Value of repeat cranial computed axial tomography scanning in patients with minimal head injury

BACKGROUND: Patients with minimal head injury (MHI) and a cranial computed axial tomography (CAT) scan positive for the presence of intracranial injury routinely undergo a repeat CAT scan within 24 hours after injury. The value of this repeat cranial CAT scan is unclear in those patients who are neurologically normal or improving. METHODS: A retrospective analysis of all adult patients admitted to a level-1 trauma center with MHI and a positive cranial CAT scan during a 32-month period was performed. The need for neurosurgical intervention after repeat CAT scan in patients with a persistently normal or improved neurological examination was recorded. RESULTS: One hundred fifty-one patients had a persistently normal or improved neurological examination, but none of these patients required neurosurgical intervention after the repeat cranial CAT scan. CONCLUSIONS: A persistently normal or improving neurological examination in a patient with MHI appears to exclude the need for neurosurgical intervention and thus a repeat cranial CAT scan.     

Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury

IntroductionPatients with traumatic brain injury (TBI) may have concomitant facial fractures. While most head injury patients receive head computed tomography (CT) scans for initial evaluation, the objective of our study was to investigate the value of simultaneous facial CT scans in assessing facial fractures in patients with TBI.MethodsFrom January 1, 2015 to December 31, 2015, 1649 consecutive patients presenting to our emergency department (ED) with a TBI who received CT scans using the protocol for head and facial bones were enrolled. The clinical data and CT images were reviewed via a standardized format.ResultsIn our cohort, 200 patients (12.1%) had at least one facial fracture shown on the CT scans. Patients with facial fractures were more likely to have initial loss of consciousness (ILOC; p < 0.001), a Glasgow coma scale of 8 or less (p < 0.001), moderate or severe degrees of head injury severity scale (p < 0.001), positive physical examination findings (p < 0.001), and positive CT cranial abnormalities (p < 0.001). A total of 166 (83.0%) patients with facial fractures required further facial CT scans instead of conventional head CT scans alone. Surgical intervention was mandatory in 73 (44.0%) of the 166 patients, who more frequently exhibited fractures of the lower third of the face (p < 0.001) and orbital fractures (p = 0.019).ConclusionsTBI patients with risk factors may have a higher probability of concomitant facial fractures. Fractures of the lower third of the face and orbit are easily overlooked in routine head CT scans but often require surgical intervention. Therefore, simultaneous head and facial CT scans are suggested in selected TBI patients.     

Extracellular glycerol in patients with severe traumatic brain injury

Objective： To study the factors affecting extracellular glycerol （Gly） in patients with severe traumatic brain injury （STBI）.
Methods： Perilesional extracellular Gly and cerebral blood flow （CBF） in 53 patients with STBI were consecutively monitored. Simultaneously, the intracranial pressure （ICP） and cerebral perfusion pressure （CCP） were monitored. The hourly minimum of CCP and CBF and the hourly maximum of ICP levels were matched with the hourly Gly. Gly values were divided into several groups according to regional ICP （〈 15 nun Hg or 〉 15 nun Hg）, CCP （〈70 nun Hg or 〉70 nun Hg）, CBF （〈50 AU or 50-150 AU） and the outcomes （death or persistent vegetative state group, severe or moderate disability group, and good recovery group）.
Results： In comparison with the severe or moderate disability group, the Gly concentration of the death or persistent vegetative state group increased significantly, but CBF and CCP decreased significantly. In comparison with the good recovery group, the Gly concentration of the severe or moderate disability group increased significantly, but CBF and CCP decreased significantly. The Gly concen- trations in patients with ICP〉15 mm Hg, CCP〈70 mm Hg and CBF〈50 AU were respectively higher than those of patients with ICP 〈15 mm Hg, CCP〉70 mm Hg and 50AU 〈CBF〈150AU. In patients with diffuse axial injury, the mean Gly concentration was （201.17±55.00） μmol/L, which was significantly higher than that of the patients with epidural hematoma （n=7, 73.26±8.37, P〈O.05） or subdural hematoma （n=9, 114.67 ±62.88, P〈O.05）, but it did not increase signifi- cantly when compared with those in patients with contusion （n=24, 167.48±52.63）.
Conclusion： Gly can be taken as a marker for degrada- tion of membrane phospholipids and ischemia, which reflects the severity of primary or secondary insult.     

