Quantitative patterns of visual impairment and recovery in children with brain injury.

Brain injury can cause many distinct types of visual impairment in children, but these deficits are difficult to quantify due to co-morbid deficits in communication and cognition. Clinicians must instead rely on low-resolution, subjective judgements of simple reactions to handheld stimuli, which limits treatment potential. We have developed an interactive assessment program called the Visual Ladder, which uses gaze-based responses to intuitive, game-like tasks to address the lack of broad-spectrum quantified data on the visual abilities of children with brain injury. Here, we present detailed metrics on eye movements, field asymmetries, contrast sensitivity, and other critical visual abilities measured longitudinally using the Ladder in hospitalized children with varying types and degrees of brain injury, many of whom were previously considered untestable. Our findings show which abilities are most likely to exhibit recovery and reveal how distinct patterns of task outcomes defined unique diagnostic clusters of visual impairment.

A Protocol to Understand the Implementation and Experiences of an Online Community-Based Performance Arts Programme Through and Beyond the COVID-19 Pandemic, Brain Waves.

Introduction: Individuals living with acquired brain injury experience numerous psychological, physical, and social challenges. Since the COVID-19 pandemic, many have experienced additional isolation, mental health issues and have had limited access to social and physical activities otherwise available in the community. Materials and Methods: Brain Waves is a 12-week online performance arts programme developed during the COVID-19 pandemic, for people with acquired brain injury (ABI). The research component of Brain Waves is a qualitative study, using Interpretative Phenomenological Analysis (IPA) and ethnographic methods (Observations and Interviews). The study will recruit two distinct populations: individuals living with acquired brain injury (including people who have experienced traumatic brain injury and stroke who are participating in the programme) and stakeholders (facilitators, involved in the delivery of Brain Waves). This paper presents the protocol for a project which aims to gain an understanding of the implementation and experiences of creating and participating in an online community-based performance arts programme.

One-year outcome of brain injured patients undergoing early neurological rehabilitation: a prospective observational study.

BACKGROUND: The present study intended to analyze the outcome of patients with severe brain injury one-year after discharge from early rehabilitation. METHODS: Early neurological rehabilitation patients admitted to intensive or intermediate care units and discharged between June 2018 and May 2020 were screened for eligibility. The level of consciousness was evaluated using the Coma Recovery Scale-Revised (CRS-R) upon admission and at discharge. At one-year follow-up, the outcome was assessed with the Glasgow Outcome Scale-extended (GOSE). Demographical and clinical data collected during inpatient rehabilitation were used to predict the outcome 1 year after discharge. RESULTS: Two hundred sixty-four patients (174 males, 90 females) with a median age of 62 years (IQR = 51-75) and a median duration of their disease of 18 days (IQR = 12-28) were included in the study. At follow-up, the mortality rate was 27% (n = 71). Age and discharge CRS-R total score were independent predictors in a Cox proportional hazards model with death (yes/no) as the dependent variable. According to the GOSE interviews, most patients were either dead (n = 71; 27%), in a vegetative state (n = 28; 11%) or had a severe disability (n = 124; 47%), whereas only a few patients showed a moderate disability (n = 18; 7%) or a good recovery (n = 23; 9%) 1 year after discharge. Age, non-traumatic etiology, discharge CRS-R total score and length of stay independently predicted whether the outcome was good or poor at follow-up. CONCLUSION: Age was an important predictor for outcome at one-year follow-up, which might be due to altered brain plasticity and more comorbidities in elderly subjects. In addition, the present study demonstrated that the CRS-R total score at discharge might be more important for the prediction of one-year outcome than the initial assessment upon admission.

Effects of positive end-expiratory pressure on lung ultrasound patterns and their correlation with intracranial pressure in mechanically ventilated brain injured patients.

