Severe traumatic brain injury in a high-income country: an epidemiological study

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

A proof of concept model to calculate white and grey matter AIS injuries in pedestrian collisions

In the real world, the severity of traumatic injuries is measured using the Abbreviated Injury Scale (AIS) and is often estimated, in finite element human computer models, with the maximum principal strains (MPS) tensor. MPS can predict when a serious injury is reached, but cannot provide any AIS measures lower and higher from this. To overcome these limitations, a new organ trauma model (OTM2), capable of calculating the threat to life of any organ injured, is proposed. The OTM2 model uses a power method, namely peak virtual power, and defines brain white and grey matters trauma responses. It includes human age effect (volume and stiffness), localised impact contact stiffness and provides injury severity adjustments for haemorrhaging. The focus, in this case, is on real-world pedestrian brain injuries. OTM2 model was tested against three real-life pedestrian accidents and has proven to reasonably predict the post mortem (PM) outcome. Its AIS predictions are closer to the real-world injury severity than the standard maximum principal strain (MPS) methods currently used. This proof of concept suggests that OTM2 has the potential to improve forensic predictions as well as contribute to the improvement in vehicle safety design through the ability to measure injury severity. This study concludes that future advances in trauma computing would require the development of a brain model that could predict haemorrhaging.

The incidence of brain trauma caused by road injuries: Results from the Global Burden of Disease Study 2019

BACKGROUND

Road collisions are a significant source of traumatic brain injury (TBI). We aimed to determine the pattern of road injury related TBI (RI-TBI) incidence, as well as its temporal trends.

METHODS

We collected detailed information on RI-TBI between 1990 and 2019, derived from the Global Burden of Disease Study 2019. Estimated annual percentage changes (EAPCs) of RI-TBI age standardized incidence rate (ASIR), by sex, region, and cause of road injuries, were assessed to quantify the temporal trends of RI-TBI burden.

RESULTS

Globally, incident cases of RI-TBI increased 68.1% from 6,900,000 in 1990 to 11,600,000 in 2019. The overall ASIR increased by an average of 0.43% (95% CI 0.30%-0.56%) per year during this period. The ASIR of RI-TBI due to cyclist, motorcyclist and other road injuries increased between 1990 and 2019; the corresponding EAPCs were 0.56 (95% CI 0.37-0.75), 1.60 (95% CI 1.35-1.86), and 0.75 (95% CI 0.59-0.91), respectively. In contrast, the ASIR of RI-TBI due to motor vehicle and pedestrian decreased with an EAPC of -0.12 and -0.14 respectively. The changing pattern for RI-TBI was heterogeneous across countries and regions. The most pronounced increases were observed in Mexico (EAPC = 3.74), followed by China (EAPC = 2.45) and Lesotho (EAPC = 1.91).

CONCLUSIONS

RI-TBI remains a major public health concern worldwide, although road safety legislations have contributed to the decreasing incidence in some countries. We found an unfavorable trend in several countries with a relatively low socio-demographic index, suggesting that much more targeted and specific approaches should be adopted in these areas to forestall the increase in RI-TBI.

Epidemiological and clinical characteristics predictive of ICU mortality of patients with traumatic brain injury treated at a trauma referral hospital - a cohort study

BACKGROUND

Traumatic brain injury (TBI) has substantial physical, psychological, social and economic impacts, with high rates of morbidity and mortality. Considering its high incidence, the aim of this study was to identify epidemiological and clinical characteristics that predict mortality in patients hospitalized for TBI in intensive care units (ICUs).

METHODS

A retrospective cohort study was carried out with patients over 18 years old with TBI admitted to an ICU of a Brazilian trauma referral hospital between January 2012 and August 2019. TBI was compared with other traumas in terms of clinical characteristics of ICU admission and outcome. Univariate and multivariate analyses were used to estimate the odds ratio for mortality.

