Background
Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical ...data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty.
Aim
To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities.
Methods
A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants.
Results
Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence.
Conclusion
The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
Background: Patients who present with central nervous system (CNS) hemorrhage while on anticoagulation (AC) for thromboembolic (TE) risk factors are a challenge to manage. Objective: We sought to ...inform decisions surrounding the timing and intensity of AC resumption by performing a systematic review. Methods: Three reviewers screened publications from Medline and EMBASE and extracted data. Hemorrhagic and TE adverse events that occurred subsequent to the index hemorrhage were recorded, as was their timing relative to presentation and covariates that might influence their occurrence. Results: Data were extracted from 63 publications detailing 492 patients; 7.7% of patients experienced hemorrhagic complications and 6.1% experienced TE complications. Hemorrhagic complications were more common within 72 h of presentation while TE complications were more common thereafter. Patients restarted on AC after 72 h were significantly more likely to have a TE complication (P = 0.006) and those restarted before 72 h were more likely to hemorrhage (P = 0.0727). Factors associated with re‐hemorrhage included younger age, traumatic cause, subdural hematomas and failure to reverse AC. TE complications were more common in younger patients and those with spinal hemorrhage, multiple hemorrhages, and non‐traumatic causes of the index hemorrhage. Re‐initiation of AC at a lower intensity also significantly increased the risk of TE complications. Interpretation: Our results suggest that it may be prudent to re‐initiate AC earlier than previously thought, with the timing and intensity modified based on predictors of TE and hemorrhagic complications. These findings must be explored in a prospective study because of limitations inherent to the analyzed studies.
Impaired cerebrovascular reactivity in adult moderate and severe traumatic brain injury (TBI) is known to be associated with worse global outcome at 6–12 months. As technology has improved over the ...past decades, monitoring of cerebrovascular reactivity has shifted from intermittent measures, to experimentally validated continuously updating indices at the bedside. Such advances have led to the exploration of individualised physiologic targets in adult TBI management, such as optimal cerebral perfusion pressure (CPP) values, or CPP limits in which vascular reactivity is relatively intact. These targets have been shown to have a stronger association with outcome compared with existing consensus-based guideline thresholds in severe TBI care. This has sparked ongoing prospective trials of such personalised medicine approaches in adult TBI. In this narrative review paper, we focus on the concept of cerebral autoregulation, proposed mechanisms of control and methods of continuous monitoring used in TBI. We highlight multimodal cranial monitoring approaches for continuous cerebrovascular reactivity assessment, physiologic and neuroimaging correlates, and associations with outcome. Finally, we explore the recent ‘state-of-the-art’ advances in personalised physiologic targets based on continuous cerebrovascular reactivity monitoring, their benefits, and implications for future avenues of research in TBI.
(Lancet. 2018;391:1197–204)Among patients who undergo lumbar puncture, up to 35% return to the hospital with a postdural puncture headache, which is caused by continuing leakage of the cerebrospinal ...fluid (CSF) from the dural defect created by the spinal needle. Conventional needles are most frequently used in clinical practice by nonanesthesiologists and have a sharp slanted tip designed to cut through the dura with a distal opening for injection of drugs or collection of CSF. As these needles cut through tissues, they cause irregular lacerations that can increase the potential for CSF leakage. In contrast, atraumatic needles are blunt with a closed pencil point tip and a side port for drug injection or CSF collection. They separate and dilate dural fibers rather than cutting through the fibers; thus they have been postulated to reduce the incidence of postdural puncture headache because they limit the leakage of CSF after lumbar puncture. Although atraumatic needles are now commonly used by anesthesiologists for spinal anesthesia, they are infrequently used by other clinicians as they seem unaware of their existence. This systematic review and meta-analysis of randomized controlled trials was performed to compare atraumatic and conventional lumbar puncture needles.
