Neuroimmunology of Traumatic Brain Injury: A Longitudinal Study of Interdependency of Inflammatory Markers and Heart Rate Variability in Severe Traumatic Brain Injury.

The aim of the present study is to evaluate the interdependency between heart rate variability (HRV) and inflammatory markers in patients with severe traumatic brain injury (TBI). A prospective exploratory study was done with a sample size of 89 patients. HRV of these patients was recorded using a telemetric device. The recordings were made on day 1 of the patients' admission into the intensive care unit followed by serial recordings on day 3 and day 10. Serum samples of the patients were also collected on these days for analysis of interleukin (IL)-1ß, IL-6, IL-10, and tumor necrosis factor alpha levels using enzyme-linked immunosorbent assay kits. The outcome assessment was done using the Disability Rating Scale at discharge and Glasgow Outcome Scale-Extended at 6 months post-trauma. The data were analyzed by grouping the patients on based on mortality and outcome. In the present study, there was significant subclinical autonomic dysfunction in patients with severe TBI. Among the serum cytokines, levels of IL-10 had a significant impact on outcome. An increase in IL-10 levels correlated with the unfavorable outcome. This study highlights the association between the HRV parameters and immune response. The timely management of both autonomic and immune dysfunction in patients with severe TBI may have an impact in preventing the secondary injury process.

Demonstration of autonomic dysfunction in traumatic brachial plexus injury using quantitative sudomotor axon reflex test: Preliminary results.

OBJECTIVE: To objectively document autonomic dysfunction in the affected arm with traumatic brachial plexus injury (TBPI) using quantitative sudomotor axon reflex test (QSART). MATERIALS AND METHODS: Patients with TBPI presenting to the neurosurgical outpatient department from August 2013 to November 2014 were included in the study. The QSART was administered to each patient with prior informed consent detailing the procedure. A total of 20 patients with TBPI were included in the study. The age, sex, mode of injury, date of injury, side of injury, and type of injury (pan brachial plexus vs preserved distal function) were recorded. The presence of any pain was also recorded. The injuries were also grouped as preganglionic and postganglionic injuries based on clinical, electroneuromyography (ENMG) and magnetic resonance imaging (MRI) findings. The results of the test for the affected and normal limb were recorded and analyzed with appropriate statistical tests to determine any significant differences. RESULTS: The study included 20 patients, with their age ranging from 15 to 50 years. Out of the 20 patients, one was female and the rest 19 were males. Seven (35%) of the injuries were complete (pan brachial plexus) and 13 (65%) were incomplete (preserved distal function). All patients had preganglionic TBPI. There was no evidence of any statistically significant difference between the affected and normal arm for total sweat volume (P = 0.20) and latency period (P = 0.42). However, the average mean values for the same were lower in the affected arm as compared to the normal. The baseline sweat output (P = 0.010), however, was significantly lower in the affected arm as compared to the normal arm. CONCLUSION: QSART has demonstrated reduced baseline sweat output in the affected arm in patients with TBPI. This indicates the presence of autonomic dysfunction in the injured arm.

Correlation of ubiquitin C terminal hydrolase and S100ß with cognitive deficits in young adults with mild traumatic brain injury.

OBJECTIVE: To study the acute phase serum biomarkers in patients with mild traumatic brain injury (mTBI) and to correlate them with short term cognitive deficits. MATERIALS AND METHODS: This is a prospective observational study conducted at a tertiary care center for neurotrauma. The participants included patients with mTBI (n = 20) and age, gender, and education-status matched healthy controls (n = 20). In both the groups, the serum concentrations of biomarkers ubiquitin C terminal hydrolase (UCH-L1) and S100 calcium-binding protein B (S100B) were measured. Both the groups underwent neuropsychological tests. The serum tests were done in the acute stage after injury and the neuropsychological tests were done 3 months after injury. RESULTS: There was no significant increase in the serum S100B and UCH-L1 levels in patients with mTBI. Patients with mTBI had significant cognitive deficits at 3 months after injury, which was suggestive of involvement of diffuse areas of the brain, in particular, the premotor, prefrontal, and medial inferior frontal lobes and the basitemporal region. The correlation of biomarkers with cognitive deficits in patients with mTBI was found in the following domains: working memory, verbal learning, verbal fluency, and visual memory. CONCLUSION: The serum biomarkers of mTBI have a correlation with selective domains of neuropsychological outcome.

