Elderly Patients with Severe Traumatic Brain Injury Could Benefit from Surgical Treatment

Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury

PURPOSE

This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition.

METHOD

Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines.

RESULTS

64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %).

CONCLUSION

Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.

Risk factors of prognosis in older patients with severe brain injury after surgical intervention

BACKGROUND

Older patients (aged ≥ 60 years) with severe brain injury have a high mortality and disability rate. The objective of this retrospective study was to assess the clinical risk factors of prognosis in older patients with severe brain injury after surgical intervention and to analyze the prognosis of the surviving group of patients 1 year after discharge.

METHODS

Clinical data of older patients with severe brain injury who were admitted to two neurosurgical centers between January 2010 and December 2020 were collected. Patient age, sex, Glasgow Coma Scale (GCS) score at admission, underlying disease, mechanisms of injury, abnormal pupillary reflex, head computed tomography imaging findings (such as hematoma type),intraoperative brain swelling and other factors were reviewed. All the patients were categorized into a good prognosis (survival) group and a poor prognosis (death) group by the Glasgow Outcome Score (GOS); also, the related factors affecting the prognosis were screened and the independent risk factors were identified by the Binary logistic regression analysis. GOS was used to evaluate the prognosis of the surviving group of patients 1 year after discharge.

RESULTS

Out of 269 patients, 171 (63.6%) survived, and 98 (36.4%) died during hospitalization. Univariate analysis showed that age, GCS score at admission, underlying diseases, abnormal pupillary reflex, the disappearance of ambient cistern, the midline structure shift, intraoperative brain swelling, oxygen saturation < 90%, and cerebral hernia were risk factors for the prognosis of older patients with severe brain injury after surgical intervention. Multivariate analysis showed that age, underlying diseases, disappearance of ambient cistern, Oxygen saturation < 90% and intraoperative brain swelling were independent risk factors of the prognosis in the population. The effect of surgical intervention differed among various age groups at 1-year follow-up after surgery.

CONCLUSIONS

The results of this retrospective study confirmed that age, underlying diseases, disappearance of ambient cistern, intraoperative brain swelling, and oxygen saturation < 90% are associated with poor prognosis in older postoperative patients with severe brain injury. Surgical intervention may improve prognosis and reduce mortality in older patients (age < 75 years). But for those patients (age ≥ 75 years), the prognosis was poor after surgical intervention.

Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.

Neurosurgical treatment in elderly patients with Traumatic brain injury: A 20-year follow-up study

Introduction

Traumatic brain injury in the elderly population can have a substantial impact on patients' quality of life. In this regard, successful treatment strategies are hard to define to date.

Research question

In order to facilitate further insight, this study assessed outcomes following acute subdural hematoma evacuation in patients aged ≥65 years in a large patient series.

Material and methods

A manual screening of the clinical records of 2999 TBI patients aged ≥65 years, admitted to the University Hospital Leuven (Belgium) between 1999 and 2019, was performed.

Results

A total of 149 patients were identified with aSDH, of whom 32 underwent early surgery, 33 underwent delayed surgery and 84 were treated conservatively. Patients who underwent early surgery had the lowest median GCS, poorest Marshall CT scores, longest hospital and ICU stay, and highest intensive care unit admission and redo surgery rates. 30-d mortality was 21.9% in patients undergoing early surgery, 3.0% in patients undergoing late surgery and 16.7% in patients who were treated conservatively.

Discussion and conclusion

In conclusion, patients in whom surgery could not be delayed had the worst presentation and poorest outcomes as opposed in patients in whom delay was possible. Surprisingly, patients treated conservatively had worse outcomes than those treated with delayed surgery. These results might indicate that if the GCS at admission is still adequate, an initial strategy of waiting and seeing might be associated with better outcomes. Future prospective studies with sufficient sample size are warranted to draw more definitive conclusions on the value of early vs. late surgery in elderly patients with aSDH.

Traumatic brain injury in the elderly after a skiing accident: A retrospective cohort study in a level 1 emergency department in Switzerland

Background

Skiing is a very popular sport worldwide, with increasing trends over the past decades. This study aimed to evaluate the importance of traumatic brain injury (TBI), especially in the elderly, after a ski accident, and to describe its short-term repercussions.

Methodology

Patients were analyzed who were admitted to our neurotrauma center from 2012–2018 after a head trauma while skiing. Three different age groups were differentiated and analyzed for the severity of TBI depending on the initial Glasgow Coma Scale as the primary outcome and as secondary outcomes need and type of surgery, Glasgow Outcome Score, preexisting use of anticoagulant or antiplatelet drugs, time to presentation, and pattern of brain injury. TBI severity was adjusted to the time to initial medical consultation.

