Magnus Olivecrona

Absence of electroencephalographic seizure activity in patients treated for head injury with an intracranial pressure-targeted therapy.

OBJECTnThe authors prospectively studied the occurrence of clinical and nonclinical electroencephalographically verified seizures during treatment with an intracranial pressure (ICP)-targeted protocol in patients with traumatic brain injury (TBI).nnnMETHODSnAll patients treated for TBI at the Department of Neurosurgery, University Hospital Umeå, Sweden, were eligible for the study. The inclusion was consecutive and based on the availability of the electroencephalographic (EEG) monitoring equipment. Patients were included irrespective of pupil size, pupil reaction, or level of consciousness as long as their first measured cerebral perfusion pressure was > 10 mm Hg. The patients were treated in a protocol-guided manner with an ICP-targeted treatment based on the Lund concept. The patients were continuously sedated with midazolam, fentanyl, propofol, or thiopental, or combinations thereof. Five-lead continuous EEG monitoring was performed with the electrodes at F3, F4, P3, P4, and a midline reference. Sensitivity was set at 100 muV per cm and filter settings 0.5-70 Hz. Amplitude-integrated EEG recording and relative band power trends were displayed. The trends were analyzed offline by trained clinical neurophysiologists.nnnRESULTSnForty-seven patients (mean age 40 years) were studied. Their median Glasgow Coma Scale score at the time of sedation and intubation was 6 (range 3-15). In 8.5% of the patients clinical seizures were observed before sedation and intubation. Continuous EEG monitoring was performed for a total of 7334 hours. During this time neither EEG nor clinical seizures were observed.nnnCONCLUSIONSnOur protocol-guided ICP targeted treatment seems to protect patients with severe TBI from clinical and subclinical seizures and thus reduces the risk of secondary brain injury.

The apolipoprotein E epsilon4 allele and outcome in severe traumatic brain injury treated by an intracranial pressure-targeted therapy.

OBJECTnIn this paper, the authors goal was to study the influence of the apolipoprotein E epsilon4 allele on the clinical outcome in patients treated for severe traumatic brain injury (TBI) with an intracranial pressure (ICP)-targeted therapy based on the Lund concept.nnnMETHODSnThe authors conducted a prospective double-blinded randomized trial in which they examined patients with severe TBI. Inclusion criteria consisted of a Glasgow Coma Scale (GCS) score < or = 8 at the time of intubation and sedation, patient age between 15 and 70 years, an initial cerebral perfusion pressure > 10 mm Hg, and arrival to the hospital < 24 hours after trauma. Blood samples for the analysis of apolipoprotein E allele types were collected. Independent staff members evaluated outcomes by obtaining Glasgow Outcome Scale (GOS) scores at 3, 12, and 24 months.nnnRESULTSnThe occurrence of the epsilon4 allele was analyzed in 46 patients (mean age 35 +/- 2.2 years with a median GCS score of 6 [range 3-8]). The epsilon4 allele was present in 39.1% of the patients. The ICP, cerebral perfusion pressure, and injury severity score were not statistically significantly different between the groups. The median GOS score at 3 months was 3.5, and at 12 and 24 months was 4 (range 1-5). Except for the GOS score at 3 months, which was dichotomized as favorable (GOS Score 4 or 5) and unfavorable (GOS Scores 1-3), no statistically significant differences in outcome, irrespective of GOS dichotomization used, were found between the patients with the epsilon4 allele and those without. The presence of the epsilon4 allele did not predict for clinical outcome, but GCS and ICP did.nnnCONCLUSIONSnThe presence of epsilon4 is not associated with long-term clinical outcome in patients with severe TBI treated with an ICP targeted therapy, based on the Lund concept.

Prostacyclin treatment normalises the MCA flow velocity in nimodipine-resistant cerebral vasospasm after aneurysmal subarachnoid haemorrhage : a pilot study

BackgroundCerebral vasospasm triggered by subarachnoid haemorrhage is one of the major causes of post-haemorrhage morbidity and mortality. Several treatment modalities have been proposed, and none of them are fully effective.MethodsIn this study we treated five patients with prostacyclin suffering vasospasm after a ruptured aneurysm not responding to high i.v. doses of nimodipine. All patients were severely ill, unconscious and in need of intensive care.FindingsA low dose of prostacyclin i.v. infusion for 72 h reversed the vasospasm as measured by transcranial Doppler technique. The mean MCA blood flow velocity decreased from 199u2009±u200931xa0cm/s to 92u2009±u20096xa0cm/s within 72 h after the start of the prostacyclin infusion.ConclusionsWe suggest that low-dose prostacyclin treatment, an old treatment strategy, can be a treatment option in patients with vasospasm not responding to ordinary measures.

