Emergency Department Risk Factors for Post-Concussion Syndrome After Mild Traumatic Brain Injury: A Systematic Review

轻度脑外伤后脑震荡后综合征急诊危险因素的系统评价

Approximately 16% of patients with mild traumatic brain injury (mTBI) develop a post-concussion syndrome (PCS) with persistent physical, neurological, and behavioral complaints. PCS has a great impact on a patient's quality of life, often decreases the ability to return to work, and henceforth has a great economic impact. Recent studies suggest that early treatment can greatly improve prognosis and prevent long-term effects in these patients. However, early recognition of patients at high risk of PCS remains difficult. The objective of this systematic review is to assess risk factors associated with the development of PCS, primarily aimed at the group of non-hospitalized patients who were seen with mTBI at the emergency department (ED). We searched PubMed/MEDLINE, Cochrane Library and EMBASE on September 23, 2022, for prospective studies that assessed the risk factors for the development of PCS. Exclusion criteria were: retrospective studies; > 20% computed tomography (CT) abnormalities, <18 years of age, follow-up <4 weeks, severe trauma, and study population <100 patients. The search strategy identified 1628 articles, of which 17 studies met eligibility criteria. Risk factors found in this systematic review are pre-existing psychiatric history, headache at the ED, neurological symptoms at the ED, female sex, CT abnormalities, pre-existent sleeping problems, and neck pain at the ED. This systematic review identified seven risk factors for development of PCS in patients with mTBI. Future research should assess if implementation of these risk factors into a risk stratification tool will assist the emergency physician in the identification of patients at high risk of PCS.

大约16% % 的轻度创伤性脑损伤 (mTBI) 患者会出现脑震荡后综合征 (PCS)，并伴有持续的身体，神经和行为不适。PCS对患者的生活质量有很大的影响，通常会降低重返工作岗位的能力，因此具有很大的经济影响。最近的研究表明，早期治疗可以大大改善预后，并防止这些患者的长期影响。然而，早期识别PCS高风险患者仍然很困难。本系统评价的目的是评估与PCS发展相关的危险因素，主要针对在急诊科 (ED) 发现mTBI的非住院患者。我们于2022年9月23日检索了PubMed/MEDLINE，Cochrane Library和EMBASE，以进行评估PCS发展风险因素的前瞻性研究。排除标准为: 回顾性研究> 20% 计算机断层扫描 (CT) 异常，<18岁，随访 <4周，严重创伤，研究人群 <100例患者。搜索策略确定了1628篇文章，其中17项研究符合资格标准。本系统回顾中发现的危险因素是先前存在的精神病史，ED头痛，ED神经系统症状，女性，CT异常，先前存在的睡眠问题以及ED颈部疼痛。本系统评价确定了mTBI患者发生PCS的七个危险因素。未来的研究应评估将这些风险因素实施到风险分层工具中是否将有助于急诊医师识别PCS高风险的患者。

REF: Lubbers VF, van den Hoven DJ, van der Naalt J, Jellema K, van den Brand C, Backus B. Emergency Department Risk Factors for Post-Concussion Syndrome After Mild Traumatic Brain Injury: A Systematic Review. J Neurotrauma. 2024;41(11-12):1253-1270. doi:10.1089/neu.2023.0302 PMID: 38390830

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Comparing Randomized Controlled Trials of Moderate to Severe Traumatic Brain Injury in Lower to Middle Income Countries Versus High Income Countries