Clinical outcomes in patients on preinjury ibuprofen with traumatic brain injury

Background

The aim of our study was to evaluate the clinical outcomes in patients on preinjury Ibuprofen with traumatic brain injury.

Methods

We performed a 2-year analysis of all patients on prehospital Ibuprofen with traumatic brain injury and intracranial hemorrhage. Patients on preinjury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale, head-abbreviated injury scale, injury severity score, International Normalized Ratio, and neurologic examination. Outcome measures were progression on repeat head computed tomography (RHCT) and neurosurgical intervention.

Results

A total of 195 matched (Ibuprofen 65, no-Ibuprofen 130) patients were included. There was no difference in the progression on RHCT (Ibuprofen 18% vs no-Ibuprofen 24%; P = .50). The neurosurgical intervention rate was 18.9% (n = 37). There was no difference for need for neurosurgical intervention (26% vs 16%; P = .10) between the 2 groups.

Conclusions

In a matched cohort of trauma patients, preinjury Ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Preinjury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan.     

The utility of the Mini-Mental Status Exam in older adults with traumatic brain injury

Primary objective: To assess the utility of the Mini-Mental Status Examination (MMSE) among the older TBI population.

Methods and procedures: The MMSE and a number of other neuropsychological tests were administered to forty-three adults aged 50 and over one year following mild to moderate TBI. The sensitivity, specificity, and predictive value of the MMSE were evaluated in relation to these tests.

Main outcomes and results: The domains of the MMSE generally exhibited low sensitivity while high specificity was demonstrated by Attention and Language. Positive predictive value was high only for Language but negative predictive value was moderate to high for all domains.

Conclusions: These results suggest that one year following mild to moderate TBI among older adults, the MMSE should not be used to identify those with cognitive impairment; if administered, a perfect score on a component of the MMSE suggests that enhanced testing in that given domain may not reveal further impairment. A small sample size and a small number of those impaired limit our results.     

颅脑对冲伤与冲击伤再手术病例诊治探讨

目的探讨颅脑对冲伤与冲击伤患者需再次手术的原因与处理方法。方法回顾性分析2010-01—2014-01受伤机制为对冲伤与冲击伤的需再次开颅手术的24例患者的病例资料。结果本组再次开颅病例术后随访3~6个月,按格拉斯哥预后评分(GOS)判定预后,恢复良好12例(50%),重残2例,植物生存2例,死亡8例(33%)。结论颅脑创伤需手术患者术前应仔细研究患者的受伤机制,分析影像学资料,及时诊断并处理对侧迟发性颅内血肿和扩大的脑挫裂伤灶,能提高其治愈率,减少死残率,改善患者预后。     

Gender differences in outcome in patients with hypotension and severe traumatic brain injury

BACKGROUND: Animal studies have identified hormonal influences on responses to injury and recovery, creating a potential gender effect on outcome. Progesterone and oestrogen are thought to afford protection in the immediate post-injury period, suggesting females have an advantage, although there has been limited evidence of this in human outcome studies. METHODS: This study examined the influence of gender on outcome in 229 adults (151 males), aged >17 years, with severe blunt head trauma, initial GCS <9 and hypotension, recruited into a randomised controlled trial of pre-hospital hypertonic saline resuscitation versus conventional fluid management. Outcome was measured by survival and Glasgow Outcome Scale-Extended version (GOS-E) scores at 6 months post-injury. RESULTS: Females recruited into the study had a higher mean age. Females were more likely to be injured as passengers and pedestrians and males as drivers or motorcyclists. There were no gender differences in GCS or injury severity scores, ICP, cerebral perfusion pressure, gas exchange (PaO2/FiO2 ratio), or duration of mechanical ventilation. After controlling for GCS, age and cause of injury, females had a lower rate of survival. They also showed a lower rate of good outcome (GOS-E score >4) at 6 months, but this appeared to reflect the lower rate of initial survival. Those females surviving had similar outcomes to males. CONCLUSIONS: The study provides no evidence that females fare better than males following severe TBI, suggesting rather that females may fare worse.     

