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Flores-Sandoval C, MacKenzie HM, McIntyre A, Sait M, Teasell R, Bateman EA. Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury. Arch Gerontol Geriatr 2024; 125:105488. [PMID: 38776698 DOI: 10.1016/j.archger.2024.105488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition. METHOD Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines. RESULTS 64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %). CONCLUSION Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.
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Affiliation(s)
| | - Heather M MacKenzie
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
| | - Amanda McIntyre
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Muskan Sait
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; University College Cork, Ireland
| | - Robert Teasell
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada.
| | - Emma A Bateman
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
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Rafieezadeh A, Zangbar B, Zeeshan M, Gandhi C, Al-Mufti F, Jehan F, Kirsch J, Rodriguez G, Samson D, Prabhakaran K. Predictors of mortality after craniotomy for geriatric traumatic brain injury. Injury 2024; 55:111585. [PMID: 38704345 DOI: 10.1016/j.injury.2024.111585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/02/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy. METHODS We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08. RESULTS We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all). CONCLUSIONS Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome. LEVEL OF EVIDENCE Level III retrospective study.
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Affiliation(s)
- Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States.
| | - Muhammad Zeeshan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Chirag Gandhi
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Fawaz Al-Mufti
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Faisal Jehan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Gabriel Rodriguez
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - David Samson
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Kartik Prabhakaran
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
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Ma Z, He Z, Li Z, Gong R, Hui J, Weng W, Wu X, Yang C, Jiang J, Xie L, Feng J. Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals. Ageing Res Rev 2024; 99:102376. [PMID: 38972601 DOI: 10.1016/j.arr.2024.102376] [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: 03/26/2024] [Revised: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population. METHODS We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses. FINDINGS We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality. CONCLUSIONS In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population. REVIEW REGISTRATION PROSPERO CRD42022323231.
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Affiliation(s)
- Zixuan Ma
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Zhenghui He
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Zhifan Li
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Ru Gong
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Jiyuan Hui
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Weiji Weng
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Xiang Wu
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Chun Yang
- Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Jiyao Jiang
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Junfeng Feng
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Shanghai Institute of Head Trauma, Shanghai 200127, China.
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Zuniga RDDR, Vieira RDCA, Solla DJF, Godoy DA, Kolias A, de Amorim RLO, de Andrade AF, Teixeira MJ, Paiva WS. Long-term outcome of traumatic brain injury patients with initial GCS of 3-5. World Neurosurg X 2024; 23:100361. [PMID: 38511161 PMCID: PMC10950742 DOI: 10.1016/j.wnsx.2024.100361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 03/01/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
| | | | - Davi Jorge Fontoura Solla
- Department of Neurology, Clinics Hospital of the University of São Paulo Medical School, São Paulo, São Paulo, Brazil
| | | | | | - Robson Luis Oliveira de Amorim
- Department of Neurology, Clinics Hospital of the University of São Paulo Medical School, São Paulo, São Paulo, Brazil
- Federal University of Amazonas, Manaus, Amazonas, Brazil
| | - Almir Ferreira de Andrade
- Department of Neurology, Clinics Hospital of the University of São Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurology, Clinics Hospital of the University of São Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Department of Neurology, Clinics Hospital of the University of São Paulo Medical School, São Paulo, São Paulo, Brazil
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Kazimierska A, Uryga A, Mataczyński C, Czosnyka M, Lang EW, Kasprowicz M. Relationship between the shape of intracranial pressure pulse waveform and computed tomography characteristics in patients after traumatic brain injury. Crit Care 2023; 27:447. [PMID: 37978548 PMCID: PMC10656987 DOI: 10.1186/s13054-023-04731-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Midline shift and mass lesions may occur with traumatic brain injury (TBI) and are associated with higher mortality and morbidity. The shape of intracranial pressure (ICP) pulse waveform reflects the state of cerebrospinal pressure-volume compensation which may be disturbed by brain injury. We aimed to investigate the link between ICP pulse shape and pathological computed tomography (CT) features. METHODS ICP recordings and CT scans from 130 TBI patients from the CENTER-TBI high-resolution sub-study were analyzed retrospectively. Midline shift, lesion volume, Marshall and Rotterdam scores were assessed in the first CT scan after admission and compared with indices derived from the first 24 h of ICP recording: mean ICP, pulse amplitude of ICP (AmpICP) and pulse shape index (PSI). A neural network model was applied to automatically group ICP pulses into four classes ranging from 1 (normal) to 4 (pathological), with PSI calculated as the weighted sum of class numbers. The relationship between each metric and CT measures was assessed using Mann-Whitney U test (groups with midline shift > 5 mm or lesions > 25 cm3 present/absent) and the Spearman correlation coefficient. Performance of ICP-derived metrics in identifying patients with pathological CT findings was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS PSI was significantly higher in patients with mass lesions (with lesions: 2.4 [1.9-3.1] vs. 1.8 [1.1-2.3] in those without; p << 0.001) and those with midline shift (2.5 [1.9-3.4] vs. 1.8 [1.2-2.4]; p < 0.001), whereas mean ICP and AmpICP were comparable. PSI was significantly correlated with the extent of midline shift, total lesion volume and the Marshall and Rotterdam scores. PSI showed AUCs > 0.7 in classification of patients as presenting pathological CT features compared to AUCs ≤ 0.6 for mean ICP and AmpICP. CONCLUSIONS ICP pulse shape reflects the reduction in cerebrospinal compensatory reserve related to space-occupying lesions despite comparable mean ICP and AmpICP levels. Future validation of PSI is necessary to explore its association with volume imbalance in the intracranial space and a potential complementary role to the existing monitoring strategies.
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Affiliation(s)
- Agnieszka Kazimierska
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 27 Wybrzeze Wyspianskiego Street, 50-370, Wroclaw, Poland.
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 27 Wybrzeze Wyspianskiego Street, 50-370, Wroclaw, Poland
| | - Cyprian Mataczyński
- Department of Computer Engineering, Faculty of Electronics, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
| | - Erhard W Lang
- Neurosurgical Associates, Red Cross Hospital, Kassel, Germany
- Department of Neurosurgery, Faculty of Medicine, Georg-August-Universität, Göttingen, Germany
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 27 Wybrzeze Wyspianskiego Street, 50-370, Wroclaw, Poland.
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Gavrila Laic RA, Sloten JVANDER, Depreitere B. Neurosurgical treatment in elderly patients with Traumatic brain injury: A 20-year follow-up study. BRAIN & SPINE 2023; 3:101723. [PMID: 37383432 PMCID: PMC10293208 DOI: 10.1016/j.bas.2023.101723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 06/30/2023]
Abstract
Introduction Traumatic brain injury in the elderly population can have a substantial impact on patients' quality of life. In this regard, successful treatment strategies are hard to define to date. Research question In order to facilitate further insight, this study assessed outcomes following acute subdural hematoma evacuation in patients aged ≥65 years in a large patient series. Material and methods A manual screening of the clinical records of 2999 TBI patients aged ≥65 years, admitted to the University Hospital Leuven (Belgium) between 1999 and 2019, was performed. Results A total of 149 patients were identified with aSDH, of whom 32 underwent early surgery, 33 underwent delayed surgery and 84 were treated conservatively. Patients who underwent early surgery had the lowest median GCS, poorest Marshall CT scores, longest hospital and ICU stay, and highest intensive care unit admission and redo surgery rates. 30-d mortality was 21.9% in patients undergoing early surgery, 3.0% in patients undergoing late surgery and 16.7% in patients who were treated conservatively. Discussion and conclusion In conclusion, patients in whom surgery could not be delayed had the worst presentation and poorest outcomes as opposed in patients in whom delay was possible. Surprisingly, patients treated conservatively had worse outcomes than those treated with delayed surgery. These results might indicate that if the GCS at admission is still adequate, an initial strategy of waiting and seeing might be associated with better outcomes. Future prospective studies with sufficient sample size are warranted to draw more definitive conclusions on the value of early vs. late surgery in elderly patients with aSDH.
