Impact of Early Microparticle Release during Isolated Severe Traumatic Brain Injury: Correlation with Coagulopathy and Mortality.

BACKGROUND: Microparticles (MPs) have been implicated in thrombosis and endothelial dysfunction. Their involvement in early coagulopathy and in worsening of outcomes in isolated severe traumatic brain injury (sTBI) patients remains ill defined. OBJECTIVE: We sought to quantify the circulatory MP subtypes derived from platelets (PMPs; CD42), endothelial cells (EMPs; CD62E), and those bearing tissue factor (TFMP; CD142) and analyze their correlation with early coagulopathy, thrombin generation, and in-hospital mortality. MATERIALS AND METHODS: Prospective screening of sTBI patients was done. Blood samples were collected before blood and fluid transfusion. MP enumeration and characterization were performed using flow cytometry, and thrombin-antithrombin complex (TAT) levels were determined using enzyme-linked immunosorbent assay (ELISA). Circulating levels of procoagulant MPs were compared between isolated sTBI patients and age- and gender-matched healthy controls (HC). Patients were stratified according to their PMP, EMP, and TFMP levels, respectively (high ≥HC median and low < HC median). RESULTS: Isolated sTBI resulted in an increased generation of PMPs (456.6 [228-919] vs. 249.1 [198.9-404.5]; P = 0.01) and EMPs (301.5 [118.8-586.7] vs. 140.9 [124.9-286]; P = 0.09) compared to HCs. Also, 5.3% of MPs expressed TF (380 [301-710]) in HCs, compared to 6.6% MPs (484 [159-484]; P = 0.87) in isolated sTBI patients. Early TBI-associated coagulopathy (TBI-AC) was seen in 50 (41.6%) patients. PMP (380 [139-779] vs. 523.9 [334-927]; P = 0.19) and EMP (242 [86-483] vs. 344 [168-605]; P = 0.81) counts were low in patients with TBI-AC, compared to patients without TBI-AC. CONCLUSION: Our results suggest that enhanced cellular activation and procoagulant MP generation are predominant after isolated sTBI. TBI-AC was associated with low plasma PMPs count compared to the count in patients without TBI-AC. Low PMPs may be involved with the development of TBI-AC.

Re-Admissions of 'Unknown' Traumatic Brain Injury Patients - Inadequacy of Rehabilitative Services in a Developing Country.

BACKGROUND: In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India. OBJECTIVE: We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers. MATERIAL AND METHODS: The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission. RESULTS: Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality. CONCLUSIONS: There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.

The effect of amantadine treatment on neurological outcome and mortality in mechanically ventilated severe head trauma patients in intensive care unit.

This study aims to investigate the effect of amantadine use on neurological outcomes and mortality in patients with severe traumatic brain injury (TBI) (Glasgow coma score [GCS] between 3 and 8) who have been followed up on mechanical ventilators in the intensive care unit (ICU). Data from the hospital's electronic records were retrospectively searched. Patients over 18 years of age, with severe brain trauma (GCS between 3-8), who were treated with endotracheal intubation and invasive mechanical ventilation at admission to the ICU, and who were treated with Amantadine hydrochloride at least once in the first week of follow-up were included in the study. To evaluate the patients' neurological outcomes, the GCS and FOUR scores were used. GCS and FOUR scores were recorded on the 1st, 3rd, and 7th days of the first week. In addition, the score difference between the 1st and 7th day was calculated for both scores. The patients were divided into 2 groups: those receiving amantadine treatment (Group A, n = 44) and the control group (Group C, n = 47). The median age of all patients was 39 (18-81) (P = .425). When Group A and Group C were compared, no statistically significant results were found between the 1st, 3rd, and 7th day GCS values (P = .474, P = .483, and P = 329, respectively). However, the difference in GCS values between day 1 and day 7 (∆ GCS 7-1) was statistically significant (P = .012). Similarly, when Group A and Group C were compared, no statistically significant results were found between the 1st, 3rd, and 7th day FOUR score values (P = .948, P = .471, and P = .057, respectively). However, the FOUR score values between day 1 and day 7 (∆ FOUR score 7-1) were statistically significant (P = .004). There was no statistically significant difference among the groups in terms of ICU length of stay, duration of non-ICU hospital stay, and length of hospital stay (P = .222, P = .175, and P = .067, respectively). Amantadine hydrochloride may help improve neurological outcomes in patients with severe TBI. However, further research is needed to investigate this topic.

EASIX is an effective marker in predicting mortality of traumatic brain injury patients.

