Thalamic deep brain stimulation in traumatic brain injury: a phase 1, randomized feasibility study.

Converging evidence indicates that impairments in executive function and information-processing speed limit quality of life and social reentry after moderate-to-severe traumatic brain injury (msTBI). These deficits reflect dysfunction of frontostriatal networks for which the central lateral (CL) nucleus of the thalamus is a critical node. The primary objective of this feasibility study was to test the safety and efficacy of deep brain stimulation within the CL and the associated medial dorsal tegmental (CL/DTTm) tract.Six participants with msTBI, who were between 3 and 18 years post-injury, underwent surgery with electrode placement guided by imaging and subject-specific biophysical modeling to predict activation of the CL/DTTm tract. The primary efficacy measure was improvement in executive control indexed by processing speed on part B of the trail-making test.All six participants were safely implanted. Five participants completed the study and one was withdrawn for protocol non-compliance. Processing speed on part B of the trail-making test improved 15% to 52% from baseline, exceeding the 10% benchmark for improvement in all five cases.CL/DTTm deep brain stimulation can be safely applied and may improve executive control in patients with msTBI who are in the chronic phase of recovery.ClinicalTrials.gov identifier: NCT02881151 .

Using the Decrease in Trauma Admissions During the COVID-19 Pandemic to Evaluate Compliance With Stay-at-Home and Social Distancing Guidelines.

Introduction The coronavirus disease 2019 (COVID-19) virus was declared a pandemic on March 10, 2020 by the World Health Organization (WHO) and has massively burdened healthcare systems with cases exponentially rising throughout the United States and the rest of the world. Since implementing precautions to reduce the spread of this disease, emergency departments have seen a decrease in the number of traumas. By evaluating the differences in the number of trauma admissions in different subgroups of patients, we can assess where to target messaging to increase compliance with these precautions. In this study, we aim to analyze the effect of the COVID-19 pandemic on trauma admissions. Methodology This was a retrospective review of the trauma database at our institution, a level 2 trauma center in Southern California, to assess the impact of COVID-19 on the number of traumas. The inclusion criteria were patients activated as traumas, regardless of age. Patients were excluded from the study if they did not have complete information in the trauma database. Data were stratified by date into two groups: (a) COVID period (January to April 2020) and (b) pre-COVID period (January to April 2019). The primary endpoint of this study was to determine whether there was a significant change in the number of patients presenting as trauma during the COVID-19 pandemic. This difference was analyzed and divided into subgroups based on age and trauma type. Results In our review, an average of 279 patients per month presented as trauma from January to April in 2019, and an average of 222 patients per month presented as trauma from January to April 2020 (p = 0.049). We found a significant decrease in the number of patients presenting with the chief complaint of fall and vehicular accident, but a nonsignificant difference in patients presenting as assaults or pedestrian accidents. There was also a significant decrease in the number of traumas in the 18-39 and 65+ age groups and a nonsignificant decrease in the 40-64 age group. It was also noted that the number of trauma admissions in May 2020 increased to 253 compared to 269 in 2019. This increase was most notable in the 18-39 and 40-64 age groups. Discussion As seen in the data, the most notable year-over-year difference was seen in March and April. In California specifically, a stay-at-home order was set in place in March, which was in conjunction with the WHO's declaration of a pandemic. An interesting finding was the significant decrease in patients with traumas in the age groups of 18-39 and 65+ from 2019 to 2020. There was a smaller, nonsignificant decrease in patients aged 40-64. This would be a good group to target with future messaging to increase compliance with health advisories. There was also a notable increase in the number of traumas in May 2020, signaling an end to the cooperation of the majority of people, also indicating that further measures needed to be enacted in all groups. Conclusions COVID-19 has disrupted social structures worldwide. As the pandemic continued, even the observers of stay-at-home and social distancing measures, the 18-39 age group, became fatigued with the guidelines and ventured out into the warming weather and summer activities. This difference in trauma admission due to COVID-19 between subsequent years can highlight the behavioral changes in our patient population and can be further extrapolated to target additional messaging to help reduce the spread of COVID-19.