RESULTS

Of the 4816 patients included, 1114 had TBI, with a predominance of males (85.1%). Compared with patients with other traumas, patients with TBI had a lower mean age (45.3 ± 19.1 versus 57.1 ± 24.1 years, p < 0.001), higher median APACHE II (19 versus 15, p < 0.001) and SOFA (6 versus 3, p < 0.001) scores, lower median Glasgow Coma Scale (GCS) score (10 versus 15, p < 0.001), higher median length of stay (7 days versus 4 days, p < 0.001) and higher mortality (27.6% versus 13.3%, p < 0.001). In the multivariate analysis, the predictors of mortality were older age (OR: 1.008 [1.002-1.015], p = 0.016), higher APACHE II score (OR: 1.180 [1.155-1.204], p < 0.001), lower GCS score for the first 24 h (OR: 0.730 [0.700-0.760], p < 0.001), greater number of brain injuries and presence of associated chest trauma (OR: 1.727 [1.192-2.501], p < 0.001).

CONCLUSION

Patients admitted to the ICU for TBI were younger and had worse prognostic scores, longer hospital stays and higher mortality than those admitted to the ICU for other traumas. The independent predictors of mortality were older age, high APACHE II score, low GCS score, number of brain injuries and association with chest trauma.

The Epidemiology of Moderate and Severe Traumatic Brain Injury in Central Norway

INTRODUCTION

Few studies account for prehospital deaths when estimating incidence and mortality rates of moderate and severe traumatic brain injury (msTBI). In a population-based study, covering both urban and rural areas, including also prehospital deaths, the aim was to estimate incidence and mortality rates of msTBI. Further, we studied the 30-day and 6-month case-fatality proportion of severe TBI in relation to age.

METHODS

All patients aged ≥17 years who sustained an msTBI in Central Norway were identified by three sources: (1) the regional trauma center, (2) the general hospitals, and (3) the Norwegian Cause of Death Registry. Incidence and mortality rates were standardized according to the World Health Organization's world standard population. Case-fatality proportions were calculated by the number of deaths from severe TBI at 30 days and 6 months, divided by all patients with severe TBI.

RESULTS

The overall incidence rates of moderate and severe TBI were 4.9 and 6.7 per 100,000 person-years, respectively, increasing from age 70 years. The overall mortality rate was 3.4 per 100,000 person-years, also increasing from age 70 years. Incidence and mortality rates were highest in men. The case-fatality proportion in people with severe TBI was 49% in people aged 60-69 years and 81% in people aged 70-79 years.

CONCLUSION

The overall incidence and mortality rates for msTBI in Central Norway were low but increased from age 70 years, and among those ≥80 years of age with severe TBI, nearly all died. Overall estimates are strongly influenced by high incidence and mortality rates in the elderly, and studies should therefore report age-specific estimates, for better comparison of incidence and mortality rates.

Is there a weekend effect on mortality rate and outcome for moderate and severe traumatic brain injury? A population-based, observational cohort study

Purpose

The aim of the study was to analyse patient and injury characteristics and the effects of weekend admissions on mortality rate and outcome after moderate and severe traumatic brain injuries.

Methods

This is an observational cohort study based on data from a prospectively maintained regional trauma registry in South Western Norway. Patients with moderate and severe traumatic brain injury admitted between January 1st, 2004 and December 31st, 2019 were included in this study.

Results

During the study period 688 patients were included in the study with similar distribution between moderate (n ​= ​318) and severe (n ​= ​370) traumatic brain injury. Mortality rate was 46% in severe and 13% in moderate traumatic brain injury. Two hundred and thirty-one (34%) patients were admitted during weekends. Patients admitted during weekends were significantly younger (median age (IQR) 32.0 (25.5-67.0) vs 47.0 (20.0-55.0), p ​< ​0.001). Pre-injury ASA 1 was significantly more common in patients admitted during weekends (n ​= ​146, 64%, p ​= ​0.001) while ASA 3 showed significance during weekdays compared to weekends (n ​= ​101, 22%, p ​= ​0.013). On binominal logistic regression analysis mortality rate was significantly higher with older age (OR 1.03, 95% CI for OR 1.02-1.04, p ​< ​0.001) and increasing TBI severity (OR 7.08, 95% CI for OR 4.67-10.73, p ​< ​0.001).

