Tag: Traumatic brain injury

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Rotterdam ct scores before decompressive craniectomy

CT score TBI

J Neurosurg 124:1640–1645, 2016

Rotterdam CT scoring is a CT classification system for grouping patients with traumatic brain injury (TBI) based on multiple CT characteristics. This retrospective study aimed to determine the relationship between initial or preoperative Rotterdam CT scores and TBI prognosis after decompressive craniectomy (DC).

Methods: The authors retrospectively reviewed the medical records of all consecutive patients who underwent DC for nonpenetrating TBI in 2 hospitals from January 2006 through December 2013. Univariate and multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used to determine the relationship between initial or preoperative Rotterdam CT scores and mortality at 30 days or Glasgow Outcome Scale (GOS) scores at least 3 months after the time of injury. Unfavorable outcomes were GOS Scores 1–3 and favorable outcomes were GOS Scores 4 and 5.

Results: A total of 48 cases involving patients who underwent DC for TBI were included in this study. Univariate analyses showed that initial Rotterdam CT scores were significantly associated with mortality and both initial and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes. Multivariable logistic regression analysis adjusted for established predictors of TBI outcomes showed that initial Rotterdam CT scores were significantly associated with mortality (OR 4.98, 95% CI 1.40–17.78, p = 0.01) and unfavorable outcomes (OR 3.66, 95% CI 1.29–10.39, p = 0.02) and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes (OR 15.29, 95% CI 2.50–93.53, p = 0.003). ROC curve analyses showed cutoff values for the initial Rotterdam CT score of 5.5 (area under the curve [AUC] 0.74, 95% CI 0.59–0.90, p = 0.009, sensitivity 50.0%, and specificity 88.2%) for mortality and 4.5 (AUC 0.71, 95% CI 0.56–0.86, p = 0.02, sensitivity 62.5%, and specificity 75.0%) for an unfavorable outcome and a cutoff value for the preoperative Rotterdam CT score of 4.5 (AUC 0.81, 95% CI 0.69–0.94, p < 0.001, sensitivity 90.6%, and specificity 56.2%) for an unfavorable outcome.

Conclusions: Assessment of changes in Rotterdam CT scores over time may serve as a prognostic indicator in TBI and can help determine which patients require DC.

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Is Intracranial Pressure Monitoring of Patients With Diffuse Traumatic Brain Injury Valuable?

ICP

Neurosurgery 78:361–369, 2016

Although intracranial pressure (ICP) monitoring of patients with severe traumatic brain injury (TBI) is recommended by the Brain Trauma Foundation, any benefits remain controversial.

OBJECTIVE: To evaluate the effects of ICP monitoring on the mortality of and functional outcomes in patients with severe diffuse TBI.

METHODS: Data were collected on patients with severe diffuse TBI (Glasgow Coma Scale [GCS] score on admission ,9 and Marshall Class II-IV) treated from January 2012 to December 2013 in 24 hospitals (17 level I trauma centers and 7 level II trauma centers) in 9 Chinese provinces. We evaluated the impact of ICP monitoring on 6-month mortality and favorable outcome using propensity score–matched analysis after controlling for independent predictors of these outcomes.

RESULTS: ICP monitors were inserted into 287 patients (59.5%). After propensity score matching, ICP monitoring significantly decreased 6-month mortality. ICP monitoring also had a greater impact on the most severely injured patients on the basis of head computed tomography data (Marshall computed tomography classification IV) and on patients with the lowest level of consciousness (GCS scores 3-5). After propensity score matching, monitoring remained nonassociated with a 6-month favorable outcome for the overall sample. However, monitoring had a significant impact on the 6-month favorable outcomes of patients with the lowest level of consciousness (GCS scores 3-5).

CONCLUSION: ICP monitor placement was associated with a significant decrease in 6-month mortality after adjustment for the baseline risk profile and the monitoring propensity of patients with diffuse severe TBI, especially those with GCS scores of 3 to 5 or of Marshall computed tomography classification IV.

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Aspirin is associated with an increased risk of subdural hematoma in normal-pressure hydrocephalus patients following shunt implantation

Subdural Hematoma

J Neurosurg 123:423–426, 2015

In this paper the authors investigate whether shunt-treated patients with normal-pressure hydrocephalus receiving aspirin therapy are at increased risk of developing subdural hematoma (SDH).

