Riesgo de hemorragia cerebral en el traumatismo craneal leve y tratamiento antitrombótico / Risk of cerebral hemorrhage in mild traumatic brain injury and antithrombotic treatment

Objetivo El tiempo de observación en el traumatismo craneoencefálico leve (TCEL) es controvertido. Nuestro objetivo se basó en evaluar el riesgo de complicaciones neurológicas en el TCEL con y sin tratamiento antitrombótico. Método Evaluamos retrospectivamente los pacientes con TCEL atendidos en urgencias durante 3 años. Consideramos TCEL aquellos con Glasgow ≥13 al ingreso. Se realizó una TC craneal en todos los casos con >1 factor de riesgo al ingreso y a las 24h en aquellos con deterioro neurológico o TC craneal inicial patológica. Se revisó retrospectivamente las complicaciones en los siguientes 3 meses. Resultados Evaluamos 907 pacientes con una edad media de 73±19 años. El 91% presentaron factores de riesgo, con un 60% en tratamiento antitrombótico. Detectamos un 11% de hemorragia cerebral inicial, 0,4% a las 24h y ningún caso a los 3 meses. El tratamiento antitrombótico no se asoció con incremento de riesgo de hemorragia cerebral (9,9 con vs. 11,9% sin tratamiento; p=0,3). El 39% de las hemorragias presentaron síntomas neurológicos (18% amnesia postraumática, 12% cefalea, 8% vómitos, 1% convulsiones), siendo en un 78,4% síntomas leves. De las 4 hemorragias detectadas a las 24h, 3 fueron asintomáticas y un caso emporó la cefalea inicial. Ningún paciente asintomático sin lesión en la TC craneal inicial presentó clínica a las 24h. Conclusiones Nuestro estudio sugiere que los pacientes con TCEL asintomáticos, sin lesión en la TC craneal inicial no precisarían periodo de observación ni TC craneal de control, independientemente del tratamiento antitrombótico o nivel de INR (AU)

Introduction The observation time in mild traumatic brain injury (mTBI) is controversial. Our aim was to assess the risk of neurological complications in mTBI with and without antithrombotic treatment. Method We retrospectively evaluated patients with mTBI seen in the emergency room for 3 years. We considered MTBI those with Glasgow ≥13 at admission. A cranial CT was performed in all cases with >1 risk factor at admission and at 24h in those with neurological impairment or initial pathological cranial CT. Complications in the following 3 months were retrospectively reviewed. Results We evaluated 907 patients with a mean age of 73±19 years. Ninety-one percent presented risk factors, with 60% on antithrombotic treatment. We detected 11% of initial brain hemorrhage, 0.4% at 24h, and no cases at 3 months. Antithrombotic treatment was not associated with an increased risk of brain hemorrhage (9.9% with vs. 11.9% without treatment, P=.3). 39% of the hemorrhages presented neurological symptoms (18% post-traumatic amnesia, 12% headache, 8% vomiting, 1% seizures), with 78.4% having mild symptoms. Of the 4 hemorrhages detected at 24h, 3 were asymptomatic and one case that worsened the initial headache. No asymptomatic patient without lesion on initial clinical cranial CT presented at 24h. Conclusions Our study suggests that patients with asymptomatic mTBI, without a lesion on the initial cranial CT, would not require the observation period or CT control regardless of antithrombotic treatment or INR level (AU)

Early enteral nutrition intervention promotes multiple functional recovery in patients with traumatic intracerebral hemorrhage: A prospective randomized controlled study.

OBJECTIVE: To delve into how early enteral nutrition intervention exert its part in promoting multiple functional recovery in patients with traumatic intracerebral hemorrhage (TICH). METHOD: This prospective randomized controlled study recruited 152 traumatic intracerebral hemorrhage patients in our hospital. The observation group (n = 77) received early enteral nutrition intervention (≤ 48 h), while the control group (n = 75) were given delayed enteral nutrition (> 48 h). Further comparison was performed on the recovery of various physiologic functions between the two groups. RESULTS: After treatment, GCS score and GOS score in the observation group were significantly higher than those in the control group (P < 0.05), and mRS Score was significantly lower than that in the control group (P < 0.05). Moreover, the observation group demonstrated a considerable post-treatment elevation in adrenocorticotropic hormone (ACTH) and cortisol (Cor) levels, which were notably higher than the control group's levels (both P < 0.05). The changes in Bifidobacteria, Enterococcus, and Escherichia coli values pre and post-treatment were more remarkable in the observation group (all P < 0.05). Kaplan-Meier survival curve analysis indicated a substantial difference in survival curves between patients who provided with early enteral nutrition and those where it later (P < 0.05). CONCLUSION: The early application of enteral nutrition can promote neurological function recovery, improve the disorder of intestinal flora and the patient's nutritional status, reduce the increase of injury factors under stress, and lower the mortality risk among patients suffering from TICH.

