bluuebunny/crossref_metadata_2025_split huggingface dataset:
472 Effects of Recurrent Mild Traumatic Brain Injuries on Incidence, Severity, and Recovery of Concussion in Young Student-Athletes
Authors: Hannah Theodore , Spiera Zachary , Li Adam Y. , Dreher Nickolas , Ali Muhammad , Marayati Naoum F. , Lovell Mark R. , Choudhri Tanvir 
Published: March 2022

INTRODUCTION:
Currently, it is known that athletes who sustain recurrent concussions are at an increased risk for long-term neurological consequences. Moreover, in the short term, athletes with a history of concussions are significantly more likely to sustain future concussions. Although the increased incidence of mTBI among athletes with a history of concussions has been well documented, there is less consensus about how recurrent concussions affect the severity and recovery of the next head trauma.

METHODS:
Data from 11 563 ImPACT baseline evaluations of US student-athletes aged 12 to 22 years were separated into 2 cohorts: subjects reporting 2 or more previous concussions (PC; n = 976 baseline evaluations) at baseline and a control group reporting zero previous concussions (CT; n = 7743 baseline evaluations). Subjects reporting 1 prior concussion were excluded. Differences in SND incidence, severity, and recovery between the 2 cohorts were assessed using chi-squared tests, t tests, survival analyses, and multivariate regressions.

RESULTS:
The PC cohort had a higher incidence of head injury leading to ImPACT (436.7 per 1000 person-years vs 194.4 per 1000 person-years, P < .0001) and a higher incidence of SND (140.4 vs 71.8, P < .0001) than controls. However, the Severity Index (SI) demonstrated that SND severity was lower in the PC group (7.55 vs 8.59, P = .04). Adjusted analyses similarly demonstrated that the PC cohort had increased SND incidence (odds ratio = 1.93; 95% CI, 1.61 to 2.31; P < .0001), decreased SI (β = −1.37; 95% CI, −2.40 to −0.34; P = .009), and equivalent recovery (hazard ratio = 0.98; 95% CI, 0.76 to 1.72; P = .90).

CONCLUSION:
Participants with a history of concussion have a higher incidence of SND but present with lower severity SND, which may be a result of increased concussion education or symptom awareness. Recurrent concussion has no significant impact on acute neurocognitive recovery. Together, these results provide evidence against the supposition that a history of concussion increases the severity of future SND.
473 The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691,821 Nationwide Cases
Authors: Tang Oliver Y. , Shao Belinda , Kimata Anna , Sastry Rahul , Asaad Wael 
Published: March 2022

INTRODUCTION:
Earlier research has demonstrated that patient frailty, a decline in physiologic reserve, is associated with higher morbidity and mortality for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury (TBI) outcomes is poorly characterized.

METHODS:
We identified all adult admissions for traumatic intracranial hemorrhage (tICH) in the National Trauma Data Bank from 2007-2017. Frailty was quantified via the validated mFI-5 metric (0-5), with mFI-5 =2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition (discharge home or to short-term care), complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression was used to assess the association between mFI-5 and outcomes, adjusting for patient demographics (age, sex, insurance, transfer status), hospital characteristics (teaching status, trauma center level, bed size), injury severity on admission (penetrating injury, Glasgow Coma Scale [GCS], Injury Severity Score, hypotension, number of tICH subtypes), and neurosurgical procedures.

RESULTS:
691,821 tICH admissions were analyzed. 63.2% were male and average age was 57.6 years (standard deviation=21.2). 43.5% were above 65 years of age. 18.0% of patients were classified as frail (mFI-5 = 2), and the percentage of frail patients grew from 7.9% in 2007 to 21.9% in 2017. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < 0.001) and decreased odds of favorable discharge disposition (OR = 0.72, P < 0.001). Frail patients also exhibited an elevated rate of complications (OR = 1.06, P < 0.001), including unplanned return to the ICU (OR = 1.55, P < 0.001) and operating room (OR = 1.17, P = 0.003). Finally, ventilator days (+12%, P < 0.001), ICU LOS (+11%, P < 0.001), and total LOS (+13%, P < 0.001) were significantly higher in frail patients. All associations with death and disposition remained significant following stratification for age, polytrauma, ICU stay, and GCS on admission.

