Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement From the International Liaison Committee on Resuscitation.

This scientific statement presents a conceptual framework for the pathophysiology of post-cardiac arrest brain injury, explores reasons for previous failure to translate preclinical data to clinical practice, and outlines potential paths forward. Post-cardiac arrest brain injury is characterized by 4 distinct but overlapping phases: ischemic depolarization, reperfusion repolarization, dysregulation, and recovery and repair. Previous research has been challenging because of the limitations of laboratory models; heterogeneity in the patient populations enrolled; overoptimistic estimation of treatment effects leading to suboptimal sample sizes; timing and route of intervention delivery; limited or absent evidence that the intervention has engaged the mechanistic target; and heterogeneity in postresuscitation care, prognostication, and withdrawal of life-sustaining treatments. Future trials must tailor their interventions to the subset of patients most likely to benefit and deliver this intervention at the appropriate time, through the appropriate route, and at the appropriate dose. The complexity of post-cardiac arrest brain injury suggests that monotherapies are unlikely to be as successful as multimodal neuroprotective therapies. Biomarkers should be developed to identify patients with the targeted mechanism of injury, to quantify its severity, and to measure the response to therapy. Studies need to be adequately powered to detect effect sizes that are realistic and meaningful to patients, their families, and clinicians. Study designs should be optimized to accelerate the evaluation of the most promising interventions. Multidisciplinary and international collaboration will be essential to realize the goal of developing effective therapies for post-cardiac arrest brain injury.

Microvascular Network Remodeling in the Ischemic Mouse Brain Defined by Light Sheet Microscopy.

BACKGROUND: Until now, the analysis of microvascular networks in the reperfused ischemic brain has been limited due to tissue transparency challenges. METHODS: Using light sheet microscopy, we assessed microvascular network remodeling in the striatum from 3 hours to 56 days post-ischemia in 2 mouse models of transient middle cerebral artery occlusion lasting 20 or 40 minutes, resulting in mild ischemic brain injury or brain infarction, respectively. We also examined the effect of a clinically applicable S1P (sphingosine-1-phosphate) analog, FTY720 (fingolimod), on microvascular network remodeling. RESULTS: Over 56 days, we observed progressive microvascular degeneration in the reperfused striatum, that is, the lesion core, which was followed by robust angiogenesis after mild ischemic injury induced by 20-minute middle cerebral artery occlusion. However, more severe ischemic injury elicited by 40-minute middle cerebral artery occlusion resulted in incomplete microvascular remodeling. In both cases, microvascular networks did not return to their preischemic state but displayed a chronically altered pattern characterized by higher branching point density, shorter branches, higher unconnected branch density, and lower tortuosity, indicating enhanced network connectivity. FTY720 effectively increased microvascular length density, branching point density, and volume density in both models, indicating an angiogenic effect of this drug. CONCLUSIONS: Utilizing light sheet microscopy together with automated image analysis, we characterized microvascular remodeling in the ischemic lesion core in unprecedented detail. This technology will significantly advance our understanding of microvascular restorative processes and pave the way for novel treatment developments in the stroke field.

Head Injury and Risk of Incident Ischemic Stroke in Community-Dwelling Adults.

BACKGROUND: While stroke is a recognized short-term sequela of traumatic brain injury, evidence about long-term ischemic stroke risk after traumatic brain injury remains limited. METHODS: The Atherosclerosis Risk in Communities Study is an ongoing prospective cohort comprised of US community-dwelling adults enrolled in 1987 to 1989 followed through 2019. Head injury was defined using self-report and hospital-based diagnostic codes and was analyzed as a time-varying exposure. Incident ischemic stroke events were physician-adjudicated. We used Cox regression adjusted for sociodemographic and cardiovascular risk factors to estimate the hazard of ischemic stroke as a function of head injury. Secondary analyses explored the number and severity of head injuries; the mechanism and severity of incident ischemic stroke; and heterogeneity within subgroups defined by race, sex, and age. RESULTS: Our analysis included 12 813 participants with no prior head injury or stroke. The median follow-up age was 27.1 years (25th-75th percentile=21.1-30.5). Participants were of median age 54 years (25th-75th percentile=49-59) at baseline; 57.7% were female and 27.8% were Black. There were 2158 (16.8%) participants with at least 1 head injury and 1141 (8.9%) participants with an incident ischemic stroke during follow-up. For those with head injuries, the median age to ischemic stroke was 7.5 years (25th-75th percentile=2.2-14.0). In adjusted models, head injury was associated with an increased hazard of incident ischemic stroke (hazard ratio [HR], 1.34 [95% CI, 1.12-1.60]). We observed evidence of dose-response for the number of head injuries (1: HR, 1.16 [95% CI, 0.97-1.40]; ≥2: HR, 1.94 [95% CI, 1.39-2.71]) but not for injury severity. We observed evidence of stronger associations between head injury and more severe stroke (National Institutes of Health Stroke Scale score ≤5: HR, 1.31 [95% CI, 1.04-1.64]; National Institutes of Health Stroke Scale score 6-10: HR, 1.64 [95% CI, 1.06-2.52]; National Institutes of Health Stroke Scale score ≥11: HR, 1.80 [95% CI, 1.18-2.76]). Results were similar across stroke mechanism and within strata of race, sex, and age. CONCLUSIONS: In this community-based cohort, head injury was associated with subsequent ischemic stroke. These results suggest the importance of public health interventions aimed at preventing head injuries and primary stroke prevention among individuals with prior traumatic brain injuries.