BACKGROUND: The Endothelial Activation and Stress Index (EASIX) is a novel marker of endothelial injury and correlates with survival of various patients. The endothelial dysfunction plays an important role on the pathophysiological process of traumatic brain injury (TBI). This study was designed to explore the prognostic value of EASIX on TBI patients. METHODS: 358 TBI patients hospitalized in the West China hospital between October 2018 and October 2022 were enrolled for this study. The EASIX was calculated based on the formula: lactate dehydrogenase (U/L) × creatinine (mg/dL)/platelets (109 cells/L). The univariate and multivariate logistic regression with forward method was performed to explore the association between EASIX and mortality. A prognostic model was developed combining significant risk factors in the multivariate logistic regression. The receiver operating characteristic (ROC) curve was used to compare the predictive accuracy of the EASIX and the developed model. RESULTS: The 30-day mortality of enrolled 358 TBI patients was 51.1%. Non-survivors had higher EASIX than survivors (p < 0.001). The multivariate logistic regression confirmed seven risk factors for mortality of TBI including injury mechanism (p = 0.010), GCS (p < 0.001), glucose (p < 0.001), EASIX (p = 0.017), subdural hematoma (p = 0.012), coagulopathy (p = 0.001). The AUC of EASIX, SOFA, GCS was 0.747, 0.748 and 0.774, respectively. The AUC of developed predictive model was 0.874 with the sensitivity of 0.913 and specificity of 0.686. CONCLUSIONS: The EASIX is a reliable marker for predicting mortality of TBI patients. The predictive model incorporating EASIX is helpful for clinicians to evaluate the mortality risk of TBI patients.

Brain tissue oxygen plus intracranial pressure monitoring versus isolated intracranial pressure monitoring in patients with traumatic brain injury: an updated meta-analysis of randomized controlled trials.

BACKGROUND: Intracranial pressure (ICP) monitoring plays a key role in patients with traumatic brain injury (TBI), however, cerebral hypoxia can occur without intracranial hypertension. Aiming to improve neuroprotection in these patients, a possible alternative is the association of Brain Tissue Oxygen Pressure (PbtO2) monitoring, used to detect PbtO2 tension. METHOD: We systematically searched PubMed, Embase and Cochrane Central for RCTs comparing combined PbtO2 + ICP monitoring with ICP monitoring alone in patients with severe or moderate TBI. The outcomes analyzed were mortality at 6 months, favorable outcome (GOS ≥ 4 or GOSE ≥ 5) at 6 months, pulmonary events, cardiovascular events and sepsis rate. RESULTS: We included 4 RCTs in the analysis, totaling 505 patients. Combined PbtO2 + ICP monitoring was used in 241 (47.72%) patients. There was no significant difference between the groups in relation to favorable outcome at 6 months (RR 1.17; 95% CI 0.95-1.43; p = 0.134; I2 = 0%), mortality at 6 months (RR 0.82; 95% CI 0.57-1.18; p = 0.281; I2 = 34%), cardiovascular events (RR 1.75; 95% CI 0.86-3.52; p = 0.120; I2 = 0%) or sepsis (RR 0.75; 95% CI 0.25-2.22; p = 0.604; I2 = 0%). The risk of pulmonary events was significantly higher in the group with combined PbtO2 + ICP monitoring (RR 1.44; 95% CI 1.11-1.87; p = 0.006; I2 = 0%). CONCLUSIONS: Our findings suggest that combined PbtO2 + ICP monitoring does not change outcomes such as mortality, functional recovery, cardiovascular events or sepsis. Furthermore, we found a higher risk of pulmonary events in patients undergoing combined monitoring.

Brain tissue oxygen partial pressure monitoring and prognosis of patients with traumatic brain injury: a meta-analysis.

To assess whether monitoring brain tissue oxygen partial pressure (PbtO2) or employing intracranial pressure (ICP)/cerebral perfusion pressure (CCP)-guided management improves patient outcomes, including mortality, hospital length of stay (LOS), mean daily ICP and mean daily CCP during the intensive care unit(ICU)stay. We searched the Web of Science, EMBASE, PubMed, Cochrane Library, and MEDLINE databases until December 12, 2023. Prospective randomized controlled and cohort studies were included. A meta-analysis was performed for the primary outcome measure, mortality, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eleven studies with a total of 37,492 patients were included. The mortality in the group with PbtO2 was 29.0% (odds ratio: 0.73;95% confidence interval [CI]:0.56-0.96; P = 0.03; I = 55%), demonstrating a significant benefit. The overall hospital LOS was longer in the PbtO2 group than that in the ICP/CPP group (mean difference:2.03; 95% CI:1.03-3.02; P<0.0001; I = 39%). The mean daily ICP in the PbtO2 monitoring group was lower than that in the ICP/CPP group (mean difference:-1.93; 95% CI: -3.61 to -0.24; P = 0.03; I = 41%). Moreover, PbtO2 monitoring did not improve the mean daily CPP (mean difference:2.43; 95%CI: -1.39 to 6.25;P = 0.21; I = 56%).Compared with ICP/CPP monitoring, PbtO2 monitoring reduced the mortality and the mean daily ICP in patients with severe traumatic brain injury; however, no significant effect was noted on the mean daily CPP. In contrast, ICP/CPP monitoring alone was associated with a short hospital stay.