中低收入国家与高收入国家中重度创伤性脑损伤随机对照试验的比较

Outcomes from traumatic brain injury (TBI) including death differ significantly between high-, middle-, and low-income countries. Little is known, however, about differences in TBI research across the globe. The objective of this article was to examine randomized controlled trials (RCTs) of moderate-to-severe TBI in high-income countries (HICs) compared with low- and middle-income countries (LMICs), as defined by the World Bank income per capita cutoff of $13,205 US dollars. A systematic review was conducted for articles published in the English language to December 2022 inclusive using MEDLINE, PubMed, Scopus, CINAHL, EMBASE, and PsycINFO in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria: (1) human participants with a mean age of ≥18 years; (2) ≥50% of the sample had moderate to severe TBI; and (3) the study design was a RCT. Data extracted included author, year, country, sample size, primary focus (medical/surgical management or rehabilitation), injury etiology, time post-injury, and indicator(s) used to define TBI severity. There were 662 RCTs (published 1978-2022) that met inclusion criteria comprising 91,946 participants. There were 48 countries represented: 30 HICs accounting for 451 RCTs (68.1%) and 18 LMICs accounting for 211 RCTs (31.9%). The 62.6% of RCTs from LMICs were conducted in the acute phase post-injury (≤1 month) compared with 42.1% of RCTs from HICs. Of RCTs from LMICs, 92.4% focused on medical/surgical management compared with 52.5% from HICs. Since 2016, more RCTs have been conducted in LMICs than in HICs, indicating the importance of better understanding this pattern of research output.

包括死亡在内的创伤性脑损伤 (TBI) 的结局在高，中等和低收入国家之间存在显着差异。然而，关于全球TBI研究的差异知之甚少。本文的目的是研究高收入国家 (hic) 与低收入和中等收入国家 (LMICs) 相比，中度至重度TBI的随机对照试验 (rct)，根据世界银行人均收入13,205美元的定义。使用MEDLINE、PubMed、Scopus、CINAHL、EMBASE和PsycINFO，根据系统评价和荟萃分析首选报告项目 (PRISMA) 指南，对2022年12月以英语发表的文章进行系统评价。纳入标准 :( 1) 平均年龄 ≥ 18岁的参与者; (2) ≥ 50% % 的样本患有中度至重度TBI; (3) 研究设计为RCT。提取的数据包括作者，年份，国家，样本量，主要重点 (医疗/手术管理或康复)，损伤病因，损伤后时间和用于定义TBI严重程度的指标。有662项rct (已发表的1978-2022) 符合纳入标准，包括91,946名参与者。有48个国家代表: 30个HICs占451个rct (68.1%)，18个LMICs占211个rct (31.9%)。与来自HICs的rct 42.1% 相比，来自lmic的rct 62.6% 在损伤后急性期 (≤ 1个月) 进行。在LMICs的随机对照试验中，92.4% 项侧重于医疗/外科管理，而52.5% 项来自HICs。自2016以来，在lmic中进行的rct比在hic中进行的更多，这表明了更好地理解这种研究输出模式的重要性。

REF: Teasell R, Flores-Sandoval C, Janzen S, et al. Comparing Randomized Controlled Trials of Moderate to Severe Traumatic Brain Injury in Lower to Middle Income Countries Versus High Income Countries. J Neurotrauma. 2024;41(11-12):1271-1281. doi:10.1089/neu.2023.0383 PMID: 38450568

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Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review

使用经颅多普勒超声对创伤性脑损伤进行颅内压监测的无创方法:描述性系统综述

Intracranial pressure (ICP) monitoring is necessary for managing patients with traumatic brain injury (TBI). Although gold-standard methods include intraventricular or intraparenchymal transducers, these systems cannot be used in patients with coagulopathies or in those who are at high risk of catheter-related infections, nor can they be used in resource-constrained settings. Therefore, a non-invasive modality that is more widely available, cost effective, and safe would have tremendous impact. Among such non-invasive choices, transcranial Doppler (TCD) provides indirect ICP estimates through waveform analysis of cerebral hemodynamic changes. The objective of this scoping review is to describe the existing evidence for the use of TCD-derived methods in estimating ICP in adult TBI patients as compared with gold-standard invasive methods. TCD-derived methods could be useful in assessing ICP changes instead of absolute ICP values for high-risk patients, especially in low-resource settings.