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Launey Y, Coquet A, Lasocki S, Dahyot-Fizelier C, Huet O, Le Pabic E, Roquilly A, Seguin P. Factors associated with an unfavourable outcome in elderly intensive care traumatic brain injury patients. a retrospective multicentre study. BMC Geriatr 2022; 22:1004. [PMID: 36585608 PMCID: PMC9801582 DOI: 10.1186/s12877-022-03651-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/24/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Changes in the epidemiology of traumatic brain injury (TBI) in older patients have received attention, but limited data are available on the outcome of these patients after admission to intensive care units (ICUs). The aim of this study was to evaluate the outcomes of patients over 65 years of age who were admitted to an ICU for TBI. METHODS This was a multicentre, retrospective, observational study conducted from January 2013 to February 2019 in the surgical ICUs of 5 level 1 trauma centres in France. Patients aged ≥ 65 years who were hospitalized in the ICU for TBI with or without extracranial injuries were included. The main objective was to determine the risk factors for unfavourable neurological outcome at 3 months defined as an Extended Glasgow Outcome Scale (GOSE) score < 5. RESULTS Among the 349 intensive care patients analysed, the GOSE score at 3 months was ≤ 4 and ≥ 5 in 233 (67%) and 116 (33%) patients, respectively. The mortality rate at 3 months was 157/233 (67%), and only 7 patients (2%) fully recovered or had minor symptoms. Withdrawal or withholding of life-sustaining therapies in the ICU was identified in 140 patients (40.1%). Multivariate analysis showed that age (OR 1.09, CI 95% 1.04-1.14), male sex (OR 2.94, CI95% 1.70-5.11), baseline Glasgow Coma Scale score (OR 1.20, CI95% 1.13-1.29), injury severity score (ISS; OR 1.04, CI95% 1.02-1.06) and use of osmotherapy (OR 2.42, CI95% 1.26-4.65) were associated with unfavourable outcomes (AUC = 0.79, CI 95% [0.74-0.84]). According to multivariate analysis, the variables providing the best sensitivity and specificity were age ≥ 77 years, Glasgow Coma Scale score ≤ 9 and ISS ≥ 25 (AUC = 0.79, CI 95% [0.74-0.84]). CONCLUSIONS Among intensive care patients aged ≥ 65 years suffering from TBI, age (≥ 77 years), male sex, baseline Glasgow coma scale score (≤ 9), ISS (≥ 25) and use of osmotherapy were predictors of unfavourable neurological outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04651803. Registered 03/12/2020. Retrospectively registered.
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Affiliation(s)
- Y Launey
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - A Coquet
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - S Lasocki
- grid.411147.60000 0004 0472 0283Département d’Anesthésie Réanimation, CHU de Angers, Angers, France
| | - C Dahyot-Fizelier
- grid.411162.10000 0000 9336 4276Département d’Anesthésie Réanimation, CHU de Poitiers, Poitiers, France
| | - O Huet
- grid.411766.30000 0004 0472 3249Département d’Anesthésie Réanimation, CHU de Brest, Brest, France
| | - E Le Pabic
- grid.411154.40000 0001 2175 0984Centre d’Investigation Clinique, CHU de Rennes, 2 Rue Henri Le Guilloux, 35000 Rennes, France
| | - A Roquilly
- grid.277151.70000 0004 0472 0371Département d’Anesthésie Réanimation, CHU de Nantes, Nantes, France
| | - P Seguin
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
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Singh RD, van Dijck JTJM, van Essen TA, Lingsma HF, Polinder SS, Kompanje EJO, van Zwet EW, Steyerberg EW, de Ruiter GCW, Depreitere B, Peul WC. Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design. Trials 2022; 23:242. [PMID: 35351178 PMCID: PMC8962939 DOI: 10.1186/s13063-022-06184-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. DISCUSSION The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. TRIAL REGISTRATION Nederlands Trial Register (NTR), Trial NL9012 . CLINICALTRIALS gov, Trial NCT04648436 .
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Affiliation(s)
- Ranjit D Singh
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Thomas A van Essen
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hester F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Suzanne S Polinder
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Godard C W de Ruiter
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | | | - Wilco C Peul
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Bobeff EJ, Stawiski K, Stanisławska PA, Posmyk BJ, Wiśniewski K, Bryl M, Piotrowski MM, Fortuniak J, Jaskólski DJ. Validation of the Elderly Traumatic Brain Injury Score: an observational case-control study. World Neurosurg 2022; 161:e464-e472. [PMID: 35176521 DOI: 10.1016/j.wneu.2022.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) poses a particular health risk for the elderly. The recently developed Elderly Traumatic Brain Injury Score (eTBI Score) combines the prognostic information of the risk factors characteristic of the geriatric population. We aimed to determine its validity and reliability on an independent sample. METHODS We present a retrospective analysis of 506 consecutive patients after TBI aged ≥65 years. The previously described nomogram and the eTBI Score were used. The primary outcome measure was mortality or vegetative state at 30 days after hospital admission. RESULTS Mortality or vegetative state rate was 21.3%. The nomogram and eTBI Score showed similar predictive performance with accuracy of 83.8% (95%CI 80.2%-87%) and 84.4% (95%CI 80.8%-87.6%), respectively. Based on the Youden index and C4.5 algorithm we divided patients according to the 3-tier pattern into low, high and medium risk groups. The outcome prediction in the first two groups was correct in 93.1% (survival in the low risk group) and 94.4% (mortality in the high risk group). Patients included in the medium risk group usually required surgical treatment (85.3%), and characterized for increased mortality or vegetative state (55%). Among patients with eTBI≥5 (n=221), there was no difference in outcome between those treated conservatively and surgically. CONCLUSIONS This is the first study confirming the validity of the eTBI Score and its close association with outcome of geriatric population after TBI. The novel 3-tier risk stratification scheme was applicable to both conservatively and surgically treated patients.
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Affiliation(s)
- Ernest Jan Bobeff
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Konrad Stawiski
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Patrycja Alicja Stanisławska
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Bartłomiej Józef Posmyk
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Karol Wiśniewski
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Maciej Bryl
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Michał Mateusz Piotrowski
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Jan Fortuniak
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Dariusz Jan Jaskólski
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
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Reza Bagheri S, Abdi A, Benson J, Naghdi N, Eden SV, Arjmand M, Amini Z, Lawton MT, Alimohammadi E. The significant impact of Coronavirus disease 2019 (COVID-19) on in-hospital mortality of elderly patients with moderate to severe traumatic brain injury: A retrospective observational study. J Clin Neurosci 2021; 93:241-246. [PMID: 34656255 PMCID: PMC8462266 DOI: 10.1016/j.jocn.2021.09.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/19/2021] [Accepted: 09/15/2021] [Indexed: 12/23/2022]
Abstract
Background Traumatic brain injury (TBI) is one of the main causes of death and disability among the elderly patient population. This study aimed to assess the predictors of in-hospital mortality of elderly patients with moderate to severe TBI who presented during the Coronavirus disease 2019 (COVID-19) pandemic. Methods In this retrospective analytical study, all elderly patients with moderate to severe TBI who were referred to our center between March 2nd, 2020 to August 1st, 2020 were investigated and compared against the TBI patients receiving treatment during the same time period within the year 2019. Patients were followed until discharge from the hospital or death. The demographic, clinical, radiological, and laboratory test data were evaluated. Data were analyzed using SPSS-21 software. Findings In this study, 359 elderly patients were evaluated (n = 162, Post-COVID-19). Fifty-four patients of the cohort had COVID-19 disease with a mortality rate was 33.3%. The patients with COVID-19 were 5.45 times more likely to expire before discharge (P < 0.001) than the TBI patients who were not COVID-19 positive. Other variables such as hypotension (OR, 4.57P < 0.001), hyperglycemia (OR, 2.39, P = 0.002), and use of anticoagulant drugs (OR, 2.41P = 0.001) were also associated with in-hospital death. According to the binary logistic regression analysis Age (OR, 1.72; 95% CI: 1.26–2.18; P = 0.033), Coronavirus infection (OR, 2.21; 95% CI: 1.83–2.92; P = 0.011) and Glasgow Coma Scale (GCS) (OR, 3.11; 95% CI: 2.12–4.53; P < 0.001) were independent risk factors correlated with increased risk of in-hospital mortality of elderly patients with moderate to severe TBI. Conclusion Our results showed that Coronavirus infection could increase the risk of in-hospital mortality of elderly patients with moderate to severe TBI significantly.
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Affiliation(s)
- Seyed Reza Bagheri
- Department of Neurosurgery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Abdi
- Nursing and Midwifery School, Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran
| | | | - Negin Naghdi
- Clinical Research Development Center, Taleghani and Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Sonia V Eden
- Wayne State University School of Medicine, Detroit, MI, USA.
| | - Minoo Arjmand
- Kermanshah University of Medical Sciences, Taleghani Hospital, Kermanshah, Iran
| | - Zahra Amini
- Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Ehsan Alimohammadi
- Department of Neurosurgery, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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11
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Hosomi S, Kitamura T, Sobue T, Ogura H, Shimazu T. Sex and age differences in isolated traumatic brain injury: a retrospective observational study. BMC Neurol 2021; 21:261. [PMID: 34225691 PMCID: PMC8256599 DOI: 10.1186/s12883-021-02305-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/22/2021] [Indexed: 11/12/2022] Open
Abstract
Background Among the many factors that may influence traumatic brain injury (TBI) progression, sex is one of the most controversial. The objective of this study was to investigate sex differences in TBI-associated morbidity and mortality using data from the largest trauma registry in Japan. Methods This retrospective, population-based observational study included patients with isolated TBI, who were registered in a nationwide database between 2004 and 2018. We excluded patients with extracranial injury (Abbreviated Injury Scale score ≥ 3) and removed potential confounding factors, such as non-neurological causes of mortality. Patients were stratified by age and mortality and post-injury complications were compared between males and females. Results A total of 51,726 patients with isolated TBI were included (16,901 females and 34,825 males). Mortality across all ages was documented in 12.01% (2030/16901) and 12.76% (4445/34825) of males and females, respectively. The adjusted odds ratio (OR) of TBI mortality for males compared to females was 1.32 (95% confidence interval [CI], 1.22–1.42]. Males aged 10–19 years and ≥ 60 years had a significantly higher mortality than females in the same age groups (10–19 years: adjusted OR, 1.97 [95% CI, 1.08–3.61]; 60–69 years: adjusted OR, 1.24 [95% CI, 1.02–1.50]; 70–79 years: adjusted OR, 1.20 [95% CI, 1.03–1.40]; 80–89 years: adjusted OR, 1.50 [95% CI, 1.31–1.73], and 90–99 years: adjusted OR, 1.72 [95% CI, 1.28–2.32]). In terms of the incidence of post-TBI neurologic and non-neurologic complications, the crude ORs were 1.29 (95% CI, 1.19–1.39) and 1.14 (95% CI, 1.07–1.22), respectively, for males versus females. This difference was especially evident among elderly patients (neurologic complications: OR, 1.27 [95% CI, 1.14–1.41]; non-neurologic complications: OR, 1.29 [95% CI, 1.19–1.39]). Conclusions In a nationwide sample of patients with TBI in Japan, males had a higher mortality than females. This disparity was particularly evident among younger and older generations. Furthermore, elderly males experienced more TBI complications than females of the same age. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02305-6.
