The relation of alcohol intake to clinical features and outcomes in traffic accident were scarcely reported in literature. This study was conducted to clarify these issues, including the effectiveness of safety devices.
Among 1002 cases registered in the Japan Neurotrauma Data Bank, 474 (47%) were documented about alcohol intake and enrolled. Those were divided into 2 groups: drinking group in 112 cases (24%) and non-drinking in 362 (76%). Results: The age was younger and the Glasgow Coma Scale (GCS) score was lower in the drinking group. The four wheel vehicle and the motorcycle accidents were more common, and the safety device, especially the helmet was less frequently worn in the drinking group. In addition, the incidence of basal skull fracture was higher, and diffuse injury and subarachnoid hemorrhage on CT were more frequently observed in the drinking group. However, the outcome at discharge was not different significantly between two groups. These analyses were also done in both severely injured group (GCS: 3 – 8 on admission), and less severe group (GCS: 9 – 15). But the clinical features, the x-ray findings and the outcomes did not differ significantly between the drinking and the non-drinking groups in the less severe group, perhaps due to the small number of the cases.
The above results suggested that the injury itself may be more severe, and the younger age might correct the outcome difference in the drinking group, especially in the severe head injury.
The clinical effect of the brain hypothermia treatment was denied as a whole with Prospective Randomized Controlled Trials (PRCT) of the severe brain injury in U.S.A. at 2001 report. However, the efficacy of the brain hypothermia was proven with PRCT to the post-resuscitative brain damage in 2002. It is not necessary to deny all of them under the lack condition of other clinically effective brain protection treatment. It is meaningful to check in which part of the hypothermia therapy is effective and to re-examine the treatment indication aiming at the efficacy that is already proven with the basic experiment. We have analyzed comparatively the brain hypothermia therapy and conventional neurotrauma treatment in the Japan Neurotrauma Data Bank data. Better outcome was obtained with the hypothermia group. The rate of good outcome (GR/MD) and that of death at GOS on discharge and final GOS were 10.9%, 15.7%, 68%, 69% in the non-hypothermia group and 21.8%, 28.7%, 43%, 45% in the hypothermia group respectively. GCS on admission, pupil size, blood pressure (shock level), light reflexes, initial ICP, body temperature on arrival, blood sugar on arrival and effacement of the basal cistern in CT on admission showed the strong correlation with outcome (GOS) in the former. The correlation of each other was not so in the latter. The effect of hypothermia therapy was high in the severely injured group. In other words, it was expected that the group predicted of bad outcome in the non-hypothermia treatment was good indication of the hypothermia therapy. It was suggested that positive expansion of indication for the hypothermia therapy in younger age group and limit of all multidisciplinary treatment in the aged over 50 years old.
Objective: The purpose of this study was to explore the regional cerebral metabolism in a diffuse axonal injury (DAI) group compared with normal controls and the relationship between regional cerebral metabolism and cognitive function at the chronic stage of DAI.
Methods: In 29 DAI patients, we performed 2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) study using statistical parametric mapping (SPM) analysis at 6 months or more after head injury. With the same protocols, thirty healthy control subjects were also studied. All DAI patients were tested with neuropsychological batteries to assess cognitive function.
Results: Between the DAI patients and normal control, group comparison showed diffuse metabolic decreases in the DAI group. Significant regional hypometabolism was found in bilateral frontal, temporal lobes, and thalamus. WAIS-R full-scale intelligent quotient (IQ) correlated positively with regional cerebral metabolism in the right cingulate gyrus and the bilateral medial frontal gyrus. In other examinations, the correlation was not provided.
Conclusion: In the DAI group, these hypometabolism may be the result of the functional cortical disconnections of the neural networks rather than of direct brain injury. Medial prefrontal cortex and anterior cingulate cortex may be an important component in supporting cognitive function following DAI, which showed diffuse cerebral metabolic reduction compared with normal controls.
Recent experimental studies have demonstrated that oxygen free radicals have important roles of various neuronal conditions. Especially, neuroemergency diseases such as neurotrauma are strongly related with oxidative stress. However, there are few studies proved the existence of free radicals in human because of difficulty in measurement. In this study we introduced free radical (alkoxyl radical) monitoring in neurotrauma. Blood samples were collected from the catheter of the internal jugular bulb. The alkoxyl radical level was measured extra vivo by ESR spectrometry using 5, 5-dimethyl-1-pyrroline-1-oxide (DMPO) as a spin trap, which was obtained from Dojin Chemical (Tokyo, Japan). Electron spin response detection of the spin adduct was performed at room temperature using a JESREIX X-band spectrometer (JEOL, Tokyo, Japan).
Alkoxyl radical levels of all patients were elevated in comparison with control. Alkoxyl radical level was suppressed after administration of edaravone (30 mg i.v). Brain hypothermia treatment suppressed alkoxyl radical in the injured brain while conversely causing systemic oxidative stress formation. Alkoxyl radical levels in patients treated with hyperbaric oxygen therapy (HBO) were elevated within treatment rapidly.
