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Pantelatos RI, Stenberg J, Follestad T, Sandrød O, Einarsen CE, Vik A, Skandsen T. Improvement in Functional Outcome from 6 to 12 Months After Moderate and Severe Traumatic Brain Injury Is Frequent, But May Not Be Detected With the Glasgow Outcome Scale Extended. Neurotrauma Rep 2024; 5:139-149. [PMID: 38435078 PMCID: PMC10908320 DOI: 10.1089/neur.2023.0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
The aims of this study were (1) to report outcome and change in outcome in patients with moderate and severe traumatic brain injury (mo/sTBI) between 6 and 12 months post-injury as measured by the Glasgow Outcome Scale Extended (GOSE), (2) to explore if demographic/injury-related variables can predict improvement in GOSE score, and (3) to investigate rate of improvement in Disability Rating Scale (DRS) score, in patients with a stable GOSE. All surviving patients ≥16 years of age who were admitted with mo/sTBI (Glasgow Coma Scale [GCS] score ≤13) to the regional trauma center in Central Norway between 2004 and 2019 were prospectively included (n = 439 out of 503 eligible). GOSE and DRS were used to assess outcome. Twelve-months post-injury, 13% with moTBI had severe disability (GOSE 2-4) versus 27% in sTBI, 26% had moderate disability (GOSE 5-6) versus 41% in sTBI and 62% had good recovery (GOSE 7-8) versus 31% in sTBI. From 6 to 12 months post-injury, 27% with moTBI and 32% with sTBI had an improvement, whereas 6% with moTBI and 6% with sTBI had a deterioration in GOSE score. Younger age and higher GCS score were associated with improved GOSE score. Improvement was least frequent for patients with a GOSE score of 3 at 6 months. In patients with a stable GOSE score of 3, an improvement in DRS score was observed in 22 (46%) patients. In conclusion, two thirds and one third of patients with mo/sTBI, respectively, had a good recovery. Importantly, change, mostly improvement, in GOSE score between 6 and 12 months was frequent and argues against the use of 6 months outcome as a time end-point in research. The GOSE does, however, not seem to be sensitive to actual change in function in the lower categories and a combination of outcome measures may be needed to describe the consequences after TBI.
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Affiliation(s)
- Rabea Iris Pantelatos
- Department of Neuromedicine, Movement Science, and Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jonas Stenberg
- Department of Neuromedicine, Movement Science, and Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology and Nuclear Medicine, Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Turid Follestad
- Clinical Research Unit Central Norway, Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Oddrun Sandrød
- Clinic of Anaesthesia and Intensive Care, Department of Intensive Care Medicine, Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cathrine Elisabeth Einarsen
- Department of Neuromedicine, Movement Science, and Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Rehabilitation, Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine, Movement Science, and Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Neuroclinic, Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine, Movement Science, and Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Rehabilitation, Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Czyżewski W, Mazurek M, Sakwa L, Szymoniuk M, Pham J, Pasierb B, Litak J, Czyżewska E, Turek M, Piotrowski B, Torres K, Rola R. Astroglial Cells: Emerging Therapeutic Targets in the Management of Traumatic Brain Injury. Cells 2024; 13:148. [PMID: 38247839 PMCID: PMC10813911 DOI: 10.3390/cells13020148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Traumatic Brain Injury (TBI) represents a significant health concern, necessitating advanced therapeutic interventions. This detailed review explores the critical roles of astrocytes, key cellular constituents of the central nervous system (CNS), in both the pathophysiology and possible rehabilitation of TBI. Following injury, astrocytes exhibit reactive transformations, differentiating into pro-inflammatory (A1) and neuroprotective (A2) phenotypes. This paper elucidates the interactions of astrocytes with neurons, their role in neuroinflammation, and the potential for their therapeutic exploitation. Emphasized strategies encompass the utilization of endocannabinoid and calcium signaling pathways, hormone-based treatments like 17β-estradiol, biological therapies employing anti-HBGB1 monoclonal antibodies, gene therapy targeting Connexin 43, and the innovative technique of astrocyte transplantation as a means to repair damaged neural tissues.
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Affiliation(s)
- Wojciech Czyżewski
- Department of Didactics and Medical Simulation, Medical University of Lublin, 20-954 Lublin, Poland;
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (M.M.); (R.R.)
| | - Marek Mazurek
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (M.M.); (R.R.)
| | - Leon Sakwa
- Student Scientific Society, Kazimierz Pulaski University of Radom, 26-600 Radom, Poland;
| | - Michał Szymoniuk
- Student Scientific Association, Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Jennifer Pham
- Student Scientific Society, Medical University of Lublin, 20-954 Lublin, Poland; (J.P.); (M.T.)
| | - Barbara Pasierb
- Department of Dermatology, Radom Specialist Hospital, 26-600 Radom, Poland;
| | - Jakub Litak
- Department of Clinical Immunology, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Ewa Czyżewska
- Department of Otolaryngology, Mazovian Specialist Hospital, 26-617 Radom, Poland;
| | - Michał Turek
- Student Scientific Society, Medical University of Lublin, 20-954 Lublin, Poland; (J.P.); (M.T.)
| | - Bartłomiej Piotrowski
- Institute of Automatic Control and Robotics, Warsaw University of Technology, 00-661 Warsaw, Poland;
| | - Kamil Torres
- Department of Didactics and Medical Simulation, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Radosław Rola
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (M.M.); (R.R.)
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Teh J, Mazlan M, Danaee M, Waran RJ, Waran V. Outcome of 1939 traumatic brain injury patients from road traffic accidents: Findings from specialist medical reports in a low to middle income country (LMIC). PLoS One 2023; 18:e0284484. [PMID: 37703233 PMCID: PMC10499241 DOI: 10.1371/journal.pone.0284484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/31/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVE Road traffic accident (RTA) is the major cause of traumatic brain injury (TBI) in developing countries and affects mostly young adult population. This research aimed to describe the factors predicting functional outcome after TBI caused by RTA in a Malaysian setting. METHODS This was a retrospective cross-sectional study conducted on specialist medical reports written from 2009 to 2019, involving patients who survived after TBI from RTA. The functional outcome was assessed using the Glasgow Outcome Scale-Extended (GOSE). Factors associated with good outcome were analysed via logistic regression analysis. Multivariate logistic regression analysis was used to derive the best fitting Prediction Model and split-sample cross-validation was performed to develop a prediction model. RESULTS A total of 1939 reports were evaluated. The mean age of the study participants was 32.4 ± 13.7 years. Most patients were male, less than 40, and with average post RTA of two years. Good outcome (GOSE score 7 & 8) was reported in 30.3% of the patients. Factors significantly affecting functional outcome include age, gender, ethnicity, marital status, education level, severity of brain injury, neurosurgical intervention, ICU admission, presence of inpatient complications, cognitive impairment, post-traumatic headache, post traumatic seizures, presence of significant behavioural issue; and residence post discharge (p<0.05). After adjusting for confounding factors, prediction model identified age less than 40, mild TBI, absence of post traumatic seizure, absence of behaviour issue, absence of cognitive impairment and independent living post TBI as significant predictors of good functional outcome post trauma. Discrimination of the model was acceptable (C-statistic, 0.67; p<0.001, 95% CI: 0.62-0.73). CONCLUSION Good functional outcome following TBI due to RTA in this study population is comparable to other low to middle income countries but lower than high income countries. Factors influencing outcome such as seizure, cognitive and behavioural issues, and independent living post injury should be addressed early to achieve favourable long-term outcomes.
