The effects of mild hypothermia on patients with severe traumatic brain injury

Objective To investigate the protectiveeffects of mild hypothermia(33-35℃)on theoutcome of patients with severe traumaticbrain injury(TBI)(GCS<8). Methods Patients in the mild hypother-mia group were cooled to 33-35℃by coolingblanket with muscular relaxant,and patientsin the normothermia group were maintained at37-38℃. Results The result showed that the mor-     

Prehospital care in patients with severe traumatic brain injury: does the level of prehospital care influence mortality?

Introduction and purpose

The controversy between the “scoop and run” versus the “stay and play” approach in severely injured trauma patients has been an ongoing issue for decades. The present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the Netherlands have improved outcome.

Methods

In this retrospective study, files (n = 60) were analyzed from a prospectively collected database including all patients admitted to one of six hospitals in the Limburg region in the Netherlands with a Glasgow Coma Scale (GCS) score ≤8 on admittance over the period from January 2006 to December 2008. All patients had traumatic brain damage proven on computed tomography (CT) or magnetic resonance imaging (MRI). Relevant prehospital and clinical data from the present cohort were compared to data from a similar study (n = 30) conducted 20 years ago. The primary outcome assessed was mortality.

Results

The two study groups had similar characteristics with regard to the GCS score. In the historic cohort, Basic Life Support (BLS) and the “scoop and run” approach in patients with major traumatic brain injury was common, with an average time on scene of 7.5 min. Currently, prehospital care is performed mainly on the level of prehospital Advanced Life Support (ALS), with the average time on scene being about four times as long as in the historic cohort. However, the overall mortality rate for the current cohort compared to the historic cohort has not changed.

Conclusion

Despite more on-site ALS in severely head injured patients nowadays compared to the historic cohort, there was no reduction in mortality.     

Extracorporeal membrane oxygenation and severe traumatic brain injury. Is the ECMO-therapy in traumatic lung failure and severe traumatic brain injury really contraindicated?

Veno-venous extracorporeal membrane oxygenation (ECMO) may be lifesaving in multiple injured patients with acute respiratory distress syndrome (ARDS) due to chest trauma. To prevent circuit thrombosis or thrombembolic complications during ECMO systemic anticoagulation is recommended. Therefore, ECMO treatment is contraindicated in patients with intracranial bleeding. The management of veno-venous ECMO without systemic anticoagulation in a patient suffering from traumatic lung failure and severe traumatic brain injury is reported.     

Does an early onset and continuous chain of rehabilitation improve the long-term functional outcome of patients with severe traumatic brain injury?

There are currently no international guidelines regarding treatment in the early rehabilitation phase for persons with severe traumatic brain injury (TBI), and only a few studies have investigated the effect of integrating rehabilitation into acute TBI care. The aim of the study was to evaluate whether a continuous chain of rehabilitation that begins with the acute phase could improve the functional outcome of severe TBI patients, compared to a broken chain of rehabilitation that starts in the sub-acute phase of TBI. A total of 61 surviving patients with severe TBI were included in a quasi-experimental study conducted at the Level I trauma center in Eastern Norway. In the study, 31 patients were in the early rehabilitation group (Group A) and 30 patients were in the delayed rehabilitation group (Group B). The functional outcomes were assessed 12 months post-injury with the Glasgow Outcome Scale Extended (GOSE) and the Disability Rating Scale (DRS). A favorable outcome (GOSE 6-8) occurred in 71% of the patients from Group A versus 37% in Group B (p=0.007). The DRS score was significantly better in Group A (p=0.03). The ordinal logistic regression analysis was used to quantify the relationship between the type of rehabilitation chain and the GOSE. A better GOSE outcome was found in patients from Group A (unadjusted OR 3.25 and adjusted OR 2.78, respectively). These results support the hypothesis that better functional outcome occurs in patients who receive early onset and a continuous chain of rehabilitation.     

Increased inattentional blindness in severe traumatic brain injury: evidence for reduced distractibility?

Primary objective: To examine the role of selective attention and visual perception in medicating inattentional blindness in a severe traumatic brain injured sample.

Research design: Cross-sectional design with age and education matched control sample.

Methods and procedures: Twenty participants with severe traumatic brain injury (n = 10) and matched controls (n = 10) completed a series of tests of focused attention (Stroop test), divided attention (Trail Making Test), visual perception (Visual Object and Space Perception Battery) and two tasks of inattentional blindness.

Main outcomes and results: The group with severe TBI were significantly slower on the Stroop test and TMT and displayed significantly elevated Stroop interference and TMT ratio scores. On the inattentional blindness tasks, fewer TBI participants identified a distracting stimulus.

