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1.
BMC Infect Dis ; 19(1): 869, 2019 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-31640582

RESUMO

BACKGROUND: Pandoraea species is a newly described genus, which is multidrug resistant and difficult to identify. Clinical isolates are mostly cultured from cystic fibrosis (CF) patients. CF is a rare disease in China, which makes Pandoraea a total stranger to Chinese physicians. Pandoraea genus is reported as an emerging pathogen in CF patients in most cases. However, there are few pieces of evidence that confirm Pandoraea can be more virulent in non-CF patients. The pathogenicity of Pandoraea genus is poorly understood, as well as its treatment. The incidence of Pandoraea induced infection in non-CF patients may be underestimated and it's important to identify and understand these organisms. CASE PRESENTATION: We report a 44-years-old man who suffered from pneumonia and died eventually. Before his condition deteriorated, a Gram-negative bacilli was cultured from his sputum and identified as Pandoraea Apista by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS). CONCLUSION: Pandoraea spp. is an emerging opportunistic pathogen. The incidences of Pandoraea related infection in non-CF patients may be underestimated due to the difficulty of identification. All strains of Pandoraea show multi-drug resistance and highly variable susceptibility. To better treatment, species-level identification and antibiotic susceptibility test are necessary.


Assuntos
Burkholderiaceae/patogenicidade , Infecções por Bactérias Gram-Negativas/microbiologia , Hemorragia Intracraniana Traumática/complicações , Pneumonia Bacteriana/microbiologia , Adulto , Burkholderiaceae/isolamento & purificação , China , Fibrose Cística/microbiologia , Infecções por Bactérias Gram-Negativas/diagnóstico por imagem , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Humanos , Hemorragia Intracraniana Traumática/etiologia , Masculino , Pneumonia Bacteriana/diagnóstico por imagem , Pneumonia Bacteriana/tratamento farmacológico , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Escarro/microbiologia
2.
World Neurosurg ; 132: e21-e27, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31521754

RESUMO

BACKGROUND: To investigate role of Low-dose, Early Fresh frozen plasma Transfusion (LEFT) therapy in preventing perioperative coagulopathy and improving long-term outcome after severe traumatic brain injury (TBI). METHODS: A prospective, single-center, parallel-group, randomized trial was designed. Patients with severe TBI were eligible. We used a computer-generated randomization list and closed opaque envelops to randomly allocate patients to treatment with fresh frozen plasma (5 mL/kg body weight; LEFT group) or normal saline (5 mL/kg body weight; NO LEFT group) after admission in the operating room. RESULTS: Between January 1, 2018, and November 31, 2018, 63 patients were included and randomly allocated to LEFT (n = 28) and NO LEFT (n = 35) groups. The final interim analysis included 20 patients in the LEFT group and 32 patients in the NO LEFT group. The study was terminated early for futility and safety reasons because a high proportion of patients (7 of 20; 35.0%) in the LEFT group developed new delayed traumatic intracranial hematoma after surgery compared with the NO LEFT group (3 of 32; 9.4%) (relative risk, 5.205; 95% confidence interval, 1.159-23.384; P = 0.023). Demographic characteristics and indexes of severity of brain injury were similar at baseline. CONCLUSIONS: LEFT therapy was associated with a higher incidence of delayed traumatic intracranial hematoma than normal fresh frozen plasma transfusion in patients with severe TBI. A restricted fresh frozen plasma transfusion protocol, in the right clinical setting, may be more appropriate in patients with TBIs.


Assuntos
Transfusão de Sangue/métodos , Lesões Encefálicas Traumáticas/terapia , Plasma , Idoso , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/cirurgia , Craniotomia , Método Duplo-Cego , Feminino , Hematoma Subdural Agudo/cirurgia , Hematoma Subdural Agudo/terapia , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragias Intracranianas/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Prevenção Secundária , Resultado do Tratamento
3.
Australas Psychiatry ; 27(5): 462-464, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30990341

RESUMO

OBJECTIVES: Dissociative identity disorder in relation to brain injury has only rarely been reported in literature. This case report, which illustrates a de novo onset of dissociative identity for the first time in an elderly man who had a left parietal haematoma, adds to this scant literature base and supports an integrative view of bridging the dichotomy between organic and functional to explain complex psychiatric phenomena. METHODS: It is a single case report collected through serial semi-structured interviews of the patient and his family over a 12-week period. RESULTS: The patient was an elderly man transiently dissociated into various identities, some of whom seemed to be based upon individuals who had traumatized him in the past. This occurred three weeks after recovery from hemiparesis and delirium following a left parietal haematoma. The dissociations ended after six weeks, which coincided not only with the resolution of the haematoma but also with a faith-healing ritual. A speculative psychobiological formulation was drawn of possible brain origins of dissociation of identity. CONCLUSIONS: This report is a compelling account of temporal correlation between dissociation of identity and left parietal haematoma.