Utility of serum chemokine-like factor 1 as a biomarker of severity and prognosis after severe traumatic brain injury: A prospective observational study.

BACKGROUND: Chemokine-like factor 1 (CKLF1) may be involved in the inflammatory response and secondary brain injury after severe traumatic brain injury (sTBI). We determined serum CKLF1 levels of sTBI patients to further investigate the correlation of CKLF1 levels with disease severity, functional prognosis, and 180-day mortality of sTBI. METHODS: Serum CKLF1 levels were measured at admission in 119 sTBI patients and at entry into study in 119 healthy controls. Serum CKLF levels of 50 patients were also quantified at days 1-3, 5, and 7 after admission. Glasgow coma scale (GCS) scores and Rotterdam computerized tomography (CT) classification were utilized to assess disease severity. Extended Glasgow outcome scale (GOSE) scores were recorded to evaluate function prognosis at 180 days after sTBI. Relations of serum CKLF1 levels to 180-day poor prognosis (GOSE scores of 1-4) and 180-day mortality were analyzed using univariate analysis, followed by multivariate analysis. Receiver-operating characteristic (ROC) curve was built to investigate prognostic predictive capability. RESULTS: Serum CKLF1 levels of sTBI patients increased at admission, peaked at day 2, and then gradually decreased; they were significantly higher during the 7 days after sTBI than in healthy controls. Differences of areas under ROC curve (areas under the curve [AUCs]) were not significant among the six time points. Multivariate analysis showed that serum CKLF1 levels were independently correlated with GCS scores, Rotterdam CT classification, and GOSE scores. Serum CKLF1 levels were significantly higher in non-survivors than in survivors and in poor prognosis patients than in good prognosis patients. Serum CKLF1 levels independently predicted 180-day poor prognosis and 180-day mortality, and had high 180-day prognosis and mortality predictive abilities, and their AUCs were similar to those of GCS scores and Rotterdam CT classification. Combination model containing serum CKLF1, GCS scores, and Rotterdam CT classification performed more efficiently than any of them alone in predicting mortality and poor prognosis. The models were visually described using nomograms, which were comparatively stable under calibration curve and were relatively of clinical benefit under decision curve. CONCLUSION: Serum CKLF1 levels are significantly associated with disease severity, poor 180-day prognosis, and 180-day mortality in sTBI patients. Hence, complement CKLF1 may serve as a potential prognostic biomarker of sTBI.

Incidence and associated in-hospital mortality of myocardial injury characterised by elevated cardiac troponin in adult patients with traumatic brain injury: protocol for a systematic review and meta-analysis.

INTRODUCTION: Myocardial injury is a relatively common complication of traumatic brain injury (TBI). However, the incidence and clinical impact of myocardial injury characterised by elevated cardiac troponin (cTn) levels after TBI are still poorly known. The objective of our study is to assess the global incidence of myocardial injury characterised by elevated cTn in adult patients with TBI and its association with in-hospital mortality. METHODS AND ANALYSIS: The protocol of our systematic review and meta-analysis is performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will search the Medline, Embase, Cochrane Library, Scopus and Web of Science databases from inception to 1 January 2024, for observational studies in any language that reported the incidence of elevated cTn and/or in-hospital mortality associated with elevated cTn among adult patients with TBI. Two reviewers will independently assess study eligibility, extract the data and assess the risk of bias. ORs and 95% CIs will be used with a random-effects or fixed-effects model according to the estimated heterogeneity among studies assessed by the I2 index. We will perform a quantitative synthesis for the incidence of elevated cTn and in-hospital mortality data. If sufficient data are available, we will perform subgroup analysis and meta-regression to address the heterogeneity. In addition, we will perform a narrative analysis if quantitative synthesis is not appropriate. ETHICS AND DISSEMINATION: Ethics approval was not required for this study. We intend to publish our findings in a high-quality, peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42023454686.