A neurophysiological profiling of the heartbeat-evoked potential in severe acquired brain injuries: A focus on unconsciousness.

Unconsciousness in severe acquired brain injury (sABI) patients occurs with different cognitive and neural profiles. Perturbational approaches, which enable the estimation of proxies for brain reorganization, have added a new avenue for investigating the non-behavioural diagnosis of consciousness. In this prospective observational study, we conducted a comparative analysis of the topological patterns of heartbeat-evoked potentials (HEP) between patients experiencing a prolonged disorder of consciousness (pDoC) and patients emerging from a minimally consciousness state (eMCS). A total of 219 sABI patients were enrolled, each undergoing a synchronous EEG-ECG resting-state recording, together with a standardized consciousness diagnosis. A number of graph metrics were computed before/after the HEP (Before/After) using the R-peak on the ECG signal. The peak value of the global field power of the HEP was found to be significantly higher in eMCS patients with no difference in latency. Power spectrum was not able to discriminate consciousness neither Before nor After. Node assortativity and global efficiency were found to vary with different trends at unconsciousness. Lastly, the Perturbational Complexity Index of the HEP was found to be significantly higher in eMCS patients compared with pDoC. Given that cortical elaboration of peripheral inputs may serve as a non-behavioural determinant of consciousness, we have devised a low-cost and translatable technique capable of estimating causal proxies of brain functionality with an endogenous, non-invasive stimulus. Thus, we present an effective means to enhance consciousness assessment by incorporating the interaction between the autonomic nervous system (ANS) and central nervous system (CNS) into the loop.

Incidence of brain injuries in a large cohort of very preterm and extremely preterm infants at term-equivalent age: results of a single tertiary neonatal care center over 10 years.

OBJECTIVES: Cerebral magnetic resonance imaging (cMRI) at term-equivalent age (TEA) can detect brain injury (BI) associated with adverse neurological outcomes in preterm infants. This study aimed to assess BI incidences in a large, consecutive cohort of preterm infants born < 32 weeks of gestation, the comparison between very (VPT, ≥ 28 + 0 to < 32 + 0 weeks of gestation) and extremely preterm infants (EPT, < 28 + 0 weeks of gestation) and across weeks of gestation. METHODS: We retrospectively analyzed cMRIs at TEA of VPT and EPT infants born at a large tertiary center (2009-2018). We recorded and compared the incidences of BI, severe BI, intraventricular hemorrhage (IVH), periventricular hemorrhagic infarction (PVHI), cerebellar hemorrhage (CBH), cystic periventricular leukomalacia (cPVL), and punctate white matter lesions (PWML) between VPTs, EPTs, and across weeks of gestation. RESULTS: We included 507 preterm infants (VPT, 335/507 (66.1%); EPT, 172/507 (33.9%); mean gestational age (GA), 28 + 2 weeks (SD 2 + 2 weeks); male, 52.1%). BIs were found in 48.3% of the preterm infants (severe BI, 12.0%) and increased with decreasing GA. IVH, PVHI, CBH, cPVL, and PWML were seen in 16.8%, 0.8%, 10.5%, 3.4%, and 18.1%, respectively. EPT vs. VPT infants suffered more frequently from BI (59.3% vs. 42.7%, p < 0.001), severe BI (18.6% vs. 8.7%, p = 0.001), IVH (31.9% vs. 9.0%, p < 0.001), and CBH (18.0% vs. 6.6%, p < 0.001). CONCLUSION: Brain injuries are common cMRI findings among preterm infants with a higher incidence of EPT compared to VPT infants. These results may serve as reference values for clinical management and research. CLINICAL RELEVANCE STATEMENT: Our results with regard to gestational age might provide valuable clinical insights, serving as a key reference for parental advice, structured follow-up planning, and enhancing research and management within the Neonatal Intensive Care Unit. KEY POINTS: • Brain injury is a common cMRI finding in preterm infants seen in 48.3% individuals. • Extremely preterm compared to very preterm infants have higher brain injury incidences driven by brain injuries such as intraventricular and cerebellar hemorrhage. • Reference incidence values are crucial for parental advice and structured follow-up planning.