Prostacyclin treatment and clinical outcome in severe traumatic brain injury patients managed with an ICP-targeted therapy: a prospective study.

Objective: To prospectively assess clinical outcome in patients with severe traumatic brain injury (sTBI) managed according to an ICP-targeted programme as well as additional treatment with prostacyclin. Materials and methods: Inclusion criteria were GCS ≤8, age 15–70 years, first recorded cerebral perfusion pressure (CPP)u2009>u200910u2009mmu2009Hg. Exclusion criteria were pregnancy, breastfeeding or penetrating brain injury. The patients were treated using the same ICP-guided protocol, with one group randomized to receive prostacyclin in a low dose (0.5u2009ngu2009kg−1u2009min−1). The clinical outcome was prospectively assessed at 3, 6, 12, 18 and 24 months using structured interviews. Results: Forty-eight patients were included, mean age 35.5 years, median GCS 6 (3–8), 69% were multi-traumatized. Mortality at 3 months was 12.5%. Median Glasgow Outcome Scale (GOS) at all follow-up points was 4. Favourable outcome (GOS 4–5) at 3 months was 52%, at 24 months 64%. Favourable outcome increased over time. There was a statistically significant association between GOS, GCS at admission and age. Higher ICPmax was associated with worse outcome. Conclusion: With this treatment protocol, a low number of deaths and a high number of favourable outcomes in sTBI were observed. Prostacyclin in this low dose does not seem to improve the outcome. ICPmax is a positive predictor of worse outcome. Higher GCS at admission and lower age are correlated to better outcome.

Aspects on the Physiological and Biochemical Foundations of Neurocritical Care

Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood–brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.

A study of the opinions of Swedish healthcare personnel regarding acceptable outcome following decompressive hemicraniectomy for ischaemic stroke

BackgroundDecompressive hemicraniectomy (DC) is an established lifesaving treatment for malignant infarction of the middle cerebral artery (mMCAI). However, surgical decompression will not reverse the effects of the stroke and many survivors will be left severely disabled. The objective of this study was to assess what neurological outcome would be considered acceptable in these circumstances amongst Swedish healthcare workers.MethodHealthcare workers were invited to participate in a presentation that outlined the pathophysiology of mMCAI, the rationale behind DC and outcome data from randomised controlled trials that have investigated efficacy of the procedure. They were then asked which neurological outcome would they feel to be acceptable based on the modified Rankin Score (mRS) and the Aphasia Handicap Scale (AHS). Information regarding sex, age, marital status, relatives, religion, earlier experience of stroke and occupation was also collected.ResultsSix hundred and nine persons participated. The median accepted mRS was 3. An mRS of 4 or 5 was perceived to be acceptable by only 30.5% of participants. Therefore the most likely outcome, based on the results of the randomised controlled trials, would be unacceptable to most of the participants [OR 0.39 (CI, 0.22–0.69)]. The median accepted AHS was 3. A worst language outcome of restricted autonomy of verbal communication (AHS 3) or better would be accepted by 44.6%.ConclusionsThis study has highlighted the ethical problems when obtaining consent for DC following mMCAI, because for many of the participants the most likely neurological outcome would be deemed unacceptable. These issues need to be considered prior to surgical intervention and the time may have come for a broader societal discussion regarding the value of a procedure that converts death into survival with severe disability given the attendant financial and healthcare resource implications.

