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Merakis M, Lewis DP, Weaver N, Balogh ZJ. Time from injury to operative intervention in traumatic intracranial hematoma: A systematic literature review and meta-analysis. World J Surg 2024. [PMID: 39031939 DOI: 10.1002/wjs.12298] [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: 05/20/2024] [Accepted: 07/07/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND The outcomes in traumatic intracranial hematoma (TICH) have not improved significantly despite advances in trauma care. A modifiable factor in TICH management is time to operation room (TOR). TOR has become a key marker in Traumatic brain injury care despite a lack of contemporary evidence. This study aimed to determine the timing of TICH evacuation and its association with mortality and neurological outcomes. METHODS A systematic review of PubMed, OVID MEDLINE, CINAHL, and Web of Science. Included studies reported data on adult patients with acute TICH who underwent surgical evacuation. The primary outcome was TOR and its association with mortality or functional neurological recovery. RESULTS From 1838 articles screened, 17 were included. Eight studies reported TOR as a continuous variable, ranging between 3 and 7.1 h. Three studies found better outcomes with shorter TOR, five found no difference, and one found worse outcomes with shorter TOR. Five articles were included in meta-analysis of mortality in patients undergoing operative decompression less than or greater than 4 h from injury which found lower mortality in the >4-h group, OR = 1.53. Longitudinal regression analysis showed no difference in TOR over the 33-year span of articles included. CONCLUSION There is limited data available on TOR in TICH, with equivocal results on the effect of timing on outcomes. TOR has not decreased over the last 4 decades. The unvalidated 4-h cut-off seems to be associated with better survival. Contemporary assessment of this potentially important performance indicator is required.
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Affiliation(s)
- Michael Merakis
- John Hunter Hospital and University of Newcastle, Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Daniel P Lewis
- Department of Traumatology, John Hunter Hospital, University of Newcastle, New Lambton, New South Wales, Australia
| | - Natasha Weaver
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
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2
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Merakis MP, Weaver N, Fischer A, Balogh ZJ. Time to traumatic intracranial hematoma evacuation: contemporary standard and room for improvement. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02573-0. [PMID: 38888792 DOI: 10.1007/s00068-024-02573-0] [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: 09/03/2023] [Accepted: 06/01/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Traumatic intracranial hematoma (TICH) is a neurosurgical emergency with high mortality and morbidity. The time to operative decompression is a modifiable but inconsistently reported risk factor for TICH patients? OUTCOMES We aimed to provide contemporary time to evacuation data and long-term trends in timing of TICH evacuation in a trauma system. METHODS A 13-year retrospective cohort study ending in 2021 at a trauma system with one level-1 trauma center included all patients undergoing urgent craniotomy or craniectomy for evacuation of TICH. Demographics, injury severity and key timeframes of care were collected. Subgroups analyzed were polytrauma versus isolated head injury, direct admissions versus transfers and those who survived versus those who died. Linear regression of times from injury to operating room was performed. RESULTS Seventy-eight TICH patients (Age: 35 (22-56); 58 (74%) males; ISS: 25(25-41); AIS head: 5 (4-5); mortality: 21 (27%) patients) were identified. Initial GCS was 8 (3.25-14) which decreased to 3 (3-7) by arrival in the trauma center. There were 46 (59%) patients intubated prior to arrival. Median time from injury to operation was 4.88 (3.63-6.80) hours. Linear regression of injury to OR showed increasing times to operative intervention for direct admissions to the trauma center over the study period (p=0.04). There was no associated change in mortality or Glasgow outcome score over the same time. CONCLUSION This contemporary data shows timing from injury to evacuation is approaching 5 hours. Over the 13-year study period the time to operative intervention significantly increased for direct admissions. This study will guide our institutions response to TICH presentations in the future. Other trauma systems should critically appraise their results with the same reporting standard.
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Affiliation(s)
- Michael P Merakis
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia
| | - Natasha Weaver
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia
| | - Angela Fischer
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital & University of Newcastle, Newcastle, NSW, Australia.