Conclusions

Mortality rate and poor clinical outcome remain high in severe traumatic brain injury. While a higher number of patients are admitted during the weekend, mortality rate does not differ from weekday admissions.

Investigating the Association between Orthopedic Fractures and Head Injury due to Road Traffic Accidents

BACKGROUND

Traumatic head injury (THI) due to road traffic accidents (RTAs) is a global health problem. Studies exploring the association between RTA-related THI and concurrent orthopedic fractures are lacking. We aim to provide a detailed analysis of this association and its impact on inhospital outcomes.

METHODS

Retrospective analysis of RTA-related THI associated with orthopedic fractures admitted to a large tertiary center, Southwest, Saudi Arabia, over ten years. Descriptive statistics for participant demographics and clinical outcomes were represented by percentages. The associations between head injury diagnosis or orthopedic fractures region and patient demographics are analyzed using the Chi-square test. Post hoc analysis for the significant Chi-square values was carried out by calculating the significant adjusted residuals. Adjust p value was obtained by using the Benjamini-Hochberg procedure to control for multiplicity testing. A p value less than 0.05 was considered statistically significant.

RESULTS

Concurrent orthopedic fractures are present in one-tenth of RTA-related THI. The cohort was dominated by young males, with 46.5% of the population between 18 and 29 years old. There was a significant association between the head injury diagnosis and the region of orthopedic fracture (p = 0.028). The type of head injury had significant associations with mortality and duration of hospital stay (p = 0.039 and p = 0.037, respectively). The region of orthopedic fracture significantly (p = 0.018) affected the duration of hospital stay, with fractures in the clavicle/shoulder region significantly (p = 0.035) having a short course of hospital admission.

CONCLUSION

Orthopedic fractures concomitant with RTA-related THI are common. The associations between the two injuries tend to happen in specific patterns. The inhospital stay duration and mortality significantly correlated with the site of the head or orthopedic injury. Knowledge of these patterns improves the care of THI victims, triaging, and resource allocations.

Self-Rated Health Among Patients With Severe Traumatic Brain Injury and Their Close Relatives: The Role of Posttraumatic Stress Symptoms

OBJECTIVE

Severe traumatic brain injury (sTBI) is accompanied by significant declines in self-rated health (SRH). Although such deteriorations in SRH are related to various consequences of sTBI, the effect of posttraumatic reactions (i.e., posttraumatic stress [PTS] symptoms) has been tested insufficiently to date, especially among civilians. The present investigation is based on Trajectories of Recovery After Severe Traumatic brain injury-Matters In families (TRAST-MI), a unique study among civilians with sTBI and their families. Previous research revealed that civilian sTBI has effects beyond the injured patient, influencing their close relatives as well. The aim of this study was to assess the association between PTS symptoms and SRH among patients with civilian sTBI and their close relatives.

METHODS

Patients with sTBI (assessed by an Abbreviated Injury Scale of the head region score >3) and their close relatives participated in TRAST-MI. One hundred twenty-six patient-relative dyads were assessed at 3, 6, and 12 months after the injury.

RESULTS

Multilevel modeling revealed that patients' PTS symptoms were associated with consequent SRH (slope = 0.42; p < .001), and relatives' PTS symptoms were associated with their respective SRH (slope = 0.2; p = .012).

CONCLUSIONS

The findings of this study reveal that SRH of both patients with sTBI and their relatives are negatively affected by their own PTS symptoms. These findings underline the understanding that sTBI is not merely a medical trauma but rather a comprehensive psychosocial trauma, which has consequences for the whole family system.

Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review

This systematic review provides a comprehensive, up-to-date summary of traumatic brain injury (TBI) epidemiology in Europe, describing incidence, mortality, age, and sex distribution, plus severity, mechanism of injury, and time trends. PubMed, CINAHL, EMBASE, and Web of Science were searched in January 2015 for observational, descriptive, English language studies reporting incidence, mortality, or case fatality of TBI in Europe. There were no limitations according to date, age, or TBI severity. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. Data were presented narratively. Sixty-six studies were included in the review. Country-level data were provided in 22 studies, regional population or treatment center catchment area data were reported by 44 studies. Crude incidence rates varied widely. For all ages and TBI severities, crude incidence rates ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Crude mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies), and 3.3 to 24.4 per 100,000 population per year (regional-level studies.) The most common mechanisms of injury were traffic accidents and falls. Over time, the contribution of traffic accidents to total TBI events may be reducing. Case ascertainment and definitions of TBI are variable. Improved standardization would enable more accurate comparisons.