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Affiliation(s)
- Sanae Hosomi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan. .,Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan.
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
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Gavrila Laic RA, Bogaert L, Vander Sloten J, Depreitere B. Functional outcome, dependency and well-being after traumatic brain injury in the elderly population: A systematic review and meta-analysis. BRAIN AND SPINE 2021; 1:100849. [PMID: 36247393 PMCID: PMC9560680 DOI: 10.1016/j.bas.2021.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022]
Abstract
Introduction Traumatic brain injury (TBI) rates in the elderly are increasing worldwide, mainly due to fall accidents. However, TBI's impact on elderly patients' lives has not been thoroughly investigated. Research question This systematic review and meta-analysis aims at describing post-TBI incidence of functional decline, dependency, nursing home admission, reduced quality of life and depression in the elderly. Materials and methods A systematic literature search was performed in PubMed, EMBASE, Web Of Science, BIOSIS, Current Contents Connect, Data Citation Index, MEDLINE, SciELO, Cochrane library and CINAHL. Study selection was conducted by two independent reviewers. Meta-analysis was performed using a random-effects model. Results Twenty-seven studies were included in the qualitative synthesis and twenty-five in a random-effects meta-analysis. The prevalence of unfavorable functional outcomes after TBI was 65.2% (95% CI: 51.1–78.0). Admission to a nursing home had a pooled prevalence of 28.5% (95% CI: 17.1–41.6) and dependency rates ranged between 16.9% and 74.0%. A reduced quality of life was documented throughout follow-up with SF12/36 scores between 35.3 and 52.3/100.2.6–4.8% of the patients with mild TBI reported depressive symptoms. A large heterogeneity was found among studies for functional outcomes and discharge destination. Discussion and conclusion In conclusion, elderly patients have a significant risk for functional decline, dependency, nursing home admission and low quality of life following TBI. Moreover, more severe injuries lead to worse outcomes. These findings are important to provide accurate patient and family counseling, set realistic treatment targets and aim at relevant outcome variables in prognostic models for TBI in elderly patients. Traumatic Brain Injury in the elderly has a major impact on functional outcomes. Traumatic Brain Injury in elderly leads to dependency and nursing home admission. Elderly patients have a lower quality of life after Traumatic Brain Injury. Older age and injury severity are risk factors for poor functional outcome.
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13
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Posti JP, Sipilä JOT, Luoto TM, Rautava P, Kytö V. A decade of geriatric traumatic brain injuries in Finland: population-based trends. Age Ageing 2020; 49:779-785. [PMID: 32134443 DOI: 10.1093/ageing/afaa037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND we investigated trends of traumatic brain injury (TBI)-related hospitalisations, deaths, acute neurosurgical operations (ANO), and lengths of hospital stay (LOS) in patients aged ≥70 years in Finland using a population-based cohort. METHODS nationwide databases were searched for all admissions with a TBI diagnosis as well as later deaths for persons ≥70 years of age during 2004-2014. RESULTS the study period included 20,259 TBI-related hospitalisations (mean age = 80.7 years, men = 48.9%). The incidence of TBI-related hospitalisations was 283/100,000 person-years with an estimated overall annual increase of 2.9% (95% CI: 0.4-5.9%). There was an annual decrease of 2.2% in in-hospital mortality (IHM) in men (95% CI: 0.1-4.3%), with no change in women or overall. There was an annual decrease of 1.1% in odds for ANOs among hospitalised overall (95% CI: 0.1-2.1%) and of 1.4% in men (95% CI: 0.0-2.7%), while no change was observed in women. LOS decreased annually by 2.5% (95% CI: 2.1-2.9%). The incidence of TBI-related deaths was 70/100,000 person-years with an estimated annual increase of 1.6% in women (95% CI: 0.2-2.9%), but no change in men or overall. Mean ages of TBI-related admissions and deaths increased (P < 0.001). INTERPRETATION the incidence rate of geriatric TBI-related hospitalisations increased, especially in women, but LOS and the rate of ANOs among hospitalised decreased. The overall TBI-related mortality remained stable, and IHM decreased in men, while in women, the overall mortality increased and IHM remained stable. However, the overall incidence rates of TBI-related hospitalisations and deaths and the number of cases of IHM were still higher in men.
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Affiliation(s)
- Jussi P Posti
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Turku Brain Injury Centre, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, Finland
| | - Jussi O T Sipilä
- Department of Clinical Neurosciences, University of Turku, Finland
- Division of Clinical Neurosciences, Department of Neurology, Turku University Hospital, Turku, Finland
- Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital, Turku, Finland
- Department of Public Health, University of Turku, Turku, Finland
| | - Ville Kytö
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
- Heart Centre, Turku University Hospital, University of Turku, Turku, Finland
- Center for Population Health Research, Turku University Hospital, University of Turku, Turku, Finland
- Administative Center, Hospital District of Southwest Finland, Turku, Finland
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Martín‐Saborido C, López‐Alcalde J, Ciapponi A, Sánchez Martín CE, Garcia Garcia E, Escobar Aguilar G, Palermo MC, Baccaro FG. Indomethacin for intracranial hypertension secondary to severe traumatic brain injury in adults. Cochrane Database Syst Rev 2019; 2019:CD011725. [PMID: 31752052 PMCID: PMC6872435 DOI: 10.1002/14651858.cd011725.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Among people who have suffered a traumatic brain injury, increased intracranial pressure continues to be a major cause of early death; it is estimated that about 11 people per 100 with traumatic brain injury die. Indomethacin (also known as indometacin) is a powerful cerebral vasoconstrictor that can reduce intracranial pressure and, ultimately, restore cerebral perfusion and oxygenation. Thus, indomethacin may improve the recovery of a person with traumatic brain injury. OBJECTIVES To assess the effects of indomethacin for adults with severe traumatic brain injury. SEARCH METHODS We ran the searches from inception to 23 August 2019. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 8) in the Cochrane Library, Ovid MEDLINE, Ovid Embase, CINAHL Plus (EBSCO), four other databases, and clinical trials registries. We also screened reference lists and conference abstracts, and contacted experts in the field. SELECTION CRITERIA Our search criteria included randomised controlled trials (RCTs) that compared indomethacin with any control in adults presenting with severe traumatic brain injury associated with elevated intracranial pressure, with no previous decompressive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently decided on the selection of the studies. We followed standard Cochrane methods. MAIN RESULTS We identified no eligible studies for this review, either completed or ongoing. AUTHORS' CONCLUSIONS We found no studies, either completed or ongoing, that assessed the effects of indomethacin in controlling intracranial hypertension secondary to severe traumatic brain injury. Thus, we cannot draw any conclusions about the effects of indomethacin on intracranial pressure, mortality rates, quality of life, disability or adverse effects. This absence of evidence should not be interpreted as evidence of no effect for indomethacin in controlling intracranial hypertension secondary to severe traumatic brain injury. It means that we have not identified eligible research for this review.