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3
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Baker C, Cox P, Gamboa NT, Bollo RJ. Pediatric Traumatic Brain Injury in a Geographically Dispersed Population: A Relationship Between Distance to Definitive Neurosurgical Treatment and Outcome. World Neurosurg 2022; 166:e924-e932. [PMID: 35940502 DOI: 10.1016/j.wneu.2022.07.135] [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: 04/21/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND There are limited data on the association between transport distance and outcomes in pediatric patients with severe traumatic brain injuries (sTBIs), despite children having to travel further to pediatric trauma centers (PTCs). OBJECTIVE To assess whether distance from a PTC is associated with outcomes in children who undergo cranial surgery after sTBI. METHODS Children with sTBI who underwent craniectomy/craniotomy at our PTC between 2010 and 2019 were identified retrospectively. Of these 92 patients, 83 sustained blunt injury and underwent surgery within 24 hours. The distance from injury location to PTC was based on injury zip code and calculated as Euclidean distance. Variables associated with transport, including distance, time, and rural-urban disparity, were analyzed for correlation with poor outcome. RESULTS Of the 83 patients identified, 81 had injury location information. Forty patients were injured within 30 miles and 41 were injured ≥30 miles from the PTC. Injury severity and pediatric trauma scores were not significantly different between groups. Sixty-eight children (82%) had a satisfactory outcome and 10 children (12%) died. There was a nonsignificant association between distance traveled and poor outcome, even when the cohort was stratified into those with subdural hematomas and those with nonabusive injuries. CONCLUSIONS Regardless of the distance from the PTC at which their injury occurred, most children in this cohort made a moderate to good recovery. Children injured at greater distances from the PTC did not have worse outcomes; however, studies with larger cohorts are needed to more definitively assess prehospital pediatric transport systems in this population.
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Affiliation(s)
- Cordell Baker
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Parker Cox
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Nicholas T Gamboa
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA.
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Barrett JW, Williams J, Griggs J, Skene S, Lyon R. 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. Brain Inj 2022; 36:841-849. [PMID: 35767716 DOI: 10.1080/02699052.2022.2093398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Jack W Barrett
- Department of Research and Development, South East Coast Ambulance Service NHS Foundation Trust, Nexus House, Crawley, UK.,Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - Julia Williams
- Department of Research and Development, South East Coast Ambulance Service NHS Foundation Trust, Nexus House, Crawley, UK.,School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Joanna Griggs
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK.,Department of Research and Innovation, Air Ambulance Kent, Surrey, Sussex, Surrey, UK
| | - Simon Skene
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - Richard Lyon
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK.,Department of Research and Innovation, Air Ambulance Kent, Surrey, Sussex, Surrey, UK
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5
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Mangat HS, Wu X, Gerber LM, Shabani HK, Lazaro A, Leidinger A, Santos MM, McClelland PH, Schenck H, Joackim P, Ngerageza JG, Schmidt F, Stieg PE, Hartl R. Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort. J Neurosurg 2021; 135:1190-1202. [PMID: 33482641 PMCID: PMC8295409 DOI: 10.3171/2020.8.jns201243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania. METHODS A neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model. RESULTS In total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model. CONCLUSIONS The 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.