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Affiliation(s)
- Justina Teh
- Department of Rehabilitation Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Rehabilitation Medicine, Hospital Tuanku Ja’afar Seremban, Seremban, Negeri Sembilan, Malaysia
| | - Mazlina Mazlan
- Department of Rehabilitation Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mahmoud Danaee
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ria Johanna Waran
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Vicknes Waran
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Deng H, Nwachuku EL, Wilkins TE, Yue JK, Fetzick A, Chang YF, Beers SR, Okonkwo DO, Puccio AM. Time to Follow Commands in Severe Traumatic Brain Injury Survivors With Favorable Recovery at 2 Years. Neurosurgery 2022; 91:633-640. [PMID: 35833650 PMCID: PMC10553145 DOI: 10.1227/neu.0000000000002087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The recovery of severe traumatic brain injury (TBI) survivors with long-term favorable outlook is understudied. Time to follow commands varies widely in this patient population but has important clinical implications. OBJECTIVE To (1) evaluate time to follow commands in severe patients with TBI with favorable outcomes, (2) characterize their trajectory of recovery, and (3) identify predictors associated with delayed cognitive improvement. METHODS Participants were recruited prospectively at a Level I trauma center through the Brain Trauma Research Center from 2003 to 2018. Inclusion criteria were age 16 to 80 years, Glasgow Coma Scale score ≤8 and motor score <6, and Glasgow Outcome Scale-Extended measure ≥4 at 2 years postinjury. RESULTS In 580 patients, there were 229 (39.5%) deaths and 140 (24.1%) patients had favorable outcomes at 2 years. The mean age was 33.7 ± 14.5 years, median Glasgow Coma Scale was 7 (IQR 6-7), and median Injury Severity Score was 30 (IQR 26-38). The mean time to follow commands was 12.7 ± 11.8 days. On multivariable linear regression, the presence of diffuse axonal injury (B = 9.2 days [4.8, 13.7], P < .0001) or intraventricular hemorrhage (B = 6.4 days [0.5, 12.3], P < .035) was associated with longer time before following commands and patients who developed nosocomial infections (B = 6.5 days [1.6-11.4], P < .01). CONCLUSION In severe TBI survivors with favorable outcomes, time to follow commands varied widely. Most patients began to follow commands within 2 weeks. Evidence of diffuse axonal injury, intraventricular hemorrhage, and infections can delay cognitive improvement in the acute period. Patients make considerable recovery up to 2 years after their injury.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Enyinna L. Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tiffany E. Wilkins
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Anita Fetzick
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sue R. Beers
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Yabuno S, Yasuhara T, Murai S, Yumoto T, Naito H, Nakao A, Date I. Predictive Factors of Return Home and Return to Work for Intensive Care Unit Survivors after Traumatic Brain Injury with a Follow-up Period of 2 Years. Neurol Med Chir (Tokyo) 2022; 62:465-474. [PMID: 36130904 PMCID: PMC9637400 DOI: 10.2176/jns-nmc.2022-0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Intensive care unit (ICU) survivors after traumatic brain injury (TBI) frequently have serious disabilities with subsequent difficulty in reintegration into society. We aimed to investigate outcomes for ICU survivors after moderate to severe TBI (msTBI) and to identify predictive factors of return home (RH) and return to work (RTW). This single-center retrospective cohort study was conducted on all trauma patients admitted to the emergency ICU of our hospital between 2013 and 2017. Of these patients, adult (age ≥ 18 years) msTBI patients with head Abbreviated Injury Scale ≥ 3 were extracted. We performed univariate/multivariate logistic regression analyses to explore the predictive factors of RH and RTW. Among a total of 146 ICU survivors after msTBI, 107 were included (median follow-up period: 26 months). The RH and RTW rates were 78% and 35%, respectively. Multivariate analyses revealed that the predictive factors of RH were age < 65 years (P < 0.001), HR < 76 bpm (P = 0.015), platelet count ≥ 19 × 104/μL (P = 0.0037), D-dimer < 26 μg/mL (P = 0.034), and Glasgow Coma Scale (GCS) score > 8 (P = 0.0015). Similarly, the predictive factors of RTW were age < 65 years (P < 0.001) and GCS score > 8 (P = 0.0039). This study revealed that “age” and “GCS score on admission” affected RH and RTW for ICU survivors after msTBI.
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Affiliation(s)
- Satoru Yabuno
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takao Yasuhara
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences
| | - Satoshi Murai
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences
| | - Isao Date
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences
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6
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Mostert CQB, Singh RD, Gerritsen M, Kompanje EJO, Ribbers GM, Peul WC, van Dijck JTJM. Long-term outcome after severe traumatic brain injury: a systematic literature review. Acta Neurochir (Wien) 2022; 164:599-613. [PMID: 35098352 DOI: 10.1007/s00701-021-05086-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/07/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Expectation of long-term outcome is an important factor in treatment decision-making after severe traumatic brain injury (sTBI). Conclusive long-term outcome data substantiating these decisions is nowadays lacking. This systematic review aimed to provide an overview of the scientific literature on long-term outcome after sTBI. METHODS A systematic search was conducted using PubMed from 2008 to 2020. Studies were included when reporting long-term outcome ≥ 2 years after sTBI (GCS 3-8 or AIS head score ≥ 4), using standardized outcome measures. Study quality and risk of bias were assessed using the QUIPS tool. RESULTS Twenty observational studies were included. Studies showed substantial variation in study objectives and study methodology. GOS-E (n = 12) and GOS (n = 8) were the most frequently used outcome measures. Mortality was reported in 46% of patients (range 18-75%). Unfavourable outcome rates ranged from 29 to 100% and full recovery was seen in 21-27% of patients. Most surviving patients reported SF-36 scores lower than the general population. CONCLUSION Literature on long-term outcome after sTBI was limited and heterogeneous. Mortality and unfavourable outcome rates were high and persisting sequelae on multiple domains common. Nonetheless, a considerable proportion of survivors achieved favourable outcome. Future studies should incorporate standardized multidimensional and temporal long-term outcome measures to strengthen the evidence-base for acute and subacute decision-making. HIGHLIGHTS 1. Expectation of long-term outcome is an important factor in treatment decision-making for patients with severe traumatic brain injury (sTBI). 2. Favourable outcome and full recovery after sTBI are possible, but mortality and unfavourable outcome rates are high. 3. sTBI survivors are likely to suffer from a wide range of long-term consequences, underscoring the need for long-term and multi-modality outcome assessment in future studies. 4. The quality of the scientific literature on long-term outcome after sTBI can and should be improved to advance treatment decision-making.
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Affiliation(s)
- Cassidy Q B Mostert
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands.
| | - Ranjit D Singh
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Maxime Gerritsen
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
- Rijndam Rehabilitation, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
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Suehiro E, Kiyohira M, Haji K, Suzuki M. Changes in Outcomes after Discharge from an Acute Hospital in Severe Traumatic Brain Injury. Neurol Med Chir (Tokyo) 2021; 62:111-117. [PMID: 34880162 PMCID: PMC8918365 DOI: 10.2176/nmc.oa.2021-0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neurological improvement occurs from the subacute to chronic phases in severe traumatic brain injury. We analyzed factors associated with improved neurological findings in the subacute phase, using data from the Japan Neurotrauma Data Bank (JNTDB). The subjects were 1345 patients registered in the JNTDB (Project 2015). Clinical improvement was evaluated by comparing the Glasgow Outcome Scale (GOS) at discharge and 6 months after injury. Of these patients, 157 with severe disability (SD) on the discharge GOS were examined to evaluate factors associated with neurological improvement in the subacute phase. Cases were defined as those with (group I) and without (group N) improvement: a change from SD at discharge to good recovery (GR) or moderate disability (MD) at 6 months after injury. Patient background, admission findings, treatment, and discharge destination were examined. In all patients, the favorable outcome (GR, MD) rate improved from 30.2% at discharge to 35.7% at 6 months after injury. Of SD cases at discharge, 44.6% had a favorable outcome at 6 months (group I). Patients in group I were significantly younger, and had a significantly lower D-dimer level in initial blood tests and a lower incidence of convulsions. In multivariate analysis, discharge to home was a significant factor associated with an improved outcome. Many SD cases at discharge ultimately showed neurological improvement, and the initial D-dimer level may be a predictor of such improvement. The environment after discharge from an acute care hospital may also contribute to an improved long-term prognosis.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine.,The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology
| | - Miwa Kiyohira
- Department of Neurosurgery, Yamaguchi University School of Medicine
| | - Kohei Haji
- Department of Neurosurgery, Yamaguchi University School of Medicine
| | - Michiyasu Suzuki
- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology.,Department of Neurosurgery, Yamaguchi University School of Medicine
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- The Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology
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8
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Basha AK, Mahmoud MA, Al Ashwal MI, Aglan O, ElShawady SB, Abdel-Latif AM, Elsayed AM, AbdelGhany W. Management of Severe Traumatic Brain Injury: A Single Institution Experience in a Middle-Income Country. Front Surg 2021; 8:690723. [PMID: 34746219 PMCID: PMC8570277 DOI: 10.3389/fsurg.2021.690723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Severe traumatic brain injury (TBI) is a major public health problem usually resulting in mortality or severe disabling morbidities of the victims. Intracranial pressure (ICP) monitoring is recently recognized as an imperative modality in the management of severe TBI, whereas growing evidence, based on randomized controlled trials (RCTs), suggests that ICP monitoring does not affect the outcome when compared with clinical and radiological data-based management. Also, ICP monitoring carries a considerable risk of intracranial infection that cannot be overlooked. The aim of this study is to assess the different aspects of our current local institutional management of severe TBI using non-invasive ICP monitoring for a potential need to change our management strategy. Methods: We retrospectively reviewed our data of TBI from June 2019 through January 2020. Patients with severe TBI were identified. Their demographics, Glasgow coma score (GCS) at presentation, treatments received, and imaging data were extracted from the charts. Glasgow outcome scale extended (GOS-E) at 6 months was also assessed for the patients. Results: Twenty patients with severe TBI were identified on chart review. Ten patients received only medical treatment measures to lower the ICP, whereas the other 10 patients had additional surgical interventions. In one patient, a ventriculostomy tube was inserted to monitor ICP and to drain cerebrospinal fluid (CSF). This was complicated by ventriculostomy-associated infection (VAI) and the tube was removed. In our cohort, the total mortality rate was 40%. The average GOS-E for the survivor patients managed without ICP monitoring based on the clinical and radiological data was 6.2 at 6 months follow-up. The 6-month overall good outcome, based on GOS-E, was 33.3%. Conclusion: Although recent guidelines advocate for the use of ICP monitoring in the management of severe TBI, they remain underutilized in our practice due to many factors. External ventricular drains were mainly used to drain CSF; however, the higher rates of VAIs in our institution compared with the literature-reported rates are not in favor of the use of ICP monitoring. We recommend doing a comparative study between our current practice using clinical-and radiological-based management and subdural or intraparenchymal bolts. More structured RCTs are needed to validate these findings in our setting.