Safety and Efficacy of Transcatheter Administration of Tissue Plasminogen Activating Factor as Adjuvant Therapy for Intraventricular Hemorrhage.

Objective Stroke is the fifth leading cause of death in the United States and the leading cause of disability. Hemorrhagic stroke has higher risks of mortality and neurologic deficit. Higher still, acute intraventricular hemorrhage (IVH) has mortality between 50% and 80% while complicating subarachnoid hemorrhage in 15% of cases and intracerebral hemorrhage in 40% of cases. We sought to demonstrate that early adjuvant intraventricular recombinant tissue plasminogen activating factor (rt-PA) improved outcomes. Methods Retrospective chart review was performed on patients aged 18-95 years with external ventricular drain (EVD) and intraventricular rt-PA for clot evacuation in IVH between 2005 and 2015. In total, 22 patients met the inclusion criteria. Generalized linear modeling was performed with factorial analysis using the Glasgow Coma Score (GCS) on arrival, GCS at EVD placement, EVD day of onset of rt-PA administration, GCS at onset of rt-PA administration, total duration of EVD, necessity of ventriculoperitoneal (VP) shunt, occurrence of ventriculitis, day of ventriculitis, GCS after rt-PA, length of stay (LOS) in the intensive care unit (ICU), and hospital disposition. Results Presenting GCS affected LOS significantly. Ventriculitis only significantly affected ICU LOS. GCS after rt-PA only significantly affected discharge GCS. EVD day of rt-PA protocol commencement demonstrated significant effects on EVD duration and cerebrospinal fluid (CSF) diversion requirement. Age affected ICU and hospital LOS. Conclusion These findings argue for larger prospective trials of EVD day two rt-PA protocol inception in acute IVH. Reported ventriculitis rates with EVDs are 8.8%, while we demonstrated a rate of 18% without significant effects except in ICU LOS. Transcatheter intraventricular rt-PA is safe and effective as an adjuvant in acute spontaneous intraventricular hemorrhage with the greatest benefit of rt-PA protocol at EVD day two.

Safety of the transventricular approach to deep brain stimulation: A retrospective review.

BACKGROUND: Anatomically, deep brain stimulation (DBS) targets such as the ventral intermediate and subthalamic nucleus are positioned such that the long axis of the nucleus is often most accessible through a transventricular trajectory. We hypothesize that using this trajectory does not place patients at increased risk of neurologic complications. METHODS: A series of 206 patients at a single institution between 2000 and 2017 were reviewed. All patients had a confirmed transventricular trajectory and their clinical course was reviewed to assess neurologic complication rates in the postoperative period. RESULTS: The average length of hospital stay was 2.4 days. The most common neurologic complication was altered mental status in 1.2% of cases (four patients). This was followed by seizure in 0.6% of cases (two patients). No patients had ischemic stroke or postoperative hemiparesis. There were two mortalities in this series, one with lobar hemorrhage contralateral from the surgical site and one with a thalamic hemorrhage. There was only one confirmed intraventricular hemorrhage postoperatively; however, this was clinically asymptomatic. CONCLUSION: Although the total incidence of intraventricular or intracerebral hemorrhage cannot be reliably assessed from this data set, the low incidence of neurologic complications challenges the notion that DBS electrode trajectories that transgress the ventricle significantly increase the risk of complications.

Tight Control of Systolic Blood Pressure in Spontaneous Intraparenchymal Brain Hemorrhage.

