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Shakir M, Irshad HA, Ibrahim NUH, Alidina Z, Ahmed M, Pirzada S, Hussain N, Park KB, Enam SA. Temporal Delays in the Management of Traumatic Brain Injury: A Comparative Meta-Analysis of Global Literature. World Neurosurg 2024:S1878-8750(24)00827-1. [PMID: 38762022 DOI: 10.1016/j.wneu.2024.05.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE A meta-analysis was conducted to compare: 1) time from traumatic brain injury (TBI) to the hospital, and 2) time within the hospital to intervention or surgery, by country-level income, World Health Organization region, and healthcare payment system. METHODS A comprehensive literature search was conducted and followed by a meta-analysis comparing duration of delays (prehospital and intrahospital) in TBI management. Means and standard deviations were pooled using a random effects model and subgroup analysis was performed using R software. RESULTS Our analysis comprised 95,554 TBI patients from 45 countries. BY COUNTRY-LEVEL INCOME From 23 low- and middle-income countries, a longer mean time from injury to surgery (862.53 minutes, confidence interval [CI]: 107.42-1617.63), prehospital (217.46 minutes, CI: -27.34-462.25), and intrahospital (166.36 minutes, 95% CI: 96.12-236.60) durations were found compared to 22 high-income countries. BY WHO REGION African Region had the greatest total (1062.3 minutes, CI: -1072.23-3196.62), prehospital (256.57 minutes [CI: -202.36-715.51]), and intrahospital durations (593.22 minutes, CI: -3546.45-4732.89). BY HEALTHCARE PAYMENT SYSTEM Multiple-Payer Health Systems had a greater prehospital duration (132.62 minutes, CI: 54.55-210.68) but greater intrahospital delays were found in Single-Payer Health Systems (309.37 minutes, CI: -21.95-640.69). CONCLUSION Our study concludes that TBI patients in low- and middle-income countries within African Region countries face prolonged delays in both prehospital and intrahospital management compared to high-income countries. Additionally, patients within Single-Payer Health System experienced prolonged intrahospital delays. An urgent need to address global disparities in neurotrauma care has been highlighted.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | | | | | - Zayan Alidina
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Muneeb Ahmed
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Sonia Pirzada
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Nowal Hussain
- Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Kee B Park
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Nagy L, Morgan RD, Collins RA, Kharbat AF, Garza J, Belirgen M. Impact of timing of decompressive craniectomy on outcomes in pediatric traumatic brain injury. Surg Neurol Int 2023; 14:436. [PMID: 38213457 PMCID: PMC10783660 DOI: 10.25259/sni_472_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/16/2023] [Indexed: 01/13/2024] Open
Abstract
Background Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC. Methods This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month-18 years who underwent DC for TBI. Patients were stratified as acute (<24 h) and subacute (>24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates. Results A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% (n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) (P = 0.030). Timing of DC was not associated with GOS at discharge (P = 0.938), 3-month follow-up (P = 0.225), 6-month follow-up (P = 0.074), or complication rate (P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% (n = 3). Conclusion Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.
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Affiliation(s)
- Laszlo Nagy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Ryan D. Morgan
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Reagan A. Collins
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Abdurrahman F. Kharbat
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - John Garza
- Department of Mathematics, University of Texas Permian Basin, Odessa, Texas, United States
| | - Muhittin Belirgen
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