Prevalence of Cardiovascular Conditions After Traumatic Brain Injury: A Comparison Between the Traumatic Brain Injury Model Systems and the National Health and Nutrition Examination Survey.

BACKGROUND: The purpose of this study is to compare the prevalence of self-reported cardiovascular conditions among individuals with moderate to severe traumatic brain injury (TBI) to a propensity-matched control cohort. METHODS AND RESULTS: A cross-sectional study described self-reported cardiovascular conditions (hypertension, congestive heart failure [CHF], myocardial infarction [MI], and stroke) from participants who completed interviews between January 2015 and March 2020 in 2 harmonized large cohort studies, the TBI Model Systems and the National Health and Nutrition Examination Survey. Mixed-effect logistic regression models were used to compare the prevalence of cardiovascular conditions after 1:1 propensity-score matching based on age, sex, race, ethnicity, body mass index, education level, and smoking status. The final sample was 4690 matched pairs. Individuals with TBI were more likely to report hypertension (odds ratio [OR], 1.18 [95% CI, 1.08-1.28]) and stroke (OR, 1.70 [95% CI, 1.56-1.98]) but less likely to report CHF (OR, 0.81 [95% CI, 0.67-0.99]) or MI (OR, 0.66 [95% CI, 0.55-0.79]). There was no difference in rate of CHF or MI for those ≤50 years old; however, rates of CHF and MI were lower in the TBI group for individuals >50 years old. Over 65% of individuals who died before the first follow-up interview at 1 year post-TBI were >50 years old, and those >50 years old were more likely to die of heart disease than those ≤50 years old (17.6% versus 8.6%). CONCLUSIONS: Individuals with moderate to severe TBI had an increased rate of self-reported hypertension and stroke but lower rate of MI and CHF than uninjured adults, which may be due to survival bias.

Efficacy and safety of tranexamic acid in acute traumatic brain injury: A meta-analysis of randomized controlled trials.

INTRODUCTION: Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate. METHODS: PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety. RESULTS: Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I2: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I2: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I2: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I2: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I2: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I2: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I2: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I2: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I2: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I2: 0%, p = 0.94). CONCLUSIONS: TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.

Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation.

INTRODUCTION: This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy. METHODS: In this analysis of 2018-2020 ACS-TQIP, patients with isolated blunt severe TBI (Head-AIS≥3, nonhead-AIS<2) using preinjury anticoagulants who underwent craniotomy/craniectomy were identified and stratified into PCC and No-PCC groups. Outcomes were time to surgery and mortality. Multivariable binary logistic and linear regression analyses were performed. RESULTS: 1598 patients were identified (PCC-107[7 %], No-PCC-1491[93 %]). Mean age was 74(11) years, 65 % were male, median head AIS was 4. Median time to PCC administration was 109 â€‹min. On univariable analysis, PCC group had shorter time to surgery (PCC-341, No-PCC-620 â€‹min, p â€‹= â€‹0.002), but higher mortality (PCC35 %, No-PCC21 %,p â€‹= â€‹0.001). On regression analysis, PCC was independently associated with shorter time to surgery (ߠ​= â€‹-1934,95 %CI â€‹= â€‹-3339to-26), but not mortality (aOR â€‹= â€‹0.70,95 %CI â€‹= â€‹0.14-3.62). CONCLUSION: PCC may be a safe adjunct for urgent reversal of coagulopathy in TBI patients using preinjury anticoagulants.

How significant is the BIG score in childhood traumatic brain injury?

BACKGROUND: This study aims to evaluate the reliability of the BIG score in predicting mortality in children with traumatic brain injury (TBI) and to compare it with the literature and other scoring systems. METHODS: Patients who were followed up in the Pediatric Intensive Care Unit (PICU) for TBI between 2014 and 2019 in a tertiary reference hospital were evaluated retrospectively. RESULTS: One hundred fifty-nine patients met the inclusion criteria. The most common injury mechanisms were falling from a height (39.6%). The mortality rate was 12.6% (n = 20). The mean BIG score, ISS, and PRISM III were statistically significantly higher in the mortality group (p < 0.001). The AUC values found in the ROC analysis in the whole study group, respectively, 0.962 (CI 0.920-0.986) for the BIG score, 0.952 (CI 0.906-0.979) for the ISS, 0.957 (CI 0.913-0.983) for the GCS, and 0.981 (CI 0.946-0.996) for the PRISM III. In the patients with isolated TBI, the AUC value for the BIG score was 0.988 (0.967-1.000) and higher than the ISS and PRISM 3 [0.983 (0.956-1.000), 0.969 (0.932-1.000) respectively]). The cut-off point for the BIG score in the whole group was 19 (sensitivity 95%, specificity 88%, positive predictive value 0.58, negative predictive value 0.99). In logistic regression model, we found that BIG score is an independent variable for mortality (AOR:1.4, 95%CI 1.22-1.63). CONCLUSION: In children with traumatic brain injury, the BIG score is simple, quickly calculated, and a good predictor of mortality and disease severity. Prospective studies with more extensive series are needed on this subject.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study.

