Galvos smegenų trauminių subdurinių higromų diagnostika ir gydymo taktikos pasirinkimas

Laimutis Kalasauskas, Juozas Šidiškis, Rimantas VilcinisKauno medicinos universiteto klinikų Neurochirurgijos klinika,Eivenių g. 2, Kaunas LT-3007El paštas: [email protected] Įvadas / tikslas Trauminės subdurinės higromos vis dažniau pasitaiko neurochirurgijos praktikoje. Jų skaičius per pastaruosius penkerius metus kasmet didėja, nes didėja ir traumų skaičius. Chirurgų pasirenkama gydymo taktika, nustačius subdurinę higromą, dažnai skiriasi. Šiuolaikinės diagnostikos priemonės ne visada leidžia iš karto pasirinkti tinkamą gydymo metodą. Dėl lėtai ryškėjančios smegenų kompresijos kompiuterinės tomografijos (KT) ir transkranijinės doplerografijos (TKD) tyrimai kartojami po kelis kartus, kadangi negaunama pakankamai informacijos gydymo metodui pasirinkti. Pagrindinis šio darbo tikslas – nustatyti taikytų tyrimo metodų diagnostinę reikšmę ir chirurginio gydymo indikacijas, sukurti trauminių subdurinių higromų diagnostikos ir gydymo algoritmą. Metodai Straipsnyje pateikiami 98 ligonių, gydytų Kauno medicinos universiteto klinikų Neurochirurgijos klinikoje nuo trauminių subdurinių higromų 1997–2001 metais, tyrimo ir gydymo retrospektyvinės analizės duomenys. Daugiausia dėmesio kreipėme į diagnostikos metodų įtaką pasirenkant konservatyvų ar chirurginį gydymo metodą. Rezultatai KMUK 1997–2001 metais trauminės subdurinės higromos buvo nustatytos 98 ligoniams, kurių dauguma (88,8%) buvo vyrai. Ligonių amžiaus vidurkis – 54,4±17,8 metų. Dažniausia traumos priežastis buvo kritimas (30,6%) arba eismo trauma (25,5%). Pagal KT duomenis 68 (69,4%) ligonių higromos storis buvo 6–11 mm. Aštuonių (8,16%) ligonių higromos tūris dinamiškai padidėjo. Kiek dažniau iš KT duomenų nustatytos abipusės higromos – 53 (54,1%) ligoniams. Vyravo bendrieji smegenų pažeidimo simptomai, tačiau 39 (42,9%) ligoniams buvo židininių simptomų. 45 (45,9%) ligoniai buvo ištirti TKD, bet tik 18 (40%) iš jų nustatytas padidėjęs Goslingo pulsacijos indeksas (p > 0,05). Paaiškėjo, kad vyresnio amžiaus ligonių higromos storis buvo didesnis (p < 0,01). Vyresnių kaip 60 metų ligonių jos buvo vidutiniškai 2,07 mm storesnės. Vidutinis laikas nuo traumos iki higromos nustatymo buvo 12,5 paros. Operuotas 91 (92,8%) ligonis, konservatyviai gydyti 7 (7,2%) ligoniai. Dauguma ligonių, t. y. 51 (52%), buvo operuoti pirmą savaitę po traumos, o 27 (27,5%) – 1–3 parą po traumos. Išvados Tik klinikinių simptomų ir kompleksinių tyrimų visuma bei ligos dinamika gali nulemti chirurginio gydymo metodo pasirinkimą. Gauti rezultatai rodo, kad ligonių amžius turi įtakos higromos storiui, tačiau statistiškai patikimo smegenų atrofijos ryšio su gydymo taktika ar gydymo rezultatais nenustatėme. Gydymo baigtį lėmė pirminio galvos smegenų pažeidimo laipsnis. Prasminiai žodžiai: trauminė subdurinė higroma, diagnostika, chirurginis gydymas. Posttraumatic subdural hygroma diagnosis and treatment tactic Laimutis Kalasauskas, Juozas Šidiškis, Rimantas Vilcinis Background / objective This study highlights the growing rate of patients, diagnostic problems and treatment tactics in cases of traumatic subdural hygroma. Patients and method A total of 98 patients were treated with traumatic subdural hygroma (SDH) at the Kaunas Medical University Neurosurgical Clinic (Lithuania) during the last five years. 91 patients were operated on after a complex of diagnostic examination, including Computed Tomography (CT), Transcranial Doplerography (TCD), neuroophtalmological and otoneurological examination, also the lumbar puncture. Results The lesion was detected on the initial CT scans in each of 98 cases of SDH (male 88.8% and female 11.2%). The mean age of patients was 54.4 years. Most injuries were attributed to traffic injuries (25.5%) and to falling down traumas (30.6%). We detected focal lesions in 39 (42.9%) cases. SDH 6–11 mm thick was found in 68 (69.4%) cases on CT scans, but increased in size only in 8 (8.16%) cases on repeated CT scans. 45 (45.9%) patients with traumatic SDH were examined by TCD, but only in 18 (40%) cases the increase of the Gosling pulsatility index was observed (p > 0,05). The mean interval from injury to diagnosis was 12.5 days. Only 7 (7.2%) patients were managed conservatively and 91 (92.8%) were operated on. 27 (27.5%) patients were operated on 1–3 days after injury and 51 (52%) during the first week. Conclusions We had found that SDH was on average by 2.07 mm wider in patients older than 60 years. The main indications for surgery were the complex of clinical signs, thickness of subdural hygroma in Computed Tomography (CT) and the dynamics of intracranial hipertension signs. The size of SDH was not the main indication for surgery. The outcomes depended on the severity of primary brain injury, but not on the SDH itself. Keywords: subdural hygroma, diagnosis, surgical treatmen

