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Medina Carrion JP, Stanziano M, D'Incerti L, Sattin D, Palermo S, Ferraro S, Sebastiano DR, Leonardi M, Bruzzone MG, Rosazza C, Nigri A. Disorder of consciousness: Structural integrity of brain networks for the clinical assessment. Ann Clin Transl Neurol 2023; 10:384-396. [PMID: 36638220 PMCID: PMC10014003 DOI: 10.1002/acn3.51729] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/28/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
AIM When studying brain networks in patients with Disorders of Consciousness (DoC), it is important to evaluate the structural integrity of networks in addition to their functional activity. Here, we investigated whether structural MRI, together with clinical variables, can be useful for diagnostic purposes and whether a quantitative analysis is feasible in a group of chronic DoC patients. METHODS We studied 109 chronic patients with DoC and emerged from DoC with structural MRI: 65 in vegetative state/unresponsive wakefulness state (VS/UWS), 34 in minimally conscious state (MCS), and 10 with severe disability. MRI data were analyzed through qualitative and quantitative approaches. RESULTS The qualitative MRI analysis outperformed the quantitative one, which resulted to be hardly feasible in chronic DoC patients. The results of the qualitative approach showed that the structural integrity of HighOrder networks, altogether, had better diagnostic accuracy than LowOrder networks, particularly when the model included clinical variables (AUC = 0.83). Diagnostic differences between VS/UWS and MCS were stronger in anoxic etiology than vascular and traumatic etiology. MRI data of all LowOrder and HighOrder networks correlated with the clinical score. The integrity of the left hemisphere was associated with a better clinical status. CONCLUSIONS Structural integrity of brain networks is sensitive to clinical severity. When patients are chronic, the qualitative analysis of MRI data is indicated.
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Affiliation(s)
- Jean Paul Medina Carrion
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mario Stanziano
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Neurosciences Department "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Ludovico D'Incerti
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Radiology Unit, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - Davide Sattin
- IRCCS Istituti Clinici Scientifici Maugeri di Milano, Milan, Italy
| | - Sara Palermo
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Psychology, University of Turin, Turin, Italy
| | - Stefania Ferraro
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,School of Life Science and Technology, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
| | - Davide Rossi Sebastiano
- Department of Neurophysiology and Diagnostic, Epileptology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Maria Grazia Bruzzone
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Cristina Rosazza
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Humanistic Studies, University of Urbino Carlo Bo, Urbino, Italy
| | - Anna Nigri
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Ruzinak R, Bittsansky M, Martinikova M, Nosal V, Kantorova E, Ballova J, Turcanova Koprusakova M, Hnilicova P, Grendar M, Dusenka R, Kolarovszki B, Zelenak K, Kurca E, Sivak S. Proton magnetic resonance spectroscopy changes in the brainstem in patients after mild traumatic brain injury with loss of consciousness. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 166:84-90. [PMID: 33976431 DOI: 10.5507/bp.2021.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/26/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Loss of consciousness (LOC) is used as a diagnostic feature of mild traumatic brain injury (MTBI). However, only 10% of concussions result in LOC. There are only a limited number of in-vivo studies dealing with unconsciousness and structural and functional integrity of the brainstem in patients with MTBI. The aim of our pilot study was to assess the sensitivity of proton magnetic resonance spectroscopy (1H-MRS) to detect metabolic changes in the brainstem in patients after MTBI with unconscioussness. METHODS Twenty-four patients (12 with LOC, and 12 without LOC) within 3 days of MTBI and 19 healthy controls were examined. All subjects underwent single-voxel 1H-MRS examination of the upper brainstem. Spectra were evaluated using LCModel software. Ratios of total N-acetylaspartate (tNAA), total choline-containing compounds (tCho) and glutamate plus glutamine (Glx) to total creatine (tCre) were used for calculations. RESULTS We found a significant decrease in tNAA/tCre and tCho/tCre ratios in the patient group with LOC when compared with the control group of healthy volunteers (P=0.002 and P=0.041, respectively), and a significant decrease in the tNAA/tCre ratio in the LOC group when compared with patients without LOC (P=0.04). Other metabolite ratios in the brainstem did not show any significant group differences. CONCLUSION Our findings indicate that decrease of tNAA/tCre ratio in the upper brainstem using single-voxel 1H-MRS may provide a potential biomarker for MTBI associated with LOC.
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Affiliation(s)
- Robert Ruzinak
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Michal Bittsansky
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratilava, Slovak Republic
| | - Martina Martinikova
- Department of Neurology, F.D. Roosevelt Hospital, Banska Bystrica, Slovak Republic
| | - Vladimir Nosal
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Ema Kantorova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Jana Ballova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Monika Turcanova Koprusakova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Petra Hnilicova
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratilava, Slovak Republic
| | - Marian Grendar
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratilava, Slovak Republic
| | | | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Egon Kurca
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
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Weppner J, Ide W, Tu J, Boomgaardt J, Chang A, Suskauer S. Prognostication and Determinants of Outcome in Adults and Children with Moderate-to-Severe Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00298-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Portnova G, Girzhova I, Filatova D, Podlepich V, Tetereva A, Martynova O. Brain Oscillatory Activity during Tactile Stimulation Correlates with Cortical Thickness of Intact Areas and Predicts Outcome in Post-Traumatic Comatose Patients. Brain Sci 2020; 10:brainsci10100720. [PMID: 33053681 PMCID: PMC7601666 DOI: 10.3390/brainsci10100720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/23/2020] [Accepted: 10/07/2020] [Indexed: 11/24/2022] Open
Abstract
In this study, we have reported a correlation between structural brain changes and electroencephalography (EEG) in response to tactile stimulation in ten comatose patients after severe traumatic brain injury (TBI). Structural morphometry showed a decrease in whole-brain cortical thickness, cortical gray matter volume, and subcortical structures in ten comatose patients compared to fifteen healthy controls. The observed decrease in gray matter volume indicated brain atrophy in coma patients induced by TBI. In resting-state EEG, the power of slow-wave activity was significantly higher (2–6 Hz), and the power of alpha and beta rhythms was lower in coma patients than in controls. During tactile stimulation, coma patients’ theta rhythm power significantly decreased compared to that in the resting state. This decrease was not observed in the control group and correlated positively with better coma outcome and the volume of whole-brain gray matter, the right putamen, and the insula. It correlated negatively with the volume of damaged brain tissue. During tactile stimulation, an increase in beta rhythm power correlated with the thickness of patients’ somatosensory cortex. Our results showed that slow-wave desynchronization, as a nonspecific response to tactile stimulation, may serve as a sensitive index of coma outcome and morphometric changes after brain injury.
