Objective Neuroworsening portends poor outcomes after traumatic brain injury (TBI) and is protocolized in intensive care unit (ICU) settings. The utility of neuroworsening assessments in non-ICU settings for intervention and prognostication requires further understanding. This study assessed relationships among neuroworsening in the emergency department (ED), clinicoradiological injury, blood-based biomarkers, neurosurgical interventions, and outcomes in TBI patients without Glasgow Coma Scale-Motor Score (GCS-M) impairment at ED arrival. Methods Adult subjects from the 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI; ClinicalTrials.gov #NCT02119182) Study with ED arrival GCS-M = 6 and ED disposition GCS-M were analyzed. Neuroworsening was defined as ED disposition GCS-M < 6. Subjects received clinically-indicated head computed tomography (CT) scan within 24-hours (h) post-TBI. Clinical characteristics, acute plasma TBI biomarker levels (glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase-L1 (UCH-L1); pg/ml), neurosurgical procedural interventions, hospital outcomes, and 3- and 6-month outcomes (Glasgow Outcome Scale-Extended (GOSE)) were compared. Multivariable logistic regressions examined predictors of neurosurgical interventions and unfavorable outcomes (GOSE ≤ 4) using adjusted odds ratios (AOR [95 % confidence intervals (CI)]). Cox proportional hazards model examined hospital discharge rate over time using adjusted hazard ratios (AHR). Results In 1210 subjects, 36 (3.0 %) had ED neuroworsening. Neuroworsening was associated with features of more severe injuries, including ICU admission (91.7 % vs. 30.3 %, p < 0.0001), post-traumatic amnesia duration (>24 h: 26.7 % vs. 4.2 %, p < 0.0001), and traumatic intracranial injuries on CT (72.2 % vs. 39.7 %, p = 0.00020). Neuroworsening subjects had higher GFAP (median = 1400 [Q1-Q3:864-3663] vs. 306 [82-839], p < 0.0001) and UCH-L1 (median = 459 [287-1036] vs. 170 [94-322], p < 0.0001), neurosurgical procedural interventions (38.9 % vs. 2.1 %, p < 0.0001), in-hospital mortality (8.6 % vs. 1.0 %, p = 0.018), hospital length of stay (6.9 days [Q1-Q3:4.8-16.8] vs. 2.2 days [1.3-4.0], p < 0.0001), and 3- and 6-month unfavorable outcomes (26.1 % vs. 3.5 %, p = 0.00040; 26.1 % vs. 3.7 %, p = 0.00050). Neuroworsening independently predicted neurosurgical interventions (AOR = 18.7 [95 % CI: 7.9-44.1], p < 0.0001), lower discharge rate [AHR = 0.35 [0.24-0.50], p < 0.0001), 3-month unfavorable outcome (AOR = 9.8 [3.0-31.9], p = 0.00010), and 6-month unfavorable outcome (AOR = 11.0 [3.1-38.7], p = 0.00020). Conclusions ED neuroworsening is an early indicator of clinicoradiological TBI severity, and predicted neurosurgical procedural interventions, longer hospitalizations, and 3- and 6-month unfavorable outcomes. Higher blood-based TBI biomarker levels were associated with ED neuroworsening, suggesting their potential role to aid in the assessment of TBI patients at high risk of neurological deterioration.

