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Continuum (Minneapolis, Minn.) Oct 2021Traumatic brain injury (TBI) encompasses a group of heterogeneous manifestations of a disease process with high neurologic morbidity and, for severe TBI, high... (Review)
Review
PURPOSE OF REVIEW
Traumatic brain injury (TBI) encompasses a group of heterogeneous manifestations of a disease process with high neurologic morbidity and, for severe TBI, high probability of mortality and poor neurologic outcomes. This article reviews TBI in neurocritical care, hence focusing on moderate and severe TBI, and includes an up-to-date review of the many variables to be considered in clinical care.
RECENT FINDINGS
With advances in medicine and biotechnology, understanding of the impact of TBI has substantially elucidated the distinction between primary and secondary brain injury. Consequently, care of TBI is evolving, with intervention-based modalities targeting multiple physiologic variables. Multimodality monitoring to assess intracranial pressure, cerebral oxygenation, cerebral metabolism, cerebral blood flow, and autoregulation is at the forefront of such advances.
SUMMARY
Understanding the anatomic and physiologic principles of acute brain injury is necessary in managing moderate to severe TBI. Management is based on the prevention of secondary brain injury from resultant trauma. Care of patients with TBI should occur in a dedicated critical care unit with subspecialty expertise. With the advent of multimodality monitoring and targeted biomarkers in TBI, patient outcomes have a higher probability of improving in the future.
Topics: Brain; Brain Injuries; Brain Injuries, Traumatic; Cerebrovascular Circulation; Humans; Intracranial Pressure; Monitoring, Physiologic
PubMed: 34618760
DOI: 10.1212/CON.0000000000001036 -
Handbook of Clinical Neurology 2015Traumatic brain injury, a leading cause of mortality and morbidity, is divided into three grades of severity: mild, moderate, and severe, based on the Glasgow Coma... (Review)
Review
Traumatic brain injury, a leading cause of mortality and morbidity, is divided into three grades of severity: mild, moderate, and severe, based on the Glasgow Coma Scale, the loss of consciousness, and the development of post-traumatic amnesia. Although mild traumatic brain injury, including concussion and subconcussion, is by far the most common, it is also the most difficult to diagnose and the least well understood. Proper recognition, management, and treatment of acute concussion and mild traumatic brain injury are the fundamentals of an emerging clinical discipline. It is also becoming increasingly clear that some mild traumatic brain injuries have persistent, and sometimes progressive, long-term debilitating effects. Evidence indicates that a single traumatic brain injury can precipitate or accelerate multiple age-related neurodegenerations, increase the risk of developing Alzheimer's disease, Parkinson's disease, and motor neuron disease, and that repetitive mild traumatic brain injuries can provoke the development of a tauopathy, chronic traumatic encephalopathy. Clinically, chronic traumatic encephalopathy is associated with behavioral changes, executive dysfunction, memory loss, and cognitive impairments that begin insidiously and progress slowly over decades. Pathologically, chronic traumatic encephalopathy produces atrophy of the frontal and temporal lobes, thalamus, and hypothalamus, septal abnormalities, and abnormal deposits of hyperphosphorylated tau (τ) as neurofibrillary tangles and disordered neurites throughout the brain. The incidence and prevalence of chronic traumatic encephalopathy and the genetic risk factors critical to its development are currently unknown. Chronic traumatic encephalopathy frequently occurs as a sole diagnosis, but may be associated with other neurodegenerative disorders, including Alzheimer's disease, Lewy body disease, and motor neuron disease. Currently, chronic traumatic encephalopathy can be diagnosed only at autopsy; however, promising efforts to develop imaging, spinal fluid, and peripheral blood biomarkers are underway to diagnose and monitor the course of disease in living subjects.
Topics: Animals; Brain; Brain Injuries; Encephalitis; Glasgow Coma Scale; Humans
PubMed: 25702209
DOI: 10.1016/B978-0-444-52892-6.00004-0 -
Journal of Internal Medicine Jun 2019Traumatic brain injury (TBI) is a major cause of acquired disability globally, and effective treatment methods are scarce. Lately, there has been increasing recognition... (Review)
Review
Traumatic brain injury (TBI) is a major cause of acquired disability globally, and effective treatment methods are scarce. Lately, there has been increasing recognition of the devastating impact of TBI resulting from sports and other recreational activities, ranging from primarily sport-related concussions (SRC) but also more severe brain injuries requiring hospitalization. There are currently no established treatments for the underlying pathophysiology in TBI and while neuro-rehabilitation efforts are promising, there are currently is a lack of consensus regarding rehabilitation following TBI of any severity. In this narrative review, we highlight short- and long-term consequences of SRCs, and how the sideline management of these patients should be performed. We also cover the basic concepts of neuro-critical care management for more severely brain-injured patients with a focus on brain oedema and the necessity of improving intracranial conditions in terms of substrate delivery in order to facilitate recovery and improve outcome. Further, following the acute phase, promising new approaches to rehabilitation are covered for both patients with severe TBI and athletes suffering from SRC. These highlight the need for co-ordinated interdisciplinary rehabilitation, with a special focus on cognition, in order to promote recovery after TBI.