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Affiliation(s)
- Galina Portnova
- Human High Nervous Activity Laboratory, Institute of Higher Nervous Activity and Neurophysiology of the Russian Academy of Science, 5A Butlerova str., 117485 Moscow, Russia; (A.T.); (O.M.)
- Correspondence: ; Tel.: +7-9031256186
| | - Irina Girzhova
- Faculty of Medicine, Lomonosov Moscow State University, 27 Lomonosovsky pr-t., 119991 Moscow, Russia; (I.G.); (D.F.)
| | - Daria Filatova
- Faculty of Medicine, Lomonosov Moscow State University, 27 Lomonosovsky pr-t., 119991 Moscow, Russia; (I.G.); (D.F.)
| | - Vitaliy Podlepich
- Federal State Autonomous Institution N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, 16 4-ya Tverskaya-Yamskaya str., 125047 Moscow, Russia;
| | - Alina Tetereva
- Human High Nervous Activity Laboratory, Institute of Higher Nervous Activity and Neurophysiology of the Russian Academy of Science, 5A Butlerova str., 117485 Moscow, Russia; (A.T.); (O.M.)
| | - Olga Martynova
- Human High Nervous Activity Laboratory, Institute of Higher Nervous Activity and Neurophysiology of the Russian Academy of Science, 5A Butlerova str., 117485 Moscow, Russia; (A.T.); (O.M.)
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Snider SB, Bodien YG, Bianciardi M, Brown EN, Wu O, Edlow BL. Disruption of the ascending arousal network in acute traumatic disorders of consciousness. Neurology 2019; 93:e1281-e1287. [PMID: 31484715 DOI: 10.1212/wnl.0000000000008163] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/30/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether ascending arousal network (AAn) connectivity is reduced in patients presenting with traumatic coma. METHODS We performed high-angular-resolution diffusion imaging in 16 patients with acute severe traumatic brain injury who were comatose on admission and in 16 matched controls. We used probabilistic tractography to measure the connectivity probability (CP) of AAn axonal pathways linking the brainstem tegmentum to the hypothalamus, thalamus, and basal forebrain. To assess the spatial specificity of CP differences between patients and controls, we also measured CP within 4 subcortical pathways outside the AAn. RESULTS Compared to controls, patients showed a reduction in AAn pathways connecting the brainstem tegmentum to a region of interest encompassing the hypothalamus, thalamus, and basal forebrain. When each pathway was examined individually, brainstem-hypothalamus and brainstem-thalamus CPs, but not brainstem-forebrain CP, were significantly reduced in patients. Only 1 subcortical pathway outside the AAn showed reduced CP in patients. CONCLUSIONS We provide initial evidence for the reduced integrity of axonal pathways linking the brainstem tegmentum to the hypothalamus and thalamus in patients presenting with traumatic coma. Our findings support current conceptual models of coma as being caused by subcortical AAn injury. AAn connectivity mapping provides an opportunity to advance the study of human coma and consciousness.
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Affiliation(s)
- Samuel B Snider
- From the Center for Neurotechnology and Neurorecovery (S.B.S., Y.G.B., B.L.E.), Department of Neurology, and Department of Anesthesiology (E.N.B.), Massachusetts General Hospital, Boston; Department of Physical Medicine and Rehabilitation (Y.G.B.), Spaulding Rehabilitation Hospital, Charlestown, MA; Department of Radiology (M.B., O.W., B.L.E.), Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown; Department of Brain and Cognitive Sciences (E.N.B.), Massachusetts Institute of Technology; and Harvard-MIT Division of Health Science and Technology (E.N.B.), Cambridge, MA
| | - Yelena G Bodien
- From the Center for Neurotechnology and Neurorecovery (S.B.S., Y.G.B., B.L.E.), Department of Neurology, and Department of Anesthesiology (E.N.B.), Massachusetts General Hospital, Boston; Department of Physical Medicine and Rehabilitation (Y.G.B.), Spaulding Rehabilitation Hospital, Charlestown, MA; Department of Radiology (M.B., O.W., B.L.E.), Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown; Department of Brain and Cognitive Sciences (E.N.B.), Massachusetts Institute of Technology; and Harvard-MIT Division of Health Science and Technology (E.N.B.), Cambridge, MA
| | - Marta Bianciardi
- From the Center for Neurotechnology and Neurorecovery (S.B.S., Y.G.B., B.L.E.), Department of Neurology, and Department of Anesthesiology (E.N.B.), Massachusetts General Hospital, Boston; Department of Physical Medicine and Rehabilitation (Y.G.B.), Spaulding Rehabilitation Hospital, Charlestown, MA; Department of Radiology (M.B., O.W., B.L.E.), Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown; Department of Brain and Cognitive Sciences (E.N.B.), Massachusetts Institute of Technology; and Harvard-MIT Division of Health Science and Technology (E.N.B.), Cambridge, MA
| | - Emery N Brown
- From the Center for Neurotechnology and Neurorecovery (S.B.S., Y.G.B., B.L.E.), Department of Neurology, and Department of Anesthesiology (E.N.B.), Massachusetts General Hospital, Boston; Department of Physical Medicine and Rehabilitation (Y.G.B.), Spaulding Rehabilitation Hospital, Charlestown, MA; Department of Radiology (M.B., O.W., B.L.E.), Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown; Department of Brain and Cognitive Sciences (E.N.B.), Massachusetts Institute of Technology; and Harvard-MIT Division of Health Science and Technology (E.N.B.), Cambridge, MA
| | - Ona Wu
- From the Center for Neurotechnology and Neurorecovery (S.B.S., Y.G.B., B.L.E.), Department of Neurology, and Department of Anesthesiology (E.N.B.), Massachusetts General Hospital, Boston; Department of Physical Medicine and Rehabilitation (Y.G.B.), Spaulding Rehabilitation Hospital, Charlestown, MA; Department of Radiology (M.B., O.W., B.L.E.), Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown; Department of Brain and Cognitive Sciences (E.N.B.), Massachusetts Institute of Technology; and Harvard-MIT Division of Health Science and Technology (E.N.B.), Cambridge, MA
| | - Brian L Edlow
- From the Center for Neurotechnology and Neurorecovery (S.B.S., Y.G.B., B.L.E.), Department of Neurology, and Department of Anesthesiology (E.N.B.), Massachusetts General Hospital, Boston; Department of Physical Medicine and Rehabilitation (Y.G.B.), Spaulding Rehabilitation Hospital, Charlestown, MA; Department of Radiology (M.B., O.W., B.L.E.), Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown; Department of Brain and Cognitive Sciences (E.N.B.), Massachusetts Institute of Technology; and Harvard-MIT Division of Health Science and Technology (E.N.B.), Cambridge, MA.