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Shakir M, Altaf A, Irshad HA, Hussain N, Pirzada S, Tariq M, Trillo-Ordonez Y, Enam SA. Factors Delaying the Continuum of Care for the Management of Traumatic Brain Injury in Low- and Middle-Income Countries: A Systematic Review. World Neurosurg 2023; 180:169-193.e3. [PMID: 37689356 DOI: 10.1016/j.wneu.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Considering the disproportionate burden of delayed traumatic brain injury (TBI) management in low- and middle-income countries (LMICs), there is pressing demand for investigations. Therefore, our study aims to evaluate factors delaying the continuum of care for the management of TBIs in LMICs. METHODS A systematic review was conducted with PubMed, Scopus, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Observational studies with TBI patients in LMIC were included. The factors affecting management of TBI were extracted and analyzed descriptively. RESULTS A total of 55 articles were included consisting of 60,603 TBI cases from 18 LMICs. Road traffic accidents (58.7%) were the most common cause of injury. Among included studies, factors contributing to prehospital delays included a poor referral system and lack of an organized system of referral (14%), long travel distances (11%), inadequacy of emergency medical services (16.6%), and self-treatment practices (2.38%). For in-hospital delays, factors such as lack of trained physicians (10%), improper triage systems (20%), and absence of imaging protocols (10%), lack of in-house computed tomography scanners (35%), malfunctioning computed tomography scanners (10%), and a lack of invasive monitoring of intracranial pressure (5%), limited theater space (28%), lack of in-house neurosurgical facilities (28%), absence of in-house neurosurgeons (28%), and financial constraints (14%) were identified. CONCLUSIONS Several factors, both before and during hospitalization contribute to delays in the management of TBIs in LMICs. Strategically addressing these factors can help overcome delays and improve TBI management in LMICs.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | - Ahmed Altaf
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Nowal Hussain
- Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sonia Pirzada
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Mahnoor Tariq
- Department of Community Health Sciences, Aga Khan University Hospital, Karachi, Pakistan
| | - Yesel Trillo-Ordonez
- Duke University Division of Global Neurosurgery and Neurology, Durham, North Carolina, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Tang Z, Hu K, Yang R, Zou M, Zhong M, Huang Q, Wei W, Jiang Q. Development and validation of a prediction nomogram for a 6-month unfavorable prognosis in traumatic brain-injured patients undergoing primary decompressive craniectomy: An observational study. Front Neurol 2022; 13:944608. [PMID: 35989929 PMCID: PMC9382105 DOI: 10.3389/fneur.2022.944608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/12/2022] [Indexed: 12/03/2022] Open
Abstract
Objective This study was designed to develop and validate a risk-prediction nomogram to predict a 6-month unfavorable prognosis in patients with traumatic brain-injured (TBI) undergoing primary decompressive craniectomy (DC). Methods The clinical data of 391 TBI patients with primary DC who were admitted from 2012 to 2020 were reviewed, from which 274 patients were enrolled in the training group, while 117 were enrolled in the internal validation group, randomly. The external data sets containing 80 patients were obtained from another hospital. Independent predictors of the 6-month unfavorable prognosis were analyzed using multivariate logistic regression. Furthermore, a nomogram prediction model was constructed using R software. After evaluation of the model, internal and external validations were performed to verify the efficiency of the model using the area under the receiver operating characteristic curves and the calibration plots. Results In multivariate analysis, age(p = 0.001), Glasgow Score Scale (GCS) (p < 0.001), operative blood loss of >750 ml (p = 0.045), completely effaced basal cisterns (p < 0.001), intraoperative hypotension(p = 0.001), and activated partial thromboplastin time (APTT) of >36 (p = 0.012) were the early independent predictors for 6-month unfavorable prognosis in patients with TBI after primary DC. The AUC for the training, internal, and external validation cohorts was 0.93 (95%CI, 0.89–0.96, p < 0.0001), 0.89 (95%CI, 0.82–0.94, p < 0.0001), and 0.90 (95%CI, 0.84–0.97, p < 0.0001), respectively, which indicated that the prediction model had an excellent capability of discrimination. Calibration of the model was exhibited by the calibration plots, which showed an optimal concordance between the predicted 6-month unfavorable prognosis probability and actual probability in both training and validation cohorts. Conclusion This prediction model for a 6-month unfavorable prognosis in patients with TBI undergoing primary DC can evaluate the prognosis accurately and enhance the early identification of high-risk patients.