OBJECTIVE:Traumatic brain injury (TBI) affects approximately two million individuals in the United States annually, with most cases classified as mild (mTBI). Reported prevalence of insomnia, excessive daytime sleepiness, or obstructive sleep apnea (OSA) ranges from 30% to 70% in patients with mTBI. Sleep disorders may interfere with recovery and contribute to disability. This study characterizes self-reported impairments in sleep and mood among patients with mTBI. METHODS:This cross-sectional retrospective study at a Level 1 trauma center included adults with mTBI (Glasgow Coma Scale ≥ 13) diagnosed ≥ 6 months prior. Patients with substance dependence were excluded. Patients completed the Neurobehavioral Symptom Inventory (NSI), Epworth Sleepiness Scale (ESS), STOP-BAG, Insomnia Severity Index (ISI), Functional Outcome of Sleep Questionnaire-10 (FOSQ-10), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). Regression analyses controlling for age, body mass index, and time from injury were performed. RESULTS:We recruited 46 subjects, of which 74% (34) were male and 61% (28) were White. Mean (±SD) age was 53 (±17.07) years. Mean (±SD) scores were ESS 8.32 (±5.86), STOP-BAG 2.5 (±1.57), ISI 10.05 (±8.87), FOSQ-10 13.02 (±6.90), PHQ-9 7.02 (±6.72), and GAD-7 6.71 (±6.81). Univariate analyses showed significant associations between NSI and each of ESS, ISI, FOSQ-10, PHQ-9, and GAD-7 (p < 0.01). CONCLUSION:Patients with mTBI commonly report chronic impairments in sleep and psychological well-being. These findings emphasize the need for comprehensive management and identify the importance of screening for sleep disorders in this population. LEVEL OF EVIDENCE: 3:

Background Insurance-based disparities associated with outcomes in traumatic brain injury (TBI), including acute care discharge dispositions, remain understudied. This study aims to evaluate the associations between Medicaid versus private insurance (PI) on hospital length of stay (LOS) and discharge disposition in patients with TBI across severities. Methods This is a retrospective multicenter cohort study utilizing data from United States trauma centers from the National Trauma Data Bank (NTDB) years 2014-2016. Inclusion criteria were: identified to have TBI based on ICD-9 codes. Exclusion criteria were: missing gender, race, Glasgow Coma Scale (GCS) score, or LOS; not admitted as inpatient to hospital; did not have Medicaid or PI; age <14 or >89 years; extracranial AIS=6. Patients were grouped into those with Medicaid and those with PI. Results Of 808,120 NTDB patients with TBI, 188,756 met inclusion criteria (Medicaid: N=58,867, PI: N=129,889). Overall, PI patients were older and more frequently female, with differences in racial distribution and TBI severity compared to Medicaid patients. On multivariable analysis, Medicaid patients demonstrated longer inpatient LOS across all TBI severities, corresponding to a 7.3% increase after mild TBI (95% CI: 6.4%-8.2%, p<0.001), a 7.4% increase after moderate TBI (95% CI: 2.8%-12.2%, p=0.001), and an 8.7% increase after severe TBI (95% CI: 6.2%-11.3%, p<0.001) compared to PI patients. Across TBI severities, Medicaid patients had higher adjusted odds of routine discharge to home/self-care (mild: 15.9% increase; moderate: 28.2% increase; severe: 42.3% increase; all p<0.001) and to skilled nursing facilities (SNF) (mild: 63.6% increase; moderate: 54.6% increase; severe: 54.9% increase; all p<0.001). Conversely, Medicaid patients had significantly lower odds of discharge to inpatient rehabilitation (mild: 33.7% lower; moderate: 37.9% lower; severe: 42.6% lower; all p<0.001). For discharge to home health services, Medicaid patients had lower odds after mild TBI (13.0% lower, p<0.001), higher odds after severe TBI (17.5% higher, p=0.017), and no significant difference after moderate TBI. Sensitivity analysis using highest in-hospital GCS for severity classification demonstrated consistent direction and magnitude of associations, supporting the robustness of these findings. Conclusion Medicaid patients had longer LOS compared to PI patients, which was more pronounced within increasing TBI severity. Medicaid patients were more likely to be discharged to home/self-care and SNF, and less likely to be discharged to acute rehabilitation compared to those with PI. Our study confirms and extends prior studies on Medicaid as a risk factor for increased hospital LOS and lower likelihood for discharge to acute rehabilitation after TBI, which should be studied in near-term healthcare policy interventions.