Methods Records from 80 consecutive patients who had undergone implantation of a cerebrospinal fluid shunt for the treatment of normal-pressure hydrocephalus were retrospectively reviewed.

Results Eleven cases of symptomatic SDH occurred, all among patients receiving aspirin or clopidogrel. The 5-year survival estimate was 0.3 (p < 0.0001) for users of aspirin and the hazard ratio was 12.8 (95% CI 3.1–53).

Conclusions Patients on an aspirin therapy regimen have a markedly increased risk of SDH after a shunt has been implanted for the treatment of normal-pressure hydrocephalus. Users of clopidogrel may have an even greater risk.

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Bur hole craniostomy for chronic subdural hematoma

Bur hole craniostomy for chronic subdural hematoma

J Neurosurg 123:65–74, 2015

There is inconsistency among the perioperative management strategies currently used for chronic subdural hematoma (cSDH). Moreover, postoperative complications such as acute intracranial bleeding and cSDH recurrence affect clinical outcome of cSDH surgery. This study evaluated the risk factors associated with acute intracranial bleeding and cSDH recurrence and identified an effective perioperative strategy for cSDH patients.

Methods A retrospective study of patients who underwent bur hole craniostomy for cSDH between 2008 and 2012 was performed.

Results A consecutive series of 303 cSDH patients (234 males and 69 females; mean age 67.17 years) was analyzed. Postoperative acute intracranial bleeding developed in 14 patients (4.57%) within a mean of 3.07 days and recurrence was observed in 37 patients (12.21%) within a mean of 31.69 days (range 10–104 days) after initial bur hole craniostomy. The comorbidities of hematological disease and prior shunt surgery were clinical factors associated with acute bleeding. There was a significant risk of recurrence in patients with diabetes mellitus, but recurrence did not affect the final neurological outcome (p = 0.776). Surgical details, including the number of operative bur holes, saline irrigation of the hematoma cavity, use of a drain, and type of postoperative ambulation, were not significantly associated with outcome. However, a large amount of drainage was associated with postoperative acute bleeding.

Conclusions Bur hole craniostomy is an effective surgical procedure for initial and recurrent cSDH. Patients with hematological disease or a history of prior shunt surgery are at risk for postoperative acute bleeding; therefore, these patients should be carefully monitored to avoid overdrainage. Surgeons should consider informing patients with diabetes mellitus that this comorbidity is associated with an increased likelihood of recurrence.

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Traumatic Brain Injuries: The Influence of the Direction of Impact

Traumatic Brain Injuries- The Influence of the Direction of Impact

Neurosurgery 76:81–91, 2015

Head impact direction has been identified as an influential risk factor in the risk of traumatic brain injury (TBI) from animal and anatomic research; however, to date, there has been little investigation into this relationship in human subjects. If a susceptibility to certain types of TBI based on impact direction was found to exist in humans, it would aid in clinical diagnoses as well as prevention methods for these types of injuries.

OBJECTIVE: To examine the influence of impact direction on the presence of TBI lesions, specifically, subdural hematomas, subarachnoid hemorrhage, and parenchymal contusions.

METHODS: Twenty reconstructions of falls that resulted in a TBI were conducted in a laboratory based on eyewitness, interview, and medical reports. The reconstructions involved impacts to a Hybrid III anthropometric dummy and finite element modeling of the human head to evaluate the brain stresses and strains for each TBI event.

RESULTS: The results showed that it is likely that increased risk of incurring a subdural hematoma exists from impacts to the frontal or occipital regions, and parenchymal contusions from impacts to the side of the head. There was no definitive link between impact direction and subarachnoid hemorrhage. In addition, the results indicate that there is a continuum of stresses and strain magnitudes between lesion types when impact location is isolated, with subdural hematoma occurring at lower magnitudes for frontal and occipital region impacts, and contusions lower for impacts to the side.

CONCLUSION: This hospital data set suggests that there is an effect that impact direction has on TBI depending on the anatomy involved for each particular lesion.

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Relevance of early head CT scans following neurosurgical procedures

early CT postcranio

J Neurosurg 121:307–312, 2014

Early postoperative head CT scanning is routinely performed following intracranial procedures for detection of complications, but its real value remains uncertain: so-called abnormal results are frequently found, but active, emergency intervention based on these findings may be rare. The authors’ objective was to analyze whether early postoperative CT scans led to emergency surgical interventions and if the results of neurological examination predicted this occurrence.

