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Traumatic Brain Injury: Clinical Characteristics and Outcomes

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (30 September 2021) | Viewed by 40696

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Prof. Dr. Rafael Badenes

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Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, Universitat de València, Valencia, Spain
Interests: traumatic brain injury; brain oxygenation; sedation; ICP; delirium; mechanical ventilation; organ donation
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Dear Colleagues,

As many of you already know, traumatic brain injury (TBI) is a growing public health problem of substantial proportions. More than 50 million TBIs occur internationally each year. Across all ages, TBI represents 30–40% of all injury-related deaths, and neurological injury is projected to remain the most important cause of disability from neurological disease until 2030. Severe TBI has a high mortality rate, estimated at 30–40% in observational studies on unselected populations.

Survivors experience a substantial burden of physical, psychiatric, emotional, and cognitive disabilities, which disrupt the lives of individuals and their families, and impose huge costs on society. Wide variations in the clinical manifestations of TBI are attributable to the complexity of the brain and to the pattern and extent of damage.

Over the past few years, a number of multicenter studies on the topic have emerged, helping to provide a better understanding of the condition. However, it is also clear that much remains to be learned.

With this Special Issue, we hope to encourage submissions that discuss the current state-of-the-art, address ongoing knowledge gaps, and focus on ongoing controversies related to Traumatic Brain Injury: Clinical Characteristics and Outcomes.

Dr. Rafael Badenes
Guest Editor

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Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

traumatic brain injury
brain oxygenation
intracranial pressure
autoregulation
delirium
sedation
organ donation.

Published Papers (11 papers)

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Research

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9 pages, 559 KiB

Open AccessArticle

Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study

by Francesco Corallo, Viviana Lo Buono, Rocco Salvatore Calabrò and Maria Cristina De Cola

J. Clin. Med. 2021, 10(22), 5437; https://doi.org/10.3390/jcm10225437 - 21 Nov 2021

Cited by 5 | Viewed by 2126

Abstract

Cranioplasty (CP) is a neurosurgical intervention of skull repairing following a decompressive craniectomy. Unfortunately, the impact of cranioplasty on cognitive and motor function is still controversial. Fifteen TBI subjects aged 26–54 years with CP after decompressive craniectomy were selected in this observational retrospective study. As per routine clinical practice, a neuropsychological evaluation carried out immediately before the cranioplasty (Pre CP) and one month after the cranioplasty (T0) was used to measure changes due to CP surgery. This assessment was performed each year for 5 years after discharge in order to investigate long-term cognitive changes (T1-T5). Before cranioplasty, about 53.3% of subjects presented a mild to severe cognitive impairment and about 40.0% a normal cognition. After CP, we found a significant improvement in all neuropsychological test scores. The more significant differences in cognitive recovery were detected after four years from CP. Notably, we found significant differences between T4 and T0-T1, as well as between T5 and T0-T1-T2 in all battery tests. This retrospective study further suggests the importance of CP in the complex management of patients with TBI showing how these patients might improve their cognitive function over a long period after the surgical procedure. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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11 pages, 3817 KiB

Open AccessArticle

Suppression of Electrographic Seizures Is Associated with Amelioration of QTc Interval Prolongation in Patients with Traumatic Brain Injury

by Wojciech Dabrowski, Dorota Siwicka-Gieroba, Todd T. Schlegel, Chiara Robba, Sami Zaid, Magdalena Bielacz, Andrzej Jaroszyński and Rafael Badenes

J. Clin. Med. 2021, 10(22), 5374; https://doi.org/10.3390/jcm10225374 - 18 Nov 2021

Viewed by 1857

Abstract

Introduction: Disorders in electroencephalography (EEG) are commonly noted in patients with traumatic brain injury (TBI) and may be associated with electrocardiographic disturbances. Electrographic seizures (ESz) are the most common features in these patients. This study aimed to explore the relationship between ESz and possible changes in QTc interval and spatial QRS-T angle both during ESz and after ESz resolution. Methods: Adult patients with TBI were studied. Surface 12-lead ECGs were recorded using a Cardiax device during ESz events and 15 min after their effective suppression using barbiturate infusion. The ESz events were diagnosed using Masimo Root or bispectral index (BIS) devices. Results: Of the 348 patients considered for possible inclusion, ESz were noted in 72, with ECG being recorded in 21. Prolonged QTc was noted during ESz but significantly ameliorated after ESz suppression (540.19 ± 60.68 ms vs. 478.67 ± 38.52 ms, p < 0.001). The spatial QRS-T angle was comparable during ESz and after treatment. Regional cerebral oximetry increased following ESz suppression (from 58.4% ± 6.2 to 60.5% ± 4.2 (p < 0.01) and from 58.2% ± 7.2 to 60.8% ± 4.8 (p < 0.05) in the left and right hemispheres, respectively). Conclusion: QTc interval prolongation occurs during ESz events in TBI patients but both it and regional cerebral oximetry are improved after suppression of seizures. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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13 pages, 3159 KiB

