Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System.

BACKGROUND: Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization. METHODS: To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection. RESULTS: The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 109 cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics. CONCLUSIONS: The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.

Reorganization of language centers in patients with brain tumors located in eloquent speech areas - A pre- and postoperative preliminary fMRI study.

INTRODUCTION: The aim of this study was to determine in pre- and postsurgical fMRI studies the rearrangement of the Broca's and Wernicke's areas and the lateralization index for these areas in patients with brain tumors located near speech centers. Impact of the surgical treatment on the brain plasticity was evaluated. MATERIALS AND METHODS: Pre- and postoperative fMRI examinations were performed in 10 patients with low grade glial, left-sided brain tumors located close to the Broca's (5 patients) or Wernicke's area (5 patients). BOLD signal was recorded in regions of interest: Broca's and Wernicke's areas, and their anatomic right-sided homologues. RESULTS: In the preoperative fMRI study the left Broca's area was activated in all cases. The right Broca's area was activated in all the patients with no speech disorders. In the postoperative fMRI the activation of both Broca's areas increased in two cases. In other two cases activation of one of the Broca's area increased along with the decrease in the contralateral hemisphere. In all patients with temporal lobe tumors, the right Wernicke's area was activated in the pre- and postsurgical fMRI. After the operation, in two patients with speech disorder, the activation of both Broca's areas decreased and the activation of one of the Wernicke's areas increased. CONCLUSIONS: In the cases of tumors localized near the left Broca's area, a transfer of the function to the healthy hemisphere seems to take place. Resection of tumors located near Broca's or Wernicke's areas may lead to relocation of the brain language centers.

Reorganization of Language Areas in Patient with a Frontal Lobe Low Grade Glioma - fMRI Case Study.

BACKGROUND: Functional magnetic resonance (fMRI) studies results in case of an adult patient with low grade glioma (LGG) in dominant hemisphere suggest brain plasticity process with acquisition of language functions by the non-dominant hemisphere speech regions. CASE REPORT: A 36-years old right-handed woman was admitted to the Department of Neurosurgery for surgical treatment of brain tumor. An MRI examination revealed a pathological mass in the left frontal lobe, in close topographical relationship to the Broca's area. A left fronto-parietal craniotomy was performed, with an intraoperative awake language mapping procedure. A total resection of the pathological mass was achieved. The tumor was examined histologically as LGG. In the follow-up MRI exam 32 months after the operation a tumor recurrence was suggested. The fMRI exams performed preoperative and 3, 32 and 41 months after the operation showed changes in language regions activation patterns, with a progressive right-sided activation of Broca's and Wernicke's areas. Pre- and postoperative cognitive evaluation by a neuropsychologist did not detect any language impairment. We present a running process of reorganization of language areas in a patient after brain tumor resection, from strong left-sided to symmetrical lateralization. CONCLUSIONS: 1. FMRI results in comparison with the psychological status of the patient proved contribution of functional reorganization to the preservation of language performance. 2. A slow growing LGG as well as the recurrence of the tumor near the left Broca's area might be the factors leading to reorganization of language-related areas by recruiting the right hemisphe.

Rearrangement of motor centers and its relationship to the neurological status of low-grade glioma examined on pre- and postoperative fMRI.

OBJECTIVE: Well-developed compensatory mechanisms, based on the phenomenon of brain plasticity, exist in patients with neuroepithelial tumors, especially with highly differentiated gliomas (WHO grade II). We studied phenomenon of rearrangement of sensorimotor cortex using functional magnetic resonance imaging (fMRI), and verified relationship between observed changes and results of neurological and neuropsychological assessment. METHODS: Study group included 20 patients with WHO grade II gliomas located within motor or sensory cortex. fMRI examination, as well as clinical, neurological (Karnofsky performance score [KPS] and Lovett's scale [Lo]), and neuropsychological assessment (Digit Coding Symbol Test and Digit Span Test) were performed pre-operatively and 3 months post-surgery. RESULTS: There were no significant differences in pre- and postoperative performance status of patients. Although statistically insignificant, an increase in frequency of activation of primary and secondary cortical motor centers was observed postoperatively (p>0.05). Prior to surgery, motor centers were characterized by lower values of t-statistics than in postoperative period (p>0.05). In contrast, values of parameters describing the size of examined centers, i.e. mean number of clusters, were lower, but not statistically significant on postoperative examination (p>0.05). Compared to individuals without motor deficit, patients with preoperative Lo3/Lo4 paralysis showed significantly higher mean values of t-statistics in the accessory motor area on postoperative examination (p<0.05). CONCLUSIONS: The processes of motor cortex rearrangement seemed to be associated with the pre- and postoperative neurological and neuropsychological status of patients. After contralateral primary motor cortex, accessory motor area was the second most frequently activated center, both pre- and postoperatively.