颅内压 (ICP) 监测对于管理创伤性脑损伤 (TBI) 患者是必要的。尽管金标准方法包括心室内或实质内换能器，但这些系统不能用于凝血病患者或导管相关感染风险高的患者，也不能用于资源受限的环境。因此，更广泛可用、成本有效且安全的非侵入性模态将具有巨大影响。在这些非侵入性选择中，经颅多普勒 (TCD) 通过脑血流动力学变化的波形分析提供间接ICP估计。这项综述的目的是描述与金标准侵入性方法相比，使用TCD衍生方法评估成人TBI患者ICP的现有证据。TCD衍生方法可用于评估高危患者的ICP变化，而不是绝对ICP值，尤其是在资源匮乏的情况下。

REF: Martínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM. Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review. J Neurotrauma. 2024;41(11-12):1282-1298. doi:10.1089/neu.2023.0001 PMID: 37861291

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Head Injury Treatment With Healthy and Advanced Dietary Supplements: A Pilot Randomized Controlled Trial of the Tolerability, Safety, and Efficacy of Branched Chain Amino Acids in the Treatment of Concussion in Adolescents and Young Adults

健康和高级膳食补充剂治疗颅脑损伤: 支链氨基酸治疗青少年脑震荡的耐受性，安全性和有效性的初步随机对照试验

Concussion is a common injury in the adolescent and young adult populations. Although branched chain amino acid (BCAA) supplementation has shown improvements in neurocognitive and sleep function in pre-clinical animal models of mild-to-moderate traumatic brain injury (TBI), to date, no studies have been performed evaluating the efficacy of BCAAs in concussed adolescents and young adults. The goal of this pilot trial was to determine the efficacy, tolerability, and safety of varied doses of oral BCAA supplementation in a group of concussed adolescents and young adults. The findings provide important preliminary data to inform a larger trial of BCAA therapy to expedite concussion recovery.

脑震荡是青少年和年轻成年人的常见伤害。尽管支链氨基酸 (BCAA) 补充剂已在轻度至中度创伤性脑损伤 (TBI) 的临床前动物模型中显示出神经认知和睡眠功能的改善，但迄今为止，尚无研究评估BCAA在脑震荡的青少年和年轻人中的功效。这项初步试验的目的是确定在一组脑震荡的青少年和年轻人中口服不同剂量的BCAA补充剂的功效，耐受性和安全性。这些发现提供了重要的初步数据，为BCAA治疗加速脑震荡恢复的大型试验提供了信息。

REF: Corwin DJ, Myers SR, Arbogast KB, et al. Head Injury Treatment With Healthy and Advanced Dietary Supplements: A Pilot Randomized Controlled Trial of the Tolerability, Safety, and Efficacy of Branched Chain Amino Acids in the Treatment of Concussion in Adolescents and Young Adults. J Neurotrauma. 2024;41(11-12):1299-1309. doi:10.1089/neu.2023.0433 PMID: 38468511

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Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI) Study

头部计算机断层扫描中孤立的创伤性蛛网膜下腔出血可能不是孤立的: 创伤性脑损伤研究 (TRACK-TBI) 的转化和临床知识

Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The findings should be interpreted cautiously given our small sample size and await validation from larger studies.

头部计算机断层扫描 (CT) 扫描的创伤性脑损伤 (TBI) 后孤立的创伤性蛛网膜下腔出血 (tSAH) 通常被认为是 “轻度” 损伤，减少了对其他检查的需求。然而，tSAH也是不完全恢复和不利结果的预测因子。本研究旨在评估急诊科 (ED) 到达格拉斯哥昏迷量表 (GCS) 评分13-15和CT上孤立的tSAH的TBI患者脑磁共振成像 (MRI) 扫描中CT隐匿性颅内损伤的特征。鉴于我们的样本量较小，因此应谨慎解释这些发现，并等待大型研究的验证。

REF: Yue JK, Yuh EL, Elguindy MM, et al. Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI) Study. J Neurotrauma. 2024;41(11-12):1310-1322. doi:10.1089/neu.2023.0253 PMID: 38450561

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Development of a Multimodal Machine Learning-Based Prognostication Model for Traumatic Brain Injury Using Clinical Data and Computed Tomography Scans: A CENTER-TBI and CINTER-TBI Study

使用临床数据和计算机断层扫描开发基于多模态机器学习的创伤性脑损伤预测模型: CENTER-TBI和CINTER-TBI研究

Computed tomography (CT) is an important imaging modality for guiding prognostication in patients with traumatic brain injury (TBI). However, because of the specialized expertise necessary, timely and dependable TBI prognostication based on CT imaging remains challenging. This study aimed to enhance the efficiency and reliability of TBI prognostication by employing machine learning (ML) techniques on CT images. This study established an ML-based model that provides efficient and reliable TBI prognosis based on CT scans, with potential implications for earlier intervention and improved patient outcomes.