Assuntos
Transtorno Dissociativo de Identidade/etiologia , Hematoma/complicações , Hemorragia Intracraniana Traumática/complicações , Lobo Parietal/patologia , Idoso , Humanos , Masculino
4.
J Med Case Rep ; 13(1): 44, 2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30803441

RESUMO

BACKGROUND: Atlanto-occipital dislocation is a rare and severe injury of the upper spine associated with a very poor prognosis. CASE PRESENTATION: We report the case of a 59-year-old European man who suffered from out-of-hospital cardiac arrest following a motor vehicle accident. Cardiopulmonary resuscitation was initiated immediately by bystanders and continued by emergency medical services. After 30 minutes of cardiopulmonary resuscitation with a total of five shocks following initial ventricular fibrillation, return of spontaneous circulation was achieved. An electrocardiogram recorded after return of spontaneous circulation at the scene showed signs of myocardial ischemia as a possible cause for the cardiac arrest. No visible signs of injury were found. He was transferred to the regional academic trauma center. Following an extended diagnostic and therapeutic workup in the emergency room, including extended focused assessment with sonography for trauma ultrasound, whole-body computed tomography, and magnetic resonance imaging (of his head and neck), a diagnosis of major trauma (atlanto-occipital dislocation, bilateral serial rip fractures and pneumothoraces, several severe intracranial bleedings, and other injuries) was made. An unfavorable outcome was initially expected due to suspected tetraplegia and his inability to breathe following atlanto-occipital dislocation. Contrary to initial prognostication, after 22 days of intensive care treatment and four surgical interventions (halo fixation, tracheostomy, intracranial pressure probe, chest drains) he was awake and oriented, spontaneously breathing, and moving his arms and legs. Six weeks after the event he was able to walk without aid. After 2 months of clinical treatment he was able to manage all the activities of daily life on his own. It remains unclear, whether cardiac arrest due to a cardiac cause resulted in complete atony of the paravertebral muscles and caused this extremely severe lesion (atlanto-occipital dislocation) or whether cardiac arrest was caused by apnea due the paraplegia following the spinal injury of the trauma. CONCLUSIONS: A plausible cause for the trauma was myocardial infarction which led to the car accident and the major trauma in relation to the obviously minor trauma mechanism. With this case report we aim to familiarize clinicians with the mechanism of injury that will assist in the diagnosis of atlanto-occipital dislocation. Furthermore, we seek to emphasize that patients presenting with electrocardiographic signs of myocardial ischemia after high-energy trauma should primarily be transported to a trauma facility in a percutaneous coronary intervention-capable center rather than the catheterization laboratory directly.


Assuntos
Acidentes de Trânsito , Articulação Atlantoccipital/lesões , Hemorragia Intracraniana Traumática/fisiopatologia , Luxações Articulares/fisiopatologia , Parada Cardíaca Extra-Hospitalar/terapia , Recuperação de Função Fisiológica/fisiologia , Traumatismos da Coluna Vertebral/fisiopatologia , Articulação Atlantoccipital/diagnóstico por imagem , Vértebras Cervicais/diagnóstico por imagem , Cuidados Críticos , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Luxações Articulares/complicações , Luxações Articulares/diagnóstico por imagem , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Ressuscitação , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento
5.
Epileptic Disord ; 20(6): 551-556, 2018 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-30530419

RESUMO

Seizures and other electrophysiological disturbances are an under-recognized cause of coma, focal deficits, and prolonged encephalopathy following subdural hematoma evacuation. In these patients, it is possible that seizures remain unrecognized on scalp EEG. It has been shown that a high burden of seizures and other electrophysiological disturbances exist following surgical evacuation and underlie the encephalopathy commonly seen in this patient population, predisposing them to medical complications and confounding estimates of prognosis. As part of a research protocol, we are performing intraoperative placement of cortical surface (non-parenchyma penetrating) intracranial EEG on patients who present after trauma and require emergent decompressive hemicraniectomy. In this case report of a patient with high-velocity traumatic epidural, subdural, and subarachnoid hemorrhages, we identified frequent non-convulsive seizures or seizure-like SIRPIDs with intracranial cortical surface monitoring that were not identified on simultaneous scalp EEG. Stimulation consistently triggered these electrographic seizures in addition to rhythmic lateralized periodic discharges. His mental status improved rapidly after resolution of these electrographic seizures shortly after increasing antiseizure medications, suggesting that they may have been contributing to his encephalopathy. More research is needed to determine the frequency of this phenomenon and determine whether treatment of such seizures improves patient outcomes.