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Prediction of Minimally Conscious State With Brain Stem Reflexes in Unconscious Patients After Traumatic Brain Injury. J Craniofac Surg 2019; 30:1942-1945. [PMID: 30908437 DOI: 10.1097/scs.0000000000005404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the predictive power of the brain stem reflexes (BSRs) for minimally conscious state in unconscious patients after traumatic brain injury. MATERIALS AND METHODS A total of 120 patients with duration of unconsciousness were enrolled in this study. BSRs were recorded 14 days after Traumatic brain injury, and classified into 3 grades. Predictors including BSRs, age, sex, Glasgow Coma Scale (GCS), and cause of injury were also analyzed, respectively. The outcome was divided into 2 groups including unconscious group and minimally conscious state (MCS) group. RESULTS Seventy-two of 120 were minimally conscious and 48 of 120 were unconscious at 6 months from the onset of injury. The BSRs outmatched the predictive accuracy of the GCS for outcome (AUROC, 0.853; 95% confidence interval, 0.753-0.953; and AUROC, 0.655; 95% confidence interval, 0.512-0.799, respectively). BSRs grade (P < 0.001) and GCS (P < 0.05) were significantly associated with the outcome. The accuracy of the whole regression model for predicting unconscious and MCS was 91.7% and 79.2%, respectively. CONCLUSION The BSRs grade shows a significantly higher accuracy for prediction of MCS compared with the GCS. BSRs grade is a simple, yet reliable and stratification tool for early decision making.
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van Eijck MM, Sprengers MO, Oldenbeuving AW, de Vries J, Schoonman GG, Roks G. The use of the PSH-AM in patients with diffuse axonal injury and autonomic dysregulation: A cohort study and review. J Crit Care 2019; 49:110-117. [DOI: 10.1016/j.jcrc.2018.10.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 09/17/2018] [Accepted: 10/25/2018] [Indexed: 01/19/2023]
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Wu B, Yang Y, Zhou S, Wang W, Wang Z, Hu G, He J, Wu X. Could Arterial Spin Labeling Distinguish Patients in Minimally Conscious State from Patients in Vegetative State? Front Neurol 2018; 9:110. [PMID: 29551989 PMCID: PMC5840257 DOI: 10.3389/fneur.2018.00110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/14/2018] [Indexed: 01/12/2023] Open
Abstract
Purpose Diagnostic error is common among patients with vegetative state (VS) and minimally conscious state (MCS). The purpose of this article is to use three-dimensional pseudo-continuous arterial spin labeling (pcASL) to compare cerebral blood flow (CBF) patterns in patients in MCS with those in VS. Methods Patients meeting MCS and VS criteria were identified. Two post-labeling delay (PLD) time pcASL on 3.0-Tesla magnetic resonance imaging scanner system were performed with patients in the resting awake state. After registration to T1WI structure imaging, multiple brain regions of interest of ASL CBF map were automatically separated. The average CBF value of every brain region was calculated and compared between the MCS and VS groups with t-tests. Results Fifteen patients with VS were identified, with ages ranging from 33 to 71 years. Eight patients who met the MCS criteria ranged in age from 23 to 61 years. Compared with VS, the regional CBF for MCS had a pattern of significantly increased CBF in the regions including the putamen, anterior cingulate gyrus, and medial frontal cortex. A left-lateralized pattern was observed to differentiate MCS from VS. CBF with PLD 2.5 s could find more regions of pattern differentiating MCS from VS than with PLD 1.5 s, except for the pallidum. Conclusion MCS might be differentiated from VS by different ranges of regional CBF as measured by ASL. Multi-PLD ASL may serve as an adjunct method to separate MCS from VS and assess functional reserve in patients recovering from severe brain injuries.
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Affiliation(s)
- Bing Wu
- Department of Radiology, PLA Army General Hospital, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Shuai Zhou
- Inner Mongolia Medical University, Hohhot, China
| | - Wei Wang
- Department of Radiology, PLA Army General Hospital, Beijing, China
| | - Zizhen Wang
- Department of Radiology, PLA Army General Hospital, Beijing, China
| | - Gang Hu
- Department of Radiology, PLA Army General Hospital, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Xinhuai Wu
- Department of Radiology, PLA Army General Hospital, Beijing, China.,Inner Mongolia Medical University, Hohhot, China
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Yawning-Its anatomy, chemistry, role, and pathological considerations. Prog Neurobiol 2017; 161:61-78. [PMID: 29197651 DOI: 10.1016/j.pneurobio.2017.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 10/29/2017] [Accepted: 11/28/2017] [Indexed: 12/11/2022]
Abstract
Yawning is a clinical sign of the activity of various supra- and infratentorial brain regions including the putative brainstem motor pattern, hypothalamic paraventricular nucleus, probably the insula and limbic structures that are interconnected via a fiber network. This interaction can be seen in analogy to other cerebral functions arising from a network or zone such as language. Within this network, yawning fulfills its function in a stereotype, reflex-like manner; a phylogenetically old function, preserved across species barriers, with the purpose of arousal, communication, and maybe other functions including respiration. Abnormal yawning with ≥3 yawns/15min without obvious cause arises from lesions of brain areas involved in the yawning zone, its trajectories causing a disconnection syndrome, or from alteration of network activity by physical or metabolic etiologies including medication.