BACKGROUND: The effects of positive end-expiratory pressure (PEEP) on lung ultrasound (LUS) patterns, and their relationship with intracranial pressure (ICP) in brain injured patients have not been completely clarified. The primary aim of this study was to assess the effect of two levels of PEEP (5 and 15 cmH2O) on global (LUStot) and regional (anterior, lateral, and posterior areas) LUS scores and their correlation with changes of invasive ICP. Secondary aims included: the evaluation of the effect of PEEP on respiratory mechanics, arterial partial pressure of carbon dioxide (PaCO2) and hemodynamics; the correlation between changes in ICP and LUS as well as respiratory parameters; the identification of factors at baseline as potential predictors of ICP response to higher PEEP. METHODS: Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP. Total and regional LUS scores, ICP, respiratory mechanics, and arterial blood gases values were analyzed at PEEP 5 and 15 cmH2O. RESULTS: Thirty patients were included; 19 of them (63.3%) were male, with median age of 65 years [interquartile range (IQR) = 66.7-76.0]. PEEP from 5 to 15 cmH2O reduced LUS score in the posterior regions (LUSp, median value from 7 [5-8] to 4.5 [3.7-6], p = 0.002). Changes in ICP were significantly correlated with changes in LUStot (rho = 0.631, p = 0.0002), LUSp (rho = 0.663, p < 0.0001), respiratory system compliance (rho = - 0.599, p < 0.0001), mean arterial pressure (rho = - 0.833, p < 0.0001) and PaCO2 (rho = 0.819, p < 0.0001). Baseline LUStot score predicted the increase of ICP with PEEP. CONCLUSIONS: LUS-together with the evaluation of respiratory and clinical variables-can assist the clinicians in the bedside assessment and prediction of the effect of PEEP on ICP in patients with acute brain injury.

Delayed awakening in neurocritical care.

Delayed awakening is defined as a persistent disorder of arousal or consciousness 48 to 72h after sedation interruption in critically ill patients. Delayed awakening is either a component of coma or delirium. It results in longer hospital stays and increased mortality. It is therefore a diagnostic, therapeutic and prognostic emergency. In severe brain injured patients, delayed awakening may be related to the primary neurological injury or to secondary systemic insults related to organ failure associated with intensive care. In the present review, we propose diagnostic, therapeutic and prognostic algorithms for managing delayed awaking in neuro-ICU brain injured patients.

Effects of Positive End-Expiratory Pressure on Lung Recruitment, Respiratory Mechanics, and Intracranial Pressure in Mechanically Ventilated Brain-Injured Patients.

Background: The pathophysiological effects of positive end-expiratory pressure (PEEP) on respiratory mechanics, lung recruitment, and intracranial pressure (ICP) in acute brain-injured patients have not been completely elucidated. The primary aim of this study was to assess the effects of PEEP augmentation on respiratory mechanics, quantitative computed lung tomography (qCT) findings, and its relationship with ICP modifications. Secondary aims included the assessment of the correlations between different factors (respiratory mechanics and qCT features) with the changes of ICP and how these factors at baseline may predict ICP response after greater PEEP levels. Methods: A prospective, observational study included mechanically ventilated patients with acute brain injury requiring invasive ICP and who underwent two-PEEP levels lung CT scan. Respiratory system compliance (Crs), arterial partial pressure of carbon dioxide (PaCO2), mean arterial pressure (MAP), data from qCT and ICP were obtained at PEEP 5 and 15 cmH2O. Results: Sixteen examinations (double PEEP lung CT and neuromonitoring) in 15 patients were analyzed. The median age of the patients was 54 years (interquartile range, IQR = 39-65) and 53% were men. The median Glasgow Coma Scale (GCS) at intensive care unit (ICU) admission was 8 (IQR = 3-12). Median alveolar recruitment was 2.5% of total lung weight (-1.5 to 4.7). PEEP from 5 to 15 cmH2O increased ICP [median values from 14.0 (11.2-17.5) to 23.5 (19.5-26.8) mmHg, p < 0.001, respectively]. The amount of recruited lung tissue on CT was inversely correlated with the change (Δ) in ICP (rho = -0.78; p = 0.0006). Additionally, ΔCrs (rho = -0.77, p = 0.008), ΔPaCO2 (rho = 0.81, p = 0.0003), and ΔMAP (rho = -0.64, p = 0.009) were correlated with ΔICP. Baseline Crs was not predictive of ICP response to PEEP. Conclusions: The main factors associated with increased ICP after PEEP augmentation included reduced Crs, lower MAP and lung recruitment, and increased PaCO2, but none of these factors was able to predict, at baseline, ICP response to PEEP. To assess the potential benefits of increased PEEP in patients with acute brain injury, hemodynamic status, respiratory mechanics, and lung morphology should be taken into account.

Tracking-Based Interactive Assessment of Saccades, Pursuits, Visual Field, and Contrast Sensitivity in Children With Brain Injury.

