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Traumatic brain injury (TBI) is recognized as the significant cause of mortality and morbidity in the world. To reduce unfavorable outcome in TBI patients, many researches have made much efforts for the innovation of TBI treatment. With the results from several basic and clinical studies, targeted temperature management (TTM) including therapeutic...
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... Animal experiments investigating ASDH have shown brain swelling after hematoma removal [84], while early preoperative TH reduced ischemia-reperfusion injury following surgical evacuation [85]. Early TH may therefore offer potential benefits in attenuating ischemia-reperfusion injury in patients requiring ASDH removal [86]. In existing RCTs, the benefits of early TH have also suggested for young patients with evacuated mass lesions, although individual RCTs included only a small number of eligible patients [44,45,55]. ...
Fever control is essential in patients with severe traumatic brain injury (TBI). The efficacy of therapeutic hypothermia (TH) in severe TBI has been investigated over the last few decades; however, in contrast to experimental studies showing benefits, no evidence of efficacy has been demonstrated in clinical practice. In this review, the mechanisms and history of hypothermia were briefly outlined, while the results of major randomized controlled trials (RCTs) and meta-analyses investigating TH for adult TBI are introduced and discussed. The retrieved meta-analyses showed conflicting results, with a limited number of studies indicating benefits of TH. Some studies have shown benefits of long-term TH compared with short-term TH. Although TH is effective at lowering elevated intracranial pressure (ICP), reduced ICP does not lead to favorable outcomes. Low-quality RCTs overestimated the benefits of TH, while high-quality RCTs showed no difference or worse outcomes with TH. RCTs assessing standardized TH quality demonstrated the benefits of TH. As TBI has heterogeneous and complicated pathologies, applying a uniform treatment may not be ideal. A meta-analysis of young patients who underwent early cooling and hematoma removal showed better TH results. TH should not be abandoned, and its optimal should be advocated on an individual basis.
... However, it is rare to perform TTM for trauma patients because hypothermia leads to coagulopathy and there is not enough evidence. There are some papers reporting the effectiveness of TTM for brain injury including traumatic cases [6,7]. They suggested that fever was associated with adverse outcomes and TTM might be effective especially for the ischemia-reperfusion pathophysiology of traumatic brain injury (TBI). ...
... On the other hand, fever may be associated with poor neurological prognosis, and TTM might improve it. There are scattered reports of its usefulness in patients with severe TBI [7]. To the best of our knowledge, this is the first reported case of TA which underwent TTM with a good neurological outcome. ...
Traumatic asphyxia (TA) is a rare condition due to severe crush injury to the upper abdomen or chest region. Elevated intrathoracic pressure causes impaired venous return, which damages the small vessels. Consciousness is reportedly lost in many TA cases. In the most severe cases, hypoxic encephalopathy occurs. Since TA patients usually have other traumatic complications such as thoracic or abdominal injury, the mortality rate of this syndrome is quite variable.
Hypothermia is a risk factor for mortality in trauma patients, and targeted temperature management (TTM) is rarely performed for trauma cases. There are scattered articles reporting the usefulness of TTM in severe traumatic brain injury. To our best knowledge, there have been no reports of TTM in TA cases. We herein report a TA case with decorticate rigidity having a good neurological outcome after TTM.
... By design, TIL does not encompass all facets of modern intensive care for TBI patients. Brain tissue oxygen tension (PbtO 2 ), 38 cerebral microdialysis, 39 and brain temperature 40 have emerged as multi-modal neuromonitoring targets that may affect ICU management in addition to ICP or CPP. Therefore, TIL should be interpreted not as general treatment intensity but rather as the intensity of ICP-directed therapy specifically. ...
Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified-through expert consensus-during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL(Basic)) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL(Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients (n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL(Basic) scores (TIL24 and TIL(Basic)24, respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL(Basic) scores by taking the first-week maximum (TILmax and TIL(Basic)max) and first-week median (TILmedian and TIL(Basic)median) of TIL24 and TIL(Basic)24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL(Basic)) and integrates the widest range of modern ICP treatments. TILmedian outperforms both TILmax and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TILmedian ≥ 7.5 and TILmax ≥ 14. The TIL24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL24 ≥ 9. The median scores of each TIL component therapy over increasing TIL24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL(Basic)max suffers from a strong statistical ceiling effect and only covers 17% (95% confidence interval [CI]: 16-18%) of the information in TILmax, TIL(Basic) should not be used instead of TIL for rating maximum treatment intensity. TIL(Basic)24 and TIL(Basic)median can be suitable replacements for TIL24 and TILmedian, respectively (with up to 33% [95% CI: 31-35%] information coverage) when full TIL assessment is infeasible. Accordingly, we derive numerical ranges for categorising TIL24 scores into TIL(Basic)24 scores. In conclusion, our results validate TIL across a spectrum of ICP management and monitoring approaches. TIL is a more sensitive surrogate for pathophysiology than ICP and thus can be considered an intermediate outcome after TBI.
... Unlike APOE e2 and e3, APOE e4 showed negative effects on the balance of calcium and excited amino acids, inflammatory response, and apoptosis, which might cause impairment of blood-brain barrier (BBB) permeability. 6,7,18,19,33,34 Therefore, we speculate that APOE e4 leads to a disorder in cerebral perfusion and cerebral oxygen metabolism by impairing BBB permeability, which ultimately influences the prognosis of TBI. ...
Objective:
To investigate the effects of the apolipoprotein E (APOE) gene on oxygen saturation and cerebral perfusion in the early stages of traumatic brain injury (TBI).
Methods:
This study included 136 consecutive TBI patients and 51 healthy individuals. The APOE genotypes of all subjects were determined using quantitative fluorescence polymerase chain reaction (QF-PCR). Regional cerebral oxygen saturation (rScO2) of patients with TBI and normal subjects was monitored using near-infrared spectroscopy (NIRS). Computed tomography (CT) perfusion was used to obtain cerebral perfusion in patients with TBI and normal subjects.
Results:
In the TBI group, the rScO2 of APOEε4 carriers (53.06 ± 6.87%) was significantly lower than that of non-carriers (58.19 ± 5.83%, p < 0.05). Meanwhile, the MTT of APOEε4 carriers (6.75 ± 1.30 s) was significantly longer than that of non-carriers (5.87 ± 1.00 s, p < 0.05). Furthermore, correlation analysis showed a negative correlation between rSCO2 and MTT in patients with TBI. Both the univariate and multifactorial logistic regression analyses revealed that APOE ε4, hypoxia, MTT >5.75 s, Marshall CT Class, and GCS were independent risk factors for early poor prognosis in patients with TBI.
Conclusion:
Both cerebral perfusion and cerebral oxygen were significantly impaired after TBI, and low cerebral perfusion and hypoxia were related to poor prognosis of patients with TBI. Compared with APOE ε4 non-carriers, APOE ε4 carriers not only had poorer cerebral perfusion and cerebral oxygen metabolism but also worse prognosis in the early stages of TBI. Furthermore, a negative correlation was observed between the rSCO2 and MTT levels. In addition, both CT perfusion scanning (CTP) and NIRS are reliable for monitoring the condition of patients with TBI in the neurological intensive care unit (NICU).
... Infection management is beyond the scope of this review, but is obviously crucial. Targeted temperature management outside ICP control, aimed at avoiding fever or maintaining strict normothermia, may be neuroprotective, but evidence from interventional trials is currently lacking to demonstrate the impact of such approach on patient outcomes [101]. PbtO 2 values appear to be unaffected during episodes of fever unless hypotension is present [100]. ...
Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit.
... At present, functional recovery in the later stage is the main treatment expec-tation, which mainly includes two parts, motor function and cognitive function. Recovering cognitive function is the difficulty and focus of rehabilitation, and patient's cognitive ability can also affect the recovery of motor ability to a certain extent [21,22]. ...