Assuntos
Córtex Cerebral/fisiopatologia , Hemorragia Intracraniana Traumática/complicações , Convulsões/diagnóstico , Adulto , Eletroencefalografia , Humanos , Hemorragia Intracraniana Traumática/fisiopatologia , Masculino , Couro Cabeludo/fisiopatologia , Convulsões/etiologia , Convulsões/fisiopatologia
6.
PLoS One ; 13(9): e0203088, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30235226

RESUMO

OBJECT: Traumatic intracranial hemorrhage (TICH) patients with acute kidney injury (AKI) were reported to have a high mortality rate. Renal replacement therapy (RRT) is indicated for patients with a severe kidney injury. This study aimed to compare the effects of different RRT modalities regarding chronic dialysis rate among adult TICH patients with AKI. METHODS: A retrospective search of computerized hospital records from 2000 to 2010 for patients with a discharge diagnosis of TICH was conducted to identify the index cases. We collected the data of TICH patients with increased intracranial pressure combined with severe AKI who received intermittent hemodialysis (IHD) or continuous veno-venous hemofiltration (CVVH) as RRT. The outcome was dialysis dependence between 2000 and 2010. RESULTS: From a total of 310 patients who were enrolled in the study, 134 (43%) received CVVH and 176 (57%) received IHD. The risk of dialysis dependency was significantly lower in the CVVH group than in the IHD group (adjusted hazard ratio: 0.368, 95% CI, 0.158-0.858, P = 0.034). Diabetes mellitus and coronary artery disease were risk factors for dialysis dependency. CVVH compared with IHD modality was associated with lower dialysis dependency rate in TICH patients combined with AKI and diabetes mellitus and those with an injury severity score (ISS) ≥16. CONCLUSION: CVVH may yield better renal outcomes than IHD among TICH patients with AKI, especially those with diabetes mellitus and an ISS ≥16. The beneficial impact of CVVH on TICH patients needs to be clarified in a large cohort study in future.


Assuntos
Lesão Renal Aguda/complicações , Lesão Renal Aguda/terapia , Hemofiltração , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/terapia , Diálise Renal , Lesão Renal Aguda/epidemiologia , Adulto , Complicações do Diabetes/epidemiologia , Feminino , Seguimentos , Humanos , Hemorragia Intracraniana Traumática/epidemiologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Taiwan
7.
J Pediatr Surg ; 53(10): 2048-2054, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29784284

RESUMO

BACKGROUND: Mild traumatic brain injury (mTBI) comprises the majority of pediatric traumatic brain injury. Children with mTBI even with traumatic intracranial hemorrhage (tICH) rarely experience a clinically significant neurologic decline (CSND). The utility of routine surveillance imaging in the pediatric population also remains controversial, especially owing to concerns about the risks of radiation exposure at a young age. This study aims to identify demographic or injury-related characteristics that may facilitate recognition of children at risk of progression with mTBI. METHODS: We performed a retrospective review of patients <16 years old with mTBI (GCS 13-15) and tICH admitted to a Level I pediatric trauma center between 2009 and 2014. Management of these patients was directed by the Cincinnati Children's Hospital Medical Center Minor Head Injury Algorithm. We reviewed each chart with emphasis on patient demographics, injury specific data, and radiographic or clinical progression. RESULTS: 154 patients met inclusion criteria with mean age of 4 [0-16]; 116 sustained an tICH and 38 patients had isolated skull fractures. Repeat neuroimaging was obtained in 68 patients (59%). Only 9 patients (13%) with tICH had radiographic progression, none of which resulted in CSND. In addition, 9 patients experienced CSND, leading to neurosurgical intervention in 6 patients. Notably, none of these patients had repeat imaging prior to their neurologic changes. Both CSND and need for intervention were significantly higher in patients with epidural hematomas than other types of tICH (19.2% vs. 1.1%, p = 0.002). Of 154 patients, 19 did not have documented follow-up, 135 were seen as outpatients and 65 (48%) had follow up neuroimaging. All patients who had surveillance imaging in the outpatient setting had stable or resolved tICH. CONCLUSION: Few children with mTBI and tICH experience clinical decline. Importantly, all patients that required neurosurgical intervention were identified by clinical changes rather than via repeat imaging. Our study suggests that in the vast majority of cases, clinical monitoring alone is safe and sufficient in patients in order to avoid exposure to repeat radiographic imaging. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological.


Assuntos
Concussão Encefálica , Hemorragia Intracraniana Traumática , Radiografia/estatística & dados numéricos , Adolescente , Concussão Encefálica/complicações , Concussão Encefálica/diagnóstico por imagem , Concussão Encefálica/epidemiologia , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/epidemiologia , Estudos Retrospectivos
8.
Acta Neurochir Suppl ; 126: 21-24, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29492525