Functional rearrangement of language areas in patients with tumors of the central nervous system using functional magnetic resonance imaging.

BACKGROUND: The aim of this study was to determine the reorganization of the language areas in patients with tumors located near speech centers using functional magnetic resonance imaging (fMRI). MATERIAL/METHODS: fMRI was performed prior to the surgical treatment of 11 right-handed patients with tumors located close to the Broca's or Wernicke's areas of the left hemisphere. The analysis included a record of the activity in four regions of interest (ROIs): Broca's and Wernicke's areas, and their anatomic homologues in the right hemisphere. For each patient a regional lateralization index was calculated separately for Broca's area versus its right-hemisphere homolog and Wernicke's area versus its right-hemisphere homolog. The results were correlated with the histopathological type of the tumor and its size. RESULTS: Our fMRI examinations showed activation of the Broca's area in the right hemisphere in 3/4 cases of low grade gliomas (LGG) localized in the left frontal lobe. In one case of the high grade glioma (HGG) only the left hemisphere Broca's area was activated (LI=1). Activation in Wernicke's area in both hemispheres was obtained irrespective of the size and histological type of the tumor. All tumors localized in the left temporal lobe were HGG. We obtained activation only in the right hemisphere Wernicke's area in 4/5 of the cases. In 4/5 of the cases activation in Broca's area was present- in 2 cases in the left hemisphere, in 1 case in the right hemisphere and in 1 case bilateral. CONCLUSIONS: The presence of a neoplastic lesion in close topographic relationship to language areas induces their functional reorganization. fMRI is an useful method for determination of language areas localization in pre-operative planning. HGG tumors localized near Wernicke's area lead to transfer its function to the healthy hemisphere and/or to decreased activity in the affected hemisphere.

Functional rearrangement of the primary and secondary motor cortex in patients with primary tumors of the central nervous system located in the region of the central sulcus depending on the histopathological type and the size of tumor: Examination by means of functional magnetic resonance imaging.

BACKGROUND: The aim of this study was to analyze the reorganization of the centers of the motor cortex in patients with primary neuroepithelial tumors of the central nervous system (CNS) located in the region of the central sulcus in relation to the histopathological type and the size of tumor, as determined by means of functional magnetic resonance imaging (fMRI). MATERIAL/METHODS: The fMRI was performed prior to the surgical treatment of patients with tumors located in the region of the central sulcus (WHO stage I and II, n=15; WHO stage III and IV, n=25). The analysis included a record of the activity in the areas of the primary motor cortex (M1) and the secondary motor cortex: the premotor cortex (PMA) and the accessory motor area (SMA). The results were correlated with the histopathological type of the tumor and its size expressed in cm(3). RESULTS: The frequency of activation of the motor center was higher in the group of patients who had less aggressive tumors, such as low-grade glioma (LGG), as well as in tumors of lower volume, and this was true both for the hemisphere where the tumor was located and in the contralateral one. Mean values of t-statistics of activation intensity, mean numbers of activated clusters, and their ranges were lower in all analyzed motor areas of LGG tumors. The values of t-statistics and activation areas were higher in the case of small tumors located in ipsilateral centers, and in large tumors located in contralateral centers, aside from the SMA area where the values of t-statistics were equal for both groups. The contralateral SMA area was characterized by the highest stability of all examined centers of secondary motor cortex. No significant association (p>0.05) was observed between the absolute value of the mean registered activity (t-statistics) and the size of examined areas (number of clusters) when the groups were stratified with regards to the analyzed parameters. CONCLUSIONS: The presence of a neoplastic lesion, its histopathological type and finally its size modulate the functional reorganization of the motor centers as suggested by the differences in the frequency of the neural center activation in the analyzed groups. Processes of functional rearrangement are more pronounced and more precisely defined in patients with less aggressive and/or smaller tumors. The contralateral accessory area is the most frequently activated center in all analyzed groups irrespective of the grade and size of the tumor.