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Izzy S, Mazwi NL, Martinez S, Spencer CA, Klein JP, Parikh G, Glenn MB, Greenberg SM, Greer DM, Wu O, Edlow BL. Revisiting Grade 3 Diffuse Axonal Injury: Not All Brainstem Microbleeds are Prognostically Equal. Neurocrit Care 2017; 27:199-207. [PMID: 28477152 PMCID: PMC5877823 DOI: 10.1007/s12028-017-0399-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recovery of functional independence is possible in patients with brainstem traumatic axonal injury (TAI), also referred to as "grade 3 diffuse axonal injury," but acute prognostic biomarkers are lacking. We hypothesized that the extent of dorsal brainstem TAI measured by burden of traumatic microbleeds (TMBs) correlates with 1-year functional outcome more strongly than does ventral brainstem, corpus callosal, or global brain TMB burden. Further, we hypothesized that TMBs within brainstem nuclei of the ascending arousal network (AAN) correlate with 1-year outcome. METHODS Using a prospective outcome database of patients treated for moderate-to-severe traumatic brain injury at an inpatient rehabilitation hospital, we retrospectively identified 39 patients who underwent acute gradient-recalled echo (GRE) magnetic resonance imaging (MRI). TMBs were counted on the acute GRE scans globally and in the dorsal brainstem, ventral brainstem, and corpus callosum. TMBs were also mapped onto an atlas of AAN nuclei. The primary outcome was the disability rating scale (DRS) score at 1 year post-injury. Associations between regional TMBs, AAN TMB volume, and 1-year DRS score were assessed by calculating Spearman rank correlation coefficients. RESULTS Mean ± SD number of TMBs was: dorsal brainstem = 0.7 ± 1.4, ventral brainstem = 0.2 ± 0.6, corpus callosum = 1.8 ± 2.8, and global = 14.4 ± 12.5. The mean ± SD TMB volume within AAN nuclei was 6.1 ± 18.7 mm3. Increased dorsal brainstem TMBs and larger AAN TMB volume correlated with worse 1-year outcomes (R = 0.37, p = 0.02, and R = 0.36, p = 0.02, respectively). Global, callosal, and ventral brainstem TMBs did not correlate with outcomes. CONCLUSIONS These findings suggest that dorsal brainstem TAI, especially involving AAN nuclei, may have greater prognostic utility than the total number of lesions in the brain or brainstem.
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Affiliation(s)
- Saef Izzy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Nicole L Mazwi
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sergi Martinez
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Camille A Spencer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua P Klein
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gunjan Parikh
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mel B Glenn
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David M Greer
- Department of Neurology, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
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Girlanda R. Deceased organ donation for transplantation: Challenges and opportunities. World J Transplant 2016; 6:451-459. [PMID: 27683626 PMCID: PMC5036117 DOI: 10.5500/wjt.v6.i3.451] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/25/2016] [Accepted: 07/18/2016] [Indexed: 02/05/2023] Open
Abstract
Organ transplantation saves thousands of lives every year but the shortage of donors is a major limiting factor to increase transplantation rates. To allow more patients to be transplanted before they die on the wait-list an increase in the number of donors is necessary. Patients with devastating irreversible brain injury, if medically suitable, are potential deceased donors and strategies are needed to successfully convert them into actual donors. Multiple steps in the process of deceased organ donation can be targeted to increase the number of organs suitable for transplant. In this review, after describing this process, we discuss current challenges and potential strategies to expand the pool of deceased donors.
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Smitherman E, Hernandez A, Stavinoha PL, Huang R, Kernie SG, Diaz-Arrastia R, Miles DK. Predicting Outcome after Pediatric Traumatic Brain Injury by Early Magnetic Resonance Imaging Lesion Location and Volume. J Neurotrauma 2015; 33:35-48. [PMID: 25808802 DOI: 10.1089/neu.2014.3801] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Brain lesions after traumatic brain injury (TBI) are heterogeneous, rendering outcome prognostication difficult. The aim of this study is to investigate whether early magnetic resonance imaging (MRI) of lesion location and lesion volume within discrete brain anatomical zones can accurately predict long-term neurological outcome in children post-TBI. Fluid-attenuated inversion recovery (FLAIR) MRI hyperintense lesions in 63 children obtained 6.2±5.6 days postinjury were correlated with the Glasgow Outcome Scale Extended-Pediatrics (GOS-E Peds) score at 13.5±8.6 months. FLAIR lesion volume was expressed as hyperintensity lesion volume index (HLVI)=(hyperintensity lesion volume / whole brain volume)×100 measured within three brain zones: zone A (cortical structures); zone B (basal ganglia, corpus callosum, internal capsule, and thalamus); and zone C (brainstem). HLVI-total and HLVI-zone C predicted good and poor outcome groups (p<0.05). GOS-E Peds correlated with HLVI-total (r=0.39; p=0.002) and HLVI in all three zones: zone A (r=0.31; p<0.02); zone B (r=0.35; p=0.004); and zone C (r=0.37; p=0.003). In adolescents ages 13-17 years, HLVI-total correlated best with outcome (r=0.5; p=0.007), whereas in younger children under the age of 13, HLVI-zone B correlated best (r=0.52; p=0.001). Compared to patients with lesions in zone A alone or in zones A and B, patients with lesions in all three zones had a significantly higher odds ratio (4.38; 95% confidence interval, 1.19-16.0) for developing an unfavorable outcome.