Methods. The authors retrospectively analyzed 892 intracranial procedures followed by an early postoperative CT scan performed over a 1-year period at Rush University Medical Center and classified these cases according to postoperative neurological status: baseline, predicted neurological change, unexpected neurological change, and sedated or comatose. The interpretation of CT results was reviewed and unexpected CT findings were classified based on immediate action taken: Type I, additional observation and CT; Type II, active nonsurgical intervention; and Type III, surgical intervention. Results were compared between neurological examination groups with the Fisher exact test.

Results. Patients with unexpected neurological changes or in the sedated or comatose group had significantly more unexpected findings on the postoperative CT (p < 0.001; OR 19.2 and 2.3, respectively) and Type II/III interventions (p < 0.001) than patients at baseline. Patients at baseline or with expected neurological changes still had a rate of Type II/III changes in the 2.2%–2.4% range; however, no patient required an immediate return to the operating room.

Conclusions. Over a 1-year period in an academic neurosurgery service, no patient who was neurologically intact or who had a predicted neurological change required an immediate return to the operating room based on early postoperative CT findings. Obtaining early CT scans should not be a priority in these patients and may even be cancelled in favor of MRI studies, if the latter have already been planned and can be performed safely and in a timely manner. Early postoperative CT scanning does not assure an uneventful course, nor should it replace accurate and frequent neurological checks, because operative interventions were always decided in conjunction with the neurological examination.

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Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution

Patients with brain contusions_ predictors of outcome and

J Neurosurg 120:908–918, 2014

Traumatic parenchymal mass lesions are common sequelae of traumatic brain injuries (TBIs). They occur in up to 8.2% of all TBI cases and 13%–35% of severe TBI cases, and they account for up to 20% of surgical intracranial lesions. Controversy exists concerning the association between radiological and clinical evolution of brain contusions. The aim of this study was to identify predictors of unfavorable outcome, analyze the evolution of brain contusions, and evaluate specific indications for surgery.

Methods. In a retrospective, multicenter study, patients with brain contusions were identified in separate patient cohorts from 11 hospitals over a 4-year period (2008–2011). Data on clinical parameters and course of the contusion were collected. Radiological parameters were registered by using CT images taken at the time of hospital admission and at subsequent follow-up times. Patients who underwent surgical procedures were identified. Outcomes were evaluated 6 months after trauma by using the Glasgow Outcome Scale-Extended.

Results. Multivariate analysis revealed the following reliable predictors of unfavorable outcome: 1) increased patient age, 2) lower Glasgow Coma Scale score at first evaluation, 3) clinical deterioration in the first hours after trauma, and 4) onset or increase of midline shift on follow-up CT images. Further multivariate analysis identified the following as statistically significant predictors of clinical deterioration during the first hours after trauma: 1) onset of or increase in midline shift on follow-up CT images (p < 0.001) and 2) increased effacement of basal cisterns on follow-up CT images (p < 0.001).

Conclusions. In TBI patients with cerebral contusion, the onset of clinical deterioration is predictably associated with the onset or increase of midline shift and worsened status of basal cisterns but not with hematoma or edema volume increase. A combination of clinical deterioration and increased midline shift/basal cistern compression is the most reasonable indicator for surgery.

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Decompressive craniectomy for severe traumatic brain injury: is life worth living?

decompressive craniectomy

J Neurosurg 119:1566–1575, 2013

The object of this study was to assess the long-term outcome and quality of life of patients who have survived with severe disability following decompressive craniectomy for severe traumatic brain injury (TBI).

Methods. The authors assessed outcome beyond 3 years among a cohort of 39 patients who had been adjudged either severely disabled or in vegetative state 18 months after decompressive craniectomy for TBI. Assessments performed included the Extended Glasgow Outcome Scale, modified Barthel Index (mBI), Zarit Burden Interview, and 36-Item Short-Form Health Survey (SF-36). The issue of retrospective consent for surgery was also assessed.

Results. Of the 39 eligible patients, 7 died, 12 were lost to follow-up, and 20 patients or their next of kin consented to participate in the study. Among those 20 patients, 5 in a vegetative state at 18 months remained so beyond 3 years, and the other 15 patients remained severely disabled after a median follow-up of 5 years. The patients’ average daily activity per the mBI (Pearson correlation coefficient [r] = -0.661, p = 0.01) and SF-36 physical score (r = -0.543, p = 0.037) were inversely correlated with the severity of TBI. However, the SF-36 mental scores of the patients were reasonably high (median 46, interquartile range 37–52). The majority of patients and their next of kin believed that they would have provided consent for surgical decompression even if they had known the eventual outcome.

