Jefferson Chen

Traumatic Brain Injury Advanced Multimodal Neuromonitoring From Theory to Clinical Practice

Traumatic brain injury accounts for nearly 1.4 million injuries and 52 000 deaths annually in the United States. Intensive bedside neuromonitoring is critical in preventing secondary ischemic and hypoxic injury common to patients with traumatic brain injury in the days following trauma. Advancements in multimodal neuromonitoring have allowed the evaluation of changes in markers of brain metabolism (eg, glucose, lactate, pyruvate, and glycerol) and other physiological parameters such as intracranial pressure, cerebral perfusion pressure, cerebral blood flow, partial pressure of oxygen in brain tissue, blood pressure, and brain temperature. This article highlights the use of multimodal monitoring in the intensive care unit at a level I trauma center in the Pacific Northwest. The trends in and significance of metabolic, physiological, and hemodynamic factors in traumatic brain injury are reviewed, the technical aspects of the specific equipment used to monitor these parameters are described, and how multimodal monitoring may guide therapy is demonstrated. As a clinical practice, multimodal neuromonitoring shows great promise in improving bedside therapy in patients with traumatic brain injury, ultimately leading to improved neurological outcomes.

Infrared pupillometry, the Neurological Pupil index and unilateral pupillary dilation after traumatic brain injury: implications for treatment paradigms

Pupillary dysfunction, a concerning finding in the neurologic examination of the patient with an acute traumatic brain injury often dictates the subsequent treatment paradigm. Patients were monitored closely with an infrared pupillometer, with NPi technology, for acute changes in pupillary function. NPi technology applies a scalar value to pupillary function. A retrospective chart review was performed of traumatic brain injury patients with acute unilateral pupillary dilation, admitted to Legacy Emanuel Medical Center’s NeuroTrauma Unit, Portland, OR, and followed as outpatients, between January 2012 and December 2013. Clinical exam findings of pupillary size, NPi scores, and brain Magnetic Resonance Imaging and Computed Tomography images were analyzed. Five traumatic brain injury patients were identified with unilateral pupillary dysfunction with long-term follow-up after the initial injury. Each patient was monitored closely in the trauma bay for neurological deterioration with a pupillometer and the clinical exam. Two patients underwent subsequent intracranial pressure monitoring based on a deteriorating clinical scenario, including consistent abnormal unilateral NPi scores. One patient with consistent abnormal NPi scores and an improved clinical exam did not undergo invasive interventions. Two patients showed early improvement in NPi scores correlating with the normalization of their pupillary reactivity. Anisocoria improved in all patients despite concurrent abnormal NPi scores. Magnetic Resonance Imaging and Computed Tomography imaging studies, with a focus on the third nerve, revealed focal abnormalities consistent with the clinical findings. A unilateral blown pupil and abnormal NPi score in a traumatic brain injury patient are not necessarily indicative of intracranial pressure issues, and must be correlated with the entire clinical scenario, to determine the etiology of the third nerve injury and direct potential therapeutic interventions. Early NPi score normalization suggests pupillary function may improve. We found that NPi scores, as a component of the clinical exam, provide a sensitive, noninvasive and quantitative means of following pupillary function acutely and chronically after a traumatic brain injury.

Chronic Subdural Hematoma: A Perspective on Subdural Membranes and Dementia

OBJECTIVE To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics. METHODS A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases. RESULTS Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance. CONCLUSIONS Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.

Chronic Subdural Hematoma: A Historical and Clinical Perspective

BACKGROUND This review aims to highlight the clinical complexity of chronic subdural hematoma (cSDH) while presenting a brief historical discussion of cSDH. METHODS A thorough literature search of published English-language papers was performed in PubMed, Ovid, and Cochrane databases. RESULTS cSDH affects 1-5.3 per 100,000 individuals annually, with the incidence expected to rise as the U.S. population ages. The symptoms of cSDH are often nonspecific, with headaches being the most common complaint. Other symptoms include weakness, balance and gait problems, and memory problems. CONCLUSIONS A variety of clinical factors must be taken into account in the treatment of cSDH, and the multifaceted treatment paradigms continue to evolve.

A novel integrative healing services approach for neurosurgery inpatients: Preliminary experiences and cost calculations

