizure, history of anticoagulant use, presence of neurological deficits, significant wound at the scalp, signs of skull base fracture, palpable stepping at the skull, and GCS <15 at 2 hours. For the model-based score, the area under the receiver operating characteristic curve (AuROC) was 0.85 (95%CI 0.82, 0.87) for positive CT results and 0.87 (95%CI 0.83, 0.91) for requirement of neurosurgical intervention. For the clinical-based score, the AuROC for positive CT results and requirement of neurosurgical intervention was 0.82 (95%CI 0.79, 0.85) and 0.84 (95%CI 0.80, 0.88), respectively. CONCLUSIONS: The models delivered good calibration and excellent discrimination both in the development and internal validation cohort. These rules can be used as assisting tools in risk stratification of patients with mild TBI to be sent for CT scans or admitted for clinical observation.

Influence of Simulated Pre-Hospital Transport, Time to Analysis, and Storage Temperature on S100 Calcium-Binding Protein B Values.

According to in-hospital guidelines, the biomarker, S100 calcium-binding protein B (S100B), is used to rule out intracranial lesions in mild-moderate traumatic brain injury (TBI). It is currently investigated whether S100B is applicable in a pre-hospital setting. The aim was to compare S100B values and hemolysis index in blood samples drawn and stored under simulated pre-hospital conditions to standardized blood samples. Thirty patients undergoing craniotomy at Department of Neurosurgery, Aarhus University Hospital (Aarhus, Denmark) each had six blood samples drawn. Two samples, drawn in in-hospital standardized Beckton Dickinson tubes and pre-hospital Monovette tubes, respectively, were stored as references at 21°C for 30 min. Two samples were stored at 15°C and 29°C, respectively, one sample was stored at prolonged time (60 min), and one sample was transported for 30 min before centrifugation. S100B values were compared by equivalence test with a pre-defined equivalence margin of ±8.5%. There was no clinically relevant difference between samples stored in different tubes, at various temperatures, or time to analysis compared to reference samples. Transported samples had an 11.5% (90% confidence interval [CI], 6.55; 16.61) higher median S100B value and a 430% (95% CI, 279.6; 661.4) higher median hemolysis index compared to reference samples. Three of 30 (10%) patients had an S100B value above guideline cutoff in the transported sample, which was not found in reference samples (false positive). There were no false negatives. In conclusion, S100B values were not influenced by different tubes, temperatures, and time to analysis. Transported samples had higher median S100B values and hemolysis, icterus, and lipemia index compared to reference samples.

Mild traumatic brain injury in children with ventricular shunts: a PREDICT study.

OBJECTIVE: Current clinical decision rules (CDRs) guiding the use of CT scanning in pediatric traumatic brain injury (TBI) assessment generally exclude children with ventricular shunts (VSs). There is limited evidence as to the risk of abnormalities found on CT scans or clinically important TBI (ciTBI) in this population. The authors sought to determine the frequency of these outcomes and the presence of CDR predictor variables in children with VSs. METHODS: The authors undertook a planned secondary analysis on children with VSs included in a prospective external validation of 3 CDRs for TBI in children presenting to 10 emergency departments in Australia and New Zealand. They analyzed differences in presenting features, management and acute outcomes (TBI on CT and ciTBI) between groups with and without VSs, and assessed the presence of CDR predictors in children with a VS. RESULTS: A total of 35 of 20,137 children (0.2%) with TBI had a VS; only 2 had a Glasgow Coma Scale score < 15. Overall, 49% of patients with a VS underwent CT scanning compared with 10% of those without a VS. One patient had a finding of TBI on CT scanning, with positive predictor variables on CDRs. This patient had a ciTBI. No patient required neurosurgery. For children with and without a VS, the frequency of ciTBI was 2.9% (95% CI 0.1%-14.9%) compared with 1.4% (95% CI 1.2%-1.6%) (difference 1.5% [95% CI -4.0% to 7.0%]), and TBI on CT 2.9% (95% CI 0.1%-14.9%) compared with 2.0% (95% CI 1.8%-2.2%) (difference 0.9%, 95% CI -4.6% to 6.4%). CONCLUSIONS: The authors' data provide further support that the risk of TBI is similar for children with and without a VS.

