A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol

Chesnut, Randall M.; Temkin, Nancy; Dikmen, Sureyya; Rondina, Carlos; Videtta, Walter; Petroni, Gustavo; Lujan, Silvia; Alanis, Victor; Falcão, Antônio Luis Eiras; Fuenta, Gustavo de la; González, Luis; Jibaja, Manuel; Lavarden, Arturo; Sandi, Freddy; Mérida, Roberto; Romero, Ricardo Fernández; Pridgeon, James; Barber, Jason; Machamer, Joan; Chaddock, Kelley

doi:10.1089/neu.2016.4472

Cited by 59 publications

(48 citation statements)

References 23 publications

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“…Abnormal pupillary reactivity is often used in clinical decision-making to predict intracranial hypertension in severe TBI [19,20]. Monitoring of pupillary function helps provide insight into secondary insults (e.g., high ICP), as sustained or new-onset pupillary abnormalities are associated with worse outcome [8].…”

Section: Discussionmentioning

confidence: 99%

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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Background: Elevated intracranial pressure (ICP) is frequent after traumatic brain injury (TBI) and may cause abnormal pupillary reactivity, which in turn is associated with a worse prognosis. Using automated infrared pupillometry, we examined the relationship between the Neurological Pupil index (NPi) and invasive ICP in patients with severe TBI. Methods: This was an observational cohort of consecutive subjects with severe TBI (Glasgow Coma Scale [GCS] < 9 with abnormal lesions on head CT) who underwent parenchymal ICP monitoring and repeated NPi assessment with the NPi-200® pupillometer. We examined NPi trends over time (four consecutive measurements over intervals of 6 h) prior to sustained elevated ICP > 20 mmHg. We further analyzed the relationship of cumulative abnormal NPi burden (%NPi values < 3 during total ICP monitoring time) with intracranial hypertension (ICHT)-categorized as refractory (ICHT-r; requiring surgical decompression) vs. non-refractory (ICHT-nr; responsive to medical therapy)-and with the 6-month Glasgow Outcome Score (GOS). Results: A total of 54 patients were studied (mean age 54 ± 21 years, 74% with focal injuries on CT), of whom 32 (59%) had ICHT. Among subjects with ICHT, episodes of sustained elevated ICP (n = 43, 172 matched ICP-NPi samples; baseline ICP [T − 6 h ] 14 ± 5 mmHg vs. ICPmax [T 0 h ] 30 ± 9 mmHg) were associated with a concomitant decrease of the NPi (baseline 4.2 ± 0.5 vs. 2.8 ± 1.6, p < 0.0001 ANOVA for repeated measures). Abnormal NPi values were more frequent in patients with ICHT-r (n = 17; 38 [3-96]% of monitored time vs. 1 [0-9]% in patients with ICHT-nr [n = 15] and 0.5 [0-10]% in those without ICHT [n = 22]; p = 0.007) and were associated with an unfavorable 6-month outcome (15 [1-80]% in GOS 1-3 vs. 0 [0-7]% in GOS 4-5 patients; p = 0.002). Conclusions: In a selected cohort of severe TBI patients with abnormal head CT lesions and predominantly focal cerebral injury, elevated ICP episodes correlated with a concomitant decrease of NPi. Sustained abnormal NPi was in turn associated with a more complicated ICP course and worse outcome.

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Section: Discussionmentioning

confidence: 99%

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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“…For the most part, efforts to implement and assess clinical protocols that are specific to low-resource environments have taken place in LMICs. [1394041] The feasibility of conducting such a study in a HIC, however, is limited. For example, although 60 million people live in rural areas of the U.S., the number of patients per center presenting with severe TBI is low.…”

Section: Discussionmentioning

confidence: 99%

Geographical disparity and traumatic brain injury in America: Rural areas suffer poorer outcomes

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Kheng

Carney

et al. 2019

Journal of Neurosciences in Rural Practice

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Introduction:Significant heterogeneity exists in traumatic brain injury (TBI) outcomes. In the United States, TBI remains a primary driver of injury-related mortality and morbidity. Prior work has suggested that disparity exists in rural areas; our objective was to evaluate potential differences in TBI mortality across urban and rural areas on a national scale.Methods:Age-adjusted TBI fatality rates were obtained at the county level across the U.S. from 2008 to 2014. To evaluate geography, urban influence codes (UIC) were also obtained at the county level. UIC codes range from 1 (most urban) to 12 (most rural). Metropolitan counties are defined as those with an UIC ≤2, while nonmetropolitan counties are defined as an UIC ≥3. County-level fatality rates and UIC classification were geospatially mapped. Linear regression was used to evaluate the change in TBI fatality rate at each category of UIC. The median TBI fatality rate was also compared between metropolitan and nonmetropolitan counties.Results:Geospatial analysis demonstrated higher fatality rates distributed among nonmetropolitan counties across the United States. The TBI fatality rate was 13.00 deaths per 100,000 persons higher in the most rural UIC category compared to the most urban UIC category (95% confidence interval 12.15, 13.86; P < 0.001). The median TBI rate for nonmetropolitan counties was significantly higher than metropolitan counties (22.32 vs. 18.22 deaths per 100,000 persons, P < 0.001).Conclusions:TBI fatality rates are higher in rural areas of the United States. Additional studies to evaluate the mechanisms and solutions to this disparity are warranted and may have implications for lower-and middle-income countries.

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“…Care for the ICE group was guided by a protocol based on the pretrial standard for care at the participating hospitals (for more information, see the description of treatment protocols in Ref. 17).…”

Section: Methodsmentioning

confidence: 99%

IMPACT and CRASH prognostic models for traumatic brain injury: external validation in a South-American cohort

et al. 2020

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ObjectiveTo develop a robust prognostic model, the more diverse the settings in which the system is tested and found to be accurate, the more likely it will be generalisable to untested settings. This study aimed to externally validate the International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization after Significant Head Injury (CRASH) models for low-income and middle-income countries using a dataset of patients with severe traumatic brain injury (TBI) from the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure study and a simultaneously conducted observational study.MethodA total of 550 patients with severe TBI were enrolled in the study, and 466 of those were included in the analysis. Patient admission characteristics were extracted to predict unfavourable outcome (Glasgow Outcome Scale: GOS<3) and mortality (GOS 1) at 14 days or 6 months.ResultsThere were 48% of the participants who had unfavourable outcome at 6 months and these included 38% who had died. The area under the receiver operating characteristic curve (AUC) values were 0.683–0.775 and 0.640–0.731 for the IMPACT and CRASH models respectively. The IMPACT CT model had the highest AUC for predicting unfavourable outcomes, and the IMPACT Lab model had the best discrimination for predicting 6-month mortality. The discrimination for both the IMPACT and CRASH models improved with increasing complexity of the models. Calibration revealed that there were disagreement between observed and predicted outcomes in the IMPACT and CRASH models.ConclusionThe overall performance of all IMPACT and CRASH models was adequate when used to predict outcomes in the dataset. However, some disagreement in calibration suggests the necessity for updating prognostic models to maintain currency and generalisability.

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A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol

Cited by 59 publications

References 23 publications

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Geographical disparity and traumatic brain injury in America: Rural areas suffer poorer outcomes

IMPACT and CRASH prognostic models for traumatic brain injury: external validation in a South-American cohort

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