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Affiliation(s)
| | | | | | - Osama Aglan
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
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9
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Singh R, Dawson J, Mason PS, Lecky F. What are the functional consequences after TBI? The SHEFBIT cohort experience. Brain Inj 2021; 35:1630-1636. [PMID: 34711118 DOI: 10.1080/02699052.2021.1978549] [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: 10/20/2022]
Abstract
OBJECTIVES To investigate functional outcome after TBI and identify variables that predict outcome in a multiordinal regression model. BACKGROUND The results of global outcome studies after Traumatic Brain Injury(TBI) differ widely due to differences in outcome measure, attrition to follow-up and selection bias. Outcome information would inform patients/families, guide service development and target high-risk individuals. SUBJECTS/SETTING prospective cohort of 1322 admissions with TBI, assessed by face to face interviews at 1 yr. MEASURES Extended Glasgow Outcome Scale (GOSE) by structured questionnaire. RESULTS At 1 year, outcome was determined in 1207(91.3%). Mean age was 46.9(SD17.3); Almost half(49.2%) had mild injury. At one year, 42.9% achieved Good Recovery but GOSE declined in 11.4% of the cohort compared to 10 weeks including 60(4.9%) deaths. In an ordinal logistic regression, increasing TBI severity, etiology (assault), more prominent CT abnormality, past psychiatric history and alcohol intoxication were independent predictors of worse GOSE. A pseudo-R2 of 0.38 suggested that many unmeasured factors also contribute to TBI outcome. Future work needs to identify other variables that may influence outcome. CONCLUSIONS In a large TBI cohort, there is still considerable functional disability at 1 year. It may be possible to target high-risk groups for rehabilitation.
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Affiliation(s)
- Rajiv Singh
- School of Health and Related Research (Scharr), Faculty of Medicine, Dentistry and Health, University of Sheffield S1 4DA, Sheffield, United Kingdom.,Osborn Neurorehabilitation Unit, Department of Rehabilitation Medicine, Sheffield Teaching Hospitals, Sheffield, UK
| | - Jeremy Dawson
- Institute of Work Psychology, Sheffield University Management School, Sheffield, United Kingdom
| | - Prof Suzanne Mason
- School of Health and Related Research (Scharr), Faculty of Medicine, Dentistry and Health, University of Sheffield S1 4DA, Sheffield, United Kingdom
| | - Fiona Lecky
- School of Health and Related Research (Scharr), Faculty of Medicine, Dentistry and Health, University of Sheffield S1 4DA, Sheffield, United Kingdom
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10
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The Experience of Caregivers Following a Moderate to Severe Traumatic Brain Injury Requiring ICU Admission. J Head Trauma Rehabil 2021; 35:E299-E309. [PMID: 31479080 DOI: 10.1097/htr.0000000000000525] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Survivors of moderate and severe traumatic brain injury (TBI) require substantial care, much of which is ultimately provided by friends and family. We sought to describe the unmet needs of informal caregivers. DESIGN Qualitative, semistructured interviews with informal caregivers of moderate and severe TBI survivors were conducted 72 hours, 1 month, 3 months, and 6 months after injury. SETTING Intensive care unit of a level 1 trauma center. PARTICIPANTS Informal caregivers were friends or family who planned to provide care for the patient. Patients were 18 years or older with a moderate to severe TBI, and not expected to imminently die of their injuries. MEASUREMENTS AND MAIN RESULTS Eighteen patient-caregiver dyads were enrolled. Fifty-three interviews with caregivers were completed and analyzed over the course of 6 months. Three themes were identified in the qualitative analysis: caregiver burden, caregiver health-related quality of life, and caregiver needs for information and support. CONCLUSIONS This study provides new information about the experience of informal caregivers during the 6 months after their friend or family member survived a moderate to severe TBI. Interventions to promote caregiving may be a substantial opportunity to improve patient-centered outcomes following TBI.
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Behranwala R, Aojula N, Hagana A, Houbby N, de Preux DL. An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension. Brain Inj 2021; 35:444-452. [PMID: 33529095 DOI: 10.1080/02699052.2021.1878556] [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: 10/22/2022]
Abstract
Objectives: The management of intracranial hypertension is a primary concern following traumatic brain injury. Data from recent randomized controlled trials have indicated that decompressive craniectomy results in some improved clinical outcomes compared to medical treatment for patients with refractory intracranial hypertension post-traumatic brain injury (TBI). This economic evaluation aims to assess the cost-effectiveness of decompressive craniectomy as a last-tier intervention for refractory intracranial hypertension from the perspective of the National Health Service (NHS).Methods: A Markov model was used to present the results from an international, multicentre, parallel-group, superiority, randomized trial. A cost-utility analysis was then carried out over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling.Results: The cost-utility analysis produced an incremental cost-effectiveness ratio (ICER) of £96,155.67 per QALY. This means that for every additional QALY gained by treating patients with decompressive craniectomy, a cost of £96,155.67 is incurred to the NHS.Conclusions: The ICER calculated is above the National Institute for Health and Care Excellence (NICE) threshold of £30,000 per QALY. This indicates that decompressive craniectomy is not a cost-effective first treatment option for refractory intracranial hypertension and maximum medical management is preferable initially.
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Affiliation(s)
| | - Nivaran Aojula
- Faculty of Medicine, Imperial College London, London, UK
| | - Arwa Hagana
- Faculty of Medicine, Imperial College London, London, UK
| | - Nour Houbby
- Faculty of Medicine, Imperial College London, London, UK
| | - Dr Laure de Preux
- Department of Economics and Public Policy, Imperial College London, Business School, London, UK
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12
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Wiginton J, Brazdzionis J, Patchana T, Dorkoski R, Miulli DE, Sweiss R, Wacker MR. Optimal Partial Pressure of Oxygen Affects Outcomes in Patients With Severe Traumatic Brain Injury. Cureus 2020; 12:e9964. [PMID: 32983668 PMCID: PMC7510506 DOI: 10.7759/cureus.9964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/23/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction Severe traumatic brain injury (TBI) is a leading cause of death and disability. Not all neuronal damage occurs at the time of primary injury, but rather TBI initiates a cascade of events that leads to secondary brain injury. Oxygenation is one crucial factor in maintaining brain tissue homeostasis post-injury. We performed a retrospective review of patients admitted to a single trauma center after TBI. Statistical analysis was performed to ascertain if the measured partial pressure of oxygen (PaO₂) affected overall outcome at the time of discharge from the hospital. Materials and Methods Statistical analysis was performed retrospectively on patients admitted with a Glasgow Coma Scale (GCS) < 8 and a diagnosis of TBI. GCS and Glasgow Outcome Scale (GOS) were calculated from physical examination findings at the time of hospital discharge or death. Patient data were separated into two groups: those with consistently higher average PaO₂ scores (≥ 150 mmHg; n = 7) and those with lower average PaO₂ scores (< 150 mmHg; n = 8). The minimum requirement to be categorized in the consistently higher group was to have an average hospital day 1 through 5 PaO₂ value of ≥ 150 mmHg. Results Patients with consistent hospital Day 1 through 5 PaO₂ scores of ≥ 150 mmHg had statistically significant higher GCS scores at the end of intensive care unit (ICU)-level care or hospital discharge (mean = 12, p = 0.01), compared to those in group 2 with lower PaO₂ levels (mean = 7.9). There was no statistically significant difference in GOS when comparing the two groups (p = 0.055); however, the data did show a trend toward significance. Discussion and Conclusion In our study we analyzed patients diagnosed with TBI and stratified them into groups based on PaO₂ ≥ or < 150 mmHg. We demonstrate overall outcome improvement based on GCS with a trend toward improved GOS. The GCS showed statistical significance in patients with PaO₂ consistently ≥ 150 mmHg versus those in group 2 over the first five days of hospitalization.