Outcome of Severe Traumatic Brain Injury at KSMC: Functional Outcomes of ICP Monitor Insertion-Two Years' Experience

PURPOSE

To evaluate functional outcomes of severe traumatic brain injuries after insertion of intracranial pressure (ICP) monitor at King Saud Medical City (KSMC) and their correlation to each other.

PATIENTS AND METHODS

A retrospective observational study for all adult patients (age >18 years) who were diagnosed with severe head injury and underwent ICP insertion at KSMC. Patients diagnosed between 2017 and 2019 were included. Data for measured outcomes, Glasgow outcome scale (GOS), Karnofsky Performance Score (KPS) and length of stay (LOS) and prognostic factors, data like: age, gender and primary Glasgow coma score (GCS) was obtained from patients' files and direct communication with patients or their caregivers. We also compared patients who underwent ICP monitoring alone with those who underwent ICP with decompressive craniectomy (DC). Follow-up period ranged from 6-24 months.

RESULTS

Seventy-four patients were included in this cohort study. Outcome measurements for patients with decompression and ICP were lower than those with ICP alone. KPS and GOS showed strong correlation (p<0.01) in whole cohort and in both subgroups (ICP alone and ICP with DC). KPS showed significant correlation with length of stay (p=0.026).

CONCLUSION

ICP monitoring is valid tool in management of severely head injured patients. Patients who underwent DC had a worse outcome. KPS can be used as alternative tool to measure functional outcome in severe traumatic brain injury.

Microcirculatory Biomarkers of Secondary Cerebral Ischemia in Traumatic Brain Injury

AIM

The purpose of this study was to study changes in cerebral microcirculation parameters in the development of secondary cerebral ischemia (SCI).

METHODS

A total of 202 patients with a Glasgow Coma Scale score ≤ 12 after experiencing a traumatic brain injury (TBI) were recruited for the study within 6 h of the injury. All patients were subjected to perfusion computed tomography. The cerebral blood flow velocity was recorded using transcranial Doppler ultrasound. The arterial blood pressure was measured noninvasively. The cerebrovascular resistance (CVR), cerebral arterial compliance (CAC), cerebrovascular time constant (CTC), and critical closing pressure (CCP) were measured using the neuromonitoring complex. All patients had unilateral foci of posttraumatic ischemia. Statistical analysis was performed using a paired Student's t test and factor analysis.

RESULTS AND CONCLUSION

The CVR and CCP were significantly increased in patients who developed SCI after TBI, whereas the CAC and CTC were significantly decreased (P < 0.05). Factor analyses revealed that the CVR, CAC, and CTC were significantly associated with development of posttraumatic ischemia (P < 0.05). The changes in the CVR and CCP in patients with TBI were significantly associated with SCI development (P < 0.05).

Prediction of in-hospital mortality in patients on mechanical ventilation post traumatic brain injury: machine learning approach

Background

The study aimed to introduce a machine learning model that predicts in-hospital mortality in patients on mechanical ventilation (MV) following moderate to severe traumatic brain injury (TBI).

Methods

A retrospective analysis was conducted for all adult patients who sustained TBI and were hospitalized at the trauma center from January 2014 to February 2019 with an abbreviated injury severity score for head region (HAIS) ≥ 3. We used the demographic characteristics, injuries and CT findings as predictors. Logistic regression (LR) and Artificial neural networks (ANN) were used to predict the in-hospital mortality. Accuracy, area under the receiver operating characteristics curve (AUROC), precision, negative predictive value (NPV), sensitivity, specificity and F-score were used to compare the models` performance.