Anti-CD47 antibody administration via cisterna magna in proper dosage can reduce perihematomal cell death following intracerebral hemorrhage in rats.

OBJECTIVE: The secondary injury caused by RBC autolysis after intracerebral hemorrhage (ICH) can be reduced by increasing the efficiency of microglia (MG)/macrophages (Mø) phagocytizing red blood cells (RBCs). CD47 is an important regulator of MG/Mø phagocytosis. This study aims to clarify whether anti-CD47 antibody administrated into the cisterna magna after ICH can transfer to the hematoma site, promote MG/Mø gathering to phagocytize RBCs and ultimately reduce cell death. METHODS: Forty male Wistar rats were divided into sham, ICH, low-dosage (group A, 0.3 µg), medium-dosage (group B, 0.9 µg) and high-dosage (group C, 1.8 µg) anti-CD47 antibody groups. For the rats in group A, B and C, anti-CD47 antibody solution was administrated into the cisterna magna at 10 min after ICH. Brain tissue was harvested 3 days after the operation. Western blotting was performed to detect the expression of Caspase-3 and Bcl-2. Immunofluorescence was performed to detect the CD68 expression. TUNEL was performed to detect the cell death. RESULTS: The hematoma of the ICH rats was located in the basal ganglia, with a good homogeneity of hematoma volume. Low-dosage anti-CD47 antibody in group A had no effects on the perihematomal CD68 (P = 0.338), Caspase-3 (P = 0.769), Bcl-2 (P = 0.176) expression and cell death (P = 0.698), compared with the ICH group. CD68 and Bcl-2 expression increased and Caspase-3 expression decreased significantly in group B (P < 0.001 for all) and group C (P < 0.001 for all). The increase of CD68 expression in group C was greater than that in group B (P < 0.01) by a large margin, while there was no difference for Bcl-2 (P = 0.908) and Caspase-3 (P = 0.913) expression between the 2 groups. Compared with the ICH group, medium-dosage of anti-CD47 antibody in group B significantly reduced the number of TUNEL-positive cells (P < 0.005), but not for group C (P = 0.311). CONCLUSION: The results suggested that anti-CD47 antibody administration into the cisterna magna in proper dosage (0.9 µg) can effectively reach the hematoma, induce more MG/Møs to gather around the hematoma, and reduce cell death in perihematomal brain tissue. The results of this study has provided a basic theory for improving the efficiency of MG/Mø phagocytizing RBCs and hematoma clearance after ICH by administrating anti-CD47 antibody via the cisterna magna.

Neutrophil to lymphocyte ratio predicts early growth of traumatic intracerebral haemorrhage.

OBJECTIVE: The neutrophil to lymphocyte ratio (NLR) has been proposed to capture the inflammatory status of patients with various conditions involving the brain. This retrospective study aimed to explore the association between the NLR and the early growth of traumatic intracerebral haemorrhage (tICH) in patients with traumatic brain injury (TBI). METHODS: A multicentre, observational cohort study was conducted. Patients with cerebral contusion undergoing baseline computed tomography for haematoma volume analysis within 6 h after primary injury and follow-up visits within 48 h were included. Routine blood tests were performed upon admission, and early growth of tICH was assessed. Prediction accuracies of the NLR for the early growth of tICH and subsequent surgical intervention in patients were analysed. RESULTS: There were a total of 1077 patients who met the criteria included in the study cohort. Univariate analysis results showed that multiple risk factors were associated with the early growth of tICH and included in the following multivariate analysis models. The multivariate logistic regression analysis results revealed that the NLR was highly associated with the early growth of tICH (p < 0.001) while considering other risk factors in the same model. The prediction accuracy of the NLR for the early growth of tICH in patients is 82%. INTERPRETATION: The NLR is easily calculated and might predict the early growth of tICH for patients suffering from TBI.

Connection between traumatic frontal intracerebral hemorrhage and lower urinary tract symptoms.