Drugs, Delirium, and Trauma: Substance Use and Incidence of Delirium After Traumatic Brain Injury.

INTRODUCTION: There is a paucity of data on the effect of preinjury substance (alcohol, drugs) abuse on the risk of delirium in patients with traumatic brain injury (TBI). This study aimed to assess the incidence of delirium among patients with blunt TBI in association with different substances. METHODS: We analyzed the 2020 American College of Surgeons-Trauma Quality Improvement Program. We included all adult (≥18 y) patients with blunt TBI who had a recorded substance (drugs and alcohol) screening. Our primary outcome was the incidence of delirium. RESULTS: A total of 72,901 blunt TBI patients were identified. The mean (standard deviation) age was 56 (20) years and 68.0% were males. The median (interquartile range) injury severity score was 17 (10-25). Among the study population, 23.1% tested positive for drugs (Stimulants: 3.0%; Depressants: 2.9%, hallucinogens: 5.1%, Cannabinoids: 13.4%, TCAs: 0.1%), and 22.8% tested positive for Alcohol. Overall, 1856 (2.5%) experienced delirium. On univariate analysis, patients who developed delirium were more likely to have positive drug screening results. On multivariable regression analyses, positive screen tests for isolated stimulants (adjusted odds ratio [aOR]: 1.340, P = 0.018), tricyclic antidepressants (aOR: 3.107, P = 0.019), and cannabinoids (aOR: 1.326, P ≤ 0.001) were independently associated with higher odds of developing delirium. CONCLUSIONS: Nearly one-fourth of adult patients with blunt TBI had an initial positive substance screening test. Patients with positive results for isolated stimulants, tricyclic antidepressants, and cannabinoids were at a higher risk of developing delirium, whereas this association was not evident with other drugs and alcohol-positive tests. These findings emphasize the need for early drug screening in TBI patients and close monitoring of patients with positive screening tests.

National Analysis of Outcomes for Adult Trauma Patients With Isolated Severe Blunt Traumatic Brain Injury Following Venous Thromboembolism Prophylaxis.

INTRODUCTION: We aim to evaluate the association of early versus late venous thromboembolism (VTE) prophylaxis on in-hospital mortality among patients with severe blunt isolated traumatic brain injuries. METHODS: Data from the American College of Surgeons Trauma Quality Program Participant Use File for 2017-2021 were analyzed. The target population included adult trauma patients with severe isolated traumatic brain injury (TBI). VTE prophylaxis types (low molecular weight heparin and unfractionated heparin) and their administration timing were analyzed in relation to in-hospital complications and mortality. RESULTS: The study comprised 3609 patients, predominantly Caucasian males, with an average age of 48.5 y. Early VTE prophylaxis recipients were younger (P < 0.01) and more likely to receive unfractionated heparin (P < 0.01). VTE prophylaxis later than 24 h was associated with a higher average injury severity score and longer intensive care unit stays (P < 0.01). Logistic regression revealed that VTE prophylaxis later than 24 h was associated with significant reduction of in-hospital mortality by 38% (odds ratio 0.62, 95% confidence interval 0.40-0.94, P = 0.02). Additionally, low molecular weight heparin use was associated with decreased mortality odds by 30% (odds ratio 0.70, 95% confidence interval 0.55-0.89, P < 0.01). CONCLUSIONS: VTE prophylaxis later than 24 h is associated with a reduced risk of in-hospital mortality in patients with severe isolated blunt TBI, as opposed to VTE prophylaxis within 24 h. These findings suggest the need for timely and appropriate VTE prophylaxis in TBI care, highlighting the critical need for a comprehensive assessment and further research concerning the safety and effectiveness of VTE prophylaxis in these patient populations.

Comparing neuropsychological, typical, and ADNI criteria for the diagnosis of mild cognitive impairment in Vietnam-era veterans.