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Affiliation(s)
- James Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Tye Patchana
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Ryan Dorkoski
- Environmental and Plant Science, Ohio University, Athens, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Raed Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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13
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Maiden MJ, Cameron PA, Rosenfeld JV, Cooper DJ, McLellan S, Gabbe BJ. Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study. Am J Respir Crit Care Med 2020; 201:167-177. [PMID: 31657946 DOI: 10.1164/rccm.201903-0673oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.
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Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, Barwon Health, Geelong, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Peter A Cameron
- Emergency and Trauma Centre.,School of Public Health and Preventive Medicine and
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, and.,Department of Surgery, Monash University, Melbourne, Australia.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; and
| | - D James Cooper
- Intensive Care Unit, The Alfred Hospital, Prahran, Australia.,School of Public Health and Preventive Medicine and
| | | | - Belinda J Gabbe
- School of Public Health and Preventive Medicine and.,Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
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Timmer ML, Jacobs B, Schonherr MC, Spikman JM, van der Naalt J. The Spectrum of Long-Term Behavioral Disturbances and Provided Care After Traumatic Brain Injury. Front Neurol 2020; 11:246. [PMID: 32318019 PMCID: PMC7154103 DOI: 10.3389/fneur.2020.00246] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 03/13/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction: Behavioral disturbances are found in 50–60% of traumatic brain injury (TBI) survivors with an enormous impact on daily functioning and level of recovery. However, whether typical profiles can be distinguished and how these relate to provided care is unclear. The purpose of this study is to specify the characteristics of behavioral disturbances in patients with various severity of TBI and the impact on functional outcome. Furthermore, the pathways of care after hospital discharge for patients and their care givers are analyzed. Methods: We performed a retrospective cohort study comprising 226 patients with mild TBI (mTBI; n = 107) and moderate-to-severe TBI (mod/sevTBI; n = 119) treated at the outpatient clinic and/or rehabilitation center of our university hospital between 2010 and 2015. Inclusion criteria were: behavioral disturbances as determined with the Differential Outcome Scale and age ≥16 years. Functional outcome was determined by the Glasgow Outcome Scale Extended and return to work (RTW) at six months to one year post-injury. Behavioral impairments and pathway of care were derived from medical files and scored according to predefined criteria. Results: Overall 24% of patients showed serious behavioral disturbances; three times higher in mod/sevTBI (35%) compared to mTBI (13%). mTBI patients mostly showed irritation (82%) and anger (49%), while mod/sevTBI patients mostly showed irritation (65%) and disinhibition (55%). Most (92%) patients returned home, half of the patients did not RTW. Deficits in judgment and decision-making increased risk of no RTW 10-fold. One in ten patients was (temporarily) admitted to a nursing home or psychiatric institution. 13% Of caregivers received support for dealing with impairments of patients and 13% of the mTBI and 17% of the mod/sevTBI patients experienced relational problems. Conclusions: The spectrum of behavioral disturbances differs between TBI severity categories and serious behavioral disturbances are present in a quarter of patients. Only half of the patients resumed work regardless of severity of injury suggesting that particularly the presence and not the severity of long-term behavioral disturbances interferes with RTW. Most patients returned home despite these behavioral disturbances. These findings underline the importance of early identification and appropriate treatment of behavioral disturbances in TBI patients.
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Affiliation(s)
- Marlies L Timmer
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Marleen C Schonherr
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Jacoba M Spikman
- Department of Clinical Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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15
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Dijkink S, Meier K, Krijnen P, Yeh DD, Velmahos GC, Arbous MS, Salim A, Hoogendoorn JM, Schipper IB. The malnutrition in polytrauma patients (MaPP) study: Research protocol. Nutr Health 2019; 25:291-301. [PMID: 31456469 PMCID: PMC6900577 DOI: 10.1177/0260106019868884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Polytrauma patients are at risk of considerable harm from malnutrition due to the metabolic response to trauma. However, there is little knowledge of (the risk of) malnutrition and its consequences in these patients. Recognition of sub-optimally nourished polytrauma patients and their nutritional needs is crucial to prevent complications and optimize their clinical outcomes. AIM The primary objective is to investigate whether polytrauma patients admitted to the Intensive Care Unit (ICU) who have or develop malnutrition have a higher complication rate than patients who are and remain well nourished. Secondary objectives are to determine the prevalence of pre-existent and in-hospital acquired malnutrition in these patients, to assess the association between malnutrition and long-term outcomes, and to determine the association between serum biomarkers (albumin and pre-albumin) and malnutrition. METHODS This international observational prospective cohort study will be performed at three Level-1 trauma centers in the United States and two Level-1 centers in the Netherlands. Adult polytrauma patients (Injury Severity Score ≥16) admitted to the ICU of one of the participating centers directly from the Emergency Department are eligible for inclusion. Nutritional status and risk of malnutrition will be assessed using the Subjective Global Assessment (SGA) scale and Nutritional Risk in Critically Ill (NUTRIC) score, respectively. Nutritional intake, biomarkers and complications will be collected daily. Patients will be followed up to one year after discharge for long-term outcomes. CONCLUSIONS This international prospective cohort study aims to gain more insight into the effect and consequences of malnutrition in polytrauma patients admitted to the ICU.
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Affiliation(s)
- Suzan Dijkink
- Department of Surgery, Leiden University Medical Center, The
Netherlands
- Contributed equally to this manuscript and therefore share first
authorship
| | - Karien Meier
- Department of Surgery, Leiden University Medical Center, The
Netherlands
- Contributed equally to this manuscript and therefore share first
authorship
| | - Pieta Krijnen
- Department of Surgery, Leiden University Medical Center, The
Netherlands
| | - D Dante Yeh
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery,
University of Miami Miller School of Medicine, Florida, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care,
Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center Leiden, The
Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, The
Netherlands
| | - Ali Salim
- Department of Surgery, Division of Trauma, Burn and Surgical Critical Care,
Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jochem M Hoogendoorn
- Department of General Surgery, Haaglanden Medical Center Westeinde, The
Hague, The Netherlands
| | - Inger B Schipper
- Department of Surgery, Leiden University Medical Center, The
Netherlands
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16
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Wilkins TE, Beers SR, Borrasso AJ, Brooks J, Mesley M, Puffer R, Chang YF, Okonkwo DO, Puccio AM. Favorable Functional Recovery in Severe Traumatic Brain Injury Survivors beyond Six Months. J Neurotrauma 2019; 36:3158-3163. [PMID: 31210093 DOI: 10.1089/neu.2018.6153] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Favorable long-term functional outcomes after severe traumatic brain injury (TBI) may be underestimated. We analyzed 24-month functional outcomes from a consecutive series of severe TBI survivors. A prospective, observational database of severe TBI survivors from a single institution was analyzed. Glasgow Outcome Scale-Extended (GOS-E) scores were obtained at 3, 6, 12, and 24 months post-injury. GOS-E scores were dichotomized into unfavorable and favorable outcomes, and the proportion of survivors changing from unfavorable to favorable outcomes was calculated using Wilcoxon signed-rank tests. Surviving adults (N = 304; mean age ± standard deviation = 35.06 ± 15.11; 80.92% male; mode of initial GCS = 7) were analyzed. A statistically significant mean increase in GOS-E was noted from 3 to 6, 6 to 12, 12 to 24, and 6 to 24 months after injury (0.65 [p < 0.0001], 0.42 [p < 0.0001], 0.23 [p = 0.020], and 0.61 [p < 0.0001], respectively). Moreover, 43% of survivors from 3 to 6 months, 36% from 6 to 12 months, 38% from 12 to 24 months, and 54% from 6 to 24 months progressed from an unfavorable to a favorable outcome. Two thirds of survivors in the unfavorable category at 3 months had favorable outcomes at 2 years. Overall, 74% of surviving adults with a documented GOS-E at 2 years after injury had a favorable outcome. Severe TBI survivors demonstrated significant improvement in functional outcomes from 3 to 24 months after injury. At 2 years, three fourths of survivors had a favorable outcome. Long-term prognosis in severe TBI is better than broadly appreciated.
