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BACKGROUND: Healthcare inequities for patients with traumatic brain injury (TBI) represent a major priority area for trauma quality improvement. We hypothesized a relationship between health insurance status and timing of withdrawal of life sustaining treatment (WLST) for adults with severe TBI. METHODS: This multicenter retrospective observational cohort study utilized data collected between 2017 and 2020. We identified adult (age ≥ 16) patients with isolated severe TBI admitted participating Trauma Quality Improvement Program centers. We determined the relationship between insurance status (public, private, and uninsured) and the timing of WLST using a competing risk survival analysis framework adjusting for baseline, clinical, injury and trauma center characteristics. Multivariable cause-specific Cox regressions were used to compute adjusted hazard ratios (HR) reflecting timing of WLST, accounting for mortality events. We also quantified the between-center residual variability in WLST using the median odds ratio (MOR) and measured insurance status association with access to rehabilitation at discharge. RESULTS: We identified 42,111 adults with isolated severe TBI treated across 509 trauma centers across North America. There were 10,771 (25.6%) WLST events in the cohort and a higher unadjusted incidence of WLST events was evident in public insurance patients compared to private or uninsured groups. After adjustment, WLST occurred earlier for publicly insured (HR 1.07, 95% CI 1.02-1.12) and uninsured patients (HR 1.29, 95% CI 1.18-1.41) compared to privately insured patients. Access to rehabilitation was lower for both publicly insured and uninsured patients compared to patients with private insurance. Accounting for case-mix, the MOR was 1.49 (95% CI 1.43-1.55), reflecting significant residual between-center variation in WLST decision-making. CONCLUSIONS: Our findings highlight the presence of disparate WLST practices independently associated with health insurance status. Additionally, these results emphasize between-center variability in WLST, persisting despite adjustments for measurable patient and trauma center characteristics.
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Lesões Encefálicas Traumáticas , Seguro Saúde , Suspensão de Tratamento , Humanos , Estudos Retrospectivos , Lesões Encefálicas Traumáticas/terapia , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Seguro Saúde/estatística & dados numéricos , Estudos de Coortes , Suspensão de Tratamento/estatística & dados numéricos , Suspensão de Tratamento/tendências , Cobertura do Seguro/estatística & dados numéricos , Cobertura do Seguro/normas , IdosoRESUMO
BACKGROUND: Impaired cerebrovascular reactivity following moderate/severe traumatic brain injury (TBI) has emerged as a key potential driver of morbidity and mortality. However, the major contributions to the literature so far have been solely focused on single point measures of long-term outcome. Therefore, it remains unknown whether cerebrovascular reactivity impairment, during the acute phase of TBI, is associated with failure to improve in outcome across time. METHODS: Cerebrovascular reactivity was measured using three intracranial pressure-based surrogate metrics. For each patient, % time spent above various literature-defined thresholds was calculated. Patients were dichotomized based on outcome transition into Improved vs Not Improved between 1 and 3 months, 3 and 6 months, and 1 and 6 months, based on the Glasgow Outcome Scale-Extended (GOSE). Univariate and multivariable logistic regression analyses were performed, adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. RESULTS: Seventy-eight patients from the Winnipeg Acute TBI Database were included in this study. On univariate logistic regression analysis, higher % time with cerebrovascular reactivity metrics above clinically defined thresholds was associated with a lack of clinical improvement between 1 and 3 months and 1 and 6 months post injury (p < 0.05). These relationships held true on multivariable logistic regression analysis. CONCLUSION: Our study demonstrates that impaired cerebrovascular reactivity, during the acute phase of TBI, is associated with failure to improve clinically over time. These preliminary findings highlight the significance that cerebrovascular reactivity monitoring carries in outcome recovery association in moderate/severe TBI.