Results

No significant difference in TBI severity was found when comparing the middle (>29–54) and older (≥54) age groups to the reference group <30 years (OR:0.45, p = 0.127; OR:0.46, p = 0.17). Acute subdural hemorrhage was present in 21.2% of the ≥55 group and 14.5% of the 30–54 age group, compared to 12.8% of the youngest group (p = <0.001). Overall, 39.4% of the patients in the ≥55 group and 8.1% of the 30–54 age group presented with chronic subdural hemorrhage, whereas none of the youngest patients did (p = <0.001).

Conclusion

No differences were observed in terms of TBI severity between age groups after acute trauma. Nonetheless, a different pattern of head injury after TBI in older patients was demonstrated. Accordingly, the management differs for these TBIs compared to those of younger patients.

What are the demographic and clinical differences between those older adults with traumatic brain injury who receive a neurosurgical intervention to those that do not? A systematic literature review with narrative synthesis

OBJECTIVES

This review aimed to identify the demographic and clinical differences between those older adults admitted directly under neurosurgical care and those that were not, and whether EMS clinicians could use these differences to improve patient triage.

METHODS

The authors searched for papers that included older adults who had suffered a TBI and were either admitted directly under neurosurgical care or were not. Titles and abstracts were screened, shortlisting potentially eligible papers before performing a full-text review. The Newcastle-Ottawa Scale was used to assess the risk of bias.

RESULTS

A total of nine studies were eligible for inclusion. A high abbreviated injury score head, Marshall score or subdural hematoma greater than 10 mm were associated with neurosurgical care. There were few differences between those patients who did and did not receive neurosurgical intervention.

CONCLUSIONS

Absence of guidelines and clinician bias means that differences between those treated aggressively and conservatively observed in the literature are fraught with bias. Further work is required to understand which patients would benefit from an escalation of care and whether EMS can identify these patients so they are transported directly to a hospital with the appropriate services on-site.

Neurointensive care of traumatic brain injury in the elderly-age-specific secondary insult levels and optimal physiological levels to target need to be defined

BACKGROUND

Elderly patients with traumatic brain injury increase. Current targets and secondary insult definitions during neurointensive care (NIC) are mostly based on younger patients. The aim was therefore to study the occurrence of predefined secondary insults and the impact on outcome in different ages with particular focus on elderly.

METHODS

Patients admitted to Uppsala 2008-2014 were included. Patient characteristics, NIC management, monitoring data, and outcome were analyzed. The percentage of monitoring time for ICP, CPP, MAP, and SBP above-/below-predefined thresholds was calculated.

RESULTS

Five hundred seventy patients were included, 151 elderly ≥ 65 years and 419 younger 16-64 years. Age ≥ 65 had significantly higher percentage of CPP > 100, MAP > 120, and SBP > 180 and age 16-64 had higher percentage of ICP ≥ 20, CPP ≤ 60, and MAP ≤ 80. Age ≥ 65 contributed independently to the different secondary insult patterens. When patients in all ages were analyzed, low percentage of CPP > 100 and SBP > 180, respectively, was significant predictors of favorable outcome and high percentage of ICP ≥ 20, CPP > 100, SBP ≤ 100, and SBP > 180, respectively, was predictors of death. Analysis of age interaction showed that patients ≥ 65 differed and had a higher odds for favorable outcome with large proportion of good monitoring time with SBP > 180.

CONCLUSIONS

Elderly ≥ 65 have different patterns of secondary insults/physiological variables, which is independently associated to age. The finding that SBP > 180 increased the odds of favorable outcome in the elderly but decreased the odds in younger patients may indicate that blood pressure should be treated differently depending on age.

The Morbidity and Mortality of Surgery for Traumatic Brain Injury in Geriatric Patients: A Study of Over 100 000 Patient Cases

BACKGROUND

Geriatric patients have the highest rates of Traumatic Brain Injury (TBI)-related hospitalization and death. This contributes to an assumption of futility in aggressive management in this population.

OBJECTIVE

To evaluate the effect of surgical intervention on the morbidity and mortality of geriatric patients with TBI.

METHODS

A retrospective analysis of patients ≥80 yr old with TBI from 2003 to 2016 was performed using the National Trauma Data Bank. Univariate and multivariate analyses were performed to compare outcomes between surgery and nonsurgery groups.

