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On evolution of intracranial changes after severe traumatic brain injury and its impact on clinical outcome
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Severe traumatic brain injury (sTBI) is a cause of death and disability worldwide and requires treatment at specialized neuro-intensive care units (NICU) with a multimodal monitoring approach. The CT scan imaging supports the monitoring and diagnostics. The level of S100B and neuron specific enolase (NSE) reflects the severity of the injury. The therapy resistant intracranial hypertension requires decompressive craniectomy (DC). After DC, the cranium must be reconstructed to recreate the normal intracranial physiology as well as to address cosmetic issues. The evolution of the pathological intracranial changes was analyzed in accordance with the three CT classifications: Marshall, Rotterdam and Morris-Marshall. The Rotterdam scale was best in describing the dynamics of the pathological evolution. Both the Rotterdam score and Morris- Marshall classification showed strong correlation with the clinical outcome, a finding that suggests that they could be used for prognostication. We demonstrated a clear correlation between the CT classifications and concentrations of S100B and NSE. The results revealed a concomitant correlation between NSE and S100B and clinical outcome. We found that the interaction between the ICP, Rotterdam CT classification, and concentrations of biochemical biomarkers are all associated with DC. We found a high percentage of complications following cranioplasty. Our results call into question whether custom-made allograft should be considered the best material for cranioplasty. It is concluded that both the Rotterdam and Morris-Marshall classification contribute to clinical evaluation of intracranial dynamics after sTBI, and might be used in combination with biochemical biomarkers for better assessment. The decision to perform DC should include a re-assesment of ICP evolution, CT scan images and concentration of the biochemical biomarkers. Furthermore, when determining whether DC treatment should be used, surgeon should also consider the risks of the following cranioplasty.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 132 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1836
Keyword [en]
Severe traumatic brain injury, ICP targeted therapy, ICP, decompressive craniectomy, S100B, NSE, cranioplasty
National Category
Other Medical Sciences Neurology
Research subject
Neurosurgery
Identifiers
URN: urn:nbn:se:umu:diva-124069ISBN: 978-91-7601-442-4OAI: oai:DiVA.org:umu-124069DiVA: diva2:948423
Public defence
2016-09-02, Sal E04, byggnad 6A, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-08-18 Created: 2016-07-11 Last updated: 2016-08-17Bibliographically approved
List of papers
1. Association of ICP, CPP, CT findings and S-100B and NSE in severe traumatic head injury. Prognostic value of the biomarkers
Open this publication in new window or tab >>Association of ICP, CPP, CT findings and S-100B and NSE in severe traumatic head injury. Prognostic value of the biomarkers
2015 (English)In: Brain Injury, ISSN 0269-9052, E-ISSN 1362-301X, Vol. 29, no 4, 446-454 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The association was studied of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) on S-100B and neuron-specific enolase (NSE) in severe traumatic brain injury (sTBI). The relationship was explored between biomarkers, ICP, CPP, CT-scan classifications and the clinical outcome.

Materials and methods: Data were collected prospectively and consecutively in 48 patients with Glasgow Coma Scale score ≤ 8, age 15–70 years. NSE and S-100B were analysed during 5 consecutive days. The initial and follow-up CT-scans were classified according to the Marshall, Rotterdam and Morris-Marshall classifications. Outcome was evaluated with extended Glasgow outcome scale at 3 months.

Results: Maximal ICP and minimal CPP correlated with S-100B and NSE levels. Complex relations between biomarkers and CT classifications were observed. S-100B bulk release (AUC = 0.8333, p = 0.0009), and NSE at 72 hours (AUC = 0.8476, p = 0.0045) had the highest prediction power of mortality. Combining Morris-Marshall score and S-100B bulk release improved the prediction of clinical outcome (AUC = 0.8929, p = 0.0008).

Conclusion: Biomarker levels are associated with ICP and CPP and reflect different aspects of brain injury as evaluated by CT-scan. The biomarkers might predict mortality. There are several pitfalls influencing the interpretation of biomarker data in respect to ICP, CPP, CT-findings and clinical outcome.