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Lesões Encefálicas Traumáticas , Lesões Encefálicas , Adulto , Humanos , Lesões Encefálicas Traumáticas/terapia , Escala de Resultado de Glasgow , Pressão Intracraniana , BenchmarkingRESUMO
OBJECTIVES: Ischemic stroke has been estimated to occur in up to 26% of patients with blunt cerebrovascular injury (BCVI). Antithrombotic therapy (AT) may be used for stroke prevention, but the role of endovascular treatment (ET) remains unclear. We systematically reviewed the literature on AT and ET for the treatment of patients with BCVIs. MATERIALS AND METHODS: PubMed, EMBASE, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies reporting the use of ET in BCVI patients. Post-ET neurologic outcomes, radiographic responses, and complication rates were assessed. A fixed-effect model meta-analysis was performed to compare treatment-related post-BCVI ischemic stroke rates between AT and ET protocols. RESULTS: We included 16 studies comprising 352 patients undergoing ET for BCVI. Mean post-ET rates of good neurologic outcomes and radiologic responses were 86.9% (range, 63.6-100%) and 94.0% (range 57.1-100%), respectively. Mean post-ET complication rate was 5.2% (range, 0-66.7%). Seven studies compared the roles of AT (delivered in 805 patients) and ET (performed in 235 patients) for preventing the onset of post-BCVI ischemic strokes. No significant difference in rates of post-BCVI ischemic stroke was found between patients receiving AT vs patients undergoing ET (OR 0.71, 95% CI: 0.35-1.42, p = 0.402). CONCLUSION: AT and ET may be comparable in preventing the occurrence of ischemic stroke following BCVIs. AT may be preferred as the less-invasive first-line therapy, but ET showed favorable rates of post-treatment clinical and radiologic outcomes, coupled with low rates of treatment-related complications.
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Traumatismo Cerebrovascular , AVC Isquêmico , Acidente Vascular Cerebral , Ferimentos não Penetrantes , Traumatismo Cerebrovascular/complicações , Fibrinolíticos/efeitos adversos , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/prevenção & controle , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/terapiaRESUMO
In recent years, multi-petawatt laser installations have achieved unprecedented peak powers, opening new horizons to laser-matter interaction studies. Ultra-broadband and extreme temporal contrast pulse requirements make optical parametric chirped pulse amplification (OPCPA) in the few-picosecond regime the key technology in these systems. To guarantee high fidelity output, however, OPCPA requires excellent synchronization between pump and signal pulses. Here, we propose a new highly versatile architecture for the generation of optically synchronized pump-signal pairs based on the Kerr shutter effect. We obtained >550µJ pump pulses of 12 ps duration at 532 nm optically synchronized with a typical ultrashort CPA source at 800 nm. As a proof-of-principle demonstration, our system was also used for amplification of â¼20µJ ultra-broadband pulses based on an OPCPA setup.
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We demonstrate the impact of the optics roughness in Öffner stretchers used in chirped pulse amplification laser chains and how it is possible to improve the temporal contrast ratio in the temporal range of 10-100 ps by adequately choosing the optical quality of the key components. Experimental demonstration has been realized in the front-end source of the multi-petawatt (PW) laser facility Apollon, resulting in an enhancement of the contrast ratio by two to three orders of magnitude.
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The supplementary motor area (SMA) syndrome is characterized by transient weakness and akinesia contralateral to the side of the affected hemisphere. The underlying pathology of the syndrome is not fully understood but is thought to be related to lesions in the SMA, residing principally in the mesial superior frontal gyrus (Broadmann's area 6c). Although the SMA syndrome a well-characterized clinical entity, we report herein, to our knowledge, the first case of isolated lower extremity SMA syndrome in the literature. This case highlights the importance of considering this rare clinical entity in the context of new or worsening postoperative neurologic deficits. Moreover, early studies did not support somatotopic organization of the SMA as in the primary motor cortex; emerging evidence suggests that delicate somatotopic representation may underlie distinct presentations like that reported in the present case.
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Neoplasias Encefálicas , Córtex Motor , Humanos , Extremidade Inferior , Período Pós-Operatório , SíndromeRESUMO
The original version of this article unfortunately contained an error. The author apologizes for having provided an incorrect name: "Ali Moghadammjou" should be "Ali Moghaddamjou". Given in this article is the correct author name.