Background Neurosurgery inpatients are oftentimes critically ill, and face significant stress, post-operative pain, and/or emotional distress. As a result, the use of non-pharmacologic, alternative therapies as adjuncts in surgical care may benefit this patient population. Hospital economics related to integrative services may also provide additional incentive to providing alternative therapies. This study characterizes and evaluates how Integrative Healing Services (IHS) affects patient pain levels and length of stay. We also performed a literature review to examine national trends in inpatient integrative healing. Methods An IHS team (e.g. acupuncture, healing touch, music therapy, pet therapy, and counseling) was incorporated into the treatment regimen of neurosurgery inpatients (with >4days of stay) with chronic or intractable pain, stress or depression, and/or patients intolerant to or who failed physical or occupational therapy. Results 34 charts were retrospectively reviewed, with 17 patients receiving IHS (11 cranial and 6 spine cases), and 17 age and gender matched controls receiving routine care (11 cranial and 6 spine patients). Overall, 71% (12/17) of patients had a reduction in pain medication consumption, with 55% (6/11) of cranial and 100% (6/6) of spine patients reporting a reduction compared to baseline. The average pre-treatment pain-scale score was 5.5 out of 10 across all patients, while the average post-treatment pain-scale score was 3 out of 10 (p<0.01). 59% of patients had improved mobility. The average length of stay in the IHS group was 12.6days, and 19.6days in the routine care group (range 4-45) (p<0.01). Conclusions IHS intervention may be an effective option for treating pain and decreasing hospital length of stay. National trends support the use of integrative healing and will likely continue to increase as further studies are performed.

Resistant Hypertension after Hypertensive Intracerebral Hemorrhage Is Associated with More Medical Interventions and Longer Hospital Stays without Affecting Outcome

Background Hypertension (HTN) is the most common cause of spontaneous intracerebral hemorrhage (ICH). The aim of this study is to investigate the role of resistant HTN in patients with ICH. Methods and results We conducted a retrospective study of all consecutive ICH admissions at our medical center from November 2013 to October 2015. The clinical features of patients with resistant HTN (requiring four or more antihypertensive agents to keep systolic blood pressure <140 mm Hg) were compared with those with responsive HTN (requiring three or fewer agents). Of the 152 patients with hypertensive ICH, 48 (31.6%) had resistant HTN. Resistant HTN was independently associated with higher body mass index and proteinuria. Compared to the responsive group, patients with resistant HTN had higher initial blood pressures and greater requirement for ventilator support, hematoma evacuation, hypertonic saline therapy, and nicardipine infusion. Resistant HTN increases length of stay (LOS) in the intensive care unit (ICU) (4.2 vs 2.1 days; p = 0.007) and in the hospital (11.5 vs 7.0 days; p = 0.003). Multivariate regression analysis showed that the rate of systolic blood pressure >140 mm Hg and duration of nicardipine infusion were independently associated with LOS in the ICU. There was no significant difference in hematoma expansion and functional outcome at hospital discharge between the two groups. Conclusion Resistant HTN in patients with ICH is associated with more medical interventions and longer LOS without effecting outcome at hospital discharge.

Unsupervised 3-D Feature Learning for Mild Traumatic Brain Injury

We present an unsupervised three-dimensional feature clustering algorithm to gather the mTOP2016 challenge data into 3 groups. We use the brain MR-T1, diffusion tensor fractional anisotropy, and diffusion tensor mean diffusivity images provided by the mTOP2016 competition. A distance-based size constraint method for data clustering is used. The proposed approach achieves 0.267 adjusted rand index and 0.3556 homogeneity score within the 15 labeled subjects, corresponding to 10 correctly classified data items. Based on visual exploration of the data, we believe that a localized analysis of the lesion regions, using the computed tractography data, is a promising direction to pursue.

THE EFFICACY OF INTERACTIVE IBOOKS IN EDUCATING OLDER PATIENTS ON TBI, CONCUSSION, AND NPH

tered treatment at homewith an 810 nm intranasal device (13 mW) or sham equivalent. Memory and cognition were assessed using MMSE and ADAS-cog at Baseline, at Week 12; and follow-up after 4 weeks of no treatment. Results:Mean(SD) baseline MMSE and ADAS-cog scores were 18.4(9.37) and 32.1(21.41) in the active group, (n1⁄413, 10M, 3F) compared with 25.8(4.36) and 14.8(7.91) in the sham group (n1⁄46, 5M, 1F). Since these were significantly different (p<0.1 for both), data were analyzed by baseline MMSE. In the baseline MMSE 0-24 subgroup, Week 12 scores were significantly improved for the 8 participants on active treatment: MMSE increased 2.00 points (p1⁄40.03, 2-tailed) and ADAS-cog decreased 5.00 points (p1⁄40.03). The only sham participant in this subgroup dropped out before post-baseline assessment. Slight declines in performance were noted at follow-up after 4 weeks of no treatment. In the baseline MMSE 25-30 subgroup, mean changes at Week 12 in MMSE and ADAS-cog were 1.80 and -2.27 in the active group (n1⁄45), versus 1.50 and -3.67 in the sham group (n1⁄45). None of the within-group or between-group comparisons were statistically significant for this milder group. Qualitative feedback from participants and caregivers in the active group reported better sleep, fewer angry outbursts and decreased anxiety, and wandering. No adverse events related to treatment were reported. Conclusions: The large significant improvements in cognitive functioning, QoL and lack of adverse events suggest that PBM therapy may show promise in treatment of individuals experiencing dementia/AD.