Conclusion: The results indicate severe TBI is associated with deficits to focused and divided attention with the finding of a potentially more debilitating impairment arising from reduced distractibility following severe TBI.     

Do long-term results justify decompressive craniectomy after severe traumatic brain injury?

OBJECT: A decompressive craniectomy can be a life-saving procedure to relieve critically increased intracranial pressure. The survival of a patient is important as well as the subsequent and long-term quality of life. In this paper the authors' goal was to investigate whether long-term clinical results justify the use of a decompressive craniectomy. METHODS: Thirty-three patients (20 males and 13 females) with a mean age of 36.3 years (range 13-60 years) with severe traumatic brain injury (Grades III and IV) and subsequent massive brain swelling were examined. For postoperative assessment the Barthel Index was used. A surgical intervention was based on the following criteria: 1) The intracranial pressure could not be controlled by conservative treatment and constantly exceeded 30 mm Hg (cerebral perfusion pressure<50 mm Hg). 2) Transcranial Doppler ultrasonography revealed only a systolic flow pattern or systolic peaks. 3) There were no other major injuries. 4) The patient was not older than 60 years. RESULTS: One-fifth of all patients died and one-fifth remained in a vegetative state. Mild deficits were seen in 6 of 33 patients. A full rehabilitation (Barthel Index 90-100) was achieved in 13 patients (39.4%). Five patients could resume their former occupation, and another 4 had to change jobs. CONCLUSIONS: Age remains to be one of the most important exclusion factors. Decompressive craniectomy provided good clinical results in nearly 40% of patients who were otherwise most likely to die. Therefore, long-term results justify the use of decompressive craniectomy in this case series.     

Significance of serum neuron-specific enolase in patients with acute traumatic brain injury

OBJECTIVE: To study the association between serum neuron-specific enolase (NSE) and the extent of brain damage and the outcome after acute traumatic brain injury (TBI). METHODS: The release patterns of serum NSE in 78 patients after acute TBI were analyzed by using the enzyme linked immunosorbent assay. The levels of NSE were compared with Glasgow coma scale, the category of brain injury and the outcome after 6 months of injury. RESULTS: There were different NSE values in patients with minor (12.96 microg/L+/-2.39 microg/L), moderate (23.44 microg/L+/-5.33 microg/L) and severe brain injury (42.68 microg/L+/-4.57 microg/L). After severe TBI, the concentration of NSE in patients with epidural hematomas was 13.38 microg/L+/-4.01 microg/L, 24.03 microg/L+/-2.85 microg/L in brain contusion without surgical intervention group, 55.20 microg/L+/-6.35 microg/L in brain contusion with surgical intervention group, and 83.85 microg/L+/-15.82 microg/L in diffuse brain swelling group. There were close correlations between NSE values and Glasgow coma scale (r=-0.608, P<0.01) and the extent of brain injury (r=0.75, P<0.01). Patients with poor outcome had significantly higher initial and peak NSE values than those with good outcome (66.40 microg/L+/-9.46 microg/L, 94.24 microg/L+/-13.75 microg/L vs 32.16 microg/L+/-4.21 microg/L, 34.08 microg/L+/-4.40 microg/L, P<0.01, respectively). Initial NSE values were negatively related to the outcome (r=-0.501, P<0.01). Most patients with poor outcomes had persisting or secondary elevated NSE values. CONCLUSIONS: Serum NSE is one of the valuable neurobiochemical markers for assessment of the severity of brain injury and outcome prediction.     

Gender and traumatic brain injury: do the sexes fare differently?

Objective: To examine the relationship between gender and cognitive recovery 1 year following traumatic brain injury (TBI).

Methods: Patients with blunt TBI were identified from the TBI Model Systems of Care National Database, multi-centre cohort study. The included patients (n = 325) were 16-45 years at injury, admitted to an acute care facility within 24 hours, received inpatient rehabilitation, had documented admission Glasgow Coma Scale (GCS) scores, completed neuropsychological follow-up 1 year post-injury and did not report pre-morbid learning problems. Multivariate analyses of variance examined the unadjusted association between gender and six cognitive domains examining attention/working memory, verbal memory, language, visual analytic skills, problem-solving and motor functioning. Analyses of covariance models were constructed to determine if confounding factors biased the observed associations.

Results: Females performed significantly better than males on tests of attention/working memory and language. Males outperformed females in visual analytic skills. Gender remained significantly associated with performance in these areas when controlling for confounding variables.

Conclusions: These results suggest a better cognitive recovery of females than males following TBI. However, future studies need to include non-TBI patients to control for possible pre-injury gender-related differences, as well as to conduct extended follow-ups to determine the stability of the observed differences.