OBJECTIVE: There have been no previous studies of urinary symptoms in patients with traumatic frontal intracerebral hemorrhage. The purpose of this work was to provide first insights into the potential role of traumatic frontal intracerebral hemorrhage in the development of urinary symptoms. This condition is known to cause compression in and around the prefrontal cortex, and we wanted to examine its effect on the micturition center. PATIENTS AND METHODS: Patients with voiding dysfunction (n = 176) were assessed for lower urinary tract symptoms using the International Prostate Symptom Score (IPSS). Out of 176 patients, 52 symptomatic patients with voiding difficulties underwent urodynamic testing. All patients with traumatic frontal intracerebral hemorrhage were treated at the University Medical Center Tuebingen, Germany, and the Azad University of Medical Sciences in Tehran, Iran, between 2017 and 2020. Lower urinary tract symptoms (LUTS) were documented in patients with compression of the frontal lobe due to local hemorrhage. All patients routinely performed Brain CT scans. Brain magnetic resonance (MRI) images of the patients with suspicion of diffuse axonal injuries were additionally performed. Out of 176 treated patients (median age of 49 years), 52 patients with voiding difficulties were evaluated. RESULTS: Urodynamic testing of 52 symptomatic patients revealed detrusor overactivity in 25 (48%), low-compliance bladder in 4 (7.7%), detrusor-sphincter dyssynergia in 20 (38%), and uninhibited sphincter relaxation in 11 patients (21%). There was no significant correlation between the volume of hemorrhage and urinary symptoms (p=0.203, Spearman q=0.726). Frontal intracerebral hemorrhage compressing the pre-frontal cortex influences the micturition center and is responsible for lower urinary tract symptoms. CONCLUSIONS: Hemorrhage of the right or left frontal lobe does have a direct relationship with incontinence which completely disappeared in 85% of the patients within 9 months.

Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

The Effect of Antithrombotics on Hematoma Expansion in Small- to Moderate-Sized Traumatic Intraparenchymal Hemorrhages.

BACKGROUND: Although pre-injury antithrombotic agents, including antiplatelets and anticoagulants, are historically associated with expansion of traumatic intraparenchymal hemorrhage (tIPH), the literature has poorly elucidated the actual risk of hematoma expansion on repeat computed tomography (CT). The objective was to determine the effect of antithrombotic agents on hematoma expansion in tIPH by comparing patients with and without pre-injury antithrombotic medication. METHODS: The volume of all tIPHs over a 5-year period at an academic Level 1 trauma center was measured retrospectively. The initial tIPH was divided into 3 equally sized quantiles. The third tercile, representing the largest subset of tIPH, was then removed from the study population because these patients reflect a different pathophysiologic mechanism that may require a more acute and aggressive level of care with reversal agents and/or operative management. Per institutional policy, all patients with small- to moderate-sized hemorrhages received a 24-hour stability CT scan. Patients who received reversal agents were excluded. RESULTS: Of the 105 patients with a tIPH on the initial head CT scan, small- to moderate-sized hemorrhages were <5 cm3. The size of tIPH on initial imaging did not statistically significantly differ between the antithrombotic cohort (0.7 ± 0.1 cm3) and the non-antithrombotic cohort (0.5 ± 0.1 cm3) (P = 0.091). Similarly, the volume of tIPH failed to differ on 24-hour repeat imaging (1.0 ± 0.2 cm3 vs. 0.6 ± 0.1 cm3, respectively, P = 0.172). Following a multiple linear regression, only history of stroke, not antithrombotic medications, predicted increased tIPH on 24-hour repeat imaging. CONCLUSIONS: In small- to moderate-sized tIPH, withholding antithrombotic agents without reversal may be sufficient.

Antiplatelet Agent Reversal Is Unnecessary in Blunt Traumatic Brain Injury Patients Not Requiring Immediate Craniotomy.

BACKGROUND: The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy. METHODS: All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. RESULTS: 169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56). DISCUSSION: Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.

First case of delayed traumatic intracerebral hemorrhage in a patient with undiagnosed factor XI deficiency: diagnosis and management review.

Factor XI (FXI) deficiency, also known as hemophilia C, is included in the rare bleeding disorders (RBDs). It is distinct from other coagulation factor deficiencies because it rarely presents as spontaneous hemorrhage, but rather as bleeding after trauma or surgery; in addition, the severity of bleeding does not correlate with FXI levels. Most delayed traumatic intracerebral hemorrhage (DTICH) occurs during the first 72 hours of the trauma. Factors that contribute to its formation include local or systemic coagulopathy, among others. Hemorrhagic cases of FXI deficiency related to the central nervous system (CNS) are very rare, with only 13 reported cases. To the best of our knowledge, this is the first reported case of a DTICH in a patient with undiagnosed FXI deficiency.

Prevalence and Incidence of Microhemorrhages in Adolescent Football Players.