Results

Across the study duration; 785 patients met the inclusion criteria (581 survived and 204 deceased). The two models (LR and ANN) achieved good performance with an accuracy over 80% and AUROC over 87%. However, when taking the other performance measures into account, LR achieved higher overall performance than the ANN with an accuracy and AUROC of 87% and 90.5%, respectively compared to 80.9% and 87.5%, respectively. Venous thromboembolism prophylaxis, severity of TBI as measured by abbreviated injury score, TBI diagnosis, the need for blood transfusion, heart rate upon admission to the emergency room and patient age were found to be the significant predictors of in-hospital mortality for TBI patients on MV.

Conclusions

Machine learning based LR achieved good predictive performance for the prognosis in mechanically ventilated TBI patients. This study presents an opportunity to integrate machine learning methods in the trauma registry to provide instant clinical decision-making support.

Physical and Mental Health and Functioning Among Traumatic Brain Injury Close Relatives: The Role of Posttraumatic Stress Symptoms

Severe Traumatic brain injury (sTBI) often instigates widespread long-lasting disability and is accompanied by extensive rehabilitation. Unsurprisingly, sTBI also holds malignant consequences for patients' close relatives. The burden caused by the injury and its severity explains some of the ramifications for the relatives. Additionally, some findings demonstrate that patients with sTBI and their relatives develop posttraumatic stress (PTS) symptoms. However, although the link between PTS symptoms and physical and mental health is well-documented in literature, the effect of PTS symptoms on relatives of patients with sTBI has barely been examined. This study examines the influence of PTS symptoms of patients with sTBI and their relatives on the physical and mental health and functioning of the relatives. Patients who sustained a severe sTBI (Abbreviated Injury Scale of the head region > 3) and close relatives were included in a multi-center, prospective cohort study (TRAST-MI). One-hundred patients and their relatives were assessed at 2, 6, and 12 months post injury. Outcome variables included health-related quality of life (SF-12) as well as emotional, cognitive, interpersonal, and total functioning (PCRS). Relatives' physical health was predicted by relatives' PTS symptoms (Slope=-1.76; p = .043), and mental health was predicted by both patients' (Slope=-2.77; p = .034) and relatives' (Slope=-6.59; p < .001) PTS symptoms. Functioning level was only predicted by patients' PTS symptoms (Slope=-.25; p_< .001). The findings emphasize that TBI should be considered a comprehensive traumatic experience reaching further than mere physical damage to the brain and its direct consequences, affecting the injured individual and close relatives.

Prediction of in-hospital mortality in patients with post traumatic brain injury using National Trauma Registry and Machine Learning Approach

BACKGROUND

The use of machine learning techniques to predict diseases outcomes has grown significantly in the last decade. Several studies prove that the machine learning predictive techniques outperform the classical multivariate techniques. We aimed to build a machine learning predictive model to predict the in-hospital mortality for patients who sustained Traumatic Brain Injury (TBI).

METHODS

Adult patients with TBI who were hospitalized in the level 1 trauma center in the period from January 2014 to February 2019 were included in this study. Patients' demographics, injury characteristics and CT findings were used as predictors. The predictive performance of Artificial Neural Networks (ANN) and Support Vector Machines (SVM) was evaluated in terms of accuracy, Area Under the Curve (AUC), sensitivity, precision, Negative Predictive Value (NPV), specificity and F-score.

RESULTS

A total of 1620 eligible patients were included in the study (1417 survival and 203 non-survivals). Both models achieved accuracy over 91% and AUC over 93%. SVM achieved the optimal performance with accuracy 95.6% and AUC 96%.

CONCLUSIONS

for prediction of mortality in patients with TBI, SVM outperformed the well-known classical models that utilized the conventional multivariate analytical techniques.

