Circulating Brain Injury Biomarkers: A Novel Method for Quantification of the Impact on the Brain After Tumor Surgery.

BACKGROUND: Clinical methods to quantify brain injury related to neurosurgery are scarce. Circulating brain injury biomarkers have recently gained increased interest as new ultrasensitive measurement techniques have enabled quantification of brain injury through blood sampling. OBJECTIVE: To establish the time profile of the increase in the circulating brain injury biomarkers glial fibrillary acidic protein (GFAP), tau, and neurofilament light (NfL) after glioma surgery and to explore possible relationships between these biomarkers and outcome regarding volume of ischemic injury identified with postoperative MRI and new neurological deficits. METHODS: In this prospective study, 34 adult patients scheduled for glioma surgery were included. Plasma concentrations of brain injury biomarkers were measured the day before surgery, immediately after surgery, and on postoperative days 1, 3, 5, and 10. RESULTS: Circulating brain injury biomarkers displayed a postoperative increase in the levels of GFAP ( P < .001), tau ( P < .001), and NfL ( P < .001) on Day 1 and a later, even higher, peak of NFL at Day 10 ( P = .028). We found a correlation between the increased levels of GFAP, tau, and NfL on Day 1 after surgery and the volume of ischemic brain tissue on postoperative MRI. Patients with new neurological deficits after surgery had higher levels of GFAP and NfL on Day 1 compared with those without new neurological deficits. CONCLUSION: Measuring circulating brain injury biomarkers could be a useful method for quantification of the impact on the brain after tumor surgery or neurosurgery in general.

Risk and cause of death in post-traumatic epilepsy: a register-based retrospective cohort study.

OBJECTIVE: Post-traumatic epilepsy (PTE) is common, but its impact on survival after traumatic brain injury (TBI) of different severity and in different demographic patient groups is unknown. We analyzed the risk of death associated with PTE with adjustment for TBI severity, causes of death, and the contribution of epilepsy as direct or contributing cause of death. METHODS: Register-based, retrospective cohort study. All individuals hospitalized in Sweden for a TBI between 2000 and 2010 without prior seizures were identified in the National Patient Register, with follow-up until 2017. Subsequent epilepsy was identified by ICD-10 codes. Time-dependent Cox proportional hazard ratio (HR) was used to assess hazard of death, with epilepsy as a time-updated covariate. Adjusted analyses for age, gender, injury severity and comorbidities were also performed. Causes of death were analyzed using the Cause of Death Register. RESULTS: Among 111 947 individuals with TBI, subsequent epilepsy diagnosis was associated with a crude HR of 2.3 (95% CI: 2.2-2.4) for death. Stratified analyses showed a HR of 7.8 (95% CI: 6.5-9.4) for death in younger individuals. Epilepsy was a more common underlying cause of death in younger individuals. CONCLUSION: PTE is associated with a higher risk of death and epilepsy seems to contribute to a significant proportion of deaths, especially in younger age groups. Future studies on whether improved epilepsy treatment can reduce mortality are needed.

Long-term outcomes after aneurysmal subarachnoid hemorrhage: A prospective observational cohort study.

OBJECTIVES: The survival rates for patients affected by aneurysmal subarachnoid hemorrhage (aSAH) have increased in recent years; however, many patients continue to develop cognitive dysfunctions that affect their quality of life. The commonly used outcome measures often fail to identify these cognitive dysfunctions. This study aimed to evaluate the long-term outcomes at 1 and 3 years after aSAH to assess changes over time and relate outcomes to patient characteristics and events during the acute phase. MATERIALS AND METHODS: This prospective observational study included patients that experienced aSAH. Patients were assessed according to the extended Glasgow Outcome Scale, Life Satisfaction Questionnaire, Mayo-Portland Adaptability inventory-4, and Mental Fatigue scale. RESULTS: Patients were assessed after 1 year (n = 62) and 3 years (n = 54). At 3 years, the extended Glasgow Outcome Scale score improved in 15% and worsened in 12% of the patients. Mental fatigue was observed in 57% of the patients at 1 year. Patients <60 years of age at the time of aSAH had more self-assessed problems, including pain/headache (p < .01), than patients >60 years of age. Patients with delayed cerebral ischemia during the acute phase reported more dissatisfaction at 3 years, whereas no significant result was seen at 1 year. CONCLUSIONS: Cognitive dysfunction, especially mental fatigue, is common in patients with aSAH, which affects quality of life and recovery. Patient outcome is a dynamic process developing throughout years after aSAH, involving both improvement and deterioration. This study indicates the importance of longer follow-up periods with broad outcome assessments.

Patients' Experiences of Self-Administered Electrotherapy for Spasticity in Stroke and Cerebral Palsy: A Qualitative Study.