227例颅脑创伤患者凝血功能的动态变化及其临床意义

目的：观察和研究各类颅脑创伤患者凝血功能异常的发生率及其临床意义。方法对本院2013年收治的227例单纯性颅脑创伤患者按损伤的性质和类型进行分组并分别检测凝血酶原时间（PT）、部分凝血活酶时间（APTT）、凝血酶时间（TT）和纤维蛋白原（FIB）等凝血功能指标的动态变化。结果227例患者中,颅脑外伤后24小时内凝血功能指标PT、APTT、TT和FIB检测值异常的发生率分别为11%、71.4%、34.4%和21.2%;颅脑外伤后72小时PT、APTT、TT和FIB检测值异常的发生率明显降至2.6%、33.9%、5.7%和17.6%。在各类颅脑创伤中,急性硬膜下血肿患者24小时、48小时、72小时和7天时间段凝血功能指标PT、APTT、TT和FIB检测值异常的发生率均明显高于其他颅脑外伤患者,差异有统计学意义（P＜0.05）。结论颅脑创伤患者伤后24小时内即可出现凝血功能异常,72小时后凝血功能异常的发生率明显降低;颅脑创伤患者凝血功能异常的发生率和持续时间可能与颅脑创伤的性质和类型有关。     

急性颅脑损伤后进展性出血性损伤危险因素分析

目的探讨急性颅脑损伤后发生进展性出血性损伤危险因素。方法分析274例你和性颅脑外伤患者临床资料,分为进展组86例和非进展组188例,对照分析两组相关因素。结果两组除首次头颅CT时间外,年龄、性别、GCS评分、瞳孔扩大、平均动脉压、合并颅骨折、合并硬膜外血肿、合并脑挫伤、合并蛛网膜下腔出血、双侧伤、首次CT血肿量、两次CT血肿量差之间差异,均有统计学意义(P均<0.05)。GCS<12分、瞳孔扩大、合并脑挫伤、合并蛛网膜下腔出血及首次CT血肿量>10ml为发生进展性出血性损伤的独立危险因素(P均<0.05)。结论急性颅脑损伤患者及时进行头颅CT检查,对血肿量>10ml,GCS评分1<12分、瞳孔扩大及合并脑挫伤和蛛网膜下腔出血患者,应密切观察病情进展,尽早复查头颅CT以及时发现进展性出血性损伤。     

颅脑外伤患者凝血功能异常与预后的相关性研究

目的了解颅脑外伤患者急性期凝血功能改变情况,并分析凝血功能异常与颅脑损伤程度（GCS评分）及预后（GOS评分）的关系。方法监测124例单纯颅脑外伤患者急性期凝血指标,进行DIC评分,对患者入院时颅脑损伤程度及外伤后6个月的临床预后进行评分。结果超过50%的单纯颅脑外伤患者发生凝血功能异常,其中重型颅脑外伤患者及预后不良的颅脑外伤患者PT明显延长,D-DT水平明显升高,其差异具有显著性。结论凝血功能改变,尤其是DIC多发生于脑外伤后6小时内,在重型颅脑外伤患者及预后不良的颅脑外伤患者中表现的更加明显。PT、D-DT水平在颅脑外伤患者预后的评估中起重要作用,可作为患者预后的预测指标。     

外伤性蛛网膜下腔出血对重型颅脑损伤患者Marshall CT分级预后的影响

目的研究外伤性蛛网膜下腔出血是否影响颅脑损伤患者Marshall CT分级的预后。方法收集本院2008年2月至2008年12月间共66例重型颅脑损伤患者,按照Marshall CT分级分为弥漫性损伤组和局灶性损伤组,分析外伤性蛛网膜下腔出血的发生率及对其预后的影响。结果66例重型颅脑损伤的患者中,合并外伤性蛛网膜下腔出血的发生率高达77．27％,并且预后较差。根据Marshall CT分级,弥漫性损伤组中,伤后6个月GOS评分合并蛛网膜下腔出血者平均为3．00,不合并者为4．25;局灶性损伤组中,伤后6个月GOS评分合并蛛网膜下腔出血者平均为1．91,不合并者为3．00,鼹者有统计学差异（P〈0．05）。结论外伤性蛛网膜下腔出血在重型颅脑损伤患者中极为常见,并且影响Marshall CT分级的预后。     