Low-resolution pressure reactivity index and its derived optimal cerebral perfusion pressure in adult traumatic brain injury: a CENTER-TBI study

Abstract: Background: After traumatic brain injury (TBI), brain tissue can be further damaged when cerebral autoregulation is impaired. Managing cerebral perfusion pressure (CPP) according to computed “optimal CPP” values based on cerebrovascular reactivity indices might contribute to preventing such secondary injuries. In this study, we examined the discriminative value of a low-resolution long pressure reactivity index (LPRx) and its derived “optimal CPP” in comparison to the well-established high-resolution pressure reactivity index (PRx). Methods: Using the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset, the association of LPRx (correlation between 1-min averages of intracranial pressure and arterial blood pressure over a moving time frame of 20 min) and PRx (correlation between 10-s averages of intracranial pressure and arterial blood pressure over a moving time frame of 5 min) to outcome was assessed and compared using univariate and multivariate regression analysis. “Optimal CPP” values were calculated using a multi-window algorithm that was based on either LPRx or PRx, and their discriminative ability was compared. Results: LPRx and PRx were both significant predictors of mortality in univariate and multivariate regression analysis, but PRx displayed a higher discriminative ability. Similarly, deviations of actual CPP from “optimal CPP” values calculated from each index were significantly associated with outcome in univariate and multivariate analysis. “Optimal CPP” based on PRx, however, trended towards more precise predictions. Conclusions: LPRx and its derived “optimal CPP” which are based on low-resolution data were significantly associated with outcome after TBI. However, they did not reach the discriminative ability of the high-resolution PRx and its derived “optimal CPP.” Nevertheless, LPRx might still be an interesting tool to assess cerebrovascular reactivity in centers without high-resolution signal monitoring. Trial registration: ClinicalTrials.gov Identifier: NCT02210221. First submitted July 29, 2014. First posted August 6, 2014

Evaluation of the relationship between slow-waves of intracranial pressure, mean arterial pressure and brain tissue oxygen in TBI: a CENTER-TBI exploratory analysis

Abstract: Brain tissue oxygen (PbtO2) monitoring in traumatic brain injury (TBI) has demonstrated strong associations with global outcome. Additionally, PbtO2 signals have been used to derive indices thought to be associated with cerebrovascular reactivity in TBI. However, their true relationship to slow-wave vasogenic fluctuations associated with cerebral autoregulation remains unclear. The goal of this study was to investigate the relationship between slow-wave fluctuations of intracranial pressure (ICP), mean arterial pressure (MAP) and PbtO2 over time. Using the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) high resolution ICU sub-study cohort, we evaluated those patients with recorded high-frequency digital intra-parenchymal ICP and PbtO2 monitoring data of a minimum of 6 h in duration. Digital physiologic signals were processed for ICP, MAP, and PbtO2 slow-waves using a moving average filter to decimate the high-frequency signal. The first 5 days of recording were analyzed. The relationship between ICP, MAP and PbtO2 slow-waves over time were assessed using autoregressive integrative moving average (ARIMA) and vector autoregressive integrative moving average (VARIMA) modelling, as well as Granger causality testing. A total of 47 patients were included. The ARIMA structure of ICP and MAP were similar in time, where PbtO2 displayed different optimal structure. VARIMA modelling and IRF plots confirmed the strong directional relationship between MAP and ICP, demonstrating an ICP response to MAP impulse. PbtO2 slow-waves, however, failed to demonstrate a definite response to ICP and MAP slow-wave impulses. These results raise questions as to the utility of PbtO2 in the derivation of cerebrovascular reactivity measures in TBI. There is a reproducible relationship between slow-wave fluctuations of ICP and MAP, as demonstrated across various time-series analytic techniques. PbtO2 does not appear to reliably respond in time to slow-wave fluctuations in MAP, as demonstrated on various VARIMA models across all patients. These findings suggest that PbtO2 should not be utilized in the derivation of cerebrovascular reactivity metrics in TBI, as it does not appear to be responsive to changes in MAP in the slow-waves. These findings corroborate previous results regarding PbtO2 based cerebrovascular reactivity indices