OBJECTIVE: Neuropsychological criteria for mild cognitive impairment (MCI) more accurately predict progression to Alzheimer's disease (AD) and are more strongly associated with AD biomarkers and neuroimaging profiles than ADNI criteria. However, research to date has been conducted in relatively healthy samples with few comorbidities. Given that history of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are risk factors for AD and common in Veterans, we compared neuropsychological, typical (Petersen/Winblad), and ADNI criteria for MCI in Vietnam-era Veterans with histories of TBI or PTSD. METHOD: 267 Veterans (mean age = 69.8) from the DOD-ADNI study were evaluated for MCI using neuropsychological, typical, and ADNI criteria. Linear regressions adjusting for age and education assessed associations between MCI status and AD biomarker levels (cerebrospinal fluid [CSF] p-tau181, t-tau, and Aß42) by diagnostic criteria. Logistic regressions adjusting for age and education assessed the effects of TBI severity and PTSD symptom severity simultaneously on MCI classification by each criteria. RESULTS: Agreement between criteria was poor. Neuropsychological criteria identified more Veterans with MCI than typical or ADNI criteria, and were associated with higher CSF p-tau181 and t-tau. Typical and ADNI criteria were not associated with CSF biomarkers. PTSD symptom severity predicted MCI diagnosis by neuropsychological and ADNI criteria. History of moderate/severe TBI predicted MCI by typical and ADNI criteria. CONCLUSIONS: MCI diagnosis using sensitive neuropsychological criteria is more strongly associated with AD biomarkers than conventional diagnostic methods. MCI diagnostics in Veterans would benefit from incorporation of comprehensive neuropsychological methods and consideration of the impact of PTSD.

Factors Related to the Quality and Stability of Partner Relationships After Stroke: A Systematic Literature Review.

OBJECTIVE: To provide an overview of the current state of knowledge on factors related to relationship quality and relationship stability after stroke. DATA SOURCES: Cumulative Index to Nursing and Allied Health (CINAHL), Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on November 15, 2022, for literature on factors associated with (1) relation quality and (2) relation stability after stroke. STUDY SELECTION: English quantitative and qualitative studies investigating factors associated with relation quality and/or stability after stroke were included. Three reviewers independently assessed eligibility. Consensus meetings were held in case of divergent opinions. A total of 44 studies were included. DATA EXTRACTION: Information regarding study objectives and characteristics, participant demographics, independent and dependent variables, and main findings was extracted. Study quality was rated using the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies and/or the Critical Appraisal Skills Programme Checklist for Qualitative Research. Both were administered by the lead reviewer and checked by the second reviewer. Identified factors are described and presented according to the domains of the International Classification of Functioning, Disability, and Health model. DATA SYNTHESIS: Thirty-seven factors related to relationship quality after stroke were identified, covering the domains of body functions and structures (eg, cognitive problems), activities (eg, decrease in physical intimacy), participation (eg, being socially active), environment (eg, medication side effects), and personal factors (eg, hypervigilance). Eight factors related to relationship stability were identified, covering the domains of participation (agreement on reciprocal roles) and personal factors (eg, quality of prestroke relation). CONCLUSIONS: Relationship quality and stability after stroke are related to a multitude of factors. Future research should confirm the relevance of factors found in a few studies of suboptimal quality; explore possible associations between relationship stability and factors falling in the domains of body functions and structure, activity, and environmental factors; and explicitly explore potential positive effects of stroke on relationships.

Longitudinal Investigation of Alexithymia as a Predictor of Empathy, Emotional Functioning, Resilience, and Life Satisfaction 2 Years After Brain Injury.

OBJECTIVE: To examine the unique contribution of alexithymia at 1 year after traumatic brain injury (TBI) to the prospective prediction of emotional and social health outcomes at 2 years after injury. DESIGN: Multicenter, longitudinal cohort study. SETTING: Data were collected during year 1 and year 2 postinjury follow-up interviews across 4 TBI Model System centers. PARTICIPANTS: Persons with TBI (N=175; 134 men and 41 women) who had English fluency and were capable of providing self-reported data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary independent variable was the Toronto Alexithymia Scale-20. Outcome measures included the Interpersonal Reactivity Index, National Institute of Health Toolbox Emotion Battery Anger, Difficulty with Emotion Regulation Scale, Connor-Davidson Resilience Scale, Posttraumatic Stress Disorder Checklist - Civilian, Satisfaction with Life Scale, General Anxiety Disorder-7, Patient Health Questionnaire 9, suicidal ideation, and problematic substance use. RESULTS: Simple adjusted models demonstrated that after controlling for the specific outcome at year 1, Toronto Alexithymia Scale-20 scores significantly predicted year 2 scores for perspective-taking, physical aggression, emotional dysregulation, resilience, anxiety, depression, and suicidal ideation. All of these predictive findings except for physical aggression were maintained in the fully adjusted models that also controlled for age, sex, education level, number of prior TBIs, and motor and cognitive functioning. CONCLUSIONS: Compared with those with lower alexithymia scores, persons with TBI who had higher alexithymia scores at 1 year after injury reported poorer emotional health at 2 years after TBI, even after controlling for year 1 outcome scores, sociodemographic characteristics, and injury-related factors. These results support the need to assess for elevated alexithymia and to provide interventions targeting alexithymia early in the TBI recovery process.