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Affiliation(s)
- Emily Smitherman
- 1 University of Texas Southwestern Medical Center, University of Texas Southwestern Medical Center , Dallas, Texas
| | - Ana Hernandez
- 2 Department of Neuropsychology, Children's Medical Center , Dallas, Texas
| | - Peter L Stavinoha
- 2 Department of Neuropsychology, Children's Medical Center , Dallas, Texas.,3 Department of Psychiatry, University of Texas Southwestern Medical Center , Dallas, Texas
| | - Rong Huang
- 4 Department of Clinical Research, Children's Medical Center , Dallas, Texas
| | - Steven G Kernie
- 5 Department of Pediatrics, University of Texas Southwestern Medical Center , Dallas, Texas
| | - Ramon Diaz-Arrastia
- 6 Department of Neurology, University of Texas Southwestern Medical Center , Dallas, Texas
| | - Darryl K Miles
- 5 Department of Pediatrics, University of Texas Southwestern Medical Center , Dallas, Texas
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Immediate, irreversible, posttraumatic coma: a review indicating that bilateral brainstem injury rather than widespread hemispheric damage is essential for its production. J Neuropathol Exp Neurol 2015; 74:198-202. [PMID: 25668566 DOI: 10.1097/nen.0000000000000170] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Traumatic brain injury may result in immediate long-lasting coma. Much attention has been given to predicting this outcome from the initial examination because these predictions can guide future treatment and interactions with the patient's family. Reports of diffuse axonal injury in these cases have ascribed the coma to widespread damage in the deep white matter that disconnects the hemispheres from the ascending arousal system (AAS). However, brainstem lesions are also present in such cases, and the AAS may be interrupted at the brainstem level. This review examines autopsy and imaging literature that assesses the presence, extent, and predictive value of lesions in both sites. The evidence suggests that diffuse injury to the deep white matter is not the usual cause of immediate long-lasting posttraumatic coma. Instead, brainstem lesions in the rostral pons or midbrain are almost always the cause but only if the lesions are bilateral. Moreover, recovery is possible if critical brainstem inputs to the AAS are spared. The precise localization of the latter is subject to ongoing investigation with advanced imaging techniques using magnets of very high magnetic gradients. Limited availability of this equipment plus the need to verify the findings continue to require meticulous autopsy examination.
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Hinson HE, Puybasset L, Weiss N, Perlbarg V, Benali H, Galanaud D, Lasarev M, Stevens RD. Neuroanatomical basis of paroxysmal sympathetic hyperactivity: a diffusion tensor imaging analysis. Brain Inj 2015; 29:455-61. [PMID: 25565392 DOI: 10.3109/02699052.2014.995229] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE Paroxysmal sympathetic hyperactivity (PSH) is observed in a sub-set of patients with moderate-to-severe traumatic brain injury (TBI). The neuroanatomical basis of PSH is poorly understood. It is hypothesized that PSH is linked to changes in connectivity within the central autonomic network. RESEARCH DESIGN Retrospective analysis in a sub-set of patients from a multi-centre, prospective cohort study Methods and procedures: Adult patients who were <3 weeks after severe TBI were enrolled and screened for PSH using a standard definition. Patients underwent multimodal MRI, which included quantitative diffusion tensor imaging. MAIN OUTCOMES AND RESULTS Principal component analysis (PCA) was used to resolve the set of tracts into components. Ability to predict PSH was evaluated via area under the receiver operating characteristic (AUROC) and tree-based classification analyses. Among 102 enrolled patients, 16 met criteria for PSH. The first principle component was significantly associated (p = 0.024, AUROC = 0.867) with PSH status even after controlling for age and admission GCS. In a classification tree analysis, age, GCS and decreased FA in the splenium of the corpus callosum and in the right posterior limb of the internal capsule discriminated PSH vs no PSH with an AUROC of 0.933. CONCLUSIONS Disconnection involving the posterior corpus callosum and of the posterior limb of the internal capsule may play a role in the pathogenesis or expression of PSH.
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Affiliation(s)
- Holly E Hinson
- Department of Neurology and Emergency Medicine, Oregon Health & Science University , Portland, OR , USA
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Gosseries O, Zasler ND, Laureys S. Recent advances in disorders of consciousness: Focus on the diagnosis. Brain Inj 2014; 28:1141-50. [PMID: 25099018 DOI: 10.3109/02699052.2014.920522] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Olivia Gosseries
- Coma Science Group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liege , Liege , Belgium
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17
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Laouchedi M, Galanaud D, Delmaire C, Fernandez-Vidal S, Messé A, Mesmoudi S, Oulebsir Boumghar F, Pélégrini-Issac M, Puybasset L, Benali H, Perlbarg V. Deafferentation in thalamic and pontine areas in severe traumatic brain injury. J Neuroradiol 2014; 42:202-11. [PMID: 24997478 DOI: 10.1016/j.neurad.2014.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/19/2014] [Accepted: 03/19/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Severe traumatic brain injury (TBI) is characterized mainly by diffuse axonal injuries (DAI). The cortico-subcortical disconnections induced by such fiber disruption play a central role in consciousness recovery. We hypothesized that these cortico-subcortical deafferentations inferred from diffusion MRI data could differentiate between TBI patients with favorable or unfavorable (death, vegetative state, or minimally conscious state) outcome one year after injury. METHODS Cortico-subcortical fiber density maps were derived by using probabilistic tractography from diffusion tensor imaging data acquired in 24 severe TBI patients and 9 healthy controls. These maps were compared between patients and controls as well as between patients with favorable (FO) and unfavorable (UFO) 1-year outcome to identify the thalamo-cortical and ponto-thalamo-cortical pathways involved in the maintenance of consciousness. RESULTS Thalamo-cortical and ponto-thalamo-cortical fiber density was significantly lower in TBI patients than in healthy controls. Comparing FO and UFO TBI patients showed thalamo-cortical deafferentation associated with unfavorable outcome for projections from ventral posterior and intermediate thalamic nuclei to the associative frontal, sensorimotor and associative temporal cortices. Specific ponto-thalamic deafferentation in projections from the upper dorsal pons (including the reticular formation) was also associated with unfavorable outcome. CONCLUSION Fiber density of cortico-subcortical pathways as measured from diffusion MRI tractography is a relevant candidate biomarker for early prediction of one-year favorable outcome in severe TBI.
