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Correlation Between Serum Homocysteine Levels and Outcome of Patients with Severe Traumatic Brain Injury
Accepted Manuscript Correlation between Serum Homocysteine Levels and Outcome of Patients with Severe Traumatic Brain Injury Asghar Rahmani, Masoud Hatefi, Somaye Bezadi, Masoud Moghadas Dastjerdi, Mahsa Zare, Asad Imani, Davood Shirazi PII:
S1878-8750(15)01179-1
DOI:
10.1016/j.wneu.2015.09.016
Reference:
WNEU 3202
To appear in:
World Neurosurgery
Received Date: 16 June 2015 Revised Date:
8 September 2015
Accepted Date: 8 September 2015
Please cite this article as: Rahmani A, Hatefi M, Bezadi S, Moghadas Dastjerdi M, Zare M, Imani A, Shirazi D, Correlation between Serum Homocysteine Levels and Outcome of Patients with Severe Traumatic Brain Injury, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.09.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Correlation between Serum Homocysteine Levels and Outcome of Patients with Severe Traumatic Brain Injury
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Running title: Plasma level of homocysteine in traumatic brain injury Rahmani Asghar1*, Hatefi Masoud 2, Bezadi Somaye3, Moghadas Dastjerdi Masoud4, Zare Mahsa5, Imani Asad6, Shirazi Davood7.
6. 7.
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Medical student , Student research committee, Ilam University of medical science, Ilam, Iran Department of neurosurgery, school of medicine, Ilam University of medical science, Ilam, Iran. Department of radiology, school of medicine, Ilam University of medical science, Ilam, Iran. Department of emergency medicine, school of medicine, Esfahan University of medical science, Iran Department of pharmacology, school of pharmacology, international Shiraz University of medical science, Shiraz, Iran. Department of nursing and midwifery, master in medical and surgical nursing education, Shahid Beheshti University of Medical Science, Tehran, Iran. General medicine, Student research committee, school of medicine, Ilam University of medical science, Ilam, Iran.
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1. 2. 3. 4. 5.
Abbreviations:
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Corresponding author: Dr. Asghar Rahmani Medical student, student research committee, Ilam University of medical science, Iran. Email: [email protected] Tel: +989010662205, fax: +988412223471
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CHF: Chronic Heart Failure CVP: Central Venous Pressure CNS: Central Nervous System DAI: Diffuse axonal injury ESRD: End Stage Renal Disease GCS: Glasgow coma scale GOS: Glasgow outcome scale HPLC: High Performance Liquid Chromatography Hyc: Homocysteine ICP: Intracranial Pressure ICU: Intensive Care Units ISS: Injury Severity Score MRI: Magnetic Resonance Imaging ROS: Reactive Oxygen Species TBI: Traumatic Brain Injury ROC: Receiver-Operator Characteristic
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Abstract
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Background: Effective clinical variables are required for determining the severity of trauma and prognosis in patients with Traumatic Brain Injury (TBI).The aim of the present study was to examine the relationship between homocysteine (Hcy) plasma levels and prognosis of TBI patients
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Materials and Methods: In a prospective case- control study, all demographic, clinical and Glasgow Coma Scale (GCS) data were collected. Prognosis was evaluated according to Glasgow Outcome Scale (GOS) at the time of discharge from hospital and 6 months after hospitalization. The levels of Hcy plasma were measured using the High Performance Liquid Chromatography (HPLC) tool. The Computed Tomography (CT) scan of the brain was performed in the first 24 hours of hospitalization.
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Results: In this study, 150 TBI patients as a case group (male, 54.7%, mean age, 55.90±12.31) and 150 healthy persons as a control group (male, 52%, mean of age, 49.56±15.64) were studied. The mean ± SD plasma Hyc level in TBI patients (20.91±15.56µmol/L) was significantly higher than that of the control group (7.45±13.54 µmol/L, P =0.000).There was a significant relationship between the Hyc plasma levels and GCS and CT findings classified by the Marshall score. (P =0.001 and P =0.028, respectively).Also, there was a significant difference in the mean Hcy plasma between dead and alive patients according to GOS (P=0.000 and P = 0.054, respectively).
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Conclusion: According to the results of this study, there was a significant correlation between the plasma Hcy levels and severity of trauma and prognosis in patients with TBI.
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Keywords: Traumatic Brain Injury, Homocysteine, Prognosis, CT scan, Glasgow Coma Scale, Outcome
ACCEPTED MANUSCRIPT Introduction Traumatic Brain Injury (TBI) is one of the problems in human health in a way that it is one of the main causes of mortality and morbidity of trauma (9, 20, 29). Exact determination of brain damage in the early stage of the event is a necessary factor to neurologic prognosis and doing appropriate treatment acts (23). At the present time, Glasgow Coma Scale (GCS) is the
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best scale to predict the severity of damage in TBI patients (30). So, predicting the outcomes of patients with TBI is confronting, because neurologic assessment in these patients is affected by an analgesics, sedatives and relaxants (15). On the other hand, radiologic studies such as Computed Tomography (CT) scan are considered as a limitation in the TBI patients
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and can miss Diffuse Axonal Injury (DAI) and increase Intracranial Pressure (ICP) in some patients(16). Also, CT scan has limitations in determining prognosis of patients and showing
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brain microscopic changes (2). In addition, these results even after treatment deeds and diagnose of TBI are high because of secondary cell damage and decreased Central Nervous System (CNS)(4, 17). Secondary damage after TBI is consisted of some processes such as oxidative stress, inflammatory damages and metabolite’s that can create vascular and structural damages in brain (10, 32). One of the related markers with stress oxidative is Homocysteine (Hcy), which can lead to lipid preoxidation and Reactive Oxygen Species
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(ROS) (6, 11). High levels of Hcy were reported with an increased risk of subclinical stroke, Alzheimer, dementia and other neuropsychotic disorders(23).Also,a higher level of Hyc is associated with Magnetic Resonance Imaging (MRI) findings such as brain atrophy, silent brain infracts and white matter hyper intensity (13, 18, 25, 26). Regarding to the above-
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mentioned issue, the Hcy level can change in patients with TBI. Since there is no specific study to assess the Hcy level in patients with TBI, the present study aimed to examine the
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relationship between this marker and clinical trend and prognosis of such patients. Therefore, the objectives of our study were to examine the relationship between the Hcy level and
outcome at discharge or 6months after discharge in TBI patients.
ACCEPTED MANUSCRIPT Materials and Methods Patients This prospective case- control study was conducted on 150 patients with TBI admitted to Imam Khomeini Hospital in Ilam City, west of Iran, from February 2014 to
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February2015.This medical center is a trauma and referral center in west of Iran that covers700 thousand patients. The present study was approved by the ethics committee of Ilam University of Medical Science, Ilam, Iran. A written informed consent was obtained from all the patients and patients' demographic data including gender, age, Body Mass Index
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(BMI) and medical history were collected. TBI was confirmed by the CT scan. All patients were under CT scan based on the protocol of Marshall and colleagues (15), and it were repeated based on
any clinical deterioration such as rapidly disturbed consciousness, acute focal
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neurologic deficit, seizure, status epilepticus .Patients with the age range of 20-70 years, GCS of eight or less on admission were entered into the study. Exclusion criteria included Injury Severity Score (ISS) more than 15, multiple trauma, pregnancy, consuming oral contraceptive or hormone therapy, bleeding disorders, endocrine disorders, anticoagulant treatment, alcoholism, drug abuse, and systematic diseases such as End Stage Renal Disease(ESRD),
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cirrhosis, Chronic Heart Failure (CHF), diabetes and age under 20. Patients were checked based on the guideline for the management of brain trauma including GCS, blood pressure, pulses, temperature, electrocardiogram, liquid equality and laboratory parameters. Also, ventricular drain replacement, monitoring of ICP, replacement of CVP catheter and surgical
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intervention were done for decompression of the mass. One hundred and fifty healthy adults (age range, 20-70 years) with no brain damages, none neurologic diseases or other medical Prognosis of TBI patients was divided
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problems were selected as the control group.
according to inter-hospital mortality, duration of hospitalization, and GOS after 6 months (5). In addition, to better analyze the data and compare the Hcy level in healthy people, 150 healthy subjects were selected during six months period as the control group.
Laboratory Measurements On admission, 5mL serum brachial vein was collected from all patients and were inserted in ice immediately. Samples were centrifuged for minutes at 4000 rpm, frozen and stored at 70°C until the time of analysis. Plasma concentrations of Hyc were measured using a
ACCEPTED MANUSCRIPT standard High Performance Liquid Chromatography (HPLC) with florometric evaluation. Normal concentration of total Hcy in adult people was considered 5-15 µmol/L (median10 µmol/l). Also, in the present study, hyper-Hcy was considered higher than total Hcy (15 µmol/L) (12).
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Statistical Analysis Data were expressed as Mean ± SD for quantitative variables and frequencies for qualitative variables. The normality of data was assessed using the Kolmogorov-Smirnov test. The Student’s t-test and chi-square test were also used to analyze the data. Correlations between
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the changes in the Hcy plasma level and classification of Marshall and outcome were analyzed according to the patients' GCS. Also, the Receiver-Operator Characteristic (ROC )analysis of hyper-Hcy was assessed for in-hospital outcome and 6 months after discharge. A
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P value less than 0.05 was considered statistically significant for all variables. Statistical analysis was performed by SPSS software version 19 (SPSS Inc, Chicago, USA).
Results
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Table 1
Table 1shows the demographic and clinical characteristics of studied people. Data of 150 patients with TBI were studied. Eighty-two cases (54.7%) were males and 68cases (45.3%)
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were females. In the control group, 78 cases were males (52%) and 72 cases (48%) were females. There was no significant difference in gender between the treatment and control groups (P= 0.545). The mean age of TBI patients was 55.90±12.31 years and for the control
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group was 49.56±15.46 years that there was no significant difference in the mean age between the two groups (P =0.657). Body Mass Index (BMI) in the treatment group was 23.54±12.67 kg/m2 and in the control group 24.23±21.65 kg/m2 (P =0.342).Mean blood pressure in the treatment group (110.12±25.43 mmHg) was lower than that of the control group (145.44±37.65 mmHg), which showed no significant difference (P =0.076).The mean GCS in TBI patients was 5(range 2-8). The most frequent mechanism of trauma was related to motor vehicle accidents with 49 cases (32.7%), followed by falling down with 39 cases (26%). Also, motorcycle accidents with 18 cases (12%), gun shot with 12 cases (8%), and assault with 18 cases (12%) were the other frequent mechanisms of trauma respectively. Fourteen cases (9.3%) had mechanisms other than the above-mentioned factors. In Marshall
ACCEPTED MANUSCRIPT scoring system, it was determined that the frequency rate of diffuse I was in 25 cases (16.7%), diffuse II in 31 cases (20.7%) and diffuse III in 10 cases (6.7%) and diffuse IV in 14 cases (9.3%). Moreover, evacuated focal mass lesion type V was in 11 cases (7.3%) and focal mass lesion VI was found in 59 cases (39.3%). The mean hospitalization period in TBI patients was 12.04±6.71 days and the mean Intensive Care Unit (ICU) staywas4.55±1.88
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days. The results of in-hospital outcome in TBI patients showed that among 150 cases, 103cases were alive (68.7%) and only 47 cases were died (31.3%). Also, results showed that among 103 cases, 75 cases (72.81%) were alive and 28 cases (18.5%) were died6 months after discharge. Moreover, the results indicated that the Hcy plasma level in the treatment
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group (20.91±15.65 µmol/L) was higher than that of the control group (7.45±13.54 µmol/L)(P=0.001).
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Figure 1:
This figure shows that in the patients with focal injury, the mean ± SD level of Hcy was22.28±16.08 µmol/Land in patients with evacuated focal injury was24.45±22.74 µmol/L. Among patients with diffuse injury, cases in classes III and IV had high Hcy levels of29.32±12.93and 25.70±13.42 µmol/L, respectively. Also, the mean ± SD of Hcy in patients
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with classes I and II were 19.93±15.22and15.04±6.45 µmol/L, respectively. There was a meaningful correlation between changes in the Hcy levels and classification of Marshall (P = 0.028).
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Figure 2:
As shown in figure 2, with increasing the classification of Marshall, the level of Hcy was significantly increased. It is a linear relationship that creates an incremental slope from class I
injury
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toward class IV. Figure 2 shows that the highest level of Hcy was seen in patients with focal
Figure 3
Figure 3 shows the relationship between the mean Hcy plasma level and type of in-hospital prognosis among TBI patients based on their GCS score. As it can be seen in the figure, among patients that their in-hospital prognosis was death, with decreasing GCS of the patient, the mean Hcy plasma level was increased in a way that in patients with prognosis of death that their GCS was lower than 4, the mean Hcy level was more than those that their GCS score was more than 4. Also, the rate of Hcy in TBI patients that their in-hospital prognosis
ACCEPTED MANUSCRIPT was alive was less than those with death prognosis. However, as shown in this figure, the rate of Hcy in patients with death prognosis and lower GCS score was higher than that in patients with higher GCS score; in total, the Hcy concentration in deceased cases was higher than that of the alive patients.
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Figure 4 Figure 4studied the relationship between the mean plasma Hcy level and6- month outcomes based on their GCS scores. As it was seen in the figure, among patients that their prognosis at 6 months after discharge was death, with decreasing GCS of patients, the mean plasma level
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was increased in a way that in patients with the prognosis of death that their GCS was lower than 4, the mean Hcy was more than that in those patients that their GCS score was more than 4. Also, the rate of Hcy in TBI patients that their in-hospital prognosis was alive was less
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than those patients with death prognosis. In other words, regarding to this figure, the rate of Hcy in patients with death prognosis and lower GCS score was higher than those with higher GCS score. In total, the rate of Hcy in the deceased patients was higher than that in the alive patients. Figure 5
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This figure shows the relationship between the mean Hcy plasma level and their GCS scores; the mean plasma level in patients that their GCS scores were less than 4 their Hcy level was more than those patients that have GCS score higher than 4. In other words, there was a linear
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relationship between the Hcy rate and GCS score, which it was shown in figure 4 clearly. Figure 6 and Table 2:
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Table 2 studied the rates under diagram to determine the sensitivity and specificity values of Hcy in determining in-hospital prognosis and 6-month outcome in the TBI patients. As shown in table 2, the Hcy level under the table for in-hospital prognosis was higher than that in the 6-month outcome. The rate of ROC was 0.740 (CI%95: 0.648-0.832) for in-hospital outcome and 0.546 (CI%95:0.417-0.675) for6-month outcome. This result showed that the index of hyper-Hcy had a higher sensitivity to determine the results of in-hospital outcome compared to 6-month outcome. This result showed in figure 6.
ACCEPTED MANUSCRIPT Discussion The aim of the present study was to assess the correlation between the plasma Hcy level and clinical outcomes of patients with TBI. Different studies have reported the relationship between some biomarkers and the prognosis of patients with TBI (3).Biological or pathological markers are unique markers which in cerebrospinal fluid or blood samples are
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measured. Specifically, biomarkers show the possibility of brain injury caused by disintegrates of brain tissue or neurocellular damages. Furthermore, increased levels of biomarkers are associated with early changes of path physiologic resulting from TBI. There is a relationship between these changes and disease conditions. Determining the clinical
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application of biomarkers in patients with TBI faced some challenges. many studies have been conducted about effect of Hyc on the CNS diseases (11). The aim of this study was to
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measure the levels of Hcy and assess the relationship between the Hcy plasma level and clinical characteristics and prognosis of the TBI patients. Most patients with TBI have motor vehicle accidents and falling down and also according to Marshall Classification, have diffuse and focal injury of type I, and II. The results of the present study show that patients with TBI had the higher levels of Hcy compared to the control group. According to the results of this study, although changes in Hcy levels were irregular, these changes in patients
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with diffuse injury were higher than those with focal injury. Furthermore, as it was shown in table 3, there was a significant correlation between the Hcy level changes were have a relationship with and severity of diffuse injury in Marshall Classification. Results of the present study showed that there was a significant relationship between the Hcy levels and in-
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hospital prognosis in TBI patients according to GCS. In patients with death prognosis, the Hcy levels were significantly increased by decreasing GCS. Also, the level of Hcy in TBI
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patients with death prognosis in hospital was higher than patients with alive prognosis. In this study, In addition, to better analyze the data and compare the Hcy level in healthy people, 150 healthy subjects were selected during six months period as the control group. Results showed that in patients with death prognosis after 6 months, the Hcy levels were increased by decreasing the GCS. In patients with alive prognosis after 6 months the mean Hcy plasma level was lower than that in patients with death prognosis. In total, according to these findings the mean Hcy plasma level in patients with death prognosis after 6 months and lower GCS was significantly higher than that in patients with alive prognosis. It can be concluded that there is a linear and direct relationship between Hcy levels and GCS score. This is the first study conducted to measure the levels of Hcy in TBI patients and determine the
ACCEPTED MANUSCRIPT relationship between the plasma Hcy level and prognosis of patients according to the Marshall Protocol and GCS score. So far, no similar study about this subject has been done yet. Our study is the first report on the relationship between the Hcy level and prognosis of patients with TBI and severity of trauma in these patients. Although this study shows that there is a relationship between the Hcy level changes and prognosis of patients with TBI, no
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information about the role of Hcy in pathologic trend in terms of cellular and molecular was exist. Moreover, in some studies the mechanisms of neurotoxicity of Hcy for CNS has been shown (25, 26, 13).For example, the neurotoxicity of Hcy is caused by glutaminergic receptors which are the receptors that cause ischemic Islands (7). Some neurons damage
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mechanisms caused by neurotoxicity of Hcy include: neuron apoptosis induction by caspase pathway (31), change of brain metabolism (33), decreased activity of Na+,K+ ATPase pump(27), increasing intracellular calcium(28), and most important of them is producing of
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reactive oxygen species (ROC) (21). It seems that neuron damage mechanism primary resulting from increasing in the level of Hcy related to stress oxidative after production of ROC that is increased (21). Laboratory studies showed that hypertrophy of vascular and thrombosis created by deregulation of Redox and stress oxidative can result in increasing of the Hcy levels (16). Homocysteine is a cause of change in structure and function of brain
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vascular with nitric oxide (21). Some MRI findings in some studies show that a high level of Hcy can be associated with microcephaly and silent infarcts (28). Although there is a relationship between the level of Hcy and changes in CNS, in these changes the cellular and molecular role of Hcy was not determined clearly. At the present time, the assess mentis
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performed with neurological and radiological tools, but these instruments because of heterogeneity in brain injuries and concomitant injury response are not effective. As
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mentioned in the introduction, the assessments of neurological and brain neuroimaging studies in TBI patients are limited and can miss many pathological processes (20). Biomarkers could explicit diagnostic criteria for TBI and as a suitable complement to clinical and imaging evaluation. This biomarker can be a rapid diagnostic test, noninvasive and costeffective for brain injury and could be an appropriate guide for medical triage and management of trauma patients and provide a careful approach to treatment (19). Previous studies have reported an association between Hcy and pathological processes associated with diseases of the CNS (13, 26, 27). Therefore, we conducted a study to investigate the association between Hcy and prognosis of TBI patients. In this study, we obtained blood samples from the patients on admission to measure the Hcy level. It can be said that one of the limitations of our study was not to measure Hcy in series and in different time intervals
ACCEPTED MANUSCRIPT from admission to hospital. There is limited information on this issue and future studies are recommended to measure the Hcy level in a series and each of these measurements to assess the prognosis of patients. Biomarkers can be used as effective tools for determining the prognosis in patients with TBI. More studies are required to perform in this issue. Furthermore, biomarkers can be used in the management of TBI patients and also to make the
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best clinical decision. These biomarkers must have some criteria as a tool; these criteria include basic characteristics, sensitivity, specificity and clinical value. In total, this study concluded that there is a meaningful relationship between the level of Hcy and prognosis of patients with TBI. In this study, the level of Hcy in series trend was not measured, and this is
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one of the limitations of this study. Also, this study was performed as a prospective approach and the basic level of Hcy in studied patients did not exist. We suggest that future studies be
and using the cohort approach. Conflict of Interests
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performed based on the following features: larger sample sizes, serial measurement of Hcy,
The authors do not have any actual or potential conflict of interests in this study. Acknowledgments
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We would like to thank the school of medicine, Ilam University of Medical Sciences, participants, coordinators and data reviewers who assisted us to conduct this study.
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Funding/Support
This study was supported by school of medicine, Ilam University of Medical Sciences.
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Authors’ Contributions
Rahmani Asghar and Hatefi Masoud contributed to data analysis, interpretation of the results and drafted the manuscript. Rahmani Asghar participated in manuscript preparation. Rahmani Asghar and Imani Asad and Shirazi Davood participated in data collection. Hatefi Masoud contributed to the design of the study and Zare Mahsa participated in the laboratory work and manuscript preparation. All author s have read and approved the article for publication. Hafezi Ahamdi Mohammad Reza and Bezadi Somaye participated in revise of manuscript
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ACCEPTED MANUSCRIPT 78(52) 72(48) 49.56±15.64 24.23±21.65 145.44±37.65
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0.657 0.342 0.076
0.000
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0.545
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Sex, n (%) Male 82(54.7) Female 68(45.3) Age(y) 55.90±12.31 2 BMI( kg/m ) 23.45±12.67 BP(mmHg) 110.12±25.43 Injury mechanism Motor Vehicle Accident 49(32.7) Motor Cycle Accident 18(12.0) Gun Shot Wound 12(8.0) Fall 39(26.0) Assault 18(12.0) Other 14(9.3) GCS, median (range) 5(2-8) Marshall score, n (%) Diffuse I 25(16.7) Diffuse II 31(20.7) Diffuse III 10(6.7) Diffuse IV 14(9.3) Evacuated focal mass lesion V11(7.3) Focal mass lesion VI 59(39.3) Day in hospitalization 12.04±6.71 Day in intensive care units 4.55±1.88 Outcome In hospital, n (%) Deceased (GOS 1) 47(31.3) Live (GOS 2-5) 103(68.7) Outcome In 6 months, n (%) Deceased (GOS 1) 28(18.5) Live (GOS 2-5) 75(72.81) Homocysteine (µmol/l) 20.91±15.65
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7.45±13.54
0.001
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Table 1. Demographic and clinical characteristic of the TBI patients.
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Asymptotic 95% Confidence Interval Lower Bound Upper Bound
Asymptotic Sig.
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Table 2. Receiver-Operator Characteristic (ROC) Analysis hyper Hcy for two Outcomes.
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Figure 1.Relationship Between the Homocysteine Plasma Level and Marshall Score (diffuse injury or focal mass lesion.) in Patients with Traumatic Brain Injury. The Homocysteine Plasma Level in Patients With Diffuse Injury Was Higher Than Those With Focal Mass Lesion. Data Are Expressed as Mean ± SD, P = 0.001.
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Figure2: Relationship between Homocysteine Plasma Levels and Classification of Marshall Score in Patients with Traumatic Brain Injury. The Homocysteine Level Was Increased With Increase in the MarshallClassification.1= Diffuse I, 2= Diffuse II, 3=Diffuse III, 4=Diffuse IV, 5= Evacuated Focal V, 6= Focal VI. Data Are Expressed as Mean ± SD, P=0.028.
Deceased
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alive
In hospital outcome
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Figure 3.Relationship Between Homocysteine Plasma Levels and In-hospital Outcome in patients With Traumatic Brain Injury Based on Their Glasgow Coma Score. Level of Homocysteine in Patients with In-hospital Death Prognosis and Low Glasgow Coma Score Was Higher than Those with Alive Prognosis and High Glasgow Coma Score. Data Are Expressed as Mean ± SD, P=0.000.
Deceased
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6 Month outcome
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Figure 4.Relationship Between Homocysteine Plasma Levelsand6-month Outcome after Discharge in Patients with Traumatic Brain Injury based on Their Glasgow Coma Score. The Homocysteine level in Patients with 6-month Death Prognosis and Low Glasgow Coma Score Was Higher than that in Patients with Alive Prognosis and High Glasgow Coma Score. Data Are Expressed as Mean ± SD, P=0.048.
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Figure5. Relationship between Homocysteine Plasma Levels and Their Glasgow Coma Score in Patients with Traumatic Brain Injury. Data Are Expressed as Mean ± SD, P=0.001.
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Figure 6.Receiver-Operator Characteristic Curves Analysis of Hyper-Homocysteine for the Patients' Outcome. A) Receiver-Operator Characteristic of hyper-Homocysteine for Inhospital Outcome (alive vs. dead), B) Receiver-Operator Characteristic of hyperHomocysteine for 6-MonthOutcome (dead vs. alive).
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Table 2. Receiver-Operator Characteristic (ROC) Analysis hyper Hcy for two Outcomes. ROC
Asymptotic Sig. Asymptotic 95% Confidence Interval Lower Bound
In hospital outcome 6 month outcome
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78(52) 72(48) 49.56±15.64 24.23±21.65 145.44±37.65
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Sex, n (%) Male 82(54.7) Female 68(45.3) Age(y) 55.90±12.31 2 BMI( kg/m ) 23.45±12.67 BP(mmHg) 110.12±25.43 Injury mechanism Motor Vehicle Accident 49(32.7) Motor Cycle Accident 18(12.0) Gun Shot Wound 12(8.0) Fall 39(26.0) Assault 18(12.0) Other 14(9.3) GCS, median (range) 5(2-8) Marshall score, n (%) Diffuse I 25(16.7) Diffuse II 31(20.7) Diffuse III 10(6.7) Diffuse IV 14(9.3) Evacuated focal mass lesion V11(7.3) Focal mass lesion VI 59(39.3) Day in hospitalization 12.04±6.71 Day in intensive care units 4.55±1.88 Outcome In hospital, n (%) Deceased (GOS 1) 47(31.3) Live (GOS 2-5) 103(68.7) Outcome In 6 months, n (%) Deceased (GOS 1) 28(18.5) Live (GOS 2-5) 75(72.81) Homocysteine (µmol/l) 20.91±15.65
Control , n=150
P value 0.545
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Table 1. Demographic and clinical characteristic of the TBI patients.
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0.657 0.342 0.076
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Our study can be said that mean level of Hcy plasma in TBI patients significantly is higher than healthy subjects. Also we concluded that there is a linear and direct relationship between levels of Hcy and GCS score. Our study can be said that the mean level of Hcy plasma in TBI patients with death outcome in during of hospitalization and after 6 months and lower GCS significantly is higher than patients with alive outcome.
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CHF: Chronic Heart Failure CVP: Central Venous Pressure CNS: Central Nervous System DAI: Diffuse axonal injury ESRD: End Stage Renal Disease GCS: Glasgow coma scale GOS: Glasgow outcome scale HPLC: High Performance Liquid Chromatography Hyc: Homocysteine ICP: Intracranial Pressure ICU: Intensive Care Units ISS: Injury Severity Score MRI: Magnetic Resonance Imaging ROS: Reactive Oxygen Species TBI: Traumatic Brain Injury ROC: Receiver-Operator Characteristic
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Abbreviations
S1878-8750(15)01179-1
DOI:
10.1016/j.wneu.2015.09.016
Reference:
WNEU 3202
To appear in:
World Neurosurgery
Received Date: 16 June 2015 Revised Date:
8 September 2015
Accepted Date: 8 September 2015
Please cite this article as: Rahmani A, Hatefi M, Bezadi S, Moghadas Dastjerdi M, Zare M, Imani A, Shirazi D, Correlation between Serum Homocysteine Levels and Outcome of Patients with Severe Traumatic Brain Injury, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.09.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Correlation between Serum Homocysteine Levels and Outcome of Patients with Severe Traumatic Brain Injury
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Running title: Plasma level of homocysteine in traumatic brain injury Rahmani Asghar1*, Hatefi Masoud 2, Bezadi Somaye3, Moghadas Dastjerdi Masoud4, Zare Mahsa5, Imani Asad6, Shirazi Davood7.
6. 7.
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Medical student , Student research committee, Ilam University of medical science, Ilam, Iran Department of neurosurgery, school of medicine, Ilam University of medical science, Ilam, Iran. Department of radiology, school of medicine, Ilam University of medical science, Ilam, Iran. Department of emergency medicine, school of medicine, Esfahan University of medical science, Iran Department of pharmacology, school of pharmacology, international Shiraz University of medical science, Shiraz, Iran. Department of nursing and midwifery, master in medical and surgical nursing education, Shahid Beheshti University of Medical Science, Tehran, Iran. General medicine, Student research committee, school of medicine, Ilam University of medical science, Ilam, Iran.
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1. 2. 3. 4. 5.
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Corresponding author: Dr. Asghar Rahmani Medical student, student research committee, Ilam University of medical science, Iran. Email: [email protected] Tel: +989010662205, fax: +988412223471
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CHF: Chronic Heart Failure CVP: Central Venous Pressure CNS: Central Nervous System DAI: Diffuse axonal injury ESRD: End Stage Renal Disease GCS: Glasgow coma scale GOS: Glasgow outcome scale HPLC: High Performance Liquid Chromatography Hyc: Homocysteine ICP: Intracranial Pressure ICU: Intensive Care Units ISS: Injury Severity Score MRI: Magnetic Resonance Imaging ROS: Reactive Oxygen Species TBI: Traumatic Brain Injury ROC: Receiver-Operator Characteristic
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Abstract
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Background: Effective clinical variables are required for determining the severity of trauma and prognosis in patients with Traumatic Brain Injury (TBI).The aim of the present study was to examine the relationship between homocysteine (Hcy) plasma levels and prognosis of TBI patients
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Materials and Methods: In a prospective case- control study, all demographic, clinical and Glasgow Coma Scale (GCS) data were collected. Prognosis was evaluated according to Glasgow Outcome Scale (GOS) at the time of discharge from hospital and 6 months after hospitalization. The levels of Hcy plasma were measured using the High Performance Liquid Chromatography (HPLC) tool. The Computed Tomography (CT) scan of the brain was performed in the first 24 hours of hospitalization.
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Results: In this study, 150 TBI patients as a case group (male, 54.7%, mean age, 55.90±12.31) and 150 healthy persons as a control group (male, 52%, mean of age, 49.56±15.64) were studied. The mean ± SD plasma Hyc level in TBI patients (20.91±15.56µmol/L) was significantly higher than that of the control group (7.45±13.54 µmol/L, P =0.000).There was a significant relationship between the Hyc plasma levels and GCS and CT findings classified by the Marshall score. (P =0.001 and P =0.028, respectively).Also, there was a significant difference in the mean Hcy plasma between dead and alive patients according to GOS (P=0.000 and P = 0.054, respectively).
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Conclusion: According to the results of this study, there was a significant correlation between the plasma Hcy levels and severity of trauma and prognosis in patients with TBI.
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Keywords: Traumatic Brain Injury, Homocysteine, Prognosis, CT scan, Glasgow Coma Scale, Outcome
ACCEPTED MANUSCRIPT Introduction Traumatic Brain Injury (TBI) is one of the problems in human health in a way that it is one of the main causes of mortality and morbidity of trauma (9, 20, 29). Exact determination of brain damage in the early stage of the event is a necessary factor to neurologic prognosis and doing appropriate treatment acts (23). At the present time, Glasgow Coma Scale (GCS) is the
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best scale to predict the severity of damage in TBI patients (30). So, predicting the outcomes of patients with TBI is confronting, because neurologic assessment in these patients is affected by an analgesics, sedatives and relaxants (15). On the other hand, radiologic studies such as Computed Tomography (CT) scan are considered as a limitation in the TBI patients
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and can miss Diffuse Axonal Injury (DAI) and increase Intracranial Pressure (ICP) in some patients(16). Also, CT scan has limitations in determining prognosis of patients and showing
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brain microscopic changes (2). In addition, these results even after treatment deeds and diagnose of TBI are high because of secondary cell damage and decreased Central Nervous System (CNS)(4, 17). Secondary damage after TBI is consisted of some processes such as oxidative stress, inflammatory damages and metabolite’s that can create vascular and structural damages in brain (10, 32). One of the related markers with stress oxidative is Homocysteine (Hcy), which can lead to lipid preoxidation and Reactive Oxygen Species
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(ROS) (6, 11). High levels of Hcy were reported with an increased risk of subclinical stroke, Alzheimer, dementia and other neuropsychotic disorders(23).Also,a higher level of Hyc is associated with Magnetic Resonance Imaging (MRI) findings such as brain atrophy, silent brain infracts and white matter hyper intensity (13, 18, 25, 26). Regarding to the above-
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mentioned issue, the Hcy level can change in patients with TBI. Since there is no specific study to assess the Hcy level in patients with TBI, the present study aimed to examine the
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relationship between this marker and clinical trend and prognosis of such patients. Therefore, the objectives of our study were to examine the relationship between the Hcy level and
outcome at discharge or 6months after discharge in TBI patients.
ACCEPTED MANUSCRIPT Materials and Methods Patients This prospective case- control study was conducted on 150 patients with TBI admitted to Imam Khomeini Hospital in Ilam City, west of Iran, from February 2014 to
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February2015.This medical center is a trauma and referral center in west of Iran that covers700 thousand patients. The present study was approved by the ethics committee of Ilam University of Medical Science, Ilam, Iran. A written informed consent was obtained from all the patients and patients' demographic data including gender, age, Body Mass Index
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(BMI) and medical history were collected. TBI was confirmed by the CT scan. All patients were under CT scan based on the protocol of Marshall and colleagues (15), and it were repeated based on
any clinical deterioration such as rapidly disturbed consciousness, acute focal
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neurologic deficit, seizure, status epilepticus .Patients with the age range of 20-70 years, GCS of eight or less on admission were entered into the study. Exclusion criteria included Injury Severity Score (ISS) more than 15, multiple trauma, pregnancy, consuming oral contraceptive or hormone therapy, bleeding disorders, endocrine disorders, anticoagulant treatment, alcoholism, drug abuse, and systematic diseases such as End Stage Renal Disease(ESRD),
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cirrhosis, Chronic Heart Failure (CHF), diabetes and age under 20. Patients were checked based on the guideline for the management of brain trauma including GCS, blood pressure, pulses, temperature, electrocardiogram, liquid equality and laboratory parameters. Also, ventricular drain replacement, monitoring of ICP, replacement of CVP catheter and surgical
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intervention were done for decompression of the mass. One hundred and fifty healthy adults (age range, 20-70 years) with no brain damages, none neurologic diseases or other medical Prognosis of TBI patients was divided
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problems were selected as the control group.
according to inter-hospital mortality, duration of hospitalization, and GOS after 6 months (5). In addition, to better analyze the data and compare the Hcy level in healthy people, 150 healthy subjects were selected during six months period as the control group.
Laboratory Measurements On admission, 5mL serum brachial vein was collected from all patients and were inserted in ice immediately. Samples were centrifuged for minutes at 4000 rpm, frozen and stored at 70°C until the time of analysis. Plasma concentrations of Hyc were measured using a
ACCEPTED MANUSCRIPT standard High Performance Liquid Chromatography (HPLC) with florometric evaluation. Normal concentration of total Hcy in adult people was considered 5-15 µmol/L (median10 µmol/l). Also, in the present study, hyper-Hcy was considered higher than total Hcy (15 µmol/L) (12).
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Statistical Analysis Data were expressed as Mean ± SD for quantitative variables and frequencies for qualitative variables. The normality of data was assessed using the Kolmogorov-Smirnov test. The Student’s t-test and chi-square test were also used to analyze the data. Correlations between
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the changes in the Hcy plasma level and classification of Marshall and outcome were analyzed according to the patients' GCS. Also, the Receiver-Operator Characteristic (ROC )analysis of hyper-Hcy was assessed for in-hospital outcome and 6 months after discharge. A
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P value less than 0.05 was considered statistically significant for all variables. Statistical analysis was performed by SPSS software version 19 (SPSS Inc, Chicago, USA).
Results
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Table 1
Table 1shows the demographic and clinical characteristics of studied people. Data of 150 patients with TBI were studied. Eighty-two cases (54.7%) were males and 68cases (45.3%)
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were females. In the control group, 78 cases were males (52%) and 72 cases (48%) were females. There was no significant difference in gender between the treatment and control groups (P= 0.545). The mean age of TBI patients was 55.90±12.31 years and for the control
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group was 49.56±15.46 years that there was no significant difference in the mean age between the two groups (P =0.657). Body Mass Index (BMI) in the treatment group was 23.54±12.67 kg/m2 and in the control group 24.23±21.65 kg/m2 (P =0.342).Mean blood pressure in the treatment group (110.12±25.43 mmHg) was lower than that of the control group (145.44±37.65 mmHg), which showed no significant difference (P =0.076).The mean GCS in TBI patients was 5(range 2-8). The most frequent mechanism of trauma was related to motor vehicle accidents with 49 cases (32.7%), followed by falling down with 39 cases (26%). Also, motorcycle accidents with 18 cases (12%), gun shot with 12 cases (8%), and assault with 18 cases (12%) were the other frequent mechanisms of trauma respectively. Fourteen cases (9.3%) had mechanisms other than the above-mentioned factors. In Marshall
ACCEPTED MANUSCRIPT scoring system, it was determined that the frequency rate of diffuse I was in 25 cases (16.7%), diffuse II in 31 cases (20.7%) and diffuse III in 10 cases (6.7%) and diffuse IV in 14 cases (9.3%). Moreover, evacuated focal mass lesion type V was in 11 cases (7.3%) and focal mass lesion VI was found in 59 cases (39.3%). The mean hospitalization period in TBI patients was 12.04±6.71 days and the mean Intensive Care Unit (ICU) staywas4.55±1.88
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days. The results of in-hospital outcome in TBI patients showed that among 150 cases, 103cases were alive (68.7%) and only 47 cases were died (31.3%). Also, results showed that among 103 cases, 75 cases (72.81%) were alive and 28 cases (18.5%) were died6 months after discharge. Moreover, the results indicated that the Hcy plasma level in the treatment
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group (20.91±15.65 µmol/L) was higher than that of the control group (7.45±13.54 µmol/L)(P=0.001).
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Figure 1:
This figure shows that in the patients with focal injury, the mean ± SD level of Hcy was22.28±16.08 µmol/Land in patients with evacuated focal injury was24.45±22.74 µmol/L. Among patients with diffuse injury, cases in classes III and IV had high Hcy levels of29.32±12.93and 25.70±13.42 µmol/L, respectively. Also, the mean ± SD of Hcy in patients
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with classes I and II were 19.93±15.22and15.04±6.45 µmol/L, respectively. There was a meaningful correlation between changes in the Hcy levels and classification of Marshall (P = 0.028).
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Figure 2:
As shown in figure 2, with increasing the classification of Marshall, the level of Hcy was significantly increased. It is a linear relationship that creates an incremental slope from class I
injury
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toward class IV. Figure 2 shows that the highest level of Hcy was seen in patients with focal
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Figure 3 shows the relationship between the mean Hcy plasma level and type of in-hospital prognosis among TBI patients based on their GCS score. As it can be seen in the figure, among patients that their in-hospital prognosis was death, with decreasing GCS of the patient, the mean Hcy plasma level was increased in a way that in patients with prognosis of death that their GCS was lower than 4, the mean Hcy level was more than those that their GCS score was more than 4. Also, the rate of Hcy in TBI patients that their in-hospital prognosis
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Figure 4 Figure 4studied the relationship between the mean plasma Hcy level and6- month outcomes based on their GCS scores. As it was seen in the figure, among patients that their prognosis at 6 months after discharge was death, with decreasing GCS of patients, the mean plasma level
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was increased in a way that in patients with the prognosis of death that their GCS was lower than 4, the mean Hcy was more than that in those patients that their GCS score was more than 4. Also, the rate of Hcy in TBI patients that their in-hospital prognosis was alive was less
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than those patients with death prognosis. In other words, regarding to this figure, the rate of Hcy in patients with death prognosis and lower GCS score was higher than those with higher GCS score. In total, the rate of Hcy in the deceased patients was higher than that in the alive patients. Figure 5
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This figure shows the relationship between the mean Hcy plasma level and their GCS scores; the mean plasma level in patients that their GCS scores were less than 4 their Hcy level was more than those patients that have GCS score higher than 4. In other words, there was a linear
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relationship between the Hcy rate and GCS score, which it was shown in figure 4 clearly. Figure 6 and Table 2:
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Table 2 studied the rates under diagram to determine the sensitivity and specificity values of Hcy in determining in-hospital prognosis and 6-month outcome in the TBI patients. As shown in table 2, the Hcy level under the table for in-hospital prognosis was higher than that in the 6-month outcome. The rate of ROC was 0.740 (CI%95: 0.648-0.832) for in-hospital outcome and 0.546 (CI%95:0.417-0.675) for6-month outcome. This result showed that the index of hyper-Hcy had a higher sensitivity to determine the results of in-hospital outcome compared to 6-month outcome. This result showed in figure 6.
ACCEPTED MANUSCRIPT Discussion The aim of the present study was to assess the correlation between the plasma Hcy level and clinical outcomes of patients with TBI. Different studies have reported the relationship between some biomarkers and the prognosis of patients with TBI (3).Biological or pathological markers are unique markers which in cerebrospinal fluid or blood samples are
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measured. Specifically, biomarkers show the possibility of brain injury caused by disintegrates of brain tissue or neurocellular damages. Furthermore, increased levels of biomarkers are associated with early changes of path physiologic resulting from TBI. There is a relationship between these changes and disease conditions. Determining the clinical
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application of biomarkers in patients with TBI faced some challenges. many studies have been conducted about effect of Hyc on the CNS diseases (11). The aim of this study was to
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measure the levels of Hcy and assess the relationship between the Hcy plasma level and clinical characteristics and prognosis of the TBI patients. Most patients with TBI have motor vehicle accidents and falling down and also according to Marshall Classification, have diffuse and focal injury of type I, and II. The results of the present study show that patients with TBI had the higher levels of Hcy compared to the control group. According to the results of this study, although changes in Hcy levels were irregular, these changes in patients
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with diffuse injury were higher than those with focal injury. Furthermore, as it was shown in table 3, there was a significant correlation between the Hcy level changes were have a relationship with and severity of diffuse injury in Marshall Classification. Results of the present study showed that there was a significant relationship between the Hcy levels and in-
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hospital prognosis in TBI patients according to GCS. In patients with death prognosis, the Hcy levels were significantly increased by decreasing GCS. Also, the level of Hcy in TBI
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patients with death prognosis in hospital was higher than patients with alive prognosis. In this study, In addition, to better analyze the data and compare the Hcy level in healthy people, 150 healthy subjects were selected during six months period as the control group. Results showed that in patients with death prognosis after 6 months, the Hcy levels were increased by decreasing the GCS. In patients with alive prognosis after 6 months the mean Hcy plasma level was lower than that in patients with death prognosis. In total, according to these findings the mean Hcy plasma level in patients with death prognosis after 6 months and lower GCS was significantly higher than that in patients with alive prognosis. It can be concluded that there is a linear and direct relationship between Hcy levels and GCS score. This is the first study conducted to measure the levels of Hcy in TBI patients and determine the
ACCEPTED MANUSCRIPT relationship between the plasma Hcy level and prognosis of patients according to the Marshall Protocol and GCS score. So far, no similar study about this subject has been done yet. Our study is the first report on the relationship between the Hcy level and prognosis of patients with TBI and severity of trauma in these patients. Although this study shows that there is a relationship between the Hcy level changes and prognosis of patients with TBI, no
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information about the role of Hcy in pathologic trend in terms of cellular and molecular was exist. Moreover, in some studies the mechanisms of neurotoxicity of Hcy for CNS has been shown (25, 26, 13).For example, the neurotoxicity of Hcy is caused by glutaminergic receptors which are the receptors that cause ischemic Islands (7). Some neurons damage
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mechanisms caused by neurotoxicity of Hcy include: neuron apoptosis induction by caspase pathway (31), change of brain metabolism (33), decreased activity of Na+,K+ ATPase pump(27), increasing intracellular calcium(28), and most important of them is producing of
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reactive oxygen species (ROC) (21). It seems that neuron damage mechanism primary resulting from increasing in the level of Hcy related to stress oxidative after production of ROC that is increased (21). Laboratory studies showed that hypertrophy of vascular and thrombosis created by deregulation of Redox and stress oxidative can result in increasing of the Hcy levels (16). Homocysteine is a cause of change in structure and function of brain
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vascular with nitric oxide (21). Some MRI findings in some studies show that a high level of Hcy can be associated with microcephaly and silent infarcts (28). Although there is a relationship between the level of Hcy and changes in CNS, in these changes the cellular and molecular role of Hcy was not determined clearly. At the present time, the assess mentis
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performed with neurological and radiological tools, but these instruments because of heterogeneity in brain injuries and concomitant injury response are not effective. As
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mentioned in the introduction, the assessments of neurological and brain neuroimaging studies in TBI patients are limited and can miss many pathological processes (20). Biomarkers could explicit diagnostic criteria for TBI and as a suitable complement to clinical and imaging evaluation. This biomarker can be a rapid diagnostic test, noninvasive and costeffective for brain injury and could be an appropriate guide for medical triage and management of trauma patients and provide a careful approach to treatment (19). Previous studies have reported an association between Hcy and pathological processes associated with diseases of the CNS (13, 26, 27). Therefore, we conducted a study to investigate the association between Hcy and prognosis of TBI patients. In this study, we obtained blood samples from the patients on admission to measure the Hcy level. It can be said that one of the limitations of our study was not to measure Hcy in series and in different time intervals
ACCEPTED MANUSCRIPT from admission to hospital. There is limited information on this issue and future studies are recommended to measure the Hcy level in a series and each of these measurements to assess the prognosis of patients. Biomarkers can be used as effective tools for determining the prognosis in patients with TBI. More studies are required to perform in this issue. Furthermore, biomarkers can be used in the management of TBI patients and also to make the
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best clinical decision. These biomarkers must have some criteria as a tool; these criteria include basic characteristics, sensitivity, specificity and clinical value. In total, this study concluded that there is a meaningful relationship between the level of Hcy and prognosis of patients with TBI. In this study, the level of Hcy in series trend was not measured, and this is
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one of the limitations of this study. Also, this study was performed as a prospective approach and the basic level of Hcy in studied patients did not exist. We suggest that future studies be
and using the cohort approach. Conflict of Interests
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performed based on the following features: larger sample sizes, serial measurement of Hcy,
The authors do not have any actual or potential conflict of interests in this study. Acknowledgments
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We would like to thank the school of medicine, Ilam University of Medical Sciences, participants, coordinators and data reviewers who assisted us to conduct this study.
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Funding/Support
This study was supported by school of medicine, Ilam University of Medical Sciences.
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Authors’ Contributions
Rahmani Asghar and Hatefi Masoud contributed to data analysis, interpretation of the results and drafted the manuscript. Rahmani Asghar participated in manuscript preparation. Rahmani Asghar and Imani Asad and Shirazi Davood participated in data collection. Hatefi Masoud contributed to the design of the study and Zare Mahsa participated in the laboratory work and manuscript preparation. All author s have read and approved the article for publication. Hafezi Ahamdi Mohammad Reza and Bezadi Somaye participated in revise of manuscript
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ACCEPTED MANUSCRIPT 14. Lehotsky J, Petras M, Kovalska M, Tothova B, Drgova A, Kaplan P . Mechanisms Involved in the Ischemic Tolerance in Brain: Effect of the Homocysteine. Cell Mol Neurobiol (2015) 35:7–15. 15. Marshall LF, Marshall SB, Klauber MR, Van Berkum Clark M, Eisenber HM, Jane JA, Luersse TJ, Marmarou A, Foulkes Ma: A new classification of head injury based on computerized tomography. J Neurosurg 1991, 75:14-20.
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Control , n=150
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Sex, n (%) Male 82(54.7) Female 68(45.3) Age(y) 55.90±12.31 2 BMI( kg/m ) 23.45±12.67 BP(mmHg) 110.12±25.43 Injury mechanism Motor Vehicle Accident 49(32.7) Motor Cycle Accident 18(12.0) Gun Shot Wound 12(8.0) Fall 39(26.0) Assault 18(12.0) Other 14(9.3) GCS, median (range) 5(2-8) Marshall score, n (%) Diffuse I 25(16.7) Diffuse II 31(20.7) Diffuse III 10(6.7) Diffuse IV 14(9.3) Evacuated focal mass lesion V11(7.3) Focal mass lesion VI 59(39.3) Day in hospitalization 12.04±6.71 Day in intensive care units 4.55±1.88 Outcome In hospital, n (%) Deceased (GOS 1) 47(31.3) Live (GOS 2-5) 103(68.7) Outcome In 6 months, n (%) Deceased (GOS 1) 28(18.5) Live (GOS 2-5) 75(72.81) Homocysteine (µmol/l) 20.91±15.65
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Figure 1.Relationship Between the Homocysteine Plasma Level and Marshall Score (diffuse injury or focal mass lesion.) in Patients with Traumatic Brain Injury. The Homocysteine Plasma Level in Patients With Diffuse Injury Was Higher Than Those With Focal Mass Lesion. Data Are Expressed as Mean ± SD, P = 0.001.
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Figure2: Relationship between Homocysteine Plasma Levels and Classification of Marshall Score in Patients with Traumatic Brain Injury. The Homocysteine Level Was Increased With Increase in the MarshallClassification.1= Diffuse I, 2= Diffuse II, 3=Diffuse III, 4=Diffuse IV, 5= Evacuated Focal V, 6= Focal VI. Data Are Expressed as Mean ± SD, P=0.028.
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Figure 3.Relationship Between Homocysteine Plasma Levels and In-hospital Outcome in patients With Traumatic Brain Injury Based on Their Glasgow Coma Score. Level of Homocysteine in Patients with In-hospital Death Prognosis and Low Glasgow Coma Score Was Higher than Those with Alive Prognosis and High Glasgow Coma Score. Data Are Expressed as Mean ± SD, P=0.000.
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Figure 4.Relationship Between Homocysteine Plasma Levelsand6-month Outcome after Discharge in Patients with Traumatic Brain Injury based on Their Glasgow Coma Score. The Homocysteine level in Patients with 6-month Death Prognosis and Low Glasgow Coma Score Was Higher than that in Patients with Alive Prognosis and High Glasgow Coma Score. Data Are Expressed as Mean ± SD, P=0.048.
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Figure5. Relationship between Homocysteine Plasma Levels and Their Glasgow Coma Score in Patients with Traumatic Brain Injury. Data Are Expressed as Mean ± SD, P=0.001.
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Figure 6.Receiver-Operator Characteristic Curves Analysis of Hyper-Homocysteine for the Patients' Outcome. A) Receiver-Operator Characteristic of hyper-Homocysteine for Inhospital Outcome (alive vs. dead), B) Receiver-Operator Characteristic of hyperHomocysteine for 6-MonthOutcome (dead vs. alive).
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Table 2. Receiver-Operator Characteristic (ROC) Analysis hyper Hcy for two Outcomes. ROC
Asymptotic Sig. Asymptotic 95% Confidence Interval Lower Bound
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78(52) 72(48) 49.56±15.64 24.23±21.65 145.44±37.65
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Sex, n (%) Male 82(54.7) Female 68(45.3) Age(y) 55.90±12.31 2 BMI( kg/m ) 23.45±12.67 BP(mmHg) 110.12±25.43 Injury mechanism Motor Vehicle Accident 49(32.7) Motor Cycle Accident 18(12.0) Gun Shot Wound 12(8.0) Fall 39(26.0) Assault 18(12.0) Other 14(9.3) GCS, median (range) 5(2-8) Marshall score, n (%) Diffuse I 25(16.7) Diffuse II 31(20.7) Diffuse III 10(6.7) Diffuse IV 14(9.3) Evacuated focal mass lesion V11(7.3) Focal mass lesion VI 59(39.3) Day in hospitalization 12.04±6.71 Day in intensive care units 4.55±1.88 Outcome In hospital, n (%) Deceased (GOS 1) 47(31.3) Live (GOS 2-5) 103(68.7) Outcome In 6 months, n (%) Deceased (GOS 1) 28(18.5) Live (GOS 2-5) 75(72.81) Homocysteine (µmol/l) 20.91±15.65
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Our study can be said that mean level of Hcy plasma in TBI patients significantly is higher than healthy subjects. Also we concluded that there is a linear and direct relationship between levels of Hcy and GCS score. Our study can be said that the mean level of Hcy plasma in TBI patients with death outcome in during of hospitalization and after 6 months and lower GCS significantly is higher than patients with alive outcome.
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CHF: Chronic Heart Failure CVP: Central Venous Pressure CNS: Central Nervous System DAI: Diffuse axonal injury ESRD: End Stage Renal Disease GCS: Glasgow coma scale GOS: Glasgow outcome scale HPLC: High Performance Liquid Chromatography Hyc: Homocysteine ICP: Intracranial Pressure ICU: Intensive Care Units ISS: Injury Severity Score MRI: Magnetic Resonance Imaging ROS: Reactive Oxygen Species TBI: Traumatic Brain Injury ROC: Receiver-Operator Characteristic
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Abbreviations