Conclusions. Substantial physical recovery beyond 18 months after decompressive craniectomy for severe TBI was not observed; however, many patients appeared to have recalibrated their expectations regarding what they believed to be an acceptable quality of life.

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Nonsurgical treatment of chronic subdural hematoma with tranexamic acid

SDH

J Neurosurg 119:332–337, 2013

Chronic subdural hematoma (CSDH) is a common condition after head trauma. It can often be successfully treated surgically by inserting a bur hole and draining the liquefied hematoma. However, to the best of the authors’ knowledge, for nonemergency cases not requiring surgery, no reports have indicated the best approach for preventing hematoma enlargement or resolving it completely. The authors hypothesized that hyperfibrinolysis plays a major role in liquefaction of the hematoma. Therefore, they evaluated the ability of an antifibrinolytic drug, tranexamic acid, to completely resolve CSDH compared with bur hole surgery alone.

METHODS
From 2007 to 2011, a total of 21 patients with CSDH seen consecutively at Kuki General Hospital, Japan, were given 750 mg of tranexamic acid orally every day. Patients were identified by a retrospective records review, which collected data on the volume of the hematoma (based on radiographic measurements) and any complications. Follow-up for each patient consisted of CT or MRI every 21 days from diagnosis to resolution of the CSDH.

RESULTS
Of the 21 patients, 3 with early stages of CSDH were treated by bur hole surgery before receiving medical therapy. The median duration of clinical and radiographic follow-up was 58 days (range 28–137 days). Before tranexamic acid therapy was initiated, the median hematoma volume for the 21 patients was 58.5 ml (range 7.5–223.2 ml); for the 18 patients who had not undergone surgery, the median hematoma volume was 55.6 ml (range 7.5–140.5 ml). After therapy, the median volume for all 21 patients was 3.7 ml (range 0–22.1 ml). No hematomas recurred or progressed.

CONCLUSIONS
Chronic subdural hematoma can be treated with tranexamic acid without concomitant surgery. Tranexamic acid might simultaneously inhibit the fibrinolytic and inflammatory (kinin-kallikrein) systems, which might consequently resolve CSDH. This medical therapy could prevent the early stages of CSDH that can occur after head trauma and the recurrence of CSDH after surgery.

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Automated intracranial pressure-controlled cerebrospinal fluid external drainage with LiquoGuard®

Automated intracranial pressure-controlled CSF LiquoGuard

Acta Neurochir (2013) 155:1589–1595

LiquoGuard is a new device for intracranial pressure (ICP)-controlled drainage of cerebrospinal fluid (CSF). This present study evaluates the accuracy of ICP measurement via the LiquoGuard device in comparison with Spiegelberg. Thus, we compared data ascertained from simultaneous measurement of ICP using tip-transducer and tip-sensor devices.

Material and Methods A total of 1,764 monitoring hours in 15 patients (range, 52–219 h) were analysed. All patients received an intraventricular Spiegelberg III probe with the drainage catheter connected to the LiquoGuard system. ICP reading of both devices was performed on an hourly basis. Statistical analysis was done by applying Pearson correlation and Wilcoxon-matched pair test (p<0.05).

Results Mean ICP values were 11±5 mmHg (Spiegelberg) and 10±7 mmHg (LiquoGuard); the values measured with both devices correlated well (p=0.001; Pearson correlation =0.349; n=1,764). In two of the 15 patients with slit ventricles, episodes of significant differences in measured values could be observed. Both patients suffering from slit ventricles failed to produce reliable measurement with the external transducer of the LiquoGuard.

Conclusions LiquoGuard is a valuable new device for ICP-controlled CSF drainage. However, LiquoGuard tends to provide misleading results in slit ventricles. Thus, before these drawbacks are further analysed, the authors recommend additional ICP measurement with internal tip-sensor devices to avoid dangerous erroneous interpretation of ICP data.