CONCLUSION:
For tICH patients, frailty was associated with elevated mortality, unfavorable discharge disposition, complications, ventilator days, and LOS, regardless of age or injury severity. Further research into integrated care pathways for this high-risk population is warranted.
474 Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians With Subdural Hematomas
Authors: Kashkoush Ahmed , Petitt Jordan , Ladhani Husayn , Ho Vanessa , Kelly Michael L. 
Published: March 2022

INTRODUCTION:
Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS), pupil non-reactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly.

METHODS:
A prospectively collected multi-center database of 3,279 TBI admissions to 45 different U.S. trauma centers between 2017-2019 was queried to identify patients >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables.

RESULTS:
A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil non-reactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures.

CONCLUSION:
Poor GCS, pupil non-reactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of lifesustaining measures.
480 Deep Learning Analysis of Early MRI Scans After Severe Traumatic Brain Injury Predicts Long-term Outcomes
Authors: Pease Matthew , Arefan Dooman , Puccio Ava , Roy Souvik , Nwachuku Enyinna , Wu Shandong , Okonkwo David O. 
Published: March 2022

INTRODUCTION:
Nearly three quarters of deaths in clinical trials of severe traumatic brain injury (TBI) occur due to withdrawal of life sustaining therapies, often due to perceived poor neurological prognosis. Most of these deaths occur within the first week when physicians historically lack enough accuracy to make these decisions. Prognostic models, such as the International Mission for Prognosis and Analysis of Clinical Trials in TBI, are designed to prognose outcomes upon admission and fail to utilize clinical information accumulated after admission. Quantitative prognostic models capturing this informaiton are needed to help guide care decisions.

METHODS:
We built our model using 266 patients from a prospective database of severe TBI patients from 2002 through 2018 with an MRI obtained 1 to 9 days post-trauma. We developed a customized, multi-channel, deep convolutional neural network model with an AlexNet backbone and pre-trained with ImageNet. The cohort was split into 80% training, 10% validation, and 10% independent testing set. We built separate models using T2 FLAIR and DWI sequences. To reduce the heterogeneity of imaging after a decompressive hemicraniectomy (DHC), we only used DHC patients for model training.

RESULTS:
No adverse clinical events occurred while obtaining early MRIs. The overall mortality was 25% (68) and 20% (34) in the 170 patients who did not have a DHC. In the independent test cohort, the T2 FLAIR model performed best, with an area under the curve (AUC) of 0.80 (95% Confidence Interval: 0.57-0.94) and accuracy of 83%. The DWI model had an AUC of 0.64 (0.50 – 0.79) with an accuracy of 78%. With a specificity of 100% (i.e., never recommending withdrawal of care in a patient who would otherwise survive), the sensitivity for mortality was 57%. For identifying patients with favorable recovery potential, the sensitivity was 83% with a specificity of 80%.

CONCLUSION:
Early MRIs are safe to obtain in the severe TBI patient population. Deep learning analysis of these MRIs can predict 6-month mortality to help guide neurological prognostication.
483 Improvement in Behavioral, Cellular and Molecular Outcomes with Connexin Inhibitors Administration in a Porcine Spinal Cord Injury Model
Authors: Alok Khaled , Moussalem Charbel , Minassian Georges , Baassiri Wassim , Kobeissy Firas , Jurjus Abdo , Hamade Eva , Ayoub Abeer J. , Habib Aida , Fahs Assil , El Houshiemy Mohamad N. , Bsat Shadi , Alomari Safwan , Omeis Ibrahim 
Published: March 2022

INTRODUCTION:
Connexin inhibition has demonstrated promising results in rodents spinal cord injury models (SCI) as a neuroprotective strategy that improves SCI outcomes. However, it has not been tested in a larger animal yet, a necessary step before conducting a human clinical trial.