Visual deficits in children that result from brain injury, including cerebral/cortical visual impairment (CVI), are difficult to assess through conventional methods due to their frequent co-occurrence with cognitive and communicative disabilities. Such impairments hence often go undiagnosed or are only determined through subjective evaluations of gaze-based reactions to different forms, colors, and movements, which limits any potential for remediation. Here, we describe a novel approach to grading visual health based on eye movements and evidence from gaze-based tracking behaviors. Our approach-the "Visual Ladder"-reduces reliance on the user's ability to attend and communicate. The Visual Ladder produces metrics that quantify spontaneous saccades and pursuits, assess visual field responsiveness, and grade spatial visual function from tracking responses to moving stimuli. We used the Ladder to assess fourteen hospitalized children aged 3 to 18 years with a diverse range of visual impairments and causes of brain injury. Four children were excluded from analysis due to incompatibility with the eye tracker (e.g., due to severe strabismus). The remaining ten children-including five non-verbal children-were tested multiple times over periods ranging from 2 weeks to 9 months, and all produced interpretable outcomes on at least three of the five visual tasks. The results suggest that our assessment tasks are viable in non-communicative children, provided their eyes can be tracked, and hence are promising tools for use in a larger clinical study. We highlight and discuss informative outcomes exhibited by each child, including directional biases in eye movements, pathological nystagmus, visual field asymmetries, and contrast sensitivity deficits. Our findings indicate that these methodologies will enable the rapid, objective classification and grading of visual impairments in children with CVI, including non-verbal children who are currently precluded from most vision assessments. This would provide a much-needed differential diagnostic and prognostic tool for CVI and other impairments of the visual system, both ocular and cerebral.

Acquired Brain Injury and Interventions in the Offender Population: A Systematic Review.

Background and Aims: The prevalence of acquired brain injury (ABI) in offender populations appears much higher than in the general population, being estimated at 50% compared to 12%, respectively. Taking into account ABI-related cognitive and social impairments or behavioral changes in forensic treatments might be relevant and may improve treatment outcomes. The aim of the current review is to summarize and integrate the literature on psychological interventions or treatments for consequences of ABI in the forensic setting. Reviewing this literature could provide crucial information for improving treatment options for offenders with ABI, which may contribute to reducing recidivism. Methods: The PubMed/MEDLINE, PsychInfo, CINAHL, COCHRANE, and Web of Science databases were searched for studies in adult offenders with ABI that evaluated the effect of psychological interventions with a focus on ABI-related impairments and recidivism. Results: This review identified four intervention studies that met the inclusion criteria. These included an adult population (≥18-year-old) in a forensic setting (given the focus of the current review on treatment, defined here as an environment in which offenders are treated while being incarcerated or as outpatients), non-pharmacological treatments and were published in English or Dutch between 2005 and 2020. All studies reported some positive effects of the intervention on interpersonal behavior, cognition and recidivism. The aspects of the interventions that seemed most beneficial included personalized treatment and re-entry plans, support for the individual and their environment and psychoeducation about the effects of ABI. Discussion: Although positive effects were reported in the studies reviewed, all studies had methodological limitations in terms of sample size, study design and outcome measures which affects the strength of the evidence. This limits strong conclusions and generalizability to the entire offender population. Conclusion: Despite high prevalence of ABI in offender populations, interventions in forensic settings seldom address the effect of ABI. The few studies that did take ABI into account reported positive effects, but those results should be interpreted with caution. Future studies are warranted, since this does seem an important venue to improve treatment, which could eventually contribute to reducing recidivism.

Predictors and outcomes of heart transplantation utilizing donors with different brain death mode: A propensity-score matching study from China.

BACKGROUND: Heart transplantation (HTx) of brain-dead donors in China has not been reported, not to mention analysis of donors with different brain death mechanisms. The present study aimed to compare clinical outcomes between HTx of traumatically brain-injured (TBI) and non-TBI donors, as well as to establish a risk-prediction model of mortality. METHODS: All patients undergoing HTx at our institute between January 1st, 2015 and December 31st, 2018 were dichotomized according to cause of donor death, and outcomes between the two groups were compared based on propensity score matching (PSM). The primary endpoint was all-cause mortality. Secondary endpoints included cardiac allograft vasculopathy and other postoperative complications. RESULTS: 342 eligible HTx recipients were included. TBI grafts accounted for 62.87% (215/342). 121 pairs of candidates were generated from PSM. Actuarial and risk-adjusted survival were similar between TBI and non-TBI groups. Risk factors associated with all-cause mortality included recipient age > 60y (HR = 2.781, p = .002), history of cardiac surgery (HR = 2.186, p = .032), chronic kidney disease (HR = 2.948, p = .033) and smoking (HR = 0.465, p = .041), as well as donor age > 45y (HR = 2.701, p = .003) and BMI > 25 kg/m2 (HR = 2.025, p = .045). The risk-prediction model was established successfully based on specific preoperative variables and high-risk group with a score>10 had nearly fourfold increase in mortality (HR = 3.726, p < 0.001) compared to the low-risk group. CONCLUSIONS: In this largest single-center cohort from China, we found similar survival and rates of complications between HTx recipients with TBI and non-TBI donors. The risk-prediction model may help to identify high-risked recipients and donors and optimize organ-sharing.

