Traumatic brain injury (TBI) is the leading cause of death and disability in children. Pediatric TBI is associated with several distinctive characteristics that differ from adults and are ...attributable to age-related anatomical and physiological differences, pattern of injuries based on the physical ability of the child, and difficulty in neurological evaluation in children. Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. Here a review of recent studies relevant to important issues in pediatric TBI is presented, and recent specific topics are also discussed. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of pediatric TBI.
Summary Background The decision of whether to treat incidental intracranial saccular aneurysms is complicated by limitations in current knowledge of their natural history. We combined individual ...patient data from prospective cohort studies to determine predictors of aneurysm rupture and to construct a risk prediction chart to estimate 5-year aneurysm rupture risk by risk factor status. Methods We did a systematic review and pooled analysis of individual patient data from 8382 participants in six prospective cohort studies with subarachnoid haemorrhage as outcome. We analysed cumulative rupture rates with Kaplan-Meier curves and assessed predictors with Cox proportional-hazard regression analysis. Findings Rupture occurred in 230 patients during 29 166 person-years of follow-up. The mean observed 1-year risk of aneurysm rupture was 1·4% (95% CI 1·1–1·6) and the 5-year risk was 3·4% (2·9–4·0). Predictors were age, hypertension, history of subarachnoid haemorrhage, aneurysm size, aneurysm location, and geographical region. In study populations from North America and European countries other than Finland, the estimated 5-year absolute risk of aneurysm rupture ranged from 0·25% in individuals younger than 70 years without vascular risk factors with a small-sized (<7 mm) internal carotid artery aneurysm, to more than 15% in patients aged 70 years or older with hypertension, a history of subarachnoid haemorrhage, and a giant-sized (>20 mm) posterior circulation aneurysm. By comparison with populations from North America and European countries other than Finland, Finnish people had a 3·6-times increased risk of aneurysm rupture and Japanese people a 2·8-times increased risk. Interpretation The PHASES score is an easily applicable aid for prediction of the risk of rupture of incidental intracranial aneurysms. Funding Netherlands Organisation for Health Research and Development.
Coagulopathy is a common sequela of traumatic brain injury. Consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability. In addition, fibrinolytic pathways are ...hyperactivated as a result of vascular endothelial cell damage in the injured brain. Coagulation and fibrinolytic parameters change dynamically to reflect these pathologies. Fibrinogen is consumed and degraded after injury, with fibrinogen concentrations at their lowest 3-6 h after injury. Hypercoagulability causes increased fibrinolytic activity, and plasma levels of D-dimer increase immediately after traumatic brain injury, reaching a maximum at 3 h. Owing to disseminated intravascular coagulation in the presence of fibrinolysis, the bleeding tendency is highest within the first 3 h after injury, and often a condition called "talk and deteriorate" occurs. In neurointensive care, it is necessary to measure coagulation and fibrinolytic parameters such as fibrinogen and D-dimer routinely to predict and prevent the development of coagulopathy and its negative outcomes. Currently, the only evidence-based treatment for traumatic brain injury with coagulopathy is tranexamic acid in the subset of patients with mild-to-moderate traumatic brain injury. Coagulation and fibrinolytic parameters should be closely monitored, and treatment should be considered on a patient-by-patient basis.
Japanese horseradish (wasabi) grows in very specific conditions, and recent environmental climate changes have damaged wasabi production. In addition, the optimal culture methods are not well known, ...and it is becoming increasingly difficult for incipient farmers to cultivate it. Chlorophyll a, b and carotenoid contents, as well as their allocation, could be an adequate indicator in evaluating its production and environmental stress; thus, developing an in situ method to monitor photosynthetic pigments based on reflectance could be useful for agricultural management. Besides original reflectance (OR), five pre-processing techniques, namely, first derivative reflectance (FDR), continuum-removed (CR), de-trending (DT), multiplicative scatter correction (MSC), and standard normal variate transformation (SNV), were compared to assess the accuracy of the estimation. Furthermore, five machine learning algorithms—random forest (RF), support vector machine (SVM), kernel-based extreme learning machine (KELM), Cubist, and Stochastic Gradient Boosting (SGB)—were considered. To classify the samples under different pH or sulphur ion concentration conditions, the end of the red edge bands was effective for OR, FDR, DT, MSC, and SNV, while a green-peak band was effective for CR. Overall, KELM and Cubist showed high performance and incorporating pre-processing techniques was effective for obtaining estimated values with high accuracy. The best combinations were found to be DT–KELM for chl a (RPD = 1.511–5.17, RMSE = 1.23–3.62 μg cm−2) and chl a:b (RPD = 0.73–3.17, RMSE = 0.13–0.60); CR–KELM for chl b (RPD = 1.92–5.06, RMSE = 0.41–1.03 μg cm−2) and chl a:car (RPD = 1.31–3.23, RMSE = 0.26–0.50); SNV–Cubist for car (RPD = 1.63–3.32, RMSE = 0.31–1.89 μg cm−2); and DT–Cubist for chl:car (RPD = 1.53–3.96, RMSE = 0.27–0.74).