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Affiliation(s)
- Tiffany E Wilkins
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sue R Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Allison J Borrasso
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jordan Brooks
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew Mesley
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ross Puffer
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Puffer RC, Yue JK, Mesley M, Billigen JB, Sharpless J, Fetzick AL, Puccio AM, Diaz-Arrastia R, Okonkwo DO. Recovery Trajectories and Long-Term Outcomes in Traumatic Brain Injury: A Secondary Analysis of the Phase 3 Citicoline Brain Injury Treatment Clinical Trial. World Neurosurg 2019; 125:e909-e915. [PMID: 30763755 DOI: 10.1016/j.wneu.2019.01.207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prospects for recovery after traumatic brain injury (TBI) are often underestimated, potentially leading to withdrawal of care in the comatose TBI patient who may ultimately have a favorable outcome with aggressive care. Outcomes and trajectories of recovery in a large series of patients with TBI were evaluated at 30, 90, and 180 days postinjury. METHODS A secondary analysis of the phase 3 Citicoline Brain Injury Treatment (COBRIT) trial was performed analyzing recovery trajectories and long-term outcomes at 30, 90, and 180 days postinjury. A Glasgow Outcome Scale-Extended (GOS-E) score of 5 or higher was considered favorable. Pearson χ2 analysis was used, and a P value of 0.05 was considered significant. A locally weighted, polynomial regression model was used to model recovery trajectories in a nonlinear fashion. RESULTS Subjects with TBI in the COBRIT trial had high rates of favorable outcome (57% of severe TBI, 86% of moderate TBI, and 93% of complicated mild TBI) at 6-month follow-up. These favorable outcomes often converted from high rates of unfavorable outcome at initial 1-month follow-up (85% of severe TBI, 57% of moderate TBI, and 21% of complicated mild TBI). Recovery trajectories had not plateaued at 6 months, suggesting that further improvement occurs beyond 6 months postinjury. CONCLUSIONS In this secondary analysis of the COBRIT trial, most patients had favorable outcomes by the GOS-E at 6 months postinjury in all complicated mild and moderate TBI groups, with over half of patients with severe TBI achieving a favorable outcome as well. Of subjects in a vegetative state (GOS-E score 2) at 1 month postinjury, 18% improved to a favorable outcome by 6 months postinjury. There was substantial improvement in all groups from 1 to 6 months, and this improvement may continue beyond 6 months. Clinical trials in TBI should consider recovery curves with repeated measures to assess outcomes because arbitrary single-moment outcome determination likely underestimates treatment effect in TBI care.
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Affiliation(s)
- Ross C Puffer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John K Yue
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Matthew Mesley
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Jane Sharpless
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Anita L Fetzick
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Ava M Puccio
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA.
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18
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Lindfors M, Vehviläinen J, Siironen J, Kivisaari R, Skrifvars MB, Raj R. Temporal changes in outcome following intensive care unit treatment after traumatic brain injury: a 17-year experience in a large academic neurosurgical centre. Acta Neurochir (Wien) 2018; 160:2107-2115. [PMID: 30191364 DOI: 10.1007/s00701-018-3670-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/31/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of morbidity and mortality. However, it remains undetermined whether long-term outcomes after TBI have improved over the past two decades. METHODS We conducted a retrospective analysis of consecutive TBI patients admitted to an academic neurosurgical ICU during 1999-2015. Primary outcomes of interest were 6-month all-cause mortality (available for all patients) and 6-month Glasgow Outcome Scale (GOS, available from 2005 onwards). GOS was dichotomized to favourable and unfavourable functional outcome. Temporal changes in outcome were assessed using multivariate logistic regression analysis, adjusting for age, sex, GCS motor score, pupillary light responsiveness, Marshall CT classification and major extracranial injury. RESULTS Altogether, 3193 patients were included. During the study period, patient age and admission Glasgow Coma Scale score increased, while the overall TBI severity did not change. Overall unadjusted 6-month mortality was 25% and overall unadjusted unfavourable outcome (2005-2015) was 44%. There was no reduction in the adjusted odds of 6-month mortality (OR 0.98; 95% CI 0.96-1.00), but the adjusted odds of favourable functional outcome significantly increased (OR 1.08; 95% CI 1.04-1.11). Subgroup analysis showed outcome improvements only in specific subgroups (conservatively treated patients, moderate-to-severe TBI patients, middle-aged patients). CONCLUSIONS During the past two decades, mortality after significant TBI has remained largely unchanged, but the odds of favourable functional outcome have increased significantly in specific subgroups, implying an improvement in quality of care. These developments have been paralleled by notable changes in patient characteristics, emphasizing the importance of continuous epidemiological monitoring.
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Vedantam A, Robertson CS, Gopinath SP. Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury. J Neurosurg 2017; 129:234-240. [PMID: 28937323 DOI: 10.3171/2017.3.jns162720] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early withdrawal of life-sustaining treatment due to expected poor prognosis is responsible for the majority of in-house deaths in severe traumatic brain injury (TBI). With increased focus on the decision and timing of withdrawal of care in patients with severe TBI, data on early neurological recovery in patients with a favorable outcome is needed to guide physicians and families. METHODS The authors reviewed prospectively collected data obtained in 1241 patients with head injury who were treated between 1986 and 2012. Patients with severe TBI, motor Glasgow Coma Scale (mGCS) score < 6 on admission, and those who had favorable outcomes (Glasgow Outcome Scale [GOS] score of 4 or 5, indicating moderate disability or good recovery) at 6 months were selected. Baseline demographic, clinical, and imaging data were analyzed. The time from injury to the first record of following commands (mGCS score of 6) after injury was recorded. The temporal profile of GOS scores from discharge to 6 months after the injury was also assessed. RESULTS The authors studied 218 patients (183 male and 35 female) with a mean age of 28.9 ± 11.2 years. The majority of patients were able to follow commands (mGCS score of 6) within the 1st week after injury (71.4%), with the highest percentage of patients in this group recovering on Day 1 (28.6%). Recovery to the point of following commands beyond 2 weeks after the injury was seen in 14.8% of patients, who experienced significantly longer durations of intracranial pressure monitoring (p = 0.001) and neuromuscular blockade (p < 0.001). In comparison with patients with moderate disability, patients with good recovery had a higher initial GCS score (p = 0.01), lower incidence of anisocoria at admission (p = 0.048), and a shorter ICU stay (p < 0.001) and total hospital stay (p < 0.001). There was considerable improvement in GOS scores from discharge to follow-up at 6 months. CONCLUSIONS Up to 15% of patients with a favorable outcome after severe TBI may begin to follow commands beyond 2 weeks after the injury. These data caution against early withdrawal of life-sustaining treatment in patients with severe TBI.