Open AccessArticle

Effects of the COVID-19 Pandemic on Treatment Efficiency for Traumatic Brain Injury in the Emergency Department: A Multicenter Study in Taiwan

by Carlos Lam, Ju-Chuan Yen, Chia-Chieh Wu, Heng-Yu Lin and Min-Huei Hsu

J. Clin. Med. 2021, 10(22), 5314; https://doi.org/10.3390/jcm10225314 - 15 Nov 2021

Cited by 2 | Viewed by 1667

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has impacted emergency department (ED) practice, including the treatment of traumatic brain injury (TBI), which is commonly encountered in the ED. Our study aimed to evaluate TBI treatment efficiency in the ED during the COVID-19 pandemic. A retrospective observational study was conducted using the electronic medical records from three hospitals in metropolitan Taipei, Taiwan. The time from ED arrival to brain computed tomography (CT) and the time from ED arrival to surgical management were used as measures of treatment efficiency. TBI treatment efficiencies in the ED coinciding with a small-scale local COVID-19 outbreak in 2020 (P1) and large-scale community spread in 2021 (P2) were compared against the pre-pandemic efficiency recorded in 2019. The interval between ED arrival and brain CT was significantly shortened during P1 and P2 compared with the pre-pandemic interval, and no significant delay between ED arrival and surgical management was found, indicating increased treatment efficiency for TBI in the ED during the COVID-19 pandemic. Minimizing viral spread in the community and the hospital is vital to maintaining ED treatment efficiency and capacity. The ED should retain sufficient capacity to treat older patients with serious TBI during the COVID-19 pandemic. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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14 pages, 2167 KiB

Open AccessArticle

Implementation of Computed Tomography Angiography (CTA) and Computed Tomography Perfusion (CTP) in Polish Guidelines for Determination of Cerebral Circulatory Arrest (CCA) during Brain Death/Death by Neurological Criteria (BD/DNC) Diagnosis Procedure

by Romuald Bohatyrewicz, Joanna Pastuszka, Wojciech Walas, Katarzyna Chamier-Cieminska, Wojciech Poncyljusz, Wojciech Dabrowski, Joanna Wojczal, Piotr Luchowski, Maciej Guzinski, Elzbieta Jurkiewicz, Monika Bekiesinska-Figatowska, Radoslaw Owczuk, Jerzy Walecki, Olgierd Rowinski, Maciej Zukowski, Krzysztof Kusza, Mariusz Piechota, Andrzej Piotrowski, Marek Migdal, Marzena Zielinska and Marcin Sawicki Show full author list Hide full author list

J. Clin. Med. 2021, 10(18), 4237; https://doi.org/10.3390/jcm10184237 - 18 Sep 2021

Cited by 9 | Viewed by 2176

Abstract

Background: Brain death/death by neurologic criteria (BD/DNC) guidelines are routinely analyzed, compared and updated in the majority of countries and are later implemented as national criteria. At the same time, extensive works have been conducted in order to unify clinical procedures and to validate and implement new technologies into a panel of ancillary tests. Recently evaluated computed tomography angiography and computed tomography perfusion (CTA/CTP) seem to be superior to traditionally used digital subtraction angiography (DSA), transcranial Doppler (TCD) and cerebral perfusion scintigraphy for diagnosis of cerebral circulatory arrest (CCA). In this narrative review, we would like to demonstrate scientific evidence supporting the implementation of CTA/CTP in Polish guidelines for BD/DNC diagnosis. Research and implementation process: In the first of our base studies concerning the potential usefulness of CTA/CTP for the confirmation of CCA during BD/DNC diagnosis procedures, we showed a sensitivity of 96.3% of CTA in a group of 82 patients. CTA was validated against DSA in this report. In the second study, CTA showed a sensitivity of 86% and CTP showed a sensitivity of 100% in a group of 50 patients. In this study, CTA and CTP were validated against clinical diagnosis of BD/DNC supported by TCD. Additionally, we propose our CCA criteria for CTP test, which are based on ascertainment of cerebral blood flow (CBF) < 10 mL/100 g/min and cerebral blood volume < 1 mL/100 g in regions of interest (ROIs) localized in all brain regions. Based on our research results, CTA/CTP methods were implemented in Polish BD/DNC criteria. To our knowledge, CTP was implemented for the first time in national guidelines. Conclusions: CTA and CTP-derived CTA might be in future the tests of choice for CCA diagnosis, proper and/or Doppler pretest might significantly increase sensitivity of CTA in CCA diagnosis procedures. Whole brain CTP might be decisive in some cases of inconclusive CTA. Implementation of CTA/CTP in the Polish BD/DNC diagnosis guidelines does not show any major obstacles. We believe that in next edition of “The World Brain Death Project” CTA and CTP will be recommended as ancillary tests of choice for CCA confirmation during BD/DNC diagnosis procedures. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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10 pages, 721 KiB