BACKGROUND: Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. METHODS: Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. RESULTS: Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. DISCUSSION: Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

Comparison of on-scene Glasgow Coma Scale with GCS-motor for prediction of 30-day mortality and functional outcomes of patients with trauma in Asia.

BACKGROUND AND IMPORTANCE: This study compared the on-scene Glasgow Coma Scale (GCS) and the GCS-motor (GCS-M) for predictive accuracy of mortality and severe disability using a large, multicenter population of trauma patients in Asian countries. OBJECTIVE: To compare the ability of the prehospital GCS and GCS-M to predict 30-day mortality and severe disability in trauma patients. DESIGN: We used the Pan-Asia Trauma Outcomes Study registry to enroll all trauma patients >18 years of age who presented to hospitals via emergency medical services from 1 January 2016 to November 30, 2018. SETTINGS AND PARTICIPANTS: A total of 16,218 patients were included in the analysis of 30-day mortality and 11 653 patients in the analysis of functional outcomes. OUTCOME MEASURES AND ANALYSIS: The primary outcome was 30-day mortality after injury, and the secondary outcome was severe disability at discharge defined as a Modified Rankin Scale (MRS) score ≥4. Areas under the receiver operating characteristic curve (AUROCs) were compared between GCS and GCS-M for these outcomes. Patients with and without traumatic brain injury (TBI) were analyzed separately. The predictive discrimination ability of logistic regression models for outcomes (30-day mortality and MRS) between GCS and GCS-M is illustrated using AUROCs. MAIN RESULTS: The primary outcome for 30-day mortality was 1.04% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.917 (0.887-0.946) vs. GCS-M:0.907 (0.875-0.938), P  = 0.155. The secondary outcome for poor functional outcome (MRS ≥ 4) was 12.4% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.617 (0.597-0.637) vs. GCS-M: 0.613 (0.593-0.633), P  = 0.616. The subgroup analyses of patients with and without TBI demonstrated consistent discrimination ability between the GCS and GCS-M. The AUROC values of the GCS vs. GCS-M models for 30-day mortality and poor functional outcome were 0.92 (0.821-1.0) vs. 0.92 (0.824-1.0) ( P  = 0.64) and 0.75 (0.72-0.78) vs. 0.74 (0.717-0.758) ( P  = 0.21), respectively. CONCLUSION: In the prehospital setting, on-scene GCS-M was comparable to GCS in predicting 30-day mortality and poor functional outcomes among patients with trauma, whether or not there was a TBI.

Evaluating mortality and 6-month functional outcomes of patients with dural venous sinus thrombosis in traumatic brain injury.

OBJECTIVE: Patients with dural venous sinus thrombosis (DVST) in select populations following traumatic brain injury (TBI), including those with blunt mechanism or depressed skull fractures, have been shown to have an increased risk of mortality. The purpose of this study was to assess these findings in a mixed population of head trauma patients. METHODS: The authors performed a case-control study using propensity score matching by reviewing 17 years (2004-2021) of data from their institutional trauma registry. Patients with imaging-confirmed DVST were matched to a control group of TBI patients without identified DVST based on age, sex, postresuscitation Glasgow Coma Scale (GCS) score, and Injury Severity Score. All age groups and injury mechanisms were included with a head Abbreviated Injury Scale score ≥ 3. Data on demographics, injury and radiographic characteristics, and patient outcomes were collected. Multivariable logistic regression was performed to identify predictors of inpatient mortality. An additional subgroup analysis of patients with concurrent DVST and blunt cerebrovascular injury (BCVI) was planned a priori. RESULTS: The authors identified 9875 patients who presented to their institution over the study period with TBIs, with a 1.64% incidence of DVST. Concurrent BCVI was diagnosed in 23.5% of patients with a DVST. Following matching, the presence of DVST itself was not significantly associated with inpatient mortality (OR 0.68, 95% CI 0.24-1.88). On regression analysis, penetrating injuries (8.19, 95% CI 1.21-80.0) and lower postresuscitation GCS scores (0.69, 95% CI 0.53-0.84) were independently associated with inpatient mortality for patients with traumatic DVST. Significantly worse functional outcomes were observed in those with DVST at 3 months, with no significant difference at 6 months. CONCLUSIONS: The authors observed a prevalence of traumatic DVST of 1.64% in a mixed population of head-injured patients, with 23.5% of patients with DVST having concurrent BCVI. Traumatic DVST alone was not associated with a significantly increased risk of inpatient mortality.