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BACKGROUND: Failure of cerebral autoregulation and progression of intracranial lesion have both been shown to contribute to poor outcome in patients with acute traumatic brain injury (TBI), but the interplay between the two phenomena has not been investigated. Preliminary evidence leads us to hypothesize that brain tissue adjacent to primary injury foci may be more vulnerable to large fluctuations in blood flow in the absence of intact autoregulatory mechanisms. The goal of this study was therefore to assess the influence of cerebrovascular reactivity measures on radiological lesion expansion in a cohort of patients with acute TBI. METHODS: We conducted a retrospective cohort analysis on 50 TBI patients who had undergone high-frequency multimodal intracranial monitoring and for which at least two brain computed tomography (CT) scans had been performed in the acute phase of injury. We first performed univariate analyses on the full cohort to identify non-neurophysiological factors (i.e., initial lesion volume, timing of scan, coagulopathy) associated with traumatic lesion growth in this population. In a subset analysis of 23 patients who had intracranial recording data covering the period between the initial and repeat CT scan, we then correlated changes in serial volumetric lesion measurements with cerebrovascular reactivity metrics derived from the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC (correlation coefficient between the pulse amplitude of intracranial pressure and cerebral perfusion pressure). Using multivariate methods, these results were subsequently adjusted for the non-neurophysiological confounders identified in the univariate analyses. RESULTS: We observed significant positive linear associations between the degree of cerebrovascular reactivity impairment and progression of pericontusional edema. The strongest correlations were observed between edema progression and the following indices of cerebrovascular reactivity between sequential scans: % time PRx > 0.25 (r = 0.69, p = 0.002) and % time PAx > 0.25 (r = 0.64, p = 0.006). These associations remained significant after adjusting for initial lesion volume and mean cerebral perfusion pressure. In contrast, progression of the hemorrhagic core and extra-axial hemorrhage volume did not appear to be strongly influenced by autoregulatory status. CONCLUSIONS: Our preliminary findings suggest a possible link between autoregulatory failure and traumatic edema progression, which warrants re-evaluation in larger-scale prospective studies.
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Pressão Arterial/fisiologia , Edema Encefálico/fisiopatologia , Lesões Encefálicas Traumáticas/fisiopatologia , Circulação Cerebrovascular/fisiologia , Hemorragia Intracraniana Traumática/fisiopatologia , Pressão Intracraniana/fisiologia , Adulto , Contusão Encefálica/diagnóstico por imagem , Contusão Encefálica/fisiopatologia , Edema Encefálico/diagnóstico por imagem , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Progressão da Doença , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Homeostase/fisiologia , Humanos , Unidades de Terapia Intensiva , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
OBJECT: Intraosseous schwanomma of the calvarium METHODS: This paper reports the case of a 7-year-old boy who presented with an intraosseous schwanomma involving the occipital bone and provides a brief overview of the literature. RESULTS: The patient presented with a mass in the midline occipital region. Neuroimaging revealed a lytic lesion in the occipital bone with lack of enhancement on gadolinium MRI sequences. A gross total resection was performed, and histopathological analysis confirmed the diagnosis of schwannoma. CONCLUSION: Intraosseous schwanomma should be considered in the differential diagnosis of skull vault lesions in the pediatric population and can be successfully managed with surgical excision.