Predictive validity of disability rating scale in determining functional outcome in patients with severe traumatic brain injury.

BACKGROUND: Most patients with severe traumatic brain injury (TBI) are discharged when they have still not recovered completely. Many such patients are not available for follow up. AIMS: We conducted this study to determine whether the condition at discharge from acute care setting, as assessed with disability rating scale (DRS), correlates with functional outcome at follow up. SETTINGS AND DESIGN: This study was conducted at a Neurosurgical intensive care unit (ICU) of a tertiary care referral center. This was a prospective observational study. MATERIALS AND METHODS: Patients admitted to ICU with a diagnosis of severe TBI were enrolled for the study. On the day of discharge, all patients underwent DRS assessment. A final assessment was performed using Glasgow outcome scale extended (GOSE) at 6 months after discharge from the hospital. STATISTICAL ANALYSIS: The correlation between the DRS scores at the time of discharge with DRS scores and GOSE categories at 6 months after discharge was determined using Spearman's rho correlation coefficient. RESULTS: A total of 88 patients were recruited for the study. The correlation coefficient of DRS at discharge for DRS at 6 months was 0.536 and for GOSE was -0.553. The area under the curve of DRS score at discharge for predicting unfavorable outcome and mortality at 6 months was 0.770 and 0.820, respectively. CONCLUSION: The predictive validity of DRS is fair to good in determining GOSE at follow-up. Pending availability of a more accurate outcome assessment tool, DRS at discharge can be used as a surrogate outcome for GOSE at follow up.

Paroxysmal sympathetic hyperactivity in severe traumatic brain injury.

BACKGROUND: Paroxysmal sympathetic hyperactivity (PSH) is a less-known complication of traumatic brain injury (TBI). This study was done to assess the clinical features and outcome of patients who develop PSH following severe TBI. METHODS: A prospective observational study was done on patients, admitted in the intensive care unit, for treatment of severe TBI. The clinical characteristics and outcome of patients, with and without PSH, was compared. At the time of discharge, patients were assessed with the Disability Rating Scale (DRS), and at 6 months with the Glasgow Outcome Score Extended (GOSE). RESULTS: The incidence of PSH was 8 % (29/343). Tachycardia, hypertension, and sweating were seen in all of the patients. Tachypnea was seen in 24 (82.8 %), hyperthermia in 28 (96.6 %), and posturing in 13 (44.8 %) patients. Thirteen (44.8 %) patients had all six symptoms of PSH. Follow-up data were available for 23 (79.3 %) patients. At the end of 6 months, 14 (60.9 %) patients had died, seven (30.4 %) were severely disabled, and two (8.7 %) were moderately disabled. There was a significant correlation of GOSE with the number of symptoms of PSH (Spearman's rho = 0.502, p = 0.015). The patients with PSH had significantly higher DRS scores at discharge, 25.3 vs. 19.9, p < 0.001; higher mortality at 6 months 60.9 vs. 30.4 %, p < 0.001; and higher proportions with unfavorable outcome. CONCLUSIONS: Presence of PSH in patients with severe TBI was associated with prolonged hospital stay, poorer DRS at discharge, more deaths, and unfavorable outcome. The number of symptoms of PSH had a significant effect on outcome at 6 months.

Comparison of predictability of Marshall and Rotterdam CT scan scoring system in determining early mortality after traumatic brain injury.

BACKGROUND: Marshall computed tomographic (CT) classification is widely used as a predictor of outcome. However, this grading system lacks the following variables, which are found to be useful predictors: subarachnoid/intraventricular hemorrhage, extradural hematoma, and extent of basal cistern compression. A new classification called the Rotterdam grading system, incorporating the above variables, was proposed later. In the original paper, this system was found to have superior discrimination as compared to Marshall grading, however, Rotterdam grading has not been validated widely. We aimed to compare the discriminatory power of both grading systems. METHODS: This is a prospective study of patients with moderate and severe TBI (Glasgow coma scale (GCS) 3-12) who presented to our casualty. All the patients were followed up for 2 weeks to determine early mortality. The discriminatory power of each grading system was determined using area under the receiver operating characteristic curve (AUC). RESULTS: A total of 134 patients, mean age 38.3 (±15.7) years, were recruited for study. The overall mortality was 11.2 %. The mean GCS of these patients was 9.6 (±2.3). There was good correlation between Marshall and Rotterdam grading, r = 0.68 (significant at 0.01 level). The Marshall CT classification had reasonable discrimination (AUC - 0.707), and Rotterdam grading had good discrimination (AUC - 0.681). CONCLUSIONS: Both Marshal and Rotterdam grading systems are good in predicting early mortality after moderate and severe TBI. As the Rotterdam system also includes additional variables like subarachnoid hemorrhage, it may be preferable, particularly in patients with diffuse injury.