Changqin NO. 1 inhibits neuronal apoptosis via suppressing GAS5 expression in a traumatic brain injury mice model

The present study was designed to investigate the mechanism of the traditional Chinese medicine Changqin NO. 1 on the amelioration of traumatic brain injury (TBI). Adult male C57BL/6J mice and newborn mice were used to generate a mouse TBI model and harvest primary neurons, respectively. The localizations of specific neural markers neuropilin-1 (Nrp-1), growth-associated protein-43 (GAP-43) and microtubule-associated protein Tau (Tau) were examined in brain tissues by immunohistochemistry. Terminal deoxynucleotidyl transferase dUTP nick end labeling apoptotic cell detection in tissue sections and the CCK-8 cell viability assay were performed to examine neuronal apoptosis. Quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot were also carried out in this study. The association between long non-coding RNA (lncRNA) growth-arrest specific 5 (GAS5), miR-335 and RAS p21 GTPase activating protein 1 (Rasa1) was disclosed using the dual-luciferase reporter assay. Changqin NO. 1 inhibited TBI-induced neuronal apoptosis in vivo and in vitro. GAS5 functioned as a competing endogenous RNA (ceRNA) by sponging miR-335 to upregulate Rasa1 expression in mouse neuronal cells. Further investigations demonstrated that GAS5 promoted neuronal apoptosis following TBI via the miR-335/Rasa1 axis. In vivo experiments indicated that Changqin NO. 1 exerted neuroprotection during TBI via the GAS5/miR-335/Rasa1 axis. Changqin NO. 1 promoted neuroprotective effects by inhibiting neuronal apoptosis via the GAS5/miR-335/Rasa1 axis in TBI.

Severe traumatic brain injury (TBI) - a seven-year comparative study in a Department of Forensic Medicine

Deaths caused by traumatic brain injury (TBI) increase in incidence every year worldwidely, mainly in developing countries. Thus, World Health Organization (WHO) estimates that in 2020, TBI will become the third main cause of death. In our study, we evaluated the deaths caused by TBI recorded within the Institute of Forensic Medicine of Craiova, Romania, between 2011 and 2017. Therefore, according to age, the cases were divided into two groups: people aged 0-18 years old (including 18 years old) and people aged over 18 years old (a total of 1005 cases, of which 971 were adults and 34 included in the age group 0-18 years old). In both groups, most patients were males from the rural area. In adults, falling was the main legal entity of the cases, followed by car accidents (which were the most common in children). In both groups, in car accidents, most of them were pedestrians and car occupants. Various aggressions (human, animal, self-injury) were found in 94 (9.68%) of the adult cases and in four (11.76%) cases of children. Another parameter under study was the blood alcohol concentration, being observed that most of the subjects with positive blood alcohol content died from car accidents. By evaluating the Glasgow Coma Scale (GCS) score as a prognostic factor, most of the subjects presented third and fourth degree coma at admission; still, 5.14% of the adult patients who deceased had GCS score 15 at admission, death occurring probably by developing some intracranial hematomas in time. Regarding the morphology of the lesions, most patients presented various forms of cranial fractures, 185 (19.05%) adults in association with extradural hemorrhages∕hematomas, but also there were four cases with extradural hematomas without any cranial fractures. In children, there was highlighted a single case of extradural hemorrhage under the fracture line. Seventy-eight percent of the adults and 44.12% of children presented subdural hematomas associated with other meningo-cerebral lesions. Also, 83.63% of the adults and 97% of children presented brain contusions. In both groups, brain laceration was observed in approximately 50% of the cases.

Prediction of long-term quality of life after severe traumatic brain injury based on variables at hospital admission

Objectives: Variables collected early after severe traumatic brain injury (sTBI) could predict health-related quality of life (HRQoL). Our aim was to determine the prevalence of patients with a low HRQoL 4 years after sTBI and to develop a prediction model including early variables.Methods: Adult patients with both sTBI [abbreviated injury score of the head region (HAIS) >3] and disease-specific HRQoL assessments using the 'Quality of Life after Brain Injury' (QOLIBRI) were included. The outcome was the total score (TS) of QOLIBRI; cutoff for low HRQoL: <60 points. A multivariate logistic regression model and prediction model were performed.Results: One hundred-sixteen patients [median age 50.8 years (IQR 25.9-62.8; 21.6% >65 years)] were included; 68 (58.6%) with HAIS = 4, 48 (41.4%) with HAIS = 5. Median Glasgow Coma Scale (GCS) was 13 (IQR 3-15). Median TS was 77 (IQR 60-88). Low HRQoL was observed in 28 patients (24.1%). Two variables were associated with low HRQoL: GCS <13, working situation other than employed or retired. The prediction model had an AUROC of 0.765; calibration was moderate (Hosmer Lemeshow Chi2 6.82, p = .556).Conclusion: One in four patients had a low HRQoL after 4 years. A lower GCS and working situations were associated with low HRQoL.