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Neurilemoma/diagnóstico por imagem , Neurilemoma/cirurgia , Osso Occipital/diagnóstico por imagem , Osso Occipital/cirurgia , Neoplasias Cranianas/diagnóstico por imagem , Neoplasias Cranianas/cirurgia , Criança , Humanos , MasculinoRESUMO
Quality in healthcare is increasingly graded through a patient-centric lens, using reports of satisfaction and self-perceived outcome. Preestablished expectations have been recognized to influence these measures. With this review, we aim to examine the impact of expectations on satisfaction and patient-reported outcomes (PRO) for individuals undergoing elective spine surgery. We systematically searched MEDLINE, EMBASE, CINAHL, and Cochrane Library electronic databases from inception to July 2015 for studies examining the relationship between expectations and satisfaction/PROs in the context of elective spinal surgery. Qualitative synthesis centered around three key questions: (1) Does the magnitude of preoperative expectations impact patient satisfaction and/or PRO after surgery? (2) Does the underlying spinal pathology influence this relationship? (3) What is the impact of unmet expectations on satisfaction? A total of 1489 citations were retrieved. Nineteen met our inclusion criteria. These comprised 3383 patients; 3200 had lumbar and only 183 had cervical spine surgery. Three findings prevailed: (1) high preoperative expectations appear to be associated with higher satisfaction and PROs after surgery for focal lumbar disc herniation, but not for lumbar spinal stenosis; (2) patient expectations frequently exceed actual outcome, creating an "expectation-actuality discrepancy" (E-AD); and (3) high-quality studies suggest a larger E-AD portends lower satisfaction. Limitations to the data include heterogeneous study populations and surgical indications, along with the use of non-validated assessment tools, particularly for satisfaction. Our findings highlight the potential importance of establishing realistic expectations prior to surgery and may serve to direct future research efforts.
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Procedimentos Neurocirúrgicos/psicologia , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Doenças da Coluna Vertebral/psicologia , Doenças da Coluna Vertebral/cirurgia , Coluna Vertebral/cirurgia , HumanosRESUMO
BACKGROUND: Despite concussion now being recognized as a public health priority in Canada, recent studies-including our 2012 survey of Canadian medical schools-have revealed major gaps in concussion education at the undergraduate medical school level. METHODS: We re-surveyed all 17 Canadian medical schools using a questionnaire divided in two categories: (1) concussion-specific education (2) head injury education incorporating a concussion component to determine whether there have been any improvements in concussion education at the medical school level during the last five years. For each year of medical school, respondents were asked to provide the estimated number of hours and teaching format for each category. RESULTS: We received replies from 13 of the 17 medical schools (76%). 11 of the 13 (85%) medical schools now reported providing concussion-specific education compared to 29% in our 2012 survey. The mean number of hours dedicated to category 1 learning in 2017 was 2.65 h compared to 0.57 in 2012, and the mean number of hours of category 2 increased to 7.5 from 1.54. CONCLUSION: Our follow-up study reveals increased exposure to concussion-related teaching in Canadian medical schools during the last five years. Persistent deficiencies in a minority of schools are highlighted. These should be addressed by reiterating the importance of concussion education for undergraduate medical students and by developing clear concussion-specific objectives at the national licensure level.
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Concussão Encefálica , Currículo , Educação de Graduação em Medicina , Faculdades de Medicina , Inquéritos e Questionários , Traumatologia/educação , Canadá , Educação de Graduação em Medicina/normas , Educação de Graduação em Medicina/estatística & dados numéricos , Seguimentos , Pesquisas sobre Atenção à Saúde , HumanosRESUMO
BACKGROUND: Current opinions regarding the use of dexamethasone in the treatment of chronic subdural hematomas (CSDH) are only based on observational studies. Moreover, the use of corticosteroids in asymptomatic or minimally symptomatic patient with this condition remains controversial. Here, we present data from a prospective randomized pilot study of CSDH patients treated with dexamethasone or placebo. METHODS: Twenty patients with imaging-confirmed CSDH were recruited from a single center and randomized to receive dexamethasone (12 mg/day for 3 weeks followed by tapering) or placebo as a conservative treatment. Patients were followed for 6 months and the rate of success of conservative treatment with dexamethasone versus placebo was measured. Parameters such as hematoma thickness and clinical changes were also compared before and after treatment with chi-square tests. Adverse events and complications were documented. RESULTS: During the 6-month follow-up, one of ten patients treated with corticosteroids had to undergo surgical drainage and three of ten patients were treated surgically after placebo treatment. At the end of the study, all remaining patients had complete radiological resolution. No significant differences were observed in terms of hematoma thickness profile and impression of change; however, patients experienced more severe side effects when treated with steroids as compared with placebo. Dexamethasone contributed to many serious adverse events. CONCLUSIONS: Given the small sample size, these preliminary results have not shown a clear beneficial effect of dexamethasone against placebo in our patients. However, the number of secondary effects reported was much greater for corticosteroids, and dexamethasone treatment was responsible for significant complications.