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Affiliation(s)
- Zhiji Tang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Kun Hu
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Ruijin Yang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Mingang Zou
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Ming Zhong
- Department of Neurosurgery, HuiChang County People's Hospital, HuiChang, China
| | - Qiangliang Huang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Wenjin Wei
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Qiuhua Jiang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
- *Correspondence: Qiuhua Jiang
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Beez T, Schuhmann MU, Frassanito P, Di Rocco F, Thomale UW, Bock HC. Protocol for the multicentre prospective paediatric craniectomy and cranioplasty registry (pedCCR) under the auspices of the European Society for Paediatric Neurosurgery (ESPN). Childs Nerv Syst 2022; 38:1461-1467. [PMID: 35532778 PMCID: PMC9325798 DOI: 10.1007/s00381-022-05540-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE In the paediatric age group, the overall degree of evidence regarding decompressive craniectomy (DC) and cranioplasty is low, whereas in adults, randomised controlled trials and prospective multicentre registries are available. To improve the evidence-based treatment of children, a consensus was reached to establish a prospective registry under the auspices of the European Society for Pediatric Neurosurgery (ESPN). METHODS This international multicentre prospective registry is aimed at collecting information on the indication, timing, technique and outcome of DC and cranioplasty in children. The registry will enrol patients ≤ 16 years of age at the time of surgery, irrespective of the underlying medical condition. The study design comprises four obligatory entry points as a core dataset, with an unlimited number of further follow-up entry points to allow documentation until adolescence or adulthood. Study centres should commit to complete data entry and long-term follow-up. RESULTS Data collection will be performed via a web-based portal (homepage: www.pedccr.com ) in a central anonymised database after local ethics board approval. An ESPN steering committee will monitor the project's progress, coordinate analyses of data and presentation of results at conferences and in publications on behalf of the study group. CONCLUSION The registry aims to define predictors for optimal medical care and patient-centred treatment outcomes. The ultimate goal of the registry is to generate results that are so relevant to be directly transferred into clinical practice to enhance treatment protocols.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-Universität, Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Martin U. Schuhmann
- grid.411544.10000 0001 0196 8249Pediatric Neurosurgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Paolo Frassanito
- grid.414603.4Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federico Di Rocco
- grid.414103.3Service de Neurochirurgie Pédiatrique, Hôpital Femme Mère Enfant, Lyon, France
| | - Ulrich W. Thomale
- grid.6363.00000 0001 2218 4662Pediatric Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans Christoph Bock
- grid.411984.10000 0001 0482 5331Department of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
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Bruns N, Kamp O, Lange KM, Lefering R, Felderhoff-Muser U, Dudda M, Dohna-Schwake C. Functional short-term outcomes and mortality in children with severe traumatic brain injury - comparing decompressive craniectomy and medical management. J Neurotrauma 2021; 39:944-953. [PMID: 34877889 PMCID: PMC9248344 DOI: 10.1089/neu.2021.0378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The effect of decompressive craniectomy (DC) on functional outcomes and mortality in children after severe head trauma is strongly debated. The lack of high-quality evidence poses a serious challenge to neurosurgeons' and pediatric intensive care physicians' decision making in critically ill children after head trauma. This study was conducted to compare DC and medical management in severely head-injured children with respect to short-term outcomes and mortality. Data on patients < 18 years of age treated in Germany, Austria, and Switzerland during a ten-year period were extracted from TraumaRegister DGU®, forming a retrospective multi-center cohort study. Descriptive and multivariable analyses were performed to compare outcomes and mortality after DC and medical management. Of 2507 patients, 402 (16.0 %) received DC. Mortality was 20.6 % after DC and 13.7 % after medical management. Poor outcome (death or vegetative state) occurred in 27.6 % after DC and in 16.1 % after medical management. After risk adjustment by logistic regression modeling, the odds ratio was 1.56 (95% confidence interval 1.01-2.40) for poor outcome at intensive care unit discharge and 1.20 (0.74-1.95) for mortality after DC. In summary, DC was associated with increased odds for poor short-term outcomes in children with severe head trauma. This finding should temper enthusiasm for DC in children until a large randomized controlled trial has answered more precisely if DC in children is beneficial or increases rates of vegetative state.
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Affiliation(s)
- Nora Bruns
- University Hospital Essen, 39081, Department of Pediatrics I, Essen, Germany.,University Hospital Essen, 39081, Center for Translational Neuro- and Behavioural Sciences, Essen, Germany;
| | - Oliver Kamp
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Nordrhein-Westfalen, Germany;
| | - Kim Melanie Lange
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Germany;
| | - Rolf Lefering
- Witten/Herdecke University, 12263, Institute for Research in Operative Medicine, Witten, Nordrhein-Westfalen, Germany;
| | - Ursula Felderhoff-Muser
- University Hospital Essen, 39081, Department of Pediatrics I , Essen, Nordrhein-Westfalen, Germany.,University Hospital Essen, 39081, Center for Translational Neuro- and Behavioural Sciences, Essen, Germany;
| | - Marcel Dudda
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Germany;
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Du X, Liu Q, Li Q, Yang Z, Liao J, Gong H, Wu L, Wei J, Tan Q, Du H, Zhao R, Zhao L. Prognostic value of cerebral infarction coefficient in patients with massive cerebral infarction. Clin Neurol Neurosurg 2020; 196:106009. [PMID: 32554235 DOI: 10.1016/j.clineuro.2020.106009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We proposed the concept of the cerebral infarction coefficient, which is cerebral infarction volume/brain volume. This study aimed to evaluate the prognostic value of the cerebral infarction coefficient in patients with massive cerebral infarction (MCI). METHODS According to the modified Rankin score, 71 patients with acute MCI were divided into good prognosis and poor prognosis groups. Clinical and imaging data of the two groups were collected and univariate analysis was carried out. If there were significant differences in the data between the two groups, binary logistic regression analysis was performed. RESULTS The poor prognosis group had a significantly higher cerebral infarction volume, cerebral infarction coefficient, and D-dimer levels, older age, the highest body temperature, a higher rate of a history of atrial fibrillation, and a lower rate of a history of hypertension compared with the good prognosis group (all P < 0.05). Binary logistic regression analysis showed that the cerebral infarction coefficient was an independent risk factor for a poor prognosis of patients with MCI (P < 0.05, 95 % confidence interval, 2.091, 42.562), and the odds ratio was 8.506. The area under the receiver operating characteristic curve for the cerebral infarction coefficient was 0.753. When the cut-off value was 7.8 %, the sensitivity of predicting a poor prognosis of patients with MCI was 92.5 %. CONCLUSION The cerebral infarction coefficient may have predictive value in determining the prognosis of patients with MCI.
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Affiliation(s)
- Xiaoyan Du
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Qingjun Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China.
| | - Zhao Yang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Juan Liao
- Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Hongmin Gong
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Lin Wu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Jing Wei
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Qing Tan
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Hongheng Du
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Rui Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Libo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
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Kochanek PM, Tasker RC, Carney N, Totten AM, Adelson PD, Selden NR, Davis-O'Reilly C, Hart EL, Bell MJ, Bratton SL, Grant GA, Kissoon N, Reuter-Rice KE, Vavilala MS, Wainwright MS. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2020; 84:1169-1178. [PMID: 30822776 DOI: 10.1093/neuros/nyz051] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/05/2019] [Indexed: 12/28/2022] Open
Abstract
The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, 9 are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, 3 are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The complete guideline document and supplemental appendices are available electronically (https://doi.org/10.1097/PCC.0000000000001735). The online documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Department of Anesthesiology, Pe-diatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts
| | - Nancy Carney
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Annette M Totten
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - P David Adelson
- Deptartment of Pediatric Neurosurgery, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Cynthia Davis-O'Reilly
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Erica L Hart
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Michael J Bell
- Department Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Susan L Bratton
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia's Children's Hospital, Child and Family Research Institute, University of British Columbia, Vancouver, Canada
| | - Karin E Reuter-Rice
- School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina
| | - Monica S Vavilala
- Department of Anesthesiology & Pain Medicine, Department of Pediatrics, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, Washington
| | - Mark S Wainwright
- Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington
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9
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Lee SWY, Ming Y, Jain S, Chee SY, Teo K, Chou N, Lwin S, Yeo TT, Nga VDW. Factors Predicting Outcomes in Surgically Treated Pediatric Traumatic Brain Injury. Asian J Neurosurg 2019; 14:737-743. [PMID: 31497094 PMCID: PMC6703029 DOI: 10.4103/ajns.ajns_2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Traumatic brain injury (TBI) is a common presentation to the pediatric emergency department. Understanding factors that predict outcomes will be useful in clinical decision-making and prognostication. The objective of this study was to identify important clinical parameters predictive of outcomes in pediatric TBI patients who underwent surgery. Materials and Methods This retrospective study included 43 pediatric TBI patients who underwent surgery from January 2011 to January 2017. Clinical parameters, including presenting signs and symptoms, mechanism of injury, intracranial pressure (ICP), need for inotropes, and computed tomography findings were collected. Outcomes were assessed using the Glasgow outcome score (GOS) based on the latest follow-up. Outcomes were divided into favorable (GOS 4-5) and unfavorable (GOS 1-3). Results Surgery was performed in 43 patients. The mean age was 9.6 ± 4.9. The mean follow-up period was 31 weeks. Thirty (70%) patients had favorable outcome and 13 (30%) had unfavorable outcome. On univariate analysis, mechanism of injury, vomiting, Glasgow coma scale score, pupil size and reactivity, hypotension, inotropic use, need for blood transfusion, and raised ICP (all P < 0.005) were significantly associated with outcomes. On step-wise logistic regression, only raised ICP (odds ratio [OR] = 35.6, P = 0.008) and hypotension (OR = 26.1, P = 0.01) were found to be statistically significant. Conclusion The present study suggests that the majority of pediatric TBI patients who required neurosurgical intervention have favorable outcomes. Closer attention should be paid to raised ICP and hypotension as they were strong predictors of unfavorable outcomes. These findings also help manage expectations of patients' family and clinicians.
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Affiliation(s)
- Sean Wei Yi Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yang Ming
- Neurosurgery Division, Department of Surgery, National University Health System, Singapore
| | - Swati Jain
- Neurosurgery Division, Department of Surgery, National University Health System, Singapore
| | - Shu Ying Chee
- Neurosurgery Division, Department of Surgery, National University Health System, Singapore
| | - Kejia Teo
- Neurosurgery Division, Department of Surgery, National University Health System, Singapore
| | - Ning Chou
- Neurosurgery Division, Department of Surgery, National University Health System, Singapore
| | - Sein Lwin
- Neurosurgery Division, Department of Surgery, National University Health System, Singapore
| | - Tseng Tsai Yeo
- Neurosurgery Division, Department of Surgery, National University Health System, Singapore
| | - Vincent Diong Weng Nga
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Neurosurgery Division, Department of Surgery, National University Health System, Singapore
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Manfiotto M, Beccaria K, Rolland A, Paternoster G, Plas B, Boetto S, Vinchon M, Mottolese C, Beuriat PA, Szathmari A, Di Rocco F, Scavarda D, Seigneuret E, Wrobleski I, Klein O, Joud A, Gimbert E, Jecko V, Vignes JR, Roujeau T, Dupont A, Zerah M, Lonjon M. Decompressive Craniectomy in Children with Severe Traumatic Brain Injury: A Multicenter Retrospective Study and Literature Review. World Neurosurg 2019; 129:e56-e62. [PMID: 31054345 DOI: 10.1016/j.wneu.2019.04.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Pediatr Crit Care Med 2019; 20:280-289. [PMID: 30830016 DOI: 10.1097/pcc.0000000000001736] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. METHODS AND MAIN RESULTS This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. CONCLUSIONS New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Tang Z, Huang Q, Zhang J, Yang R, Wei W, Liu H. Fourteen-Day Mortality in Pediatric Patients with Traumatic Brain Injury After Early Decompressive Craniectomy: A Single-Center Retrospective Study. World Neurosurg 2018; 119:e389-e394. [PMID: 30071325 DOI: 10.1016/j.wneu.2018.07.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the risk factors for 14-day mortality in pediatric patients undergoing early decompressive craniectomy (DC) after traumatic brain injury (TBI). METHODS This retrospective analysis included all pediatric patients (≤16 years of age) undergoing DC within 12 hours of TBI between August 2011 and July 2017 at the authors' institute. Demographic information, clinical characteristics, surgical information, and laboratory parameters were retrieved from medical records. Risk factors for 14-day mortality were analyzed using multivariate logistic regression models. First, potentially relevant variables were compared between those who died within 14 days versus those who did not. Variables with P < 0.10 were entered into the final multivariate regression analysis. RESULTS A total of 36 patients (23 boys and 13 girls; median age, 7 years) were included in the analysis. Fall (n = 19, 52.8%) was the leading cause of injury. The 14-day mortality was 38.9% (14/36). At the time of admission, the median Glasgow Score Scale (GCS) was 6 (IQR 4-8), and the mean Injury Severity Score (ISS) (± standard deviation) was 29.03 ± 8.54. Preoperative hypoxia, defined as oxyhemoglobin arterial saturation <90% or apnea >20 seconds, was observed in 6 patients (16.7%). Coagulopathy was present in 14 patients (38.9%). Multivariate logistic regression analysis suggested an association between 14-day mortality and younger age (odds ratio [OR] = 0.708, 95% confidence interval [CI]: 0.513-0.978; P = 0.036) and higher ISS (OR = 1.399; 95% CI: 1.023-1.914; P = 0.035). CONCLUSIONS In children undergoing early DC after TBI, risk factors for 14-day mortality include younger age and higher ISS.
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Affiliation(s)
- Zhiji Tang
- Department of Neurosurgery, the Affiliated Brain Hospital, Nanjing Medical University, Nanjing, People's Republic of China; Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Qianliang Huang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Jinshi Zhang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Ruijin Yang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Wenjin Wei
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Hongyi Liu
- Department of Neurosurgery, the Affiliated Brain Hospital, Nanjing Medical University, Nanjing, People's Republic of China.
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Prasad GL, Gupta DK, Mahapatra AK, Sharma BS. Surgical results of decompressive craniectomy in very young children: A level one trauma centre experience from India. Brain Inj 2015; 29:1717-24. [DOI: 10.3109/02699052.2015.1075146] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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