Objective:
To innvestigate the rehabilitation effects of repetitive transcranial magnetic stimulation (rTMS) combined with cognitive training on cognitive impairment in patients with traumatic brain injury (TBI) by using multimodal magnetic resonance imaging.
Methods:
Clinical data of 166 patients with cognitive impairment after TBI were retrospectively analyzed. The patients were assigned into an observation group and a control group according to different treatment methods, with 83 cases in each group. The observation group was given rTMS + cognitive training, and the control group was given cognitive training only. The changes in GCS score, the Cho/Cr, Cho/NAA and NAA/Cr ratios examined by MRSI, the score of cognitive impairment, the grading of cognitive impairment, and the changes in modified Barthel index were observed and compared between the two groups.
Results:
The GCS score, and the ratios of Cho/Cr, Cho/NAA and NAA/Cr after treatment were better than those before treatment in both groups and were lower in the observation group compared with the control group (all P<0.05). The score and grading of cognitive impairment as well as modified Barthel index after treatment were all significantly better in the observation group than in the control group (all P<0.05).
Conclusion:
rTMS can improve the rehabilitation effect on cognitive impairment in patients after TBI and is recommended for clinical use.
... Gambar 2. Mekanisme terapi hipotermi dalam mencegah kerusakan otak (9) Surface cooling merupakan salah satu intervensi yang dapat dilakukan pada pasien cidera kepala, satu penelitian randomized controlled trial yang bertujuan menilai keefektifan surface cooling dengan kompres dingin untuk menurunkan suhu tubuh pasien cidera kepala. Penelitian dilakukan pada pada 47 pasien cidera kepala dengan terpasang ventilator, kompres dingin dilakukan selama 3 jam, hasil penelitian menunjukan Surface cooling dengan kompres dingin efektif menurunkan suhu tubuh pasien (4) . ...
... Penelitian dilakukan pada pada 47 pasien cidera kepala dengan terpasang ventilator, kompres dingin dilakukan selama 3 jam, hasil penelitian menunjukan Surface cooling dengan kompres dingin efektif menurunkan suhu tubuh pasien (4) . Sebuah penelitian lain menjelaskan bahwa surface cooling dengan target suhu 32-34 0 C efektif mencegah kerusakan otak (9) . ...
... Pasien yang dilakukan early hipotermia dalam waktu kurang dari 24 jam, dapat berefek menurunkan risiko kematian akibat cidera kepala (8) . Selain itu, manajemen hipotermia dengan target suhu 32-34 0 C efektif mencegah kerusakan otak (9) . ...
Head injury is a crucial public health problem and causes social and economic problems throughout the world. Increased brain blood volume associated with increased body temperature will increase intracranial pressure (ICP) and cause the brain at risk of other injuries. This paper aims to identify the effect of hypothermia management on head injury patients. This article was a review of literature from several data bases, Pubmed, EBSCO Host, Google scholar, and Web of Science. Article search was restricted from 2007 to 2018 using the keyword "head injury", "hypothermia management", "hypothermia in head injury". The search results of the article were that management of hypothermia in head injury patients can reduce metabolic requirements, cerebral metabolic rate for oxygen (CMRO2), excitotoxicity, reduce glutamate release, reduce free radical formation, reduce edema formation, stabilize membranes, maintain adenosine triphosphate (ATP), reduce influx Ca, and intracranial pressure so that it can reduce brain damage and risk of death. Keywords: head injury; hypothermia in head injury; hypothermia management ABSTRAK Cedera kepala merupakan masalah kesehatan masyarakat yang krusial dan menyebabkan permasalahan sosial serta ekonomi di seluruh dunia. Peningkatan volume darah otak yang dihubungkan dengan kenaikan suhu tubuh akan meningkatkan tekanan intrakranial (intracranial pressure/ICP) dan menyebabkan otak berisiko terkena cedera lain. Tulisan