METHODS:
SCI was induced using a compression/contusion weight drop model in three groups of pigs with 2 animals per group. Group A: control, Group B: treated with nonselective gap junctions blocker: Carbenoxolone, Group C: treated with connexin-43 memetic peptide: Gap26. All medications were delivered intrathecally at the time of injury. We assessed the locomotor development of the animals over 11 weeks. After which the animals were euthanized and their spinal cords were harvested for histological and immunofluorescence assessment.

RESULTS:
Treatment with intrathecal connexins inhibitors improved SCI outcomes. In terms of locomotion recovery, Groups B and C regained the stepping ability in their hind limbs, whereas the control group did not. Similarly, groups B and C exhibited a decreased level of astrocytes activation at the injury site, and their PGE2 serum levels remained low in the two treated groups. The histological damage was particularly limited in Gap 26-treated group (C).

CONCLUSION:
We translated the positive neuroprotective effect of a connexin-43 mimetic peptide and a gap junction blocker in a porcine SCI model. This study supports the potential role of these agents in improving SCI outcome.
485 Identifying the Minimum Clinically Important Differences (MCID) in ISNCSCI Score for Patients with Traumatic Spinal Cord Injury: An Analysis from the National Spinal Cord Injury Model Systems (SCIMS) Database
Authors: Yolcu Yagiz , Doherty Ronan , Michalopoulos Giorgos , Ghaith Abdul K. , Shah Nilay , Garlanger Kristin , Madigan Nicolas , Bydon Mohamad 
Published: March 2022

INTRODUCTION:
Spinal Cord Injury (SCI) is a major cause of disability, mostly presenting due to a traumatic event such as a motor vehicle accident or a fall. To evaluate and follow-up the neurological recovery for patients with SCI, several scales, and scoring systems have been published with the collaborative multidisciplinary efforts, including the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Identifying an MCID for this scoring system is crucial to evaluate patient improvement and provide hints about the success of any intervention.

METHODS:
National Spinal Cord Injury Model Systems Database was queried from 2001-2016 for patients admitted to rehabilitation centers following traumatic spinal cord injury. The following methods were used to identify MCIDs; (i) anchor-based methods where an outcome measure is selected to be the “anchor” (Functional Independence Measure) and defined changes in this anchor is linked to the changes in the investigated outcome measure (ISNCSCI motor scores) and (ii) distribution-based methods where several different parameters (Standard error of measurement, half standard deviation, etc.) are used determine one MCID.

RESULTS:
A total of 1,521 patients were identified. MCIDs for the overall cohort ranged from 3.25 to 6.6 for the anchor-based methods and 0.93 to 5.30 based on the distribution-based methods. Although slight changes were seen, the range of MCIDs was found to be similar to the overall cohort when cohorts were stratified by sex, the level of injury, complete/incomplete injury, and different age groups. The highest MCID was detected for patients with cervical injury in both anchor-based (9.03) and distribution-based approaches (6.06), while the lowest MCID was detected for patients with thoracic injury in both anchor-based (1.0) and distribution-based approaches (0.23).

CONCLUSION:
Our findings demonstrated similar results with regards to MCIDs for ISNCSCI scoring between different patient profiles (stratified by sex, the level of injury, complete/incomplete injury, and age groups) with scores ranging from 0.23 to 9.09 based on different approaches. Anchor-based methods provided higher MCIDs overall when compared to distribution-based methods.
486 Patients Who Die, Then Talk: Outcomes in Patients with Traumatic Extra-Arachnoid Subdural Hematoma
Authors: Eaton Jessica C. , Meyer R. Michael , Greil Madeline , Young Christopher C. , Temkin Nancy , Barber Jason , Bonow Robert H. , Chesnut Randall M. 
Published: March 2022

INTRODUCTION:
A critical step in the management of TBI patients is evaluating for lesions that require urgent surgical evacuation. Amongst the most common of these surgical lesions are subdural hematomas (SDH). A subset of patients with SDH have purely extra-arachnoid lesions (EASDH). These patients present in similarly grave neurologic condition as the general SDH hematoma population.