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Anti-Inflamatórios/uso terapêutico , Dexametasona/uso terapêutico , Hematoma Subdural Crônico/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVES: Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI. METHODS: This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation. RESULTS: The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest. CONCLUSION: Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.
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Vértebras Cervicais , Traumatismos da Medula Espinal , Traqueostomia , Humanos , Traumatismos da Medula Espinal/cirurgia , Traqueostomia/métodos , Traqueostomia/efeitos adversos , Traqueostomia/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Estudos Retrospectivos , Vértebras Cervicais/cirurgia , Fatores de Tempo , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Tempo de Internação/estatística & dados numéricos , Idoso , Medula Cervical/lesões , Medula Cervical/cirurgia , Estudos de Coortes , Respiração Artificial/estatística & dados numéricos , Respiração Artificial/métodos , Tempo para o Tratamento/estatística & dados numéricosRESUMO
BACKGROUND AND OBJECTIVES: Withdrawal of life-sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex, with a paucity of standardized guidelines. We aimed to assess the variability in WLST practices between trauma centers in North America. METHODS: This retrospective study used data from trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. We included adult patients (>16 years) with severe TBI and a documented decision for WLST. We constructed a series of hierarchical logistic regression models to adjust for patient, injury, and hospital attributes influencing WLST; residual between-center variability was characterized using the median odds ratio. The impact of disparate WLST practices was further assessed by ranking centers by their conditional random intercept and assessing mortality, length of stay, and WLST between quartiles. RESULTS: We identified a total of 85 511 subjects with severe TBI treated across 510 trauma centers, of whom 20 300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, White race, self-pay, or Medicare insurance status (compared with private insurance). Black race was associated with reduced tendency for WLST. Treatment in nonprofit centers and higher-severity intracranial and extracranial injuries, midline shift, and pupil asymmetry also increased the likelihood for WLST. After adjustment for patient and hospital attributes, the median odds ratio was 1.45 (1.41-1.49 95% CI), suggesting residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was increased adjusted mortality and shorter length of stay in fourth compared with first quartile centers. CONCLUSION: We highlighted the presence of contextual phenomena associated with disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a need for standardized WLST guidelines to improve equity of care provision for patients with severe TBI.
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Importance: Identifying disparities in health outcomes related to modifiable patient factors can improve patient care. Objective: To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance. Design, Setting, and Participants: This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024. Exposure: Uninsured or public insurance compared with private insurance. Main Outcomes and Measures: Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients. Results: The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses. Conclusions and Relevance: Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.
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Purpose To develop an automated triage tool to predict neurosurgical intervention for patients with traumatic brain injury (TBI). Materials and Methods A provincial trauma registry was reviewed to retrospectively identify patients with TBI from 2005 to 2022 treated at a specialized Canadian trauma center. Model training, validation, and testing were performed using head CT scans with binary reference standard patient-level labels corresponding to whether the patient received neurosurgical intervention. Performance and accuracy of the model, the Automated Surgical Intervention Support Tool for TBI (ASIST-TBI), were also assessed using a held-out consecutive test set of all patients with TBI presenting to the center between March 2021 and September 2022. Results Head CT scans from 2806 patients with TBI (mean age, 57 years ± 22 [SD]; 1955 [70%] men) were acquired between 2005 and 2021 and used for training, validation, and testing. Consecutive scans from an additional 612 patients (mean age, 61 years ± 22; 443 [72%] men) were used to assess the performance of ASIST-TBI. There was accurate prediction of neurosurgical intervention with an area under the receiver operating characteristic curve (AUC) of 0.92 (95% CI: 0.88, 0.94), accuracy of 87% (491 of 562), sensitivity of 87% (196 of 225), and specificity of 88% (295 of 337) on the test dataset. Performance on the held-out test dataset remained robust with an AUC of 0.89 (95% CI: 0.85, 0.91), accuracy of 84% (517 of 612), sensitivity of 85% (199 of 235), and specificity of 84% (318 of 377). Conclusion A novel deep learning model was developed that could accurately predict the requirement for neurosurgical intervention using acute TBI CT scans. Keywords: CT, Brain/Brain Stem, Surgery, Trauma, Prognosis, Classification, Application Domain, Traumatic Brain Injury, Triage, Machine Learning, Decision Support Supplemental material is available for this article. © RSNA, 2024 See also commentary by Haller in this issue.