Open AccessArticle

Association of Flow Rate of Prehospital Oxygen Administration and Clinical Outcomes in Severe Traumatic Brain Injury

by Won Pyo Hong, Ki Jeong Hong, Sang Do Shin, Kyoung Jun Song, Tae Han Kim, Jeong Ho Park, Young Sun Ro, Seung Chul Lee, Chu Hyun Kim and Joo Jeong

J. Clin. Med. 2021, 10(18), 4097; https://doi.org/10.3390/jcm10184097 - 10 Sep 2021

Cited by 2 | Viewed by 1983

Abstract

The goal of this study was to investigate the association of prehospital oxygen administration flow with clinical outcome in severe traumatic brain injury (TBI) patients. This was a cross-sectional observational study using an emergency medical services-assessed severe trauma database in South Korea. The sample included adult patients with severe blunt TBI without hypoxia who were treated by EMS providers in 2013 and 2015. Main exposure was prehospital oxygen administration flow rate (no oxygen, low-flow 1~5, mid-flow 6~14, high-flow 15 L/min). Primary outcome was in-hospital mortality. A total of 1842 patients with severe TBI were included. The number of patients with no oxygen, low-flow oxygen, mid-flow oxygen, high-flow oxygen was 244, 573, 607, and 418, respectively. Mortality of each group was 34.8%, 32.3%, 39.9%, and 41.1%, respectively. Compared with the no-oxygen group, adjusted odds (95% CI) for mortality in the low-, mid-, and high-flow oxygen groups were 0.86 (0.62–1.20), 1.15 (0.83–1.60), and 1.21 (0.83–1.73), respectively. In the interaction analysis, low-flow oxygen showed lower mortality when prehospital saturation was 94–98% (adjusted odds ratio (AOR): 0.80 (0.67–0.95)) and ≥99% (AOR: 0.69 (0.53–0.91)). High-flow oxygen showed higher mortality when prehospital oxygen saturation was ≥99% (AOR: 1.33 (1.01~1.74)). Prehospital low-flow oxygen administration was associated with lower in-hospital mortality compared with the no-oxygen group. High-flow administration showed higher mortality. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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31 pages, 621 KiB

Open AccessArticle

Translation and Linguistic Validation of Outcome Instruments for Traumatic Brain Injury Research and Clinical Practice: A Step-by-Step Approach within the Observational CENTER-TBI Study

by Nicole von Steinbuechel, Katrin Rauen, Ugne Krenz, Yi-Jhen Wu, Amra Covic, Anne Marie Plass, Katrin Cunitz, Isabelle Mueller, Fabian Bockhop, Suzanne Polinder, Lindsay Wilson, Ewout W. Steyerberg, Andrew I. R. Maas, David Menon, Marina Zeldovich and The Linguistic Validation Group of CENTER-TBI

J. Clin. Med. 2021, 10(13), 2863; https://doi.org/10.3390/jcm10132863 - 28 Jun 2021

Cited by 14 | Viewed by 3199

Abstract

Assessing outcomes in multinational studies on traumatic brain injury (TBI) poses major challenges and requires relevant instruments in languages other than English. Of the 19 outcome instruments selected for use in the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, 17 measures lacked translations in at least one target language. To fill this gap, we aimed to develop well-translated linguistically and psychometrically validated instruments. We performed translations and linguistic validations of patient-reported measures (PROMs), clinician-reported (ClinRO), and performance-based (PerfO) outcome instruments, using forward and backward translations, reconciliations, cognitive debriefings with up to 10 participants, iterative revisions, and international harmonization with input from over 150 international collaborators. In total, 237 translations and 211 linguistic validations were carried out in up to 20 languages. Translations were evaluated at the linguistic and cultural level by coding changes when the original versions are compared with subsequent translation steps, using the output of cognitive debriefings, and using comprehension rates. The average comprehension rate per instrument varied from 88% to 98%, indicating a good quality of the translations. These outcome instruments provide a solid basis for future TBI research and clinical practice and allow the aggregation and analysis of data across different countries and languages. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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34 pages, 897 KiB

