Prognostic Value of Spreading Depolarizations in Patients With Severe Traumatic Brain Injury

Jed A Hartings ^1,2, Norberto Andaluz ^1,3, M Ross Bullock ⁴

¹Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
²Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
³Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky.
⁴Department of Neurological Surgery, University of Miami, Miami, Florida.
⁵Division of Neurosurgery, Virginia Commonwealth University, Richmond.
⁶Department of Critical Care Medicine, King's College London, London, United Kingdom.
⁷Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
⁸Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
⁹Department of Basic and Clinical Neuroscience, King's College London, London, United Kingdom.
¹⁰Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
¹¹Departments of Neurology, Experimental Neurology, and Neurosurgery and Centre for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹²Department of Mechanical Engineering, University of Cincinnati, Cincinnati, Ohio.
¹³Department of Public Health, Centre for Medical Decision Making, Erasmus Medical Centre, Rotterdam, the Netherlands.

⁰Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Jama Neurology +

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December 31, 2019

View abstract on PubMed

Summary

Spreading depolarizations, a brain injury mechanism, were common in trauma patients. Their occurrence, especially in clusters, independently predicted worse neurologic recovery, suggesting monitoring potential for targeted treatment.

Area Of Science

Neuroscience
Neurosurgery
Critical Care Medicine

Background

Traumatic brain injury (TBI) treatment is limited by the inability to monitor individual pathological mechanisms.
Spreading depolarizations (SDs) are a key mechanism of lesion development in animal models of TBI.
SDs represent a novel candidate for clinical monitoring in surgically treated brain trauma patients.

Purpose Of The Study

To investigate the association between spreading depolarizations (SDs) and neurologic outcomes in patients with acute brain trauma.
To test the hypothesis that SDs are not associated with worse neurologic outcomes.

Main Methods

A prospective, observational, multicenter cohort study involving 138 patients undergoing surgery for acute brain trauma.
Continuous electrocorticography (ECoG) using a 6-contact electrode strip placed on the brain surface during surgery.
Scoring of ECoG for SDs according to international consensus; 6-month neurologic outcomes assessed using the Glasgow Outcome Scale-Extended (GOSE).

Main Results

SDs occurred in 60.1% of patients, with 61% exhibiting temporal clusters (≥3 events in 2 hours).
Patients with SD clusters had significantly worse neurologic outcomes (OR, 2.29; 95% CI, 1.13-4.65; P=.02), with no motor improvement from pre- to post-ECoG.
SDs were associated with lower prehospital systolic blood pressure, increased traumatic subarachnoid hemorrhage, and worse radiographic pathology.

Conclusions

Spreading depolarizations are frequent and heterogeneous in patients with acute brain trauma.
SDs, particularly clustered events, are independently associated with poor neurologic recovery.
Monitoring SDs may help identify patients who could benefit from targeted neuroprotective management strategies.