脑外伤患者围手术期液体及代谢管理

背景 在创伤性患者中,脑外伤(traumatic brain injury,TBI)逐渐成为致残甚至致死的主要因素.快速而有效的治疗,是该类患者取得良好预后的关键. 目的 对于TBI患者,围术期治疗的关键是维持患者生命体征平稳,避免血氧不足、低血压、贫血、低(高)碳酸血症、发热、低血糖等变化,也需关注颅内血肿、颅内高压、癫痫、感染、血管痉挛等引起继发性神经损伤的因素. 内容 TBI患者围术期液体和代谢管理包括维持脑灌注压、避免血糖较大波动及控制体温,是TBI患者预后的关键.维持脑灌注压的策略在于液体的选择类型及其输注量.维持良好的血糖范围,有利于患者预后.低体温对TBI患者的影响尚存在争议. 趋向 关注液体及代谢管理,逐渐成为TBI患者围术期管理的主要内容.     

Microlinguistic deficits in the narrative discourse of adults with traumatic brain injury

Background: Recent studies of microlinguistic impairments in the narrative discourse of adults with traumatic brain injury (TBI) have applied syntactic analyses, with some noting no deficits and others specific problems with sentence formulation. An alternative approach to examining the microlinguistic dysfunction in the discourse of individuals with TBI is through the use of propositional analysis. The advantage of propositional analysis is that it enables one to assess semantic complexity of utterances apart from sentence structure and grammaticality.

Aims: The present study applied propositional analysis to the story narratives of participants with TBI and participants with no brain injury (NBI). Specifically, the mean number of propositions within a sentence was tallied, in other words the participants' ability to insert multiple ideas into single surface sentences. It was hypothesized that the participants with TBI would produce fewer propositions per sentence because of organizational problems than the participants with NBI, regardless of level of education.

Methods and procedures: Two story narratives (retelling and generation) previously elicited from the two participant groups (TBI (n = 53) and NBI (n = 42)) were analysed. For each language sample, the number of propositions was tallied and divided by the number of T-units. The resulting number, the propositional complexity index (PCI), was the average number of predicates per sentence.

Outcomes and results: Results indicated that the group with TBI produced significantly fewer propositions per T-unit.

Conclusions: The present findings are in harmony with the notion that the participants with TBI studied presented with impairments of both micro- and macrolinguistic processes involved with the organization of semantic information in discourse. Clinical implications are discussed.     

颅脑创伤后大鼠脑组织中Apelin表达变化的研究

目的研究颅脑创伤后大鼠脑组织中Apelin表达的变化规律。方法 96只雄性SD大鼠随机分为假手术组(A组)、轻型颅脑创伤组(B组)和重型颅脑创伤组(C组),每组又分6小时、24小时、72小时、168小时4亚组,RT-PCR法观测Apelin的基因表达,免疫组化法观测Apelin的表达。结果 B组和C组的Apelin表达高于A组,并在24小时达到高峰,而且在C组的升高程度大于B组。结论颅脑损伤后脑组织中Apelin的表达增加,并且与损伤严重程度相关。     

颅脑损伤后血清中sICAM-1和IL-1β含量变化的意义

目的 动态观测急性颅脑损伤患者血清中sICAM-1和IL-1β含量的变化．探讨其临床意义。方法 按入院先后随机选取25例被CT证实的颅脑损伤患者，按照入院时、24．48．96小时四个时间段分别采集血标本，应用双抗体夹心酶联免疫吸附法（ELISA）测定sICAM-1和IL-1β的含量．并与对照组比较。结果 颅脑损伤患者早期sICAM-1含量较对照组无变化，在48小时明显升高，并持续升高至96小时（P〈0．05）。sICAM-1含量与损伤程度无关，而与预后相关。皿清中IL-1β含量于入院时就有明显升高（P〈0．05），IL-1β升高不仅与损伤程度有关，而且与预后也密切相关。血清中IL-1β含量与sICAM-1含量相关。结论 血清中sICAM-1和IL-1β参与了颅脑后继发性脑损伤，sICAM-1和IL-1β升高反映了颅内的炎症反应。     