Acute traumatic brain injury (TBI) in older veterans is an under-recognized public health emergency for the Veterans Health Administration (VHA). The fastest rising incidence of TBI in the United States is in older adults, who have higher mortality, lower rates of functional recovery, and higher risk for post-TBI dementia. Pre-existing TBI, medical/psychiatric conditions, and substance use-common in older veterans-are emerging risk factors for TBI and worse outcomes thereafter. There is an urgent need to characterize acute TBI in older veterans to inform effective interventions to optimize outcomes. We aim to characterize military, clinical, and biological features using a combination of TBI common data elements (CDEs) and validated dementia and geriatrics research assessments. This single-site, longitudinal, observational research study aims to enroll 70 older veterans with acute TBI who receive computed tomography in the emergency department and 30 matched non-neurotrauma controls who present to the San Francisco VA Medical Center within 14 days of their event. Participants and study partners complete pre-injury health/military relevant exposure assessments and multi-domain geriatric and TBI CDE follow-up assessments at 2 weeks, 3, 6, and 12 months. Blood for proteomic biomarkers is collected at baseline, 6 months, and 12 months. Willing participants also undergo magnetic resonance imaging at 2 weeks, 6 months, and 12 months. This study aims for comprehensive characterization of baseline and longitudinal endophenotypes of an intentionally heterogeneous, "real-world," population of older veterans presenting with acute TBI. Findings will inform the development of future studies focused on optimizing outcomes and evaluating interventions in TBI. This study will provide critical insights into the unique characteristics and the natural history of incident TBI in older veterans, paving the way for larger, Veteran Affairs-based, multicenter prospective studies of acute TBI to inform prevention, support correct diagnosis, and optimize short- and long-term recovery.

Traumatic brain injury (TBI) is a major global health burden, with sports and recreational activities accounting for approximately 10% of all TBI cases in the United States. Helmets are widely used to mitigate head injury risk, yet prior studies have reported conflicting associations between helmet use and specific head injury patterns, medical management, and outcomes across different helmet-relevant activities. The objective of this study is to examine the associations between helmet use and head injury characteristics, injury severity, and emergency department (ED) disposition among patients with helmet-associated activity-relevant TBI. We conducted a retrospective cohort study using the National Trauma Data Bank (NTDB) research dataset (2014-2021). Patients with TBI resulting from cycling/motorcycling, skiing/snowboarding, roller-skating/skateboarding, and equestrian-related activities were included. Primary outcomes include TBI severity (based on Glasgow Coma Scale score), head injury severity scale (ISS) maximum score, loss of consciousness (LOC), intracranial hemorrhage (ICH), skull fracture, diffuse axonal injury (DAI), and ED disposition. Multivariable regression models were estimated using an inclusive analytic approach along with sensitivity analyses using complete-case analysis and multiple imputation for missing covariate data. A total of 174,892 patients were included, of whom 70,558 were helmeted and 97,606 were non-helmeted. In adjusted inclusive analyses, helmet use was associated with lower odds of more severe TBI (odds ratio [OR] = 0.60, 95% confidence interval [CI]: 0.58-0.61, p < 0.001), higher head ISS maximum scores (OR = 0.59, 95% CI: 0.58-0.60, p < 0.001), ICH (OR = 0.61, 95% CI: 0.60-0.62, p < 0.001), and skull fracture (OR = 0.35, 95% CI: 0.34-0.36, p < 0.001). Helmeted patients had slightly higher odds of LOC (OR = 1.06, 95% CI: 1.03-1.08; p < 0.001). To assess whether this association reflected increased rotational injury, analyses restricted to patients in the International Classification of Diseases, Tenth Revision (ICD-10)-era demonstrated that helmet use was associated with lower odds of DAI (OR = 0.87, 95% CI: 0.81-0.93; p < 0.001). Helmet use was also associated with substantially lower odds of high-acuity or adverse ED dispositions. Findings were consistent across inclusive, complete-case, and multiple imputation analyses. In conclusion, our findings suggest that helmet use in helmet-relevant activity-associated injuries is associated with reduced head injury severity, lower odds of ICH, skull fracture, DAI, and decreased need for high-acuity medical care. The observed increase in LOC among helmeted patients may reflect differences in reporting or injury biomechanics rather than greater injury severity. These findings support public health strategies to increase helmet use through policy, education, and advances in protective equipment design.