Topics: Brain Injuries; Brain Injuries, Traumatic; Brain Injury, Chronic; Humans; Injury Severity Score; Patient Care Team
PubMed: 30883980
DOI: 10.1111/joim.12900 -
Current Opinion in Pediatrics Dec 2019To provide a summary of recent developments in the field of paediatric traumatic brain injury (TBI). (Review)
Review
PURPOSE OF REVIEW
To provide a summary of recent developments in the field of paediatric traumatic brain injury (TBI).
RECENT FINDINGS
The epidemiology of paediatric TBI with falling rates of severe TBI, and increasing presentations of apparently minor TBI. There is growing interest in the pathophysiology and outcomes of concussion in children, and detection of 'significant' injury, arising from concern about risks of long-term chronic traumatic encephalopathy. The role of decompressive craniectomy in children is still clarifying.
SUMMARY
Paediatric TBI remains a major public health issue.
Topics: Anisotropy; Brain Concussion; Brain Injuries; Brain Injuries, Traumatic; Child; Decompressive Craniectomy; Diffusion Tensor Imaging; Humans; Pediatrics
PubMed: 31693586
DOI: 10.1097/MOP.0000000000000820 -
Handbook of Clinical Neurology 2015Traumatic brain injury (TBI) is a growing problem in the US, with significant morbidity and economic implications. This diagnosis spans a wide breath of injuries from... (Review)
Review
Traumatic brain injury (TBI) is a growing problem in the US, with significant morbidity and economic implications. This diagnosis spans a wide breath of injuries from concussion to severe TBI. Thus, rehabilitation is equally diverse in its treatment strategies targeting those symptoms that are functionally limiting with the ultimate goal of independence and community reintegration. In severe TBI, rehabilitation can be lifelong. Acute care rehabilitation focuses on emergence from coma and prognostication of recovery. Therapeutic modalities and exercise, along with pharmacologic intervention, can target long-term motor and cognitive sequelae. Complications of severe TBI that are functionally limiting and impede therapy include heterotopic ossification, agitation, dysautonomia, and spasticity. In mild TBI, most patients recover quickly but education on repeat exposure is imperative, with the implications of consecutive injuries being potentially devastating. Furthermore, rehabilitation targets lingering symptoms including sleep disturbance, visuospatial deficits, headaches, and cognitive dysfunction. As research on the entire TBI population improves, commonalities in the disease process may emerge, helping rationalize therapeutic interventions and providing more robust targets for treatment.
Topics: Brain Injuries; Humans; Outcome Assessment, Health Care; Recovery of Function; Treatment Outcome
PubMed: 25702231
DOI: 10.1016/B978-0-444-52892-6.00026-X -
Handbook of Clinical Neurology 2013In childhood, traumatic brain injury (TBI) poses the unique challenges of an injury to a developing brain and the dynamic pattern of recovery over time, inflicted TBI... (Review)
Review
In childhood, traumatic brain injury (TBI) poses the unique challenges of an injury to a developing brain and the dynamic pattern of recovery over time, inflicted TBI and its medicolegal ramifications. The mechanisms of injury vary with age, as do the mechanisms that lead to the primary brain injury. As it is common, and is the leading cause of death and disability in the USA and Canada, prevention is the key, and we may need increased legislation to facilitate this. Despite its prevalence, there is an almost urgent need for research to help guide the optimal management and improve outcomes. Indeed, contrary to common belief, children with severe TBI have a worse outcome and many of the consequences present in teenage years or later. The treatment needs, therefore, to be multifaceted and starts at the scene of the injury and extends into the home and school. In order to do this, the care needs to be multidisciplinary from specialists with a specific interest in TBI and to involve the family, and will often span many decades.
Topics: Adolescent; Brain Injuries; Child; Humans; Injury Severity Score; Prevalence
PubMed: 23622299
DOI: 10.1016/B978-0-444-52910-7.00011-8 -
The Lancet. Neurology Aug 2008Traumatic brain injury (TBI) is a major health and socioeconomic problem that affects all societies. In recent years, patterns of injury have been changing, with more... (Review)
Review
Traumatic brain injury (TBI) is a major health and socioeconomic problem that affects all societies. In recent years, patterns of injury have been changing, with more injuries, particularly contusions, occurring in older patients. Blast injuries have been identified as a novel entity with specific characteristics. Traditional approaches to the classification of clinical severity are the subject of debate owing to the widespread policy of early sedation and ventilation in more severely injured patients, and are being supplemented with structural and functional neuroimaging. Basic science research has greatly advanced our knowledge of the mechanisms involved in secondary damage, creating opportunities for medical intervention and targeted therapies; however, translating this research into patient benefit remains a challenge. Clinical management has become much more structured and evidence based since the publication of guidelines covering many aspects of care. In this Review, we summarise new developments and current knowledge and controversies, focusing on moderate and severe TBI in adults. Suggestions are provided for the way forward, with an emphasis on epidemiological monitoring, trauma organisation, and approaches to management.