RESUMO

OBJECTIVE: The main role of the cerebral arterial compliance (cAC) is to maintain the stiffness of vessels and protect downstream vessels when changing cerebral perfusion pressure. The aim was to examine the flexibility of the cerebral arterial bed based on the assessment of the cAC in patients with traumatic brain injury (TBI) in groups with and without intracranial hematomas (IHs). MATERIALS AND METHODS: We examined 80 patients with TBI (mean age, 35.7 ± 12.8 years; 42 men, 38 women). Group 1 included 41 patients without IH and group 2 included 39 polytraumatized patients with brain compression by IH. Dynamic electrocardiography (ECG)-gated computed tomography angiography (DHCTA) was performed 1-14 days after trauma in group 1 and 2-8 days after surgical evacuation of the hematoma in group 2. Amplitude of arterial blood pressure (ABP), as well as systole and diastole duration were measured noninvasively. Transcranial Doppler was measured simultaneously with DHCTA. The cAC was calculated by the formula proposed by Avezaat. RESULTS: The cAC was significantly decreased (p < 0.001) in both groups 1 and 2 compared with normal data. The cAC in group 2 was significantly decreased compared with group 1, both on the side of the former hematoma (р = 0.017). CONCLUSION: The cAC in TBI gets significantly lower compared with the conditional norm (p < 0.001). After removal of the intracranial hematomas, compliance in the perifocal zone remains much lower (р = 0.017) compared with compliance of the other brain hemisphere.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Artérias Cerebrais/fisiopatologia , Hemorragia Intracraniana Traumática/fisiopatologia , Rigidez Vascular/fisiologia , Adulto , Pressão Arterial , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Estudos de Casos e Controles , Angiografia Cerebral , Artérias Cerebrais/diagnóstico por imagem , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Eletrocardiografia , Feminino , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Ultrassonografia Doppler Transcraniana , Adulto Jovem
9.
Acta Neurochir Suppl ; 126: 25-28, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29492526

RESUMO

OBJECTIVE: The aim was to evaluate changes in cerebrovascular resistance (CVR) in combined traumatic brain injury (CTBI) in groups with and without intracranial hematomas (IH). MATERIALS AND METHODS: Treatment outcomes in 70 patients with CTBI (42 males and 28 females) were studied. Mean age was 35.5 ± 14.8 years (range, 15-73). The patients were divided into two groups: group 1 included 34 CTBI patients without hematomas; group 2 comprised 36 patients with CTBI and IH. The severity according to the Glasgow Coma Scale averaged 10.4 ± 2.6 in group 1, and 10.6 ± 2.8 in group 2. All patients underwent perfusion computed tomography (CT) and transcranial Doppler of both middle cerebral arteries. Cerebral perfusion pressure and CVR were calculated. RESULTS: The mean CVR values in each group (both with and without hematomas) appeared to be statistically significantly higher than the mean normal value. Intergroup comparison of CVR values showed statistically significant increase in the CVR level in group 2 on the side of the removed hematoma (р = 0.037). CVR in the perifocal zone of the removed hematoma remained significantly higher compared with the symmetrical zone in the contralateral hemisphere (p = 0.0009). CONCLUSION: CVR in patients with CTBI is significantly increased compared to the normal value and remains elevated after evacuation of hematoma in the perifocal zone compared to the symmetrical zone in the contralateral hemisphere. This is indicative of certain correlation between the mechanisms of cerebral blood flow autoregulation and maintaining CVR.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Circulação Cerebrovascular/fisiologia , Hemorragia Intracraniana Traumática/fisiopatologia , Artéria Cerebral Média/fisiopatologia , Resistência Vascular/fisiologia , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Estudos de Casos e Controles , Feminino , Escala de Coma de Glasgow , Homeostase , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Imagem de Perfusão , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler Transcraniana , Adulto Jovem
11.
J Clin Neurosci ; 50: 88-92, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29452965

RESUMO

Reversal of antiplatelet therapy with platelet transfusion in traumatic intracranial hemorrhage remains controversial. Several studies have examined this topic but few have investigated whether the timing of transfusion affects outcomes. Patients admitted to a level 1 trauma center from 1/1/14 to 3/31/16 with traumatic intracranial hemorrhage taking pre-injury antiplatelet therapy were retrospectively analyzed. Patients on concurrent pre-injury anticoagulant therapy were excluded. Per institutional guideline, patients on pre-injury clopidogrel received 2 doses of platelets while patients on pre-injury aspirin received 1 dose of platelets. Patients with worsening hemorrhage defined by an increase in the Rotterdam score on follow up CT were compared to those without worsening. Mortality, need for neurosurgical intervention, and timing of platelet transfusion were analyzed. A total of 243 patients were included with 23 (9.5%) having worsening hemorrhage. Patients with worsening hematoma had higher injury severity score, head abbreviated injury scale, incidence of subdural hematoma, mortality, and lower Glasgow coma scale. There was no significant difference in the number of minutes to platelet transfusion between groups. After logistic regression analysis the presence of subdural hematoma and lower admission Glasgow coma scale were predictors of worsening hematoma, while there remained no significant difference in minutes to platelet transfusion. The timing of platelet transfusion did not have any impact on rates of worsening hematoma for patients with traumatic intracranial hemorrhage on pre-injury antiplatelet therapy. Potential risk factors for worsening hematoma in this group are the presence of subdural hematoma and lower admission Glasgow coma scale.