计算机断层扫描 (CT) 是指导颅脑外伤 (TBI) 患者预后的重要成像方式。然而，由于需要专门的专业知识，基于CT成像的及时可靠的TBI预后仍然具有挑战性。本研究旨在通过在CT图像上采用机器学习 (ML) 技术来提高TBI预测的效率和可靠性。这项研究建立了基于ML的模型，该模型基于ct扫描提供了有效且可靠的TBI预后，对早期干预和改善患者预后具有潜在意义。

REF: Hibi A, Cusimano MD, Bilbily A, Krishnan RG, Tyrrell PN. Development of a Multimodal Machine Learning-Based Prognostication Model for Traumatic Brain Injury Using Clinical Data and Computed Tomography Scans: A CENTER-TBI and CINTER-TBI Study. J Neurotrauma. 2024;41(11-12):1323-1336. doi:10.1089/neu.2023.0446 PMID: 38279813

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Predicting Hematoma Expansion and Prognosis in Cerebral Contusions: A Radiomics-Clinical Approach

预测脑挫伤的血肿扩大和预后: 影像组学-临床方法

Hemorrhagic progression of contusion (HPC) often occurs early in cerebral contusions (CC) patients, significantly impacting their prognosis. It is vital to promptly assess HPC and predict outcomes for effective tailored interventions, thereby enhancing prognosis in CC patients. We utilized the Attention-3DUNet neural network to semi-automatically segment hematomas from computed tomography (CT) images of 452 CC patients, incorporating 695 hematomas. Subsequently, 1502 radiomic features were extracted from 358 hematomas in 261 patients. After a selection process, these features were used to calculate the radiomic signature (Radscore). The Radscore, along with clinical features such as medical history, physical examinations, laboratory results, and radiological findings, was employed to develop predictive models. For prognosis (discharge Glasgow Outcome Scale score), radiomic features of each hematoma were augmented and fused for correlation. We employed various machine learning methodologies to create both a combined model, integrating radiomics and clinical features, and a clinical-only model. Nomograms based on logistic regression were constructed to visually represent the predictive procedure, and external validation was performed on 170 patients from three additional centers. Predictive models that combine radiomic and clinical features exhibit robust performance in forecasting HPC and the risk of poor prognosis in CC patients. Radiomic features complement clinical features in predicting HPC, although their ability to enhance the predictive accuracy of the clinical model for adverse prognosis is limited.

挫伤出血进展 (HPC) 通常发生在脑挫裂伤 (CC) 患者的早期，严重影响其预后。及时评估HPC并预测有效的量身定制干预措施的结果至关重要，从而改善CC患者的预后。我们利用Attention-3DUNet神经网络从452例CC患者的计算机断层扫描 (CT) 图像中半自动分割血肿，其中包括695个血肿。随后，从261例患者的358个血肿中提取了1502个影像组学特征。在选择过程之后，这些特征用于计算放射组学特征 (Radscore)。Radscore以及临床特征，例如病史，体格检查，实验室检查结果和放射学发现，被用来开发预测模型。对于预后 (出院格拉斯哥预后量表评分)，增强每个血肿的影像组学特征并融合以进行相关性。我们采用各种机器学习方法来创建组合模型，整合影像组学和临床特征。我们构建了基于逻辑回归的列线图，以直观地表示预测程序，并对来自另外三个中心的170名患者进行了外部验证。结合影像组学和临床特征的预测模型在预测CC患者的HPC和不良预后风险方面表现出强大的性能。影像组学特征补充了预测HPC的临床特征，尽管它们增强不良预后临床模型的预测准确性的能力有限。