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Affiliation(s)
- M Laouchedi
- Inserm U1146, CNRS UMR7371, laboratoire d'imagerie biomédicale, Sorbonne universités, UPMC université Paris 06 UMCR2, CHU Pitié-Salpêtrière, 91, boulevard de l'hôpital, 75634 Paris, France; ParIMed Team, LRPE, USTHB, Algiers, Algeria
| | - D Galanaud
- AP-HP, Pitié-Salpêtrière Hospital, Department of Neuroradiology, Paris, France
| | - C Delmaire
- CHRU de Lille, Department of Neuroradiology, Lille, France
| | - S Fernandez-Vidal
- Inserm and UPMC université Paris 06, UMR-S 975, CNRS, UMR 7225, centre de recherche de l'institut du cerveau et de la moelle épinière, Paris, France; Institut du cerveau et de la moelle épinière, centre de neuroimagerie de recherche, Paris, France
| | - A Messé
- Inserm U1146, CNRS UMR7371, laboratoire d'imagerie biomédicale, Sorbonne universités, UPMC université Paris 06 UMCR2, CHU Pitié-Salpêtrière, 91, boulevard de l'hôpital, 75634 Paris, France
| | - S Mesmoudi
- Inserm U1146, CNRS UMR7371, laboratoire d'imagerie biomédicale, Sorbonne universités, UPMC université Paris 06 UMCR2, CHU Pitié-Salpêtrière, 91, boulevard de l'hôpital, 75634 Paris, France; MATRICE Project University Paris 1 Panthéon-Sorbonne, Paris, France
| | | | - M Pélégrini-Issac
- Inserm U1146, CNRS UMR7371, laboratoire d'imagerie biomédicale, Sorbonne universités, UPMC université Paris 06 UMCR2, CHU Pitié-Salpêtrière, 91, boulevard de l'hôpital, 75634 Paris, France
| | - L Puybasset
- Inserm U1146, CNRS UMR7371, laboratoire d'imagerie biomédicale, Sorbonne universités, UPMC université Paris 06 UMCR2, CHU Pitié-Salpêtrière, 91, boulevard de l'hôpital, 75634 Paris, France; AP-HP, Pitié-Salpêtrière Hospital, Surgical Neuro-Intensive Care Unit, Paris, France
| | - H Benali
- Inserm U1146, CNRS UMR7371, laboratoire d'imagerie biomédicale, Sorbonne universités, UPMC université Paris 06 UMCR2, CHU Pitié-Salpêtrière, 91, boulevard de l'hôpital, 75634 Paris, France
| | - V Perlbarg
- Inserm U1146, CNRS UMR7371, laboratoire d'imagerie biomédicale, Sorbonne universités, UPMC université Paris 06 UMCR2, CHU Pitié-Salpêtrière, 91, boulevard de l'hôpital, 75634 Paris, France.
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The prognostic reliability of the Glasgow coma score in traumatic brain injuries: evaluation of MRI data. Eur J Trauma Emerg Surg 2012; 39:79-86. [DOI: 10.1007/s00068-012-0240-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 11/14/2012] [Indexed: 10/27/2022]
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Mindsight: diagnostics in disorders of consciousness. Crit Care Res Pract 2012; 2012:624724. [PMID: 23213492 PMCID: PMC3505640 DOI: 10.1155/2012/624724] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/30/2012] [Accepted: 07/08/2012] [Indexed: 12/20/2022] Open
Abstract
Diagnosis of patients with disorders of consciousness (comprising coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state) has long been dependent on unstandardized behavioral tests. The arrival of standardized behavioral tools, and especially the Coma Recovery Scale revised, uncovered a high rate of misdiagnosis. Ancillary techniques, such as brain imaging and electrophysiological examinations, are ever more often being deployed to aid in the search for remaining consciousness. They are used to look for brain activity patterns similar to those found in healthy controls. The development of portable and cheaper devices will make these techniques more widely available.
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21
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Lee SY, Kim SS, Kim CH, Park SW, Park JH, Yeo M. Prediction of outcome after traumatic brain injury using clinical and neuroimaging variables. J Clin Neurol 2012; 8:224-9. [PMID: 23091533 PMCID: PMC3469804 DOI: 10.3988/jcn.2012.8.3.224] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 01/16/2012] [Accepted: 01/16/2012] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose The functional outcome of traumatic brain injury (TBI) varies widely. The aim of this study was to identify the factors predicting outcome following TBI. Methods We prospectively enrolled acute TBI patients, and assessed them clinically and radiologically using brain magnetic resonance imaging (MRI). Functional outcome was measured using the Glasgow Outcome Scale (GOS) at 3 months after TBI. A GOS score of ≤4 was regarded as an unfavorable outcome. We performed multivariate analysis to investigate the association between clinicoradiological variables and outcome. Results Forty-two patients completed the clinical evaluation in the acute phase and outcome measurement at 3 months. Motorcycle accident was associated with unfavorable outcome [odds ratio (OR)=38.3, p=0.022]. If the patients were the victims of the accident, they were more likely to have an unfavorable outcome (OR=21.3, p=0.037). All seven patients with a low Glasgow Coma Scale (GCS) score (i.e., ≤8) at 24 or 48 h after TBI were also found to have an unfavorable outcome. The presence of diffuse axonal injury (DAI) was a significant predicting factor of an unfavorable outcome (OR=8.48, p=0.042). Conclusions Motorcycle accident, being an accident victim, and a lower GCS score at 24 hours or more after the accident were found to be unfavorable prognostic variables. DAI was the only radiologic variable predicting an unfavorable outcome. Thus, it is important to identify DAI by applying MRI in the acute phase.