Assuntos
Hematoma Subdural/prevenção & controle , Hemorragia Intracraniana Traumática/terapia , Inibidores da Agregação de Plaquetas , Transfusão de Plaquetas/métodos , Adulto , Idoso , Aspirina/uso terapêutico , Clopidogrel , Feminino , Escala de Coma de Glasgow , Hematoma Subdural/etiologia , Humanos , Hemorragia Intracraniana Traumática/complicações , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Fatores de Tempo
12.
Pediatr Neurol ; 80: 70-76, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29429778

RESUMO

BACKGROUND: Hydrocephalus is a life-threatening sequela of traumatic brain injury (TBI) with poorly defined epidemiology in children. Here, we report the national incidence, risk factors, and outcomes associated with post-traumatic hydrocephalus (PTH). METHODS: The Kids Inpatient Database (2003, 2006, 2009, 2012) was queried using the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes to identify all patients (age 0 to 20) with TBI (850.xx to 854.xx) and noncongenital hydrocephalus (331.3 to 331.5, exclude 742.3). Variables included patient demographics and comorbidities, TBI severity (level of consciousness, injury type), treatment, and outcome-related measures. Risk factors associated with PTH were identified using univariate and multivariable analyses. RESULTS: PTH occurred in 1265 of 124,444 patients (1.0%) hospitalized with TBI and was managed by ventriculoperitoneal shunt (32.7%) and extraventricular drain (10.7%). PTH had the highest rate in shaken baby syndrome (6.7%, n = 19) and firearm injury (3.4%, n = 74). PTH varied by type of TBI: subdural hematoma (2.4%), subarachnoid hemorrhage (1.4%), epidural hematoma (1.0%), cerebral laceration (0.9%), concussion (0.2%). Multivariable risk factors for PTH included age zero to five years old (versus six to 20), Medicaid (versus private), electrolyte disorder, chronic neurological condition, weight loss, subarachnoid hemorrhage, subdural hematoma, open wound, postoperative neurological complication (iatrogenic stroke), and septicemia (P < 0.05). PTH rates are higher among surgically managed patients (6.0% vs 0.5%) unless managed within the first 24 hours (0.8% vs 4.1%) (P < 0.05). PTH was associated with greater length of stay (25 days versus five days) and hospital costs ($86,596 vs $16,791), but lower mortality (1.1% vs 5.4%). CONCLUSIONS: PTH in children is relatively uncommon compared with adults. Risk factors identified here, along with the influence of surgical intervention, warrant further investigation.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/epidemiologia , Hidrocefalia/epidemiologia , Hidrocefalia/etiologia , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/epidemiologia , Sistema de Registros , Adolescente , Adulto , Concussão Encefálica/complicações , Concussão Encefálica/epidemiologia , Contusão Encefálica/complicações , Contusão Encefálica/epidemiologia , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto Jovem
13.
J Trauma Acute Care Surg ; 84(3): 473-482, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29140952

RESUMO

BACKGROUND: Diffuse axonal injury (DAI) on magnetic resonance imaging has been associated with poor functional outcome after moderate-severe traumatic brain injury (msTBI). Yet, DAI assessment with highly sensitive magnetic resonance imaging techniques is unfeasible in the acute trauma setting, and computed tomography (CT) remains the key diagnostic modality despite its lower sensitivity. We sought to determine whether CT-defined hemorrhagic DAI (hDAI) is associated with discharge and favorable 3- and 12-month functional outcome (Glasgow Coma Scale score ≥4) after msTBI. METHODS: We analyzed 361 msTBI patients from the single-center longitudinal Outcome Prognostication in Traumatic Brain Injury study collected over 6 years (November 2009 to November 2015) with prospective outcome assessments at 3 months and 12 months. Patients with microhemorrhages on CT were designated "CT-hDAI-positive" and those without as "CT-hDAI-negative." For secondary analyses "CT-hDAI-positive" was stratified into two phenotypes according to presence ("associated") versus absence ("predominant") of concomitant large acute traumatic lesions to determine whether presence versus absence of additional focal mass lesions portends a different prognosis. RESULTS: Seventy (19%) patients were CT-hDAI-positive (n = 36 predominant; n = 34 associated hDAI). In univariate analyses, CT-hDAI-positive status was associated with discharge survival (p = 0.004) and favorable outcome at 3 months (p = 0.003) and 12 months (p = 0.005). After multivariable adjustment, CT-hDAI positivity was no longer associated with discharge survival and functional outcome (all ps > 0.05). Stratified by hDAI phenotype, predominant hDAI patients had worse trauma severity, longer intensive care unit stays, and more systemic medical complications. Predominant hDAI, but not associated hDAI, was an independent predictor of discharge survival (adjusted odds ratio, 24.7; 95% confidence interval [CI], 3.2-192.6; p = 0.002) and favorable 12-month outcome (adjusted odds ratio, 4.7; 95% CI, 1.5-15.2; p = 0.01). Sensitivity analyses using Cox regression confirmed this finding for 1-year survival (adjusted hazard ratio, 5.6; 95% CI, 1.3-23; p = 0.048). CONCLUSION: The CT-defined hDAI was not an independent predictor of unfavorable short- and long-term outcomes and should not be used for acute prognostication in msTBI patients. Predominant hDAI patients had good clinical outcomes when supported to intensive care unit discharge and beyond. LEVEL OF EVIDENCE: Prognostic study, level III.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Lesão Axonal Difusa/etiologia , Hemorragia Intracraniana Traumática/complicações , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Lesões Encefálicas Traumáticas/diagnóstico , Lesão Axonal Difusa/diagnóstico , Lesão Axonal Difusa/mortalidade , Feminino , Humanos , Hemorragia Intracraniana Traumática/diagnóstico , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida/tendências , Índices de Gravidade do Trauma , Adulto Jovem
14.
Acad Emerg Med ; 25(7): 769-775, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29159958

