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Abstract Background Amyotrophic lateral sclerosis (ALS) is a fatal and rapidly progressive motoneuron degenerative disorder. There are still no drugs capable of slowing disease evolution or improving life quality of ALS patients. Thus, autologous stem cell therapy has emerged as an alternative treatment regime to be investigated in clinical ALS. Method Using Proteomics and Protein-Protein Interaction Network analyses combined with bioinformatics, the possible cellular mechanisms and molecular targets related to mesenchymal stem cells (MSCs, 1 × 106 cells/kg, intrathecally in the lumbar region of the spine) were investigated in cerebrospinal fluid (CSF) of ALS patients who received intrathecal infusions of autologous bone marrow-derived MSCs thirty days after cell therapy. Data are available via ProteomeXchange with identifier PXD053129. Results Proteomics revealed 220 deregulated proteins in CSF of ALS subjects treated with MSCs compared to CSF collected from the same patients prior to MSCs infusion. Bioinformatics enriched analyses highlighted events of Extracellular matrix and Cell adhesion molecules as well as related key targets APOA1, APOE, APP, C4A, C5, FGA, FGB, FGG and PLG in the CSF of cell treated ALS subjects. Conclusions Extracellular matrix and cell adhesion molecules as well as their related highlighted components have emerged as key targets of autologous MSCs in CSF of ALS patients. Trial registration Clinicaltrial.gov identifier NCT0291768. Registered 28 September 2016.

There is currently no efficacious intervention for preventing post-traumatic epilepsy (PTE). Preclinical studies support the potential use of anticholinergics for this condition. The purpose of this study was to evaluate the effects of biperiden as an intervention for preventing PTE. A randomized, double-blinded clinical trial was conducted at HC/FMUSP between 2018–2022. Adults with acute traumatic brain injury (TBI) were randomly assigned to receive biperiden or placebo, for 10 days. The primary outcome was the incidence of PTE while the secondary outcomes included the frequency of seizures, the frequency of any adverse events and mortality after 24 months. The study was powered at a planned enrolment of 132 patients. The trial began in January 2018 and was halted by researchers on March 2020 (and terminated in December 2022) in the face of the global COVID-19 pandemic. Overall, 123 participants were randomized and 112 contributed with data for modified mITT analysis, being that 61 (49.5%) participants completed the 24-month follow-up consult. Data analysis indicated lack of evidence of biperiden for either, the incidence of post-traumatic epilepsy (2.6, 95%CI, 0.65–10.57; p = 0.170) or the mortality rate (1.57, 95%CI, 0.73–3.38; p = 0.248). The frequency of late post-traumatic seizures was higher for biperiden group (2.03, 95%CI = 0.912–3.1597; p

Key Clinical Message Regarding head immobilization practices in neurosurgery, secondary fixation fractures are rare, underscoring the importance of precise pin positioning and an adequate force in the three‐point clamp to achieve adequate fixation. Attention should be given to factors such as changes in bone metabolism.

Transcranial magnetic stimulation (TMS) represents a distinctive technique for non-invasive brain stimulation. Recent advancements in image processing have enabled the enhancement of TMS by integrating magnetic resonance imaging (MRI) modalities with TMS via a neuronavigation system. The aim of this study is to assess the efficacy of navigated TMS for cortical mapping in comparison to surgical mapping using direct electrical stimulation (DES). This study involved 30 neurosurgical procedures for tumors located in or adjacent to the precentral gyrus. The DES points were compared with TMS responses based on the original distances of vectorial modules. There was a notable similarity in the points obtained from the two mapping methods. The distances between the geometric centers of TMS and DCS were 4.85 ± 1.89 mm. A strong correlation was identified between these vectorial points (r = 0.901, p < 0.001). The motor threshold in TMS was highest in the motor cortex adjacent to the tumor compared to the normal cortex (p < 0.001). Patients with deficits exhibited excellent accuracy in both methods. In view of this, TMS demonstrated reliable and precise application in brain mapping, which is a promising method for preoperative functional mapping in motor cortex tumor surgery.

BackgroundSkull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis.MethodsThis is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis.ResultsThere was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = −0.4) and Barthel index (p = 0.035; r = −0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = −0.37).ConclusionMorphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.

Introduction Intracranial hypertension continues to be the most frequent cause of death in patients with traumatic brain injury (TBI). Thus, invasive monitoring of intracranial pressure (ICP) is a very important tool in neurointensivism. However, there is controversy regarding ICP monitoring and prognosis.

Background The neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), platelet-to-lymphocyte ratio (PLR), and red blood cell distribution width (RDW) have been previously studied as predictors of survival in different malignancies.

Severe traumatic brain injury (sTBI) is an important cause of disability and mortality and affects people of all ages. Current scientific evidence indicates that motor dysfunction and cognitive impairment are the main limiting factors in patients with sTBI. Transcranial direct current stimulation (tDCS) seems to be a good therapeutic option, but when it comes to patients with sTBI, the results are inconclusive, and some protocols have not yet been tested. In addition, there is still a lack of information on tDCS-related physiological mechanisms, especially during the acute phase. In the present study, based on current evidence on tDCS mechanisms of action, we hypothesized that performing tDCS sessions in individuals with sTBI, especially in the acute and subacute phases, together with conventional therapy sessions, could improve cognition and motor function in this population. This hypothesis presents a new possibility for treating sTBI, seeking to elucidate the extent to which early tDCS may affect long-term clinical outcomes.

