Postural stability in patients with chronic subdural hematoma.

BACKGROUND: Gait disturbances and falls are common in patients with chronic subdural hematoma (cSDH). Postural stability is mainly visually assessed and has not been described using an objective and quantitative measurement tool. The objective of this prospective study was to evaluate postural stability in cSDH patients by measuring trunk sway during stance and gait compared to healthy elderly (HE). It was also to evaluate the relationships among postural stability and age, hematoma size, brain midline shift and hematoma location. METHODS: Using a gyroscopic method, trunk sway was measured in 22 cSDH patients preoperatively, 5 postoperatively and 58 HE during seven standing and walking tasks. Trunk sway amplitude and velocity in the anterior-posterior and medial-lateral directions were assessed. RESULTS: Postural stability was reduced in the cSDH group compared to HE for all standing tasks. During gait, the sway angle was increased while velocity was decreased in the cSDH group. Only 18 % of the patients could perform all tasks without losing their balance. Postoperatively, postural stability was normalized in the medial-lateral direction during standing. There were no correlations among age, hematoma size, brain midline shift or location of the hematoma and trunk sway. CONCLUSIONS: The majority of cSDH patients had reduced postural stability that was partly reversed soon after surgery. It was not correlated to hematoma characteristics, indicating that an increased risk to fall is present regardless of hematoma size and midline shift. This must be accounted for when handling these patients and measures taken to prevent further fall accidents during hospital stays.

Association of ICP, CPP, CT findings and S-100B and NSE in severe traumatic head injury. Prognostic value of the biomarkers.

OBJECTIVE: The association was studied of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) on S-100B and neuron-specific enolase (NSE) in severe traumatic brain injury (sTBI). The relationship was explored between biomarkers, ICP, CPP, CT-scan classifications and the clinical outcome. MATERIALS AND METHODS: Data were collected prospectively and consecutively in 48 patients with Glasgow Coma Scale score ≤ 8, age 15-70 years. NSE and S-100B were analysed during 5 consecutive days. The initial and follow-up CT-scans were classified according to the Marshall, Rotterdam and Morris-Marshall classifications. Outcome was evaluated with extended Glasgow outcome scale at 3 months. RESULTS: Maximal ICP and minimal CPP correlated with S-100B and NSE levels. Complex relations between biomarkers and CT classifications were observed. S-100B bulk release (AUC = 0.8333, p = 0.0009), and NSE at 72 hours (AUC = 0.8476, p = 0.0045) had the highest prediction power of mortality. Combining Morris-Marshall score and S-100B bulk release improved the prediction of clinical outcome (AUC = 0.8929, p = 0.0008). CONCLUSION: Biomarker levels are associated with ICP and CPP and reflect different aspects of brain injury as evaluated by CT-scan. The biomarkers might predict mortality. There are several pitfalls influencing the interpretation of biomarker data in respect to ICP, CPP, CT-findings and clinical outcome.

The release of S-100B and NSE in severe traumatic head injury is associated with APOE ε4.

OBJECT: In this article we tested the hypothesis that the level of two biochemical markers of brain injury may be associated with the apolipoprotein E (APOE) ε4 allele. METHODS: In this prospective consecutive study patients with sTBI were included (n = 48). Inclusion criteria were Glasgow Coma Scale (GCS) score ≤ 8 at the time of intubation and sedation, patient age between 15 and 70 years, an initial cerebral perfusion pressure > 10 mmHg, and arrival to our level-one trauma university hospital within 24 h after trauma. Blood samples for neuron-specific enolase (NSE) and S-100B were collected as soon as possibly after arrival, and then twice daily (12-h intervals) for 5 consecutive days. Venous blood was used for APOE genotype determination. Clinical outcome at 3 months after injury was assessed with the Extended Glasgow Outcome Scale (GOSE). RESULTS: Significantly higher levels of the maximal S-100B (S-100B(max)) and area under the curve (S-100B(AUC)) were found in subjects with the APOE ε4 allele compared to those with non-ε4. A similar tendency was observed for NSE(max) and NSE(AUC), though not statistically significant. CONCLUSION: Our data indicate that there might be a gene-induced susceptibility to severe traumatic brain injury and that patients with the APOE ε4 allele may be more predisposed to brain cellular damage measured as S-100B and NSE. Thus, it seems to be of importance to consider the APOE genotype in interpreting the levels of the biomarkers.

Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey.

BACKGROUND: Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals. METHODS: This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0-17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020-March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable. RESULTS: 71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006. CONCLUSIONS: TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation.

Best practice guidelines for blunt cerebrovascular injury (BCVI).

Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1-2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.

APOE ε4 positive patients suffering severe traumatic head injury are more prone to undergo decompressive hemicraniectomy.