OBJECTIVE: To explore patients' experiences of a self-administered electrotherapy treatment for muscle spasticity in cerebral palsy and stroke; the Exopulse Mollii Suit®. DESIGN: Qualitative design with an inductive approach Subjects: Fifteen patients with spasticity due to stroke or cerebral palsy, participating in a previous randomized controlled trial evaluating the treatment concept. METHODS: Information letters were sent to all potential participants (n = 27) in the previous study. Semi-structured interviews (21-57 min) were carried out with all subjects who volunteered (n = 15), administered by an experienced interviewer who was not involved in the previous study. Transcribed interviews were subject to content analysis. RESULTS: The 5 categories that emerged from the content analysis were "New method gives hope", experiences related to "Using the assistive technology", "Outcome from training with the assistive technology", "The assistive technology" and "Taking part in the study". Respondents felt hopeful when included in the previous study, motivated when experiencing a treatment effect, and disappointed when not. CONCLUSION: The qualitative approach used in this study elicited complementary information that was not evident from the previous randomized controlled trial. This included statements regarding increased mobility, reduced spasticity, reduced use of medication, and problems related to using the treatment concept.

[Meralgia paresthetica after prolonged prone position at the intensive care unit among COVID-19 patients. A case report]. / Långvarigt bukläge på IVA kan öka risken för meralgia paresthetica.

Meralgia paresthetica (MP) is an entrapment syndrome that may cause loss of sensation, numbness, paresthesia and pain within the distribution of the lateral femoral cutaneous nerve. This condition is more common in persons with diabetes mellitus, obesity and in old age. MP has previously been described in patients that have undergone surgery in the prone position (PP) and in a case report of a patient with ARDS (Acute Respiratory Distress Syndrome) who was cared for in the intensive care unit (ICU). Due to the COVID-19 pandemic PP has been widely used for periods of 12-16 hours to improve oxygenation. At the rehabilitation unit at our hospital, we have identified cases of MP in patients with COVID-19 that have required this type of positioning for long periods in the ICU. We would like to draw attention to the fact that there is a risk of peripheral nerve injury in the event of prolonged PP and recommend extra controls, careful positioning and extra padding at the areas where peripheral nerves may be exposed to pressure.

Pre-traumatic conditions can influence cortisol levels before and after a brain injury.

OBJECTIVE: Satisfactory anabolic reactions, including the activation of the hypothalamic-pituitary-adrenal (HPA) axis, are essential following severe traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH). Many factors may influence this activation. This study aimed to investigate whether individuals who reported chronic diseases, psychosocial afflictions, or stressful events before a severe brain injury display a different pattern regarding cortisol levels retrospectively and up to three months compared with those who did not report stressful experiences. MATERIALS AND METHODS: Fifty-five patients aged 16-68 years who were admitted to the neurointensive care unit (NICU) were included. Hair cortisol measurements offer a unique opportunity to monitor cortisol levels retrospectively and after the trauma. Hair strands were collected as soon as possible after admission to the NICU and every month until three months after the injury/insult. The participants/relatives were asked about stressful events, psychosocial afflictions and recent and chronic diseases. RESULTS: The group who reported chronic diseases and/or stressful events before the brain injury had more than twice as high median hair cortisol levels before the brain injury compared with those who did not report stress, but the difference was not statistically significant (P = .12). Those who reported stress before the brain injury had statistically significantly lower hair cortisol values after the brain injury and they remained until three months after the injury. CONCLUSIONS: Stressful events and/or chronic disease before brain injury might affect mobilization of adequate stress reactions following the trauma. However, the large variability in cortisol levels in these patients does not allow firm conclusions and more studies are needed.

Mental fatigue assessment may add information after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Mental fatigue, as part of cognitive dysfunction, has been reported to be common after subarachnoid hemorrhage and it significantly affects quality of life. AIMS OF THE STUDY: The aim of this study was to assess mental fatigue one year after an aneurysmal subarachnoid hemorrhage and to correlate the degree of mental fatigue to functional outcome assessed with the Extended Glasgow Outcome Scale (GOSE). METHODS: One year after an aneurysmal subarachnoid hemorrhage, the GOSE was assessed and a questionnaire for self-assessment of mental fatigue, the Mental Fatigue Scale, was distributed to all included patients. The maximum score is 42 and a score of ≥10.5 indicates mental fatigue. RESULTS: All patients with GOSE 8, indicating full recovery, had a mental fatigue score of <10.5. A linear correlation between the GOSE and the mental fatigue score was observed (p < 0.0001). CONCLUSIONS: Patients with a favorable outcome and GOSE 5-7 could benefit from the assessments of mental fatigue in order to receive satisfactory rehabilitation.

Evaluation of a self-administered transcutaneous electrical stimulation concept for the treatment of spasticity: a randomized placebo-controlled trial.