Paroxysmal sympathetic hyperactivity in pediatric traumatic brain injury: A case series of four patients.

Paroxysmal sympathetic hyperactivity (PSH) is a condition in which there is extreme autonomic dysregulation leading to multiple episodes of sympathetic hyperactivity. Its occurrence after traumatic brain injury (TBI) in pediatric population is a neglected scenario. In our series, all pediatric patients with moderate and severe head injuries were studied and those patients who developed PSH were monitored for the PSH episodes. Four children out of 36 cases of pediatric severe traumatic brain injury developed features of PSH. Admission GCS of 3 children were 4/15 and 1 child was 6/15 and each of them had an ICU stay of more than 2 weeks and a poor DRS score at discharge. The presence of PSH is known to produce poorer outcome in terms of overall mortality, time needed for recovery, chances of developing infections, etc. which was also seen in these cases presented here. Though some studies have provided guidelines for the management of PSH like symptomatic management and use of drugs like clonidine, bromocriptine, benzodiazepines, and gabapentin, strict management guidelines are not established and exact incidence in pediatric population is not determined.

Does isolated traumatic subarachnoid hemorrhage affect outcome in patients with mild traumatic brain injury?

BACKGROUND: The importance of isolated traumatic subarachnoid hemorrhage (SAH) in relation to functional outcome in patients with mild traumatic brain injury (TBI) has not been frequently studied. The aim of this study was to compare the impact of isolated SAH with normal computed tomographic (CT) scan on outcome of patients with mild TBI. METHODS: This is a retrospective study of clinical records and CT scans of all patients with mild TBI (Glasgow Coma Scale score ≥13) evaluated from January 1, 2010, to March 15, 2010, at our institution. The patients were divided into 2 groups: isolated SAH and normal CT scan. The telephonic Glasgow Outcome Scale-Extended, Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ), and Rivermead Head Injury Follow-up Questionnaire (RHFUQ) scores were used to assess outcome after 1 year of injury. Independent sample t test in SPSS was used to assess difference in outcome. RESULTS: A total of 1149 patients with mild TBI were evaluated during study period. Among them, 34 (2.9%) patients had isolated SAH. Twenty-eight patients were male and 6 were female, with a mean age of 36.5 years. Subarachnoid hemorrhage was cortical in 19 (55.9%) patients, interhemispheric in 3 (8.8%) patients, Sylvian fissure in 2 (5.9%) patients, and basal cisternal in 1 (2.9%) patient. Nine (26.5%) patients had SAH at multiple locations. The mean RPCSQ and RHFUQ scores for patients with isolated SAH were 1.38 ± 2.40 and 1.11 ±3.305, respectively. The mean RPCSQ and RHFUQ scores for patients with normal CT scans were 0.40 ± 1.549 and 0.533 ± 1.59, respectively. There was no significant difference in the outcome scores between the SAH and the normal CT scan groups (RHFUQ, P = .45; RPCSQ, P = .248). CONCLUSION: In our study sample of patients with mild TBI, there is no difference in outcome of patients with isolated SAH compared with those with normal CT scans 1 year after injury.

Can an abnormal CT scan be predicted from common symptoms after mild head injury in children?

INTRODUCTION: Children have non specific symptoms after mild head injury (MHI). It is difficult to define indication of CT scan among them. We aimed at identification of predictors of CT scan findings after MHI. MATERIALS AND METHODS: Children aged ≤12 years with GCS 13-15 after head injury were retrospectively evaluated for their clinical and CT scan findings during January to March 2010. The variables used for detection of abnormal (positive) CT scan were age, gender, cause of injury (road traffic accident, fall, and assault), loss of consciousness, vomiting, ear or nose bleed, seizure, and GCS score. RESULTS: A total of 133 children were included in study. Sixty nine (51.9%) children had abnormal CT findings. There was no statistical difference in patients with normal vs abnormal CT scan for presence of any of the variables evaluated. CONCLUSION: An abnormal CT scan cannot be reliably ruled out in a child with MHI based on symptoms; hence a policy of liberal CT scan based on clinical acumen is advisable.