Evolução clínica e sobrevida de pacientes vítimas de traumatismo cranioencefálico / Clinical evolution and survival of patients victims of head trauma / Evolución clínica y supervivencia de pacientes víctimas de trauma cerebral

Introdução: Trauma cranioencefálico é causa importante de morbimortalidade e incapacidades, principalmente em indivíduos com idade inferior a 45 anos. Doenças neurológicas possuem um processo de recuperação lenta, requerem internação prolongada e, consequentemente, predispõem os pacientes a complicações. Objetivo: Descrever a evolução clínica e a sobrevida de pacientes vítimas de traumatismo crânioencefálico internados em uma Unidade de Terapia Intensiva. Método: Estudo transversal com delineamento descritivo e abordagem quantitativa. Resultados: No período do estudo, foram internadas 33 pessoas diagnosticadas com traumatismo cranioencefálico numa Unidade de Terapia Intensiva Neurológica Adulta de um hospital de ensino no Noroeste Paulista. Em relação ao perfil, 75,7% dos pacientes eram do sexo masculino e a faixa etária predominante de 31 a 59 anos (51,5%). Quanto à causa do trauma, o principal motivo foi a queda, com valor equivalente a 57,58%. Quanto à classificação da lesão, 57,58% foram traumas graves e 66,67% receberam tratamento cirúrgico. O tempo médio de permanência na Unidade de Terapia Intensiva foi superior a 7 dias (42,4%). Sobre a evolução clínica, 42,42% necessitaram de cateter para monitoração da pressão intracraniana, 63,64% foram submetidos à ventilação mecânica invasiva e 78,79% fizeram uso de drogas vasoativas sendo a mais utilizada a Noradrenalina em 67,65% dos casos, seguida do Nitroprussiato de sódio (Nipride®) em 17,65% e a Vasopressina em 14,70%, associada a Noradrenalina. Complicações ocorreram em 54,5% dos pacientes, sendo mais frequente a pneumonia, com 47,83%. O desfecho clínico foi a alta hospitalar para 75,76%, enquanto 12% apresentaram sequelas neurológicas. Conclusão: A maioria dos pacientes necessitou de monitoração da pressão intracraniana, ventilação mecânica e drogas vasoativas. Por ocasião da alta hospitalar, se observou uma pequena porcentagem de pacientes com sequelas neurológicas, reforçando a importância, expertise e competência da equipe multiprofissional no trabalho assistencial em unidades de neurointensivismo.

Introduction: Cranioencephalic trauma is an important cause of morbidity, mortality and disability, especially in individuals under the age of 45. Neurological diseases have a slow recovery process, require prolonged hospitalization and, consequently, predispose patients to complications. Objective: To describe the clinical evolution and survival of patients suffering from traumatic brain injury admitted to an Intensive Care Unit. Method: Cross-sectional study with a descriptive design and quantitative approach. Results: During the study period, 33 people diagnosed with traumatic brain injury were admitted to an Adult Neurological Intensive Care Unit of a teaching hospital in the Northwest of São Paulo. Regarding the profile, 75.7% of patients were male and the predominant age range was 31 to 59 years old (51.5%). As for the cause of the trauma, the main reason was the fall, with a value equivalent to 57.58%. Regarding the classification of the injury, 57.58% were severe traumas and 66.67% received surgical treatment. The average length of stay in the Intensive Care Unit was more than 7 days (42.4%). Regarding clinical evolution, 42.42% required an catheter to monitor intracranial pressure, 63.64% underwent invasive mechanical ventilation and 78.79% used vasoactive drugs, with Noradrenaline being the most used in 67.65% of cases, followed by sodium nitroprusside (Nipride®) in 17.65% and vasopressin in 14.70%, associated with noradrenaline. Complications occurred in 54.5% of patients, with pneumonia being the most common, with 47.83%. The clinical outcome was hospital discharge for 75.76%, while 12% had neurological sequelae. Conclusion: Most patients required intracranial pressure monitoring, mechanical ventilation and vasoactive drugs. At the time of hospital discharge, a small percentage of patients with neurological sequelae were observed, reinforcing the importance, expertise and competence of the multidisciplinary team in care work in neurointensive care units