RESULTS

A total of 127 129 patient incidents were included: 121 185 (95.3%) without surgery and 5944 (4.7%) with surgery. The surgical group was slightly younger (84.0 vs 84.3, P < .001) and predominantly male (60.2% vs 44.4%, P < .001). Mean emergency department (ED) Glasgow Coma Scale (GCS) was lower in surgical patients (12.4 vs 13.7, P < .001). Complications (OR = 1.91, CI:1.80-2.02, P < .001) and hospital length of stay (LOS, ß = 5.25, CI:5.08-5.42, P < .001) were independently associated with surgery. Intensive care unit (ICU) LOS (ß = 3.19, CI:3.05-3.34, P < .001), ventilator days (ß = 1.57, CI:1.22-1.92, P < .001), and reduced discharge home (OR = 0.434, CI:0.400-0.470, P < .001) were also independently associated with surgery. However, surgery was not independently associated with mortality on multivariate analysis (OR = 1.03, CI:0.955-1.12, P = .423). Recursive partitioning analysis identified ED GCS and injury severity score (ISS) as prognosticators of mortality following surgical intervention.

CONCLUSION

Surgical treatment of geriatric patients with TBI is associated with increased complications, hospital LOS, ICU LOS, and ventilator days as well as reduced discharge to home. However, surgery is not associated with increased mortality. ISS and ED GCS are prognosticators of mortality following surgical intervention.

Outcome and its predictors in traumatic brain injury in elderly population: Institutional study from Northern India

Introduction:

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Survival and functional outcome is significantly poor in the elderly population. There is a need to develop better geriatric specific prognostic models and evidence-based geriatric traumatic brain injury management protocols for better treatment, rehabilitation, and prevention.

Aims and objectives:

To study the frequency, outcome and correlates of traumatic brain injury in elderly patients.

Material and Methods:

Frequency, outcome and correlates of traumatic brain injury in patients more than 65 years of age admitted in tertiary care hospital were studied in 160 patients admitted between 1^st January 2016 and 31^st December 2016 (retrospective analysis) and between 1^st January 2017 and 30^th June 2018 (prospective analysis). Institutional ethical committee approval was taken.

Results:

This study concluded that road side accident was the most common cause of traumatic brain injury in elderly in this study. Incidence of traumatic brain injury in elderly was found to be 11.45%. Both non-reacting pupils and low Glasgow coma scale on arrival were significantly associated with poor outcome in terms of mortality. Most of the patients who expired or were discharged against medical advice had associated skull bone fractures, cerebral infarct, diffuse brain edema, subarachnoid hemorrhage, midline shift, lower hemaglobin, higher random blood sugar and higher creatinine as compared to patients who were discharged. All these findings were statistically significant.

Conclusion:

Low Glasgow coma scale on arrival, non reacting pupils, low hemoglobin, high random blood sugar, high creatinine and intubation on arrival are associated with increased mortality. Associated skull bone fractures, cerebral infarct, diffuse brain edema are predictors of poor outcome. Anticoagulants and associated co-morbidities do not increase the risk of mortality in traumatic brain injury in elderly.

Functional outcome, dependency and well-being after traumatic brain injury in the elderly population: A systematic review and meta-analysis

Introduction

Traumatic brain injury (TBI) rates in the elderly are increasing worldwide, mainly due to fall accidents. However, TBI's impact on elderly patients' lives has not been thoroughly investigated.

Research question

This systematic review and meta-analysis aims at describing post-TBI incidence of functional decline, dependency, nursing home admission, reduced quality of life and depression in the elderly.

Materials and methods

A systematic literature search was performed in PubMed, EMBASE, Web Of Science, BIOSIS, Current Contents Connect, Data Citation Index, MEDLINE, SciELO, Cochrane library and CINAHL. Study selection was conducted by two independent reviewers. Meta-analysis was performed using a random-effects model.

Results

Twenty-seven studies were included in the qualitative synthesis and twenty-five in a random-effects meta-analysis. The prevalence of unfavorable functional outcomes after TBI was 65.2% (95% CI: 51.1–78.0). Admission to a nursing home had a pooled prevalence of 28.5% (95% CI: 17.1–41.6) and dependency rates ranged between 16.9% and 74.0%. A reduced quality of life was documented throughout follow-up with SF12/36 scores between 35.3 and 52.3/100.2.6–4.8% of the patients with mild TBI reported depressive symptoms. A large heterogeneity was found among studies for functional outcomes and discharge destination.