Open AccessArticle

Psychometric Characteristics of the Patient-Reported Outcome Measures Applied in the CENTER-TBI Study

by Nicole von Steinbuechel, Katrin Rauen, Fabian Bockhop, Amra Covic, Ugne Krenz, Anne Marie Plass, Katrin Cunitz, Suzanne Polinder, Lindsay Wilson, Ewout W. Steyerberg, Andrew I. R. Maas, David Menon, Yi-Jhen Wu, Marina Zeldovich and the CENTER-TBI Participants and Investigators

J. Clin. Med. 2021, 10(11), 2396; https://doi.org/10.3390/jcm10112396 - 28 May 2021

Cited by 17 | Viewed by 3458

Abstract

Traumatic brain injury (TBI) may lead to impairments in various outcome domains. Since most instruments assessing these are only available in a limited number of languages, psychometrically validated translations are important for research and clinical practice. Thus, our aim was to investigate the psychometric properties of the patient-reported outcome measures (PROM) applied in the CENTER-TBI study. The study sample comprised individuals who filled in the six-months assessments (GAD-7, PHQ-9, PCL-5, RPQ, QOLIBRI/-OS, SF-36v2/-12v2). Classical psychometric characteristics were investigated and compared with those of the original English versions. The reliability was satisfactory to excellent; the instruments were comparable to each other and to the original versions. Validity analyses demonstrated medium to high correlations with well-established measures. The original factor structure was replicated by all the translations, except for the RPQ, SF-36v2/-12v2 and some language samples for the PCL-5, most probably due to the factor structure of the original instruments. The translation of one to two items of the PHQ-9, RPQ, PCL-5, and QOLIBRI in three languages could be improved in the future to enhance scoring and application at the individual level. Researchers and clinicians now have access to reliable and valid instruments to improve outcome assessment after TBI in national and international health care. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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10 pages, 4398 KiB

Open AccessArticle

Performance of Modified Early Warning Score (MEWS) for Predicting In-Hospital Mortality in Traumatic Brain Injury Patients

by Dong-Ki Kim, Dong-Hun Lee, Byung-Kook Lee, Yong-Soo Cho, Seok-Jin Ryu, Yong-Hun Jung, Ji-Ho Lee and Jun-Ho Han

J. Clin. Med. 2021, 10(9), 1915; https://doi.org/10.3390/jcm10091915 - 28 Apr 2021

Cited by 6 | Viewed by 2742

Abstract

The present study aimed to analyze and compare the prognostic performances of the Revised Trauma Score (RTS), Injury Severity Score (ISS), Shock Index (SI), and Modified Early Warning Score (MEWS) for in-hospital mortality in patients with traumatic brain injury (TBI). This retrospective observational study included severe trauma patients with TBI who visited the emergency department between January 2018 and December 2020. TBI was considered when the Abbreviated Injury Scale was 3 or higher. The primary outcome was in-hospital mortality. In total, 1108 patients were included, and the in-hospital mortality was 183 patients (16.3% of the cohort). Receiver operating characteristic curve analyses were performed for the ISS, RTS, SI, and MEWS with respect to the prediction of in-hospital mortality. The area under the curves (AUCs) of the ISS, RTS, SI, and MEWS were 0.638 (95% confidence interval (CI), 0.603–0.672), 0.742 (95% CI, 0.709–0.772), 0.524 (95% CI, 0.489–0.560), and 0.799 (95% CI, 0.769–0.827), respectively. The AUC of MEWS was significantly different from the AUCs of ISS, RTS, and SI. In multivariate analysis, age (odds ratio (OR), 1.012; 95% CI, 1.000–1.023), the ISS (OR, 1.040; 95% CI, 1.013–1.069), the Glasgow Coma Scale (GCS) score (OR, 0.793; 95% CI, 0.761–0.826), and body temperature (BT) (OR, 0.465; 95% CI, 0.329–0.655) were independently associated with in-hospital mortality after adjustment for confounders. In the present study, the MEWS showed fair performance for predicting in-hospital mortality in patients with TBI. The GCS score and BT seemed to have a significant role in the discrimination ability of the MEWS. The MEWS may be a useful tool for predicting in-hospital mortality in patients with TBI. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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Review