Effect of Pre-Hospital Intubation in Patients with Severe Traumatic Brain Injury on Outcome: A Prospective Cohort Study

Secondary injuries are associated with bad outcomes in the case of severe traumatic brain injury (sTBI). Patients with a Glasgow Coma Scale (GCS) < 9 should undergo pre-hospital intubation (PHI). There is controversy about whether PHI is beneficial. The aim of this study was to estimate the effect of PHI in patients after sTBI. A multicenter, prospective cohort study was performed in Switzerland, including 832 adults with sTBI. Outcomes were death and impaired consciousness at 14 days. Associations between risk factors and outcomes were assessed with univariate and multivariate Cox models for survival, and univariate and multivariate regression models for impaired consciousness. Potential risk factors were age, GCS on scene, pupil reaction, Injury Severity Score (ISS), PHI, oxygen administration, and type of admission to trauma center. Age, GCS on scene < 9, abnormal pupil reaction and ISS ≥ 25 were associated with mortality. GCS < 9 and ISS ≥ 25 were correlated with impaired consciousness. PHI was overall not associated with short-term mortality and consciousness. However, there was a significative interaction with PHI and major trauma. PHI improves outcome from patients with sTBI and an ISS ≥ 25.

Estimating the global incidence of traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.

METHODS

Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.

RESULTS

Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.

CONCLUSIONS

Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Neurorehabilitation of Traumatic Brain Injury (TBI): A Clinical Review

Traumatic brain injury (TBI) and its potential long-term consequences are of major concern for public health. Neurorehabilitation of affected individuals has some specific characteristics in contrast to neurorehabilitation of patients with acquired brain lesions of other aetiology. This review will deal with the clinical consequences of the distinct lesions of TBI. In severe TBI, clinical course often follows a typical initial sequence of coma; followed by disturbed consciousness; later, post-traumatic agitation and amnesia; and finally, recovery of function occurs. In the different phases of neurorehabilitation, physicians should be aware of typical medical complications such as paroxysmal sympathetic hyperactivity, posttraumatic hydrocephalus, and posttraumatic neuroendocrine dysfunctions. Furthermore, we address questions on timing and on existing evidence for different rehabilitation programmes and for holistic neuropsychological rehabilitation approaches.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

Comparison of two simple models for prediction of short term mortality in patients after severe traumatic brain injury

INTRODUCTION

The subscale motor score of Glasgow Coma Scale (msGCS) and the Abbreviated Injury Score of head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim was to compare the prognostic performance of a HAIS-based prediction model including HAIS, pupil reactivity and age, and the reference prediction model including msGCS in emergency department (ED), pupil reactivity and age.

METHODS

Secondary analysis of a prospective epidemiological study including patients after severe TBI (HAIS > 3) with follow-up from the time of accident until 14 days or earlier death was performed in Switzerland. Performance of prediction, based on accuracy of discrimination [area under the receiver-operating curve (AUROC)], calibration (Hosmer-Lemeshow test) and validity (bootstrapping with 2000 repetitions to correct) for optimism of the two prediction models were investigated. A non-inferiority approach was performed and an a priori threshold for important differences was established.

RESULTS

The cohort included 808 patients [median age 56 {inter-quartile range (IQR) 33-71}, median motor part of GCS in ED 1 (1-6), abnormal pupil reactivity 29.0%] with a death rate of 29.7% at 14 days. The accuracy of discrimination was similar (AUROC HAIS-based prediction model: 0.839; AUROC msGCS-based prediction model: 0.826, difference of the 2 AUROC 0.013 (-0.007 to 0.037). A similar calibration was observed (Hosmer-Lemeshow X² 11.64, p = 0.168 vs. Hosmer-Lemeshow X² 8.66, p = 0.372). Internal validity of HAIS-based prediction model was high (optimism corrected AUROC: 0.837).

