Traumatic Brain Injury

Continuous Optical Monitoring of Cerebral Hemodynamics During Head-of-Bed Manipulation in Brain-Injured Adults

Authors: Kim MN, Edlow BL, Durduran T, Frangos S, Mesquita RC, Levine JM, Greenberg JH, Yodh AG, Detre JA.

INTRODUCTION: Head-of-bed manipulation is commonly performed in the neurocritical care unit to optimize cerebral blood flow (CBF), but its effects on CBF are rarely measured. This pilot study employs a novel, non-invasive instrument combining two techniques, diffuse correlation spectroscopy (DCS) for measurement of CBF and near-infrared spectroscopy (NIRS) for measurement of cerebral oxy- and deoxy-hemoglobin concentrations, to monitor patients during head-of-bed lowering.

CORRESPONDENCE: Intracranial-Pressure Monitoring in Traumatic Brain Injury

N Engl J Med 2013; 368:1748-1752May 2, 2013DOI: 10.1056/NEJMc1301076

To the Editor:

In response to the article by Chesnut et al. (Dec. 27 issue)1 reporting results of the trial on intracranial-pressure monitoring, we want to mention that environment must be taken into consideration to understand the role of intracranial-pressure monitoring on outcome. Approximately 80% of severe traumatic brain injuries occur in austere environments,2 defined as regions lacking in prehospital and advanced care in an intensive care unit (ICU). Care within organized trauma systems has been shown to reduce mortality associated with severe traumatic brain injury.3-5 Studies of traumatic brain injury in austere environments have shown rates of death that are 2 to 3 times as high as those in environments where advanced care is available.6
As the authors mention, several patients in this study arrived after 1 hour without appropriate prehospital care. In this real scenario, ICU monitoring has very little chance of making a difference by itself.  ...

A trial of intracranial-pressure monitoring in traumatic brain injury

Authors: Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T.

BACKGROUND: Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed.

Predictive value of initial intracranial pressure for refractory intracranial hypertension in persons with traumatic brain injury: A prospective observational study

Authors:  Yuan Q, Liu H, Wu X, Sun Y, Zhou L, Hu J.

Abstract Objective: To prospectively investigate the predictive value of initial intracranial pressure (ICP) for refractory intracranial hypertension and outcomes in persons with diffuse traumatic brain injury (TBI). Methods: A prospective observational study was conducted in 107 adult persons with diffuse TBI (Marshall CT Class II-IV). Initial ICP was defined as the first ICP recorded in the operating room. Refractory intracranial hypertension was defined as ICP increases to more than 30 mmHg and/or reduces in cerebral perfusion pressure to less than 60 mmHg for a period longer than 15 minutes and failure to respond to the maximum medical treatment. Baseline demographics and injury-specific data were recorded. Multiple logistic regression models were used to determine independent risk factors for refractory intracranial hypertension and unfavourable outcomes. A receiver-operating characteristic (ROC) curve was then drawn. Results: The initial ICP allowed for a better refractory intracranial hypertension prediction (ROC area = 0.868; 95% CI = 0.799-0.937) than the Marshall Classification (ROC area = 0.670; 95% CI = 0.569-0.772) or Rotterdam Classification scores (ROC area = 0.679; 95% CI = 0.577-0.780). An initial ICP value higher than 20 mmHg had 83% sensitivity and 83% specificity, whereas an initial ICP value higher than 25 mmHg had 64% sensitivity and 92% specificity for refractory intracranial hypertension. A multivariable logistic regression model showed that any 5 mmHg pressure increase in a patient with initial ICP led to 2.884-times higher odds of refractory intracranial hypertension (95% CI = 1.893-4.395; p < 0.001). Head Abbreviated Injury Scale score, initial Glasgow Coma Scale (GCS) and initial GCS motor scores were not predictive of refractory intracranial hypertension (p > 0.05). Conclusion: For persons with diffuse TBI, the initial ICP provides great prognostic discrimination and is an independent predictor of refractory intracranial hypertension.

Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort

Authors: Kuczynski A, Crawford S, Bodell L, Dewey D, Barlow KM.

AIM: Post-traumatic headaches (PTHs) following mild traumatic brain injury (mTBI) are common; however, few studies have examined the characteristics of PTHs or their response to treatment. The aims of this study were (1) to describe the clinical characteristics of PTH in a prospective cohort of children presenting to a paediatric emergency department with mTBI, and (2) to evaluate the response of PTH to treatment.

Costs of care following traumatic brain injury

Authors: Ponsford J, Spitz G, Cromarty F, Gifford D, Attwood D.

Traumatic brain injuries (TBI) impose a significant burden on the health care system. The aim of the current study was to explore variation in costs in a group of rehabilitation patients following complicated mild to severe TBI in Victoria, Australia, treated under the accident compensation system administered by the Transport Accident Commission. Study participants included 1237 individuals with mild-to-severe TBI recruited consecutively from a TBI rehabilitation program. Long term care, hospital, medical, and paramedical costs were obtained 10 years post-injury and their association with demographic and injury-related variables examined. Significant variability in costs was evident. Long term care costs were highest, followed by hospital, paramedical and medical costs. Duration of post-traumatic amnesia (PTA) was a strong predictor of all costs and stronger than Glasgow Coma Score. Longer acute hospital stay was related to higher costs. In addition to PTA duration and GCS, other factors associated with higher of long-term costs were having an abnormal CT scan and epilepsy early after injury. Higher hospital and medical costs were associated with these factors, but also with other physical injuries, lower education, pre-injury unemployment, living outside the city, speaking English at home and in the case of medical costs, older age and having had pre-injury psychiatric treatment. Higher paramedical costs were associated with most of these variables, but also with being employed prior to injury and being female. In line with the multifaceted nature of TBI, the current findings suggest that both injury-related and demographic factors determine costs following injury.

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