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The prognostic significance of traumatic brainstem injury detected on T2-weighted MRI

J Neurosurg 117:722–728, 2012

Magnetic resonance imaging is frequently used to evaluate patients with traumatic brain injury in the acute and subacute setting, and it can detect injuries to the brainstem, which are often associated with poor outcomes. This study was undertaken to determine which MRI and clinical factors provide prognostic information in patients with traumatic brainstem injuries.
Methods
The authors performed a retrospective analysis of cases involving patients admitted to a Level I trauma center who were identified in a prospective database as having suffered traumatic brainstem injury identified on MRI. Patient outcomes were dichotomized to dead/vegetative versus functional groups. Standard demographic data, admission Glasgow Coma Scale (GCS) scores, results of the motor component of the GCS examination at admission and 24 hours later, CT scan findings, and peak intracranial pressure were collected from medical records. Volumetric analysis of each patient’s injuries was performed with T2-weighted and gradient echo sequences. The T2-weighted MRI sequence for each patient was reviewed to determine the anatomical location of injury within the brainstem and whether the injury crossed the midline.
Results
Thirty-six patients who met the study inclusion criteria were identified. At 6-month follow-up, 53% of these patients had poor outcomes and 47% had recovered. Patients with injuries to the medulla or deep bilateral injuries to the pons did not recover. The T2 volumes were found superior to gradient echo sequences in regard to predicting survival (ROC/AUC 0.67, p = 0.07 vs 0.60, p = 0.29, respectively), but neither reached statistical significance. The timing of MR image acquisition did not influence the findings. The time from admission to MRI did not differ significantly between the recovered group and the poor-outcome group (p = 0.52, Mann-Whitney test), and lesion size as measured by T2 volume did not vary with time to scan (R2 = 0.03, p = 0.3, linear regression). Performing a stepwise logistic regression with all the variables yielded the following factors related to recovery: crossing midline, p = 0.0156, OR 0.075; and 24-hour GCS motor score, p = 0.0045, OR = 2.25, c-statistic 0.913. Further examination of these 2 factors disclosed the following: none of 15 patients with midline-crossing lesions and a 24-hour GCS motor score of 4 or less recovered; conversely, 12 of 13 patients with lesions that did not cross midline recovered, regardless of GCS motor score.
Conclusions
Bilateral injury to the pons and medulla as detected on T2-weighted MRI sequences was associated with poor outcome in patients with brainstem injuries; T2 volumes were found superior to gradient echo sequences in regard to predicting survival, but neither reached statistical significance. When MRI findings were coupled with clinical examination findings, a strong correlation existed between poor outcome and the combination of bilateral brainstem injury and a motor GCS score of 4 or less 24 hours after admission.

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Traumatic subdural effusion with concomitant hydrocephalus

J Neurosurg 116:558–565, 2012. DOI: 10.3171/2011.10.JNS11711

Traumatic subdural effusion (TSE) is a common sequela of traumatic brain injury. Surgical intervention is suggested only when TSE exerts mass effect. The authors have found that many patients with TSE exerting mass effect have concomitant hydrocephalus. Patient experiencing this occurrence were studied, and the pathogenesis of this phenomenon was discussed in the context of recent advances in the understanding of CSF circulation.

Methods. During a 2-year period, the authors’ institution treated 14 patients with TSE who developed hydrocephalus, after 1 of the patients suffered subdural drainage and other 13 received subdural peritoneal shunt (SPSs). Thirteen of those who had SPSs received programmable ventriculoperitoneal shunts (VPSs) for the hydrocephalus. The clinical characteristics as well as the imaging and operative findings of these patients were reviewed.

Results. All patients with symptomatic TSE exerting mass effect received SPSs. All of these patients had a modified Frontal Horn Index of more than 0.33 at presentation, and high opening pressure on durotomy. Following a brief period (4–7 days) of clinical improvement, the condition of all patients deteriorated due to hydrocephalus. Programmable VPSs were inserted with the initial pressure set at approximately 8–10 cm H2O according to opening pressure at ventriculostomy. Shunt valve pressure was gradually decreased to 5–7 cm H2O, according to clinical and radiological follow-up.

Conclusions. Elevated modified Frontal Horn Index in patients with TSE is suggestive of concomitant hydrocephalus. The authors propose that tearing of the dura-arachnoid plane following trauma contributes to TSE and may also impede CSF circulation, causing hydrocephalus. Shunt pressure was adjusted to relative low pressure, indicating the old age of the patients and poor reexpansion of brain parenchyma after the mass effect. Subdural peritoneal shunts and VPSs are indicated in those patients with TSE exerting mass effect with concomitant hydrocephalus.