RESUMO

OBJECTIVES: Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH. METHODS: This retrospective cohort study was approved by the institutional review board. Study subjects were patients ≥ 18 years of age with an International Classification of Diseases code corresponding to a traumatic ICH and admitted to an ED observation unit (EDOU) of an urban, academic Level I trauma center between February 1, 2015, and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record, and imaging data, from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU before and after protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit, or operating room from the EDOU and the proportion of patients with worsening findings on repeat computed tomography (CT) head scan in the EDOU. RESULTS: A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Inter-rater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the preprotocol period and 153 after protocol implementation. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR = 0.45, 95% confidence interval [CI] = 0.25-0.82, p = 0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission before implementation of the protocol and 13% (20/153) of patients required an inpatient admission after protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p = 0.34). CONCLUSIONS: While there was no difference in EDOU LOS, implementing a low-risk mild TBI and ICH protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol-driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.


Assuntos
Concussão Encefálica/diagnóstico , Unidades de Observação Clínica/organização & administração , Serviço Hospitalar de Emergência/normas , Hemorragia Intracraniana Traumática/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Concussão Encefálica/complicações , Estudos Controlados Antes e Depois , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Hemorragia Intracraniana Traumática/complicações , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
15.
Neurosurgery ; 81(6): 1016-1020, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-28973510

RESUMO

BACKGROUND: Venous thromboembolism is a common complication of traumatic brain injury with an estimated incidence of 25% when chemoprophylaxis is delayed. The timing of initiating prophylaxis is controversial given the concern for hemorrhage expansion. OBJECTIVE: To determine the safety of initiating venous thromboembolic event (VTE) chemoprophylaxis within 24 h of presentation. METHODS: We performed a retrospective analysis of patients with traumatic intracranial hemorrhage presenting to a level I trauma center. Patients receiving early chemoprophylaxis (<24 h) were compared to the matched cohort of patients who received heparin in a delayed fashion (>48 h). The primary outcome of the study was radiographic expansion of the intracranial hemorrhage. Secondary outcomes included VTE, use of intracranial pressure (ICP) monitoring, delayed decompressive surgery, and all-cause mortality. RESULTS: Of 282 patients, 94 (33%) received chemoprophylaxis within 24 h of admission. The cohorts were evenly matched across all variables. The primary outcome occurred in 18% of patients in the early cohort compared to 17% in the delayed cohort (P = .83). Fifteen patients (16%) in the early cohort underwent an invasive procedure in a delayed fashion; this compares to 35 patients (19%) in the delayed cohort (P = .38). Five patients (1.7%) in our study had a VTE during their hospitalization; 2 of these patients received early chemoprophylaxis (P = .75). The rate of mortality from all causes was similar in both groups. CONCLUSION: Early (<24 h) initiation of VTE chemoprophylaxis in patients with traumatic intracranial hemorrhage appears to be safe. Further prospective studies are needed to validate this finding.


Assuntos
Anticoagulantes/administração & dosagem , Hemorragia Intracraniana Traumática/complicações , Tromboembolia Venosa/prevenção & controle , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Tromboembolia Venosa/etiologia
16.
Heart ; 103(16): 1286-1291, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28389522