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20
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Thelin EP, Nelson DW, Vehviläinen J, Nyström H, Kivisaari R, Siironen J, Svensson M, Skrifvars MB, Bellander BM, Raj R. Evaluation of novel computerized tomography scoring systems in human traumatic brain injury: An observational, multicenter study. PLoS Med 2017; 14:e1002368. [PMID: 28771476 PMCID: PMC5542385 DOI: 10.1371/journal.pmed.1002368] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/05/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major contributor to morbidity and mortality. Computerized tomography (CT) scanning of the brain is essential for diagnostic screening of intracranial injuries in need of neurosurgical intervention, but may also provide information concerning patient prognosis and enable baseline risk stratification in clinical trials. Novel CT scoring systems have been developed to improve current prognostic models, including the Stockholm and Helsinki CT scores, but so far have not been extensively validated. The primary aim of this study was to evaluate the Stockholm and Helsinki CT scores for predicting functional outcome, in comparison with the Rotterdam CT score and Marshall CT classification. The secondary aims were to assess which individual components of the CT scores best predict outcome and what additional prognostic value the CT scoring systems contribute to a clinical prognostic model. METHODS AND FINDINGS TBI patients requiring neuro-intensive care and not included in the initial creation of the Stockholm and Helsinki CT scoring systems were retrospectively included from prospectively collected data at the Karolinska University Hospital (n = 720 from 1 January 2005 to 31 December 2014) and Helsinki University Hospital (n = 395 from 1 January 2013 to 31 December 2014), totaling 1,115 patients. The Marshall CT classification and the Rotterdam, Stockholm, and Helsinki CT scores were assessed using the admission CT scans. Known outcome predictors at admission were acquired (age, pupil responsiveness, admission Glasgow Coma Scale, glucose level, and hemoglobin level) and used in univariate, and multivariable, regression models to predict long-term functional outcome (dichotomizations of the Glasgow Outcome Scale [GOS]). In total, 478 patients (43%) had an unfavorable outcome (GOS 1-3). In the combined cohort, overall prognostic performance was more accurate for the Stockholm CT score (Nagelkerke's pseudo-R2 range 0.24-0.28) and the Helsinki CT score (0.18-0.22) than for the Rotterdam CT score (0.13-0.15) and Marshall CT classification (0.03-0.05). Moreover, the Stockholm and Helsinki CT scores added the most independent prognostic value in the presence of other known clinical outcome predictors in TBI (6% and 4%, respectively). The aggregate traumatic subarachnoid hemorrhage (tSAH) component of the Stockholm CT score was the strongest predictor of unfavorable outcome. The main limitations were the retrospective nature of the study, missing patient information, and the varying follow-up time between the centers. CONCLUSIONS The Stockholm and Helsinki CT scores provide more information on the damage sustained, and give a more accurate outcome prediction, than earlier classification systems. The strong independent predictive value of tSAH may reflect an underrated component of TBI pathophysiology. A change to these newer CT scoring systems may be warranted.
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Affiliation(s)
- Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David W. Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Juho Vehviläinen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harriet Nyström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Markus B. Skrifvars
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Aminmansour B, Tabesh H, Rezvani M, Poorjafari H. Effects of Mannitol 20% on Outcomes in Nontraumatic Intracerebral Hemorrhage. Adv Biomed Res 2017; 6:75. [PMID: 28706883 PMCID: PMC5501019 DOI: 10.4103/2277-9175.192628] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND A large number of stroke patients are not the perfect candidate for craniotomy and invasive procedures, so providing an alternative and noninvasive method, which is applicable in terms of costs and facilities, is necessary. Thus, the present study aimed to determine the effects of mannitol 20% on outcome of the patients with nontraumatic intracerebral hemorrhage (ICH) in patients admitted to Isfahan's Al-Zahra Hospital during 2012 and 2013. MATERIALS AND METHODS This is a clinical trial study which is conducted during 2012-2013 in Isfahan's Al-Zahra Hospital. In this study, 41 patients suffering from ICH received mannitol 20% for 3 days, and volume of hemorrhage and Glasgow Coma Scale (GCS) of patients were controlled every 12 h. The collected data were analyzed via SPSS software. RESULTS The mean ICH volume was 22.1 ± 6.3 ml in pre intervention and 38.4 ± 19.3 ml in post intervention, and according to the t-paired test, before and after treatment the difference was significant (P < 0.001). Hemorrhage volume was stable in nine patients (22%), it increased in 25 patients (61%), and decreased in seven patients (17.1%). The mean index of GCS before and after treatment was 11.85 ± 1.6 and 9.37 ± 2.65, respectively. Moreover according to t-paired test, the difference was significant before and after treatment (P < 0.001). During using mannitol, the GCS index was stable in eight patients (19.5%), it increased in eight patients (19.5%) and decreased in 25 patients (61%). CONCLUSIONS Mannitol injection was not effective in reducing hemorrhage size, and its use is not recommended, also, further studies in this field have been proposed.
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Affiliation(s)
- Bahram Aminmansour
- From the Department of Neurosurgery, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Homayoun Tabesh
- From the Department of Neurosurgery, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Rezvani
- From the Department of Neurosurgery, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossain Poorjafari
- From the Department of Neurosurgery, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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Andersson E, Rackauskaite D, Svanborg E, Csajbók L, Öst M, Nellgård B. A prospective outcome study observing patients with severe traumatic brain injury over 10-15 years. Acta Anaesthesiol Scand 2017; 61:502-512. [PMID: 28374472 DOI: 10.1111/aas.12880] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/16/2017] [Accepted: 02/20/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe traumatic brain injury (sTBI) can be divided into primary and secondary injuries. Intensive care protocols focus on preventing secondary injuries. This prospective cohort study was initiated to investigate outcome, including mortality, in patients treated according to the Lund Concept after a sTBI covering 10-15 years post-trauma. METHODS Patients were included during 2000-2004 when admitted to the neurointensive care unit, Sahlgrenska University Hospital. Inclusion criteria were: Glasgow coma scale score of ≤8, need for artificial ventilation and intracranial monitoring. Glasgow Outcome Scale (GOS) was used to evaluate outcome both at 1-year and 10-15 years post-trauma. RESULTS Ninety-five patients, (27 female and 68 male), were initially included. Both improvement and deterioration were noted between 1- and 10-15 years post-injury. Mortality rate (34/95) was higher in the studied population vs. a matched Swedish population, (Standard mortality rate (SMR) 9.5; P < 0.0001). When dividing the cohort into Good (GOS 4-5) and Poor (GOS 2-3) outcome at 1-year, only patients with Poor outcome had a higher mortality rate than the matched population (SMR 7.3; P < 0.0001). Further, good outcome (high GOS) at 1-year was associated with high GOS 10-15 years post-trauma (P < 0.0001). Finally, a majority of patients demonstrated symptoms of mental fatigue. CONCLUSION This indicates that patients with severe traumatic brain injury with Good outcome at 1-year have similar survival probability as a matched Swedish population and that high Glasgow outcome scale at 1-year is related to good long-term outcome. Our results further emphasise the advantage of the Lund concept.
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Affiliation(s)
- E. Andersson
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska University Hospital and Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - D. Rackauskaite
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska University Hospital and Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - E. Svanborg
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska University Hospital and Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - L. Csajbók
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska University Hospital and Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - M. Öst
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska University Hospital and Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - B. Nellgård
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska University Hospital and Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Haller CS, Delhumeau C, De Pretto M, Schumacher R, Pielmaier L, Rebetez MML, Haller G, Walder B. Trajectory of disability and quality-of-life in non-geriatric and geriatric survivors after severe traumatic brain injury. Brain Inj 2017; 31:319-328. [DOI: 10.1080/02699052.2016.1255777] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Chiara S. Haller
- Department of Psychology, Harvard University, Cambridge, Boston, MA, USA
- Division of Public Psychiatry, Massachusetts Mental Health Center, Boston, MA, USA
| | - Cecile Delhumeau
- Division of Anaesthesiology, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Michael De Pretto
- Division of Anaesthesiology, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Rahel Schumacher
- Division of Cognitive and Restorative Neurology, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | | | - Guy Haller
- Division of Anaesthesiology, University Hospitals of Geneva (HUG), Geneva, Switzerland
- Division of Clinical Epidemiology, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva (HUG), Geneva, Switzerland
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24
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Mohseni S, Bellander BM, Riddez L, Talving P, Thelin EP. Positive blood alcohol level in severe traumatic brain injury is associated with better long-term functional outcome. Brain Inj 2016; 30:1256-60. [DOI: 10.1080/02699052.2016.1183823] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Flygt J, Gumucio A, Ingelsson M, Skoglund K, Holm J, Alafuzoff I, Marklund N. Human Traumatic Brain Injury Results in Oligodendrocyte Death and Increases the Number of Oligodendrocyte Progenitor Cells. J Neuropathol Exp Neurol 2016; 75:503-15. [PMID: 27105664 DOI: 10.1093/jnen/nlw025] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 02/28/2016] [Indexed: 12/13/2022] Open
Abstract
Oligodendrocyte (OL) death may contribute to white matter pathology, a common cause of network dysfunction and persistent cognitive problems in patients with traumatic brain injury (TBI). Oligodendrocyte progenitor cells (OPCs) persist throughout the adult CNS and may replace dead OLs. OL death and OPCs were analyzed by immunohistochemistry of human brain tissue samples, surgically removed due to life-threatening contusions and/or focal brain swelling at 60.6 ± 75 hours (range 4-192 hours) postinjury in 10 severe TBI patients (age 51.7 ± 18.5 years). Control brain tissue was obtained postmortem from 5 age-matched patients without CNS disorders. TUNEL and CC1 co-labeling was used to analyze apoptotic OLs, which were increased in injured brain tissue (p < 0.05), without correlation with time from injury until surgery. The OPC markers Olig2, A2B5, NG2, and PDGFR-α were used. In contrast to the number of single-labeled Olig2, A2B5, NG2, and PDGFR-α-positive cells, numbers of Olig2 and A2B5 co-labeled cells were increased in TBI samples (p < 0.05); this was inversely correlated with time from injury to surgery (r = -0.8, p < 0.05). These results indicate that severe focal human TBI results in OL death and increases in OPCs postinjury, which may influence white matter function following TBI.