Introducción: El trauma craneoencefálico es una causa importante de morbilidad, mortalidad y discapacidad, especialmente en individuos menores de 45 años. Las enfermedades neurológicas tienen un proceso de recuperación lento, requieren hospitalización prolongada y, en consecuencia, predisponen a los pacientes a sufrir complicaciones. Objetivo: Describir la evolución clínica y supervivencia de pacientes con traumatismo craneoencefálico ingresados en una Unidad de Cuidados Intensivos. Método: Estudio transversal con diseño descriptivo y enfoque cuantitativo. Resultados: Durante el período de estudio, 33 personas diagnosticadas con lesión cerebral traumática fueron internadas en una Unidad de Cuidados Intensivos Neurológicos de Adultos de un hospital universitario del Noroeste de São Paulo. En cuanto al perfil, el 75,7% de los pacientes fueron del sexo masculino y el rango de edad predominante fue de 31 a 59 años (51,5%). En cuanto a la causa del traumatismo, el motivo principal fue la caída, con un valor equivalente al 57,58%. En cuanto a la clasificación de la lesión, el 57,58% fueron traumatismos graves y el 66,67% recibió tratamiento quirúrgico. La estancia media en la Unidad de Cuidados Intensivos fue superior a 7 días (42,4%). En cuanto a la evolución clínica, el 42,42% requirió catéter para monitorizar la presión intracraneal, el 63,64% recibió ventilación mecánica invasiva y el 78,79% utilizó fármacos vasoactivos, siendo la noradrenalina la más utilizada en el 67,65% de los casos, seguida del nitroprusiato de sodio (Nipride®) en 17,65% y vasopresina en 14,70%, asociada a noradrenalina. Las complicaciones ocurrieron en el 54,5% de los pacientes, siendo la neumonía la más común, con el 47,83%. El resultado clínico fue el alta hospitalaria para el 75,76%, mientras que el 12% tuvo secuelas neurológicas. Conclusión: La mayoría de los pacientes requirieron monitorización de la presión intracraneal, ventilación mecánica y fármacos vasoactivos. Al momento del alta hospitalaria se observó un pequeño porcentaje de pacientes con secuelas neurológicas, lo que refuerza la importancia, experiencia y competencia del equipo multidisciplinario en el trabajo asistencial en las unidades de cuidados neurointensivos

Serum cystatin C is correlated with mortality of traumatic brain injury patients partially mediated by acute kidney injury.

BACKGROUND: Evaluating risk of poor outcome for Traumatic Brain Injury (TBI) in early stage is necessary to make treatment strategies and decide the need for intensive care. This study is designed to verify the prognostic value of serum cystatin C in TBI patients. METHODS: 415 TBI patients admitted to West China hospital were included. Logistic regression was performed to explore risk factors of mortality and testify the correlation between cystatin C and mortality. Mediation analysis was conducted to test whether Acute Kidney Injury (AKI) and brain injury severity mediate the relationship between cystatin C level and mortality. Area under the receiver operating characteristic curve (AUC) was used to evaluate the prognostic value of cystatin C and the constructed model incorporating cystatin C. RESULTS: The mortality rate of 415 TBI patients was 48.9%. Non-survivors had lower GCS (5 vs 8, p < 0.001) and higher cystatin C (0.92 vs 0.71, p < 0.001) than survivors. After adjusting confounding effects, multivariate logistic regression indicated GCS (p < 0.001), glucose (p < 0.001), albumin (p = 0.009), cystatin C (p < 0.001) and subdural hematoma (p = 0.042) were independent risk factors of mortality. Mediation analysis showed both AKI and brain injury severity exerted mediating effects on relationship between cystatin C and mortality of included TBI patients. The AUC of combining GCS with cystatin C was 0.862, which was higher than that of GCS alone (Z = 1.7354, p < 0.05). CONCLUSION: Both AKI and brain injury severity are mediating variables influencing the relationship between cystatin C and mortality of TBI patients. Serum cystatin C is an effective prognostic marker for TBI patients.