Ten-year follow-up of patients in a double blinded randomized study on prostacyclin treatment in severe traumatic brain injury

Ten-year follow-up of patients in a double blinded randomized study on prostacyclin treatment in severe traumatic brain injuryMental fatigue is a common symptom in the chronic phase of traumatic brain injury. Despite its high prevalence, no treatmentis available for this disabling symptom, and the mechanisms underlying fa ...Accepted Abstracts from the International Brain Injury Association’s 12 World Congress on Brain Injury March 29, 2017−April 1, 2017 New Orleans, Louisiana 0001 Enhancing emotional insight after traumatic brain injury: A treatment for alexithymia Dawn Neumann, James Malec, and Flora Hammond Indiana University, Indianapolis, IN, USA; Rehabilitation Hospital of Indiana, Indianapolis, IN, USA; EmotEd, Indianapolis, IN, USA ABSTRACT Objective: Alexithymia is a common problem after traumatic brain injury (TBI), with a prevalence ranging between 30% and 61%. Characteristic features of alexithymia are poor emotional awareness, difficulty in labelling and differentiating emotions and poor interoceptive awareness. Alexithymia is often associated with emotion dysregulation, including anxiety, depression and anger. The purpose of this study was to explore the preliminary effectiveness of an intervention designed to improve emotional insight in people with TBI. Methods: Seventeen adults who had a moderate-to-severe TBI, who had a minimum of 1 year after injury and had moderate-tosevere alexithymia and completed an intervention targeting problems with alexithymia. The study was a within-subject design with three assessment times: baseline, post-test and 2-month follow-up. Primary outcome measures were the Toronto Alexithymia Scale-20 (TAS-20) for alexithymia and the Levels of Emotional Awareness Scale (LEAS), which is a performancebased assessment pertaining to emotional cognizance and labelling. Secondary outcome measures evaluated anxiety [Trait Anxiety Inventory(TAI)], depression (PHQ-9), anger [State Trait Anger Expression Inventory(STAXI)], affect [Positive and Negative Affect Scale(PANAS)] and overall emotional dysregulation [Difficulty with Emotion Regulation Scale(DERS)]. The intervention consisted of eight 60to 90-minute sessions (2 per week) for 1month. Sessions were one-on-one between a therapist research assistant and participant, in which a web-based training programme was used to deliver structured content and exercises aimed at enhancing participants’ emotional vocabulary, emotional insight and interoceptive awareness were conducted. Results: Thirteen participants completed the intervention. Repeated-measures analysis of variance revealed significant improvements on the TAS-20, LEAS, TAI, STAXI, Positive Affect and DERS, which were followed by planned comparisons. Changes on these measures were all significant between baseline and post test. Changes between baseline and 2-month follow-up continued to show significant improvements on the TAS-20, LEAS, TAI and Positive affect. Effect sizes were mostly medium to large. Post-treatment satisfaction scores showed strong satisfaction for the programme. Conclusions: These preliminary findings suggest that alexithymia can be reduced after TBI with treatment and may also coincide with better emotional regulation. More research needs to be conducted using a randomized controlled trial and a larger sample.Objective: Alexithymia is a common problem after traumatic brain injury (TBI), with a prevalence ranging between 30% and 61%. Characteristic features of alexithymia are poor emotional awareness, difficulty in labelling and differentiating emotions and poor interoceptive awareness. Alexithymia is often associated with emotion dysregulation, including anxiety, depression and anger. The purpose of this study was to explore the preliminary effectiveness of an intervention designed to improve emotional insight in people with TBI. Methods: Seventeen adults who had a moderate-to-severe TBI, who had a minimum of 1 year after injury and had moderate-tosevere alexithymia and completed an intervention targeting problems with alexithymia. The study was a within-subject design with three assessment times: baseline, post-test and 2-month follow-up. Primary outcome measures were the Toronto Alexithymia Scale-20 (TAS-20) for alexithymia and the Levels of Emotional Awareness Scale (LEAS), which is a performancebased assessment pertaining to emotional cognizance and labelling. Secondary outcome measures evaluated anxiety [Trait Anxiety Inventory(TAI)], depression (PHQ-9), anger [State Trait Anger Expression Inventory(STAXI)], affect [Positive and Negative Affect Scale(PANAS)] and overall emotional dysregulation [Difficulty with Emotion Regulation Scale(DERS)]. The intervention consisted of eight 60to 90-minute sessions (2 per week) for 1month. Sessions were one-on-one between a therapist research assistant and participant, in which a web-based training programme was used to deliver structured content and exercises aimed at enhancing participants’ emotional