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Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery

Neurosurg Focus 31 (5):E5, 2011. DOI: 10.3171/2011.8.FOCUS11177

Traumatic brain injury (TBI) is the current leading cause of death in children over 1 year of age. Adequate management and care of pediatric patients is critical to ensure the best functional outcome in this population.

In their controversial trial, Cooper et al. concluded that decompressive craniectomy following TBI did not improve clinical outcome of the analyzed adult population. While the study did not target pediatric populations, the results do raise important and timely clinical questions regarding the effectiveness of decompressive surgery in pediatric patients. There is still a paucity of evidence regarding the effectiveness of this therapy in a pediatric population, and there is an especially noticeable knowledge gap surrounding age-stratified interventions in pediatric trauma.

The purposes of this review are to first explore the anatomical variations between pediatric and adult populations in the setting of TBI. Second, the authors assess how these differences between adult and pediatric populations could translate into differences in the impact of decompressive surgery following TBI.

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Dysfunction of hypothalamic-hypophysial axis after traumatic brain injury in adults

J Neurosurg 113:581–584, 2010. DOI: 10.3171/2009.10.JNS09930

Traumatic brain injury (TBI) is a major cause of serious morbidity and mortality. The incidence is 100–500/100,000 inhabitants/year. Chronic pituitary dysfunction is increasingly recognized after TBI. To define the incidence of endocrine dysfunction and risk factors, the authors describe a prospectively assessed group of patients in whom they documented hormonal functions, early diagnosis, and treatment of neuroendocrine dysfunction after TBI.

Methods. Patients aged 18–65 years were prospectively observed from the time of injury to 1 year postinjury; the Glasgow Coma Scale score ranged from 3 to 14. Patients underwent evaluation of hormonal function at the time of injury and at 3, 6, and 12 months postinjury. Magnetic resonance imaging was also conducted at 1 year postinjury.

Results. During the study period, 89 patients were observed. The mean age of the patients was 36 years, there were 23 women, and the median Glasgow Coma Scale score was 7. Nineteen patients (21%) had primary hormonal dysfunction. Major deficits included growth hormone dysfunction, hypogonadism, and diabetes insipidus. Patients in whom the deficiency was major had a worse Glasgow Outcome Scale score, and MR imaging demonstrated empty sella syndrome more often than in patients without a deficit.

Conclusions. To the authors’ knowledge, this is the third largest study of its kind worldwide. The incidence of chronic hypopituitarism after TBI was higher than the authors expected. After TBI, patients are usually observed on the neurological and rehabilitative wards, and endocrine dysfunction can be overlooked. This dysfunction can be life threatening and other clinical symptoms can worsen the neurological deficit, extend the duration of physiotherapy, and lead to mental illness. The authors recommend routine pituitary hormone testing after moderate or severe TBI within 6 months and 1 year of injury.

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Update on protein biomarkers in traumatic brain injury with emphasis on clinical use in adults and pediatrics

Purpose  This review summarizes protein biomarkers in mild and severe traumatic brain injury in adults and children and presents a strategy for conducting rationally designed clinical studies on biomarkers in head trauma.
Methods  We performed an electronic search of the National Library of Medicine’s MEDLINE and Biomedical Library of University of Pennsylvania database in March 2008 using a search heading of traumatic head injury and protein biomarkers. The search was focused especially on protein degradation products (spectrin breakdown product, c-tau, amyloid-β1–42) in the last 10 years, but recent data on “classical” markers (S-100B, neuron-specific enolase, etc.) were also examined.
Results  We identified 85 articles focusing on clinical use of biomarkers; 58 articles were prospective cohort studies with injury and/or outcome assessment.
Conclusions  We conclude that only S-100B in severe traumatic brain injury has consistently demonstrated the ability to predict injury and outcome in adults. The number of studies with protein degradation products is insufficient especially in the pediatric care. Cohort studies with well-defined end points and further neuroproteomic search for biomarkers in mild injury should be triggered. After critically reviewing the study designs, we found that large homogenous patient populations, consistent injury, and outcome measures prospectively determined cutoff values, and a combined use of different predictors should be considered in future studies.
Doi: 10.1007/s00701-009-0463-6
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