BACKGROUND AND PURPOSE: SWI is an advanced imaging modality that is especially useful in cerebral microhemorrhage detection. Such microhemorrhages have been identified in adult contact sport athletes, and the sequelae of these focal bleeds are thought to contribute to neurodegeneration. The purpose of this study was to utilize SWI to determine whether the prevalence and incidence of microhemorrhages in adolescent football players are significantly greater than those of adolescent noncontact athletes. MATERIALS AND METHODS: Preseason and postseason SWI was performed and evaluated on 78 adolescent football players. SWI was also performed on 27 adolescent athletes who reported no contact sport history. Two separate one-tailed Fisher exact tests were performed to determine whether the prevalence and incidence of microhemorrhages in adolescent football players are greater than those of noncontact athlete controls. RESULTS: Microhemorrhages were observed in 12 football players. No microhemorrhages were observed in any controls. Adolescent football players demonstrated a significantly greater prevalence of microhemorrhages than adolescent noncontact controls (P = .02). Although 2 football players developed new microhemorrhages during the season, microhemorrhage incidence during 1 football season was not statistically greater in the football population than in noncontact control athletes (P = .55). CONCLUSIONS: Adolescent football players have a greater prevalence of microhemorrhages compared with adolescent athletes who have never engaged in contact sports. While microhemorrhage incidence during 1 season is not significantly greater in adolescent football players compared to adolescent controls, there is a temporal association between playing football and the appearance of new microhemorrhages.

Low Risk of Traumatic Intracranial Hematoma Expansion with Factor Xa Inhibitors without Andexanet Reversal.

BACKGROUND: Andexanet alfa, a novel anticoagulation reversal agent for factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors study established the efficacy of andexanet alfa in reversing factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood. The objective of this study was to determine progression rates of patients with traumatic intracranial hemorrhage on factor Xa inhibitors prior to hospitalization who were managed without the use of andexanet alfa. METHODS: A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans. RESULTS: We identified 25 patients meeting the inclusion criteria. Two patients were excluded because of a lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 were (48%) on rivaroxaban. On admission CT scan, 14 patients had subdural hematoma, 6 had traumatic intraparenchymal hemorrhage, and 3 had subarachnoid hemorrhage. Anticoagulation reversal was attempted in 17 patients (74%), primarily using 4-factor prothrombin complex concentrate. Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging. CONCLUSIONS: Our results indicate that patients on factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after andexanet alfa administration.

Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking. METHODS: This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes. RESULTS: A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes. CONCLUSIONS: The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.

Early computed tomography for acute post-traumatic diffuse axonal injury: a systematic review.

PURPOSE: Diffuse axonal injury (DAI) is the rupture of multiple axons due to acceleration and deceleration forces during a closed head injury. Most traumatic brain injuries (TBI) have some degree of DAI, especially severe TBI. Computed tomography (CT) remains the first imaging test performed in the acute phase of TBI, but has low sensitivity for detecting DAI, since DAI is a cellular lesion. The aim of this study is to search in the literature for CT signs, in the first 24 h after TBI, that may help to differentiate patients in groups with a better versus worst prognosis. METHODS: We searched for primary scientific articles in the PubMed database, in English, indexed since January 1st, 2000. RESULTS: Five articles were selected for review. In the DAI group, traffic accidents accounted 70% of the cases, 79% were male, and the mean age was 41 years. There was an association between DAI and intraventricular hemorrhage (IVH) and traumatic subarachnoid hemorrhage (tSAH); an association between the IVH grade and number of corpus callosum lesions; and an association between blood in the interpeduncular cisterns (IPC) and brainstem lesions. CONCLUSION: In closed TBI with no tSAH, severe DAI is unlikely. Similarly, in the absence of IVH, any DAI is unlikely. If there is IVH, patients generally are clinically worse; and the more ventricles affected, the worse the prognosis.

Surgical management of traumatic supra and infratentorial extradural hematomas: our experience and systematic literature review.