Attention Training after Moderate-to-Severe Traumatic Brain Injury in Adults: A Systematic Review.

OBJECTIVE: To determine the extent and efficacy of attentional training as a form of neuropsychological rehabilitation to ameliorate attention deficits in adults with moderate-to-severe traumatic brain injury. DATA SOURCES: Articles published in Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, PubMed, PsycINFO, Scopus, and Web of Science were searched between January 17, and February 27, 2021. STUDY SELECTION: Two reviewers blindly assessed studies for eligibility according to the following criteria: any article evaluating the efficacy of any type of behavioral intervention that targeted attention (by means of cognitive rehabilitative, psychoeducational, or neuropsychological strategies, at either an individual or group level) in adults who had sustained a formally documented moderate-to-severe traumatic brain injury. DATA EXTRACTION: Methodological quality of each article was blindly assessed by 2 reviewers. Data were extracted from each study, including study type, sample size, sample characteristics, summary of intervention, measures used to assess attention, statistical outcomes and results, effect size, conclusion, and limitations. DATA SYNTHESIS: 7314 articles were retrieved from databases, 4325 articles remained after duplicate removal, and finally 21 articles met eligibility criteria and were included in this review. Articles represented varied methodological quality in group or single subject design. Irrespective of the heterogeneity regarding intervention types and attentional outcome measures used across the studies, overall findings suggest that attentional gains can be made in this sample, irrespective of time since injury, age, and injury severity. Further, a growing interest in technology-based interventions is frequently used and holds promise to bettering rehabilitation efforts. However, there is still limited evidence supporting the ecological validity of attentional training interventions (eg, the transfer of treatment effects to daily activities). CONCLUSIONS: This article plays a crucial role in informing ongoing rehabilitation practices, guiding clinicians with evidence-based strategies and shaping future research directions for more effective attentional training guidelines.

Mental Illness in the 2 Years Prior to Pregnancy in a Population With Traumatic Brain Injury: A Cross-Sectional Study: La maladie mentale dans les deux ans précédant une grossesse dans une population souffrant de lésion cérébrale traumatique : une étude transversale.

OBJECTIVE: Existing studies, in mostly male samples such as veterans and athletes, show a strong association between traumatic brain injury (TBI) and mental illness. Yet, while an understanding of mental health before pregnancy is critical for informing preconception and perinatal supports, there are no data on the prevalence of active mental illness before pregnancy in females with TBI. We examined the prevalence of active mental illness ≤2 years before pregnancy (1) in a population with TBI, and (2) in subgroups defined by sociodemographic, health, and injury-related characteristics, all compared to those without TBI. METHOD: This population-based cross-sectional study was completed in Ontario, Canada, from 2012 to 2020. Modified Poisson regression generated adjusted prevalence ratios (aPRs) of active mental illness ≤2 years before pregnancy in 15,585 females with TBI versus 846,686 without TBI. We then used latent class analysis to identify subgroups with TBI according to sociodemographic, health, and injury-related characteristics and subsequently compared them to females without TBI on their outcome prevalence. RESULTS: Females with TBI had a higher prevalence of active mental illness ≤2 years before pregnancy than those without TBI (44.1% vs. 25.9%; aPR 1.46, 95% confidence interval, 1.43 to 1.49). There were 3 TBI subgroups, with Class 1 (low-income, past assault, recent TBI described as intentional and due to being struck by/against) having the highest outcome prevalence. CONCLUSIONS: Females with TBI, and especially those with a recent intentional TBI, have a high prevalence of mental illness before pregnancy. They may benefit from mental health screening and support in the post-injury, preconception, and perinatal periods. PLAIN LANGUAGE TITLE: Mental illness in the 2 years before pregnancy in a population with traumatic brain injury.