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Affiliation(s)
- Johanna Flygt
- From the Department of Neuroscience, Neurosurgery (JF, KS, JH, NM), and Department of Public Health and Caring Sciences, Geriatrics (AG, MI), and Department of Immunology, Genetics and Pathology (IA), Uppsala University, Uppsala, Sweden
| | - Astrid Gumucio
- From the Department of Neuroscience, Neurosurgery (JF, KS, JH, NM), and Department of Public Health and Caring Sciences, Geriatrics (AG, MI), and Department of Immunology, Genetics and Pathology (IA), Uppsala University, Uppsala, Sweden
| | - Martin Ingelsson
- From the Department of Neuroscience, Neurosurgery (JF, KS, JH, NM), and Department of Public Health and Caring Sciences, Geriatrics (AG, MI), and Department of Immunology, Genetics and Pathology (IA), Uppsala University, Uppsala, Sweden
| | - Karin Skoglund
- From the Department of Neuroscience, Neurosurgery (JF, KS, JH, NM), and Department of Public Health and Caring Sciences, Geriatrics (AG, MI), and Department of Immunology, Genetics and Pathology (IA), Uppsala University, Uppsala, Sweden
| | - Jonatan Holm
- From the Department of Neuroscience, Neurosurgery (JF, KS, JH, NM), and Department of Public Health and Caring Sciences, Geriatrics (AG, MI), and Department of Immunology, Genetics and Pathology (IA), Uppsala University, Uppsala, Sweden
| | - Irina Alafuzoff
- From the Department of Neuroscience, Neurosurgery (JF, KS, JH, NM), and Department of Public Health and Caring Sciences, Geriatrics (AG, MI), and Department of Immunology, Genetics and Pathology (IA), Uppsala University, Uppsala, Sweden
| | - Niklas Marklund
- From the Department of Neuroscience, Neurosurgery (JF, KS, JH, NM), and Department of Public Health and Caring Sciences, Geriatrics (AG, MI), and Department of Immunology, Genetics and Pathology (IA), Uppsala University, Uppsala, Sweden.
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26
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Mortality and One-Year Functional Outcome in Elderly and Very Old Patients with Severe Traumatic Brain Injuries: Observed and Predicted. Behav Neurol 2015; 2015:845491. [PMID: 26688614 PMCID: PMC4672101 DOI: 10.1155/2015/845491] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 10/29/2015] [Accepted: 11/08/2015] [Indexed: 11/21/2022] Open
Abstract
The aim of the present study was to evaluate mortality and functional outcome in old and very old patients with severe traumatic brain injury (TBI) and compare to the predicted outcome according to the internet based CRASH (Corticosteroid Randomization After Significant Head injury) model based prediction, from the Medical Research Council (MRC). Methods. Prospective, national multicenter study including patients with severe TBI ≥65 years. Predicted mortality and outcome were calculated based on clinical information (CRASH basic) (age, GCS score, and pupil reactivity to light), as well as with additional CT findings (CRASH CT). Observed 14-day mortality and favorable/unfavorable outcome according to the Glasgow Outcome Scale at one year was compared to the predicted outcome according to the CRASH models. Results. 97 patients, mean age 75 (SD 7) years, 64% men, were included. Two patients were lost to follow-up; 48 died within 14 days. The predicted versus the observed odds ratio (OR) for mortality was 2.65. Unfavorable outcome (GOSE < 5) was observed at one year follow-up in 72% of patients. The CRASH models predicted unfavorable outcome in all patients. Conclusion. The CRASH model overestimated mortality and unfavorable outcome in old and very old Norwegian patients with severe TBI.
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27
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Al Nimer F, Thelin E, Nyström H, Dring AM, Svenningsson A, Piehl F, Nelson DW, Bellander BM. Comparative Assessment of the Prognostic Value of Biomarkers in Traumatic Brain Injury Reveals an Independent Role for Serum Levels of Neurofilament Light. PLoS One 2015; 10:e0132177. [PMID: 26136237 PMCID: PMC4489843 DOI: 10.1371/journal.pone.0132177] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/10/2015] [Indexed: 11/18/2022] Open
Abstract
Traumatic brain injury (TBI) is a common cause of death and disability, worldwide. Early determination of injury severity is essential to improve care. Neurofilament light (NF-L) has been introduced as a marker of neuroaxonal injury in neuroinflammatory/-degenerative diseases. In this study we determined the predictive power of serum (s-) and cerebrospinal fluid (CSF-) NF-L levels towards outcome, and explored their potential correlation to diffuse axonal injury (DAI). A total of 182 patients suffering from TBI admitted to the neurointensive care unit at a level 1 trauma center were included. S-NF-L levels were acquired, together with S100B and neuron-specific enolase (NSE). CSF-NF-L was measured in a subcohort (n = 84) with ventriculostomies. Clinical and neuro-radiological parameters, including computerized tomography (CT) and magnetic resonance imaging, were included in the analyses. Outcome was assessed 6 to 12 months after injury using the Glasgow Outcome Score (1-5). In univariate proportional odds analyses mean s-NF-L, -S100B and -NSE levels presented a pseudo-R2 Nagelkerke of 0.062, 0.214 and 0.074 in correlation to outcome, respectively. In a multivariate analysis, in addition to a model including core parameters (pseudo-R2 0.33 towards outcome; Age, Glasgow Coma Scale, pupil response, Stockholm CT score, abbreviated injury severity score, S100B), S-NF-L yielded an extra 0.023 pseudo-R2 and a significantly better model (p = 0.006) No correlation between DAI or CT assessed-intracranial damage and NF-L was found. Our study thus demonstrates that S-NF-L correlates to TBI outcome, even if used in models with S100B, indicating an independent contribution to the prediction, perhaps by reflecting different pathophysiological processes, not possible to monitor using conventional neuroradiology. Although we did not find a predictive value of NF-L for DAI, this cannot be completely excluded. We suggest further studies, with volume quantification of axonal injury, and a prolonged sampling time, in order to better determine the connection between NF-L and DAI.
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Affiliation(s)
- Faiez Al Nimer
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Eric Thelin
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | - Harriet Nyström
- Department of Clinical Neuroscience, Section of Neuroradiology, Karolinska Institutet, Stockholm, Sweden
| | - Ann M Dring
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Svenningsson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Stockholm, Sweden
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28
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Functional Recovery and Life Satisfaction in the First Year After Severe Traumatic Brain Injury. J Head Trauma Rehabil 2015; 30:E38-49. [DOI: 10.1097/htr.0000000000000080] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Tran TM, Fuller AT, Kiryabwire J, Mukasa J, Muhumuza M, Ssenyojo H, Haglund MM. Distribution and Characteristics of Severe Traumatic Brain Injury at Mulago National Referral Hospital in Uganda. World Neurosurg 2015; 83:269-77. [DOI: 10.1016/j.wneu.2014.12.028] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/12/2014] [Indexed: 10/24/2022]
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30
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Murthy SB, Naval NS. Decompressive craniectomy--the price is right?*. Crit Care Med 2014; 42:2305-6. [PMID: 25226128 DOI: 10.1097/ccm.0000000000000561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Santosh B Murthy
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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31
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Cusimano MD, Zanetti K, Sheridan C. Severe traumatic brain injury. J Neurosurg 2013; 119:822. [PMID: 23889137 DOI: 10.3171/2012.11.jns121419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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32
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Corral L, Javierre CF, Ventura JL, Marcos P, Herrero JI, Mañez R. Impact of non-neurological complications in severe traumatic brain injury outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R44. [PMID: 22410278 PMCID: PMC3681369 DOI: 10.1186/cc11243] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 11/15/2011] [Accepted: 03/12/2012] [Indexed: 12/18/2022]
Abstract
Introduction Non-neurological complications in patients with severe traumatic brain injury (TBI) are frequent, worsening the prognosis, but the pathophysiology of systemic complications after TBI is unclear. The purpose of this study was to analyze non-neurological complications in patients with severe TBI admitted to the ICU, the impact of these complications on mortality, and their possible correlation with TBI severity. Methods An observational retrospective cohort study was conducted in one multidisciplinary ICU of a university hospital (35 beds); 224 consecutive adult patients with severe TBI (initial Glasgow Coma Scale (GCS) < 9) admitted to the ICU were included. Neurological and non-neurological variables were recorded. Results Sepsis occurred in 75% of patients, respiratory infections in 68%, hypotension in 44%, severe respiratory failure (arterial oxygen pressure/oxygen inspired fraction ratio (PaO2/FiO2) < 200) in 41% and acute kidney injury (AKI) in 8%. The multivariate analysis showed that Glasgow Outcome Score (GOS) at one year was independently associated with age, initial GCS 3 to 5, worst Traumatic Coma Data Bank (TCDB) first computed tomography (CT) scan and the presence of intracranial hypertension but not AKI. Hospital mortality was independently associated with initial GSC 3 to 5, worst TCDB first CT scan, the presence of intracranial hypertension and AKI. The presence of AKI regardless of GCS multiplied risk of death 6.17 times (95% confidence interval (CI): 1.37 to 27.78) (P < 0.02), while ICU hypotension increased the risk of death in patients with initial scores of 3 to5 on the GCS 4.28 times (95% CI: 1.22 to15.07) (P < 0.05). Conclusions Low initial GCS, worst first CT scan, intracranial hypertension and AKI determined hospital mortality in severe TBI patients. Besides the direct effect of low GCS on mortality, this neurological condition also is associated with ICU hypotension which increases hospital mortality among patients with severe TBI. These findings add to previous studies that showed that non-neurological complications increase the length of stay and morbidity in the ICU but do not increase mortality, with the exception of AKI and hypotension in low GCS (3 to 5).