Brainstem dysfunction in critically ill patients.

The brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting.

Outcome predictors for severely brain-injured patients directly admitted or transferred from emergency departments to a trauma center / 世界急诊医学杂志（英文）

@#Dear editor, After sustaining severe traumatic brain injury (TBI), patients frequently require invasive mechanical ventilation (MV). However, up to 26% of patients require tracheostomy due to failure to wean from the ventilator.[1] The decision of when to perform tracheostomy is important as it balances the risk between avoiding prolonged MV and avoiding risk of tracheostomy. Early predictors for tracheostomy, i.e., clinical factors when patients first present to an Emergency Department after trauma or when patient first arrive at a regional trauma center, can help clinicians’ medical decision-making process.

Early Supported Discharge for Neurorehabilitation Following Acquired Brain Injury.

Introduction: Early Supported Discharge (ESD) is a clinical flow management service offering interdisciplinary rehabilitation, wherein patients are provided supported in-home rehabilitation treatment; in comparison to conventional hospital-based rehabilitation model of service delivery. There has been little research into the functional outcomes for other types of acquired brain injury (ABI). Methods: In this prospective cohort study, ABI patients presenting at a level I trauma center in Calgary, Canada were placed in either an ESD program or conventional inpatient rehabilitation (IPR) program based on their medical history and presentation. A small number of patients completed both programs (ESD+IPR group). ESD therapies were designed to emulate IPR. Participants completed professionally-rated Mayo-Portland Adaptability Index-4 (MPAI), Quality of Life after Brain Injury (QOLIBRI), Generalized Anxiety Questionnaire-7 (GAD7), Montreal Cognitive Assessment (MoCA), and Patient Health Questionnaire-9 (PHQ9) surveys at 1, 3, and 6 months following initial assessment pre-rehabilitation. Caregivers completed the Zarit Burden Interview (ZBI) at the same time points. The Supervision Rating Scale (SRS) and Disability Rating Scale (DRS) were completed at admission to rehabilitation and all follow-ups. Generalized estimate equations models were used to describe the three groups over time, including age as a covariate. Results: Significant effects of time were reported in the MPAI participant sub-score in the ESD and IPR groups ( χ ( 2 ) 2 = 42.429, p < 0.000; χ ( 2 ) 2 = 9.773, p = 0.008), showing significantly higher scores between 1 and 3 month timepoints for both groups. ZBI scores were significantly lower in the ESD group at 1 month compared to 3 and 6 months ( χ ( 2 ) 2 = 31.252, p < 0.001). The proportion of patients with medical complications during rehabilitation was 25.3% in ESD compared to 74.7% patients in IPR. Conclusions: Improvements in functional outcomes were evident in patients participating in ESD and IPR, with more medical complications reported in the IPR group. Caregiver burden lessened over time in the ESD group but not in the IPR group. Both ESD and ESD+IPR groups can be considered viable alternatives to traditional inpatient rehabilitation. A randomized control trial would be required to properly compare rehabilitation streams. Further investigation into affective and lifestyle elements of ABI recovery would also improve our understanding of targeted neurorehabilitation in this population.

A Critical Analysis of Joseph Fins' Mosaic Decisionmaking: A Response to "Mosaic Decisionmaking and Reemergent Agency after Severe Brain Injury" (CQ 27 (1)).

In this paper, the author argues that Joseph Fins' mosaic decisionmaking model for brain-injured patients is untenable. He supports this claim by identifying three problems with mosaic decisionmaking. First, that it is unclear whether a mosaic is a conceptually adequate metaphor for a decisionmaking process that is intended to promote patient autonomy. Second, that the proposed legal framework for mosaic decisionmaking is inappropriate. Third, that it is unclear how we ought to select patients for participation in mosaic decisionmaking.

Effect of Mechanical Horse Practice as New Postural Training in Patients With Neurological Disorders: A Pilot Study.