Research has shown a strong association between traumatic brain injury (TBI) and mental illness. Most previous studies have been conducted in primarily male samples, like veterans and professional athletes. Understanding mental health before pregnancy is important for deciding what supports people need before and during pregnancy. However, there are no studies on the frequency of mental illness in females with TBI before a pregnancy. We examined the frequency of mental illness 2 years before pregnancy in a population with TBI, and in subgroups defined by different social, health, and injury-related characteristics, compared to those without TBI. We undertook a population-wide study of all females with and without TBI in Ontario, Canada, with a birth in 2012­2020. We used statistical models to compare these groups on the presence of mental illness in the 2 years before pregnancy, before and after accounting for social and health characteristics. We also identified subgroups with TBI according to their social (e.g., poverty), health (e.g., chronic conditions), and injury-related characteristics (e.g., cause of injury) and subsequently compared them to females without TBI on their frequency of mental illness in the 2 years before pregnancy. Forty-four percent of females with TBI had mental illness in the 2 years before pregnancy compared to 25% of those without TBI. There were 3 TBI subgroups. Females with low-income, past assault, and injuries that were described as being intentional had the highest frequency of mental illness in the 2 years before pregnancy. Females with TBI may benefit from mental health screening and support post-injury and around the time of pregnancy.

Euglycemic diabetic ketoacidosis following traumatic brain injury.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors lower glucose levels by reducing glucose reabsorption in the kidneys, which can lead to ketogenesis. Euglycemic diabetic ketoacidosis (DKA) is a rare but potentially life-threatening complication of SGLT2 inhibitors that can be triggered by trauma. However, the absence of significant hyperglycemia can delay its diagnosis and treatment, which may lead to detrimental consequences. Herein, we report a case of euglycemic DKA following traumatic brain injury in a patient with type 2 diabetes who was taking an SGLT2 inhibitor. Delayed recognition of euglycemic DKA in this case led to progressive metabolic deterioration. This report emphasizes the importance of promptly suspecting, diagnosing, and treating euglycemic DKA in patients with traumatic injuries who exhibit high anion-gap metabolic acidosis, ketonuria, and glucosuria-even if they do not have significant hyperglycemia.

Beliefs of physician directors on the management of devastating brain injuries at the Canadian emergency department and intensive care unit interface: a national site-level survey.

PURPOSE: Insufficient evidence-based recommendations to guide care for patients with devastating brain injuries (DBIs) leave patients vulnerable to inconsistent practice at the emergency department (ED) and intensive care unit (ICU) interface. We sought to characterize the beliefs of Canadian emergency medicine (EM) and critical care medicine (CCM) physician site directors regarding current management practices for patients with DBI. METHODS: We conducted a cross-sectional survey of EM and CCM physician directors of adult EDs and ICUs across Canada (December 2022 to March 2023). Our primary outcome was the proportion of respondents who manage (or consult on) patients with DBI in the ED. We conducted subgroup analyses to compare beliefs of EM and CCM physicians. RESULTS: Of 303 eligible respondents, we received 98 (32%) completed surveys (EM physician directors, 46; CCM physician directors, 52). Most physician directors reported participating in the decision to withdraw life-sustaining measures (WLSM) for patients with DBI in the ED (80%, n = 78), but 63% of these (n = 62) said this was infrequent. Physician directors reported that existing neuroprognostication methods are rarely sufficient to support WLSM in the ED (49%, n = 48) and believed that an ICU stay is required to improve confidence (99%, n = 97). Most (96%, n = 94) felt that providing caregiver visitation time prior to WLSM was a valid reason for ICU admission. CONCLUSION: In our survey of Canadian EM and CCM physician directors, 80% participated in WLSM in the ED for patients with DBI. Despite this, most supported ICU admission to optimize neuroprognostication and patient-centred end-of-life care, including organ donation.

RéSUMé: OBJECTIF: L'insuffisance des recommandations fondées sur des données probantes pour guider les soins aux individus atteints de lésions cérébrales dévastatrices rend ces personnes vulnérables à des pratiques incohérentes à la jonction entre le service des urgences et de l'unité de soins intensifs (USI). Nous avons cherché à caractériser les croyances des directeurs médicaux canadiens en médecine d'urgence et médecine de soins intensifs concernant les pratiques de prise en charge actuelles des personnes ayant subi une lésion cérébrale dévastatrice. MéTHODE: Nous avons réalisé un sondage transversal auprès des directeurs médicaux des urgences et des unités de soins intensifs pour adultes du Canada (décembre 2022 à mars 2023). Notre critère d'évaluation principal était la proportion de répondant·es qui prennent en charge (ou jouent un rôle de consultation auprès) des personnes atteintes de lésions cérébrales dévastatrices à l'urgence. Nous avons effectué des analyses en sous-groupes pour comparer les croyances des médecins des urgences et des soins intensifs. RéSULTATS: Sur les 303 personnes répondantes admissibles, 98 (32 %) ont répondu aux sondages (directions médicales des urgences, 46; directions médicales d'USI, 52). La plupart des directeurs médicaux ont déclaré avoir participé à la décision de retirer des traitements de maintien des fonctions vitales (TFMV) pour des patient·es atteint·es de lésions cérébrales dévastatrices à l'urgence (80 %, n = 78), mais 63 % (n = 62) ont déclaré que c'était peu fréquent. Les directions médicales ont indiqué que les méthodes de neuropronostic existantes sont rarement suffisantes pour appuyer le retrait des TMFV à l'urgence (49 %, n = 48) et croyaient qu'un séjour aux soins intensifs était nécessaire pour améliorer leur confiance en ces méthodes (99 %, n = 97). La plupart (96 %, n = 94) estimaient que le fait d'offrir du temps de visite aux personnes soignantes avant le retrait des TMFV était un motif valable d'admission aux soins intensifs. CONCLUSION: Dans le cadre de notre sondage mené auprès des directions médicales des services d'urgence et des USI au Canada, 80 % d'entre elles ont participé au retrait de TMFV à l'urgence pour des patient·es souffrant de lésions cérébrales dévastatrices. Malgré cela, la plupart d'entre elles étaient en faveur d'une admission aux soins intensifs afin d'optimiser le neuropronostic et les soins de fin de vie axés sur les patient·es, y compris le don d'organes.