Factores pronósticos precoces de morbimortalidad en el traumatismo craneoencefálico grave en niños. Experiencia en una unidad de politraumatismo infantil / Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit

Objetivo Identificar factores pronósticos precoces que conduzcan a un mayor riesgo de pronóstico desfavorable. Diseño Estudio de cohortes observacional de octubre 2002 a octubre 2017. Pacientes y ámbito Se incluyeron pacientes menores de 18 años con TCE grave ingresados en cuidados intensivos (UCIP). Variables e intervenciones Se recogieron variables epidemiológicas, clínico-analíticas y terapéuticas. Se valoró la capacidad funcional del paciente a los 6 meses mediante la Glasgow Outcome Scale (GOS). Se consideró pronóstico desfavorable un GOS menor o igual a 3. Se realizó un análisis univariante para comparar grupos de buen y mal pronóstico y su relación con las diferentes variables. Se realizó un análisis multivariante para predecir el pronóstico del paciente. Resultados 98 pacientes, 61,2% varones, mediana de edad 6,4 años (RIQ 2.49–11.23). El 84,7% fueron atendidos por los servicios de emergencias extrahospitalarios. A los 6 meses, el 51% presentaba recuperación satisfactoria, 26,5% secuelas moderadas, 6,1% secuelas graves y 2% estado vegetativo. Fallecieron el 14,3%. Hubo significación estadística entre la puntuación en la escala de coma de Glasgow (ECG) prehospitalaria, reactividad pupilar, hipotensión arterial, hipoxia, ciertas alteraciones analíticas y radiológicas (compresión de las cisternas basales), con pronóstico desfavorable. El análisis multivariante demostró que es posible realizar modelos predictores de la evolución de los pacientes. Conclusiones Es posible identificar factores pronósticos de mala evolución en las primeras 24 horas postraumatismo. Su conocimiento puede ayudar a la toma de decisiones clínicas y ofrecer una mejor información a las familias (AU)

Objective To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. Design Observational cohort study from October 2002 to October 2017. Setting and patients Patients with severe TBI admitted to intensive care were included. Variables and interventions Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. Results 98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49–11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. Conclusions it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families (AU)

Association of Traumatic Brain Injury With Mortality Among Military Veterans Serving After September 11, 2001.

Importance: Emerging evidence suggests that harmful exposures during military service, such as traumatic brain injury (TBI), may contribute to mental health, chronic disease, and mortality risks. Objective: To assess the mortality rates and estimate the number of all-cause and cause-specific excess deaths among veterans serving after the September 11, 2001, terrorist attacks (9/11) with and without exposure to TBI. Design, Setting, and Participants: This cohort study analyzed administrative and mortality data from January 1, 2002, through December 31, 2018, for a cohort of US military veterans who served during the Global War on Terrorism after the 9/11 terrorist attacks. Veterans who served active duty after 9/11 with 3 or more years of care in the Military Health System or had 3 or more years of care in the Military Health System and 2 or more years of care in the Veterans Health Administration were included for analysis. The study used data from the Veterans Affairs/Department of Defense Identity Repository database, matching health records data from the Military Health Service Management Analysis and Reporting tool, the Veterans Health Administration Veterans Informatics and Computing Infrastructure, and the National Death Index. For comparison with the total US population, the study used the Centers for Disease Control and Prevention WONDER database. Data analysis was performed from June 16 to September 8, 2021. Exposure: Traumatic brain injury. Main Outcomes and Measures: Multivariable, negative binomial regression models were used to estimate adjusted all-cause and cause-specific mortality rates for the post-9/11 military veteran cohort, stratified by TBI severity level, and the total US population. Differences in mortality rates between post-9/11 military veterans and the total US population were used to estimate excess deaths from each cause of death. Results: Among 2 516 189 post-9/11 military veterans (2 167 736 [86.2%] male; and 45 324 [1.8%] American Indian/Alaska Native, 160 178 [6.4%], Asian/Pacific Islander, 259 737 [10.3%] Hispanic, 387 926 [15.4%] non-Hispanic Black, 1 619 834 [64.4%] non-Hispanic White, and 43 190 [1.7%] unknown), 17.5% had mild TBI and 3.0% had moderate to severe TBI; there were 30 564 deaths. Adjusted, age-specific mortality rates were higher for post-9/11 military veterans than for the total US population and increased with TBI severity. There were an estimated 3858 (95% CI, 1225-6490) excess deaths among all post-9/11 military veterans. Of these, an estimated 275 (95% CI, -1435 to 1985) were not exposed to TBI, 2285 (95% CI, 1637 to 2933) had mild TBI, and 1298 (95% CI, 1023 to 1572) had moderate to severe TBI. Estimated excess deaths were predominantly from suicides (4218; 95% CI, 3621 to 4816) and accidents (2631; 95% CI, 1929 to 3333). Veterans with moderate to severe TBI accounted for 33.6% of total excess deaths, 11-fold higher than would otherwise be expected. Conclusions and Relevance: This military veteran cohort experienced more excess mortality compared with the total US population than all combat deaths from 9/11/01 through 9/11/21, concentrated among individuals exposed to TBI. These results suggest that a focus on what puts veterans at risk for accelerated aging and increased mortality is warranted.