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Lesões Encefálicas Traumáticas , Lesões Encefálicas , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Canadá , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Procedimentos NeurocirúrgicosRESUMO
Rationale and objectives: To develop a method for automatic localisation of brain lesions on head CT, suitable for both population-level analysis and lesion management in a clinical setting. Materials and methods: Lesions were located by mapping a bespoke CT brain atlas to the patient's head CT in which lesions had been previously segmented. The atlas mapping was achieved through robust intensity-based registration enabling the calculation of per-region lesion volumes. Quality control (QC) metrics were derived for automatic detection of failure cases. The CT brain template was built using 182 non-lesioned CT scans and an iterative template construction strategy. Individual brain regions in the CT template were defined via non-linear registration of an existing MRI-based brain atlas.Evaluation was performed on a multi-centre traumatic brain injury dataset (TBI) (n = 839 scans), including visual inspection by a trained expert. Two population-level analyses are presented as proof-of-concept: a spatial assessment of lesion prevalence, and an exploration of the distribution of lesion volume per brain region, stratified by clinical outcome. Results: 95.7% of the lesion localisation results were rated by a trained expert as suitable for approximate anatomical correspondence between lesions and brain regions, and 72.5% for more quantitatively accurate estimates of regional lesion load. The classification performance of the automatic QC showed an AUC of 0.84 when compared to binarised visual inspection scores. The localisation method has been integrated into the publicly available Brain Lesion Analysis and Segmentation Tool for CT (BLAST-CT). Conclusion: Automatic lesion localisation with reliable QC metrics is feasible and can be used for patient-level quantitative analysis of TBI, as well as for large-scale population analysis due to its computational efficiency (<2 min/scan on GPU).
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To date, there has been limited literature exploring the association between age and sex with cerebrovascular reactivity (CVR) in moderate/severe traumatic brain injury (TBI). Given the known link between age, sex, and cerebrovascular function, knowledge of the impacts on continuously assessed CVR is critical for the development of future therapeutics. We conducted a scoping review of the literature for studies that had a direct statistical interrogation of the relationship between age, sex, and continuous intracranial pressure (ICP)-based indices of CVR in moderate/severe TBI. The ICP-based indices researched included: pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC. MEDLINE, BIOSIS, EMBASE, SCOPUS, Global Health, and the Cochrane library were searched from inception to June 2021 for relevant articles. A total of 10 original studies fulfilled our inclusion criteria. Nine of the articles documented a correlation between advanced age and worse CVR, with eight using PRx (2192 total patients), three using PAx (978 total patients), and one using RAC (358 total patients), p < 0.05; R ranging from 0.17 to 0.495 for all indices across all studies. Three articles (1256 total patients) displayed a correlation between biological sex and PRx, with females trending towards higher PRx values (p < 0.05) in the limited available literature. However, no literature exists comparing PAx or RAC with biological sex. Findings showed that aging was associated with impaired CVR. We observed a trend between female sex and worse PRx values, but the literature was limited and statistical significance was borderline. The identified studies were few in number, carried significant population heterogeneity, and utilized grand averaging of large epochs of physiology during statistical comparisons with age and biological sex. Because of the heterogeneous nature of TBI populations and limited focus on the effects of age and sex on outcomes in TBI, it is challenging to highlight the differences between the indices and patient age groups and sex. The largest study showing an association between PRx and age was done by Zeiler and colleagues, where 165 patients were studied noting that patients with a mean PRx value above zero had a mean age above 51.4 years versus a mean age of 41.4 years for those with a mean PRx value below zero (p = 0.0007). The largest study showing an association between PRx and sex was done by Czosnyka and colleagues, where 469 patients were studied noting that for patients <50 years of age, PRx was worse in females (0.11 ± 0.047) compared to males (0.044 ± 0.031), p < 0.05. The findings from these 10 studies provide preliminary data, but are insufficient to definitively characterize the impact of age and sex on CVR in moderate/severe TBI. Future work in the field should focus on the impact of age and sex on multi-modal cerebral physiological monitoring.