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Affiliation(s)
- Halinder S. Mangat
- Department of Neurology, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Xian Wu
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Linda M. Gerber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Hamisi K. Shabani
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Albert Lazaro
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Andreas Leidinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Maria M. Santos
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Paul H. McClelland
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | | | - Pascal Joackim
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Japhet G. Ngerageza
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Franziska Schmidt
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Philip E. Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Roger Hartl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
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Homo RL, Grigorian A, Chen J, Figueroa C, Chin T, Kuza CM, Lekawa M, Nahmias J. Regional, Racial, and Mortality Disparities Associated With Neurosurgeon Staffing at Level I Trauma Centers. Am Surg 2020; 87:1972-1979. [PMID: 33380167 DOI: 10.1177/0003134820983187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because neurosurgeons hold expertise in treating TBI, increased neurosurgical staffing may improve patient outcomes. We hypothesized that TBI patients treated at level I trauma centers (L1TCs) with ≥3 neurosurgeons have a decreased risk of mortality vs. those treated at L1TCs with <3 neurosurgeons. METHODS The Trauma Quality Improvement Program database (2010-2016) was queried for patients ≥18 years with TBI. Patient characteristics and mortality were compared between ≥3 and <3 neurosurgeon-staffed L1TCs. A multivariable logistic regression analysis was used to identify risk factors associated with mortality. RESULTS Traumatic brain injury occurred in 243 438 patients with 5188 (2%) presenting to L1TCs with <3 neurosurgeons and 238 250 (98%) to L1TCs with ≥3 neurosurgeons. Median injury severity score (ISS) was similar between both groups (17, P = .09). There were more Black (37% vs. 12%, P < .001) and Hispanic (18% vs. 12%, P < .001) patients in the <3 neurosurgeon group. Nearly 60% of L1TCs with <3 neurosurgeons are found in the South. Mortality was higher in the <3 vs. the ≥3 group (12% vs. 10%, P < .001). Patients treated in the <3 neurosurgeon group had a higher risk for mortality than those treated in the ≥3 neurosurgeon group (odds ratio (OR) 1.13, 95% confidence intervals (CI) 1.01-1.26, P = .028). DISCUSSION There exists a significant racial disparity in access to neurosurgeon staffing with additional disparities in outcomes based on staffing. Future efforts are needed to improve this chasm of care that exists for trauma patients of color.
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Affiliation(s)
- Richelle L Homo
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 218539University of California, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 218539University of California, CA, USA
| | - Jefferson Chen
- Department of Neurological Surgery, University of California, CA, USA
| | - Cesar Figueroa
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 218539University of California, CA, USA
| | - Theresa Chin
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 218539University of California, CA, USA
| | - Catherine M Kuza
- Department of Anesthesiology, 5116University of Southern California, CA, USA
| | - Michael Lekawa
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 218539University of California, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 218539University of California, CA, USA
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Bedard AF, Mata LV, Dymond C, Moreira F, Dixon J, Schauer SG, Ginde AA, Bebarta V, Moore EE, Mould-Millman NK. A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes. Int J Emerg Med 2020; 13:64. [PMID: 33297951 PMCID: PMC7724615 DOI: 10.1186/s12245-020-00324-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation. MAIN BODY We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure. CONCLUSION The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.
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Affiliation(s)
- Alexander F Bedard
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA.
- United States Air Force Medical Corps, 7700 Arlington Boulevard, Falls Church, VA, 22042, USA.