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12 pages, 2256 KiB

Open AccessReview

Potentially Detrimental Effects of Hyperosmolality in Patients Treated for Traumatic Brain Injury

by Wojciech Dabrowski, Dorota Siwicka-Gieroba, Chiara Robba, Magdalena Bielacz, Joanna Sołek-Pastuszka, Katarzyna Kotfis, Romuald Bohatyrewicz, Andrzej Jaroszyński, Manu L. N. G. Malbrain and Rafael Badenes

J. Clin. Med. 2021, 10(18), 4141; https://doi.org/10.3390/jcm10184141 - 14 Sep 2021

Cited by 10 | Viewed by 10894

Abstract

Hyperosmotic therapy is commonly used to treat intracranial hypertension in traumatic brain injury patients. Unfortunately, hyperosmolality also affects other organs. An increase in plasma osmolality may impair kidney, cardiac, and immune function, and increase blood–brain barrier permeability. These effects are related not only to the type of hyperosmotic agents, but also to the level of hyperosmolality. The commonly recommended osmolality of 320 mOsm/kg H₂O seems to be the maximum level, although an increase in plasma osmolality above 310 mOsm/kg H₂O may already induce cardiac and immune system disorders. The present review focuses on the adverse effects of hyperosmolality on the function of various organs. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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10 pages, 2884 KiB

Open AccessReview

Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis

by Annachiara Marra, Maria Vargas, Pasquale Buonanno, Carmine Iacovazzo, Antonio Coviello and Giuseppe Servillo

J. Clin. Med. 2021, 10(15), 3319; https://doi.org/10.3390/jcm10153319 - 28 Jul 2021

Cited by 20 | Viewed by 5263

Abstract

Introduction. Tracheostomy can help weaning in long-term ventilated patients, reducing the duration of mechanical ventilation and intensive care unit length of stay, and decreasing complications from prolonged tracheal intubation. In traumatic brain injury (TBI), ideal timing for tracheostomy is still debated. We performed a systematic review and meta-analysis to evaluate the effects of timing (early vs. late) of tracheostomy on mortality and incidence of VAP in traumatic brain-injured patients. Methods. This study was conducted in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a search in PubMed, using an association between heading terms: early, tracheostomy, TBI, prognosis, recovery, impact, mortality, morbidity, and brain trauma OR brain injury. Two reviewers independently assessed the methodological quality of eligible studies using the Newcastle–Ottawa Scale (NOS). Comparative analyses were made among Early Tracheostomy (ET) and late tracheostomy (LT) groups. Our primary outcome was the odds ratio of mortality and incidence of VAP between the ET and LT groups in acute brain injury patients. Secondary outcomes included the standardized mean difference (MD) of the duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS. Results. We included two randomized controlled trials, three observational trials, one cross-sectional study, and three retrospective cohort studies. The total number of participants in the ET group was 2509, while in the LT group it was 2597. Early tracheostomy reduced risk for incidence of pneumonia, ICU length of stay, hospital length of stay and duration of mechanical ventilation, but not mortality. Conclusions. In TBI patients, early tracheostomy compared with late tracheostomy might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, but increase the risk of mortality. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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9 pages, 256 KiB

Open AccessReview

Usefulness of Cerebral Oximetry in TBI by NIRS

by Małgorzata Barud, Wojciech Dabrowski, Dorota Siwicka-Gieroba, Chiara Robba, Magdalena Bielacz and Rafael Badenes

J. Clin. Med. 2021, 10(13), 2938; https://doi.org/10.3390/jcm10132938 - 30 Jun 2021

Cited by 12 | Viewed by 3791

Abstract

Measurement of cerebral oximetry by near-infrared spectroscopy provides continuous and non-invasive information about the oxygen saturation of haemoglobin in the central nervous system. This is especially important in the case of patients with traumatic brain injuries. Monitoring of cerebral oximetry in these patients could allow for the diagnosis of inadequate cerebral oxygenation caused by disturbances in cerebral blood flow. It could enable identification of episodes of hypoxia and cerebral ischemia. Continuous bedside measurement could facilitate the rapid diagnosis of intracranial bleeding or cerebrovascular autoregulation disorders and accelerate the implementation of treatment. However, it should be remembered that the method of monitoring cerebral oximetry by means of near-infrared spectroscopy also has its numerous limitations, resulting mainly from its physical properties. This paper summarizes the usefulness of monitoring cerebral oximetry by near-infrared spectroscopy in patients with traumatic brain injury, taking into account the advantages and the disadvantages of this technique. Full article

(This article belongs to the Special Issue Traumatic Brain Injury: Clinical Characteristics and Outcomes)

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