Keyword
CPP, CT classification, ICP targeted therapy, ICP, NSE, prognostication, S-100B, severe traumatic brain jury
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-103228 (URN)10.3109/02699052.2014.989403 (DOI)000352803300005 ()25518864 (PubMedID)
Available from: 2015-05-19 Created: 2015-05-18 Last updated: 2016-07-13Bibliographically approved
2. Dynamics of brain tissue changes induced by traumatic brain injury assessed with the Marshall, Morris-Marshall, and the Rotterdam classifications and its impact on outcome in a prostacyclin placebo-controlled study
Open this publication in new window or tab >>Dynamics of brain tissue changes induced by traumatic brain injury assessed with the Marshall, Morris-Marshall, and the Rotterdam classifications and its impact on outcome in a prostacyclin placebo-controlled study
2012 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 154, no 6, 1069-1079 p.Article in journal (Refereed) Published
Abstract [en]

The present study evaluates the types and dynamics of intracranial pathological changes in patients with severe traumatic brain injury (sTBI) who participated in a prospective, randomized, double-blinded study of add-on treatment with prostacyclin. Further, the changes of brain CT scan and their correlation to Glasgow Coma Scale score (GCS), maximal intracranial pressure (ICPmax), minimal cerebral perfusion pressure (CPPmin), and Glasgow Outcome Score (GOS) at 3, 6, and 12 months were studied. Forty-eight subjects with severe traumatic brain injury were treated according to an ICP-targeted therapy protocol based on the Lund concept with the addition of prostacyclin or placebo. The first available CT scans (CTi) and follow-up scans nearest to 24 h (CT24) were evaluated using the Marshall, Rotterdam, and Morris-Marshall classifications. There was a significant correlation of the initial Marshall, Rotterdam, Morris-Marshall classifications and GOS at 3 and 12 months. The CT24 Marshall classification did not significantly correlate to GOS while the Rotterdam and the Morris-Marshall classification did. The CTi Rotterdam classification predicted outcome evaluated as GOS at 3 and 12 months. Prostacyclin treatment did not influence the dynamic of tissue changes. The Rotterdam classification seems to be appropriate for describing the evolution of the injuries on the CT scans and contributes in predicting of outcome in patients treated with an ICP-targeted therapy. The Morris-Marshall classification can also be used for prognostication of outcome but it describes only the impact of traumatic subarachnoid hemorrhage (tSAH).

Keyword
Traumatic brain injury, Traumatic subarachnoid hemorrhage, Marshall, Morris-Marshall, Rotterdam classification
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-56190 (URN)10.1007/s00701-012-1345-x (DOI)000304113800017 ()
Available from: 2012-06-12 Created: 2012-06-12 Last updated: 2016-07-13Bibliographically approved
3. Rotterdam score, ICP, CPP, S-100B, NSE and their association with Decompressive Craniectomy in severe Traumatic Brain Injury
Open this publication in new window or tab >>Rotterdam score, ICP, CPP, S-100B, NSE and their association with Decompressive Craniectomy in severe Traumatic Brain Injury
(English)Article in journal (Other academic) Submitted
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-124076 (URN)
Available from: 2016-07-13 Created: 2016-07-13 Last updated: 2016-07-13
4. Complications following cranioplasty using autologous bone or polymethylmethacrylate-Retrospective experience from a single center
Open this publication in new window or tab >>Complications following cranioplasty using autologous bone or polymethylmethacrylate-Retrospective experience from a single center
2013 (English)In: Clinical neurology and neurosurgery (Dutch-Flemish ed. Print), ISSN 0303-8467, E-ISSN 1872-6968, Vol. 115, no 9, 1788-1791 p.Article in journal (Refereed) Published
Abstract [en]

Objective: A decompressive hemicraniectomy is a potentially life-saving intervention following head trauma. Once performed patients are obliged to undergo a second procedure with cranioplasty. Two of the most commonly used materials are autologous bone and polymethylmethacrylate (PMMA). We have now evaluated complications following a cranioplasty using these materials. Materials and methods: During a 7-year period (2002-2008) 49 patients were operated with a decompressive craniectomy following head trauma. Patients received a cranioplasty consisting of autologous bone (30 patients, 61.2%) or PMMA (19 patients, 38.8%) and were followed at least 24 months. Patient data were collected retrospectively. Results: Twenty patients (20/49, 40.8%) experienced a complication that prompted a re-operation. There was a significantly higher rate of complications leading to a re-operation (53.3% vs. 21.1%, p = 0.03) and a shorter survival time of the cranioplasty (mean 48.1 +/- 7.8 vs. 79.5 +/- 9.0 months, p = 0.035) in patients with autologous bone compared to PMMA. Bone resorption and the presence of postoperative hematomas were significantly more common in patients with autologous bone. The material used for cranioplasty was the only variable that significantly correlated to the rate of complications. Conclusions: In our series we had a high percentage of patients needing re-operation due to complications following a cranioplasty. Though generally considered a straightforward procedure, complications and associated morbidity in patients undergoing cranioplasty should not be underestimated. 

Keyword
Decompressive hemicraniectomy, Cranioplasty, Autologous bone, Polymethylmethacrylate, Complications
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-82299 (URN)10.1016/j.clineuro.2013.04.013 (DOI)000324787900039 ()
Available from: 2013-12-02 Created: 2013-10-29 Last updated: 2016-07-13Bibliographically approved

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