This method is useful to monitor the free radical level immediately at bedside and it will enable to detect the oxidative stress and the severity of brain damage.
Vascular endothelial growth factor (VEGF) is known not only as a major mediator of angiogenesis, but also as a strong vascular permeability factor, which can be involved in vasogenic edema formation subsequent to various brain insults. Therefore, VEGF blockade may become a new model of therapy for brain edema. The aim of this study was to evaluate the effect of VGA1155 (5-[N-Methyl-N-(4-octadecyloxyphenyl) acetyl] amino-2-methylthiobenzoic acid), a novel binding antagonist of VEGF to its receptor, on vasogenic edema in the rat cold injury model. Cold injury was induced by transcranial contact with a liquid nitrogen-cooled probe in rats. VGA1155 was administered at a dose of 25 or 50 mg/kg intraperitoneally at 30 minutes or 4 hours after the cold injury. Control animals received the same volume of vehicle at 30 minutes after the injury. The expression of VEGF protein was measured by ELISA. After 24 hours, the brain water content and blood-brain barrier permeability to Evans blue were determined. VEGF protein levels were significantly increased at 24 and 48 hours after the cold injury. VGA1155 treatment 30 minutes after injury significantly reduced the water content of the ipsilateral hemisphere and BBB permeability to Evans blue. Delayed treatment at 4 hours could not reduce the brain edema. Our data demonstrate that the single intraperitoneal infusion of VGA1155, an antagonist of VEGF, results in significant reduction of brain edema. VEGF receptor antagonist may be a new therapeutic drug for the treatment of vasogenic edema.
We statistically investigated the factors associated with a poor outcome of acute subdural hematoma from among the level of consciousness at presentation, vital signs, neurological findings, and CT findings. The effect of surgery on the outcome was also assessed. [Subjects and Methods] The study was performed in 333 patients with acute subdural hematoma. Logistic regression analysis was used to identify factors that were associated with a poor outcome. Also, the outcome was compared according to the presence or absence of surgery using Kaplan-Meier survival analysis. A good outcome was defined as "good recovery" or "moderate disability" according to the Glasgow Outcome Scale assessment at 6 months after injury, while a poor outcome was defined as "severe disability", "persistent vegetative state", or "death". [Results] A midline shift of greater than 20 mm, absence of the basal subarachnoid space, the presence of left temporal lesions, and the presence of pupillary abnormalities at presentation were found to be indicators of a poor outcome. Surgery was suggested to improve the outcome for 10% of acute subdural hematoma patients generally believed to have a poor prognosis.
The effect of mild hypothermia on neuronal activity in hippocampal CA1 was studied by using optical recording techniques in rats which had suffered from fluid percussion injury (FPI) at 7 days after trauma. After lateral impact, neuronal hyperexcitability was commonly induced in the bilateral hippocampal CA1 areas. Mild hypothermia was induced within 30 minutes after FPI for 1 hour or 3 hours. With the mild therapeutic hypothermia, neuronal hyperexcitability was significantly suppressed when compared with case of FPI models those without hypothermia. These results suggest that mild hypothermia for at least 1 hour suppresses the neuronal hyperexcitability induced by moderate lateral FPI.
Objective: We investigated the influence of anticoagulant and antiplatelet agents on postoperative recurrence and complication following treatment of chronic subdural hematoma.
Methods: We had consecutive 159 patients (103 men and 56 women) with chronic subdural hematoma. Bilateral hematomas were present in 28 patients. In this cohort, 93 patients (58.5%) had history of head trauma and the interval from head injury to onset of the symptom was 10 days to 5 months (median 2 months). All patients underwent burr hole craniostomy and irrigation with drainage. The recurrence and postopera-tive complication were analyzed retrospectively. For reversal of warfarin, international normalized ratio was reduced to less than 1.5 prior to surgery using vitamin K or Fresh Frozen Plasma. Warfarin was restarted 3 days to 1 month after the operation. Cessation of antiplatelet agents was required for 1 to 3 days prior to surgery. Recurrence was defined as re-accumulation of the hematoma within the postoperative hematoma cavity and the appearance of neurological symptoms.
Results: Anticoagulant and/or antiplatelet agents were administered in 29 patients (18.6%). Fourteen patients (8.8%) suffered from the recur-rence. The preoperative hematoma was significantly thicker in patients with recurrence than in those without recurrence. The recurrence rates of warfarin, antiplatelet agent and non-medication group were 20.0%, 13.6% and 7.0%, respectively. There was no significant difference of recurrence rate between 3 groups. However, 2 patients on warfarin developed intractable re-accumulation of hematoma. The postoperative complication related to the reversal of warfarin developed in one patient. No cardiovascular or cerebrovascular complication due to cessation of antiplatelet agents developed during perioperative course.
Conclusion: Postoperative recurrence rate was not significantly increased in the patients treated with anticoagulant and antiplatelet agents under appropriate perioperative management. However, recurrent hematoma of the patients on warfarin may become intractable and require additional treatment.