RESUMO

OBJECTIVE: Traumatic intracranial haemorrhage (ICH) leads to systemic inflammatory response and arrhythmia. Atrial fibrillation (AF), the most common arrhythmia, is associated with systemic inflammation. However, limited evidence is available regarding the association between traumatic ICH and AF. METHODS: This study used the National Health Insurance Research Database, a nationwide population-based cohort, in Taiwan and total 130 171 individuals with traumatic ICH from 2000 to 2011 were identified. Furthermore, individuals without traumatic ICH were selected as a comparison cohort by the propensity score method. Individuals with prior history of AF were excluded from this study. The endpoint of interest was the occurrence of AF and the follow-up was terminated by the occurrence of AF, loss of follow-up or the passing of 31 December 2011. RESULTS: During the follow-up period, the incidence of AF was higher in patients with traumatic ICH than in those without traumatic ICH (4.24 vs 4.12 per 1000 person-years). After adjustment for age, sex and all AF-associated comorbidities, the individuals with traumatic ICH had a 1.25-fold increased risk of AF (HR=1.25, 95% CI=1.18 to 1.32; p<0.001). Stratified by sex and age, the incidence of AF was consistently higher in the traumatic ICH group. Relative to the individuals without traumatic ICH and without comorbidities, the risk of AF was the highest in the individuals with both traumatic ICH and comorbidities; this risk was higher than that of the individuals with only traumatic ICH; it was also higher than the risk for those only with comorbidities. CONCLUSION: In this large-scale cohort study, the future risks of AF are higher in patients with traumatic ICH compared with the comparison cohort. Carefully monitoring the occurrence of AF and proper anticoagulation therapy might be important in patients with traumatic ICH.


Assuntos
Fibrilação Atrial/etiologia , Hemorragia Intracraniana Traumática/complicações , Vigilância da População , Medição de Risco/métodos , Fatores Etários , Fibrilação Atrial/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Hemorragia Intracraniana Traumática/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Fatores Sexuais , Taiwan/epidemiologia , Fatores de Tempo
17.
Injury ; 48(2): 230-242, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28088374

RESUMO

Haemorrhage in the setting of severe trauma is associated with significant morbidity and mortality. There is increasing awareness of the important role fibrinogen plays in traumatic haemorrhage. Fibrinogen levels fall precipitously in severe trauma and the resultant hypofibrinogenaemia is associated with poor outcomes. Hence, it has been postulated that early fibrinogen replacement in severe traumatic haemorrhage may improve outcomes, although, to date there is a paucity of high quality evidence to support this hypothesis. In addition there is controversy regarding the optimal method for fibrinogen supplementation. We review the current evidence regarding the role of fibrinogen in trauma, the rationale behind fibrinogen supplementation and discuss current research.


Assuntos
Traumatismos Craniocerebrais/terapia , Fibrinogênio/uso terapêutico , Hemostáticos/uso terapêutico , Hemorragia Intracraniana Traumática/terapia , Austrália/epidemiologia , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/mortalidade , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/mortalidade , Guias de Prática Clínica como Assunto , Resultado do Tratamento
18.
Am J Emerg Med ; 35(1): 51-54, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27743625

RESUMO

BACKGROUND: Patients presenting to the emergency department (ED) with altered mental status and alcohol intoxication can clinically resemble patients with an intracranial hemorrhage. Although intracranial hemorrhage is quickly excluded with a head computed tomographic (CT) scan, it is common practice to defer imaging and allow the patient to metabolize to spare ED resources and minimize radiation exposure to the patient. Although this reduces unnecessary scans, it may delay treatment in patients with occult intracranial hemorrhage, which some fear may increase morbidity and mortality. We sought to evaluate the safety of deferred CT imaging in these patients by evaluating whether time to scan significantly affects the rate of neurosurgical intervention. METHODS: In this retrospective medical record review, all clinically alcohol-intoxicated patients presenting to 2 university EDs were included. Time to order CT imaging, findings on imaging, and outcomes of these patients were determined. Patients were assessed in 3 groups: CT ordered within 1 hour of triage, CT ordered 1-3 hours from triage, and CT ordered 3 or more hours from triage. RESULTS: During the study period, 5943 patients were included in the study. Of these, 0 patients scanned in less than 3 hours had intracranial findings on imaging requiring neurosurgery, whereas 1 patient with a deferred CT scan required a neurosurgical intervention; however, it was not emergently performed. CONCLUSION: Routine CT scanning of alcohol-intoxicated patients with altered mental status is of low clinical value. Deferring CT imaging while monitoring improving clinical status appears to be a safe practice.


Assuntos
Intoxicação Alcoólica/complicações , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Adulto , Lesões Encefálicas Traumáticas/complicações , Serviço Hospitalar de Emergência , Feminino , Humanos , Hemorragia Intracraniana Traumática/complicações , Masculino , Pessoa de Meia-Idade , Neuroimagem , Segurança do Paciente , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento , Tomografia Computadorizada por Raios X
19.
World Neurosurg ; 96: 607.e7-607.e11, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27693821