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Affiliation(s)
- Carlos Martín‐Saborido
- San Juan De Dios Foundation, Health Sciences University Centre, Antonio de Nebrija UniversityResearch on Evidence and Decision Making GroupPaseo de la Habana 70 bisMadridComunidad de MadridSpain28036
| | - Jesús López‐Alcalde
- Cochrane Associate Centre of MadridCtra. Colmenar Km. 9,100MadridMadridSpain28034
- Universidad Francisco de VitoriaFaculty of MedicineCtra. M‐515 Pozuelo‐MajadahondaPozuelo de AlarcónMadridSpain28223
- Instituto Ramón y Cajal de Investigación SanitariaClinical Biostatistics UnitCtra. Colmenar, km. 9.100MadridSpain28034
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | | | - Elena Garcia Garcia
- San Juan De Dios FoundationHealth Services Research DepartmentC/Herreros de TejadaMadridSpain3‐28016
| | - Gema Escobar Aguilar
- San Juan de Dios Foundation/San Rafael‐Nebrija Health Sciences Center, Nebrija UniversityHealth Services Research UnitHerreros de Tejada, 5MadridSpain28036
| | - Maria Carolina Palermo
- University of Buenos AiresInstitute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Buenos AiresArgentina
| | - Fernando G Baccaro
- Juan A Fernández HospitalIntensive Care UnitCerviño 3356Buenos AiresArgentina1425
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Using computerized tomography perfusion to measure cerebral hemodynamics following treatment of traumatic brain injury in rabbits. Exp Ther Med 2019; 18:2104-2110. [PMID: 31410165 PMCID: PMC6676178 DOI: 10.3892/etm.2019.7785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 05/16/2019] [Indexed: 11/09/2022] Open
Abstract
The present study aimed to investigate the use of computerized tomography (CT) perfusion for evaluating cerebral hemodynamics following traumatic brain injury (TBI) in rabbits. The animals were randomly assigned into four groups (n=10 animals/group): i) Control, ii) TBI, iii) TBI + common decompression and iv) TBI + controlled decompression groups. A TBI model was established in rabbits using epidural balloon inflation. In the groups receiving intervention, animals were provided common decompression or controlled decompression treatments. Conventional CT and CT perfusion scanning were performed, with cerebral hemodynamic indices, including regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV) and mean transit time (MTT) being measured. Blood-brain barrier (BBB) permeability was evaluated using Evans blue staining. Compared with those in the control group, rCBF and rCBV values of the bilateral temporal lobes and basal ganglion in the TBI, TBI + common decompression and TBI + controlled decompression groups were significantly lower, whereas the MTT values were markedly prolonged and Evans blue dye content was greatly increased (P<0.01). Controlled decompression was demonstrated to be more potent than common decompression for preventing TBI-induced decline in rCBF and rCBV values in the bilateral temporal lobes and basal ganglion, as well as reversing TBI-induced extension of MTT in the bilateral temporal lobes (P<0.01 vs. TBI group). However, neither common nor controlled decompression could reduce TBI-induced increase in BBB permeability. In conclusion, these findings indicate that CT perfusion may be used to monitor cerebral hemodynamics following TBI in rabbits. Controlled decompression was deduced to be more potent than common decompression for preventing abnormalities in cerebral hemodynamics after TBI.
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16
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Operative versus non-operative treatment of traumatic brain injuries in patients 80 years of age or older. Neurosurg Rev 2019; 43:1305-1314. [PMID: 31414197 DOI: 10.1007/s10143-019-01159-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/13/2019] [Accepted: 08/05/2019] [Indexed: 12/25/2022]
Abstract
Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80 years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80 years of age. Data were derived from the TraumaRegister DGU® from 2002 to 2016. Inclusion criteria were ≥ 80 years of age, an Abbreviated Injury ScaleHead (AIS) ≥ 3, and an AISNon-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AISHead of 5/6 (p = 0.03). Patients 80 years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.
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Yamagami K, Kurogi R, Kurogi A, Nishimura K, Onozuka D, Ren N, Kada A, Nishimura A, Arimura K, Ido K, Mizoguchi M, Sakamoto T, Kayama T, Suzuki M, Arai H, Hagihara A, Iihara K. The Influence of Age on the Outcomes of Traumatic Brain Injury: Findings from a Japanese Nationwide Survey (J-ASPECT Study-Traumatic Brain Injury). World Neurosurg 2019; 130:e26-e46. [PMID: 31132488 DOI: 10.1016/j.wneu.2019.05.140] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The epidemiology of patients with traumatic brain injury (TBI) has changed dramatically over recent decades as a result of rapid advances in aging societies. We assessed the influence of age on outcomes of patients with TBI and sought to identify prognostic factors for in-hospital mortality of TBI among elderly patients. METHODS Using a nationwide database, we analyzed data from 5651 patients with TBI. Univariate analysis was conducted to compare patient demographics, neurologic status on admission, radiologic findings, systemic complication rates, length of hospital stay, in-hospital mortality, and home discharge rates between elderly and nonelderly groups. Multivariable analysis was conducted to determine prognostic factors for in-hospital mortality among elderly patients. RESULTS Overall in-hospital mortality was significantly higher in elderly patients (12.8% vs. 19.3%; P < 0.001). In-hospital mortality of elderly patients with mild TBI increased significantly at >7 days after admission, whereas that of elderly patients with moderate or severe TBI was significantly higher immediately after admission. Age (odds ratio [OR], 1.62; P = 0.024), male sex (OR, 1.30; P = 0.004), Japan Coma Scale score on admission (OR, 5.95, P < 0.001), and incidence of acute subdural hematoma (OR, 1.89; P < 0.001) were associated with in-hospital mortality in elderly patients with TBI. CONCLUSIONS Elderly patients with TBI showed significantly higher in-hospital mortality. Delayed increases in in-hospital mortality were observed among elderly patients with mild TBI. Level of consciousness on admission was the strongest predictor of in-hospital mortality among elderly patients.
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Affiliation(s)
- Keitaro Yamagami
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ai Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine, Director, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Daisuke Onozuka
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nice Ren
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Kada
- Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keisuke Ido
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Takamasa Kayama
- Department of Advanced Cancer Science, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Hajime Arai
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Akihito Hagihara
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Albrecht JS, Kibria GA, Gruber-Baldini A, Magaziner J. Risk of Mortality in Individuals with Hip Fracture and Traumatic Brain Injury. J Am Geriatr Soc 2019; 67:124-127. [PMID: 30471090 PMCID: PMC6436834 DOI: 10.1111/jgs.15661] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To estimate the prevalence of diagnosed traumatic brain injury (TBI) in individuals hospitalized with hip fracture and examine its association with all-cause mortality. DESIGN Nested cohort study. SETTING National sample of Medicare beneficiaries from 2006 to 2010. PARTICIPANTS Beneficiaries aged 65 and older hospitalized with hip fracture. MEASUREMENTS TBI at the time of hip fracture was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The main outcome was all-cause mortality during follow-up. RESULTS Prevalence of TBI in individuals with hip fracture was 2.7%. Absolute risk of mortality attributable to TBI in individuals with hip fracture was 15/100 person-years. TBI was significantly associated with risk of death in multivariable analysis (hazard ratio=1.24, 95% confidence interval=1.14-1.35). CONCLUSION TBI was associated with greater risk of mortality in individuals with hip fracture. Practitioners should consider evaluating for presence of TBI in this vulnerable population. J Am Geriatr Soc 67:124-127, 2019.
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Affiliation(s)
- Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Gulam Al Kibria
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Ann Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
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Tunthanathip T, Khocharoen K, Phuenpathom N. Blast-induced traumatic brain injury: the experience from a level I trauma center in southern Thailand. Neurosurg Focus 2018; 45:E7. [DOI: 10.3171/2018.8.focus18311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIn the ongoing conflict in southern Thailand, the improvised explosive device (IED) has been a common cause of blast-induced traumatic brain injury (bTBI). The authors investigated the particular characteristics of bTBI and the factors associated with its clinical outcome.METHODSA retrospective cohort study was conducted on all patients who had sustained bTBI between 2009 and 2017. Collected data included clinical characteristics, intracranial injuries, and outcomes. Factors analysis was conducted using a forest plot.RESULTSDuring the study period, 70 patients met the inclusion criteria. Fifty individuals (71.4%) were military personnel. One-third of the patients (32.9%) suffered moderate to severe bTBI, and the rate of intracerebral injuries on brain CT was 65.7%. Coup contusion was the most common finding, and primary blast injury was the most common mechanism of blast injury. Seventeen individuals had an unfavorable outcome (Glasgow Outcome Scale score 1–3), and the overall mortality rate for bTBI was 11.4%. In the univariate analysis, factors associated with an unfavorable outcome were preoperative coagulopathy, midline shift of the brain ≥ 5 mm, basal cistern effacement, moderate to severe TBI, hypotension, fixed and dilated pupils, surgical site infection, hematocrit < 30% on admission, coup contusion, and subdural hematoma. In the multivariable analysis, midline shift ≥ 5 mm (OR 29.1, 95% CI 2.5–328.1) and coagulopathy (OR 28.7, 95% CI 4.5–180.3) were the only factors predicting a poor outcome of bTBI.CONCLUSIONSbTBIs range from mild to severe. Midline shift and coagulopathy are treatable factors associated with an unfavorable outcome. Hence, in cases of bTBI, reversing an abnormal coagulogram is required as soon as possible to improve clinical outcomes. The management of brain shift needs further study.
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Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J Neurotrauma 2018; 35:889-906. [PMID: 29212411 PMCID: PMC5865621 DOI: 10.1089/neu.2017.5371] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.
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Affiliation(s)
- Raquel C. Gardner
- Department of Neurology, University of California San Francisco, and San Francisco VA Medical Center, San Francisco, California
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Molly Rose Morrissey
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T. Manley
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
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Karnjanasavitree W, Phuenpathom N, Tunthanathip T. The Optimal Operative Timing of Traumatic Intracranial Acute Subdural Hematoma Correlated with Outcome. Asian J Neurosurg 2018; 13:1158-1164. [PMID: 30459885 PMCID: PMC6208231 DOI: 10.4103/ajns.ajns_199_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH. Materials and Methods The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups. Results The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome. Conclusions The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.