METHODS:
This is a single-center prospective cohort of patients presenting with EASDH from January 2015 to December 2016. The senior author, an neurosurgical trauma subspecialist, made the determination of EASDH versus mixed subarachnoid and SDH based on the patient’s CT scan. Controls from the TRACK-TBI database who had SDH as well as either subarachnoid or other parenchymal injuries were included.

RESULTS:
A total of 49 patients with EASDH were compared to 246 controls. There were no significant differences in baseline demographics between the groups. A significant difference in midline shift was noted. After controlling for midline shift, EASDH patients had 5.68 greater odds of having a better 2-week GOS-E. The expected two-week mortality, as predicted by the CRASH model, was similar between the two groups, but the EASDH group fared much better than the predicted mortality, at 10%.

CONCLUSION:
Patients with EASDH represent a unique clinical entity. They are often elderly and have large lesions with significant midline shift. However, patients often have a dramatic improvement.
489 Time to Following Commands and Favorable Recovery After Severe Traumatic Brain Injury
Authors: Deng Hansen , Nwachuku Enyinna , Wilkins Tiffany , Yue John K. , Fetzick Anita L. , Chang Yue-Fang , Beers Sue , Okonkwo David O. , Puccio Ava 
Published: March 2022

INTRODUCTION:
Accurate prognostication after severe traumatic brain injury (TBI) is crucial to goals-of-care discussions and assisting with difficult medical decisions. The capacity to follow commands indicates clinical arousal from unconsciousness and higher level of cognitive function. While it is a predictor of good outcome, time to following commands after injury can widely vary.

METHODS:
Consecutive participants from 2003-2018 were recruited at the Brain Trauma Research Center (BTRC) using IRB-approved prospective observational study design. Inclusion criteria were age 16-80 years, Glasgow Coma Scale (GCS) score =8 and motor GCS score <6, and Glasgow Outcome Scale - Extended (GOS-E) measure =4 at 2 years post injury. Interquartile range (IQR), mean increases/decreases (B), and 95% confidence intervals (CIs) were reported. Statistical significance was assessed at p=0.05.

RESULTS:
A total of 580 patients were enrolled in the BTRC from 2003-2018. There were 229 (39.5%) deaths, and 140 (24.1%) patients had favorable outcomes on the GOS-E at 24 months. Average age was 33.7±14.5 years old, median GCS was 7 (IQR 6-7), and median Injury Severity Score (ISS) was 30 (IQR 26-38). Mean time to following commands was 12.7±11.8 days, median GOS-E at 2 years was 6 (IQR 5-7). On multivariate regression, evidence of diffuse axonal injury (DAI) (B=9.2 days [4.8,13.7], p<0.0001) or intraventricular hemorrhage (IVH) (B=6.4 days [0.5,12.3], p<0.035) was associated with longer time to following commands, and patients who developed nosocomial infections (B=6.5 days [1.6-11.4], p<0.01).

CONCLUSION:
The majority of patients with favorable recovery after severe TBI began to follow commands by 2 weeks. Evidence of DAI, IVH, or nosocomial infections delay cognitive improvement in the acute period during hospitalization. These patients make considerable recovery after discharge and continue to benefit from long-term tailored rehabilitation.
490 Sublaminar Sutures for Stabilization and Fusion of a C3-4 Fracture Dislocation in a 11-Month-Old Infant
Authors: Winter Kenneth A. , Kim Patrick , Smith Andrew , Smalley Zachary , Weaver Kristin J. , Shiflett J. Mason , Tullis Jason E. 
Published: March 2022

INTRODUCTION:
Pediatric spinal cord injuries (SCI) are an uncommon occurrence with a rate of 1.99 cases per 100,000 children in the United States. Sub-axial SCIs are even rarer and thus, techniques for fixation are limited. Lateral mass screws are not feasible in infants and toddlers due to limited bone volume. We describe a successful stabilization of a C3/4 fracture dislocation in a 3-month-old using sublaminar sutures.