Caregiver and family functioning after pediatric disorder of consciousness: telephone-based outcome assessment.

OBJECTIVE: Examine initial feasibility/utility of a telephone-administered measure in describing impact of child health on caregiver/family functioning in patients with a history of a disorder of consciousness (DoC) due to severe-acquired brain injury (ABI). METHOD: Caregivers of patients admitted at least 1 year prior for inpatient rehabilitation with DoC completed a battery of measures administered via telephone examining the impact of child health on caregiver/family functioning (Pediatric Quality of Life Family Impact Module; PedsQL-FIM) and child functioning. RESULTS: Forty-one caregivers of unique patients (age = 5-22 years; M = 14.9, SD = 5.1; 63% male; time since injury = 1-18 years; M = 5.3; SD = 4.2) completed the telephone measures. PedsQL-FIM floor and ceiling effects were minimal (administration time = 5-16 min, M = 7.4; SD = 2.8). Family functioning was lowest in Daily Activities and highest in Family Relationships. Relative to caregivers of patients with mild-severe ABI, caregivers reported lower caregiver/family functioning. Correlations were moderate between child functioning and caregiver/family functioning on some PedsQL-FIM scales. CONCLUSIONS: Within this relatively small convenience sample, results indicate the PedsQL-FIM administered via telephone is feasible and useful in describing the impact of child health on caregiver/family functioning long after DoC associated with ABI. Future studies are needed to understand factors contributing to caregiver/family functioning to inform targeted interventions.

Age-related smartphone use patterns among individuals with moderate-to-severe traumatic brain injury.

OBJECTIVE: With mobile health technologies serving as an alternative means of providing healthcare, evaluating patients' abilities to navigate digital infrastructures is becoming increasingly relevant. The goal of this study is to investigate smartphone use patterns among individuals with history of moderate-to-severe traumatic brain injury (TBI). METHODS: An anonymous survey was delivered via e-mail or text message to eligible participants who had a history of moderate-to-severe TBI and were prospectively followed at one of the eight participating Traumatic Brain Injury Model Systems centers for at least 1-year post-injury. The survey captured demographic data and included a questionnaire to evaluate smartphone use (calling, texting, web browsing, etc.). RESULTS: A total of 2665 eligible individuals were contacted to complete the survey, 472 of which responded. 441 of them reported smartphone use. Individuals ages 45 and older were significantly less likely to use their phones for functions other than calling and texting when compared to individuals ages 18-44 (p < 0.05). CONCLUSIONS: Most individuals with moderate-to-severe TBI in this cohort demonstrated intentional smartphone use, suggesting that mobile health technologies may be feasible as a cost-effective healthcare alternative. However, doing so will require additional interventions to provide further technological education especially in older individuals with TBI.

Virtual reality immerses you in your mind: the experience and stress-reduction benefits of VR mindfulness modules in persons with TBI.

OBJECTIVE: This pilot study tested the feasibility and stress reduction effectiveness of a one-time virtual reality mindfulness module (VRMM) in individuals with mild-to-moderate traumatic brain injury (TBI). METHODS: Thirty-eight participants participated in a pilot study utilizing a mixed methods convergent parallel design. Pretest and posttest stress levels were collected; participants engaged in a brief 4-question qualitative interview. Mann Whitney U and Wilcoxon Signed Rank Tests were used. Qualitative analysis utilized grounded theory. RESULTS: Post-VRMM, two-thirds (24) of participants had a statistically significant decrease in stress levels. A key qualitative finding indicated that participants found the immersiveness and realism of the VR environments helpful in compensating for cognitive deficits resulting from TBI. There were no adverse side effects reported, indicating that well-designed VRMMs that minimize motion-induced adverse effects are well tolerated in persons with TBI. CONCLUSION: A guided mindfulness activity in a VR environment was well tolerated, and participants overall found VRMM effective in reducing stress levels. VR-based environments have potential to harness guided mindfulness practice and may support persons with TBI to enhance concentration. Further application of this technology in TBI rehabilitation is promising and warrants future research to explore the benefit of VR in improving rehabilitation outcomes.