Objective: From a dynamic system approach, this study evaluated the impact of a new training protocol using a mechanical horse on the postural coordination of brain-damaged patients. Methods: Eighteen volunteer brain-damaged patients (i.e., post-stroke or traumatic brain injury) were recruited and randomly divided into an experimental group (horse group; n = 10, conventional therapy associated with horse-riding exercise on the mechanical horse for 30 min, twice a week, for 12 weeks) and a control group (n = 8; conventional therapy without intervention on the mechanical horse). Postural coordination was evaluated during pre- and post-tests through discrete relative phase (DRP) computation: ϕHead-Horse, ϕTrunk-Horse. Results: A significant effect of used training has been showed, F (1, 15) = 16.6 (p < 0.05) for all patients, concerning the trunk/horse coordination. Conclusion: This pilot study results showed the impact of this new training method on the postural coordination of these patients. After 24 sessions, the coordination of the horse group patients differed from that of the control group, showing their ability to adapt to constraints and develop specific modes of postural coordination (trunk/horse antiphase) to optimize their posture.

Behaviors Indicative of Pain in Brain-Injured Adult Patients With Different Levels of Consciousness in the Intensive Care Unit.

CONTEXT: Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited. OBJECTIVES: The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors. METHODS: Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3

Noninvasive continuous optical monitoring of absolute cerebral blood flow in critically ill adults.

We investigate a scheme for noninvasive continuous monitoring of absolute cerebral blood flow (CBF) in adult human patients based on a combination of time-resolved dynamic contrast-enhanced near-infrared spectroscopy (DCE-NIRS) and diffuse correlation spectroscopy (DCS) with semi-infinite head model of photon propogation. Continuous CBF is obtained via calibration of the DCS blood flow index (BFI) with absolute CBF obtained by intermittent intravenous injections of the optical contrast agent indocyanine green. A calibration coefficient ( γ ) for the CBF is thus determined, permitting conversion of DCS BFI to absolute blood flow units at all other times. A study of patients with acute brain injury ( N = 7 ) is carried out to ascertain the stability of γ . The patient-averaged DCS calibration coefficient across multiple monitoring days and multiple patients was determined, and good agreement between the two calibration coefficients measured at different times during single monitoring days was found. The patient-averaged calibration coefficient of 1.24 × 10 9 ( mL / 100 g / min ) / ( cm 2 / s ) was applied to previously measured DCS BFI from similar brain-injured patients; in this case, absolute CBF was underestimated compared with XeCT, an effect we show is primarily due to use of semi-infinite homogeneous models of the head.

Prevention of early ventilation-acquired pneumonia (VAP) in comatose brain-injured patients by a single dose of ceftriaxone: PROPHY-VAP study protocol, a multicentre, randomised, double-blind, placebo-controlled trial.

INTRODUCTION: Ventilator-associated pneumonia (VAP) is the first cause of healthcare-associated infections in intensive care units (ICUs) and brain injury is one of the main risk factors for early-onset VAP. Antibiotic prophylaxis has been reported to decrease their occurrence in brain-injured patients, but a lack of controlled randomised trials and the risk of induction of bacterial resistance explain the low level of recommendations. The goal of this study is to determine whether a single dose of ceftriaxone within the 12 hours postintubation after severe brain injury can decrease the risk of early-onset VAP. METHODS AND ANALYSIS: The PROPHY-VAP is a French multicentre, randomised, double-blind, placebo-controlled, clinical trial. Adult brain-injured patients (n=320) with a Glasgow Coma Scale ≤12, requiring mechanical ventilation for more than 48 hours, are randomised to receive either a single dose of ceftriaxone 2 g or a placebo within the 12 hours after tracheal intubation. The primary endpoint is the proportion of patients developing VAP from the 2nd to the 7th day after mechanical ventilation. Secondary endpoints include the proportion of patients developing late VAP (>7 days after tracheal intubation), the number of ventilator-free days, VAP-free days and antibiotic-free days, length of stay in the ICU, proportion of patients with ventilator-associated events and mortality during their ICU stay. ETHICS AND DISSEMINATION: The initial research project was approved by the Institutional Review Board of OUEST III (France) on 20 October 2014 (registration No 2014-001668-36) and carried out according to the principles of the Declaration of Helsinki and the Clinical Trials Directive 2001/20/EC of the European Parliament relating to the Good Clinical Practice guidelines. The results of this study will be presented in national and international meetings and published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02265406; Pre-results.

[Specificities of nursing care in neurological intensive care]. / Spécificités de la prise en charge infirmière en neuro-réanimation.

In the acute phase of the treatment of patients with brain injuries, the management of secondary brain injuries of systemic origin is a priority. A neurosurgical intensive care paramedical team shares their experience of the care delivered and the constant monitoring carried out to optimise, with the medical team, the patient's outcome and to innovate practices.