Indocyanine green (ICG) is a cyanine dye useful for visualizing blood vessels; it has been developed for endoscopy and is used in skull base surgery. Endoscopy is widely used for hematoma removal ...after an intracerebral hemorrhage since it is minimally invasive and has a shorter operation time than craniotomy. However, with this technique the surgical field is limited and it is difficult to obtain an adequate orientation; thus, it is challenging to locate the bleeding point, and postoperative rebleeding has been reported. We performed intraoperative ICG near-infrared fluorescence imaging to locate the bleeding point. This purpose of this study was to evaluate the usefulness of ICG angiography during endoscopic hematoma removal in two patients, using two endoscope types and comparing their visualization of perforating branches during the procedure. ICG angiography was performed in two different cases of putaminal hemorrhage, using the SPIES NIR/ICG-System and IMAGE1 S Rubina (both KARL STORZ, Tuttlingen, Germany) at the intraoperative bleeding site. The intraoperative use of ICG allowed the clear visualization of the perforating branches and real-time confirmation of active bleeding. We could also distinguish an old hematoma from the active bleeding point. The IMAGE1 S Rubina has adequate brightness for contrast enhancement, allowing surgical manipulation simultaneously to the enhancement phase.ICG fluorescence angiography is useful to identify the damaged vessel and perform hemostasis. We expect other similar devices to be developed in the future, accompanied by flexible and thin rigid endoscopes.
We compared the treatment satisfaction of patients who had undergone surgery for tarsal tunnel syndrome (TTS) and carpal tunnel syndrome (CTS). We enrolled 44 patients in this study; 23 were operated ...for CTS and 21 for TTS. All patients had received surgery under a microscope and under local anesthesia. Using the numerical rating scale (NRS) for numbness/pain (range 0-10) we compared their preoperative outcome expectations with their satisfaction with our treatment 6 months after the operation. We also recorded their pre- and postoperative EuroQol 5-dimension 5-level (EQ-5D-5L) scale for their health-related quality of life (QOL). The subjective assessment of their QOL showed that it was significantly lower in TTS- than CTS patients both pre- and postoperatively. Six months after the operation, the NRS for symptoms and the (EQ-5D-5L) scale for the QOL were significantly improved in TTS- and CTS patients; however, these scores were significantly better after CTS- than TTS surgery. Also, the postoperative NRS was significantly lower in the CTS- than the TTS patients. Our comparison of the patients' expected- and actual surgical outcome showed that the result was better than expected after CTS- and TTS surgery; in CTS patients the difference was significant. Overall, CTS- were more satisfied than TTS patients with the treatment outcome. Satisfaction with the treatment was greater after CTS- than TTS surgery. TTS- experienced less symptom relief than CTS patients although the actual- exceeded the expected outcome in patients operated for TTS.
Abstract
BACKGROUND
Multiple cerebral aneurysms are encountered in approximately 15% to 35% of patients harboring unruptured cerebral aneurysms. It would be of clinical value to determine which of ...them is most likely to rupture.
OBJECTIVE
To characterize features of the ruptured aneurysm relative to other concomitant fellow aneurysms in patients with multiple cerebral aneurysms.
METHODS
From a total of 5720 patients who were prospectively registered in the Unruptured Cerebral Aneurysm Study in Japan, a subgroup of patients with multiple cerebral aneurysms who developed subarachnoid hemorrhage was extracted for this post hoc analysis. Intrapatient comparisons of each aneurysm were carried out using aneurysm-specific factors such as size, location, and shape to identify predictors of rupture among the fellow aneurysms in a patient with multiple cerebral aneurysms.
RESULTS
Twenty-five patients with 62 aneurysms were identified from the total cohort of 5720 patients. With the distinctiveness in size, which means the aneurysm was the single largest among the multiple aneurysms, the ruptured aneurysm in each case was discriminated from the other coexisting aneurysms with a sensitivity of 0.76 and specificity of 0.86.
CONCLUSION
Our results suggest that the largest aneurysm is likely to rupture among coexisting aneurysms in a patient with multiple cerebral aneurysms.
Crystal violet (CV) ink has been used as a skin marker worldwide. It has been reported to be useful for vessel wall visualization of microvascular anastomoses. Contrastingly, it has been found to be ...carcinogenic and inhibit migration and proliferation of venous cells. In some countries, its use in the medical field has been restricted. Therefore, it is necessary to consider alternatives to CV. In this present study, we compared the time required for the anastomosis of a 0.8-1 mm diameter vessel in the chicken wrist artery using CV and a CV-free dye (ethyl violet; EV). The surgeon, microscope, and anastomosis microsurgical tools were standardized for comparison. CV and EV were changed for each anastomosis. The same surgeon performed 30 anastomoses using each dye. No visually obvious differences were noted in the vascular transections with CV and EV. As per the results, no statistically significant difference was observed in the time required for anastomosis using CV and EV. EV conforming to California Proposition 65 may be an effective alternative to CV for vascular visualization of microvascular anastomoses. However, further studies on the effectiveness of the EV in clinical cases are needed.
Background: Initial management of severe traumatic brain injury is important and includes treatment decision-making and prediction of prognosis. We examined whether biomarkers at admission could be ...useful prognostic predictors. We focused on electrolytes and blood glucose, which can be measured easily at any facility and for which results can be obtained promptly, before those of other biomarkers, such as D-dimer. Methods: All trauma patients with head injuries treated at Chiba Hokusoh Hospital between 2014 and 2017 were investigated. Cases of multiple trauma accompanied by fatal trauma, hemorrhagic shock, or cardiopulmonary arrest, and pediatric cases, were excluded from this study. Blood gas data at the initial hospital visit were reviewed retrospectively. A poor outcome was defined as death during hospitalization or a vegetative state due to head injury. Factors related to poor outcomes were analyzed. Results: Of the 185 male and 79 female patients studied, 34 had poor outcomes. Poor outcome was significantly correlated with potassium (P = 0.003), glucose (P < 0.001), and glucose-to-potassium ratio (P < 0.001) at arrival. The odds ratio was 4.079 for a glucose-to-potassium ratio of ≥50. Conclusions: We evaluated blood gas data at the initial hospital visit, as these results can be obtained more quickly than those of other biomarkers assessed previously. Serum glucose-to-potassium ratio at admission may be a potential predictor of prognosis for severe traumatic brain injury.
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