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Affiliation(s)
- Luisa Corral
- Intensive Care Unit, Hospital Universitari de Bellvitge, Feixa Llarga s/n, L'Hospitalet de Llobregat-08907, Barcelona, Spain.
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Kolakowsky-Hayner SA, Hammond FM, Wright J, Novack TA, Englander J, Diaz-Arrastia R, Dennison A, Sueno P. Ageing and traumatic brain injury: Age, decline in function and level of assistance over the first 10 years post-injury. Brain Inj 2012; 26:1328-37. [DOI: 10.3109/02699052.2012.706353] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Olivecrona M, Rodling-Wahlström M, Naredi S, Koskinen LOD. Prostacyclin treatment and clinical outcome in severe traumatic brain injury patients managed with an ICP-targeted therapy: A prospective study. Brain Inj 2011; 26:67-75. [DOI: 10.3109/02699052.2011.635351] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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35
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Huang SJ, Ho HL, Yang CC. Longitudinal outcomes of patients with traumatic brain injury: A preliminary study. Brain Inj 2010; 24:1606-15. [DOI: 10.3109/02699052.2010.523056] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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36
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Corral L, Herrero JI, Monfort JL, Ventura JL, Javierre CF, Juncadella M, García-Huete L, Bartolomé C, Gabarrós A. First CT findings and improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury. Brain Inj 2010; 23:403-10. [PMID: 19301165 DOI: 10.1080/02699050902788477] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PRIMARY OBJECTIVE To analyse the association between individual initial computerized tomography (CT) scan characteristics and Glasgow Outcome Scale (GOS) and Extended Glasgow Outcome Scale (GOSE) improvement between 6 months and 1 year. METHODS AND PROCEDURES Two hundred and twenty-four adult patients with severe traumatic brain injury and Glasgow Coma Scale (GCS) score of 8 or less who were admitted to an intensive care unit were studied. GOS and GOSE scores were obtained 6 and 12 months after injury in 203 subjects. Patients were predominantly male (84%) and median age was 35 years. MAIN OUTCOMES AND RESULTS Traumatic Coma Data Bank (TCDB) CT classification was associated with GOS/GOSE improvement between 6 months and 1 year, with diffuse injury type I, type II and evacuated mass improving more than diffuse injury type III, type IV and non-evacuated mass; for GOS 43/155 (28%) vs 3/48 (6%) (chi(2) = 9.66, p < 0.01) and for GOSE 71/155 (46%) vs 7/48 (15%) (chi(2) = 15.1, p < 0.01). CT individual abnormalities were not associated with GOS/GOSE improvement, with the exception of subarachnoid haemorrhage, which showed a negative association with GOSE improvement (chi(2) = 4.08, p < 0.05). CONCLUSIONS TCDB CT scan classification and subarachnoid haemorrhage were associated with GOS/GOSE improvement from 6-12 months, but individual CT abnormalities were not associated.
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Affiliation(s)
- Luisa Corral
- Intensive Care Unit, Bellvitge University Hospital, Barcelona, Spain.
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37
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Seeley HM, Kirker S, Harkin C, Dias C, Richards H, Pickard JD, Hutchinson PJ. Head injury rehabilitation: the role of a neurotrauma clinic. Br J Neurosurg 2009; 23:530-7. [DOI: 10.1080/02688690903078874] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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38
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Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care 2009; 11:135-42. [PMID: 19644774 DOI: 10.1007/s12028-009-9255-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Accepted: 07/21/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effects of the neurological "wake-up test" (NWT), defined as interruption of continuous propofol sedation and evaluation of the patient's level of consciousness, on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with severe subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI). METHODS A total of 127 NWT procedures in 21 severely brain-injured adult patients with either TBI (n = 12) or SAH (n = 9) were evaluated. ICP and CPP levels prior to, during and after the NWT procedure were recorded. RESULTS During the NWT, ICP increased from 13.4 +/- 6 mmHg at baseline to 22.7 +/- 12 (P < 0.05) and the CPP increased from 75.6 +/- 11 to 79.1 +/- 21 mmHg (P < 0.05) in TBI patients. Eight patients showed a reduced CPP during the NWT due to increased ICP. In SAH patients, ICP increased from 10.6 +/- 5 to 16.8 +/- 8 mmHg (P < 0.05) and the CPP increased from 76.9 +/- 13 to 84.6 +/- 15 mmHg (P < 0.05). CONCLUSION When continuous propofol sedation was interrupted and NWT was performed in severely brain-injured patients, the mean ICP and CPP levels were modestly increased. A subset of patients showed more pronounced changes. To date, the role of the NWT in the neurointensive care of TBI and SAH patients is unclear. Although the NWT is safe in the majority of patients and may provide useful clinical information about the patient's level of consciousness, alternate monitoring methods are suggested in patients showing marked ICP and/or CPP changes during NWT.
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Affiliation(s)
- Karin Skoglund
- Department of Neuroscience, Neurosurgery, Uppsala University Hospital, 751 85 Uppsala, Sweden
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Cureton EL, Kwan RO, Dozier KC, Sadjadi J, Pal JD, Victorino GP. A different view of lactate in trauma patients: protecting the injured brain. J Surg Res 2009; 159:468-73. [PMID: 19726055 DOI: 10.1016/j.jss.2009.04.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 04/06/2009] [Accepted: 04/09/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND The relationship between lactate and head injury is controversial. We sought to determine the relationship between initial serum lactate, severity of head injury, and outcome. We hypothesized that lactate is elevated in head injured patients, and that initial serum lactate increases as the severity of head injury increases. Furthermore, lactate may be neuroprotective and improve neurologic outcomes. MATERIALS AND METHODS We identified normotensive adult patients over a 6-y period at our university-based urban trauma center with isolated blunt head injury. We performed univariate and multivariate analysis to examine the relationship between lactate and Glasgow coma scale (GCS). The correlation of admission lactate with survival and neurologic function was also examined. RESULTS There were 555 patients who met study criteria. While controlling for injury severity score and age, increased lactate was associated with more severe head injury (P<0.0001). The admission lactate was 2.2+/-0.07, 3.7+/-0.7, and 4.7+/-0.8 mmol/L in patients with mild, moderate, and severe head injury respectively (P<0.01). Patients with moderate or severe head injury and an admission lactate>5 were more likely to have a normal mental status on discharge (P<0.0001). CONCLUSIONS In normotensive isolated head injured patients, there was an increase in serum lactate as head injuries became more severe. Since lactate is a readily available fuel source of the injured brain, this may be a mechanism by which brain function is preserved in trauma patients. Elevations in lactate due to anaerobic metabolism in trauma patients may have beneficial effects by protecting the brain during injury.
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Affiliation(s)
- Elizabeth L Cureton
- Department of Surgery, University of California San Francisco-East Bay, Alameda County Medical Center, Oakland, California 94602, USA
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