OBJECT: In this paper we tested the hypothesis if patients with severe traumatic brain injury and presence of the apolipoprotein E (APOE) ε4 allele are more prone to undergo the surgical procedure decompressive hemicraniectomy (DC) in order to bring the intracranial pressure (ICP) under control. METHODS: In this prospective consecutive study patients with sTBI were enrolled (n=48). Inclusion criteria were arrival to our level one trauma university hospital within 24h after trauma, patient age between 15 and 70years, Glasgow Coma Scale (GCS) score ≤8 at the time of intubation and sedation, an initial cerebral perfusion pressure >10mmHg. Venous blood was sampled for APOE genotype determination. Clinical outcome at 6months after injury was assessed with the Extended Glasgow Outcome Scale (GOSE). All surgical procedures needed for each patient were registered. RESULTS: Patients with the APOE ε4 allele were significantly overrepresented in the DC group. In the APOE ε4+DC group, ICPmax and ICPmean during the first 36h were significantly higher and GOSE was significantly worse at 6months. CONCLUSION: Our data suggest that patients with the APOE ε4 allele are predisposed for the need of DC more often than patients without the APOE ε4 allele. Thus, it seems to be of importance to consider the APOE genotype in patients suffering severe traumatic brain injury in order to forecast the need for a more exquisite intensive care.

Use of the CRASH study prognosis calculator in patients with severe traumatic brain injury treated with an intracranial pressure-targeted therapy.

Based on the Corticosteroid Randomisation after Significant Head Injury (CRASH) trial database, a prognosis calculator has been developed for the prediction of outcome in an individual patient with a head injury. In 47 patients with severe traumatic brain injury (sTBI) prospectively treated using an intracranial pressure (ICP) targeted therapy, the individual prognosis for mortality at 14 days and unfavourable outcome at 6 months was calculated and compared with the actual outcome. An overestimation of the risk of mortality and unfavourable outcome was found. The mean risk for mortality and unfavourable outcome were estimated to be 44.6±32.5% (95% confidence interval [CI], 35.1-54.2%) and 69.3±23.7% (95% CI, 62.3-76.2%). The actual outcome was 4.3% and 42.6% respectively. The absolute risk reduction (ARR) for mortality was 33.1% and for unfavourable outcome 29.8%. A logistic fit for outcome at 6 months shows a statistically significant difference (p<0.01). A receiver operating characteristic (ROC) curve analysis shows an area under the curve (AUC) of 0.691. The CRASH prognosis calculator overestimates the risk of mortality and unfavourable outcome in patients with sTBI treated with an ICP-targeted therapy based on the Lund concept. We do not advocate the use of the calculator for treatment decisions in individual patients. We further conclude that patients with blunt sTBI admitted within 8 hours of trauma should be treated regardless of their clinical status as long as the initial cerebral perfusion pressure is >10 mmHg.

Acute neuro-endocrine profile and prediction of outcome after severe brain injury.

OBJECT: The aim of the study was to evaluate the early changes in pituitary hormone levels after severe traumatic brain injury (sTBI) and compare hormone levels to basic neuro-intensive care data, a systematic scoring of the CT-findings and to evaluate whether hormone changes are related to outcome. METHODS: Prospective study, including consecutive patients, 15-70 years, with sTBI, Glasgow Coma Scale (GCS) score ≤ 8, initial cerebral perfusion pressure > 10 mm Hg, and arrival to our level one trauma university hospital within 24 hours after head trauma (n = 48). Serum samples were collected in the morning (08-10 am) day 1 and day 4 after sTBI for analysis of cortisol, growth hormone (GH), prolactin, insulin-like growth factor 1 (IGF-1), thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), follicular stimulating hormone (FSH), luteinizing hormone (LH), testosterone and sex hormone-binding globulin (SHBG) (men). Serum for cortisol and GH was also obtained in the evening (17-19 pm) at day 1 and day 4. The first CT of the brain was classified according to Marshall. Independent staff evaluated outcome at 3 months using GOS-E. RESULTS: Profound changes were found for most pituitary-dependent hormones in the acute phase after sTBI, i.e. low levels of thyroid hormones, strong suppression of the pituitary-gonadal axis and increased levels of prolactin. The main findings of this study were: 1) A large proportion (54% day 1 and 70% day 4) of the patients showed morning s-cortisol levels below the proposed cut-off levels for critical illness related corticosteroid insufficiency (CIRCI), i.e. <276 nmol/L (=10 ug/dL), 2) Low s-cortisol was not associated with higher mortality or worse outcome at 3 months, 3) There was a significant association between early (day 1) and strong suppression of the pituitary-gonadal axis and improved survival and favorable functional outcome 3 months after sTBI, 4) Significantly lower levels of fT3 and TSH at day 4 in patients with a poor outcome at 3 months. 5) A higher Marshall CT score was associated with higher day 1 LH/FSH- and lower day 4 TSH levels 6) In general no significant correlation between GCS, ICP or CPP and hormone levels were detected. Only ICPmax and LH day 1 in men was significantly correlated. CONCLUSION: Profound dynamic changes in hormone levels are found in the acute phase of sTBI. This is consistent with previous findings in different groups of critically ill patients, most of which are likely to be attributed to physiological adaptation to acute illness. Low cortisol levels were a common finding, and not associated with unfavorable outcome. A retained ability to a dynamic hormonal response, i.e. fast and strong suppression of the pituitary-gonadal axis (day 1) and ability to restore activity in the pituitary-thyroid axis (day 4) was associated with less severe injury according to CT-findings and favorable outcome.