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Affiliation(s)
- Seo-Young Lee
- Department of Neurology, Kangwon National University Hospital, Chuncheon, Korea
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22
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Hilario A, Ramos A, Millan JM, Salvador E, Gomez PA, Cicuendez M, Diez-Lobato R, Lagares A. Severe traumatic head injury: prognostic value of brain stem injuries detected at MRI. AJNR Am J Neuroradiol 2012; 33:1925-31. [PMID: 22576887 DOI: 10.3174/ajnr.a3092] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Traumatic brain injuries represent an important cause of death for young people. The main objectives of this work are to correlate brain stem injuries detected at MR imaging with outcome at 6 months in patients with severe TBI, and to determine which MR imaging findings could be related to a worse prognosis. MATERIALS AND METHODS One hundred and eight patients with severe TBI were studied by MR imaging in the first 30 days after trauma. Brain stem injury was categorized as anterior or posterior, hemorrhagic or nonhemorrhagic, and unilateral or bilateral. Outcome measures were GOSE and Barthel Index 6 months postinjury. The relationship between MR imaging findings of brain stem injuries, outcome, and disability was explored by univariate analysis. Prognostic capability of MR imaging findings was also explored by calculation of sensitivity, specificity, and area under the ROC curve for poor and good outcome. RESULTS Brain stem lesions were detected in 51 patients, of whom 66% showed a poor outcome, as expressed by the GOSE scale. Bilateral involvement was strongly associated with poor outcome (P < .05). Posterior location showed the best discriminatory capability in terms of outcome (OR 6.8, P < .05) and disability (OR 4.8, P < .01). The addition of nonhemorrhagic and anterior lesions or unilateral injuries showed the highest odds and best discriminatory capacity for good outcome. CONCLUSIONS The prognosis worsens in direct relationship to the extent of traumatic injury. Posterior and bilateral brain stem injuries detected at MR imaging are poor prognostic signs. Nonhemorrhagic injuries showed the highest positive predictive value for good outcome.
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Affiliation(s)
- A Hilario
- Department of Radiology, Hospital 12 de Octubre, Madrid, Spain.
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Abstract
The purpose of this review is to look at the most recent work carried out on predicting outcome after traumatic brain injury (TBI). TBI is a leading cause of death and disability but prediction of long-term outcome for individual patients is difficult. In particular, predicting outcome in the first few hours or days after injury is limited by the paucity of scoring systems or clinical models available. Many clinical variables have been studied to determine if they may play a role in outcome prediction, including age, admission Glasgow Coma Score and pupillary reactivity. Newer variables being studied include serum biomarkers, abnormalities seen on magnetic resonance imaging and data obtained from evoked potentials and electroencephalography studies. There are many factors that impact on outcome and a perfect model is yet to be developed. Models must take into account the economic status of the country in which the trauma occurs. It is important that less affluent nations are not left behind in the search for accurate prognostic modelling.
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Affiliation(s)
- Sandra Reynolds
- Specialist Registrar in Anaesthetics & ICM, Royal London Hospital, Whitechapel
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Skandsen T, Kvistad KA, Solheim O, Lydersen S, Strand IH, Vik A. Prognostic value of magnetic resonance imaging in moderate and severe head injury: a prospective study of early MRI findings and one-year outcome. J Neurotrauma 2011; 28:691-9. [PMID: 21401308 DOI: 10.1089/neu.2010.1590] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The clinical benefit of early magnetic resonance imaging (MRI) in severe and moderate head injury is unclear. We sought to explore the prognostic value of the depth of lesions depicted with early MRI, and also to describe the prevalence and impact of traumatic brainstem lesions. In a cohort of 159 consecutive patients with moderate to severe head injury (age 5-65 years and surviving the acute phase) admitted to a regional level 1 trauma center, 106 (67%) were examined with MRI within 4 weeks post-injury. Depth of lesions in MRI was categorized as: hemisphere level, central level, and brainstem injury (BSI). The outcome measure was Glasgow Outcome Scale Extended (GOSE) 12 months post-injury. Forty-six percent of patients with severe injuries and 14% of patients with moderate injuries had BSI. In severe head injury, central or brainstem lesions in MRI, together with higher Rotterdam CT score, pupillary dilation, and secondary adverse events were significantly associated with a worse outcome in age-adjusted analyses. Bilateral BSI was strongly associated with a poor outcome in severe injury, with positive and negative predictive values of 0.86 and 0.88, respectively. In moderate injury, only age was significantly associated with outcome in multivariable analyses. Limitations of the current study include lack of blinded outcome evaluations and insufficient statistical power to assess the added prognostic value of MRI when combined with clinical information. We conclude that in patients with severe head injury surviving the acute phase, depth of lesion on the MRI was associated with outcome, and in particular, bilateral brainstem injury was strongly associated with poor outcomes. In moderate head injury, surprisingly, there was no association between MRI findings and outcome when using the GOSE score as outcome measure.
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Affiliation(s)
- Toril Skandsen
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.
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Tshibanda L, Vanhaudenhuyse A, Boly M, Soddu A, Bruno MA, Moonen G, Laureys S, Noirhomme Q. Neuroimaging after coma. Neuroradiology 2010; 52:15-24. [PMID: 19862509 DOI: 10.1007/s00234-009-0614-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 10/07/2009] [Indexed: 01/12/2023]
Abstract
Following coma, some patients will recover wakefulness without signs of consciousness (only showing reflex movements, i.e., the vegetative state) or may show non-reflex movements but remain without functional communication (i.e., the minimally conscious state). Currently, there remains a high rate of misdiagnosis of the vegetative state (Schnakers et. al. BMC Neurol, 9:35, 8) and the clinical and electrophysiological markers of outcome from the vegetative and minimally conscious states remain unsatisfactory. This should incite clinicians to use multimodal assessment to detect objective signs of consciousness and validate para-clinical prognostic markers in these challenging patients. This review will focus on advanced magnetic resonance imaging (MRI) techniques such as magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI (fMRI studies in both "activation" and "resting state" conditions) that were recently introduced in the assessment of patients with chronic disorders of consciousness.