METHODS:
A standard midline incision and subperiosteal dissection was used to expose C3 to C5. The ligamentum flavum was released and the blunt end of non-absorbable braided polyester sutures were passed under the lamina. Sutures were preferred over wiring due to its tensile properties. In fragile infant bone, sutures are more likely to avoid bony laceration in the lamina, especially during reduction. Sutures were passed in tandem fashion bilaterally, from C2-C4, C3-C5 then C3-C4. Sutures were tied confirming reduction under fluoroscopy.

RESULTS:
A 3-month-old female after MVC presented with an ASIA-A SCI and a C5 motor level. Imaging revealed a C3-4 fracture-dislocation and right C3 pedicle fracture with cord transection at T1-2. The patient was placed in a c-collar until bony growth of the spine had occurred at 11 months-of-age. The patient then underwent stabilization and fusion as described above. Follow-up x-rays taken 8 months post-operatively revealed adequate bony growth and fusion.

CONCLUSION:
The literature on management of sub-axial SCIs in infants is sparse. Low bone density in this population limits surgical options for stabilization. We discuss a 3-month-old female with a C3-4 fracture-dislocation who underwent delayed posterior stabilization via sublaminar suturing at 11 months-of-age. The patient achieved successful bony fusion on follow-up imaging without evidence of non-union.
491 Usability and Acceptability of Clinical Decision Support for Children with Mild Traumatic Brain Injuries and Intracranial Injuries: A Mixed Methods Study
Authors: Greenberg Jacob K. , Otun Ayodamola , Carpenter Christopher , Brownson Ross , Kuppermann Nathan , Limbrick David D. , Foraker Randi , Yen Po-Yin 
Published: March 2022

INTRODUCTION:
Electronic clinical decision support (CDS) may improve the safe, evidence-based management of children with mild traumatic brain injuries (mTBI) and intracranial injuries.

METHODS:
Emergency medicine and neurosurgery physicians were recruited to participate in study sessions to test the usability and acceptability of a novel CDS prototype in a simulated electronic health record environment. Testing sessions included interacting with the tool using three simulated clinical cases (https://head-injury-risk-predictor.web.app/case-1.htmlt), a think-aloud protocol, an acceptability and usability survey, and a semi-structured interview. The prototype was updated twice during testing (phases 1-3) to reflect user feedback. Usability problems were categorized and quantified using content analysis and reported with a descriptive summary. The semi-structured interviews were analyzed using thematic analysis.

RESULTS:
Twenty physicians (10 each from neurosurgery and emergency medicine) were recruited from nine separate hospitals. Most participants worked at teaching hospitals (80%) and level 1 trauma centers (75%). During the prototype updates, problems with clarity of terminology and wording were identified and corrected, along with problems navigating through and using the CDS interface. Corresponding to these changes, the number of usability problems dropped from 35 in phase 1 to 8 in phase 3, and the number of mistakes made went from 18 in phase 1 to 2 in phase 3. Through the survey, most participants found the tool easy to use (90%), useful for determining a patient’s level of care (95%), and likely to improve resource use (90%) and patient safety (79%). Major interview themes related to the CDS’s ability to support evidence-based decision-making and improve clinical workflow, proposed implementation strategies, and potential pitfalls to avoid.

CONCLUSION:
After the iterative evaluation and refinement, the elctronic CDS tool was found to be highly usable and useful for aiding the management of children with mTBI and intracranial injuries.