Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

Treatment-limiting decisions in patients with severe traumatic brain injury in the Netherlands

Introduction

Treatment-limiting decisions (TLDs) can be inevitable severe traumatic brain injury (s-TBI) patients, but data on their use remain scarce.

Research question

To investigate the prevalence, timing and considerations of TLDs in s-TBI patients.

Material and methods

s-TBI patients between 2008 and 2017 were analysed retrospecively. Patient data, timing, location, involvement of proxies, and reasons for TLDs were collected. Baseline characteristics and in-hospital outcomes were compared between s-TBI patients with and without TLDs.

Results

TLDs were reported in 117 of 270 s-TBI patients (43.3%) and 95.9% of deaths after s-TBI were preceded by a TLD. The majority of TLDs (68.4%) were categorized as withdrawal of therapy, of which withdrawal of organ-support in 64.1%. Neurosurgical intervention was withheld in 29.9%. The median time from admission to TLD was 2 days [IQR, 0-8] and 50.4% of TLDs were made within 3 days of admission. The main reason for a TLD was that the patients were perceived as unsalvageable (66.7%). Nearly all decisions were made multidisciplinary (99.1%) with proxies involvement (75.2%). The predicted mortality (CRASH-score) between patients with and without TLDs were 72.6 vs. 70.6%. The percentage of TLDs in s-TBI patients increased from 20.0% in 2008 to 42.9% in 2012 and 64.3% in 2017.

Discussion and conclusion

TLDs occurred in almost half of s-TBI patients and were instituted more frequently over time. Half of TLDs were made within 3 days of admission in spite of baseline prognosis between groups being similar. Future research should address whether prognostic nihilism contributes to self-fulfilling prophecies.

Pilot Biomarker Analysis and Decision Tree Algorithm Modeling of Patients with Chronic Subdural Hematomas

The elderly population are at high risk for developing chronic subdural hematoma (cSDH). Surgical evacuation of cSDH is one of the most common procedures performed in neurosurgery. The present study aims to identify potential inflammatory biomarkers associated with its development and recurrence. Patients (>65 years of age) who presented with symptomatic cSDH (≥1 cm thickness or ≥5 mm midline shift [MLS]), requiring surgical intervention, were prospectively enrolled. The collected cSDH fluid was analyzed for inflammatory markers. Computed tomography (CT) scan data included pre-operative cSDH thickness and MLS. Outcome data included Glasgow Outcome Scale-Extended (GOS-E) score at 3, 6, and 12 months post-surgery, as well as cSDH recurrence. A decision tree model was used to determine the predictive power of extracted analytes for MLS, cSDH thickness, and recurrence. This pilot study includes 20 enrolled patients (mean age 77.9 ± 7.4 years and 85% falls). Rate of cSDH recurrence was 42%, with 21% requiring reoperation. Chemokine (C-X-C motif) ligand 9 (CXCL9) concentrations correlated with cSDH thickness (r = 0.975, p = 0.040). Interleukin (IL)-6 and vascular endothelial growth factor (VEGF)-A concentrations correlated with MLS (r = 0.974, p = 0.005; r = 0.472, p = 0.036, respectively). IL-5 concentrations correlated with more favorable GOS-E scores at 3, 6, and 12 months (r = 0.639, p = 0.006; r = 0.727, p = 0.003; r = 0.693, p = 0.026, respectively). Regulated on activation, normal T-cell expressed and secreted (RANTES) concentrations correlated with complete cSDH resolution (r = 0.514, p = 0.021). The decision tree model identified that higher concentrations of CXCL9 were predictive of MLS (risk ratio [RR] = 12.0), higher concentrations of IL-5 were predictive of cSDH thickness (RR = 4.5), and lower concentrations of RANTES were predictive of cSDH recurrence (RR = 2.2). CXCL9, IL-6, VEGF, IL-5, and RANTES are associated with recurrence after surgery and may be potential biomarkers for predicting cSDH recurrence and neurological outcomes.

A multicentre retrospective cohort study on health-related quality of life after traumatic acute subdural haematoma: does cranial laterality affect long-term recovery?

BACKGROUND

Traumatic acute subdural haematoma is a debilitating condition. Laterality intuitively influences management and outcome. However, in contrast to stroke, this research area is rarely studied. The aim is to investigate whether the hemisphere location of the ASDH influences patient outcome.

METHODS

For this multicentre observational retrospective cohort study, patients were considered eligible when they were treated by a neurosurgeon for traumatic brain injury between 2008 and 2012, were > 16 years of age, had sustained brain injury with direct presentation to the emergency room and showed a hyperdense, crescent shaped lesion on the computed tomography scan. Patients were followed for a duration of 3-9 months post-trauma for functional outcome and 2-6 years for health-related quality of life. Main outcomes and measures included mortality, Glasgow Outcome Scale and the Quality of Life after Brain Injury score. The hypothesis was formulated after data collection.

RESULTS

Of the 187 patients included, 90 had a left-sided ASDH and 97 had a right-sided haematoma. Both groups were comparable at baseline and with respect to the executed treatment. Furthermore, both groups showed no significant difference in mortality and Glasgow Outcome Scale score. Health-related quality of life, assessed 59 months (IQR 43-66) post-injury, was higher for patients with a right-sided haematoma (Quality of Life after Brain Injury score: 80 vs 61, P = 0.07).

CONCLUSIONS

This study suggests patients with a right-sided acute subdural haematoma have a better long-term health-related quality of life compared to patients with a left-sided acute subdural haematoma.

Differences in Presentation, Radiological Features, and Outcomes in Traumatic Versus Spontaneous Acute Subdural Hematomas-A Single-Institution Population-Based Study

BACKGROUND

Spontaneous acute subdural hematoma (sASDH) is a rare neurosurgical condition, with the literature mainly consisting of case reports. In the present study, we compared sASDH with traumatic ASDH (tASDH) to determine the differences in presentation, radiological features, and outcomes in a population-based setting.

METHODS

All adult patients (age ≥18 years) who had undergone surgery for ASDH (n = 266), either spontaneous or traumatic, from 2010 to 2020 were included retrospectively. The cohort was divided into 2 groups for comparative analysis: sASDH group (n = 24) versus tASDH group (n = 242).

RESULTS

Of the 266 patients, 24 (9.0%) had presented with sASDH. The sASDH group had a mean age of 66.2 years, and sudden headache was the most common presenting symptom (83.3%). The sASDH group had a higher Glasgow coma scale score at presentation compared with the tASDH group (Glasgow coma scale scores, 10 and 8, respectively; P < 0.01). The outcomes, assessed using the Glasgow outcome scale (GOS), revealed a greater incidence of more favorable outcomes (GOS score 4-5) for the sASDH group (72.7%) than for the tASDH group (41.5%).

CONCLUSIONS

In the present population-based study of surgically evacuated ASDH cases, 9% were spontaneous without previous trauma. The outcomes (GOS scores) were significantly more favorable for those with sASDH than for those with tASDH. In one half of the patients with sASDH, arterial bleeding was noted perioperatively, although the preoperative radiological examinations revealed no abnormalities for most patients. However, the lack of sufficient examinations such as computed tomography angiography made it difficult to establish the most common etiology of bleeding in those with sASDH. Further research is warranted to determine the reference standard method for the investigation of sASDH.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design

BACKGROUND

The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024.

DISCUSSION

The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered.

TRIAL REGISTRATION

Nederlands Trial Register (NTR), Trial NL9012 .

CLINICALTRIALS

gov, Trial NCT04648436 .

Considering Futility of Care Decisions in Neurosurgical Practice

Neurosurgeons commonly encounter futility of care decisions in their practice. Are these decisions being made with adequate consideration? What is the preparation of neurosurgical trainees for making these decisions? The advent of the COVID-19 pandemic with its extreme pressure on resources and, in particular, intensive care unit beds, has prompted many health care providers including neurosurgeons to consider more fully the potentially futile nature of some treatments and how we might better manage limited resources for the future. We review the concept of futility in neurosurgery and suggest potential solutions to the multiple challenges that arise.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study

BACKGROUND

The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI.

METHODS

We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation.

RESULTS

A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%).

CONCLUSION

In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond

PURPOSE OF REVIEW

There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies.

RECENT FINDINGS

Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome.

SUMMARY

Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.