Current accepted cerebrovascular reactivity indices suffer from the need of high frequency data capture and export for post-acquisition processing. The role for minute-by-minute data in ...cerebrovascular reactivity monitoring remains uncertain. The goal was to explore the statistical time-series relationships between intra-cranial pressure (ICP), mean arterial pressure (MAP) and pressure reactivity index (PRx) using both 10-s and minute data update frequency in TBI. Prospective data from 31 patients from 3 centers with moderate/severe TBI and high-frequency archived physiology were reviewed. Both 10-s by 10-s and minute-by-minute mean values were derived for ICP and MAP for each patient. Similarly, PRx was derived using 30 consecutive 10-s data points, updated every minute. While long-PRx (L-PRx) was derived via similar methodology using minute-by-minute data, with L-PRx derived using various window lengths (5, 10, 20, 30, 40, and 60 min; denoted L-PRx_5, etc.). Time-series autoregressive integrative moving average (ARIMA) and vector autoregressive integrative moving average (VARIMA) models were created to analyze the relationship of these parameters over time. ARIMA modelling, Granger causality testing and VARIMA impulse response function (IRF) plotting demonstrated that similar information is carried in minute mean ICP and MAP data, compared to 10-s mean slow-wave ICP and MAP data. Shorter window L-PRx variants, such as L-PRx_5, appear to have a similar ARIMA structure, have a linear association with PRx and display moderate-to-strong correlations (r ~ 0.700, p < 0.0001 for each patient). Thus, these particular L-PRx variants appear closest in nature to standard PRx. ICP and MAP derived via 10-s or minute based averaging display similar statistical time-series structure and co-variance patterns. PRx and L-PRx based on shorter windows also behave similarly over time. These results imply certain L-PRx variants may carry similar information to PRx in TBI.
Survival from significant closed head injury (CHI) is frequently associated with cognitive defects, physical impairment, personality change, interpersonal difficulty and, in general, some degree of ...social dependence. Here we report a multidimensional assessment of quality of life of a sample of 131 male head-injury patients suffering a range of severities of insult with specific emphasis on vocational outcome. Of those patients who sustained a severe injury and were employed full-time prior to the CHI, only 55% were able to return to this level of employment. No differences were found between the moderate and severe groups in pre- or post-CHI occupational status, as measured by the Blishen (1967) quantitative social economic index, although both groups declined from pre- to post-CHI. Lower post-CHI occupational status was associated with lower GCS on admission and longer lengths of post-traumatic amnesia, with patient self-report of physical, cognitive and psychosocial difficulties, including spousal reports of confusion, belligerance, verbal expansiveness and the decreased ability to perform socially-expected activities. Stepwise multiple regression analysis accounted for 38% of variance in post-injury vocational status, with lower pre-injury vocational status, greater age, high physical and psychological difficulties and lower admission Glasgow Coma Scale score variables forming the regression equation. Implications are discussed in terms of rehabilitation issues, including vocational programming and planning.
A 41-year-old man presented with bilateral posterior cerebral artery infarcts. He had visual object agnosia and prosopagnosia with preservation of reading abilities. There was also defective visual ...memory, topographic orientation, and color perception, as well as simultanagnosia. From the clinical facts and CT findings, it was postulated that bilateral visual-limbic disconnection accounted for the patient's visual agnosia and related disturbances.
Research has begun to identify early markers that predict survival after traumatic brain injury. In this study, trauma and biochemical indicators of severity were used to predict quality of life in ...61 adults with traumatic brain injury and no damage to other organ systems. Severity markers available within 24 hours of injury were predictive of later psychosocial, behavioural and social role functioning. Multiple regression analyses demonstrated that the Glasgow Coma Scale, plasma glucose levels, leukocyte cell count and serum potassium concentration accounted for 12% to 66% of variance in certain measures of later quality of life. The importance of health-care resource allocation and psychosocial and behavioural intervention to the outcome after moderate traumatic brain injury is discussed.
This investigation examined the ability of the Luria-Nebraska Neuropsychological Battery (LNNB) to lateralize brain damage, since substantial statistical and methodological issues have been raised ...regarding the initial LNNB lateralization validation study. A comparison was then made of the ability of the LNNB and the Halstead-Reitan Neuropsychological Test Battery to lateralize brain damage. Both neuropsychological batteries were administered to 30 predominantly left- or right-hemisphere-damaged subjects (15 in each group) with discriminant analysis classification procedures demonstrating similar, above chance, accuracy in lateralizing cerebral dysfunction. Cross-validation of objective clinical rules designed to aid in LNNB test interpretation resulted in classification of brain damage and lateralization at levels below reported values from the test developer's laboratory. The limited role such simplistic rules have in assessment is discussed, as is the need to evaluate dimensions of test usefulness other than those related to gross diagnostic decisions (e.g., presence or laterality of brain damage) in determining the instrument of choice for clinical neuropsychological practice. More research is recommended to fully define the limits of the clinical utility of the LNNB.
Compiled by/Données recueillies par: E. Carusetta, L. Dumbovic, P. Gouthro, S. Guo, S. Hall, G. Hawryluk, V. Minhinnick, A. Stewart, C. Way, J. White, E. Wicklam, N. Wright, J. Young
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