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Affiliation(s)
- Worawach Karnjanasavitree
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Nakornchai Phuenpathom
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thara Tunthanathip
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Free KE, Greene AM, Bondi CO, Lajud N, de la Tremblaye PB, Kline AE. Comparable impediment of cognitive function in female and male rats subsequent to daily administration of haloperidol after traumatic brain injury. Exp Neurol 2017; 296:62-68. [PMID: 28698031 DOI: 10.1016/j.expneurol.2017.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/06/2017] [Accepted: 07/07/2017] [Indexed: 01/09/2023]
Abstract
Antipsychotic drugs, such as haloperidol (HAL), are prescribed in the clinic to manage traumatic brain injury (TBI)-induced agitation. While preclinical studies have consistently shown that once-daily administration of HAL hinders functional recovery after TBI in male rats, its effects in females are unknown. Hence, the objective of this study was to directly compare neurobehavioral and histological outcomes in both sexes to determine whether the reported deleterious effects of HAL extend to females. Anesthetized adult female and male rats received either a controlled cortical impact (CCI) or sham injury and then were randomly assigned to a dosing regimen of HAL (0.5mg/kg, i.p.) or vehicle (VEH; 1mL/kg, i.p.) that was initiated 24h after injury and continued once daily for 19 consecutive days. Motor function was tested using established beam-balance/walk protocols on post-operative days 1-5 and acquisition of spatial learning was assessed with a well-validated Morris water maze task on days 14-19. Cortical lesion volume was quantified at 21days. No statistical differences were revealed between the HAL and VEH-treated sham groups and thus they were pooled for each sex. HAL only impaired motor recovery in males (p<0.05), but significantly diminished spatial learning in both sexes (p<0.05). Females, regardless of treatment, exhibited smaller cortical lesions vs VEH-treated males (p<0.05). Taken together, the data show that daily HAL does not prohibit motor recovery in females, but does negatively impact cognition. These task-dependent differential effects of HAL in female vs male rats may have clinical significance as they can direct therapy.
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Affiliation(s)
- Kristin E Free
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Anna M Greene
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Corina O Bondi
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, United States; Neurobiology, University of Pittsburgh, Pittsburgh, PA 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, United States; Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Naima Lajud
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, United States; División de Neurociencias, Centro de Investigación Biomédica de Michoacán, Instituto Mexicano del Seguro Social Morelia, Mexico
| | - Patricia B de la Tremblaye
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Anthony E Kline
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, United States; Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA 15213, United States; Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States; Psychology, University of Pittsburgh, Pittsburgh, PA 15213, United States.
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Sex differences in mortality following isolated traumatic brain injury among older adults. J Trauma Acute Care Surg 2017; 81:486-92. [PMID: 27280939 DOI: 10.1097/ta.0000000000001118] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Older adults have the highest rates of hospitalization and mortality from traumatic brain injury (TBI), yet outcomes in this population are not well studied. In particular, contradictory reports on the protective effect of female sex on mortality following TBI may have been related to age differences in TBI and other injury severity and mechanism. The objective of this study was to determine if there are sex differences in mortality following isolated TBI among older adults and compare with findings using all TBI. A secondary objective was to characterize TBI severity and mechanism by sex in this population. METHODS This was a retrospective cohort study conducted among adults aged 65 and older treated for TBI at a single large Level I trauma center from 1996 to 2012 (n = 4,854). Individuals treated for TBI were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Isolated TBI was defined as an Abbreviated Injury Scale score of 0 for other body regions. Our primary outcome was mortality at discharge. RESULTS Among those with isolated TBI (n = 1,320), women (45% of sample) were older (mean [SD], 78.9 [7.7] years) than men (76.8 [7.5] years) (p < 0.001). Women were more likely to have been injured in a fall (91% vs. 84%; p < 0.001). Adjusting for multiple injury severity measures, female sex was not significantly associated with decreased odds of mortality following isolated TBI (odds ratio, 1.01; 95% confidence interval, 0.66-1.54). Using all TBI cases, adjusted analysis found that female sex was significantly associated with decreased odd of mortality (odds ratio, 0.73; 95% confidence interval, 0.59-0.89). CONCLUSION We found no sex differences in mortality following isolated TBI among older adults, in contrast with other studies and our own analyses using all TBI cases. Researchers should consider isolated TBI in outcome studies to prevent residual confounding by severity of other injuries. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.
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Triage Patterns of Traumatic Subarachnoid Hemorrhage: Is Referral to a Tertiary Care Center Necessary? World Neurosurg 2017; 100:417-423. [DOI: 10.1016/j.wneu.2017.01.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 11/21/2022]
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Near-Infrared Spectroscopy: A Promising Prehospital Tool for Management of Traumatic Brain Injury. Prehosp Disaster Med 2017; 32:414-418. [DOI: 10.1017/s1049023x17006367] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroductionEarly identification of traumatic brain injury (TBI) is essential. Near-infrared spectroscopy (NIRS) can be used in prehospital settings for non-invasive monitoring and the diagnosis of patients who may require surgical intervention.MethodsThe handheld NIRS Infrascanner (InfraScan Inc.; Philadelphia, Pennsylvania USA) uses eight symmetrical scan points to detect intracranial bleeding. A scanner was tested in a physician-staffed helicopter Emergency Medical Service (HEMS). The results were compared with those obtained using in-hospital computed tomography (CT) scans. Scan time, ease-of-use, and change in treatment were scored.ResultsA total of 25 patients were included. Complete scans were performed in 60% of patients. In 15 patients, the scan was abnormal, and in one patient, the scan resulted in a treatment change. Compared with the results of CT scanning, the Infrascanner obtained a sensitivity of 93.3% and a specificity of 78.6%. Most patients had severe TBI with indication for transport to a trauma center prior to scanning. In one patient, the scan resulted in a treatment change. Evaluation of patients with less severe TBI is needed to support the usefulness of the Infrascanner as a prehospital triage tool.ConclusionPromising results were obtained using the InfraScan NIRS device in prehospital screening for intracranial hematomas in TBI patients. High sensitivity and good specificity were found. Further research is necessary to determine the beneficial effects of enhanced prehospital screening on triage, survival, and quality of life in TBI patients.PetersJ,
Van WageningenB,
HoogerwerfN,
TanE. Near-infrared spectroscopy: a promising prehospital tool for management of traumatic brain injury. Prehosp Disaster Med. 2017;32(4):414–418.
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26
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Swanson TM, Isaacson BM, Cyborski CM, French LM, Tsao JW, Pasquina PF. Traumatic Brain Injury Incidence, Clinical Overview, and Policies in the US Military Health System Since 2000. Public Health Rep 2017; 132:251-259. [PMID: 28135424 DOI: 10.1177/0033354916687748] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Exposure to explosive armaments during Operation Iraqi Freedom and Operation Enduring Freedom contributed to approximately 14% of the 352 612 traumatic brain injury (TBI) diagnoses in the US military between 2000 and 2016. The US Department of Defense issued guidelines in 2009 to (1) standardize TBI diagnostic criteria; (2) classify TBI according to mechanism and severity; (3) categorize TBI symptoms as somatic, psychological, or cognitive; and (4) systematize types of care given during the acute and rehabilitation stages of TBI treatment. Polytrauma and associated psychological and neurologic conditions may create barriers to optimal rehabilitation from TBI. Given the completion of recent combat operations and the transition of TBI patients into long-term care within the US Department of Veterans Affairs system, a review of the literature concerning TBI is timely. Long-term follow-up care for patients who have sustained TBI will remain a critical issue for the US military.
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Affiliation(s)
- Thomas M Swanson
- 1 Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,2 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA.,3 Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brad M Isaacson
- 1 Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,2 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Cherina M Cyborski
- 1 Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,4 National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Louis M French
- 1 Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,4 National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,5 Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA
| | - Jack W Tsao
- 1 Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,6 Bureau of Medicine and Surgery, Wounded, Ill and Injured, US Navy, Falls Church, VA, USA
| | - Paul F Pasquina
- 1 Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,7 Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Padovani C, Da Silva JM, Rotta BP, Neto RDCP, Fu C, Tanaka C. Recovery of functional capacity in severe trauma victims at one year after injury: association with trauma-related and hospital stay aspects. J Phys Ther Sci 2016; 28:1432-7. [PMID: 27313345 PMCID: PMC4905884 DOI: 10.1589/jpts.28.1432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/19/2016] [Indexed: 12/02/2022] Open
Abstract
[Purpose] The aim of this study was to investigate the functional capacity of trauma
survivors one year after hospital discharge and to identify associations with trauma- and
hospital stay-related aspects in a developing country. [Subjects and Methods] This study
included severe trauma patients (Injury Severity Score ≥16; ≥18 years
old) who were admitted to an intensive care unit in Sao Paulo, Brazil. Hospital stay data
were collected from the patients’ records. Functional capacity was assessed using the
Glasgow Outcome Scale and Lawton Instrumental Activities of
Daily Living Scale one year after hospital discharge. Patients were asked if
they had returned to work/school. [Results] Forty-nine patients completed follow-up.