Intimate partner violence (IPV) represents a public health crisis in the United States. Experiencing IPV is associated with various adverse health outcomes and injuries, including traumatic brain injury (TBI). Improving screening and care for individuals affected by concurrent IPV and traumatic brain injury (IPV-TBI) requires understanding its incidence, sociodemographics, risk factors, and clinical outcomes. Using standardized multicenter data from the US National Trauma Data Bank years 2018 to 2022, this study aimed to answer the following questions: (a) What is the incidence of IPV-TBI among female patients treated for TBI at US trauma facilities? (b) Are there sociodemographic and clinical differences between female IPV-TBI and female non-IPV-TBI patients? (c) What hospital outcomes (length of stay [LOS], emergency department discharge disposition, hospital discharge disposition) are associated with IPV-TBI, based on TBI severity. Statistical differences were examined using Welch's t-test and analysis of variance, Pearson's chi-squared test with post hoc Bonferroni-corrected z-tests, and multivariate logistic and linear regressions. Our findings indicate that most female trauma center patients with assault-related TBI experienced IPV (76.8%), often inflicted by male partners (97.9%). Compared to those with non-IPV TBI, IPV survivors who experienced TBI were younger (mean 37.9 ± 12.5 years vs. non-IPV: 48.0 ± 12.4; p < .001) and more commonly insured by Medicaid (47.0% vs. 36.5%, p < .001). IPV-TBI was associated with significantly higher odds of discharge to home in female patients (aOR = 1.31 [95% CI: 1.01, 1.69]), and IPV-TBI patients were likely to have shorter hospital LOS than those with TBI from non-IPV assault (4.3 ± 6.8 days vs. 5.9 ± 9.8; p < .001). Our findings underscore the critical importance of screening TBI patients for IPV, given that the social and medicolegal contexts surrounding their injury and recovery may be substantially different from TBI patients without IPV, and being discharged home may present significant safety risks.

Impaired spinal cord perfusion can negatively impact neurological outcome after acute traumatic spinal cord injury (SCI). Hemodynamic management emphasizes maintenance of mean arterial pressure (MAP), although clinical practice remains variable and may be driven by systemic perfusion goals. Growing evidence suggests that spinal cord perfusion pressure (SCPP)-defined as MAP minus intrathecal pressure (ITP) measured via lumbar cerebrospinal fluid (CSF) or intraspinal pressure (ISP) measured directly at the injury site-may be a more meaningful physiological target. This narrative review synthesizes current SCPP monitoring techniques, emphasizing technical considerations for device placement, safety profiles, practical clinical factors guiding patient selection, and key gaps in current guidelines. A targeted literature search was performed using PubMed and Ovid MEDLINE for studies examining SCPP, ITP, CSF drainage, and hemodynamic management in traumatic SCI. Additional sources were identified through reference screening of key articles and prior reviews. Intrathecal lumbar subarachnoid drains (LSADs) are widely accessible, allow estimation of ITP, and facilitate CSF drainage, but have uncertain accuracy in the setting of spinal cord swelling and restricted CSF flow. LSADs advanced toward the site of injury offer the potential for local ITP assessment, although data remain sparse. ISP monitors provide high-fidelity measurements at the lesion site but cannot drain CSF, require intraoperative placement, and lack regulatory approval. Across modalities, key unresolved questions include optimal timing of monitor insertion, target SCPP ranges, and appropriate duration of monitoring. SCPP monitoring holds promise for individualizing hemodynamic management in acute traumatic SCI. Although studies suggest feasibility and potential benefit, consensus multi-institutional standardized guidelines are lacking. Future multicenter trials are needed to define indications, refine perfusion targets, and integrate SCPP-directed therapy into routine SCI care.