Discussion and conclusion

In conclusion, elderly patients have a significant risk for functional decline, dependency, nursing home admission and low quality of life following TBI. Moreover, more severe injuries lead to worse outcomes. These findings are important to provide accurate patient and family counseling, set realistic treatment targets and aim at relevant outcome variables in prognostic models for TBI in elderly patients.

•

Traumatic Brain Injury in the elderly has a major impact on functional outcomes.

•

Traumatic Brain Injury in elderly leads to dependency and nursing home admission.

•

Elderly patients have a lower quality of life after Traumatic Brain Injury.

•

Older age and injury severity are risk factors for poor functional outcome.

Identification of Prognostic Factors in Surgically Treated Patients with Acute Epidural Hematoma

Context:

Only few comprehensive studies have investigated acute epidural hematoma (AEDH), and a low incidence of the lesion has been observed in comparison with other types of traumatic brain injuries such as subdural hematoma, traumatic subarachnoid hemorrhage, and contusion.

Aim:

This study aims to identify the prognostic factors of surgically treated AEDH.

Settings and Design:

The medical records of 58 consecutive patients with surgically treated AEDH between September 2011 and 2018 were retrospectively reviewed.

Subjects and Methods:

All patients were diagnosed with AEDHs using 5-mm-slice computed tomography (CT). Information regarding the following demographic and clinical characteristics was collected: age, sex, antithrombotic drug use, mechanisms of injury, time from onset to operation, neurological examination, vital signs, blood examination, and CT findings.

Statistical Analysis Used:

We analyzed prognostic factors in patients with AEDH using univariate and multivariate regression analyses.

Results:

Univariate and multivariate regression analyses revealed that age (P < 0.01) and the Glasgow Coma Scale (GCS; P < 0.01) were independent predictive factors for good prognosis. In addition, receiver operating characteristics (ROC) analysis showed that an age of <55 years and a GCS score of >12 were optimal cutoff values for predicting good prognoses, with the areas under the ROC curve of 0.827 and 0.810, respectively.

Conclusions:

Age and GCS are useful predictors of prognosis in patients with surgically treated AEDH. These findings are appropriate prognostic indicators for urgent surgery performed to treat AEDH and intended to help clinicians make a prompt diagnosis.

Association of APOE ε4 with progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage

OBJECTIVE

The intracranial hematoma volume in patients with traumatic brain injury is a key parameter for the determination of the management approach and outcome. Apolipoprotein E (APOE) ε4 is reported to be a risk factor for larger hematoma volume, which might contribute to a poor outcome. However, whether APOE ε4 is related to progressive hemorrhagic injury (PHI), a common occurrence in the clinical setting, remains unclear. In this study, the authors aimed to investigate the association between the APOE genotype and occurrence of PHI.

METHODS

This prospective study included a cohort of 123 patients with traumatic intracerebral hemorrhage who initially underwent conservative treatment. These patients were assigned to the PHI or non-PHI group according to the follow-up CT scan. A polymerase chain reaction and sequencing method were carried out to determine the APOE genotype. Multivariate logistic regression analysis was applied to identify predictors of PHI.

RESULTS

The overall frequency of the alleles was as follows: E2/2, 0%; E2/3, 14.6%; E3/3, 57.8%; E2/4, 2.4%; E3/4, 22.8%; and E4/4, 2.4%. Thirty-four patients carried at least one allele of ε4. In this study 60 patients (48.8%) experienced PHI, and the distribution of the alleles was as follows: E2/2, 0%; E2/3, 5.7%; E3/3, 22.8%; E2/4, 2.4%; E3/4, 16.3%; and E4/4, 1.6%, which was significantly different from that in the non-PHI group (p = 0.008). Additionally, the late operation rate in the PHI group was significantly higher than that in the non-PHI group (24.4% vs 11.4%, p = 0.002). Multivariate logistic regression identified APOE ε4 (OR 5.14, 95% CI 2.40-11.62), an elevated international normalized ratio (OR 3.57, 95% CI 1.61-8.26), and higher glucose level (≥ 10 mmol/L) (OR 3.88, 95% CI 1.54-10.77) as independent risk factors for PHI. Moreover, APOE ε4 was not a risk factor for the coagulopathy and outcome of the patients with traumatic intracerebral hemorrhage.

CONCLUSIONS

The presence of APOE ε4, an elevated international normalized ratio, and a higher glucose level (≥ 10 mmol/L) are predictors of PHI. Additionally, APOE ε4 is not associated with traumatic coagulopathy and patient outcome.