According to the Glasgow Outcome Scale data, most patients had moderate
or mild/no dysfunction. The Lawton Instrumental Activities of Daily Living
Scale showed that 60–70% of the subjects performed most activities
independently. Multiple linear regression of the Glasgow score, Acute Physiology
and Chronic Health Disease Classification System II score, length of mechanical
ventilation, and hospital length of stay revealed an association between the
Lawton Instrumental Activities of Daily Living Scale and hospital
length of stay. Overall, 32.6% of the subjects had returned to work/school. [Conclusion]
Most severe trauma patients experienced functional recovery, although only one-third had
returned to work/school one year after hospital discharge. Hospital length of stay was
identified as a significant predictor of functional recovery.
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Affiliation(s)
- Cauê Padovani
- Hospital das Clínicas da Faculdade de Medicina, University of São Paulo, Brazil; Department of Physiotherapy, Communication Science and Disorders, Occupational Therapy, University of São Paulo, Brazil
| | | | - Bruna Peruzzo Rotta
- Hospital do Servidor Público Estadual, Brazil; Department of Physiotherapy, Communication Science and Disorders, Occupational Therapy, University of São Paulo, Brazil
| | | | - Carolina Fu
- Department of Physiotherapy, Communication Science and Disorders, Occupational Therapy, University of São Paulo, Brazil
| | - Clarice Tanaka
- Hospital das Clínicas da Faculdade de Medicina, University of São Paulo, Brazil; Department of Physiotherapy, Communication Science and Disorders, Occupational Therapy, University of São Paulo, Brazil
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Elderly Patients with Severe Traumatic Brain Injury Could Benefit from Surgical Treatment. World Neurosurg 2016; 89:147-52. [DOI: 10.1016/j.wneu.2016.01.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 11/20/2022]
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Kwon YS, Lee YH, Cho JM. Early Experience of Automated Intraventricular Type Intracranial Pressure Monitoring (LiquoGuard®) for Severe Traumatic Brain Injury Patients. Korean J Neurotrauma 2016; 12:28-33. [PMID: 27182499 PMCID: PMC4866562 DOI: 10.13004/kjnt.2016.12.1.28] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 03/18/2016] [Accepted: 04/18/2016] [Indexed: 11/25/2022] Open
Abstract
Objective The LiquoGuard® system is a new ventricular-type monitoring device that facilitates intracranial pressure (ICP)-controlled or volume-controlled drainage of cerebrospinal fluid (CSF). The purpose of this study is to report the authors' experience with the LiquoGuard® ICP monitoring system, as well as the clinical safety, usefulness, and limitations of this device in the management of patients with traumatic brain injury (TBI). Methods Intraventricular ICP monitoring was performed on 10 patients with TBI using the LiquoGuard® monitoring system. ICP measurements, volume of drained CSF, and clinical outcomes were analyzed and discussed. Results ICP monitoring was performed on 10 patients for a mean duration of 6.9 days. With a mean 82,718 records per patient, the mean initial ICP was 16.4 mm Hg and the average ICP across the total duration of monitoring was 15.5 mm Hg. The mean volume of drained CSF was 29.2 cc/day, with no CSF drained in 4 patients. Seven of 10 patients showed 1 or 2 episodes of abnormal ICP measurements. No patient exhibited complications associated with ICP monitoring. Conclusion The LiquoGuard® system is a versatile tool in the management of TBI patients. Its use is both reliable and feasible for ICP monitoring and therapeutic drainage of CSF. However, episodes of abnormal ICP measurements were frequently observed in patients with slit ventricles, and further study may be needed to overcome this issue.
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Affiliation(s)
- Young Sub Kwon
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Neurosurgery, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Yun Ho Lee
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jin Mo Cho
- Department of Neurosurgery, Catholic Kwandong University, International St. Mary's Hospital, Incheon, Korea
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Promising clinical outcome of elderly with TBI after modern neurointensive care. Acta Neurochir (Wien) 2016; 158:125-33. [PMID: 26577639 DOI: 10.1007/s00701-015-2639-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The increasing number of elderly patients with traumatic brain injury (TBI) leads to specific neurointensive care (NIC) challenges. Therefore, elderly subjects with TBI need to be further studied. In this study we evaluated the demographics, management and outcome of elderly TBI patients receiving modern NIC. METHODS Patients referred to our NIC unit between 2008 and 2010 were included. Patients were divided in two age groups, elderly (E) ≥65 years and younger (Y) 64-15 years. Parameters studied were the dominant finding on CT scans, neurological motor skills and consciousness, type of monitoring, neurosurgical procedures/treatments and Glasgow Outcome Scale Extended score at 6 months after injury. RESULTS Sixty-two E (22 %) and 222 Y (78 %) patients were included. Falls were more common in E (81 %) and vehicle accidents were more common in Y patients (37 %). Acute subdural hematoma was significantly more common in E (50 % of cases) compared to Y patients (18 %). Intracranial pressure was monitored in 44 % of E and 57 % of Y patients. Evacuation of significant mass lesions was performed more common in the E group. The NIC mortality was similar in both groups (4-6 %). Favorable outcome was observed in 72 % of Y and 51 % of E patients. At the time of follow-up 25 % of E and 7 % of Y patients had died. CONCLUSIONS The outcome of elderly patients with TBI was significantly worse than in younger patients, as expected. However, as much as 51 % of the elderly patients showed a favorable outcome after NIC. We believe that these results encourage modern NIC in elderly patients with TBI. We need to study how secondary brain injury mechanisms differ in the older patients and to identify specific outcome predictors for elderly patients with TBI.
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Charry JD, Rubiano AM, Nikas CV, Ortíz JC, Puyana JC, Carney N, Adelson PD. Results of early cranial decompression as an initial approach for damage control therapy in severe traumatic brain injury in a hospital with limited resources. J Neurosci Rural Pract 2016; 7:7-12. [PMID: 26933337 PMCID: PMC4750344 DOI: 10.4103/0976-3147.172151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Severe traumatic brain injury (sTBI) is a disease that generates significant mortality and disability in Latin America, and specifically in Colombia. The purpose of this study was to evaluate the 12-month clinical outcome in patients with sTBI managed with an early cranial decompression (ECD) as the main procedure for damage control (DC) therapy, performed in a University Hospital in Colombia over a 4-year period. MATERIALS AND METHODS A database of 106 patients who received the ECD procedure, and were managed according to the strategy for DC in neurotrauma, was analyzed. Variables were evaluated, and the patient outcome was determined according to the Glasgow Outcome Score (GOS) at 12 months postinjury. This was used to generate a dichotomous variable with "favorable" (GOS of 4 or 5) or "unfavorable" (GOS of 1-3) outcomes; analysis of variance was performed with the Chi-square, Wilcoxon-Mann-Whitney and Fisher tests. RESULTS An overall survival rate of 74.6% was observed for the procedure, At 12 months postsurgery, a favorable clinical outcome (GOS 4-5) was found in 70 patients (66.1%), Unfavorable outcomes in patients were associated with the following factors: Closed trauma, an Injury Severity Score >16, obliterated basal cisterns, subdural hematoma as the main injury seen on the admission computed tomography, and nonreactive pupils observed in the emergency department. CONCLUSION Twelve months outcome of patients with sTBI managed with ECD in a neuromonitoring limited resource University Hospital in Colombia shows an important survival rate with favorable clinical outcome measure with GOS.
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Affiliation(s)
- José D. Charry
- Department of Basic and Clinical Sciences, Neuroscience and Neurosurgery, South Colombian University and University Hospital, Neiva, Colombia
- Neurotrauma Research Group, MEDITECH Foundation, Neiva, Colombia
| | - Andrés M. Rubiano
- Department of Basic and Clinical Sciences, Neuroscience and Neurosurgery, South Colombian University and University Hospital, Neiva, Colombia
- Neurotrauma Research Group, MEDITECH Foundation, Neiva, Colombia
| | | | - Juan C. Ortíz
- Department of Basic and Clinical Sciences, Neuroscience and Neurosurgery, South Colombian University and University Hospital, Neiva, Colombia
- Neurotrauma Research Group, MEDITECH Foundation, Neiva, Colombia
| | - Juan C. Puyana
- Department of Surgery, University of Pittsburgh, Pittsburgh (PA), USA
| | - Nancy Carney
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health Sciences University, Portland (OR), USA
| | - P. David Adelson
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix (AZ), USA
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Predictors of Outcomes in Traumatic Brain Injury. World Neurosurg 2015; 90:525-529. [PMID: 26721615 DOI: 10.1016/j.wneu.2015.12.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 12/12/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The purpose of this study was to retrospectively evaluate patients treated for traumatic brain injuries (TBI) to determine how multiple organ trauma (MOT) and lung injuries sustained at the time of initial injury affect outcome. METHODS A single institution retrospective review of all patients diagnosed with TBI at a level I trauma center from 2000 to 2014 was conducted. Clinical outcome was based on Glasgow Outcome Scale at hospital discharge. Lung injury was defined as the presence of pulmonary contusions, pneumothorax, hemothorax, rib fractures, or diaphragmatic rupture proven by x-ray or computed tomography scan. MOT was defined as trauma to one body region with an Abbreviated Injury Scale (AIS) score ≥3 plus trauma to 2 additional body regions with AIS scores ≥1. Regression analysis was conducted with SPSS 21. RESULTS There were 409 patients reviewed. The majority of patients were male (73%), average age was 46 years (range, 16-94 years), average Glasgow Coma Scale (GCS) score was 7, and 71% had a severe TBI (GCS ≤8). Thirty percent of patients had poor outcome (Glasgow Outcome Scale = 1-2) Regression analysis indicated age (odds ratio [OR] 1.03, P < 0.001), initial GCS (OR 0.88, P < 0.001), Injury Severity Score (OR 1.03, P = 0.021), and head AIS ≥5 (OR 0.55, P = 0.019) were significant independent predictors of poor outcome. Sex, MOT, lung injury, and lung injury severity were not significant predictors of outcome. CONCLUSIONS Age, GCS, Injury Severity Score, and critical head injuries (AIS ≥5) were significant tools in predicting outcome in this patient cohort. MOT and traumatic lung injury may cause significant damage to a patient suffering from a severe TBI, but these injuries do not predict mortality in this patient population.