Mild traumatic brain injury (mTBI) accounts for 80-90% of all traumatic brain injuries, yet its economic burden remains poorly characterized. We synthesized direct healthcare charges and costs associated with mTBI in the United States (U.S.). A PubMed search through October 14, 2025 identified primary studies reporting direct healthcare-related charges or costs among adults with mTBI. All estimates were standardized to 2025 U.S. dollars. Twenty-one studies (1996-2023) out of 3300 screened (0.64%) met inclusion criteria. Index hospitalization costs ranged from $3984 to $31,316 and remained stable over time, whereas national hospital charges increased from $26,021 (mean, standard deviation (SD) $1895) in 1996 to more than $172,080 in recent reports. First-year healthcare costs ranged from $16,898 to $29,045 in civilian populations and reached $182,094 (mean, SD $161,743) in military rehabilitation settings. These findings indicate mTBI imposes substantial costs beyond initial hospitalization and highlight growing financial pressures on trauma systems.

INTRODUCTION: Neuroworsening, commonly defined as a declining Glasgow Coma Scale motor score (GCS-M), indicates injury progression and is a component of traumatic brain injury (TBI) intensive care guidelines. The utility of assessing neuroworsening in emergency department (ED) settings requires examination. METHODS: Adult subjects from the 18-center TRACK-TBI Study (enrollment years 2014-2018) with ED arrival GCS-M=6 and ED disposition GCS-M were analyzed. Subjects received head CT <24h of TBI. Neuroworsening = ED disposition GCS-M<6. Clinical characteristics, acute plasma glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) levels, cranial surgery/intracranial pressure monitor, hospital mortality, length of stay (LOS), and 3- and 6-month functional outcomes (Glasgow Outcome Scale-Extended) were compared. Multivariable regressions were performed for procedural intervention, mortality, and unfavorable outcome (GOSE=4). Multivariable odds ratios (mOR [95%CI]) were reported. (*) denotes p<0.0001. RESULTS: In 1328 subjects, 3.1% had neuroworsening. Neuroworsening was associated with ICU admission (90.2%/30.1%*), hypoxia (17.1%/2.5%*), Marshall CT Score 3-6 (31.7%/2.8%*), subarachnoid hemorrhage (58.5%/27.0%*), subdural hematoma (51.2%/18.7%*), intracerebral contusion (41.5%/14.0%*), midline shift (24.4%/2.3%*), and downward herniation (19.5%/1.5%*). Neuroworsening subjects had higher GFAP* (median: 1400-pg/mL [IQR:864-3663] vs. 314 [82-868]) and UCH-L1* levels (459 [287-1036] vs. 170 [94-322]), procedural interventions (34.2%/2.3%*), hospital mortality (7.7%/0.9%*), LOS* (7.4-days [4.9-19.7] vs. 2.3 [1.3-4.1]), and 3- and 6-month unfavorable outcomes (23.1%/3.6%*; 23.1%/3.9%*). On multivariable regressions, neuroworsening independently predicted neurosurgical procedural interventions (mOR=9.0 [1.9-42.7]*). CONCLUSIONS: Our study confirms neuroworsening in the emergency department as an early indicator of clinical and radiological TBI severity, and a predictor of neurosurgical procedural interventions. We provide the first report on the direct relationship between ED neuroworsening and diagnostic blood-based biomarkers of TBI. Clinicians evaluating neurotrauma patients should be vigilant in detecting neuroworsening, as affected patients may benefit from immediate therapeutic interventions.

Introduction:Helmets reduce head injury severity after bicycle, scooter, and skateboard injuries. Prevention of one head injury reduces lifetime risk of reinjuries. Our clinical care quality improvement initiative (QII) aimed to improve helmet usage, education, and safety awareness in head injury patients at a United States trauma center. Research question:To assess QII feasibility. Material and methods:Head injury patients presenting to emergency department (ED) after bicycle, scooter, and skateboard accidents without helmets or with lost/damaged helmets were provided helmets free-of-charge, and in-person review of traumatic brain injury education, resources, and follow-up care. Surveys on helmet use were conducted in the ED and at ≥1 telephone appointments (2-weeks to 1-year). Results:In 21 patients aged 37.7 ± 12.5-years, 71 % were male, 38 % had traumatic intracranial hemorrhage on head computed tomography (CT) scan, and 81 % were unhelmeted. Mechanisms included scooter (48 %), bicycle (38 %), and skateboard-related (14 %) injuries. All patients reported improved understanding of risk reduction strategies and helmet use at enrollment and follow-up. At follow-up, 11/21 patients were able to resume pre-injury bicycle, scooter, and/or skateboard-related activities, of which 82 % reported consistent helmet use. Of 10 patients unable to resume pre-injury activities, reasons included head injury (50 %), polytrauma (30 %), and concern for reinjury (30 %). Discussion and conclusions:Costs of one head injury ED admission may exceed $6000, compared with $60 for one helmet. In-person provision of helmets, education, and resources is an adoptable, cost-effective intervention for improving safety awareness and reducing reinjury risk. Next steps include expanding QII implementation and refining evaluation metrics.

Objective:Traumatic brain injury affects 1.5 million people per year in the United States, with the majority classified as mild (mTBI). While many immediate symptoms are limited to the short-term, some patients experience long-term daily impairments in function and quality of life. The objective of this study was to assess the relationship between mTBI post-concussive symptoms and hearing, tinnitus, and dizziness symptoms. Study design:Cross-sectional study. Setting:Level I public trauma center. Methods:Adult patients presenting with mTBI ≥6 months prior to study enrollment were asked to complete the Neurobehavioral Symptom Inventory (NSI), Revised Hearing Handicap Inventory (RHHI), Tinnitus Functional Index (TFI), and Dizziness Handicap Inventory (DHI) survey instruments. The NSI is a validated, self-reported measure of post-concussive symptoms. Linear regression analyses were performed. Results:A total of 38 subjects were recruited, with mean age of 52 (range 24-78), 74% male, 61% self-identifying as White, and 87% self-identifying as Non-Hispanic/Latinx. Median time since injury was 32.5 months (IQR 30-35). Mean NSI score was 22.32 (range 0-70), mean RHHI was 16.05 (0-68), mean TFI was 16.00 (0-85.2), and mean DHI was 18.86 (0-100). On linear regression, NSI score was positively correlated with RHHI, TFI, and DHI scores (P < .01). Conclusion:The postconcussive symptoms of mTBI are associated with impairments in hearing, tinnitus, and dizziness. Based on this work, structural causal models may be developed to dissect associations to inform management and treatment of mTBI patients with audiovestibular symptoms.

Objective Direct electric stimulation (DES) is the gold standard for identifying cortical and subcortical regions with motor eloquence. However, DES can only be applied intraoperatively, after craniotomy, and therefore cannot be used to guide pre-operative management. Currently, there is no consensus on a gold standard for preoperative evaluation of eloquent brain areas, with surgeons relying on a multi-modal strategy to guide surgical resection. This study aims to define the role of navigated transcranial magnetic stimulation (nTMS) in surgical planning, as employed by an expert glioma surgeon. Methods An experienced glioma surgeon completed a structured questionnaire regarding the visualization of motor-eloquent brain areas and surgical access planning before and after viewing nTMS motor mapping data in the process of presurgical planning. Results A consecutive series of 90 patients with suspected glioma adjacent to the motor cortex undergoing presurgical nTMS motor mapping was analyzed. Motor-evoked potentials were obtained in 89 cases (98.9 %). The relationship between the tumor and motor-eloquent brain areas was rated as "well" or "perfectly" in 8 cases (8.9 %) before and in 28 cases (31.1 %) after nTMS motor mapping. A high probability of altering the current surgical plan intraoperatively after DES was noted in 8 cases (8.9 %) before and 18 cases (20 %) after nTMS. In addition, the number of patients with a high certainty of not changing the surgical plan increased from 6 cases (6.7 %) to 24 cases (26.7 %) after nTMS. nTMS data led to a different surgical strategy regarding the size and/or location of the craniotomy in 35 cases (38.9 %), the corticotomy in 33 cases (36.7 %), and the surgical corridor in 36 cases (40 %). nTMS data impacted patient consultation in 28 cases (31.1 %). Overall, the addition of nTMS motor mapping to the pre-operative process conferred a positive impact in 46 cases (51.1 %). Conclusions nTMS motor mapping has a major perceived impact on surgical planning for motor-eloquent gliomas, as well as on patient consultation, in the view of a highly experienced glioma surgeon.

ABSTRACT:An estimated 50% to 75% of patients with mild traumatic brain injury (mTBI) report chronic pain. Symptomatology evolution, subtypes, and risk factors remain poorly understood. We evaluated patient-reported pain intensity and interference with daily function in a longitudinal U.S. mTBI cohort. The Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study prospectively enrolled patients with TBI across 18 trauma centers who received head computed tomography (CT) within 24 hours post-injury. Subjects aged ≥17 years with arrival Glasgow Coma Scale = 13 to 15, Marshall CT Score = 1 to 2, and PROMIS-Pain Intensity and Interference assessments at 2 weeks, 3 months, 6 months, and 12 months post-injury were included. Subjects with cranial surgery, major extracranial injury, or pre-injury musculoskeletal pain were excluded. Healthy controls (HCs) completed assessments at all timepoints. Pain assessment T-scores were compared using mixed-effect linear regressions. Adjusted mean differences (aMDs; [95% confidence intervals]) were reported. In 906 subjects (mTBI = 710, HC = 196), mean age was 39.6 ± 16.7-years, 64% were male, and 75% were White/Caucasian. In subjects with mTBI, 35% were CT positive, ≥80% reported pain intensity or interference symptoms at 2 weeks post-injury, and <20% received TBI care postdischarge. Compared with HCs, CT-negative subjects had statistically elevated pain intensity (aMD; 2 weeks: +12.8 [10.9-14.6], 3 months: +4.6 [2.7-6.6], 6 months: +3.4 [1.4-5.4], 12 months: +2.7 [0.7-4.7]) and interference (aMD; 2 weeks: +12.3 [10.7-13.9], 3 months: +4.6 [3.0-6.2], 6 months: +3.1 [1.4-4.8], 12 months: +2.1 [0.4-3.8]). Similarly vs HCs, CT-positive subjects had statistically elevated pain intensity (aMD; 2 weeks: +12.5 [10.4-14.6], 3 months: +3.8 [1.7-5.9], 6 months: +2.8 [0.6-5.0], 12 months: +2.4 [0.2-4.6]) and interference (aMD; 2 weeks: +11.7 [9.9-13.5], 3 months: +4.0, [2.2-5.8], 6 months: +2.9 [1.1-4.7], and 12 months: +2.2 [0.3-4.0]). Pain intensity and daily interference symptoms remained longitudinally elevated in patients with mTBI. The majority did not receive follow-up care for TBI, underscoring opportunities for preventative and therapeutic interventions.

INTRODUCTION:There are insufficient data to guide the use of venous thromboembolism (VTE) chemical prophylaxis in traumatic brain injury (TBI) patients, leading to substantial variation in practices. We investigated the effectiveness of our institution's protocol-initiating enoxaparin 30 milligrams twice within 72 h of injury-in a cohort of severe TBI patients treated with external ventricular drains (EVD). METHODS:A retrospective cohort study of TBI patients from August 2019 to October 2023 was conducted. VTE was defined as pulmonary embolism (PE), lower extremity deep venous thrombosis (DVT), and/or upper extremity DVT. Logistic regression and time-to-event analyses were performed to identify risk factors for in-hospital VTE based on patient demographics, injury characteristics, and chemical prophylaxis data. RESULTS:We identified 129 TBI patients treated with EVDs. VTE occurred in 26 patients (20.2 %), consisting of isolated DVT in 16, isolated PE in 3, and both PE and DVT in 7. Overall mortality was 30 %, with no mortalities directly attributable to VTE. Obesity was associated with VTE (HR 3.4, 95 % CI 1.5-7.8, p = 0.009). Longer durations of EVD, mechanical ventilation, and intensive care unit (ICU) stays were associated with VTE (all p < 0.001). Other variables including extracranial injury and adherence to chemical prophylaxis were examined but did not reach statistical significance. CONCLUSIONS:Despite most patients receiving enoxaparin prophylaxis within 72 h of injury, VTE events were common in TBI patients treated with EVDs. Strategies including weight-based dosing and earlier initiation merit further consideration, though determining the neurological risks of increased dosing regimens remains a challenge.

Self-agency is being aware of oneself as the agent of one's thoughts and actions. Self-agency is necessary for successful interactions with the outside world (reality-monitoring). Prior research has shown that the medial superior prefrontal gyri (mPFC/SFG) may represent one neural correlate underlying self-agency judgments. However, the causal relationship remains unknown. Here, we applied high-frequency 10Hz repetitive transcranial magnetic stimulation (rTMS) to modulate the excitability of the mPFC/SFG site that we have previously shown to mediate self-agency. For the first time, we delineate causal neural mechanisms, revealing precisely how rTMS modulates SFG excitability and impacts directional neural information flow in the self-agency network by implementing innovative magnetoencephalography (MEG) phase-transfer entropy (PTE) metrics, measured from pre-to-post rTMS. We found that, compared to control rTMS, enhancing SFG excitability by rTMS induced significant increases in information flow between SFG and specific cingulate and paracentral regions in the self-agency network in delta-theta, alpha, and gamma bands, which predicted improved self-agency judgments. This is the first multimodal imaging study in which we implement MEG PTE metrics of 5D imaging of space, frequency and time, to provide cutting-edge analyses of the causal neural mechanisms of how rTMS enhances SFG excitability and improves neural information flow between distinct regions in the self-agency network to potentiate improved self-agency judgments. Our findings provide a novel perspective for investigating causal neural mechanisms underlying self-agency and create a path towards developing novel neuromodulation interventions to improve self-agency that will be particularly useful for patients with psychosis who exhibit severe impairments in self-agency.

INTRODUCTION:Patients with spine injuries are at risk of acute kidney injury (AKI) through several mechanisms. OBJECTIVE:This study aims to assess the rate of severe AKI in a nationally representative sample of patients with spine injuries and determine whether SCI is an independent risk factor. METHODS:We conducted a cohort study utilizing the National Trauma Databank (NTDB) Patients included were 18 years or older with cervical or thoracic spine injuries (spine fractures and/or spinal cord injury) based on International Classification of Disease (ICD) codes from 2017 to 2022. Patients with pre-existing renal impairment were excluded. Logistic regression was used to determine the association between demographic and injury variables with incident AKI. RESULTS:313,838 spinal injury patients were analyzed, of which 3,288 (1.05%) developed AKI. Patients with AKI were older (61 ± 19 vs. 55 ± 21 years, P < 0.001) and had more comorbidities. AKI was associated with higher Injury Severity Scores (23 ± 16 vs. 16 ± 12, P < 0.001) and increased blood product transfusions. After adjustment for confounders, SCI was independently associated with AKI (OR 1.41, 95% CI 1.28-1.55, P < 0.001). AKI patients experienced worse outcomes, including longer ICU stays, higher rates of withdrawal of care and unfavorable hospital dispositions (all P < 0.001). CONCLUSION:AKI is associated with morbidity and mortality in patients with spine injuries. Comorbidities and more severe injuries, including the presence of SCI, are associated with AKI. More work is warranted to understand mechanisms of AKI in these patients.