Compensatory-reserve-weighted intracranial pressure versus intracranial pressure for outcome association in adult traumatic brain injury: a CENTER-TBI validation study

Abstract: Background: Compensatory-reserve-weighted intracranial pressure (wICP) has recently been suggested as a supplementary measure of intracranial pressure (ICP) in adult traumatic brain injury (TBI), with a single-center study suggesting an association with mortality at 6 months. No multi-center studies exist to validate this relationship. The goal was to compare wICP to ICP for association with outcome in a multi-center TBI cohort. Methods: Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived ICP and wICP (calculated as wICP = (1 − RAP) × ICP; where RAP is the compensatory reserve index derived from the moving correlation between pulse amplitude of ICP and ICP). Various univariate logistic regression models were created comparing ICP and wICP to dichotomized outcome at 6 to 12 months, based on Glasgow Outcome Score—Extended (GOSE) (alive/dead—GOSE ≥ 2/GOSE = 1; favorable/unfavorable—GOSE 5 to 8/GOSE 1 to 4, respectively). Models were compared using area under the receiver operating curves (AUC) and p values. Results: wICP displayed higher AUC compared to ICP on univariate regression for alive/dead outcome compared to mean ICP (AUC 0.712, 95% CI 0.615–0.810, p = 0.0002, and AUC 0.642, 95% CI 0.538–746, p < 0.0001, respectively; no significant difference on Delong’s test), and for favorable/unfavorable outcome (AUC 0.627, 95% CI 0.548–0.705, p = 0.015, and AUC 0.495, 95% CI 0.413–0.577, p = 0.059; significantly different using Delong’s test p = 0.002), with lower wICP values associated with improved outcomes (p < 0.05 for both). These relationships on univariate analysis held true even when comparing the wICP models with those containing both ICP and RAP integrated area under the curve over time (p < 0.05 for all via Delong’s test). Conclusions: Compensatory-reserve-weighted ICP displays superior outcome association for both alive/dead and favorable/unfavorable dichotomized outcomes in adult TBI, through univariate analysis. Lower wICP is associated with better global outcomes. The results of this study provide multi-center validation of those seen in a previous single-center study

Descriptive analysis of low versus elevated intracranial pressure on cerebral physiology in adult traumatic brain injury: a CENTER-TBI exploratory study

Funder: University of CambridgeAbstract: Background: To date, the cerebral physiologic consequences of persistently elevated intracranial pressure (ICP) have been based on either low-resolution physiologic data or retrospective high-frequency data from single centers. The goal of this study was to provide a descriptive multi-center analysis of the cerebral physiologic consequences of ICP, comparing those with normal ICP to those with elevated ICP. Methods: The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) High-Resolution Intensive Care Unit (HR-ICU) sub-study cohort was utilized. The first 3 days of physiologic recording were analyzed, evaluating and comparing those patients with mean ICP 20 mmHg. Various cerebral physiologic parameters were derived and evaluated, including ICP, brain tissue oxygen (PbtO2), cerebral perfusion pressure (CPP), pulse amplitude of ICP (AMP), cerebrovascular reactivity, and cerebral compensatory reserve. The percentage time and dose above/below thresholds were also assessed. Basic descriptive statistics were employed in comparing the two cohorts. Results: 185 patients were included, with 157 displaying a mean ICP below 15 mmHg and 28 having a mean ICP above 20 mmHg. For admission demographics, only admission Marshall and Rotterdam CT scores were statistically different between groups (p = 0.017 and p = 0.030, respectively). The high ICP group displayed statistically worse CPP, PbtO2, cerebrovascular reactivity, and compensatory reserve. The high ICP group displayed worse 6-month mortality (p < 0.0001) and poor outcome (p = 0.014), based on the Extended Glasgow Outcome Score. Conclusions: Low versus high ICP during the first 72 h after moderate/severe TBI is associated with significant disparities in CPP, AMP, cerebrovascular reactivity, cerebral compensatory reserve, and brain tissue oxygenation metrics. Such ICP extremes appear to be strongly related to 6-month patient outcomes, in keeping with previous literature. This work provides multi-center validation for previously described single-center retrospective results