A Rapid Neurological Assessment Protocol for Repeated Mild Traumatic Brain Injury in Awake Rats.

Preclinical models for mild traumatic brain injury (mTBI) need to recapitulate several essential clinical features associated with mTBI, including a lack of significant neuropathology and the onset of neurocognitive symptoms normally associated with mTBI. Here we show how to establish a protocol for reliably and repeatedly inducing a mild awake closed head injury (ACHI) in rats, with no mortality or clinical indications of persistent pain. Moreover, we implement a new rapid neurological assessment protocol (NAP) that can be completely conducted within 1 min of each impact. This ACHI model will help to rectify the paucity of data on how repeated mTBI (r-mTBI) impacts the juvenile brain, an area of significant concern in clinical populations where there is evidence that behavioral sequelae following injury can be more persistent in juveniles. In addition, the ACHI model can help determine if r-mTBI early in life can predispose the brain to exhibiting greater neuropathology (i.e., chronic traumatic encephalopathy) later in life and can facilitate the identification of critical periods of vulnerability to r-mTBI across the lifespan. This article describes the protocol for administering an awake closed head mTBI (i.e., ACHI) to rats, as well as how to perform a rapid NAP following each ACHI. Methods for administering the ACHI to individual subjects repeatedly are described, as are the methods and scoring system for the NAP. The goal of this article is to provide a standardized set of procedures allowing the ACHI and NAP protocols to be used reliably by different laboratories. © 2019 by John Wiley & Sons, Inc.

Perioperative Considerations in Patients With Concussion.

Concussions affect the normal functioning of the autonomic nervous system and glucose metabolism, impair cerebral autoregulation to Paco2, and produce abnormal variances in myogenic and vagal tone. Because anesthesia also has an impact on these same processes, it is vital to delineate the best practice in the perianesthesia period to minimize additional damage to the concussed brain. There are currently no practice guidelines surrounding perianesthesia management of patients with concussion to guide practice. To answer 4 clinically pertinent questions for nurse anesthesia practice, the authors completed a literature review. Articles obtained from the search that were identified as randomized controlled trials, systematic reviews, or integrative reviews were evaluated for relevance to clinical practice. Many of the literature recommendations emphasize the prevention of secondary neurologic injury. Optimal outcomes are believed to best align with careful attention to mean arterial pressures and Paco2 to prevent global hypoperfusion. The impact of particular anesthetic agents on concussion injuries is unknown. Major advances in neuroimaging, biomarker identification, and technology have occurred. However, further research is needed to identify evidence-based interventions for managing patients after concussion requiring anesthesia.

Three­time point view of mild brain injuries' structural alteration and their association with cognitive domains.

BACKGROUND: Mild traumatic brain injury (mTBI) accounts for 70­80% of total neurotrauma, majority among them manifest with cognitive deficits. Till date there are few/or no 3­time­point longitudinal studies that have evidenced brain volume changes. The current study has investigated volume changes at 3­time­points and their association with cognitive sequel. METHODS: Twenty­one mTBI patients with normal imaging and 15 GCS were recruited. Initially these patients were evaluated with magnetic resonance imaging (MRI) scan ≤36hours and neuropsychological test (NPT) during 2­3weeks after­injury. All the patients were available for follow­up for repeat MRI and NPT on 3­4 and 6­7months. The imaging and test scores were analyzed using repeated measures of analysis (P<0.05). The brain volumes were correlated with respective test­scores using partial­correlation. RESULTS: Left frontal lobe (P<0.029) and thalamus (P=0.049) showed significant increase in mean volume overtime, whereas corpus callosum (mid­anterior [P=0.011] and central [P=0.04]) and left cerebellum (P=0.043) showed significant decrease in mean volume overtime. Clinically cognitive scores improved with time. Eventual improvements in attention and memory scores were positively associated with increase in cingulate gyrus volume. CONCLUSIONS: The 3­time­point longitudinal study illustrates brain areas that changes with time and their association with improving cognitive scores. The study provides hint about the pattern of natural recovery.