Post-traumatic supra and infratentorial acute extradural hematomas (SIEDHs) are an uncommon type of extradural hematoma with only few small series published. In this scenario, the purposes of the present study are to present our experience in the management of 8 patients with acute SIEDH and to perform a systematic literature review. The clinical and radiological data of 8 patients operated for SIEDH at our department were analyzed retrospectively. Using the PRISMA guidelines, we reviewed the articles published from January 1990 to January 2018 reporting data about SIEDH. A total of 3 articles fulfilled the inclusion criteria and were analyzed. The incidence of SIEDHs is very rare constituting < 2% of all traumatic extradural hematomas (EDH). SIEDHs are associated with non-specific symptoms. Only 20% of patients were in coma (GCS < 8) at admission. A "lucid interval" was not reported. The source of bleeding of SIEDH was venous in all cases due to the following: bone fracture with diploe bleeding (50%), transverse/sigmoid sinus injury (22%), oozing meningeal venous vessel (8%), detachment of transverse sinus without wall injury (6%), and unknown in the other cases. Due to the venous nature of the source of hemorrhage, the clinical manifestation of a SIEDH may develop in a slow way, but once a critical volume of hematoma is reached, the deterioration can become rapid and fatal for acute brain stem compression. Surgery is the mainstay of SIEDHs treatment: among 42 cases with SIEDH included in this review, 40 (95.23%) patients were treated with surgery while only two were managed conservatively. Also in our series, all patients underwent surgery. A combined supratentorial craniotomy and suboccipital craniotomy leaving in a bone bridge over the transverse sinus for dural tenting sutures resulted the most used and safe surgical approach. SIEDH is a rare type of EDH. Early diagnosis of SIEDH and prompt surgical evacuation with a combined supratentorial and suboccipital approach provide excellent recovery.

Ratio of Optic Nerve Sheath Diameter to Eyeball Transverse Diameter by Ultrasound Can Predict Intracranial Hypertension in Traumatic Brain Injury Patients: A Prospective Study.

BACKGROUND: Measuring optic nerve sheath diameter (ONSD), an indicator to predict intracranial hypertension, is noninvasive and convenient, but the reliability of ONSD needs to be improved. Instead of using ONSD alone, this study aimed to evaluate the reliability of the ratio of ONSD to eyeball transverse diameter (ONSD/ETD) in predicting intracranial hypertension in traumatic brain injury (TBI) patients. METHODS: We performed a prospective study on patients admitted to the Surgery Intensive Care Unit. The included 52 adults underwent craniotomy for TBI between March 2017 and September 2018. The ONSD and ETD of each eyeball were measured by ultrasound and computed tomography (CT) scan within 24 h after a fiber optic probe was placed into lateral ventricle. Intracranial pressure (ICP) > 20 mmHg was regarded as intracranial hypertension. The correlations between invasive ICP and ultrasound-ONSD/ETD ratio, ultrasound-ONSD, CT-ONSD/ETD ratio, and CT-ONSD were each analyzed separately. RESULTS: Ultrasound measurement was successfully performed in 94% (n = 49) of cases, and ultrasound and CT measurement were performed in 48% (n = 25) of cases. The correlation efficiencies between ultrasound-ONSD/ETD ratio, ultrasound-ONSD, CT-ONSD/ETD ratio, and ICP were 0.613, 0.498, and 0.688, respectively (P < 0.05). The area under the curve (AUC) values of the receiver operating characteristic (ROC) curve for the ultrasound-ONSD/ETD ratio and CT-ONSD/ETD ratio were 0.920 (95% CI 0.877-0.964) and 0.896 (95% CI 0.856-0.931), respectively. The corresponding threshold values were 0.25 (sensitivity of 90%, specificity of 82.3%) and 0.25 (sensitivity of 85.7%, specificity of 83.3%), respectively. CONCLUSION: The ratio of ONSD to ETD tested by ultrasound may be a reliable indicator for predicting intracranial hypertension in TBI patients.

Interventional Ultrasound Assisted Early Local Hemostatic Drug Therapy in Traumatic Intracerebral Hemorrhage.

This article aims to test a minimally invasive interventional approach by real-time transcranial contrast-enhanced ultrasound (CEUS) through a small bur hole to achieve an early local hemostatic drug therapy in a novel traumatic intracerebral hematoma (ICH) model of pigs with hemostatic abnormalities. The effects of hemostasis in the hemocoagulase atrox (HA) injection group and saline injection group groups were observed by transcranial CEUS at three time points: 0 s, 10 s, 2nd. We successfully established a novel traumatic ICH model of pigs with hemostatic abnormalities by the methods of interventional ultrasound techniques and observed the effect of hemostasis by using HA in a local injection method with the assistance of minimally invasive interventional ultrasound technique. At 0 s, four pigs (100%) were observed that active bleeding was significantly weakened, and the range of hematoma became smaller in the HA group. At 10 s, four pigs (100%) were observed that active bleeding became much weaker, and the range of hematoma became further smaller in the HA group. At 2nd, zero pigs (0/4, 0%) were observed that active bleeding could be clearly identified and four pigs (100%) with ICH could also be observed in the HA group. We believe this useful technique could minimize the invasiveness and be operated at the bedside, which would bring much more benefits for traumatic ICH patients.

Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study.

Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.