RESUMO

BACKGROUND: Deep brain stimulation (DBS) is a well-established treatment to reduce tremor, notably in Parkinson disease. DBS may also be effective in post-traumatic tremor, one of the most common movement disorders caused by head injury. However, the cohorts of patients often have multiple lesions that may impact the outcome depending on which fiber tracts are affected. CASE DESCRIPTION: A 20-year-old man presented after road traffic accident with severe closed head injury and polytrauma. Computed tomography scan showed left frontal and basal ganglia hemorrhagic contusions and intraventricular hemorrhage. A disabling tremor evolved in step with motor recovery. Despite high-intensity signals in the intended thalamic target, a visual analysis of the preoperative diffusion tensor imaging revealed preservation of connectivity of the intended target, ventralis oralis posterior thalamic nucleus (VOP). This was confirmed by the postoperative tractography study presented here. DBS of the VOP/zona incerta was performed. Six months postimplant, marked improvement of action (postural, kinetic, and intention) tremor was achieved. CONCLUSIONS: We demonstrated a strong connectivity between the VOP and the superior frontal gyrus containing the premotor cortex and other central brain areas responsible for movement control. In spite of an existing lesion in the target, the preservation of these tracts may be relevant to the improvement of the patient's symptoms by DBS.


Assuntos
Estimulação Encefálica Profunda/métodos , Imagem de Difusão por Ressonância Magnética , Traumatismos Cranianos Fechados/complicações , Traumatismos Cranianos Fechados/terapia , Hemorragia Intracraniana Traumática/complicações , Tremor/etiologia , Tremor/terapia , Núcleos Ventrais do Tálamo/fisiopatologia , Seguimentos , Traumatismos Cranianos Fechados/diagnóstico , Humanos , Hemorragia Intracraniana Traumática/diagnóstico , Hemorragia Intracraniana Traumática/terapia , Masculino , Rede Nervosa/fisiopatologia , Tomografia Computadorizada por Raios X , Tremor/diagnóstico , Adulto Jovem
20.
J Neurotrauma ; 33(14): 1279-91, 2016 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-26850305

RESUMO

The association between coagulopathy and either isolated traumatic brain injury (TBI) or progressive hemorrhagic injury (PHI) remains controversial. The aims of this study were to evaluate whether isolated TBI induces pronounced coagulopathy, in comparison with non-TBI or TBI in conjunction with other injuries (TBI + other injuries), and to examine whether there is any evidence of a relationship between coagulopathy and PHI in patients who have experienced TBI. The MEDLINE(®) and Embase databases, and the Cochrane Central Register of Controlled Trials (Central), were trawled for relevant studies. Searches covered the period from the inception of each of the databases to June 2015, and were conducted using appropriate combinations of terms and key words based on medical subject headings (MeSH). Studies were included if they compared isolated TBI with a similar severity of injury to other body regions, or compared PHI with non-PHI, with regard to coagulation tests and the prevalence of coagulopathy. We extracted the means and standard deviations (SD) of coagulation test levels, as well as their ranges or the percentage of abnormal coagulation tests, in both cases and controls. A total of 19 studies were included in our systematic review and meta-analysis. Only the mean fibrinogen (FIB) in isolated TBI was found to be significantly higher than in TBI + other injuries (pooled mean difference [MD] 32.09; 95% confidence interval [CI] 4.92-59.25; p = 0.02); in contrast, it was also significantly higher than in non-TBI (pooled MD 15.44; 95% CI 0.28-30.59; p = 0.05). We identified 15 studies that compared coagulopathy between a PHI group and a non-PHI group. The PHI group had a lower platelet count (PLT) value (pooled MD -19.21; 95% CI: -26.99 to -11.44, p < 0.001) and a higher international normalized ratio (INR) value (pooled MD 0.07; 95% CI: 0.02-0.13, p = 0.006) than the non-PHI group, but no differences were observed in the mean activated partial thromboplastin time (APTT) and prothrombin time (PT) between the PHI and non-PHI patients. In addition, PHI was significantly associated with a higher percentage of INR >1.2 (pooled OR 3.49 [95% CI 1.97-6.20], p < 0.001), PLT <100 × 109/L (pooled OR 4.74 [95% CI 2.44-9.20], p < 0.001), and coagulopathy (pooled OR 2.52; 95% CI 1.88- 3.38; p < 0.001), compared with non-PHI. The current clinical evidence does not indicate that the prevalence of coagulopathy in TBI is significantly higher than in injuries of similar severity to other areas of the body, or in multiple injuries with TBI. With respect to the association between coagulopathy and PHI, the occurrence of coagulopathy, INR, and PLT was significantly associated with PHI, but APTT and PT were not found to be associated with PHI. In the future, high quality research will be required to further characterize the effects of coagulopathy on TBI and subsequent PHI.


Assuntos
Transtornos da Coagulação Sanguínea , Lesões Encefálicas Traumáticas , Hemorragia Intracraniana Traumática , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/epidemiologia , Transtornos da Coagulação Sanguínea/etiologia , Lesões Encefálicas Traumáticas/sangue , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/epidemiologia , Humanos , Hemorragia Intracraniana Traumática/sangue , Hemorragia Intracraniana Traumática/complicações , Hemorragia Intracraniana Traumática/epidemiologia
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