| | - Lina V Mata
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Chelsea Dymond
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
- Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA
| | - Fabio Moreira
- Western Cape Government, Emergency Medical Services, 9 Wale Street, Cape Town, 8001, South Africa
| | - Julia Dixon
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, 3698 Chambers Rd., San Antonio, TX, 78234, USA
| | - Adit A Ginde
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Vikhyat Bebarta
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Ernest E Moore
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
- Ernest E. Moore Shock Trauma Center at Denver Health, 777 Bannock St, Denver, CO, 80204, USA
| | - Nee-Kofi Mould-Millman
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
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8
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Takoukam R, Kanmounye US, Robertson FC, Zimmerman K, Nguembu S, Lartigue JW, Park KB, Figuim B, Esene I. Prehospital Conditions and Outcomes After Craniotomy for Traumatic Brain Injury Performed Within 72 Hours in Central Cameroon: A Cross-Sectional Study. World Neurosurg 2020; 142:e238-e244. [PMID: 32599210 DOI: 10.1016/j.wneu.2020.06.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the most common neurosurgical condition globally. In Cameroon, there are 572 cases of TBI per 100,000 people, but <40% of Cameroonians live within 4 hours of a neurosurgical facility. We sought to understand the clinical outcomes at a neurosurgical center in Central Cameroon. METHODS This cross-sectional study was conducted at the largest neurosurgical center of Cameroon, the Yaounde Central Hospital. Data included 100 consecutive patients undergoing an intervention 72 hours after their injury from February 1, 2015 to February 1, 2019. Patients with missing data or undergoing surgery >72 hours after injury were excluded. Analyses of covariance were performed, and a P value >0.05 was considered significant. A Kaplan-Meier survival curve was computed. RESULTS The patients had a mean age of 31.3 ± 17.4 years, with a male predominance of 91.0%, and the principal mechanism of injury was road traffic accidents (68.0%). Only 11% arrived via ambulance, and 36.0% were admitted <3 hours after the traumatic event. The postoperative mortality was 15.0%, mean survival was 25.0 postoperative days (95% confidence interval, 23.42-26.52), and the mean Glasgow Outcome Scale score at 28 days was 3.9 ± 1.4. CONCLUSIONS Most patients with TBI undergoing neurosurgery 72 hours after injury in Cameroon arrive at the hospital late and have a high mortality risk during the first postoperative week. Investments in prehospital care should be made to improve surgical outcomes.
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Affiliation(s)
- Régis Takoukam
- Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon; Department of Neurosurgery, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire; Department of Research, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Ulrick Sidney Kanmounye
- Department of Research, Association of Future African Neurosurgeons, Yaounde, Cameroon; Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.
| | - Faith C Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathrin Zimmerman
- Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA; School of Medicine, University of Alabama at Birminghssam, Birmingham, Alabama, USA
| | - Stéphane Nguembu
- Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon; Department of Research, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Jean W Lartigue
- Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Bello Figuim
- Department of Neurosurgery, Yaounde Central Hospital, Yaounde, Cameroon
| | - Ignatius Esene
- Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon; Department of Neurosurgery, Garoua Regional Hospital, Garoua, Cameroon
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9
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Shackelford SA, Del Junco DJ, Reade MC, Bell R, Becker T, Gurney J, McCafferty R, Marion DW. Association of time to craniectomy with survival in patients with severe combat-related brain injury. Neurosurg Focus 2019; 45:E2. [PMID: 30544314 DOI: 10.3171/2018.9.focus18404] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2-5, quintiles 1-2 vs 3-5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30-152 minutes); 7% for quintile 2 (n = 42, 154-210 minutes); 7% for quintile 3 (n = 43, 212-320 minutes); 19% for quintile 4 (n = 42, 325-639 minutes); and 14% for quintile 5 (n = 43, 665-3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1-3) relative to longer delays (quintiles 4-5), with an adjusted hazard ratio of 0.28, 95% CI 0.10-0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.
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Affiliation(s)
| | - Deborah J Del Junco
- 1Joint Trauma System, Defense Center of Excellence, San Antonio.,2Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio, Texas
| | - Michael C Reade
- 3Joint Health Command, Australian Defence Force, Brisbane, Queensland, Australia
| | - Randy Bell
- 4Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Jennifer Gurney
- 1Joint Trauma System, Defense Center of Excellence, San Antonio
| | - Randall McCafferty
- 6Neurosurgery, San Antonio Military Medical Center, San Antonio, Texas; and
| | - Donald W Marion
- 7Defense and Veterans Brain Injury Center, Silver Spring, Maryland