颅脑损伤后继发脑梗塞的相关因素分析

目的探讨颅脑损伤后继发脑梗塞的危险因素。方法本院于2008至2010年共收治中、重型颅脑损伤病人756例,其中发生继发性脑梗塞病人45例,对756例颅脑损伤患者的年龄、休克、外侧裂池周围脑挫裂伤、颅内血肿、脑疝、血沉、D-二聚体等因素与外伤性脑梗塞的关系进行回顾性分析。结果年龄、休克、外侧裂池周围脑挫裂伤、颅内血肿、脑疝、血沉、D-二聚体等因素与外伤性脑梗塞关系密切。结论年龄、休克、外侧裂池周围脑挫裂伤、颅内血肿、脑疝、血沉、D-二聚体是颅脑损伤继发脑梗塞的相关因素,对外伤性脑梗塞的防治有一定的临床意义。     

Effects of medroxyprogesterone acetate on cerebral oedema and spatial learning performance after traumatic brain injury in rats

Background: Given after brain injury (TBI), progesterone reduces cerebral oedema and facilitates functional recovery. Progesterone analogues have been synthesized for use in many medical conditions and exhibit different chemical and biological properties. Medroxyprogesterone acetate (MPA) is widely used in clinical practice, but oestrogen/MPA combinations may increase the risk of stroke and cardiovascular disease rather than preventing them. In some conditions, MPA can exhibit pharmacological actions that are different from those of natural progesterone.

Primary objective and hypothesis: Using laboratory rats, this study assessed the efficacy of MPA to determine whether this progestin and natural progesterone exert similar effects as a treatment after bilateral injury to the frontal cortex.

Main outcomes and results: MPA produced a dose-related reduction of cerebral oedema at 48 hours post-TBI but neither 4 nor 16 mg/kg doses of MPA enhanced behavioural recovery.

Conclusion: These findings help to clarify the divergent results from prior positive progesterone studies and the negative MPA clinical trials for hormone replacement therapy. The results can be taken to suggest that the control of cerebral oedema, while clearly desirable, is not the only contributor to progesterone-induced behavioural recovery.     

Inconsistencies with screening for traumatic brain injury in spinal cord injury across the continuum of care

Objective: Explore how traumatic brain injury (TBI) is screened among spinal cord injury (SCI) patients across the continuum of care.

Design: Retrospective chart review

Setting: Emergency department, trauma, inpatient rehabilitation

Participants: 325 patients with SCI from inpatient rehabilitation facility (IRF) between March 1, 2011 and December 31, 2014 were screened. 49 eligible subjects had traumatic SCI and received care in adjoining acute care (AC) hospital.

Outcome Measures: Demographic characteristics and variables that capture diagnosis of TBI/SCI included documentation from ambulance, emergency department, AC, and IRF including ICD-9 codes, altered mental status, loss of consciousness (LOC), Glasgow Coma Score, Post Traumatic Amnesia (PTA), neuroimaging, and cognitive assessments.

Results: Participants were male (81%), white (55%), privately insured (49%), and aged 39.3±18.0 years with 51% paraplegic and 49% tetraplegic. Mechanisms of injury were gunshot wound (31%), fall (29%), and motor vehicle accident (20%). TBI occurred in 65% of SCI individuals, however documentation of identification of TBI, LOC, and CT imaging results varied in H&P, discharge notes, and ICD-9 codes across the continuum. Cognitive assessments were performed on 16% of subjects.

Conclusions: Documentation showed variability between AC and IRF and among disciplines. Imaging and GCS were more consistently documented than LOC and PTA. It is necessary to standardize screening processes between AC and IRF to identify dual diagnosis.     

氨甲环酸在创伤性脑损伤患者中的应用

创伤性脑损伤(TBI)后颅内出血很常见,可导致患者发生脑疝甚至死亡.氨甲环酸(TXA)是一种赖氨酸类似物,它竞争性抑制纤溶酶原,抑制纤维蛋白凝块溶解所必需的纤溶酶激活.TXA可以减少颅外大出血的创伤患者因失血而死亡,通过减少颅内出血的扩大来改善TBI患者的预后.全文从TBI对机体的影响、TXA在TBI患者中的应用、TX...