vocabulary, emotional insight and interoceptive awareness were conducted. Results: Thirteen participants completed the intervention. Repeated-measures analysis of variance revealed significant improvements on the TAS-20, LEAS, TAI, STAXI, Positive Affect and DERS, which were followed by planned comparisons. Changes on these measures were all significant between baseline and post test. Changes between baseline and 2-month follow-up continued to show significant improvements on the TAS-20, LEAS, TAI and Positive affect. Effect sizes were mostly medium to large. Post-treatment satisfaction scores showed strong satisfaction for the programme. Conclusions: These preliminary findings suggest that alexithymia can be reduced after TBI with treatment and may also coincide with better emotional regulation. More research needs to be conducted using a randomized controlled trial and a larger sample. 0002 The influence of alexithymia, depression and anxiety on aggression after brain injury Dawn Neumann, James Malec, and Flora Hammond Indiana University, Indianapolis, IN, USA; Rehabilitation Hospital of Indiana, Indianapolis, IN, USA; EmotEd, Indianapolis, IN, USA ABSTRACT Objective: The aims of this study were twofold: 1) To determine the differences in aggression severity and prevalence in people with traumatic brain injury (TBI) and healthy controls (HCs) and 2) examine the influence of alexithymia (blunted emotional insight), depression and anxiety on aggression. Methods: Forty-six participants with moderate-to-severe TBI with age 49 years and gender-matched HCs. Participants with TBI had a minimum of 3 months after injury. Participants completed measures of trait aggression (Buss Perry Aggression Questionnaire); depression (Patient Health Questionnaire-9); trait anxiety [State Trait Anxiety Inventory (STAI)] and alexithymia (Toronto Alexithymia Scale-20). Results: Participants with TBI had significantly higher total aggression, physical aggression, verbal aggression, anger and hostility than HCs. Compared to HCs, significantly more participants with TBI were classified as having higher than average total aggression (34.8% vs 14.3%), verbal aggression (41.3% vs 18.4%), anger (39.1% vs 20.4%) and hostility (45.7% vs 20.4%). Together alexithymia, depression and anxiety accounted for 34.2% of the adjusted aggression variance for participants with TBI and 45.7% for HCs. The largest unique contributor to these models was alexithymia for participants with TBI and depression for HCs. Conclusion: This study provides empirical data showing that aggression is more severe and prevalent in people with TBI than HCs. Moreover, our findings suggest that alexithymia is a major contributing factor to aggression after TBI. This is concerning as alexithymia is prevalent in up to 61% of people with TBI. Because people with alexithymia have poor emotional insight, they may not have the awareness needed to properly regulate escalating feelings of anger and aggression. Clinical implications for the treatment of aggression will be discussed. BRAIN INJURY 2017, VOL. 31, NOS. 6–7, 719–1017 http://dx.doi.org/10.1080/02699052.2017.1312145Objective: The aims of this study were twofold: 1) To determine the differences in aggression severity and prevalence in people with traumatic brain injury (TBI) and healthy controls (HCs) and 2) examine the influence of alexithymia (blunted emotional insight), depression and anxiety on aggression. Methods: Forty-six participants with moderate-to-severe TBI with age 49 years and gender-matched HCs. Participants with TBI had a minimum of 3 months after injury. Participants completed measures of trait aggression (Buss Perry Aggression Questionnaire); depression (Patient Health Questionnaire-9); trait anxiety [State Trait Anxiety Inventory (STAI)] and alexithymia (Toronto Alexithymia Scale-20). Results: Participants with TBI had significantly higher total aggression, physical aggression, verbal aggression, anger and hostility than HCs. Compared to HCs, significantly more participants with TBI were classified as having higher than average total aggression (34.8% vs 14.3%), verbal aggression (41.3% vs 18.4%), anger (39.1% vs 20.4%) and hostility (45.7% vs 20.4%). Together alexithymia, depression and anxiety accounted for 34.2% of the adjusted aggression variance for participants with TBI and 45.7% for HCs. The largest unique contributor to these models was alexithymia for participants with TBI and depression for HCs. Conclusion: This study provides empirical data showing that aggression is more severe and prevalent in people with TBI than HCs. Moreover, our findings suggest that alexithymia is a major contributing factor to aggression after TBI. This is concerning as alexithymia is prevalent in up to 61% of people with TBI. Because people with alexithymia have poor emotional insight, they may not have the awareness needed to properly regulate escalating feelings of anger and aggression. Clinical implications for the treatment of aggression will be discussed. BRAIN INJURY 2017, VOL. 31, NOS. 6–7, 719–1017 http://dx.doi.org/10.1080/02699052.2017.1312145