REF: He H, Liu J, Li C, et al. Predicting Hematoma Expansion and Prognosis in Cerebral Contusions: A Radiomics-Clinical Approach. J Neurotrauma. 2024;41(11-12):1337-1352. doi:10.1089/neu.2023.0410 PMID: 38326935

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Diagnostic Utility of Glial Fibrillary Acidic Protein Beyond 12 Hours After Traumatic Brain Injury: A TRACK-TBI Study

创伤性脑损伤后12小时内胶质纤维酸性蛋白的诊断效用: track-tbi研究

Blood levels of glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1) within 12h of suspected traumatic brain injury (TBI) have been approved by the Food and Drug administration to aid in determining the need for a brain computed tomography (CT) scan. The current study aimed to determine whether this context of use can be expanded beyond 12h post-TBI in patients presenting with Glasgow Coma Scale (GCS) 13-15. This study demonstrates the utility of GFAP to aid in decision-making for diagnostic brain CT imaging beyond the 12h time frame in patients with TBI who have a GCS 13-15.

疑似创伤性脑损伤 (TBI) 后12小时内的神经胶质纤维酸性蛋白 (GFAP) 和泛素羧基末端hydrolase-L1 (UCH-L1) 的血液水平已获得美国食品和药物管理局的批准，以帮助确定是否需要进行脑部计算机断层扫描 (CT) 扫描。当前的研究旨在确定在格拉斯哥昏迷量表 (GCS) 13-15的患者中，这种使用环境是否可以扩展到TBI后12小时以上。这项研究证明了GFAP的实用性，可帮助GCS 13-15的TBI患者在12小时后进行诊断性脑部CT成像的决策。

REF: Puccio AM, Yue JK, Korley FK, et al. Diagnostic Utility of Glial Fibrillary Acidic Protein Beyond 12 Hours After Traumatic Brain Injury: A TRACK-TBI Study. J Neurotrauma. 2024;41(11-12):1353-1363. doi:10.1089/neu.2023.0186 PMID: 38251868

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Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury

早期脑室外引流插入与中重度创伤性脑损伤后6个月的功能结局之间的关联

Traumatic brain injury (TBI) is a leading global cause of morbidity and mortality. Intracranial hypertension following moderate-to-severe TBI (m-sTBI) is a potentially modifiable secondary cerebral insult and one of the central therapeutic targets of contemporary neurocritical care. External ventricular drain (EVD) insertion is a common therapeutic intervention used to control intracranial hypertension and attenuate secondary brain injury. However, the optimal timing of EVD insertion in the setting of m-sTBI is uncertain and practice variation is widespread. Therefore, we aimed to assess if there is an association between timing of EVD placement and functional neurological outcome at 6 months post m-sTBI. Our study suggests that in patients with m-sTBI where an EVD is needed, early (≤ 24 h post-injury) insertion may result in better long-term functional outcomes. This finding supports future prospective investigation in this area.

创伤性脑损伤 (TBI) 在全球疾病的发病率和死亡率中的占比很高。中度至重度TBI (m-stbi) 后的颅内高压是一种潜在的可改变的继发性脑损伤，并且是当代神经重症监护的主要治疗目标之一。脑室外引流 (EVD) 是用于控制颅内高压和减轻继发性脑损伤的常见治疗手段。然而，在m-stbi的设置中EVD插入的最佳时间是不确定的，并且实践变化是普遍的。因此，我们旨在评估m-stbi后6个月时EVD放置时间与功能性神经学结果之间是否存在关联。我们的研究表明，在需要EVD的m-stbi患者中，早期 (损伤后 ≤ 24小时) 插入可能会导致更好的长期功能结局。这一发现支持未来在这一领域的前瞻性调查。

REF: Taylor JD, Bailey M, Cooper DJ, et al. Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma. 2024;41(11-12):1364-1374. doi:10.1089/neu.2023.0493 PMID: 38279804

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