BACKGROUND: Spasticity is a common consequence of injury to the central nervous system negatively affecting patient's everyday activities. Treatment mainly consists of training and different drugs, often with side effects. There is a need for treatment options that can be performed by the patient in their home environment. AIM: The objective of this study was to assess the effectiveness of an assistive technology (AT), Mollii®, a garment with integrated electrodes for multifocal transcutaneous electrical stimulation intended for self-treatment of spasticity, in study participants with spasticity due to stroke or CP. DESIGN: The study was a randomized, controlled, double-blind study with a cross-over design. SETTING: Participants were recruited from two rehabilitation clinics. Treatments were performed in participants' homes and all follow-ups were performed in the two rehabilitation clinics. POPULATION: Thirty-one participants were included in the study and 27 completed the study. Four participants discontinued the study. Two declined participation before baseline and two withdrew due to problems handling the garment. METHODS: Participants used the AT with and without electrical stimulation (active/non-active period) for six weeks each, followed by six weeks without treatment. Goal Attainment Scaling (GAS), change in mobility, arm-hand ability, spasticity and pain were measured at baseline and after 6, 12 and 18 weeks. RESULTS: Fifteen of the 27 participants fulfilled the treatment protocol in terms of recommended use. Deviations were frequent. No statistically significant differences in outcome were found between the active and the non-active treatment periods. During the active period, an improvement was seen in the 10-meter comfortable gait test, time and steps. An improvement was seen in both the active and non-active periods for the GAS. CONCLUSIONS: Compliance was low, partly due to deviations related to the garment, complicating the interpretation of the results. Further research should focus on identifying the target population and concomitant rehabilitation strategies. CLINICAL REHABILITATION IMPACT: The evaluated concept of multifocal transcutaneous electrical stimulation (TES) represents an interesting addition to the existing repertoire of treatments to alleviate muscle spasticity. The evaluated concept allows TES to be self-administered by the patient in the home environment. A more elaborate design of training activities directly related to patient's own rehabilitation goals is recommended and may increase the value of the evaluated concept.

[Prolonged disorder of consciousness after severe acquired brain injury in adults. New recommendations provide a basis for investigation and rehabilitation]. / Långvarig svår medvetande-störning efter hjärnskada hos vuxna - Nya rekommendationer ger underlag för utredning och rehabilitering.

After severe acquired brain injury some patients develop a prolonged disorder of consciousness (vegetative state or minimally conscious state), and as such cannot actively participate in neurorehabilitation. However, international opinion and recent research developments emphasize the need for involvement of rehabilitation medicine units in the care of these patients. The article presents recommendations for the care of adult patients with prolonged disorders of consciousness, which have been developed by a multidisciplinary working party, in order to promote good care, and identify areas for further improvements.

Longitudinal study of the diffusion tensor imaging properties of the corpus callosum in acute and chronic diffuse axonal injury.

BACKGROUND: Magnetic resonance diffusion tensor imaging (MR-DTI) is used increasingly to detect diffuse axonal injury (DAI) after traumatic brain injury (TBI). PRIMARY OBJECTIVE: The primary objective was to investigate the changes in the diffusion properties of the corpus callosum in the acute phase and 6 months after TBI and to examine the correlation between DTI parameters and clinical outcome. RESEARCH DESIGN: Longitudinal prospective study. METHODS AND PROCEDURES: MR-DTI was performed in eight patients with suspected DAI within 11 days and at 6 months post-injury. Six controls were also examined. Fractional anisotropy (FA), trace and parallel and perpendicular diffusivity of the corpus callosum were analysed. The main outcome was the extended Glasgow Outcome Scale score, assessed at 6 months. MAIN OUTCOMES AND RESULTS: A significant reduction in FA in the corpus callosum was seen in the acute phase in patients compared with the healthy controls. There was no significant change in the parallel or perpendicular eigenvalues or trace. At 6 months, a significant reduction in FA and a significant increase in trace and perpendicular eigenvalues were noticed compared with controls. CONCLUSIONS: The diffusion properties of the corpus callosum correlated with clinical outcome in this longitudinal investigation.

Psychosocial adjustment and life satisfaction until 5 years after severe brain damage.

The objectives of this study were to describe psychosocial adjustment and outcome over time for severely brain-injured patients and to find suitable outcome measures for clinical practice during the rehabilitation process and for individual rehabilitation planning after discharge from hospital. The methods include a descriptive, prospective, population-based study. The participants were assessed at 6 months and annually until 5 years after traumatic brain injury or nontraumatic subarachnoid haemorrhage. Inclusion criteria were age 16-65 years, severe traumatic brain injury or nontraumatic subarachnoid haemorrhage defined as Glasgow Coma Scale 8 or worse and need for neurointensive care for at least 5 days. The main outcome measures were Head Injury Evaluation Chart, Glasgow Outcome Scale Extended (GOSE) and Life Satisfaction Questionnaire (LiSat)-11 checklist. Change over time for the group and the individuals, as measured with the GOSE, was analyzed by a statistical method that is suitable for small datasets and takes into account the nonmetric properties of the data. Eighteen patients were included. Three died and one was excluded for the long-term follow-up (n=14). The group had a good outcome with no participant remaining in a vegetative state, 93% (12 of 13) went home and 60% (six of 10) returned to work. Eighty percent (eight of 10) of participants rated 'life as a whole' as satisfactory 5 years after the injury. The change at group level was significant (GOSE) until 1 year after the injury. The GOSE and the LiSat-11 were most clinically useful as they were easy to use for the rater/participants.