ini bertujuan untuk mengidentifikasi pengaruh manajemen hipotermia pada pasien cedera kepala. Tulisan ini merupakan tinjauan literature dari beberapa data base yaitu Pubmed, EBSCO Host, Google scholar, dan Web of Science. Penelusuran artikel dibatasi pada tahun 2007 sampai dengan tahun 2018 dengan menggunakan kata kunci “cedera kepala”, “manajemen hipotermia”, “hipotermia pada cedera kepala”. Hasil penelusuran artikel adalah manajemen hipotermia pada pasien cedera kepala dapat berefek mengurangi kebutuhan metabolik, cerebral metabolic rate for oxygen (CMRO2), eksitotoksisitas, menurunkan pelepasan glutamat, menurunkan pembentukan radikal bebas, mengurangi pembentukan edema, stabilisasi membran, memelihara adenosine triphosphate (ATP), menurunkan influx Ca, dan tekanan intrakranial sehingga dapat mengurangi kerusakan otak dan risiko kematian. Kata kunci: cedera kepala; hipotermia pada cedera kepala; manajemen hipotermia
... В исследовании планируется набор 350 пациентов до 2020 г., распределенных в «гипотермическую» и «нормотермическую» группы. ТГ будет осуществляться внутрисосудистыми методиками с индукцией до начала оперативного вмешательства и целевыми температурами до 33 °С [42]. ...
There is an increasing incidence of various cerebral events in Russia, as well as throughout the world. At the same time, despite of all the successes of modern medicine, the treatment outcomes of these patient groups haven’t improved. The main successes are based on faster patient delivery to hospitals and on the creation of specialized centers for this cohort of patients. At the same time, the effectiveness of pharmacological agents with neuroprotective activity is questionable. On the other hand, therapeutic hypothermia techniques have proven to be an effective method of neuroprotection in various cerebral events. These methods can be divided into local and general hypothermia. Each of these options has its own advantages and indications. Thus, the use of general hypothermia techniques maintains the target temperature of the whole body, these techniques are more controllable, but at the same time, the methods of local craniocerebral hypothermia allows to affect the target organ. The methods of hypothermia and thermostabilization have been proven to improve the treatment results of patients post-CPR and in children with neonatal hypoxia. The effectiveness of hypothermia in the remaining pathological conditions of the brain has not yet been investigated. Studies of the last 5 years have not revealed high efficacy of general hypothermia at TBI, so almost of all studies indicated that normothermia and hypothermia are equally effective. Studies are ongoing in patients with subarachnoid hemorrhage, subdural hematomas and ischemic stroke. Identifying groups of patients who are recommended for these methods for complex treatment can lead to progress in improving survival and neurological outcome.
... Если этот методический подход является реально рабочим, а так, по-видимому, и есть, то перспективы для этой методики церебральной термометрии открываются колоссальные. Но, конечно, основное поле для деятельности не анестезиология (хотя в недавней публикации Malpas et al. [6] частота спонтанной гипертермии во время краниотомии составила 33,5 %), а интенсивная терапия пациентов с тяжелыми церебральными катастрофами [4,[7][8][9][10]. ...
Комментарий к статье А.В. Бутрова и соавт. «Изменение температурного баланса головного мозга при различных видах общей анестезии»
... Если этот методический подход является реально рабочим, а так, по-видимому, и есть, то перспективы для этой методики церебральной термометрии открываются колоссальные. Но, конечно, основное поле для деятельности не анестезиология (хотя в недавней публикации Malpas et al. [6] частота спонтанной гипертермии во время краниотомии составила 33,5 %), а интенсивная терапия пациентов с тяжелыми церебральными катастрофами [4,[7][8][9][10]. ...
Комментарий к статье К.А. Токмакова и соавт. «Английский язык для врача анестезиолога-реаниматолога: дань моде или необходимость?»