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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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Fulkerson DH, White IK, Rees JM, Baumanis MM, Smith JL, Ackerman LL, Boaz JC, Luerssen TG. Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4. J Neurosurg Pediatr 2015; 16:410-9. [PMID: 26140392 DOI: 10.3171/2015.3.peds14679] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. METHODS A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a "normal" outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. RESULTS Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. CONCLUSIONS In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.
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Affiliation(s)
- Daniel H Fulkerson
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Ian K White
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jacqueline M Rees
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Maraya M Baumanis
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jodi L Smith
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Laurie L Ackerman
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Joel C Boaz
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Thomas G Luerssen
- Department of Neurological Surgery, Baylor College of Medicine, Texas Children's Hospital, Pediatric Neurosurgery, Houston, Texas
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Herou E, Romner B, Tomasevic G. Acute Traumatic Brain Injury: Mortality in the Elderly. World Neurosurg 2015; 83:996-1001. [DOI: 10.1016/j.wneu.2015.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 02/07/2015] [Accepted: 02/11/2015] [Indexed: 11/29/2022]
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Baccaro FG, Romano M, Ciapponi A, López-Alcalde J. Indomethacin in controlling intracranial hypertension secondary to severe traumatic brain injury. Hippokratia 2015. [DOI: 10.1002/14651858.cd011725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Fernando G Baccaro
- Hospital "Juan A. Fernández"; Intensive Care Unit; Cerviño 3356 Buenos Aires Argentina 1425
| | - Marina Romano
- Southern American Branch of the Iberoamerican Cochrane Centre; Argentine Cochrane Centre IECS, Institute for Clinical Effectiveness and Health Policy; Dr. Emilio Ravignani 2024 Buenos Aires Capital Federal Argentina C1414CPV
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy; Argentine Cochrane Centre IECS - Southern American Branch of the Iberoamerican Cochrane Centre; Dr. Emilio Ravignani 2024 Buenos Aires Capital Federal Argentina C1414CPV
| | - Jesús López-Alcalde
- Iberoamerican Cochrane Centre - Biomedical Research Institute Sant Pau (IIB Sant Pau); Barcelona Cataluña Spain 08041
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Al-Kashmiri AM, Al-Shaqsi SZ, Al-Kharusi AS, Al-Tamimi LA. Save the patient a trip. Outcome difference between conservatively treated patients with traumatic brain injury in a nonspecialized intensive care unit vs a specialized neurosurgical intensive care unit in the Sultanate of Oman. J Crit Care 2015; 30:465-8. [PMID: 25746586 DOI: 10.1016/j.jcrc.2015.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/05/2015] [Accepted: 02/12/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED Traumatic brain injury (TBI) continues to be the main cause of death among trauma patients. Accurate diagnosis and timely surgical interventions are critical steps in reducing the mortality from this disease. For patients who have no surgically reversible head injury pathology, the decision to transfer to a dedicated neurosurgical unit is usually controversial. OBJECTIVE To compare the outcome of patients with severe TBI treated conservatively in a specialized neurosurgical intensive care unit (ICU) and those treated conservatively at a general ICU in the Sultanate of Oman. DESIGN Retrospective cohort study. METHODS This is a retrospective study of patients with severe TBI admitted to Khoula Hospital ICU (specialized neurosurgical ICU) and Nizwa Hospital ICU (general ICU) in Oman in 2013. Surgically treated patients were excluded. Data extracted included demographics, injury details, interventions, and outcomes. The outcome variables included mortality, length of stay, length of ICU days, and ventilated days. RESULTS There were 100 patients with severe TBI treated conservatively at Khoula Hospital compared with 74 patients at Nizwa Hospital. Basic demographics were similar between the 2 groups. No significant difference was found in mortality, length of stay, ICU days, and ventilation days. CONCLUSION There is no difference in outcome between patients with TBI treated conservatively in a specialized neurosurgical ICU and those treated in a general nonspecialized ICU in Oman in 2013. Therefore, unless neurosurgical intervention is warranted or expected, patients with TBI may be managed in a general ICU, saving the risk and expense of a transfer to a specialized neurosurgical ICU.
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Affiliation(s)
| | - Sultan Z Al-Shaqsi
- Department of Plastic and Reconstructive Surgery, Khoula Hospital Muscat, Oman
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Zhang X, Yan X, Gorman J, Hoffman SN, Zhang L, Boscarino JA. Perioperative hyperglycemia is associated with postoperative neurocognitive disorders after cardiac surgery. Neuropsychiatr Dis Treat 2014; 10:361-70. [PMID: 24570589 PMCID: PMC3933727 DOI: 10.2147/ndt.s57761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Neurocognitive disorders commonly occur following cardiac surgery. However, the underlying etiology of these disorders is not well understood. The current study examined the association between perioperative glucose levels and other risk factors and the onset of neurocognitive disorders in adult patients following coronary artery bypass and/or valvular surgery. METHODS Adult patients who underwent their first cardiac surgery at a large tertiary care medical center were identified and those with neurocognitive disorders prior to surgery were excluded. Demographic, perioperative, and postoperative neurocognitive outcome data were extracted from the Society for Thoracic Surgery database, and from electronic medical records, between January 2004 and June 2009. Multiple clinical risk factors and measures associated with insulin resistance, such as hyperglycemia, were assessed. Multivariable Cox competing risk survival models were used to assess hyperglycemia and postoperative neurocognitive disorders at follow up, adjusting for other risk factors and confounding variables. RESULTS Of the 855 patients included in the study, 271 (31.7%) had new onset neurocognitive disorders at follow-up. Age, sex, New York Heart Failure (NYHF) Class, length of postoperative intensive care unit stay, perioperative blood product transfusion, and other key factors were identified and assessed as potential risk factors (or confounders) for neurocognitive disorders at follow-up. Bivariate analyses suggested that new onset neurocognitive disorders were associated with NYHF Class, cardiopulmonary bypass, history of diabetes, intraoperative blood product use, and number of diseased coronary vessels, which are commonly-accepted risk factors in cardiac surgery. In addition, higher first glucose level (median =116 mg/dL) and higher peak glucose >169 mg/dL were identified as risk factors. Male sex and nonuse of intra-operative blood products appeared to be protective. Controlling for potential risk factors and confounders, multivariable Cox survival models suggested that increased perioperative first glucose measured in 20 unit increments, was significantly associated with the onset of postoperative neurocognitive disorders at follow-up (hazard ratio [HR] =1.16, P<0.001) and that women had an elevated risk for this outcome (HR =4.18, P=0.01). CONCLUSION Our study suggests that perioperative hyperglycemia was associated with new onset of postoperative neurocognitive disorders in adult patients after cardiac surgery, and that men tended to be protected from these outcomes. These findings may suggest a need for the revision of clinical protocols for perioperative insulin therapy to prevent long-term neurocognitive complications.
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Affiliation(s)
- Xiaopeng Zhang
- Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA
| | - Xiaowei Yan
- Center for Health Research, Geisinger Clinic, Danville, PA, USA
| | - Jennifer Gorman
- Center for Health Research, Geisinger Clinic, Danville, PA, USA
| | - Stuart N Hoffman
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Li Zhang
- Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA
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Farahvar A, Gerber LM, Chiu YL, Carney N, Härtl R, Ghajar J. Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring. J Neurosurg 2012; 117:729-34. [DOI: 10.3171/2012.7.jns111816] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor.
Methods
From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension.
Results
Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality.
Conclusions
In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.
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Affiliation(s)
- Arash Farahvar
- 1Department of Neurosurgery, University of Rochester Medical Center, Rochester
| | | | | | - Nancy Carney
- 3Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Roger Härtl
- 4Neurological Surgery, Weill Cornell Medical College; and
| | - Jamshid Ghajar
- 4Neurological Surgery, Weill Cornell Medical College; and
- 5Brain Trauma Foundation, New York, New York; and
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Pearson WS, Sugerman DE, McGuire LC, Coronado VG. Emergency department visits for traumatic brain injury in older adults in the United States: 2006-08. West J Emerg Med 2012; 13:289-93. [PMID: 22928058 PMCID: PMC3426370 DOI: 10.5811/westjem.2012.3.11559] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/05/2012] [Accepted: 03/26/2012] [Indexed: 12/04/2022] Open
Abstract
Introduction: Traumatic brain injury (TBI) can be complicated among older adults due to age-related
frailty, a greater prevalence of chronic conditions and the use of anticoagulants. We
conducted this study using the latest available, nationally-representative emergency
department (ED) data to characterize visits for TBI among older adults. Methods: We used the 2006–2008 National Hospital Ambulatory Medical Care –
Emergency Department (NHAMCS-ED) data to examine ED visits for TBI among older adults.