Topics: Adult; Brain Injuries; Guidelines as Topic; Humans
PubMed: 18635021
DOI: 10.1016/S1474-4422(08)70164-9 -
Neuropharmacology Feb 2019Mortality or severe disability affects the majority of patients after severe traumatic brain injury (TBI). Adherence to the brain trauma foundation guidelines has... (Review)
Review
Mortality or severe disability affects the majority of patients after severe traumatic brain injury (TBI). Adherence to the brain trauma foundation guidelines has overall improved outcomes; however, traditional as well as novel interventions towards intracranial hypertension and secondary brain injury have come under scrutiny after series of negative randomized controlled trials. In fact, it would not be unfair to say there has been no single major breakthrough in the management of severe TBI in the last two decades. One plausible hypothesis for the aforementioned failures is that by the time treatment is initiated for neuroprotection, or physiologic optimization, irreversible brain injury has already set in. We, and others, have recently developed predictive models based on machine learning from continuous time series of intracranial pressure and partial brain tissue oxygenation. These models provide accurate predictions of physiologic crises events in a timely fashion, offering the opportunity for an earlier application of targeted interventions. In this article, we review the rationale for prediction, discuss available predictive models with examples, and offer suggestions for their future prospective testing in conjunction with preventive clinical algorithms. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
Topics: Brain Injuries; Humans; Prognosis
PubMed: 29885419
DOI: 10.1016/j.neuropharm.2018.06.005 -
Current Neurology and Neuroscience... Aug 2019Over the last years, the focus of clinical and animal research in subarachnoid hemorrhage (SAH) shifted towards the early phase after the bleeding based on the... (Review)
Review
PURPOSE OF REVIEW
Over the last years, the focus of clinical and animal research in subarachnoid hemorrhage (SAH) shifted towards the early phase after the bleeding based on the association of the early injury pattern (first 72 h) with secondary complications and poor outcome. This phase is commonly referenced as early brain injury (EBI). In this clinical review, we intended to overview commonly used definitions of EBI, underlying mechanisms, and potential treatment implications.
RECENT FINDINGS
We found a large heterogeneity in the definition used for EBI comprising clinical symptoms, neuroimaging parameters, and advanced neuromonitoring techniques. Although specific treatments are currently not available, therapeutic interventions are aimed at ameliorating EBI by improving the energy/supply mismatch in the early phase after SAH. Future research integrating brain-derived biomarkers is warranted to improve our pathophysiologic understanding of EBI in order to ameliorate early injury patterns and improve patients' outcomes.
Topics: Animals; Brain Injuries; Early Diagnosis; Humans; Subarachnoid Hemorrhage; Terminology as Topic
PubMed: 31468197
DOI: 10.1007/s11910-019-0990-3 -
Continuum (Minneapolis, Minn.) Oct 2021This article reviews the pathophysiology and management of cerebral edema, brain compression, and elevated intracranial pressure (ICP). It also provides a brief... (Review)
Review
PURPOSE OF REVIEW
This article reviews the pathophysiology and management of cerebral edema, brain compression, and elevated intracranial pressure (ICP). It also provides a brief introduction to the concept of the glymphatic system and select cellular contributors to cerebral edema.
RECENT FINDINGS
Cerebral edema and brain compression should be treated in a tiered approach after the patient demonstrates a symptomatic indication to start treatment. All patients with acute brain injury should be treated with standard measures to optimize intracranial compliance and minimize risk of ICP elevation. When ICP monitors are used, therapies should target maintaining ICP at 22 mm Hg or less. Evidence exists that serial clinical examination and neuroimaging may be a reasonable alternative to ICP monitoring; however, clinical trials in progress may demonstrate advantages to advanced monitoring techniques. Early decompressive craniectomy and hypothermia are not neuroprotective in traumatic brain injury and should be reserved for situations refractory to initial medical interventions. Medical therapies that acutely lower plasma osmolality may lead to neurologic deterioration from osmotic cerebral edema, and patients with acute brain injury and renal or liver failure are at elevated risk.
SUMMARY
A tiered approach to the management of cerebral edema and brain compression can reduce secondary brain injury when implemented according to core physiologic principles. However, our knowledge of the pathophysiology of acute brain injury is incomplete, and the conceptual framework underlying decades of clinical management may need to be revised in response to currently evolving discoveries regarding the pathophysiology of acute brain injury.
Topics: Brain; Brain Edema; Brain Injuries; Humans; Intracranial Hypertension; Intracranial Pressure
PubMed: 34618757
DOI: 10.1212/CON.0000000000000988