Background: The diagnosis and prognosis of diffuse axonal injury (DAI) remain challenging. This research aimed to analyze the impact on activities of daily living (ADL), functional outcomes, quality of life (QoL), and the association between lesion severity and DAI location identified through imaging exams. Methods: This prospective cohort study included 95 patients diagnosed with DAI. Data were collected at admission, three, six, and twelve months post-injury. The associations between variables were evaluated using a mixed-effects model. Results: Functional recovery and QoL improved between three and twelve months after DAI. An interaction was observed between independence in performing ADL and subarachnoid hemorrhage (p = 0.043) and intraventricular hemorrhage (p = 0.012). Additionally, an interaction over time was observed between the Glasgow Outcome Scale (GOS) and DAI severity (p < 0.001), brain lesions (p = 0.014), and the Disability Rating Scale (DRS) with injury in brain hemispheres (p = 0.026) and Adams classification (p = 0.013). Interaction effects over time were observed with the general health perceptions and energy/vitality domains with intraventricular hemorrhage, and the social functioning domain with the obliteration of basal cisterns and Gentry’s classification. Conclusion: The use of CT in the acute phase of DAI is important for predicting outcomes. The severity and location of DAI are associated with functional outcomes, ADL, and QoL.

Background: The impact of traumatic brain injury (TBI) on the pediatric population is profound. The aim of this study is to unveil the state of the evidence concerning acute neurosurgical intervention, hospitalizations after injury, and neuroimaging in isolated skull fractures (ISF). Materials and Methods: This systematic review was conducted in accordance with PRISMA guidelines. PubMed, Cochrane, Web of Science, and Embase were searched for papers until April 2023. Only ISF cases diagnosed via computed tomography were considered. Results: A total of 10,350 skull fractures from 25 studies were included, of which 7228 were ISF. For the need of acute neurosurgical intervention, the meta-analysis showed a risk of 0% (95% CI: 0–0%). For hospitalization after injury the calculated risk was 78% (95% CI: 66–89%). Finally, for the requirement of repeated neuroimaging the analysis revealed a rate of 7% (95% CI: 0–15%). No deaths were reported in any of the 25 studies. Conclusions: Out of 7228 children with ISF, an almost negligible number required immediate neurosurgical interventions, yet a significant 74% were hospitalized for up to 72 h. Notably, the mortality was zero, and repeat neuroimaging was uncommon. This research is crucial in shedding light on the outcomes and implications of pediatric TBIs concerning ISFs.

IntroductionThe evaluation of brain plasticity can provide relevant information for the surgical planning of patients with brain tumors, especially when it comes to intrinsic lesions such as gliomas. Neuronavigated transcranial magnetic stimulation (nTMS) is a non-invasive tool capable of providing information about the functional map of the cerebral cortex. Although nTMS presents a good correlation with invasive intraoperative techniques, the measurement of plasticity still needs standardization. The present study evaluated objective and graphic parameters in the quantification and qualification of brain plasticity in adult patients with gliomas in the vicinity of the motor area.MethodsThis is a prospective observational study that included 35 patients with a radiological diagnosis of glioma who underwent standard surgical treatment. nTMS was performed with a focus on the motor area of the upper limbs in both the affected and healthy cerebral hemispheres in all patients to obtain data on motor thresholds (MT) and graphical evaluation by three-dimensional reconstruction and mathematical analysis of parameters related to the location and displacement of the motor centers of gravity (ΔL), dispersion (SDpc) and variability (VCpc) of the points where there was a positive motor response. Data were compared according to the ratios between the hemispheres of each patient and stratified according to the final pathology diagnosis.ResultsThe final sample consisted of 14 patients with a radiological diagnosis of low-grade glioma (LGG), of which 11 were consistent with the final pathology diagnosis. The normalized interhemispheric ratios of ΔL, SDpc, VCpc, and MT were significantly relevant for the quantification of plasticity (p < 0.001). The graphic reconstruction allows the qualitative evaluation of this plasticity.ConclusionThe nTMS was able to quantitatively and qualitatively demonstrate the occurrence of brain plasticity induced by an intrinsic brain tumor. The graphic evaluation allowed the observation of useful characteristics for the operative planning, while the mathematical analysis made it possible to quantify the magnitude of the plasticity.

Oncocytic meningioma has been first identified in 1997 as a rare meningioma variant, composed predominantly of large meningothelial cells with abundant intracytoplasmic mitochondria. Here, we describe a 34-year-old male patient presenting with 2 weeks of progressive holocranial headache. Brain magnetic resonance imaging (MRI) revealed an extra axial solid-cystic expansive lesion in the left parieto-occipital parasagittal region, with intense vascularization. Histological and immunohistochemical analysis established the diagnosis. We also review briefly the pathological and radiological findings of this rare variant of meningioma as described in the literature.

The present study aims to evaluate the accuracy of the prognostic discrimination and prediction of the short-term mortality of the Marshall computed tomography (CT) classification and Rotterdam and Helsinki CT scores in a cohort of TBI patients from a low- to middle-income country. This is a post hoc analysis of a previously conducted prospective cohort study conducted in a university-associated, tertiary-level hospital that serves a population of >12 million in Brazil. Marshall CT class, Rotterdam and Helsinki scores, and their components were evaluated in the prediction of 14-day and in-hospital mortality using Nagelkerk's pseudo-R2 and area under the receiver operating characteristic curve. Multi-variate regression was performed using known outcome predictors (age, Glasgow Coma Scale, pupil response, hypoxia, hypotension, and hemoglobin values) to evaluate the increase in variance explained when adding each of the CT classification systems. Four hundred forty-seven patients were included. Mean age of the patient cohort was 40 (standard deviation, 17.83) years, and 85.5% were male. Marshall CT class was the least accurate model, showing pseudo-R2 values equal to 0.122 for 14-day mortality and 0.057 for in-hospital mortality, whereas Rotterdam CT scores were 0.245 and 0.194 and Helsinki CT scores were 0.264 and 0.229. The AUC confirms the best prediction of the Rotterdam and Helsinki CT scores regarding the Marshall CT class, which presented greater discriminative ability. When associated with known outcome predictors, Marshall CT class and Rotterdam and Helsinki CT scores showed an increase in the explained variance of 2%, 13.4%, and 21.6%, respectively. In this study, Rotterdam and Helsinki scores were more accurate models in predicting short-term mortality. The study denotes a contribution to the process of external validation of the scores and may collaborate with the best risk stratification for patients with this important pathology.

Background: Seizures in the early postoperative period may impair patient recovery and increase the risk of complications. The aim of this study is to determine whether there is any advantage in postoperative seizure prophylaxis following meningioma resection. Methods: This systematic review was conducted in accordance with PRISMA guidelines. PUBMED, Web of Science, Embase, Science Direct, and Cochrane were searched for papers until April 2023. Results: Among nine studies, a total of 3249 patients were evaluated, of which 984 patients received antiepileptic drugs (AEDs). No significant difference was observed in the frequency of seizure events between patients who were treated with antiepileptic drugs (AEDs) and those who were not. (RR 1.22, 95% CI 0.66 to 2.40; I2 = 57%). Postoperative seizures occurred in 5% (95% CI: 1% to 9%) within the early time period (7 days), with significant heterogeneity between the studies (I2 = 91% and 97%, respectively). In seizure-naive patients, the rate of postoperative seizures was 2% (95% CI: 0% to 6%) in the early period and increased to 6% (95% CI: 0% to 15%) in the late period. High heterogeneity led to the use of random-effects models in all analyses. Conclusions: The current evidence does not provide sufficient support for the effectiveness of prophylactic AED medications in preventing postoperative seizures in patients undergoing meningioma resection. This underscores the importance of considering diagnostic criteria and conducting individual patient analysis to guide clinical decision-making in this context.

Abstract Background Transcranial direct current stimulation (tDCS) has the potential to modulate cortical excitability and enhance the effects of walking training in people with Parkinson’s disease. This study will examine the efficacy of the addition of tDCS to a task-specific walking training to improve walking and mobility and to reduce falls in people with Parkinson’s disease. Methods This is a two-arm, prospectively registered, randomized trial with concealed allocation, blinded assessors, participants and therapists, and intention-to-treat analysis. Twenty-four individuals with Parkinson’s disease, categorized as slow or intermediate walkers (walking speeds ≤ 1.0 m/s), will be recruited. The experimental group will undertake a 30-min walking training associated with tDCS, for 4 weeks. The control group will undertake the same walking training, but with sham-tDCS. The primary outcome will be comfortable walking speed. Secondary outcomes will include walking step length, walking cadence, walking confidence, mobility, freezing of gait, fear of falling, and falls. Outcomes will be collected by a researcher blinded to group allocation at baseline (week 0), after intervention (week 4), and 1 month beyond intervention (week 8). Discussion tDCS associated with walking training may help improve walking of slow and intermediate walkers with Parkinson’s disease. If walking is enhanced, the benefits may be accompanied by better mobility and reduced fear of falling, and individuals may experience greater free-living physical activity at home and in the community. Trial registration Brazilian Registry of Clinical Trials (ReBEC) RBR-6bvnx6 . Registered on September 23, 2019

Abstract Background Intracranial hypertension (ICH) is a common final pathway of most neurosurgical pathologies and leads to poor prognosis if not detected and treated properly. Inflammatory markers have been assessed in clinical scenarios of neurological injuries, in which systemic and brain tissue aggressions may introduce bias. There is a lack of studies under controlled settings to isolate the ICH effect on inflammation. This study aims to evaluate the effects of ICH on the serum concentration of cytokines as biomarkers of neuroinflammation in an experimental model which isolates ICH from potential confounding variables. Methods An established model of ICH using an intracerebral pediatric bladder catheter and a multisensor intraparenchymal catheter was used in adult pigs (Sus domesticus). The animals were randomly allocated to 2 groups based on the catheter balloon volume used to simulate the ICP increase (4 ml or 7 ml). Cytokines were measured in 4 timepoints during the experiment: (1) 15 min before balloon insufflation; (2) 5 min after insufflation; (3) 125 min after insufflation; (4) 60 min after deflation. The following cytokines were measured IL-1α; IL-1β; IL–1ra; IL-2; IL-4; IL-6; IL-8; IL-10; IL-12; IL-18; TNFα. Generalized estimating equations were modeled to compare the ICP and cytokines values between the groups along the experiment. The study sample size was powered to detect interactions between the groups and the study moments with an effect size (f) of at least 0.3. The ARRIVE checklist was followed. Results A total of 20 animals were studied (10 in each group, 4 ml or 7 ml balloon volume insufflation). The animal model was successful in increasing the ICP along the moments of the experiment (p

ABSTRACT Background: After a traumatic brain injury, post-concussion symptoms are commonly reported by patients. Although common, these symptoms are difficult to diagnose and recognize. To date, no instruments evaluating post-concussion symptoms have been culturally translated or adapted to the Brazilian context. Objective: To culturally adapt the Rivermead Post-Concussion Symptoms Questionnaire for use in Brazilian Portuguese. Methods: Cross-cultural adaptation was done in five steps: translation, synthesis of translations, back-translation, evaluation by two expert committees and two pretests among adults in a target population. Results: The semantic, idiomatic, cultural and experimental aspects of the adaptation were considered adequate. The content validity coefficient of the items regarding language clarity, pratical pertinence, relevance and dimensionality were considered adequate for evaluating the desired latent variable. Both pretests demonstrated that the instrument had satisfactory acceptability. Conclusion: The Brazilian version, named Questionário Rivermead de Sintomas pós Concussionais (RPQ-Br), has been adapted, and is ready for use in the Brazilian context.

ABSTRACT Background: Diffuse axonal injury occurs with high acceleration and deceleration forces in traumatic brain injury (TBI). This lesion leads to disarrangement of the neuronal network, which can result in some degree of deficiency. The Extended Glasgow Outcome Scale (GOS-E) is the primary outcome instrument for the evaluation of TBI victims. Diffusion tensor imaging (DTI) assesses white matter (WM) microstructure based on the displacement distribution of water molecules. Objective: To investigate WM microstructure within the first year after TBI using DTI, the patient’s clinical outcomes, and associations. Methods: We scanned 20 moderate and severe TBI victims at 2 months and 1 year after the event. Imaging processing was done with the FMRIB software library; we used the tract-based spatial statistics software yielding fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) for statistical analyses. We computed the average difference between the two measures across subjects and performed a one-sample t-test and threshold-free cluster enhancement, using a corrected p-value < 0.05. Clinical outcomes were evaluated with the GOS-E. We tested for associations between outcome measures and significant mean FA clusters. Results: Significant clusters of altered FA were identified anatomically using the JHU WM atlas. We found increasing spotted areas of FA with time in the right brain hemisphere and left cerebellum. Extensive regions of increased MD, RD, and AD were observed. Patients presented an excellent overall recovery. Conclusions: There were no associations between FA and outcome scores, but we cannot exclude the existence of a small to moderate association.

Abstract Background A daily algorithm for hospital discharge (DAHD) is a key point in the concept of Enhanced Recovery After Surgery (ERAS) protocol. We aimed to evaluate the length of stay (LOS), rate of complications, and hospital costs variances after the introduction of the DAHD compared to the traditional postoperative management of brain tumour patients. Methods This is a cohort study with partial retrospective data collection. All consecutive patients who underwent brain tumour resection in 2017 were analysed. Demographics and procedure-related variables, as well as clinical outcomes, LOS and healthcare costs within 30 days after surgery were compared in patients before/pre-implementation and after/post-implementation the DAHD, which included: stable neurological examination; oral feeding without aspiration risk; pain control with oral medications; no intravenous medications. The algorithm was applied every morning and discharge was considered from day 1 after surgery if criteria was fulfilled. The primary outcome (LOS after surgery) analysis was adjusted for the preoperative performance status on a multivariable logistic regression model. Results A total of 61 patients were studied (pre-implementation 32, post-implementation 29). The baseline demographic characteristics were similar between the groups. After the DAHD implementation, LOS decreased significantly (median 5 versus 3 days; p = 0.001) and the proportion of patients who were discharged on day 1 or 2 after surgery increased (44.8% vs 3.1%; p

ABSTRACT Background: Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation. Objective: To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model. Methods: An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed. Results: Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution. Conclusions: These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.

Background Acute subdural hematoma (ASDH) is a traumatic lesion commonly found secondary to traumatic brain injury. Radiological findings on CT, such as hematoma thickness (HT) and structures midline shift (MLS), have an important prognostic role in this disease. The relationship between HT and MLS has been rarely studied in the literature. Thus, this study aimed to assess the prognostic accuracy of the difference between MLS and HT for acute outcomes in patients with ASDH in a low-income to middle-income country.Methods This was a post-hoc analysis of a prospective cohort study conducted in a university-associated tertiary-level hospital in Brazil. The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) statement guidelines were followed. The difference values between MLS and HT (Zumkeller index, ZI) were divided into three categories (3). Logistic regression analyses were performed to reveal the OR of categorized ZI in predicting primary outcome measures. A Cox regression was also performed and the results were presented through HR. The discriminative ability of three multivariate models including clinical and radiological variables (ZI, Rotterdam score, and Helsinki score) was demonstrated.Results A total of 114 patients were included. Logistic regression demonstrated an OR value equal to 8.12 for the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; p=0.01), which proved to be an independent predictor of mortality in the adjusted model for surgical intervention, age, and Glasgow Coma Scale (GCS) score. Cox regression analysis demonstrated that this category was associated with 14-day survival (HR 2.92, 95% CI 1.38 to 6.16; p=0.005). A multivariate analysis performed for three models including age and GCS with categorized ZI or Helsinki or Rotterdam score demonstrated area under the receiver operating characteristic curve values of 0.745, 0.767, and 0.808, respectively.Conclusions The present study highlights the potential usefulness of the difference between MLS and HT as a prognostic variable in patients with ASDH.Level of evidence Level III, epidemiological study.

Objective To evaluate the interobserver reliability of a new scale created for quantitatively assessing brain swelling in traumatic brain injury (TBI) patients using the computed tomography (CT) findings in three levels. Methods Computed tomography scans of severe head injury patients were randomly selected from a tertiary hospital image database and evaluated by independent groups of neurosurgeons, neurosurgery residents, radiologists, and intensivists from the same hospital. Each specialist assessed the tomographic findings, applying zero to six points in a new scale. The Kappa coefficient was calculated to assess interobserver agreement. Results The highest reliability coefficient was obtained by the neurosurgeons group (0.791; 95% confidence interval [CI]: 0.975–0.607; p

ABSTRACT. Traumatic brain injury (TBI) is a major cause of chronic disability. Less than a quarter of moderate and severe TBI patients improved in their cognition within 5 years. Non-invasive brain stimulation, including transcranial direct current stimulation (tDCS), may help neurorehabilitation by boosting adaptive neuroplasticity and reducing pathological sequelae following TBI. Methods: we searched MEDLINE/PubMed and Web of Science databases. We used Jadad scale to assess methodological assumptions. Results: the 14 papers included reported different study designs; 2 studies were open-label, 9 were crossover randomized clinical trials (RCTs), and 3 were parallel group RCTs. Most studies used anodal tDCS of the left dorsolateral prefrontal cortex, but montages and stimulation parameters varied. Multiple studies showed improved coma recovery scales in disorders of consciousness, and improved cognition on neuropsychological assessments. Some studies showed changes in neurophysiologic measures (electroencephalography (EEG) and transcranial magnetic stimulation (TMS), correlating with clinical findings. The main methodological biases were lack of blinding and randomization reports. Conclusion: tDCS is a safe, non-invasive neuromodulatory technique that can be given as monotherapy but may be best combined with other therapeutic strategies (such as cognitive rehabilitation and physical therapy) to further improve clinical cognitive and motor outcomes. EEG and TMS may help guide research due to their roles as biomarkers for neuroplasticity.

Background: This prospective study aimed to evaluate the cortical excitability (CE) of patients with brain tumors surrounding or directly involving the corticospinal tract (CST) using navigated transcranial magnetic stimulation (nTMS).Methods: We recruited 40 patients with a single brain tumor surrounding or directly involving the CST as well as 82 age- and sex-matched healthy controls. The patients underwent standard nTMS and CE evaluations. Single and paired pulses were applied to the primary motor area (M1) of both affected and unaffected cerebral hemispheres 1 week before surgery. The CE parameters included resting motor threshold (RMT), motor evoked potential (MEP) ratio for 140 and 120% stimulus (MEP 140/120 ratio), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF). Motor outcome was evaluated on hospital discharge and on 30-day and 90-day postoperative follow-up.Results: In the affected hemispheres of patients, SICI and ICF were significantly higher than in the unaffected hemispheres (p=0.002 and p=0.009, respectively). The 140/120 MEP ratio of patients' unaffected hemispheres was lower than that in controls (p=0.001). Patients with glioblastomas (GBM) had a higher interhemispheric RMT ratio than patients with grade II and III gliomas (p = 0.018). A weak correlation was observed among the RMT ratio and the preoperative motor score (R2 = 0.118, p = 0.017) and the 90-day follow-up (R2 = 0.227, p = 0.016).Conclusion: Using preoperative nTMS, we found that brain hemispheres affected by tumors had abnormal CE and that patients with GBM had a distinct pattern of CE. These findings suggest that tumor biological behavior might play a role in CE changes.

Background: Traumatic brain injury (TBI) is one of the leading causes of neuropsychiatric disorders in young adults. Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to improve psychiatric symptoms in other neurologic disorders, such as focal epilepsy, Parkinson's disease, and fibromyalgia. However, the efficacy of rTMS as a treatment for anxiety in persons with TBI has never been investigated. This exploratory post-hoc analyzes the effects of rTMS on anxiety, depression and executive function in participants with moderate to severe chronic TBI.Methods: Thirty-six participants with moderate to severe TBI and anxiety symptoms were randomly assigned to an active or sham rTMS condition in a 1:1 ratio. A 10-session protocol was used with 10-Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) for 20 min each session, a total of 2,000 pulses were applied at each daily session (40 stimuli/train, 50 trains). Anxiety symptoms; depression and executive function were analyzed at baseline, after the last rTMS session, and 90 days post intervention.Results: Twenty-seven participants completed the entire protocol and were included in the post-hoc analysis. Statistical analysis showed no interaction of group and time (p > 0.05) on anxiety scores. Both groups improved depressive and executive functions over time, without time and group interaction (ps < 0.05). No adverse effects were reported in either intervention group.Conclusion: rTMS did not improve anxiety symptoms following high frequency rTMS in persons with moderate to severe TBI.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02167971.

Background: In a time when the incidence of severe traumatic brain injury (TBI) is increasing in low- to middle-income countries (LMICs), it is important to understand the behavior of predictive variables in an LMIC's population. There are few previous attempts to generate prediction models for TBI outcomes from local data in LMICs. Our study aim is to design and compare a series of predictive models for mortality on a new cohort in TBI patients in Brazil using Machine Learning.Methods: A prospective registry was set in São Paulo, Brazil, enrolling all patients with a diagnosis of TBI that require admission to the intensive care unit. We evaluated the following predictors: gender, age, pupil reactivity at admission, Glasgow Coma Scale (GCS), presence of hypoxia and hypotension, computed tomography findings, trauma severity score, and laboratory results.Results: Overall mortality at 14 days was 22.8%. Models had a high prediction performance, with the best prediction for overall mortality achieved through Naive Bayes (area under the curve = 0.906). The most significant predictors were the GCS at admission and prehospital GCS, age, and pupil reaction. When predicting the length of stay at the intensive care unit, the Conditional Inference Tree model had the best performance (root mean square error = 1.011), with the most important variable across all models being the GCS at scene.Conclusions: Models for early mortality and hospital length of stay using Machine Learning can achieve high performance when based on registry data even in LMICs. These models have the potential to inform treatment decisions and counsel family members.Level of evidence: This observational study provides a level IV evidence on prognosis after TBI.

Abstract Background Photobiomodulation describes the use of red or near-infrared light to stimulate or regenerate tissue. It was discovered that near-infrared wavelengths (800–900 nm) and red (600 nm) light-emitting diodes (LED) are able to penetrate through the scalp and skull and have the potential to improve the subnormal cellular activity of compromised brain tissue. Different experimental and clinical studies were performed to test LED therapy for traumatic brain injury (TBI) with promising results. One of the proposals of this present study is to develop different approaches to maximize the positive effects of this therapy and improve the quality of life of TBI patients. Methods/design This is a double-blinded, randomized, controlled trial of patients with diffuse axonal injury (DAI) due to a severe TBI in an acute stage (less than 8 h). Thirty two patients will be randomized to active coil helmet and inactive coil (sham) groups in a 1:1 ratio. The protocol includes 18 sessions of transcranial LED stimulation (627 nm, 70 mW/cm2, 10 J/cm2) at four points of the frontal and parietal regions for 30 s each, totaling 120 s, three times per week for 6 weeks, lasting 30 min. Patients will be evaluated with the Glasgow Outcome Scale Extended (GOSE) before stimulation and 1, 3, and 6 months after the first stimulation. The study hypotheses are as follows: (1) transcranial LED therapy (TCLT) will improve the cognitive function of DAI patients and (2) TCLT will promote beneficial hemodynamic changes in cerebral circulation. Discussion This study evaluates early and delayed effects of TCLT on the cognitive rehabilitation for DAI following severe acute TBI. There is a paucity of studies regarding the use of this therapy for cognitive improvement in TBI. There are some experimental studies and case series presenting interesting results for TBI cognitive improvement but no clinical trials. Trial registration ClinicalTrials.gov, NCT03281759. Registered on 13 September 2017.

The ventriculoperitoneal shunt (VPS) is an established treatment for hydrocephalus. The functioning of the system requires a pressure difference between the cranial and abdominal cavities. The VPS can be particularly problematic in patients with increased intra-abdominal pressure (IAP). We report the case of a 16-year-old girl with VPS since she was 2 months old due to hydrocephalus secondary to myelomeningocele. The patient had been asymptomatic ever since, but she sought the emergency service with intermittent headache and vomiting. A non-enhanced brain tomography, a shunt trajectory X-ray and an abdominal ultrasound revealed no cause of system malfunction. In view of the persistent clinical picture, a revision of the shunt was performed, which revealed adequate intraoperative functioning. She returned with the same symptoms two weeks after surgery. The patient was obese (body mass index [BMI]: 48). We hypothesized intermittent valve malfunction due to increased intra-abdominal pressure. She underwent a ventriculoatrial shunt, without intercurrences. In the postoperative period, the patient presented transient tachycardia and was asymptomatic at the 6-month follow-up. Obesity should be considered an important variable for the inadequate functioning of the VPS due to increased IAP and catheter dystocia to the extraperitoneal cavity. Studies have already correlated the IAP with the BMI, which reaches between 8 mm Hg and 12 mm Hg in obese individuals. Therefore, the BMI can be considered during the selection of valve pressure in systems with non-adjustable valves to prevent insufficient drainage. The recognition of obesity as a cause of VPS malfunction is fundamental to avoid unnecessary surgeries and intermittent malfunction of the system.

Abstract Background Photobiomodulation using low-level laser therapy (LLLT) has been tested as a new technique to optimize recovery of patients with traumatic brain injury (TBI). The aim of this study is to evaluate inhibitory attentional control after 18 sessions of active LLLT and compare with the placebo group (sham LLLT). Our exploratory analysis will evaluate the efficacy of the active LLLT on verbal and visuospatial episodic memory, executive functions (working memory, verbal and visuospatial fluency, attentional processes), and anxiety and depressive symptoms compared to the sham group. Methods/Design A randomized double-blinded trial will be made in 36 patients with moderate and severe TBI. The active LLLT will use an optical device composed of LEDs emitting 632 nm of radiation at the site with full potency of 830 mW. The cranial region with an area of 400 cm2 will be irradiated for 30 min, giving a total dose per session of 3.74 J/cm2. The sham LLLT group contains only an LED device with power

Background: Morphological alterations in intracranial pressure (ICP) pulse waveform (ICPW) secondary to intracranial hypertension (ICP >20 mmHg) and a reduction in intracranial compliance (ICC) are well known indicators of neurological severity. The exclusive exploration of modifications in ICPW after either the loss of skull integrity or surgical procedures for intracranial hypertension resolution is not a common approach studied. The present study aimed to assess the morphological alterations in ICPW among neurocritical care patients with skull defects and decompressive craniectomy (DC) by comparing the variations in ICPW features according to elevations in mean ICP values. Methods: Patients requiring ICP monitoring because of acute brain injury were included. A continuous record of 10 min-length for the beat-by-beat analysis of ICPW was performed, with ICP elevation produced by means of ultrasound-guided manual internal jugular vein compression at the end of the record. ICPW features (peak amplitude ratio (P2/P1), time interval to pulse peak (TTP) and pulse amplitude) were counterweighed between baseline and compression periods. Results were distributed for three groups: intact skull (exclusive burr hole for ICP monitoring), craniotomy/large fractures (group 2) or DC (group 3). Results: 57 patients were analyzed. A total of 21 (36%) presented no skull defects, 21 (36%) belonged to group 2, whereas 15 (26%) had DC. ICP was not significantly different between groups: ±15.11 for intact, 15.33 for group 2 and ±20.81 mmHg for group 3, with ICP-induced elevation also similar between groups (p = 0.56). Significant elevation was observed for the P2/P1 ratio for groups 1 and 2, whereas a reduction was observed in group 3 (elevation of ±0.09 for groups 1 and 2, but a reduction of 0.03 for group 3, p = 0.01), and no significant results were obtained for TTP and pulse amplitudes. Conclusion: In the present study, intracranial pressure pulse waveform analysis indicated that intracranial compliance was significantly more impaired among decompressive craniectomy patients, although ICPW indicated DC to be protective for further influences of ICP elevations over the brain. The analysis of ICPW seems to be an alternative to real-time ICC assessment.

Traumatic brain injury (TBI) is a major public health problem in Western countries. A TBI brings many negative consequences, including behavioral and cognitive changes, which affect social adjustment and the performance of functional activities. Cognitive evaluation after TBI is a complex issue in what pertains to definition of the most appropriate questionnaires for clinical use in a comprehensive analysis of the condition of the patient. In this paper, we described a critical review of the main cognitive assessment tests currently used in clinical and research settings in patients with TBI.

Abstract Introduction Surgical treatment of brain tumors in eloquent areas has always been considered a major challenge because removal-related cortical damage can cause serious functional impairment. However, few studies have investigated the association between small craniotomies and the higher risk of incidence of motor deficits and prolonged recovery time. Here, we analyzed neurologic deficits and the prognostic variables after surgery guided by navigation for motor cortex tumors under general anesthesia. Methods This was a prospective study that included 47 patients with tumors in the precentral gyrus. All surgeries were performed with neuronavigation and cortical mapping, with direct electrical stimulation of the motor cortex. We evaluated the prognostic evolution of patients with pre- and postoperative Karnofsky Performance Scale using the Eastern Cooperative Oncology Group scale. Results Complete resection was verified in all 18 cases of metastasis, 13 patients with glioblastoma multiforme, and 5 patients with low-grade gliomas. An analysis of the motor deficits revealed that 11 patients experienced worsening of the deficit on the first day after surgery. Only four patients developed new deficits in the immediate postoperative period, and these improved after 3 weeks. After 3 months, only two patients had deficits that were worse those experienced prior to surgery; both patients had glioblastoma multiforme. Conclusion In our series, motor deficits prior to surgery were the most important factors associated with persistent postoperative deficits. Small craniotomy with navigation associated with intraoperative brain mapping allowed a safe resection and motor preservation in patients with motor cortex brain tumor.

Abstract Computed tomographic angiography (CTA) has recently gained popularity as an initial imaging test for spontaneous subarachnoid hemorrhage (SAH). This study evaluated 59 patients presenting aneurysmal SAH who underwent microsurgical clipping based on CTA findings alone and digital subtraction angiography (DSA) at postoperative follow-up. Multiple aneurysms were identified by CTA in 27% of patients and in 10% of patients, DSA identified aneurysms in addition to those diagnosed with CTA. The time between CTA and surgical treatment ranged from 0–4 days. Postoperative DSA revealed that 24% of patients had residual neck. The use of CTA alone may not be enough to detect small unruptured aneurysms in patients with multiple lesions or aneurysm remnants adjacent to an aneurysm clip. However, the advantages of CTA compared with DSA include its rapidity, reduced invasiveness, and lower cost, which allow us to proceed to ruptured aneurysm repair entirely on the basis of good-quality CTA studies.

BackgroundOveractivation of NMDA-mediated excitatory processes and excess of GABA-mediated inhibition are attributed to the acute and subacute phases, respectively, after a traumatic brain injury (TBI). However, there are few studies regarding the circuitry during the chronic phase of brain injury.ObjectiveTo evaluate the cortical excitability (CE) during the chronic phase of TBI in victims diagnosed with diffuse axonal injury (DAI).MethodsThe 22 adult subjects were evaluated after a minimum of 1 year from the onset of moderate or severe TBI. Each of the subjects first had a comprehensive neuropsychological assessment to evaluate executive functions—attention, memory, verbal fluency, and information processing speed. Then, CE assessment was performed with a circular coil applying single-pulse and paired-pulse transcranial magnetic stimulation over the cortical representation of the abductor pollicis brevis muscle on M1 of both hemispheres. The CE parameters measured were resting motor threshold (RMT), motor-evoked potentials (MEPs), short-interval intracortical inhibition (SIICI), and intracortical facilitation (ICF). All data were compared with that of a control group that consisted of the healthy age-matched individuals.ResultsNo significant differences between the left and right hemispheres were detected in the DAI subjects. Therefore, parameters were analyzed as pooled data. Values of RMT, MEPs, and ICF from DAI patients were within normal limits. However, SIICI values were higher in the DAI group—DAI SIICI = 1.28 (1.01; 1.87) versus the control value = 0.56 (0.33; 0.69)—suggesting that they had a disarranged inhibitory system (p

Background. This study aimed to analyse cerebral autoregulation (CA) during induction and treatment of intracranial hypertension (ICH) in an experimental model. Materials and Methods. Landrace and Duroc piglets were divided into mild and severe ICH groups. Four or seven millilitres of saline solution was infused into paediatric bladder catheter inserted in the parietal lobe (balloon inflation). After 1.5 h, a 3% saline solution was infused via venous catheter, and 30 min later, the bladder catheter balloon was deflated (surgery). The cerebral static autoregulation (sCA) index was evaluated using cerebral blood flow velocities (CBFV) obtained with Doppler ultrasound. Results. Balloon inflation increased ICP in both groups. The severe ICH group showed significantly lower sCA index values (p=0.001, ANOVA) after balloon inflation (ICH induction) and a higher sCA index after saline injection (p=0.02) and after surgery (p=0.04). ICP and the sCA index were inversely correlated (r=−0.68 and p

Background: The development of Holmes tremor (HT) after a direct lesion of the midbrain has rarely been reported in the literature, although several etiologies have been linked with HT, such as stroke, brainstem tumors, multiple sclerosis, head trauma, or infections.Phenomenology Shown: A 31-year-old male, having been stabbed in the right eye, presented with a rest and action tremor in the left upper limb associated with left hemiparesis with corresponding post-contrast volumetric magnetic resonance imaging T1 with sagittal oblique reformation showing the knife trajectory reaching the right midbrain.Educational Value: Despite the rarity of the etiology of HT in the present case, clinicians working with persons with brain injuries should be aware of this type of situation.

Objetivo: Neste trabalho temos o objetivo de avaliar a acurácia do sistema de aferição da pressão intracraniana (PIC) epidural com microchip. Métodos: Foram estudados 27 suínos sob anestesia geraI, devidamente assistidos com monitoração ventilatória e hemodinâmica. Durante o experimento foi reproduzido um processo expansivo intracerebral programado no lobo frontal direito. O experimento constou de três grupos (A, B e C) com hipertensão intracraniana gerada com balão reproduzindo um hematoma intracerebral. Em todos os grupos foram calibrados os parâmetros normais: os dois sistemas de PIC foram comparados e estudados quanto à correlação dos valores aferidos. Resultados: O comportamento médio da PIC ao longo dos momentos de avaliação foi estatisticamente diferente entre os grupos (p < 0,001). A reprodução de ressangramento resultou em elevação significativa da PIC (p < 0,001). Avaliando-se a acurácia comparativa geral, verificou-se um coeficiente de correlação intraclasse de 0,8. Conclusão: O modelo de hipertensão intracraniana por balão em suínos é factível e confiável na geração de hipertensão intracraniana. O sistema de aferição de pressão intracraniana epidural apresenta elevado coeficiente de correlação com o sistema de aferição parenquimatoso na avaliação global.

Abstract Introduction Epidermoid tumors represent approximately 0.3 to 1.8% of all intracranial brain tumors. Only 1.5% of all intracranial epidermoid cysts (ECs) invade the brain and secondary epilepsy is extremely rare. Since August 2014, a 59-year-old male smoker had been presenting bad smell feelings, totaling four episodes with sudden onset and duration of 2 minutes. On September 2014, after a sense of smell episode, it evolved into loss of contact and automatic movements followed by generalized tonic–clonic movements. The brain magnetic resonance imaging revealed an extensive subtemporal lesion affecting anterior, middle, and posterior fossa with invasion of the choroidal fissure and projection to the temporal horn of the lateral ventricle. Pretemporal craniotomy with combined approaches, transsylvian and subtemporal, allowed for the excision of a white keratinized and softened lesion suggestive of EC. Discussion The optimal surgical strategy in individuals with ECs and seizures is not established. The evaluation of the cause and risk–benefit must be held to choose the appropriate surgical strategy: lesionectomy, lobectomy, or amygdalohippocampectomy. In this case, a lesionectomy was performed due to an absence of evidence of involvement of hippocampus and amygdala. Conclusion Epilepsy secondary to ECs is a rare association. Lesionectomy can be an option with good results without increasing the morbidity.

BackgroundMild traumatic brain injury (MTBI) represents 70–80% of all treated brain injuries. A considerable proportion of MTBI patients experience post-concussion symptoms for a prolonged period after MTBI, and these symptoms are diagnosed as persistent post-concussion syndrome (PPCS). PPCS is defined as a range of physical, cognitive, and emotional symptoms. However, memory and executive dysfunction seems to be one of the most debilitating symptoms. Recently, non-invasive brain stimulation has been studied as a potential treatment method for traumatic brain injury (TBI) patients. Therefore, our primary goal is to verify the effects of transcranial direct current stimulation (tDCS) in patients with PPCS who demonstrate cognitive deficits in long-term episodic memory, working memory, and executive function following MTBI.Methods/designThis is a randomized crossover trial of patients with a history of MTBI with cognitive deficits in memory and executive function. Thirty adult patients will be randomized in a crossover manner to receive three weekly sessions of anodal tDCS (2 mA) at left dorsolateral prefrontal cortex, left temporal cortex, and sham stimulation that will be performed at 7-day intervals (washout period). The clinical diagnosis of PPCS will be determined using the Rivermead Post-Concussion Symptoms Questionnaire. Patients who meet the inclusion criteria will be assessed with a neuropsychological evaluation. A new battery of computerized neuropsychological tests will be performed before and immediately after each stimulation. Statistical analysis will be performed to determine trends of cognitive improvement.DiscussionThere is paucity of studies regarding the use of tDCS in TBI patients, and although recent results showed controversial data regarding the effects of tDCS in such patients, we will address specifically patients with PPCS and MTBI and no brain abnormalities on CT scan other than subarachnoid hemorrhage. Moreover, due to the missing information on literature regarding the best brain region to be studied, we will evaluate two different regions to find immediate effects of tDCS on memory and executive dysfunction.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier NCT02292589 (https://register.clinicaltrials.gov).

A embolia gordurosa é constituída pela presença de glóbulos de gordura dentro da microcirculação periférica e pulmonar, com ou sem quadro clínico. Há uma fase precoce, representada por uma obstrução mecânica, e uma fase tardia, representada por um fenômeno inflamatório, que se inicia aproximadamente 48 a 72 horas após a obstrução mecânica. O diagnóstico clínico da síndrome de embolia gordurosa pode ser auxiliado pelos critérios de Gurd-Wilson e deve ser suspeitado em doentes com traumatismo e fraturas de ossos longos e deterioração neurológica de forma inexplicada. É necessário no mínimo um critério maior (insuficiência respiratória, sinais neurológicos não relacionados ao traumatismo craniano e manifestações dermatológicas) e quatro menores ou dois maiores. Exames complementares são geralmente inespecíficos. A tomografia de crânio pode estar normal. A ressonância magnética de encéfalo pode mostrar áreas puntiformes que costumam desaparecer em 20 dias, sugerindo que a lesão pode ser predominantemente inflamatória, e não necrótico-isquêmica. Um tratamento específico para a síndrome de embolia gordurosa não existe. Ele consiste no suporte cardiopulmonar e neurológico, além de prevenção e diagnóstico precoce, auxiliando nos cuidados com o doente.

Objective Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI). Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments. Methods We describe a new experimental porcine model designed to simulate expansive brain hematoma causing IH. Under anesthesia, IH was simulated with a balloon insufflation. The IH variables were measured with intracranial pressure (ICP) parenchymal monitoring, epidural, cerebral oximetry, and transcranial Doppler (TCD). Results None of the animals died during the experiment. The ICP epidural showed a slower rise compared with parenchymal ICP. We found a correlation between ICP and cerebral oximetry. Conclusion The model described here seems useful to understand some of the pathophysiological characteristics of acute IH.

Objective Management of neuropathic pain following spinal cord injury (SCI) can be a frustrating experience for patients since it poses a therapeutic challenge. In this article the authors describe the clinical characteristics of a group of patients with pain after spinal cord injury. Methods In this retrospective study, 213 patients with SCI and neuropathic pain were assessed. We analyzed clinical characteristics, treatment options, and pain intensity for these patients. Results The main cause of SCI was spine trauma, which occurred in 169 patients, followed by tumors and infection. Complete lesions were verified in 144 patients. In our study, patients with traumatic SCI and partial lesions seem to be presented with more intense pain; however, this was not statistically significant. Conclusions Neuropathic pain is a common complaint in patients with SCI and presents a treatment challenge. Knowledge of the clinical characteristics of this group of patients may help determine the best approach to intervention.

Abstract Diffuse axonal injury (DAI), a type of traumatic injury, is known for its severe consequences. However, there are few studies describing the outcomes of DAI and the risk factors associated with it. This study aimed to describe the outcome for patients with a primary diagnosis of DAI six months after trauma and to identify sociodemographic and clinical factors associated with mortality and dependence at this time point. Seventy-eight patients with DAI were recruited from July 2013 to February 2014 in a prospective cohort study. Patient outcome was analyzed using the Extended Glasgow Outcome Scale (GOS-E) within six months of the traumatic injury. The mean Injury Severity Score was 35.0 (SD = 11.9), and the mean New Injury Severity Score (NISS) was 46.2 (SD = 15.9). Mild DAI was observed in 44.9% of the patients and severe DAI in 35.9%. Six months after trauma, 30.8% of the patients had died, and 45.1% had shown full recovery according to the GOS-E. In the logistic regression model, the severity variables—DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with NISS value—had a statistically significant association with patient mortality; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence.