Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients

The Relationship between age, injury severity, and MRI findings after traumatic brain injury

Age and injury severity are among the most significant predictors of outcome after traumatic brain injury (TBI). However, only a few studies have investigated the association between, age, injury severity, and the extent of brain damage in TBI. The purpose of this study was to investigate the association between age, measures of injury severity, and brain lesion volumes, as well as viable brain volumes, following TBI. Ninety-eight individuals with mild to very severe TBI (75.5% male, mean age at injury 34.5 years) underwent a structural MRI scan, performed with a 1.5-Tesla machine, on average 2.3 years post-injury. Lesion volumes were highly skewed in their distribution and were dichotomized for statistical purposes. Measures of injury severity were Glasgow Coma Scale score (GCS) and duration of post-traumatic amnesia (PTA). Logistic regression analyses predicting lesion volumes, controlling for participants' gender, cause of injury, time from injury to MRI scan, and total brain volume, revealed that both older age and longer PTA were associated with larger lesion volumes in both grey and white matter in almost all brain regions. Older age was also associated with smaller viable grey matter volumes in most neo-cortical brain regions, while longer PTA was associated with smaller viable white matter volumes in most brain regions. The results suggest that older age worsens the impact of TBI on the brain. They also indicate the validity of duration of PTA as a measure of injury severity that is not just related to one particular injury location.

Meta-analysis of a binary outcome using individual participant data and aggregate data

In this paper, we develop meta-analysis models that synthesize a binary outcome from health-care studies while accounting for participant-level covariates. In particular, we show how to synthesize the observed event-risk across studies while accounting for the within-study association between participant-level covariates and individual event probability. The models are adapted for situations where studies provide individual participant data (IPD), or a mixture of IPD and aggregate data. We show that the availability of IPD is crucial in at least some studies; this allows one to model potentially complex within-study associations and separate them from across-study associations, so as to account for potential ecological bias and study-level confounding. The models can produce pertinent population-level and individual-level results, such as the pooled event-risk and the covariate-specific event probability for an individual. Application is made to 14 studies of traumatic brain injury, where IPD are available for four studies and the six-month mortality risk is synthesized in relation to individual age. The results show that as individual age increases the probability of six-month mortality also increases; further, the models reveal clear evidence of ecological bias, with the mean age in each study additionally influencing an individual's mortality probability. Copyright © 2010 John Wiley & Sons, Ltd.

Ubiquitin C-terminal hydrolase is a novel biomarker in humans for severe traumatic brain injury

OBJECTIVE

Ubiquitin C-terminal hydrolase (UCH-L1), also called neuronal-specific protein gene product (PGP 9.3), is highly abundant in neurons. To assess the reliability of UCH-L1 as a potential biomarker for traumatic brain injury (TBI) this study compared cerebrospinal fluid (CSF) levels of UCH-L1 from adult patients with severe TBI to uninjured controls; and examined the relationship between levels with severity of injury, complications and functional outcome.

DESIGN

This study was designed as prospective case control study.

PATIENTS

This study enrolled 66 patients, 41 with severe TBI, defined by a Glasgow coma scale (GCS) score of < or =8, who underwent intraventricular intracranial pressure monitoring and 25 controls without TBI requiring CSF drainage for other medical reasons.

SETTING

: Two hospital system level I trauma centers.

MEASUREMENTS AND MAIN RESULTS

Ventricular CSF was sampled from each patient at 6, 12, 24, 48, 72, 96, 120, 144, and 168 hrs following TBI and analyzed for UCH-L1. Injury severity was assessed by the GCS score, Marshall Classification on computed tomography and a complicated postinjury course. Mortality was assessed at 6 wks and long-term outcome was assessed using the Glasgow outcome score 6 months after injury. TBI patients had significantly elevated CSF levels of UCH-L1 at each time point after injury compared to uninjured controls. Overall mean levels of UCH-L1 in TBI patients was 44.2 ng/mL (+/-7.9) compared with 2.7 ng/mL (+/-0.7) in controls (p <.001). There were significantly higher levels of UCH-L1 in patients with a lower GCS score at 24 hrs, in those with postinjury complications, in those with 6-wk mortality, and in those with a poor 6-month dichotomized Glasgow outcome score.

CONCLUSIONS

These data suggest that this novel biomarker has the potential to determine injury severity in TBI patients. Further studies are needed to validate these findings in a larger sample.

Prospective meta-analysis using individual patient data in intensive care medicine

Meta-analysis is a technique for combining evidence from multiple trials. However, meta-analyses of studies with substantial heterogeneity among patients within trials-common in intensive care-can lead to incorrect conclusions if performed using aggregate data. Use of individual patient data (IPD) can avoid this concern, increase the power of a meta-analysis, and is useful for exploring subgroup effects. Barriers exist to IPD meta-analysis, most of which are overcome if clinical trials are designed to prospectively facilitate the incorporation of their results with other trials. We review the features of prospective IPD meta-analysis and identify those of relevance to intensive care research. We identify three clinical questions, which are the subject of recent or planned randomised controlled trials where IPD MA offers advantages over approaches using aggregate data.

Age-dependent response of CCAAT/enhancer binding proteins following traumatic brain injury in mice

Exacerbated inflammatory responses have been reported following traumatic injury to the aged brain. The present study was designed to investigate the involvement of the transcription factors belonging to the CCAAT/enhancer binding protein (C/EBP) family that regulate expression of many of the pro-inflammatory genes which show increased expression following injury to the aged brain. Controlled cortical impact injury was induced in adult (5-6 months) and aged (22-24 months) C57/BL6 mice. C/EBP mRNA and protein expression were analyzed in injured cortex at 1, 3, and 7 days post-injury. Expression of C/EBPalpha was reduced relative to baseline at day 1 in both adult and aged mice, whereas, it increased at days 3 and 7 post-injury. No significant differences were observed between adult and aged brain. Upregulation of C/EBPbeta was observed 1 day following injury in both the adult and aged brain, but there were no major age-related differences in mRNA levels. However, there was higher C/EBPbeta protein in the aged brain. C/EBPdelta expression increased beginning 1 day post-injury in both adult and aged brain. In this case, the increase in C/EBPdelta expression was higher in the aged brain than in the adult at all time points studied. Expression of CCAAT/enhancer binding protein homologous protein (CHOP), a transcription factor involved in ER stress and protein unfolding responses, was also up-regulated in response to injury, but CHOP levels were significantly lower in the aged than the adult brain. Based on these results, we conclude that differential expression of C/EBP beta, delta and CHOP might contribute to the hyper-inflammatory response and poor prognosis following traumatic brain injury in the elderly patients. In addition elevated C/EBPdelta levels following TBI in the aged brain may play a role in the link between TBI and Alzheimer's disease.

Older people and major trauma

Major traumatic injury is a leading cause of death in younger age groups, but increasingly older people are affected also. Adverse outcomes, both physical and psychological, are associated with injury in the older population. This review aims to locate and describe the evidence relating to older people and major trauma in order to inform policy, practice, research and education. The published research and systematic reviews fall into three main topics: mechanism of traumatic injury in older people, the effects of co-morbidities on older trauma patients and outcomes following serious traumatic injury in older people. The psychological impact of traumatic injury and the resulting functional alteration cannot be underestimated in this group of patients.

The acute inflammatory response in trauma / hemorrhage and traumatic brain injury: current state and emerging prospects

Traumatic injury/hemorrhagic shock (T/HS) elicits an acute inflammatory response that may result in death. Inflammation describes a coordinated series of molecular, cellular, tissue, organ, and systemic responses that drive the pathology of various diseases including T/HS and traumatic brain injury (TBI). Inflammation is a finely tuned, dynamic, highly-regulated process that is not inherently detrimental, but rather required for immune surveillance, optimal post-injury tissue repair, and regeneration. The inflammatory response is driven by cytokines and chemokines and is partially propagated by damaged tissue-derived products (Damage-associated Molecular Patterns; DAMP's). DAMPs perpetuate inflammation through the release of pro-inflammatory cytokines, but may also inhibit anti-inflammatory cytokines. Various animal models of T/HS in mice, rats, pigs, dogs, and non-human primates have been utilized in an attempt to move from bench to bedside. Novel approaches, including those from the field of systems biology, may yield therapeutic breakthroughs in T/HS and TBI in the near future.

Predictors of in-hospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) is the single largest cause of death and disability following injury worldwide. While TBI in older adults is less common, it still contributes to significant morbidity and mortality in this group. Understanding the patient characteristics that result in good and poor outcome after TBI is important in the clinical management and prognosis of older adult TBI patients. This population-based study investigated predictors of mortality and longer term functional outcomes following serious TBI in older adults.

METHODS

All older adults (aged>64 years), isolated moderate to severe TBI cases from the population-based Victorian State Trauma Registry for the period July 2005 to June 2007 (inclusive) were extracted for analysis. Demographic, injury event, injury diagnosis, management and comorbid status information were obtained and the outcomes of interest were in-hospital mortality, and the Glasgow Outcome Scale-Extended (GOS-E) score at 6 months post-injury. Multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality and independent living (GOS-E>4) status at 6 months.

RESULTS

Of the 428 isolated, older adult TBI cases, the majority were the result of a fall (88%), male (55%), and aged>74 years (76%). The in-hospital death rate was 28% and increasing age (p=0.009), decreasing GCS (p<0.001) and injury type (p=0.002) were significant independent predictors of in-hospital mortality. Of the 310 patients who survived to discharge, 65% were successfully followed-up 6 months following injury. There was no difference between patients lost to follow-up and those successfully followed-up with respect to the key population indicators of age, gender, or head injury severity. Younger (<75 years) patients, and those with an SBP on arrival at hospital of 131-150mmHg, were at increased odds of living independently at follow-up. No patients with a GCS<9 had a good 6-month outcome, and most of them died. The survival rate for brainstem injury was also low (21%).

CONCLUSION

In this population-based study, we found that age, GCS, brainstem injury, and systolic blood pressure were the most important factors in predicting outcome in older adults with an isolated moderate to severe TBI.

Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure

OBJECT

Several approaches have been established for the treatment of intracranial hypertension; however, a considerable number of patients remain unresponsive to even aggressive therapeutic strategies. Lumbar CSF drainage has been contraindicated in the setting of increased intracranial pressure (ICP) because of possible cerebral herniation. The authors of this study investigated the efficacy and safety of controlled lumbar CSF drainage in patients suffering from intracranial hypertension following severe traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (SAH).

METHODS

The authors prospectively evaluated 100 patients-45 with TBI and 55 with SAH-having a mean age of 43.7 +/- 15.7 years (mean +/- SD) and suffering from refractory intracranial hypertension (ICP > 20 mm Hg). Intracranial pressure and cerebral perfusion pressure (CPP) before and after the initiation of lumbar CSF drainage as well as related complications were documented. Patient outcomes were assessed 6 months after injury.

RESULTS

The application of lumbar CSF drainage led to a significant reduction in ICP from 32.7 +/- 10.9 to 13.4 +/- 5.9 mm Hg (p < 0.05) and an increase in CPP from 70.6 +/- 18.2 to 86.2 +/- 15.4 mm Hg (p < 0.05). Cerebral herniation with a lethal outcome occurred in 6% of patients. Thirty-six patients had a favorable outcome, 12 were severely disabled, 7 remained in a persistent vegetative state, and 45 died.

CONCLUSIONS

Lumbar drainage of CSF led to a significant and clinically relevant reduction in ICP. The risk of cerebral herniation can be minimized by performing lumbar drainage only in cases with discernible basal cisterns.

Clinical and neuroimaging features of severely brain-injured patients treated in a neurosurgical unit compared with patients treated in peripheral non-neurosurgical hospitals

Most European TBI patients are managed in peripheral hospitals without benefit of guidelines for transfer of such patients to neurosurgical units as needed. This report compares clinical features and outcomes in two series of severe TBI patients: those admitted to a neurosurgical centre or to a general hospital, all in the Piedmont Region of Italy. Of 630 patients with a GCS of 3-8, 351 were admitted to a centralized neurosurgical unit, and 279 were admitted and treated at a peripheral hospital. All patients had a CT scan read by a neurosurgeon on duty and were classified using the Marshall criteria as having a diffuse injury or non-surgical mass lesions. Outcomes were assessed between 6 months and 6 years using either the GOS Extended or the GOS. Independent variables were age, sex, GCS score and Marshall classification. All the examined factors were significantly different between the two groups (p<0.001). For patients admitted to the neurosurgical centre, age, Marshall classification of the CT and GCS were predictors of a favourable outcome, while for patients treated in general hospitals, Marshall classification of the CT, gender and age were predictors of a favourable outcome. Patients admitted to neurosurgical centres are different from those treated in general hospitals not having these specialized facilities and personnel. The absence of guidelines for the transfer of these patients for more advanced care are lacking and should be the focus of new studies on patient referral.

Evaluation of models that predict short-term outcome after traumatic brain injury

PRIMARY OBJECTIVE

This study aimed to identify models that predicted the short-term outcome after traumatic brain injury (TBI) from the literature and to evaluate their clinical significance.

METHODS

Literatures from PubMED were reviewed. Regression coefficients and intercepts were extracted. A group of 229 cases was used for validation and the unfavourable rate was calculated to assess the validity of these models by the area under receiver operating. Characteristic curve (AUC), C-statistic and Brier score.

MAIN RESULTS

In total, 13 studies of 18 different models were included. Data from the validation group were in accordance with the indicators of the studies reviewed. All models got an AUC value ranging from 0.644-0.890 except two (AUC value <0.6) and their Brier scores were near zero. However, the calibration of most studies was insufficient (p < 0.05).

CONCLUSIONS

Most of the models included in this study have a good discriminatory power while lacking sufficient calibration. However, they all predict with relative accuracy at the level of individuals. Therefore, current models can be used to predict the survival rate of individual patients and may be useful to inform patients and relatives about the likelihood of a beneficial outcome.

Prediction of the level of cognitive functional independence in acute care following traumatic brain injury

PRIMARY OBJECTIVE

To determine a predictive model for cognitive functional outcome of patients with traumatic brain injury (TBI) at discharge from acute care.

METHODS AND PROCEDURE

Three hundred and thirty-five patients were included in this analysis. Variables considered were age, education, initial score on the Glasgow Coma Scale (GCS), duration of post-traumatic amnesia (PTA), cerebral imaging results and the need for neurosurgical intervention.

EXPERIMENTAL INTERVENTIONS

Functional Independence Measure (FIM).

MAIN OUTCOMES AND RESULTS

Results of this analysis indicated better cognitive FIM at discharge from acute care settings for patients with TBI when PTA was less than 24 hours, when level of education was higher, when no parietal lesion was identified, when no neurosurgical intervention was required, for patients with TBI who were younger and who presented with a higher GCS score upon admission.

CONCLUSIONS

This model will help to plan resource allocation for treatment and discharge planning within the first weeks following TBI.

The epidemiology of severe traumatic brain injury among persons 65 years of age and older in Oklahoma, 1992–2003

PRIMARY OBJECTIVE

To describe the epidemiology of traumatic brain injury (TBI) among persons 65 years of age and older in Oklahoma from 1992-2003.

RESEARCH DESIGN

Descriptive epidemiology of data collected through active statewide surveillance on TBI inpatient hospitalizations and fatalities.

METHODS AND PROCEDURES

Data collected from hospital medical records and the Office of the Chief Medical Examiner. TBI was defined by ICD-9-CM codes for skull fracture 800.0-801.9, 803.0-804.9, concussion or other intracranial injury 850.0-854.1 and head injury, unspecified 959.01; all cases included a description of TBI.

MAIN OUTCOME AND RESULTS

TBI rates increased 79% for the study population; however, case-fatality rates decreased from 32% in 1992 to 18% in 2003. The TBI rate increase was observed among all elderly age groups, both genders and all races. Unintentional injuries nearly doubled while both assault and self-inflicted injuries decreased. Fall-related TBI increased by 126%, while MVC-related TBI increased by 17%. Survivors were hospitalized for an average of 6.8 days and over half required post-acute care.

CONCLUSIONS

The increased TBI rate and decreased case-fatality rate among elderly persons means potentially more persons living with TBI disability. TBI prevention efforts among the elderly must be expanded, especially for fall-related TBI.

Management and outcome of patients with acute traumatic subdural hematomas and pre-injury oral anticoagulation therapy

BACKGROUND

Acute subdural hematomas (aSDHs) are found in up to one-third of patients with severe traumatic brain injury and are associated with an unfavorable outcome in the majority of cases. Mortality ranges between 40 and 60%, but was reported to be even higher in patients undergoing oral anticoagulation therapy (OAT) at the time of injury. The objective of this study is to specifically report on the peri-operative management and outcome of patients with aSDH and pre-injury OAT.

MATERIAL AND METHODS

From June 2002 to June 2006, all patients with OAT who underwent surgical treatment of aSDH were retrospectively analysed. Results of pre-operative blood tests, the peri-operative and surgical management and the clinical courses were assessed. Patient outcome is reported according to the Glasgow Outcome Scale (GOS) at 6 months.

RESULTS

Eleven (10.3%) out of 107 patients with aSDH were on OAT. Patients with OAT were significantly older than patients without OAT (72.4 +/- 9.3 versus 59.9 +/- 17.5 years; p<0.05, Mann-Whitney U-test). Intensity of head trauma was moderate in four and severe in seven patients with a median pre-operative Glasgow Coma Scale (GCS) of 8. Median pre-treatment prothrombin time and international normalized ratio were 23% (range: 10-65%) and 3.3 (range: 1.5-10.6), respectively. Replacement therapy consisted of administration of prothrombin complex concentrates, vitamin K and FFP (fresh frozen plasma). In four patients, antithrombin was additionally given to prevent disseminated intravascular coagulation. Surgical treatment consisted of craniotomy (n=10) or craniectomy (n=1) and hematoma evacuation with intracranial pressure probe placement. Low molecular weight heparin was administered as pharmacological prophylaxis of thrombembolic events in an increasing dose post-operatively. At 6 months, six out of 11 patients survived with a median GOS of 4. All-cause mortality was 45.5%. A pre-operative GCS of < or = 8 was not associated with an increased risk of mortality (p>0.5, Fisher's exact test). No relevant rebleedings or thrombembolic complications were observed. The mortality rate of patients who did not undergo OAT was 50%.

CONCLUSION

A large number of patients with aSDH are on pre-injury OAT. Specific replacement therapy facilitates successful clot evacuation without bleeding complications. The overall outcome of these patients does not seem to differ from historical cohorts with aSDH without OAT, but a large prospective multicenter study is warranted to answer that question.

Functional outcome is impaired following traumatic brain injury in aging Nogo-A/B-deficient mice

Increasing age is associated with a poor prognosis following traumatic brain injury (TBI). CNS axons may recover poorly following TBI due to expression of myelin-derived inhibitors to axonal outgrowth such as Nogo-A. To study the role of Nogo-A/B in the pathophysiological response of the elderly to TBI, 1-year-old mice deficient in Nogo-A/B (Nogo-A/B homozygous(-/-) mice), Nogo-A/B heterozygous(-/+) mice, and age-matched wild-type (WT) littermate controls were subjected to a controlled cortical impact (CCI) TBI. Sham-injured WT mice (7 months old) and 12 month old naïve Nogo-A/B(-/-) and Nogo-A/B(-/+) served as controls. Neurological motor function was evaluated up to 3 weeks, and cognitive function, hemispheric tissue loss, myelin staining and hippocampal beta-amyloid (A beta) immunohistochemistry were evaluated at 4 weeks post-injury. In WT littermates, TBI significantly impaired learning ability at 4 weeks and neurological motor function up to 2 weeks post-injury and caused a significant loss of hemispheric tissue. Following TBI, Nogo-A/B(-/-) mice showed significantly less recovery from neurological motor and cognitive deficits compared to brain-injured WT mice. Naïve Nogo-A/B(-/-) and Nogo-A/B(-/+) mice quickly learned the MWM task in contrast to brain-injured Nogo-A/B(-/-) mice who failed to learn the MWM task at 4 weeks post-injury. Hemispheric tissue loss and cortical lesion volume were similar among the brain-injured genotypes. Neither TBI nor the absence of NogoA/B caused an increased A beta expression. Myelin staining showed a reduced area and density in the corpus callosum in brain-injured Nogo-A/B(-/-) animals compared to their littermate controls. These novel and unexpected behavioral results demonstrate that the absence of Nogo-A/B may negatively influence outcome, possibly related to hypomyelination, following TBI in mice and suggest a complex role for this myelin-associated axonal growth inhibitor following TBI.

Can we improve neurological outcomes in severe traumatic brain injury? Something old (early prophylactic hypothermia) and something new (erythropoietin)

Traumatic brain injury is a leading cause of mortality and long-term morbidity, particularly affecting young people. With our best therapies, one half of the patients with severe traumatic brain injury are never capable of living independently. Two interventions, which have real potential to improve neurological outcomes in patients with traumatic brain injury, are (i) very early induction of prophylactic hypothermia and (ii) exogenous erythropoietin therapy. There is substantial experimental evidence, a plausible biological rationale, and supportive clinical evidence from clinical trials to suggest a possible beneficial effect of prophylactic hypothermia and also for exogenous erythropoietin therapy in severe traumatic brain injury. Despite the recent guidelines and publications recommending these interventions, critical care clinicians should be conservative towards implementing these therapies outside clinical trials due to substantial efficacy and safety concerns. Nevertheless the high morbidity and mortality associated with severe traumatic brain injury (TBI) demands that we investigate the safety and efficacy of these promising potential therapies as a matter of urgency.

The role of MR imaging in assessing prognosis after severe and moderate head injury

PURPOSE

The objective of this work is two-fold: to determine the role of MRI findings in establishing the prognosis of patients with moderate and severe traumatic brain injury (TBI) admitted to our centre, measured with different outcome scales; and to determine in which patients the information given by MR findings adds prognostic information to that from traditional prognostic factors.

METHODS

One hundred patients suffering moderate or severe head injury in whom MRI had been performed in the first 30 days after trauma were included. The MRI was evaluated by two neuroradiologists who were not aware of the initial CT results or the clinical situation of the patients. Outcome was determined 6 months after head injury by means of the extended version of the Glasgow Outcome Scale. The prognostic capacity of the different factors related to outcome was compared by the analysis of receiver operating characteristic (ROC) curves and the area under the curve (AUC) for each factor.

RESULTS

There exists a clear relation between the depth of the traumatic lesions shown on MRI, and their classification by the proposed scale, and the outcome of patients suffering traumatic brain injury determined by different scales 6 months after injury.

CONCLUSIONS

The anatomical substrate of TBI depicted by MRI could be a useful prognostic tool in patients suffering moderate and severe head injury. Patients with a score of 4 or less on the motor subscale of the GCS scale are those who could benefit most from the prognostic information provided by MRI.

Risk Factors Predicting Unfavorable Neurological Outcome during the Early Period after Traumatic Brain Injury

OBJECTIVE

We aimed to identify clinico-radiological risk factors that may predict unfavorable neurological outcomes in traumatic brain injury (TBI), and to establish a guideline for patient selection in clinical trials that would improve neurological outcome during the early post TBI period.

METHODS

Initial clinico-radiological data of 115 TBI patients were collected prospectively. Regular neurological assessment after standard treatment divided the above patients into 2 groups after 6 months : the Favorable neurological outcome group (GOS : good & moderate disability, DRS : 0-6, LCFS : 8-10) and the Unfavorable group (GOS : severe disability-death, DRS : 7-29 and death, LCFS : 1-7 and death).

RESULTS

There was a higher incidence of age >/=35 years, low initial GCS score, at least unilateral pupil dilatation, and neurological deficit in the Unfavorable group. The presence of bilateral parenchymal lesions or lesions involving the midline structures in the initial brain CT was observed to be a radiological risk factor for unfavorable outcome. Multivariate analysis demonstrated that age and initial GCS score were independent risk factors. The majority of the Favorable group patients with at least one or more risk factors showed improvement of GCS scores within 2 months after TBI.

CONCLUSION

Patients with the above mentioned clinico-radiological risk factors who received standard treatment, but did not demonstrate neurological improvement within 2 months after TBI were deemed at risk for unfavorable outcome. These patients may be eligible candidates for clinical trials that would improve functional outcome after TBI.

[Influence of age, gender, and severity on recovery of patients with brain injury]

PURPOSE

This study was conducted to investigate the individual and cross influences of age, gender, and severity on recovery of patients with brain injury.

METHODS

For the purpose of the study, traumatic or spontaneous brain injury patients admitted to the intensive care unit (ICU) were conveniently selected. The data regarding outcomes were collected 3 months after admission.

RESULTS

Individual influences of the study variables on patients' recovery were significant, except for gender. But while the individual influence of gender on recovery was not significant, cross influence of gender and age was significant, but only for the sub-dimension of 'arousalbility and awareness'. The study results also showed that 3-way cross influence of gender, age, and severity was only significant on the sub-dimension of 'arousalbility and awareness'.

CONCLUSION

The sub-dimension of recovery cross influenced by the demographic factors of gender and age, and severity was 'arousalbility and awareness'. This might indicate that the study variables that cross influencing recovery had more influence on consciousness compared to physical function and psycho-social adaptation.

The effect of the introduction of the Amsterdam Trauma Workflow Concept on mortality and functional outcome of patients with severe traumatic brain injury

The purpose of this study was to analyze the effect of the introduction of an all-in workflow concept that included direct computed tomography (CT) scanning in the trauma room on mortality and functional outcome of trauma patients with severe traumatic brain injury (TBI) admitted to a level-1 trauma center. To this end, a retrospective comparison was made of a 1-year cohort prior to the implementation of the all-in workflow concept (Pre-CT in trauma room cohort [Pre-TRCT]) and a 1-year cohort after the implementation (Post-TRCT). All severely injured TBI patients aged 16 years or older that were presented in our level-1 trauma center and that underwent a CT of the head were initially included. Severe TBI was defined as an Abbreviated Injury Scale (AIS) score of >2 of the head region following trauma. Primary outcome parameter was TBI-related mortality during primary hospital admission. Secondary outcome parameter was the functional outcome based on GOS-Extended. A total of 59 patients were included in the Pre-TRCT and 49 in the Post-TRCT. Median age was 49 years in the Post-TRCT and 44 years in the Pre-TRCT (not significant [NS]). Median ISS was similar (ISS = 25). Median Head-AIS was higher in the Post-TRCT (5 vs. 4, NS). Initial CT scanning was completed faster in the Post-TRCT. There was a significant difference of 23% mortality in favor of the Post-TRCT for TBI-related mortality during primary hospital admission (p < 0.05). For acute neurosurgical interventions, time until intervention tended to be faster in the Post-TRCT (NS). Functional outcomes for survivors were higher in the Post-TRCT (6 vs. 5, NS).

Cognitive and functional outcomes of terror victims who suffered from traumatic brain injury

PRIMARY OBJECTIVE

To describe the outcomes of terror victims suffered from traumatic brain injury (TBI).

RESEARCH DESIGN

Retrospective chart review of 17 terror and 39 non-terror TBI patients treated in a rehabilitation department during the same period.

METHODS AND PROCEDURE

Variables include demographic data, Injury Severity Scale (ISS), length of stay (LOS) and imaging results. ADL was measured using the Functional Independence Measurement (FIM), cognitive and memory functions were measured using the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery and the Rivermead Battery Memory Test (RBMT), respectively.

MAIN OUTCOME AND RESULTS

Terror TBI patients were significantly younger, had higher ISS score and higher rates of intracerebral haemorrhage (ICH), brain surgery and penetrating brain injuries than the non-terror TBI group. There was no difference in mean LOS, mean FIM values, mean FIM gain and mean cognitive and memory improvement between groups. Terror victims suffered from a higher percentage of post-traumatic epilepsy (35% vs. 10%, p=0.05), whereas the rate of PTSD and the rate of return to previous occupation were similar between groups.

CONCLUSIONS

Although TBI terror victims had more severe injury, they gained most of ADL functions and their rehabilitation outcomes were similar to non-terror TBI patients. These favourable results were achieved due to a comprehensive interdisciplinary approach to terror victims and also by national support which allowed an adequate period of treatment and sufficient resources as needed.

Anticoagulation and the elderly head trauma patient

We sought to determine the effect of anticoagulation therapy on outcomes in elderly patients with closed head injury. We retrospectively reviewed elderly closed head injury patients (> or = 65 years) comparing 52 patients on warfarin (AC) with 439 patients not on warfarin (NAC) with subsequent 1:3 propensity matching used to analyze comparable groups. The overall AC group had a higher head abbreviated injury score (AIS) (4.0 +/- 0.7 vs 3.8 +/- 0.7, P = 0.04) compared with the NAC group. After propensity matching, 49 AC patients were compared with 147 NAC patients who were similar for age, gender, injury severity score, and head AIS. Admission INR was higher in the AC group compared to the NAC group (2.5 +/- 1.3 vs 1.1 +/- 0.3, P < 0.0001) and the AC group had a higher mortality rate (38.8% AC (19/49) vs 23.1% NAC (34/147), P = 0.04). In the AC group, survivors and nonsurvivors had similar repeat International Normalized Ratio (INR) values (1.57 +/- 0.65 survivors vs 1.8 +/- 0.72 nonsurvivors, P = 0.31). The AC group experienced greater morbidity after trauma and had higher mortality rates than their NAC counterparts. Prevention of injury and more selective use of warfarin in this patient population are essential to decrease mortality.

A systematic review finds methodological improvements necessary for prognostic models in determining traumatic brain injury outcomes

OBJECTIVES

To describe the modeling techniques used for early prediction of outcome in traumatic brain injury (TBI) and to identify aspects for potential improvements.

STUDY DESIGN AND SETTING

We reviewed key methodological aspects of studies published between 1970 and 2005 that proposed a prognostic model for the Glasgow Outcome Scale of TBI based on admission data.

RESULTS

We included 31 papers. Twenty-four were single-center studies, and 22 reported on fewer than 500 patients. The median of the number of initially considered predictors was eight, and on average five of these were selected for the prognostic model, generally including age, Glasgow Coma Score (or only motor score), and pupillary reactivity. The most common statistical technique was logistic regression with stepwise selection of predictors. Model performance was often quantified by accuracy rate rather than by more appropriate measures such as the area under the receiver-operating characteristic curve. Model validity was addressed in 15 studies, but mostly used a simple split-sample approach, and external validation was performed in only four studies.

CONCLUSION

Although most models agree on the three most important predictors, many were developed on small sample sizes within single centers and hence lack generalizability. Modeling strategies have to be improved, and include external validation.

Traumatic brain injury: can the consequences be stopped?

Traumatic brain injury is a leading cause of morbidity and death in both industrialized and developing countries. To date, there is no targeted pharmacological treatment that effectively limits the progression of secondary injury. The delayed progression of deterioration of grey and white matter gives hope that a meaningful intervention can be applied in a realistic timeframe following initial trauma. In this review we discuss new insights into the subcellular mechanisms of secondary injury that have highlighted numerous potential targets for intervention.

Exacerbated glial response in the aged mouse hippocampus following controlled cortical impact injury

Old age is associated with enhanced susceptibility to and poor recovery from brain injury. An exacerbated microglial and astrocyte response to brain injury might be involved in poor outcomes observed in the elderly. The present study was therefore designed to quantitate the expression of markers of microglia and astrocyte activation using real-time RT-PCR, immunoblot and immunohistochemical analysis in aging brain in response to brain injury. We examined the hippocampus, a region that undergoes secondary neuron death, in aged (21-24 months) and adult (5-6 months) mice following controlled cortical impact (CCI) injury to the sensorimotor cortex. Basal mRNA expression of CD11b and Iba1, markers of activated microglia, was higher in aged hippocampus as compared to the adult. The mRNA expression of microglial markers increased and reached maximum 3 days post-injury in both adult and aged mice, but was higher in the aged mice at all time points studied, and in the aged mice the return to baseline levels was delayed. Basal mRNA expression of GFAP and S100B, markers of activated astrocytes, was higher in aged mice. Both markers increased and reached maximum 7 days post-injury. The mRNA expression of astrocyte markers returned to near basal levels rapidly after injury in the adult mice, whereas again in the aged mice return to baseline was delayed. Immunochemical analysis using Iba1 and GFAP antibodies indicated accentuated glial responses in the aged hippocampus after injury. The pronounced and prolonged activation of microglia and astrocytes in hippocampus may contribute to worse cognitive outcomes in the elderly following TBI.

Epidemiology and 12-month outcomes from traumatic brain injury in australia and new zealand

BACKGROUND

An epidemiologic profile of traumatic brain injury (TBI) in Australia and New Zealand was obtained following the publication of international evidence-based guidelines.

METHODS

Adult patients with TBI admitted to the intensive care units (ICU) of major trauma centers were studied in a 6-month prospective inception cohort study. Data including mechanisms of injury, prehospital interventions, secondary insults, operative and intensive care management, and outcome assessments 12-months postinjury were collected.

RESULTS

There were 635 patients recruited from 16 centers. The mean (+/-SD) age was 41.6 years +/- 19.6 years; 74.2% were men; 61.4% were due to vehicular trauma, 24.9% were falls in elderly patients, and 57.2% had severe TBI (Glasgow Coma Scale score </=8). Secondary brain insults were recorded in 28.5% and 34.8% underwent neurosurgical procedures before ICU admission. There was concordance with TBI and ICU practice guidelines, although intracranial pressure monitoring was used in 44.5% patients with severe TBI. Twelve-month mortality was 26.9% in all patients and 35.1% in patients with severe TBI. Favorable outcomes at 12 months were recorded in 58.8% of all patients and in 48.5% of patients with severe TBI.

CONCLUSIONS

In Australia and New Zealand, mortality and favorable neurologic outcomes after TBI were similar to published data before the advent of evidence-based guidelines. A high incidence of prehospital secondary brain insults and an ageing population may have contributed to these outcomes. Strategies to improve outcomes from TBI should be directed at preventive public health strategies and interventions to minimize secondary brain injuries in the prehospital period.

Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients

OBJECTIVE

To develop and validate practical prognostic models for death at 14 days and for death or severe disability six months after traumatic brain injury.

DESIGN

Multivariable logistic regression to select variables that were independently associated with two patient outcomes. Two models designed: "basic" model (demographic and clinical variables only) and "CT" model (basic model plus results of computed tomography). The models were subsequently developed for high and low-middle income countries separately.

SETTING

Medical Research Council (MRC) CRASH Trial.

SUBJECTS

10,008 patients with traumatic brain injury. Models externally validated in a cohort of 8509.

RESULTS

The basic model included four predictors: age, Glasgow coma scale, pupil reactivity, and the presence of major extracranial injury. The CT model also included the presence of petechial haemorrhages, obliteration of the third ventricle or basal cisterns, subarachnoid bleeding, midline shift, and non-evacuated haematoma. In the derivation sample the models showed excellent discrimination (C statistic above 0.80). The models showed good calibration graphically. The Hosmer-Lemeshow test also indicated good calibration, except for the CT model in low-middle income countries. External validation for unfavourable outcome at six months in high income countries showed that basic and CT models had good discrimination (C statistic 0.77 for both models) but poorer calibration.

CONCLUSION

Simple prognostic models can be used to obtain valid predictions of relevant outcomes in patients with traumatic brain injury.

Evaluation of the effect of intensity of care on mortality after traumatic brain injury

OBJECTIVES

To evaluate the effect of age on intensity of care provided to traumatically brain-injured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity.

DESIGN

Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients.

SETTING AND PATIENTS

A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25-84 yrs with a diagnosis of traumatic brain injury.

MEASUREMENTS

Injury severity was determined by the motor component of the Glasgow Coma Scale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy.

MAIN RESULTS

Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75-84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a do-not-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0).

CONCLUSIONS

There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, their consultation was associated with decreased risk of in-hospital death and death within 12 months. It is important that careproviders have an increased awareness of the potential contribution of multidisciplinary clinical decision making to patient outcomes in older traumatically brain-injured patients.

Decompressive craniectomy for traumatic brain injury: patient age and outcome

The overall degree by which different patients may benefit from decompressive craniectomy (DC) remains controversial. In particular, the prognostic value of age has been investigated by very few studies. Many authors state there is no significant benefit in performing a DC in severe head injury after a certain age limit, with most placing the limit at 30-50 years of age. Between 1994 and 2004, 55 patients underwent DC at our institution. Advanced age did not constitute a contraindication to surgery for both ethical and cultural reasons. Thus, the data obtained were not biased by a selection of patients based on age. We analyzed potential predictors of outcome after DC, including sex, age, Glasgow Coma Scale (GCS), and presence of mass lesion. Chi-square test was used to compare categorical variables. The independent contribution of predictive factors to outcome was studied using logistic regression analysis. Initial GCS score was found to be an independent predictor of outcome (p = 0.001). No difference in the outcome was observed between patients with GCS 6-8 and GCS 9-15. These two groups have a better prognosis than patients with GCS 3-5. Logistic regression analysis showed age as an independent predictive factor to outcome (p = 0.005). A difference in outcome exists among patients over 65 and patients aged <or=65, while groups aged <40 and 40-65 showed no difference in outcome. Based on these findings, we believe that the age limit for performing DC should be revised.

Severe traumatic brain injury in Austria IV: intensive care management

OBJECTIVES

The goal of this paper is to describe the ICU management of severe traumatic brain injury (TBI) in Austria.

PATIENTS AND METHODS

Data sets from 415 patients included by 5 Austrian hospitals were available. The analysis focused on complications and outcomes of intensive care, monitoring of intracranial pressure (ICP), efficacy of interventions to control ICP, management of hemodynamics and cerebral perfusion pressure (CPP), ventilation, and effects of hyperglycaemia.

RESULTS

Overall ICU mortality was 30.8%; 90-day mortality was 35.7%. Final outcome was favorable in 33%, unfavorable in 51%, and in 16% the final outcome was unknown. An ICP monitoring device was used in 64%; most patients received intraparenchymal sensors (77%). Events associated with mortality > 50% were CPP < 50 mm Hg for > 12 hours/day, ICP > 25 mm Hg for > 12 hours/day, and MAP < 70 mm Hg for > 18 hours/day. The use of ICP monitoring was associated with significantly reduced ICU mortality. Interventions that may have improved the outcome included the use of barbiturates (short-term), hypertonic saline, moderate hyperventilation (33 < pCO2 < 37; p < 0.001 vs. aggressive hyper-and normoventilation), and normothermia. Hyperglycaemia was associated with poor outcome.

CONCLUSIONS

Our study showed that ICU management of patients with severe TBI mostly follows international guidelines, and that outcome was comparable to or even better than that reported by other authors. Low CPP was associated with poor outcome, and was more often due to low MAP than to elevated ICP. The use of barbiturates and hypertonic saline was more common than expected. CPP should be maintained > 50 mm Hg, the use of catecholamines, fluid loading, barbiturates (short-term), moderate hyperventilation, hypertonic saline, and insulin may improve outcome after severe TBI.

Severe traumatic brain injury in Austria VI: effects of guideline-based management

OBJECTIVES

The goal of this paper is to report relations between health outcomes and implementation of individual recommendations of the guidelines.

PATIENTS AND METHODS

Data sets from 405 patients included by 5 Austrian hospitals were available. The analysis focused on the compliance of treatment modalities to TBI guidelines recommendations. Compliance was evaluated based on scores developed specifically for this purpose. To evaluate the relations between the TBI guidelines compliance and outcomes the estimation of odds ratios was computed using multiple as well as logistic regression with age, ISS and initial GCS used to control confounding.

RESULTS

The option on prehospital resuscitation was followed in 84%, the guideline on early resuscitation was followed in 79%. The guideline on intracranial pressure treatment threshold was the most closely followed one (89%). The option on cerebral perfusion pressure was followed in less than 30% of patients. Only the scores on resuscitation of blood pressure and oxygenation and on cerebral perfusion pressure were positively and statistically significantly related to ICU survival. Positive relations were also found for adherence to the recommendations on the type of monitoring, hyperventilation (guideline), prophylactic use of anti-seizure drugs, and the total of scores. The other recommendations were negatively related to ICU survival, but computed odds ratios were statistically not significant. Analysis of relations between compliance scores and length of ICU and hospitals stay in survivors showed that adherence to the recommendations on type of monitoring was related to a reduction of length of stay in ICU and hospital, adherence to the hyperventilation guideline was related to shortened ICU, but increased hospital stay, and adherence to the guideline on mannitol was related to reduced days in hospital, but not to days in ICU. Implementing the standard on corticosteroid use was related to a reduction of days both in hospital and ICU. Using the standard on prophylactic use of anti-seizure drugs was related to a reduction in ICU days. If all the recommendations were closely followed an increase of days in ICU would be observed, while the length of stay in hospital would be reduced.

CONCLUSIONS

The relatively strong relation between initial resuscitation in the hospital and ICU survival provides a firm basis for future efforts of emergency teams. The positive influence of some of the recommendations on reduction of ICU or hospital days may provide economic incentives to promote guidelines implementation.

Carbon Monoxide Poisoning

RATIONALE

Carbon monoxide poisoning is common and causes cognitive sequelae. Hyperbaric oxygen (HBO(2)) reduces cognitive sequelae incidence, but which patients may benefit from HBO(2) is unclear.

OBJECTIVES

Risk factor determination for 6-wk cognitive sequelae from CO poisoning and risk modification with HBO(2).

METHODS

Patients were from a randomized controlled trial, enrolling acutely CO-poisoned patients more than 15 years of age. Patients eligible but not enrolled in the randomized trial, and not receiving HBO(2), were followed during the study interval. In patients not receiving HBO(2), we performed univariate analyses including risk factors identified by randomized trial subgroup analyses. A multivariable analysis was performed using univariate results with and without HBO(2).

MEASUREMENTS AND MAIN RESULTS

In 163 patients not receiving HBO(2), 68 (42%) manifested sequelae. Risk factors for sequelae from subgroup analyses were loss of consciousness, age of 36 years or more, and carboxyhemoglobin levels greater than or equal to 25%. By univariate analyses, risks for sequelae were age of 36 years or more (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-4.9; P = 0.005), and exposure intervals greater than or equal to 24 hours (OR, 2.4; 95% CI, 1.2-4.8; P = 0.019). Including 75 patients receiving HBO(2), cognitive sequelae was reduced in patients age of 36 years or more (OR, 0.3; 95% CI, 0.2-0.6; P < 0.001). Exposure intervals greater than or equal to 24 hours are an independent risk factor for sequelae (OR, 2.0; 95% CI, 1.0-3.8; P = 0.046).

CONCLUSIONS

HBO(2) oxygen is indicated for patients with acute CO poisoning who are 36 years or older or have exposure intervals greater than or equal to 24 hours. In addition, subgroup analyses support that patients with loss of consciousness or higher carboxyhemoglobin levels warrant HBO(2).

Clinical significance of alphaII-spectrin breakdown products in cerebrospinal fluid after severe traumatic brain injury

Following traumatic brain injury (TBI), the cytoskeletal protein alpha-II-spectrin is proteolyzed by calpain and caspase-3 to signature breakdown products. To determine whether alpha -II-spectrin proteolysis is a potentially reliable biomarker for TBI in humans, the present study (1) examined levels of spectrin breakdown products (SBDPs) in cerebrospinal fluid (CSF) from adults with severe TBI and (2) examined the relationship between these levels, severity of injury, and clinical outcome. This prospective case control study enrolled 41 patients with severe TBI, defined by a Glasgow Coma Scale (GCS) score of < or =8, who underwent intraventricular intracranial pressure monitoring. Patients without TBI requiring CSF drainage for other medical reasons served as controls. Ventricular CSF was sampled from each patient at 6, 12, 24, 48, 72, 96, and 120 h following TBI and analyzed for SBDPs. Outcome was assessed using the Glasgow Outcome Score (GOS) 6 months after injury. Calpain and caspase-3 mediated SBDP levels in CSF were significantly increased in TBI patients at several time points after injury, compared to control subjects. The time course of calpain mediated SBDP150 and SBDP145 differed from that of caspase-3 mediated SBDP120 during the post-injury period examined. Mean SBDP densitometry values measured early after injury correlated with severity of injury, computed tomography (CT) scan findings, and outcome at 6 months post-injury. Taken together, these results support that alpha -II-spectrin breakdown products are potentially useful biomarker of severe TBI in humans. Our data further suggests that both necrotic/oncotic and apoptotic cell death mechanisms are activated in humans following severe TBI, but with a different time course after injury.

Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study

Outcome following traumatic brain injury (TBI) is not only dependent on the nature and severity of injury and subsequent treatment, but also on constituent characteristics of injured individuals. We aimed to describe and quantify the relationship between demographic characteristics and six month outcome assessed by the Glasgow Outcome Scale (GOS) after TBI. Individual patient data on age (n = 8719), gender (n = 8720), race (n = 5320), and education (n = 2201) were extracted from eight therapeutic Phase III randomized clinical trials and three surveys in moderate or severe TBI, contained in the IMPACT database. The strength of prognostic effects was analyzed with binary and proportional odds regression analysis and expressed as an odds ratio. Age was analyzed as a continuous variable with spline functions, and the odds ratio calculated over the difference between the 75 th and 25 th percentiles. Associations with other predictors were explored. Increasing age was strongly related to poorer outcome (OR 2.14; 95% CI 2.00-2.28) in a continuous fashion that could be approximated by a linear function. No gender differences in outcome were found (OR: 1.01; CI 0.92-1.11), and exploratory analysis failed to show any gender/age interaction. The studies included predominantly Caucasians (83%); outcome in black patients was poorer relative to this group (OR 1.30; CI 1.09-1.56). This relationship was sustained on adjusted analyses, and requires further study into mediating factors. Higher levels of education were weakly related to a better outcome (OR: 0.70; CI 0.52-0.94). On multivariable analysis adjusting for age, motor score, and pupils, the prognostic effect of race and education were sustained. We conclude that outcome following TBI is dependent on age, race, to a lesser extent on education, but not on gender.

Traumatic brain injury: assessment, resuscitation and early management

This review examines the evidence base for the early management of head-injured patients. Traumatic brain injury (TBI) is common, carries a high morbidity and mortality, and has no specific treatment. The pathology of head injury is increasingly well understood. Mechanical forces result in shearing and compression of neuronal and vascular tissue at the time of impact. A series of pathological events may then ensue leading to further brain injury. This secondary injury may be amenable to intervention and is worsened by secondary physiological insults. Various risk factors for poor outcome after TBI have been identified. Most of these are fixed at the time of injury such as age, gender, mechanism of injury, and presenting signs (Glasgow Coma Scale and pupillary signs), but some such as hypotension and hypoxia are potential areas for medical intervention. There is very little evidence positively in favour of any treatments or packages of early care; however, prompt, specialist neurocritical care is associated with improved outcome. Various drugs that target specific pathways in the pathophysiology of brain injury have been the subject of animal and human research, but, to date, none has been proved to be successful in improving outcome.

Head injury mortality in the Nordic countries

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in Western countries. Effective management planning for these patients requires knowledge of TBI epidemiology. The purpose of this study was to describe and analyze the development of TBI mortality in the Nordic countries during the period 1987-2001. Data on TBI deaths were retrieved from the national official statistical agencies according to specified diagnostic codes. We also collected data on the number of operations for acute TBI in the year 2000 from all Nordic hospitals admitting trauma patients. Finland had about twice as high a TBI mortality rate as the other countries. Similarly, the Finnish incidence of acute TBI operations was nearly twice that of the other countries. The median TBI death rate for Finland was 21.2 per 100,000 per year, and for Denmark, Norway, and Sweden 11.5, 10.4, and 9.5, respectively. There were more male than female deaths in all countries. The mortality rate from extracranial injuries was relatively equal between the countries. We observed a sizeable reduction in TBI mortality rates for all countries, except in Finland. Younger age groups had the most pronounced decrease in TBI mortality rates. The oldest age group had the least favorable development of TBI mortality rates, and the mean age of TBI casualties increased substantially during the study period. This study demonstrates considerable differences in and between the Nordic countries regarding TBI mortality. Preventive measures and implementation of regional guidelines are needed to assure a positive development in the future.

Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury

PRIMARY OBJECTIVE

To compare functional physical and cognitive outcome of patients in three age groups with mild, moderate and severe traumatic brain injury (TBI) at discharge from acute care.

RESEARCH DESIGN

Retrospective database review.

METHODS AND PROCEDURES

Scores on the Extended Glasgow Outcome Scale (GOSE) and on the FIM instrument,1 discharge destination and length-of-stay (LOS) were gathered and compared for 2327 patients with TBI admitted to a level 1 trauma hospital from 1997-2003 divided into three age groups; 971 patients between 18-39 years, 672 between 40-59 years and 684 aged 60-99 years.

MAIN OUTCOMES AND RESULTS

Relative to younger adults with similar TBI severity, elderly patients showed worse outcome on the GOSE and FIM instrument (physical and cognitive ratings) and longer LOS. No difference was observed between the young and middle-aged groups except for cognitive FIM ratings and LOS for severe TBI. A higher percentage of elderly patients went to in-patient rehabilitation, to long-term care facilities or died compared to young and middle-aged patients. A higher number of young and middle-aged patients were discharged home.

CONCLUSIONS

Further development of services in early rehabilitation as well as post-rehabilitation geared to the specific needs of the elderly patient with TBI is required as the population ages.

Relative Risk of Mortality after Traumatic Brain Injury: A Population-Based Study of The Role of Age And Injury Severity

To test if observed vs. expected mortality differs by age among traumatic brain injury (TBI) cases, a population-based, historical cohort study was conducted in Olmsted County, Minnesota. From all residents with any diagnosis suggestive of TBI 1985-1999, we randomly sampled 7,800 and reviewed their medical records to confirm the event. Confirmed incident cases were categorized by age in years (<16 = pediatric, 16-65 = adult, > 65 elderly) and severity (moderate/severe vs. mild) and followed for vital status through 6/30/2004. We compared observed 6-month and 10-year mortality with expected and tested if the differences varied by age. Of 1,433 confirmed incident cases, 35% were pediatric; 55% were adult; only 9% were elderly; 11.2% of all cases were moderate/severe; the proportions by increasing age group were 11.4%, 8.5%, 26.7%. The proportions who died within 6 months increased with increasing age group, both for moderate/severe (10.3%, 40.3%, 50.0%) and mild cases (0%, 0%, 9.1%); mortality for moderate/severe cases was nearly 40 times that for mild cases, independent of age. Among 6-month survivors, 10-year mortality differed from expected only for adult cases. For all cases, after adjusting for sex, year of TBI, and severity, the difference between observed and expected 10-year mortality was greater for adult cases than for pediatric cases and similar for adult and elderly cases. Elderly individuals account for <10% of TBI cases and >50% of 10-year mortality, yet much of this discrepancy reflects age-associated mortality in general. Findings have implications for (1) reducing the number of excess deaths following TBI and (2) caring for survivors.

Evidence synthesis combining individual patient data and aggregate data: a systematic review identified current practice and possible methods

OBJECTIVE

Meta-analysis of individual patient data (IPD) is the "gold-standard" for synthesizing evidence across several studies. Some studies, however, may only provide aggregate data (AD). In this situation researchers might need to combine IPD with AD to utilize all the evidence available. Here, we review applied IPD meta-analysis articles to assess if and how AD is combined with IPD in practice.

STUDY DESIGN AND SETTING

A systematic review of articles identified from bibliographic databases and searches.

RESULTS

We identified 33 applied IPD articles that combined IPD and AD and 166 that did not. For each article, we recorded the proportion of total studies providing IPD, and found that articles combining IPD and AD had, on average, IPD available in only 64% of studies (compared to 90% in articles not combining IPD and AD). Two different methods were used to combine IPD and AD, the two-stage method and analysis of partially reconstructed IPD, but a review of methodological articles identified two further methods, multilevel modeling and Bayesian hierarchical related regression. We summarize each method to aid practitioners.

CONCLUSION

Combining IPD and AD is a relevant issue for evidence synthesis, and the further development and validation of suitable meta-analysis methods is needed.

Injury in the Elderly and End-of-Life Decisions

The elderly constitute the fastest growing sector of the population of the United Stated and geriatric trauma patients are presenting for care with increasing frequency. These patients are challenging particularly because of their vulnerability to severe injury, limited physiologic response to stress, and frequent presence of comorbid medical conditions complicating care. Many elderly trauma victims require prolonged intensive care and some fail to improve or succumb despite the best efforts because of the extent of their injuries and their underlying disease. These patients may present profound ethical challenges for trauma surgeons as the goals of care shift from salvage to end-of-life care.

Long-Term Survival of Medicare Patients With Head Injury

BACKGROUND

An increasing number of older patients are being hospitalized with traumatic brain injury (TBI). Knowledge of their expected long-term survival may be useful in making clinical decisions.

METHODS

Patients age 65 or older admitted for the first time with head injury (ICD-9 800-804 or 850-854) during 1999 were identified in a complete national sample of fee-for-service Medicare hospitalization and denominator data. Cases were categorized by age, sex, maximum Abbreviated Injury Score (AISmax), and Charlson comorbidity score. Survival was determined at hospital discharge, and (using the denominator file) at 1, 6, 12, and 24 months after the initial hospital admission.

RESULTS

For all cases (n = 30,684), the hospital mortality was 14.3%, but was cumulatively 19.75%, 30.5%, 36.1%, and 44.9% at successive times up to 24 months. Long-term mortality was higher with increased age, comorbidity, or AISmax, and higher in men. These effects persisted with multivariate logistic regression analysis and were used to construct a simplified prediction score for clinical use.

CONCLUSIONS

The mortality for older patients with TBI is much higher than for an uninjured control population. The relative risk for death remains elevated after hospital discharge and for at least 2 years. Awareness of the expected prognosis may help family members and health care providers make appropriate clinical decisions during acute hospitalization.