Operative versus non-operative treatment of traumatic brain injuries in patients 80 years of age or older

Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80 years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80 years of age. Data were derived from the TraumaRegister DGU^® from 2002 to 2016. Inclusion criteria were ≥ 80 years of age, an Abbreviated Injury Scale_Head (AIS) ≥ 3, and an AIS_Non-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AIS_Head of 5/6 (p = 0.03). Patients 80 years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.

Craniocervical trauma above the age of 90: are current prognostic scores sufficient?

Clinical data following head or spine trauma in patients over 90 years is rare. The aim of this study was to analyze this patient cohort, assessing clinical characteristics, outcomes, and survival rates and to identify variables that may predict early mortality. A retrospective analysis of all patients over the age of 90 that were treated between January 2006 and December 2016 at our department was performed. Patient characteristics, type of injury, and comorbidities were analyzed with regard to the 30-day mortality rate as the primary outcome. One hundred seventy-nine patients were identified. Mean age was 93 (range 90-102); 105 (59%) patients were female. One hundred thirty-two (74%) and 34 (19%) of patients presented with head and spinal trauma, respectively. Fourteen patients (8%) had a combined head and spine injury. One hundred (56%) patients were treated operatively. Mean Charlson comorbidity index was 4.1 (range 0-18), mean diagnosis count was 6.2 (range 0-12), mean geriatric index of comorbidity (GIC) was 3.3 (range 1-4), and mean Barthel index was 28 (range 0-100). The 30-day mortality rate was 31%. Multivariate cox regression analysis showed that head trauma had a 1.66 hazard ratio (p = 0.036) of dying within 30 days of admission, whereas a higher Glasgow coma score and surgical treatment had a hazard ratio of 0.88 (p = 0.0001) and 0.72 (p = 0.05) to reach the primary outcome. None of the standard geriatric scores reached any significant correlation with the primary outcome. Standard geriatric prognostic scores seem less reliable to predict mortality for patients above the age of 90. Higher Glasgow coma score and surgical treatment were associated with a higher survival probability.

Old age increases microglial senescence, exacerbates secondary neuroinflammation, and worsens neurological outcomes after acute traumatic brain injury in mice

After traumatic brain injury (TBI), individuals aged over 65 years show increased mortality and worse functional outcomes compared with younger persons. As neuroinflammation is a key pathobiological mechanism of secondary injury after TBI, we examined how aging affects post-traumatic microglial responses and functional outcomes. Young (3-month-old) and aged (18-month-old) male C57Bl/6 mice were subjected to moderate-level controlled cortical impact or sham surgery, and neurological function was evaluated. At 72 hours after injury, brain, blood, and spleen leukocyte counts were assessed ex vivo using flow cytometry. Aged mice demonstrated more severe deficits in forelimb grip strength, balance and motor coordination, spontaneous locomotor activity, and anxiety-like behavior. These animals also exhibited more robust microglial proliferation and significantly higher numbers of brain-infiltrating leukocytes. Microglia in aged mice showed impairments in phagocytic activity and higher production of interleukin-1β (IL-1β). Infiltrating myeloid cells in aged TBI mice also had deficits in phagocytosis but showed diminished proinflammatory cytokine production and greater reactive oxygen species production. Expression of several senescence markers (Bcl-2, p16ink4a, p21cip1a, lipofuscin, and H2AX [pS139]) was increased with age and/or TBI in both microglia and injured cortex. Although there was no difference in the number of circulating blood neutrophils as a function of age, young mice exhibited more pronounced TBI-induced splenomegaly and splenic myeloid cell expansion. Thus, worse post-traumatic behavioral outcomes in aged animals are associated with exaggerated microglial responses, increased leukocyte invasion, and upregulation of senescence markers.

Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System

BACKGROUND

Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization.

METHODS

To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection.

RESULTS

The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 10⁹ cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics.

CONCLUSIONS

The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.

A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England

INTRODUCTION

Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU).

METHOD

All patients with a primary injury of TBI who were transported to hospital by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) from 1 January 2016 to 31 December 2016 and entered into the Trauma Audit & Research Network (TARN) registry were reviewed. Patients were stratified by hospital designation (MTC or TU). Severity of TBI was categorised using the patients' pre-hospital Glasgow Coma Scale (GCS) and Abbreviated Injury Score (AIS) Head. The outcomes of interest were 30-day mortality and Glasgow Outcome Score (GOS) at discharge.

RESULTS

Between 1 January and 31 December 2016, 549 TBI patients were identified in the TARN database as being transported by SECAmb to either an MTC or a TU. The majority of patients were transported to a TU (77.96%), and the median age of the TU cohort was older than the MTC group (TU 82.15 IQR 16.73 vs. MTC 62.1 IQR 42.6). The median Injury Severity Score (ISS) was greater in the MTC cohort (22 IQR 10 vs. 17 IQR 9), where falls from height and road traffic collisions (RTCs) contributed to 50.51% of all injuries. Within the TU cohort, falls from less than 2 metres (standing height) were the main mechanism of injury (MOI) (77.62%). The median length of hospital stay (LOS) was longer in the MTC cohort compared to the TU cohort (10 IQR 13.25 vs. 8 IQR 14).

CONCLUSION

The high proportion of mild TBI and absence of reliable triage guidelines make it difficult for ambulance clinicians to identify patients who will benefit from transport to an MTC. Future research should focus on how TBI triage influences outcomes and how ambulance services can better identify patients with a TBI and who would benefit from specialist care.

Traumatic brain injured patients: primum non nocere

PURPOSE OF REVIEW

Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI.

RECENT FINDINGS

Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired.

SUMMARY

Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

Artificial neural network predicts hemorrhagic contusions following decompressive craniotomy in traumatic brain injury

BACKGROUND

This study aimed to explore relevant factors of hemorrhagic contusions following decompressive craniotomy (DC) in traumatic brain injury (TBI) and create an artificial neural network (ANN) prediction model of the risk factors of hemorrhagic contusions.

METHODS

This study analyzed 425 patients with TBI who underwent DC in the Neurosurgery Department of Shaoxing People's Hospital between 2009 and 2014. Patients were divided into two groups according to the first postoperative CT scans: hemorrhage group and non-hemorrhage group. Gender, age, preoperative situations (Initial Rotterdam CT Score, GCS Score, pupillary response, laboratory data and preoperative hematoma), the time gap between trauma and DC, postoperative CT scans, and Glasgow Outcome Scale (GOS) scores were recorded. ANN was used to predict hematoma. Correlation analysis was used to state the relationship between increased hemorrhage volumes and GOS scores.

RESULTS

The ANN prediction model was established. This model included 11 parameters: initial Rotterdam CT score, GCS score, C-reactive protein, age, the time gap between trauma and DC, pupillary response, platelet count, bone-flap size, glucose level, hernia magnitude and preoperative hematoma volume. The overall predictive accuracy of the model was 73.0%.

CONCLUSIONS

Initial Rotterdam CT scores and GCS scores may predict the risk of expansion contusions following DC. The ANN prediction model has a high accuracy to forecast hemorrhage.

Progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage: characteristics, risk factors and impact on management

BACKGROUND

Progressive hemorrhagic injury (PHI) is a common occurrence in clinical practice; however, how PHI affects clinical management remains unclear. We attempt to evaluate the characteristics and risk factors of PHI and also investigate how PHI influences clinical management in traumatic intracerebral hemorrhage (TICH) patients.

METHODS

This retrospective study included a cohort of 181 patients with TICH who initially underwent conservative treatment and they were dichotomized into a PHI group and a non-PHI group. Clinical data were reviewed for comparison. Multivariate logistic regression analysis was applied to identify predictors of PHI and delayed operation.

RESULTS

Overall, 68 patients (37.6%) experienced PHI and 27 (14.9%) patients required delayed surgery. In the PHI group, 17 patients needed late operation; in the non-PHI group, 10 patients received decompressive craniectomy. Compared to patients with non-PHI, the PHI group was more likely to require late operation (P = 0.005, 25.0 vs 8.8%), which took place within 48 h (P = 0.01, 70.6 vs 30%). Multivariate logistic regression identified past medical history of hypertension (odds ratio [OR] = 4.56; 95% confidence interval [CI] = 2.04-10.45), elevated international normalized ratio (INR) (OR = 20.93; 95% CI 7.72-71.73) and linear bone fracture (OR = 2.11; 95% CI = 1.15-3.91) as independent risk factors for PHI. Hematoma volume of initial CT scan >5 mL (OR = 3.80; 95% CI = 1.79-8.44), linear bone fracture (OR = 3.21; 95% CI = 1.47-7.53) and PHI (OR = 3.49; 95% CI = 1.63-7.77) were found to be independently associated with delayed operation.

CONCLUSIONS

Past medical history of hypertension, elevated INR and linear bone fracture were predictors for PHI. Additionally, the latter was strongly predictive of delayed operation in the studied cohort.