Clinical experience with bromocriptine for central hyperthermia after brain insult.

INTRODUCTION: Bromocriptine is a dopamine receptor agonist used for central hyperthermia with limited data. We describe our single-center experience utilizing bromocriptine for central hyperthermia, including the population treated, most common dosing regimens, adverse events, and discontinuation reasons. METHODS: A retrospective study was conducted screening patients who were admitted to intensive care units for acute neurological insults and administered bromocriptine for central hyperthermia between April 2016 and September 2022. Baseline characteristics, disease severity markers, and bromocriptine doses were collected. Body temperatures prior to the first dose of bromocriptine, at the time of dose, and after each dose were recorded. Co-administration of additional hyperthermia management therapies was noted. RESULTS: Thirty patients were included. The most common diagnosis was traumatic brain injury (TBI) (N = 14). The most common reason for discontinuation was resolution of indication (N = 14). Discontinuation due to mild adverse effects occurred in four patients; hepatotoxicity was the most common. There was a paired mean difference of -0.37°C (p = 0.005) between temperatures before and after bromocriptine initiation. CONCLUSION: Bromocriptine is a potential therapy for the management of central hyperthermia in patients with severe acute neurologic insults who have failed other therapies. Bromocriptine was well tolerated and associated with a low incidence of adverse events.

Contextual factors of financial capability and financial well-being for adults living with brain injury: a qualitative photovoice study.

OBJECTIVE: To identify the contextual factors related to financial capability and financial well-being for adults living with acquired brain injury (ABI). DESIGN & METHOD: We conducted a qualitative descriptive study using photovoice and included 17 adults who live with ABI in Manitoba, Canada. Over 3-to-5 weeks, participants took photos of their financial capability (i.e. knowledge, skills, and behaviors related to managing finances) or their financial well-being (i.e. subjective and objective financial outcomes). Participants were interviewed about their photos. Five researchers iteratively and thematically analyzed interview transcripts. MAIN OUTCOMES/RESULTS: Analysis identified the importance of the economic, social, technology, and physical or sensory context. Subthemes related to: (i) hard times finding financial resources; (ii) processes not making sense; (iii) getting help from the right person; and (iv) invisible disability bias and stigma. CONCLUSIONS: There is decreased literature about financial capability or financial well-being after ABI. The results of this study highlight the salience of finance to living with ABI and the importance of the context to addressing financial-related life participation for people living with ABI. Information about contextual factors related to finance can improve rehabilitation assessment and intervention practice as well as emphasize needed accessibility changes to financial environments.

Feasibility of overground exoskeleton gait training during inpatient rehabilitation after severe acquired brain injury.

OBJECTIVE: To describe the safety, feasibility, and tolerability of overground exoskeleton gait training (OEGT) integrated into clinical practice for patients after severe acquired brain injury (ABI). SETTING: Inpatient rehabilitation hospital. PARTICIPANTS: Eligible patients with severe ABI met the following criteria: age > 18, medically stable, met exoskeleton frame limitations, and a score of ≤ 3 on the motor function portion of the Coma Recovery Scale - Revised (CRS-R). Presence of consciousness disorder was not exclusionary. DESIGN: Prospective observational study. MAIN MEASURES: Outcomes examined safety (adverse events), feasibility (session count and barriers to session completion), and tolerability of OEGT (session metrics and heart rate). RESULTS: Ten patients with ABI completed 10.4 ± 4.8 OEGT sessions with no adverse events. Barriers to session completion included clinical focus on prioritized interventions. Sessions [median up time = 17 minutes, (IQR: 7); walk time = 13 minutes, (IQR: 9); step count = 243, (IQR: 161); device assist = 74, (IQR: 28.0)] were primarily spent in Very Light to Light heart rate intensities [89%, (IQR: 42%) and 9%, (IQR: 33%), respectively]. CONCLUSION: OEGT incorporated into the rehabilitation plan of care during inpatient rehabilitation after severe ABI was observed to be safe, feasible, and tolerable. However, intentional steps must be taken to facilitate patient safety.