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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; 188:185-198.e10. [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] [MESH Headings] [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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Pisică D, Volovici V, Yue JK, van Essen TA, den Boogert HF, Vande Vyvere T, Haitsma I, Nieboer D, Markowitz AJ, Yuh EL, Steyerberg EW, Peul WC, Dirven CMF, Menon DK, Manley GT, Maas AIR, Lingsma HF. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Neurosurgery 2024:00006123-990000000-01172. [PMID: 38771081 DOI: 10.1227/neu.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Guideline recommendations for surgical management of traumatic epidural hematomas (EDHs) do not directly address EDHs that co-occur with other intracranial hematomas; the relative rates of isolated vs nonisolated EDHs and guideline adherence are unknown. We describe characteristics of a contemporary cohort of patients with EDHs and identify factors influencing acute surgery. METHODS This research was conducted within the longitudinal, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury cohort study which prospectively enrolled patients with traumatic brain injury from 65 hospitals in 18 European countries from 2014 to 2017. All patients with EDH on the first scan were included. We describe clinical, imaging, management, and outcome characteristics and assess associations between site and baseline characteristics and acute EDH surgery, using regression modeling. RESULTS In 461 patients with EDH, median age was 41 years (IQR 24-56), 76% were male, and median EDH volume was 5 cm3 (IQR 2-20). Concomitant acute subdural hematomas (ASDHs) and/or intraparenchymal hemorrhages were present in 328/461 patients (71%). Acute surgery was performed in 99/461 patients (21%), including 70/86 with EDH volume ≥30 cm3 (81%). Larger EDH volumes (odds ratio [OR] 1.19 [95% CI 1.14-1.24] per cm3 below 30 cm3), smaller ASDH volumes (OR 0.93 [95% CI 0.88-0.97] per cm3), and midline shift (OR 6.63 [95% CI 1.99-22.15]) were associated with acute surgery; between-site variation was observed (median OR 2.08 [95% CI 1.01-3.48]). Six-month Glasgow Outcome Scale-Extended scores ≥5 occurred in 289/389 patients (74%); 41/389 (11%) died. CONCLUSION Isolated EDHs are relatively infrequent, and two-thirds of patients harbor concomitant ASDHs and/or intraparenchymal hemorrhages. EDHs ≥30 cm3 are generally evacuated early, adhering to Brain Trauma Foundation guidelines. For heterogeneous intracranial pathology, surgical decision-making is related to clinical status and overall lesion burden. Further research should examine the optimal surgical management of EDH with concomitant lesions in traumatic brain injury, to inform updated guidelines.
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Affiliation(s)
- Dana Pisică
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Victor Volovici
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - John K Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Division of Neurosurgery, Department of Surgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hugo F den Boogert
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Amy J Markowitz
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center and Haaglanden Medical Center, Leiden and The Hague, the Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
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Chakradhar R, Harrylal KA, Kumari K, Karki S, Sedain G, Pradhanang A, Shilpakar SK, Sharma MR. Clinico-radiological correlation with outcome in acute epidural haematoma: a tertiary centre experience from Nepal. Ann Med Surg (Lond) 2024; 86:2446-2452. [PMID: 38694285 PMCID: PMC11060279 DOI: 10.1097/ms9.0000000000002018] [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: 10/24/2023] [Accepted: 03/18/2024] [Indexed: 05/04/2024] Open
Abstract
Background Epidural haematoma (EDH) accounts for up to 15% of severe traumatic brain injury (TBI) cases and remains the most common cause of mortality and disability. Several clinical and radiological factors affect patient outcomes. This study aims to correlate patients' clinical and radiological profiles with acute EDH outcomes. Methods A retrospective, single-centred, consecutive case series was conducted on the patients diagnosed with an acute EDH admitted to Tribhuvan University Teaching Hospital (TUTH) between May 2019 and April 2023. The modified Rankin scale (mRS) was used to assess the outcome. Univariate analysis and Kruskal-Wallis H test with Dunn-Bonferroni post-hoc test was conducted. Results There were 107 patients diagnosed with EDH, of which 52.3% were less than 20 years old with male preponderance. Falls were the most common mechanism of injury (64.5%), and most cases were referred to, not brought directly. The majority had a GCS score greater than or equal to 13 (85%) at presentation, and only 5.5% had a GCS score less than or equal to 8. According to the mRS, most patients had favourable outcomes, with 88.7% having no significant disability and 11.3% having a slight disability. Conclusion This case series is the largest and most recent report from Nepal and demonstrated that GCS, pupillary response, skull fracture, neurological symptoms, pre-hospital and intra-hospital delay, and management modalities are critical factors in determining the total hospital and ICU stay but did not have an impact on the mRS scores.
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Affiliation(s)
| | | | - Khusbu Kumari
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Susmin Karki
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Gopal Sedain
- Department of Neurosurgery, Tribhuvan University Teaching Hospital
| | - Amit Pradhanang
- Department of Neurosurgery, Tribhuvan University Teaching Hospital
| | | | - Mohan Raj Sharma
- Department of Neurosurgery, Tribhuvan University Teaching Hospital
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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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Usman B, Mohammed B, Daibu U. Outcomes of Evacuating Subacute Extradural Hematoma Through a Minicraniectomy: A 5-Year Study. INDIAN JOURNAL OF NEUROTRAUMA 2023. [DOI: 10.1055/s-0043-1760742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Background Extradural hematoma (EDH) is a hematoma between the dura and the inner surface of the skull, found in 1 to 3% of all head-injured patients, rising to 9% among the unconscious ones. It is said to be subacute when about 2 to 4 days old. Further enlargement of the burr hole to about 3 to 5 cm wide (minicraniectomy) may allow its total evacuation.
Objective To recommend it as a treatment option, this study aims to evaluate the surgical outcomes of evacuating a subacute EDH through a minicraniectomy.
Method This was a 5-year prospective study in a Nigerian tertiary health institution.
Results In total, 108 patients, consisting of 96 males and 12 females with a male to female ratio of 8:1 were included. Their ages ranged from 10 to 69 years. Etiologies were road traffic accident (RTA, 73.2%), assault (18.5%), and falls (8.3%). Hematoma ages were 2 days (61.1%), 3 days (25%), 4 days (13.9%). GCS were mild (11%), moderate (56%), and severe (33%). Locations were right-sided (59.3%), left-sided (40.7%) with 73.1% in parietotemporal area. Active bleeding was encountered in 15% only. Postoperative complications were seizure (13.9%), death (12%), and surgical site infection (4.6%) among others. Outcomes at 2 weeks were good (83, 76.9%), moderate disability (12, 11.1%), severe disability (10, 9.3%), vegetative (1, 0.9%), and death (2, 1.9%).
Conclusion Considering the significant morbidity and mortality and the need for urgent interventions in EDH, most patients presenting in the subacute acute (2– 4 days) stage can be evacuated via a minicraniectomy with good outcomes.
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Affiliation(s)
- Babagana Usman
- Neurosurgery Unit, Surgery Department, The University of Maiduguri and the University of Maiduguri Teaching Hospital, Borno State, Nigeria
- Visiting Neurosurgeon to the Surgery Department, Federal Medical Centre, Yola, Adamawa State, Nigeria
| | - Babagana Mohammed
- Neurosurgery Unit, Surgery Department, The University of Maiduguri and the University of Maiduguri Teaching Hospital, Borno State, Nigeria
| | - Usman Daibu
- Neurosurgery Unit, Surgery Department, The University of Maiduguri and the University of Maiduguri Teaching Hospital, Borno State, Nigeria
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Role of routine post-operative CT brain following evacuation of extradural haematoma in children: a single-centre experience. Childs Nerv Syst 2020; 36:3095-3098. [PMID: 32415414 DOI: 10.1007/s00381-020-04664-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Extradural haematoma (EDH) is a serious neurosurgical emergency in children, which confers significant morbidity and mortality rates. The objective of this study was to retrospectively evaluate the role of post-operative imaging in children with EDH who were managed surgically in a national paediatric neurosurgical unit over a 9-year period (January 2008 to December 2016). METHODS A retrospective case review of paediatric patients who underwent surgical evacuation of extradural haematoma between January 2008 and December 2016 was performed. This included demographic and clinical details, indications for post-operative imaging and outcomes. RESULTS Seventy patients underwent surgical management of EDH during this time period, with a male preponderance (69%) and a mean age of 8 years. The commonest location of haematoma in this cohort was in the parietal region (n = 24), with a mean maximum thickness of 25.9 mm and mean volume of 57 ml. Post-operative imaging was performed in 84% of patients. However, only one patient had a change in the course of their post-operative management as a result of post-operative imaging findings. CONCLUSIONS Post-operative imaging in asymptomatic paediatric patients after evacuation of EDH could therefore be avoided as a routine investigation.
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Uppar A, Kadregula S, Sadashiva N, Konar S, Chakrabarti D, Thombre B, Ar P, Rao KN, Shukla D. Surgical outcomes of Supra- Infra Tentorial Extradural Hematoma (SIEDH): A retrospective study from a single institution. Clin Neurol Neurosurg 2020; 200:106369. [PMID: 33243700 DOI: 10.1016/j.clineuro.2020.106369] [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: 06/27/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Bicompartmental Supra plus Infratentorial Extra Dural Hematoma (SIEDH) is an uncommon yet important category of Extradural Hematoma (EDH) straddling the transverse sinus. It requires quick decision making and proper surgical evacuation. METHODS We did a retrospective chart review of all SIEDH cases from prospectively maintained operative database in our institute between 2011 & 2017. Clinical status at discharge and follow up were used to assess outcome. Ordinal regression analysis was used for analysis of factors predicting the outcome. We also describe the surgical procedure we follow at our high-volume trauma center for this unique entity. RESULTS We had 61 operated cases of SIEDH in our series. The median age of the cohort was 30 years (IQR: 21.5-42). Road Traffic Accident was the most common mode of injury (67.2 %). Median pre-operative GCS was 12 (IQR: 9-12). The median volume of SIEDH was 50cc (IQR: 40-70). Mass effect on 4thventricle and brainstem was seen in 47 and 34 patients respectively. An associated fracture was seen in 54 patients. Sinus injury related bleed was noted intra-operatively in 57 % (N = 35). Follow up was available for 60 cases with a median of 130 days. On evaluating with ordinal regression analysis, we found that, the GCS at presentation, pupillary asymmetry, volume of SIEDH, infratentorial volume, blood loss and mass effect on 4thventricle were statistically significant factors affecting GCS at discharge. However, the GCS at presentation, infratentorial volume and blood loss were the only factors determining GOS at follow-up. CONCLUSION SIEDH are uncommon yet important type of injury type which requires prompt attention and appropriate nuanced approach. Large SIEDH are commonly associated with sinus injury, and large volume blood loss may be anticipated. In addition, SIEDH may be associated with other traumatic brain injuries which may require surgical evacuation.
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Affiliation(s)
- Alok Uppar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Sandeep Kadregula
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Bhushan Thombre
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Prabhuraj Ar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Kannepalli Narasingha Rao
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
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