Background Tight blood pressure control is critical in neurosurgical patients. Systolic blood pressure (SBP) must be low enough to avoid injury and minimize intraparenchymal hemorrhage (IPH) but high enough to maintain cerebral perfusion. American Heart Association (AHA) guidelines recommend SBP <140 in intracerebral hemorrhage. This paper sought to elucidate the effect of early control of SBP on IPH expansion. Methods 134 patients with spontaneous IPH between 2011 and 2015 were analyzed utilizing chart review. Initial versus follow-up bleed size, presentation and discharge condition, discharge disposition, and blood pressure control adequacy were analyzed using the generalized linear model. Results Altered mental status was the most common presenting complaint (78%). Presenting GCS failed to demonstrate a significant main effect. Age, initial IPH volume, presenting SBP, and one-hour SBP significantly affected IPH percent expansion (p=0.002, =0.002, <0.0005, and =0.026). Several two-way interactions affected IPH percent change implying synergistic effects of the predictor variables. Conclusion Patients aged 60-70 years had the largest percent IPH expansion followed by patients aged 20-30 years. Initial IPH volume of 65.23-78.26 ml showed the largest expansion. Initial IPH volume of 52.18-65.22 ml demonstrated the least percentage of IPH expansion. One-hour control of SBP to binned groups of 111-121 mmHg or 121-132 mmHg portends relative minima in bleed expansion corresponding with AHA recommendations for IPH patients. This study suggests that this degree of early and aggressive control of SBP is achievable, safe, and may minimize IPH expansion. Future studies are needed to elucidate the role of co-morbidities and to confirm these findings in broader populations.

Minimization of Intraparenchymal Hemorrhagic Stroke Size by Optimization of Serum Lipids.

Introduction Intraparenchymal hemorrhages (IPHs) are the most common type of hemorrhagic stroke. One of the main associated risk factors is total cholesterol (TC) above 200. A severely decreased level of TC potentially interferes with the stabilization of the cell membrane and can potentially lead to a larger hemorrhage. Previous population-based studies have confirmed an association between low TCs and a high incidence of hemorrhagic stroke. It has been established that a TC below 200 decreases the potential for cardiovascular disease. This study suggests that the balance that needs to be achieved between these two extremes presents a unique possibility for an optimal therapeutic range of total cholesterol levels. Materials & methods Inclusion criteria included all adult patients with International Classification of Diseases (ICD)-9/10 code for hemorrhagic stroke, from June 2007 to June 2017. A total of 300 patients met the criteria (N=300). For each patient, the following data were collected: NIH Stroke Scale, TC level, triglyceride level, low-density lipoprotein (LDL) and high-density lipoprotein (HDL), cholesterol reducing medications, size of hemorrhage on computed tomography (CT) of the head, location of hemorrhage, and patient disposition. Statistical analysis was done using the Generalized Linear Modeling with Wald Chi-square as the statistical determinant. Results Intracerebral hemorrhage size is dependent on the intracranial location with brain lobes having larger bleeds. Minimum hemorrhage size was noted in TC 188-196 and this effect was statistically significant independent of location. HDL has a significant independent effect on hemorrhage size with overall minimum bleed occurring in the range of 43-51 mg/dL HDL (98-106 mg/dL for men and 43-51 mg/dL for women). This sex effect within HDL on hemorrhage size is statistically significant. There was a differential effect of HDL dependent on patient race. Asian and black patients had least IPH volume with HDL 70-79 mg/dL, while Hispanic patients had a minimum at 43-51 mg/dL. White patients required a higher HDL, 80-88 mg/dL to minimize the IPH size. The triglyceride level had a statistically significant independent effect on the bleed size with the minimum hemorrhage size occurring in the range of 205-224 mg/dL. This effect was nuanced by patient race with statistically significant minimum IPH size occurring at 144-164 mg/dL for white patients, 124-143 mg/dL for Hispanic and black patients, and 84-103 mg/dL for Asian patients. Post-hospital patient disposition was not significantly affected by any of the above predictor variables. Conclusion This study found TC, HDL and triglycerides in specific ranges are associated with significantly decreased hemorrhage size across all genders and hemorrhage locations. The ranges with the strongest hemorrhage-limiting effect are as follows: TC 188-196 mg/dL, HDL 43-51 mg/dL (98-106 mg/dL for men and 43-51 mg/dL for women), triglycerides 205-224 mg/dL. Lipids both below and above these ranges yield larger bleeds. It also found larger brain areas will have more extensive hemorrhage than smaller brain areas. Future work in this arena should include collaboration with cardiology to determine ideal ranges for both cardio- and neuroprotection as well as a prospective study to validate the applicability of these findings in patient care.