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Affiliation(s)
- Luaba Tshibanda
- Coma Science Group, Cyclotron Research Center, University and University Hospital of Liège, Sart-Tilman, B30 Liège, Belgium
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Perlbarg V, Puybasset L, Tollard E, Lehéricy S, Benali H, Galanaud D. Relation between brain lesion location and clinical outcome in patients with severe traumatic brain injury: a diffusion tensor imaging study using voxel-based approaches. Hum Brain Mapp 2010; 30:3924-33. [PMID: 19507154 DOI: 10.1002/hbm.20817] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The early prediction of consciousness recovery from traumatic brain injury (TBI) is crucial to make decisions about the appropriate use of prolonged intensive care. Diffusion tensor imaging (DTI) has been proposed as a biomarker of white matter injury that could be used in a classification purpose. Instead of region-of-interest-based approach, we applied voxel-based approaches (voxel-based DTI and tract-based spatial statistics) on 30 patients with TBI to identify, without any prior, the brain regions that were specifically damaged in unfavorable 1-year outcome group compared to the favorable one. DTI were acquired at mean 23 days (5-53 days) and two DTI-derived indices, fractional anisotropy (FA) and apparent diffusion coefficient (ADC), were tested. Our results showed that (1) ADC is not a relevant biomarker for early 1-year outcome prognosis; (2) FA measured in inferior longitudinal fasciculus, in cerebral peduncle, in posterior limb of the internal capsule, and in posterior corpus callosum is specifically decreased in unfavorable outcome group compare to the favorable one; (3) a linear discriminant analysis using the FA measured in these four regions showed good classification performance (sensitivity = 86% and specificity = 86%). These findings confirm the relevance of the use of DTI as biomarkers for consciousness recovery after TBI and support the possible use of these biomarkers for early classification of patients.
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Affiliation(s)
- Vincent Perlbarg
- Inserm, UMR_S 678, Laboratoire d'Imagerie Fonctionnelle, F-75634 Paris, France.
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Experience of diffusion tensor imaging and 1H spectroscopy for outcome prediction in severe traumatic brain injury: Preliminary results. Crit Care Med 2009; 37:1448-55. [PMID: 19242330 DOI: 10.1097/ccm.0b013e31819cf050] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The objective of the study is to test whether multimodal magnetic resonance imaging can provide a reliable outcome prediction of the clinical status, focusing on consciousness at 1 year after severe traumatic brain injury (TBI). DESIGN Single center prospective cohort with consecutive inclusions. SETTING Critical Care Neurosurgical Unit of a university hospital. PATIENTS Forty-three TBI patients not responding to simple orders after sedation cessation and 15 healthy controls. INTERVENTIONS A multimodal magnetic resonance imaging combining morphologic sequences, diffusion tensor imaging (DTI), and H proton magnetic resonance spectroscopy (MRS) was performed 24 +/- 11 days after severe TBI. The ability of DTI and MRS to predict 1-year outcome was assessed by linear discriminant analysis (LDA). Robustness of the classification was tested using a bootstrap procedure. MEASUREMENTS AND MAIN RESULTS Fractional anisotropy (FA) was computed as the mean of values at discrete brain sites in the infratentorial and supratentorial regions. The N-acetyl aspartate/creatine (NAA/Cr) ratio was measured in the thalamus, lenticular nucleus, insular cortex, occipital periventricular white matter, and pons. After 1 year, 19 (44%) patients had unfavorable outcomes (death, persistent vegetative state, or minimally conscious state) and 24 (56%) favorable outcomes (normal consciousness with or without functional impairments). Analysis of variance was performed to compare FA and NAA/Cr in the two outcome groups and controls. FA and MRS findings showed highly significant differences between the outcome groups, with significant variables by LDA being supratentorial FA, NAA/Cr (pons), NAA/Cr (thalamus), NAA/Cr (insula), and infratentorial FA. LDA of combined FA and MRS data clearly separated the unfavorable outcome, favorable outcome, and control groups, with no overlap. Unfavorable outcome was predicted with up to 86% sensitivity and 97% specificity; these values were better than those obtained with DTI or MRS alone. CONCLUSION FA and NAA/Cr hold potential as quantitative outcome-prediction tools at the subacute phase of TBI.
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Multimodal magnetic resonance imaging for determining prognosis in patients with traumatic brain injury—Promising but not ready for primetime*. Crit Care Med 2009; 37:1523-4. [DOI: 10.1097/ccm.0b013e31819d2df2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stevens RD, Pustavoitau A, van Zijl P. The Role of Imaging in Acute Brain Injury. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weiss N, Galanaud D, Carpentier A, Naccache L, Puybasset L. Clinical review: Prognostic value of magnetic resonance imaging in acute brain injury and coma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:230. [PMID: 17980050 PMCID: PMC2556735 DOI: 10.1186/cc6107] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Progress in management of critically ill neurological patients has led to improved survival rates. However, severe residual neurological impairment, such as persistent coma, occurs in some survivors. This raises concerns about whether it is ethically appropriate to apply aggressive care routinely, which is also associated with burdensome long-term management costs. Adapting the management approach based on long-term neurological prognosis represents a major challenge to intensive care. Magnetic resonance imaging (MRI) can show brain lesions that are not visible by computed tomography, including early cytotoxic oedema after ischaemic stroke, diffuse axonal injury after traumatic brain injury and cortical laminar necrosis after cardiac arrest. Thus, MRI increases the accuracy of neurological diagnosis in critically ill patients. In addition, there is some evidence that MRI may have potential in terms of predicting outcome. Following a brief description of the sequences used, this review focuses on the prognostic value of MRI in patients with traumatic brain injury, anoxic/hypoxic encephalopathy and stroke. Finally, the roles played by the main anatomical structures involved in arousal and awareness are discussed and avenues for future research suggested.
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Affiliation(s)
- Nicolas Weiss
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Teaching Hospital, Assistance Publique-Hopitaux de Paris and Pierre et Marie Curie University, Bd de l'hôpital, 75013, Paris, France
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