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10
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Ajmera S, Motiwala M, Lingo R, Khan NR, Smith LJ, Giles K, Vaughn B, Klimo P. Emergent and Urgent Craniotomies in Pediatric Patients: Resource Utilization and Cost Analysis. Pediatr Neurosurg 2019; 54:301-309. [PMID: 31401624 DOI: 10.1159/000501042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/19/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pediatric neurosurgeons are occasionally tasked with performing surgery expeditiously to preserve a child's neurologic faculties and life. OBJECTIVE This study examines the etiologies, outcomes, and costs for urgent or emergent craniotomies at a Level I Pediatric Trauma center over a 7-year time period. METHODS A retrospective review was conducted for each patient who underwent an emergent or urgent craniotomy within 24 hours of presentation between January 2010 and April 2017. Demographic, clinical, and surgical details were recorded for a total of 48 variables. Any readmission within 90 days was analyzed. Hospital charges for each admission and readmission were collected and adjusted for inflation to October 2018 values. RESULTS Among the 223 children who underwent urgent or emergent craniotomies, the majority were admitted for traumatic injuries (n = 163, 73.1%). The most common traumatic mechanism was fall (n = 51, 22.9%), and the most common non-traumatic cause was tumor (n = 21, 9.4%). Overall, craniotomies were typically performed for hematoma evacuation of one type or combination (n = 115, 51.6%) during off-peak times (n = 178, 79.8%). Seventy-seven (34.5%) subjects experienced 1 or more postoperative events, 22 of whom returned to the operating room. There were 13 (5.8%) and 33 (14.8%) readmissions within 30 days and 90 days of discharge, respectively. Non-trauma patients (compared with trauma patients) and polytrauma (compared with isolated head injury) had greater healthcare needs, resulting in higher charges. CONCLUSION Most urgent or emergent pediatric craniotomies were performed for the treatment of traumatic injuries involving hematoma evacuation, but non-traumatic patients were more complex requiring greater resources.
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Affiliation(s)
- Sonia Ajmera
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Ryan Lingo
- Neurological & Spine Institute, Savannah, Georgia, USA
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lydia J Smith
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Kim Giles
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Brandy Vaughn
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA, .,Le Bonheur Children's Hospital, Memphis, Tennessee, USA, .,Semmes Murphey, Memphis, Tennessee, USA,
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Chmieliauskas S, Anuzyte JS, Liucvaikyte J, Laima S, Jurolaic E, Rocka S, Fomin D, Stasiuniene J, Jasulaitis A. Importance of effusion of blood under the dura mater in forensic medicine: A STROBE - compliant retrospective study. Medicine (Baltimore) 2018; 97:e12567. [PMID: 30278562 PMCID: PMC6181611 DOI: 10.1097/md.0000000000012567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Subdural hemorrhage is commonly associated with mechanical brain injury and has a correspondingly high mortality rate. Subdural hematomas may immediately provoke symptoms or may be initially asymptomatic, with further symptoms evolving rapidly and fatally.The data regarding forensic autopsy of victims were obtained from The State Forensic Medicine Service of Lithuania between the years 2013 and 2016. A retrospective study was performed including 110 patients, whose cause of death was subdural hemorrhage. 95% confidence intervals were calculated.It was calculated, that in cases of sudden death, after subdural hemorrhage was diagnosed, a higher concentration of ethyl alcohol in blood (mean 2.22 ± 1.3%) demanded a smaller amount of blood under the dura matter (mean 81.6 ± 60.5 g) in order for the patient to die. It was also noted that hospitalized patients with subdural hemorrhage had a smaller concentration of blood ethyl alcohol (mean 1.33 ± 1%) and a larger amount of blood under the dura (mean 135.6 ± 82.9 g).Due to the toxic effect of ethyl alcohol, even a small amount (81.6 ± 60.5 g) of blood under the dura matter can determine a sudden death.
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Affiliation(s)
- Sigitas Chmieliauskas
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | - Joginte Saule Anuzyte
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Julita Liucvaikyte
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Sigitas Laima
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | | | - Saulius Rocka
- Department of Neurology and Neurosurgery, Vilnius University, Vilnius, Lithuania
| | - Dmitrij Fomin
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | - Jurgita Stasiuniene
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Algimantas Jasulaitis
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
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12
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Chen JW. Commentary: Neurosurgical Coverage for Emergency and Trauma Call. Neurosurgery 2018; 84:985-986. [DOI: 10.1093/neuros/nyy415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/06/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, Orange, California
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