Cerebrovascular reactivity is not associated with therapeutic intensity in adult traumatic brain injury: a CENTER-TBI analysis

Abstract: Background: Impaired cerebrovascular reactivity in adult traumatic brain injury (TBI) is known to be associated with poor outcome. However, there has yet to be an analysis of the association between the comprehensively assessed intracranial hypertension therapeutic intensity level (TIL) and cerebrovascular reactivity. Methods: Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived pressure reactivity index (PRx) as the moving correlation coefficient between slow-wave in ICP and mean arterial pressure, updated every minute. Mean daily PRx, and daily % time above PRx of 0 were calculated for the first 7 days of injury and ICU stay. This data was linked with the daily TIL-Intermediate scores, including total and individual treatment sub-scores. Daily mean PRx variable values were compared for each TIL treatment score via mean, standard deviation, and the Mann U test (Bonferroni correction for multiple comparisons). General fixed effects and mixed effects models for total TIL versus PRx were created to display the relation between TIL and cerebrovascular reactivity. Results: A total of 249 patients with 1230 ICU days of high frequency physiology matched with daily TIL, were assessed. Total TIL was unrelated to daily PRx. Most TIL sub-scores failed to display a significant relationship with the PRx variables. Mild hyperventilation (p < 0.0001), mild hypothermia (p = 0.0001), high levels of sedation for ICP control (p = 0.0001), and use vasopressors for CPP management (p < 0.0001) were found to be associated with only a modest decrease in mean daily PRx or % time with PRx above 0. Conclusions: Cerebrovascular reactivity remains relatively independent of intracranial hypertension therapeutic intensity, suggesting inadequacy of current TBI therapies in modulating impaired autoregulation. These findings support the need for investigation into the molecular mechanisms involved, or individualized physiologic targets (ICP, CPP, or Co2) in order to treat dysautoregulation actively

Quality indicators for patients with traumatic brain injury in European intensive care units

Background: The aim of this study is to validate a previously published consensus-based quality indicator set for the management of patients with traumatic brain injury (TBI) at intensive care units (ICUs) in Europe and to study its potential for quality measur

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe

Purpose: To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers. Methods: This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers. Results: A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13–15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatme

Machine learning algorithms performed no better than regression models for prognostication in traumatic brain injury

Objective: We aimed to explore the added value of common machine learning (ML) algorithms for prediction of outcome for moderate and severe traumatic brain injury. Study Design and Setting: We performed logistic regression (LR), lasso regression, and ridge regression with key baseline predictors in the IMPACT-II database (15 studies, n = 11,022). ML algorithms included support vector machines, random forests, gradient boosting machines, and artificial neural networks and were trained using the same predictors. To assess generalizability of predictions, we performed internal, internal-external, and external validation on the recent CENTER-TBI study (patients with Glasgow Coma Scale <13, n = 1,554). Both calibration (calibration slope/intercept) and discrimination (area under the curve) was quantified. Results: In the IMPACT-II database, 3,332/11,022 (30%) died and 5,233(48%) had unfavorable outcome (Glasgow Outcome Scale less than 4). In the CENTER-TBI study, 348/1,554(29%) died and 651(54%) had unfavorable outcome. Discrimination and calibration varied widely between the studies and less so between the studied algorithms. The mean area under the curve was 0.82 for mortality and 0.77 for unfavorable outcomes in the CENTER-TBI study. Conclusion: ML algorithms may not outperform traditional regression approaches in a low-dimensional setting for outcome prediction after moderate or severe traumatic brain injury. Similar to regression-based prediction models, ML algorithms should be rigorously validated to ensure applicability to new populations

Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

INTRODUCTION: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. METHODS: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. RESULTS: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. CONCLUSION: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches