Useful Markers to Assess Traumatic and Hypoxic Brain Injury

Useful markers to assess traumatic and hypoxic brain injury

Violeta Ionela Chirica1,*

______Abstract: Traumatic Brain Injury, TBI, is a very important health issue world wide. Many traumatic events are not witnessed and not declared, especially in mild TBI, mTBI, and therefore not known, not treated or cured. At autopsy the diagnosis of brain injury is in many cases a challenge especially in children with physical abuse. Quite often the judicial system ask for scientific proofs of objectivity in determining the cause of death in head trauma. Sometimes legal medicine is called to determine the extent of the brain injuries following anoxia or hypoxia after a CA resuscitated. Pathology and anatomic pathology sometimes may offer important clues for diagnosis but often there are time consuming. The use of biomarkers in predictive way for prognosis and for diagnosis is a very potent and useful tool in legal medicine. Some of the brain injury biomarkers express the integrity of neurons or neurologic network, including astrocytes, and therefore express the structural integrity of the nervous system. The cutoff limit of these markers is in scientific debates and legal medicine may offer a support for their research. Some biomarkers are studied and presented such as biofluid biomarkers of astroglial injury, S100Beta, Glial Fibrillary acid protein (GFAP), biofluid biomarkers of neuronal injury, Neuron-specific enolase (NSE), Ubiquitin C-terminal hydrolase-L1 (UCH-L1), CK0BB, Brain-derived neurotrophic factor, BDNF, Biofluid biomarkers of axonal injury, Alpha-II spectrin, Tau protein, Neurofilaments, N-Cam or selectins. Biomarkers could potentially facilitate diagnosis and risk stratification of mTBI and impact management of these patients as much as the diagnosis of TBI in legal medicine practice and in justice. Key Words: traumatic brain injury, biomarkers, predictive value, diagnosis.

INTRODUCTION physical abuse. Quite often the judicial system ask for scientific proofs of objectivity in determining the cause Traumatic brain injury, TBI, occurs when an of death in head trauma. Sometimes legal medicine external mechanical force causes brain dysfunction. It is called to determine the extent of the brain injuries results usually results from a violent blow to the head. following anoxia or hypoxia after a CA resuscitated. Mild traumatic brain injury may cause temporary Pathology and anatomic pathology sometimes may dysfunction of brain cells. More serious traumatic offer important clues for diagnosis but often there are brain injury can result in cerebral bruising (cerebral time consuming. contusion), torn tissues (cerebral laceration), bleeding The use of biomarkers in predictive way for (intracranial hematoma), cerebral edema, that can prognosis and for diagnosis is a very potent and result in long-term complications or death. useful tool in legal medicine. Some of the brain Traumatic Brain Injury is a very important injury biomarkers express the integrity of neurons or health issue world wide. Many traumatic events are neurologic network, including astrocytes, and therefore not witnessed and not declared, especially in mild TBI, express the structural integrity of the nervous system. mTBI, and therefore not known, not treated or cured. The cutoff limit of these markers is in scientific debates At autopsy the diagnosis of brain injury is in and legal medicine may offer a support for their research. many cases a challenge especially in children with

1) “Carol Davila” University of Medicine and Pharmacy, Discipline of Legal Medicine and Bioethics, Bucharest, Romania * Corresponding author: E-mail: [email protected]

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Trauma lesions of the brain The signs and symptoms of mild traumatic brain The following traumatic lesions are to be found: injury may include: (1) physical symptoms such as: no Closed Head Injury, Open Head Injury, Diffuse Axonal loss of consciousness, daze state, loss of consciousness Injury, Contusion, Penetrating Trauma, Secondary seconds to minutes, headache, nausea, vomiting, sleeping, Injury (Intracranial hemorrhage -bleeding inside the dizziness, (2) sensory symptoms: blurred vision, ringing skull-, Brain swelling, Increased intracranial pressure in the ears, sensitivity to light (3) cognitive or mental -pressure inside the skull-, Brain damage associated with symptoms: memory and mood problems. lack of oxygen, Infection inside the skull, common with The signs and symptoms of moderate to severe penetrating trauma, Chemical changes leading to cell traumatic brain injuries include: (1) physical symptoms death, Increased fluid inside the skull –hydrocephalus-). such as: loss of consciousness minutes to hours, persistent Acquired Brain Injury may be non-traumatic headache, repeated vomiting, convulsions, inability to with the brain usually diffusely injured (congenital, birth awaken, loss of coordination, (2) cognitive or mental trauma, hereditary or degenerative) or traumatic brain symptoms: profound confusion, slurred speech, coma. injury. Common causes are anoxia and hypoxia leading Mechanisms are: Open head Injury, Closed Head to insufficient/lack of oxygen to the brain because of Injury, Deceleration Injuries, Chemical/Toxic, Hypoxia, mechanical problems with breathing, cardiac arrest or Tumors, Infections and Stroke. bleeding, Drugs and poisoning (i.e. carbon monoxide Several complications varying from mild to poisoning)[1]. severe and more severe can occur immediately or soon In many cases the use of the terms brain injury after a traumatic brain injury: Altered consciousness and head injury are used interchangeably. Head injury is a (Coma, Vegetative, Minimally conscious state, Locked- trauma to the head, that may or may not include injury to in syndrome, Brain death), Seizures, Cerebrospinal the brain. A brain injury can be called an acquired brain fluid buildup and cerebral oedema, Infections, Blood injury, intracranial injury, or simply head injury, and vessel damage, Nerve damage, Intellectual problems occurs when a sudden trauma causes damage to the brain. (Cognitive problems, Executive functioning problems, Common causes of both head and brain injuries Communication problems: Cognitive problems, Social include vehicle accidents, home and occupational problems, Behavioral changes, Emotional changes, accidents, falls, and assaults. Sensory problems, Degenerative brain diseases). Since in Loss of consciousness is not a must in the our brain are our personality, mood, character and this traumatic brain injury, thus many people with TBI, defines who we are, the consequences of a brain injury especially mild TBI, do not seek help and therefore can affect all aspects of our lives. doctors are not really aware of the extend of this pathology in general population [2]. Useful markers to assess TBI (Traumatic brain There are an estimated 10 million people affected Injury) annually by TBI across the globe [3]. The medical staff may conduct a number of According to the World Health Organization, TBI diagnostic tests to determine what is occurring internally will surpass many diseases as the major cause of death and after the accident or illness such as intracranial pressure, disability by the year 2020 [3]. X-rays, CT, MRI, EEG, Coma Glasgow scale evaluation. TBI is classified into mild, moderate, and severe However, CT scanning has low sensitivity to diffuse brain based on the Glasgow Coma Scale (GCS) score as a damage and confers important exposure to radiation. spectrum of injuries: a GCS equal to or less than 8 is MRI is indeed very useful to evaluate the extent of considered a “severe” TBI, a GCS of 9–12 is a “moderate” diffuse injuries but is not welcomed by all patients and is TBI, and a GCS of 13–15 is considered mild TBI, mTBI. restricted by its reduce availability and high costs. Unfortunately the term “mild TBI” coin a not dangerous Brain injury may be identifiable also using brain traumatic lesion which is not actually true [2]. biomarkers. The most frequent used are NSE (neuron- Individuals who incur a TBI and have an initial specific enolase) and S100B which are released after the GCS score of 13–15 are acutely at risk for intracranial head and brain trauma and injury in the cerebrospinal bleeding and diffuse axonal injury [4]. fluid and then in the blood. Other biomarkers may be Additionally, a significant proportion is at risk useful especially if their results are correlated with the for impairment of physical, cognitive, and psychosocial clinical status and exploratoty investigations such as MRI functioning [5-9]. and CT. Axonal injury, term coined diffuse axonal injury (DAI), more recently traumatic axonal injury (TAI) Biofluid biomarkers of astroglial injury [10] can be found after severe, moderate and mild TBI, 1. S100Beta by rotation mechanisms after rapid acceleration and S100 is a dimer which binds Calcium in the cell. deceleration forces, usually in road vehicle accidents but It is implied in the neuronal and cellular differentiation not solely. and neuronal proliferation. S100 has a half life of 2 hours.

147 Chirica V.I. Useful markers to assess traumatic and hypoxic brain injury

There are more than 19 types: 4 types are within the Roine et al. sustain a cutoff of 17 microgr/L useful tissues i.e. S100A1 in the skeletal muscle, the heart and to predict and diagnose a bad prognosis in connection kidney, S100A1B (in the astrocyte), S100B (astrocyte and with NSE rise in serum [30]. Schwann cells) and S100 BB (in the astrocyte). NSE rise to patients which will not survive With a molecular weight of 21kDa may easily after neuronal lesions versus patients which has a good penetrate the blood brain barrier and therefore may recovery prognosis [31]. easily be find in the blood stream as a witness of brain A drop of NSE after 24-48 hours from the head injuries as in trauma or hypoxia after Cardiac arrest and and brain trauma i.e. indicate a good prognosis for the cardiopulmonary resuscitation, CPR. 21.2 microgr/L patients with hypoxic coma after cardiac arrest, CA, and values are reported in anoxic coma versus 15.2 microgr/L CPR [32]. to the patients which has good recovery of their neuronal A concentration of minimum 30 microgr/L at 48 functions of the brain [11]. Prediction of outcome in hours may indicate death in 100% [31]. comatose survivors after cardiopulmonary resuscitation Mechanical methods of blood propulsion in the is a useful task for S100B based on reports of the Quality assisted circulation, open heart surgery, hemolysis, may Standards Subcommittee of the American Academy of determine NSE value modifications. External sources of Neurology [12]. NSE like in the small cell carcinoma, carcinoide tumors, Martens in 1998 [13] find also interesting neuroblastoma, hemoragic shock, femur fracture, clinical correlations in coma persistent patinets compare ischemia and local reperfusion may alter the values of to patient who recovered from coma. NSE and S100B also [32]. Usually cutoff limit for S100B are in the range NSE predict persistent hypoxic coma treated by of 0.2 -1.5 mg/L [14,15]. Sensibility of S100B for a bad hypothermia with a sensibility of 80% and a specificity of prognosis prediction is on a median of 2-5% [16, 17]. 100% when values higher than 33 microgr/L over 1 week S100B has a short half life and that is why after 48 are to be found [33] or at 72 hours from the beginning of hours its predictive value falls dramatically [18,19]. If the the postanoxic coma after CPR with similar values; false values of S100B are combined with other biomarkers and negative results were even zero in these series [34]. Glasgow scale its sensibility and specificity rise [20]. NSE cutoff of 33 microgr/L is however disputed: Hemolysis does not interfere with S100B and for values even greater than 97 microgr/L are still reported this reason it is a useful biomarker in such cases. and express a bad neurological prognosis with 100% 2. Glial Fibrillary acid protein (GFAP) is a specificity 100% and a sensibility calculated of 49% [35]. monomeric intermediate protein to be found in the Nevertheless, some studies present that a wise use astroglial skeleton (classical study of Eng et al. in of this biomarker for a long term prognosis in survivors 1971). Has a high specificity for neuronal tissue and is after CPR is to take into account values greater than found solely in the astrocyte, a fact that is very useful 0.29 mg/L at 24-48 hours that may support alterations in assessing of the injuries of the brain. Serum GFAP and disfunctions of the memory on short term and an is a useful marker for various types of brain damage, increased mortality in clinic when values are around or including neurodegenerative disorders [21,22], stroke more than 1.2 mg/L [36]. [23], severe TBI [24-27], axonal injuries [28] as much as These biomarkers, NSE and S100B may be both in the predictive prognosis in a coma after a CA and a used to assess neuronal injuries in brain trauma or CPR. hypoxia in a short or in a long term [37] but some other High values and results at 12-24 hours after studies contradictory data with above [38]. head and brain trauma or in cerebral hypoxia after a Cerebral hypoxia releases proteins that may CPR are useful predictive indicator for a bad prognosis be found useful to be diagnosis markers. Experimental in 6 months than in patients with normal values (0.1 ng/ research presents that NSE and S100B are rising up after mL) [29]. brain injuries to begin with the second day and become However, this biomarker for brain injury presents in normal range in the 4th day strong correlations being contradictory results in various studies and therefore a made between their values and severity of the injuries necroptic research may be useful. [39, 40]. A correlation of NSE with other markers or EEG Biofluid biomarkers of neuronal injury results increase the correctness of brain injury evaluation 1. Neuron-specific enolase (NSE) and increase their sensibility and specificity to express NSE is a dimeric isoform of glicolitic enolase the brain injury [41]. Daubin, 2011 presents values over (2-phosfo-d-glicerat hidrolase) usually implied in 97 microgr/L with 91% negative prognostic if results are the glucidic metabolism: neuronal yy-enolase and associated with a devastating malign pattern of EEG [42]. neuroendocrine alfa y-enolase. Normally NSE does 2. Ubiquitin C-terminal hydrolase-L1 (UCH-L1) not express in the periferic blood except for very small has an important role in the removal of excessive, traces [30]. oxidized, or misfolded proteins during both normal and

148 Romanian Journal of Legal Medicine Vol. XXV, No 2(2017) pathological conditions in neurons [43]. CONCLUSIONS Previously used as a histological marker for neurons [44] now is found to be significantly elevated in Biomarkers could potentially facilitate diagnosis human cerebrospinal fluid, CSF [45,46]) and is detectable and risk stratification of mTBI and impact management very early after injury and remains significantly elevated of these patients. for at least 1 week post injury [45]. Most probably a systematization of the patients 3. CK0BB is present in neurons and astrocytes. or victims could be useful in order to get better values In clinical set-up presents various results and thus a or a better interpretation of the scientific value of the necroptic study may be interesting in order to assess the biomarkers studied in brain injuries; thus using the value for brain injury determination [47]. same definition of sudden cardiac death or of the cardiac 4. Brain-derived neurotrophic factor, BDNF, is a arrest, CA etiology (cardiac/non-cardiac), defining the protein, a member of the neurotrophin family of nerve method to evaluate the prognosis (death or Glasgow growth factors found in the brain and the periphery. In scale), follow-up after discharging from the hospital over mouse studies values are found to rise up in CA after 3 or over 6 months, the moment to take the blood sample hyperthermia and CPR and therefore is also a useful (very important to be known and documented) could marker to evaluate brain injury [48]. improve the scientific evaluation of the cutoff limit [60]. A draw back has also to be specified: technically Biofluid biomarkers of axonal injury the prelevation of the cerebrospinal fluid from a cadaver 1. Alpha-II spectrin (280 kDa) is a major structural is difficult because of the rectitude of the spinal cord in component of the cortical membrane cytoskeleton, such circumstance. A direct prelevment form the brain abundant in axons and presynaptic terminals [49, 50]. may be a good solution if however blood leakage are not It is also a major substrate for calpain and produced and thus the necroptic approach prove to be a caspase-3 cysteine proteases [51, 52] and a marker for useful tool for research in biomarkers and brain injuries apoptosis and necrosis in an early phase. Levels of Alpha- assessment. Another limitation of the cerebrospinal fluid II spectrin were significantly greater in subjects with usage is the anatomical fact that in a coma CSF, normally moderate and severe TBI. circulate less than 20% therefore a lumbar punction will 2. Tau protein is an intracellular microtubule- not get refresh fluid and values of biomarkers in the associated protein highly enriched in axons [53] which measure it was expected. A legal medicine research has to levels are connected with related to axonal disruption provide solutions to such conditions. [54, 55]. Despite the fact that the biomarkers already cited 3. Neurofilaments (transaminaza glutamic are used in clinics there is not yet a solid correlation with oxalica cerebrala) are heteropolymeric components of the postmortem set-up and necroptic status [12]. the neuron cytoskeleton. After TBI, calcium entry into Biomarkers to evaluate brain injury in the head the cell and generates a cascade of events that activates and brain trauma as in post hypoxic coma after CPR and calcineurin (a calcium-dependent phosphatase) that will CA or in complex cases with an unclear cause of death dephosphorylate the neurofilament, which is believed to or causality but with head trauma, may offer a better contribute to the axonal injury [56]. objectivity in legal medicine and necroptic set-up a may 4. N-Cam or selectins seems to have a higher provide a better judicial support useful to find the truth predictive value in coma hypoxic injuries after CPR than in justice. neurofilaments and this may be more interesting and presenting more coherent predictive patterns [57-59]. Conflict of interest. The authors declare that there is no conflict of interest.

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