Population-level estimates of triage immediacy, receipt of a head computed tomography
(CT) and/or head magnetic resonance imaging (MRI), and hospital admission by type were
used to characterize 1,561 sample visits, stratified by age <65 and ≥65
years of age. Results: Of ED visits made by persons ≥65 years of age, 29.1% required attention
from a physician within 15 minutes of arrival; 82.1% required a head CT, and
20.9% required hospitalization. Persons ≥65 years of age were 3 times
more likely to receive a head CT or MRI compared to younger patients presenting with TBI
(adjusted odds ratio [aOR] 3.2; 95% confidence interval
[CI], 1.8–5.8), and were 4 times more likely to be admitted to
an intensive care unit, step-down unit, or surgery (aOR 4.1; 95% CI
2.1–8.0) compared to younger patients presenting with TBI, while controlling for
sex and race. Conclusion: Results demonstrate increased emergent service delivery for older persons presenting
with TBI. As the United States population ages and continues to grow, TBI will become an
even more important public health issue that will place a greater demand on the
healthcare system.
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Affiliation(s)
- William S Pearson
- Division of Injury Response, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Stocchetti N, Paternò R, Citerio G, Beretta L, Colombo A. Traumatic brain injury in an aging population. J Neurotrauma 2012; 29:1119-25. [PMID: 22220762 DOI: 10.1089/neu.2011.1995] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The epidemiology of traumatic brain injury (TBI) is changing in several Western countries, with an increasing proportion of elderly TBI patients admitted to the intensive care unit (ICU). We describe a series of 1366 adult patients admitted to three neuro-ICUs in which 44% of cases were 50 years of age or older. The health status before trauma (rated using the APACHE score) was worse in older patients. In all 604 patients had emergency removal of intracranial masses, with extradural hematomas more frequent in young cases and subdural hematomas more frequent in older patients. Outcomes were classified according to the Glasgow Outcome Scale (GOS) 6 months post-trauma, as favorable (GOS score 4-5), or unfavorable (GOS score 1-3). Favorable outcomes were achieved by 50% of patients, but the proportions of unfavorable outcomes rose with age. Mortality was the main cause of unfavorable outcomes 6 months after injury in older patients. Logistic regression analysis indicates that several parameters independently contributed to outcome, including the motor component of the Glasgow Coma Scale (GCS), pupils, CT findings, and early hypotension. Additionally, the odds ratios were very high for age and health status before TBI. Patients admitted to the ICU are increasingly older, have co-morbidities, and have specific types of intracranial lesions. Early rescue, surgical treatment, and intensive care of these patients may produce excellent results up to the age of 59 years, with favorable outcomes still possible for 39% of cases aged 60-69 years, without an excessive burden of severely disabled patients.
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Affiliation(s)
- Nino Stocchetti
- University of Milan, NeuroIntensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy.
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Mellergård P, Sjögren F, Hillman J. The Cerebral Extracellular Release of Glycerol, Glutamate, and FGF2 Is Increased in Older Patients following Severe Traumatic Brain Injury. J Neurotrauma 2012; 29:112-8. [DOI: 10.1089/neu.2010.1732] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pekka Mellergård
- Department of Neurosurgery, University Hospital, Linköping, Sweden
| | - Florence Sjögren
- Department of Dermatology, University Hospital, Linköping, Sweden
| | - Jan Hillman
- Department of Neurosurgery, University Hospital, Linköping, Sweden
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Comparison of Ventricular Type and Parenchymal Type Intracranial Pressure (ICP) Monitoring for the Severe Traumatic Brain Injury Patients. Korean J Neurotrauma 2012. [DOI: 10.13004/kjnt.2012.8.2.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Wong GKC, Graham CA, Ng E, Yeung JHH, Rainer TH, Poon WS. Neurological outcomes of neurosurgical operations for multiple trauma elderly patients in Hong Kong. J Emerg Trauma Shock 2011; 4:346-50. [PMID: 21887023 PMCID: PMC3162702 DOI: 10.4103/0974-2700.83861] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Accepted: 02/08/2011] [Indexed: 11/10/2022] Open
Abstract
Background: We aimed to investigate neurological outcomes in elderly patients with multiple trauma, and to review their clinical outcomes following neurosurgical operations. Patients and Methods: The study was conducted in a regional trauma center in Hong Kong. We collected prospective data on consecutive trauma patients from January 2001 to December 2008. Patients with multiple trauma (as defined by Injury Severity Score of 15 or more), with both head injury and extracranial injury, were included for analysis. Results: Age over 65 years, admission Glasgow Coma Scale (GCS), and Injury Severity Score were significantly poor prognostic factors in logistic regression analysis. Eleven (32%) of the 34 patients aged over 65 who underwent neurosurgical operations attained favorable neurological outcomes (GCS 4-5) at 6 months. Conclusions: Age was an important prognostic factor in multiple trauma patients requiring neurosurgical operations. Future randomized controlled clinical trials should be designed to recruit elderly patients (such as age between 65 and 75 years) at clinical equipoise for traumatic hematoma (such as subdural hematoma or traumatic intracerebral hematoma) evacuation and assess the quality of life, neurological, and cognitive outcomes.
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Affiliation(s)
- George K C Wong
- Department of Surgery, Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
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Ley EJ, Clond MA, Hussain ON, Srour M, Mirocha J, Bukur M, Margulies DR, Salim A. Mortality by Decade in Trauma Patients with Glasgow Coma Scale 3. Am Surg 2011. [DOI: 10.1177/000313481107701015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to assess how increasing age affects mortality in trauma patients with Glasgow Coma Scale (GCS) 3. The Los Angeles County Trauma System Database was queried for all patients aged 20 to 99 years admitted with GCS 3. Mortality was 41.8 per cent for the 3306 GCS 3 patients. Mortality in the youngest patients reviewed, those in the third decade, was 43.5 per cent. After logistic regression analysis, patients in the third decade had similar mortality rates to patients in the sixth (adjusted OR, 0.88; CI, 0.68 to 1.14; P = 0.33) and seventh decades (adjusted OR, 0.96; CI, 0.70 to 1.31; P = 0.79). A significantly lower mortality rate, however, was noted in the fifth decade (adjusted OR, 0.76; CI, 0.61 to 0.95; P = 0.02). Conversely, significantly higher mortality rates were noted in the eighth (adjusted OR, 1.93; CI, 1.38 to 2.71; P = 0.0001) and combined ninth/tenth decades (adjusted OR, 2.47; CI, 1.71 to 3.57; P < 0.0001). Given the high survival in trauma patients with GCS 3 as well as continued improvement in survival compared with historical controls, aggressive care is indicated for patients who present to the emergency department with GCS 3.
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Affiliation(s)
- Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Morgan A. Clond
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Omar N. Hussain
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marissa Srour
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marko Bukur
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dan R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ali Salim
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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De Bonis P, Pompucci A, Mangiola A, Paternoster G, Festa R, Nucci CG, Maviglia R, Antonelli M, Anile C. Decompressive craniectomy for elderly patients with traumatic brain injury: it's probably not worth the while. J Neurotrauma 2011; 28:2043-8. [PMID: 21639728 DOI: 10.1089/neu.2011.1889] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Decompressive craniectomy (DC) has been regarded as an ultima ratio measure in the treatment of refractory intracranial hypertension after brain injury. Most discussion about its benefits is based on studies performed in patients who are <65 years of age. The aim of this study was to identify patients aged ≥66 years who underwent DC after traumatic brain injury (TBI), in order to assess patient outcome and to correlate the values of potential predictors of survival on prognosis. From January 2002 to December 2009, 44 patients aged ≥66 underwent DC (follow-up, 12-102 months). Potential predictors of outcome were analyzed, including age, post-resuscitation Glasgow Coma Scale (GCS) score, presence of mass lesion, Simplified Acute Physiology Score (SAPS) II, Injury Severity Score (ISS), and timing of surgical decompression. Mortality was 48% at discharge from the intensive care unit (ICU), 57% at hospital discharge, and 77% at 1-year follow-up and at last follow-up. A bad outcome Glasgow Outcome Scale Dead-Vegetative State-Severely Disabled (GOS D-VS-SD) was observed in 36/44 patients both at hospital discharge and at 1-year follow-up. Mean SAPS II was 45.2 for patients who survived and 57.3 for patients who had died (p=0.0022). Patients who survived had a higher mean post-resuscitation GCS score (p=0.02). Logistical regression analysis indicated post-resuscitation GCS score as the only independent predictive factor for outcome. None of the 22 patients with a post-resuscitation GCS score of 3-5 had a good outcome, 2/10 (20%) patients with a post-resuscitation GCS score of 6-8 and 6/12 patients (50%) with a post-resuscitation GCS score ≥9 had a good outcome.
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Affiliation(s)
- Pasquale De Bonis
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy.
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