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There is an increasing number of trauma patients presenting on pre-injury antiplatelet (AP) agents attributable to an aging population and expanding cardio- or cerebrovascular indications for antithrombotic therapy. The effects of different AP regimens on outcomes after traumatic brain injury (TBI) have yet to be elucidated, despite the implications on patient/family counseling and the potential need for better reversal strategies. The goal of this systematic review and meta-analysis was to assess the impact of different pre-injury AP regimens on outcomes after TBI. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the OVID Medline, Embase, BIOSIS, Scopus, and Cochrane databases were searched from inception to February 2022 using a combination of terms pertaining to TBI and use of AP agents. Baseline demographics and study characteristics as well as outcome data pertaining to intracerebral hematoma (ICH) progression, need for neurosurgical intervention, hospital length of stay, mortality, and functional outcome were extracted. Pooled odds ratios (ORs) and mean differences comparing groups were calculated using random-effects models. Thirteen observational studies, totaling 1244 patients receiving single AP therapy with acetylsalicylic acid or clopidogrel, 413 patients on dual AP therapy, and 3027 non-AP users were included. No randomized controlled trials were identified. There were significant associations between dual AP use and ICH progression (OR, 2.81; 95% confidence interval [CI], 1.19-6.61; I 2, 85%; p = 0.02) and need for neurosurgical intervention post-TBI (OR, 1.61; 95% CI, 1.15-2.28; I 2, 15%; p = 0.006) compared to non-users, but not between single AP therapy and non-users. There were no associations between AP use and hospital length of stay or mortality after trauma. Pre-injury dual AP use, but not single AP use, is associated with higher rates of ICH progression and neurosurgical intervention post-TBI. However, the overall quality of studies was low, and this association should be further investigated in larger studies.
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BACKGROUND: Impaired cerebral autoregulation has been linked with worse outcomes, with literature suggesting that current therapy guidelines fail to significantly impact cerebrovascular reactivity. The cerebral oximetry index (COx_a) is a surrogate measure of cerebrovascular reactivity which can in theory be obtained non-invasively using regional brain tissue oxygen saturation and arterial blood pressure. The goal of this study was to assess the relationship between objectively measured depth of sedation through BIS and autoregulatory capacity measured through COx_a. METHODS: In a prospectively maintained observational study, we collected continuous regional brain tissue oxygen saturation, intracranial pressure, arterial blood pressure and BIS in traumatic brain injury patients. COx_a was obtained using the Pearson's correlation between regional brain tissue oxygen saturation and arterial blood pressure and ranges from - 1 to 1 with higher values indicating impairment of cerebrovascular reactivity. Using BIS values and COx_a, a curve-fitting method was applied to determine the minimum value for the COx_a. The associated BIS value with the minimum COx_a is called BISopt. This BISopt was both visually and algorithmically determined, which were compared and assessed over the whole dataset. RESULTS: Of the 42 patients, we observed that most had a parabolic relationship between BIS and COx_a. This suggests a potential "optimal" depth of sedation where COx_a is the most intact. Furthermore, when comparing the BISopt algorithm with visual inspection of BISopt, we obtained similar results. Finally, BISopt % yield (determined algorithmically) appeared to be independent from any individual sedative or vasopressor agent, and there was agreement between BISopt found with COx_a and the pressure reactivity index (another surrogate for cerebrovascular reactivity). CONCLUSIONS: This study suggests that COx_a is capable of detecting disruption in cerebrovascular reactivity which occurs with over-/under-sedation, utilizing a non-invasive measure of determination and assessment. This technique may carry implications for tailoring sedation in patients, focusing on individualized neuroprotection.