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Risk factors for posttraumatic cerebral infarction in patients with moderate or severe head trauma

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Abstract

We examined the incidence and timing of posttraumatic cerebral infarction (PTCI) and provide predictive factors for the development of PTCI in patients with moderate or severe traumatic brain injury. Three hundred and fifty-three consecutive patients with moderate or severe head trauma were retrospectively reviewed to determine the incidence and timing of PTCI and to evaluate the effects of age, gender, admission Glasgow Coma Scores (GCS), decompressive craniectomy, brain herniation, and low systolic blood pressure (BP) on the development of cerebral infarction. Risk factors for posttraumatic cerebral infarction were evaluated using logistic regression analysis. PTCI was observed in 36 (11.96%) of the 353 patients, and in a majority of cases, cerebral infarction developed within 2 weeks after injury. Poor admission GCS (P < 0.01), low systolic BP (P < 0.01), brain herniation (P < 0.05), and decompression craniotomy (P < 0.05) were significantly associated with the development of PTCI. No relationship was found between PTCI and gender or increased age. Posttraumatic cerebral infarction is a relatively common complication in patients with head trauma that develops early in the clinical course. Low GCS, low systolic BP, brain herniation, and decompression craniotomy may be risk factors for PTCI in patients with moderate or severe traumatic brain injury.

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Acknowledgments

This study was supported by the Shanghai Municipal Health Bureau (grant no. 054011) and Shanghai Science and Technology Council (grant no. 03ZR14059).

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Correspondence to Hao Chen.

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Comments

Jizong Zhao, Beijing, China

Posttraumatic cerebral infarction (PTCI) is one of the most severe secondary injury after brain trauma. It often results in a poor clinical outcome. Thus, recognition of this secondary brain insult and the associated risk factors may help identify the group at risk and tailor management of patients with severe TBI. In this article, the authors defined the incidence and timing of PTCI, described the risk factors after logistic regression analysis, and demonstrated that a low GCS, low systolic BP, herniation, and decompression craniotomy were risk factors for PTCI. This will help neurosurgeons to recognize PTCI in the early stage. In this paper, the patients’ ages ranged from 2 to 86 years; are there differences in the risk factors between children and adults? Since, at present, it is reported that the mechanism is different between children and adults, so perhaps there will be new findings after analyzing the data in subgroups by ages. And what is the reason of PTCI high incidence during the second week, iatrogenic, or other reasons? The author mentioned that aggressive management of PTCI should be recommended. What are effective treatments and how about the outcomes? So a more comprehensive analysis about specific interventions for PTCI is absolutely needed in the future.

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Dattatraya Muzumdar, Mumbai, India

Tian et al. present their experience of posttraumatic cerebral infarction in the management of 353 head trauma patients. They suggest that PTCI should be diagnosed early for prompt institution of treatment and possibly an improved outcome. The use of a sufficiently powered study and multivariable models to predict the long-term outcome of moderate and severe head trauma is a positive nature of this study. The identification of variables like low GCS, low systolic BP, herniation, and decompression craniotomy as risk factors early during the course of moderate to severe head trauma is also an important attribute of this study.

The limitation of the study lies in its retrospective nature. A prospective study with detailed neurologic examination and neuropsychological assessment to demonstrate that the observed morbidity could be attributed to cerebral infarction and not to primary posttraumatic brain damage or to other nonischemic complications would be helpful. A validation of surrogate PTCI outcomes would be useful for research on those measurements that can effectively predict an increased risk of cerebral infarction, hence abandoning measures whose theoretical rationale is not demonstrated. Magnetic resonance imaging, particularly diffusion-weighted and perfusion-weighted techniques, should be used as a reference standard to diagnose brain infarction and clarify whether the use of more sensitive neuroradiologic investigations actually improves detection of posttraumatic cerebral infarction.

The outcome in posttraumatic cerebral infarction is usually dismal since there is a high incidence of mortality and severe morbidity compromising quality of life and increased care cost to the family in particular and the state in general. PTCI occurs due to the severe parenchymal or vascular injury leading to primary and later secondary brain injury releasing free oxygen radicals. Until now, cerebral protective agents like Ca-channel blockers or free oxygen radical scavengers have not shown any significant encouraging results. In essence, the treatment of posttraumatic cerebral infarction lies in prevention and early detection.

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Tian, HL., Geng, Z., Cui, YH. et al. Risk factors for posttraumatic cerebral infarction in patients with moderate or severe head trauma. Neurosurg Rev 31, 431–437 (2008). https://doi.org/10.1007/s10143-008-0153-5

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  • DOI: https://doi.org/10.1007/s10143-008-0153-5

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