CONCLUSIONS

Performance of prediction for short-term mortality after severe TBI with HAIS-based prediction model was non-inferior to reference prediction model using msGCS as predictor.

Comparison of two prehospital predictive models for mortality and impaired consciousness after severe traumatic brain injury

BACKGROUND

The primary aim was to investigate the performance of a National Advisory Committee for Aeronautics based predictive model (NACA-BM) for mortality at 14 days and a reference model using motor GCS (GCS-RM). The secondary aim was to compare the models for impaired consciousness of survivors at 14 days (IC-14; GCS ≤ 13).

METHODS

Patients ≥16 years having sustained TBI with an abbreviated injury scale score of head region (HAIS) of >3 were included. Multivariate logistic regression models were used to test models for death and IC-14. The discrimination was assessed using area under the receiver-operating curves (AUROCs); noninferiority margin was -5% between the AUROCs. Calibration was assessed using the Hosmer Lemeshow goodness-of-fit test.

RESULTS

Six hundred and seventy seven patients were included. The median age was 54 (IQR 32-71). The mortality rate was 31.6%; 99 of 438 surviving patients (22.6%) had an IC-14. Discrimination of mortality was 0.835 (95%CI 0.803-0.867) for the NACA-BM and 0.839 (0.807-0.872) for the GCS-RM; the difference of the discriminative ability was -0.4% (-2.3% to +1.7%). Calibration was appropriate for the NACA-BM (χ² 8.42; P = 0. 393) and for the GCS-RM (χ² 3.90; P = 0. 866). Discrimination of IC-14 was 0.757 (0.706-0.808) for the NACA-BM and 0.784 (0.734-0.835) for the GCS-RM; the difference of the discriminative ability was -2.5% (-7.8% to +2.6%). Calibration was appropriate for the NACA-BM (χ² 10.61; P = 0.225) and for the GCS-RM (χ² 6.26; P = 0.618).

CONCLUSIONS

Prehospital prediction of mortality after TBI was good with both models, and the NACA-BM was not inferior to the GCS-RM. Prediction of IC-14 was moderate in both models.

Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review

PURPOSE OF REVIEW

Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond.

RECENT FINDINGS

The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.

Association of Lectin Pathway Protein Levels and Genetic Variants Early after Injury with Outcomes after Severe Traumatic Brain Injury: A Prospective Cohort Study

The lectin pathway of the complement system has been implicated in secondary ischemic/inflammatory injury after traumatic brain injury (TBI). However, previous experimental studies have yielded conflicting results, and human studies are scarce. In this exploratory study, we investigated associations of several lectin pathway proteins early after injury and single-nucleotide polymorphisms (SNP) with outcomes after severe TBI (mortality at 14 days [primary outcome] and consciousness assessed with the Glasgow Coma Scale [GCS] at 14 days, disability assessed with the Glasgow Outcome Scale Extended [GOSE] at 90 days). Forty-four patients with severe TBI were included. Plasma levels of lectin pathway proteins were sampled at 6, 12, 24, and 48 h after injury and eight mannose-binding lectin (MBL) and ficolin (FCN)2 SNPs were analyzed by enzyme-linked immunosorbent assay (ELISA) and genotyping, respectively. Plasma protein levels were stable with only a slight increase in mannose-binding protein-associated serine protease (MASP)-2 and FCN2 levels after 48 h (p < 0.05), respectively. Neither lectin protein plasma levels (6 h or mean levels) nor MBL2 genotypes or FCN2 variant alleles were associated with 14 day mortality or 14 day consciousness. However, FCN2, FCN3, and MASP-2 levels were higher in patients with an unfavorable outcome (GOSE 1-4) at 90 days (p < 0.05), whereas there was no difference in MBL2 genotypes or FCN2 variant alleles. In particular, higher mean MASP-2 levels over 48 h were independently associated with a GOSE score < 4 at 90 days after adjustment (odds ratio 3.46 [95% confidence interval 1.12-10.68] per 100 ng/mL increase, p = 0.03). No association was observed between the lectin pathway of the complement system and 14 day mortality or 14 day consciousness. However, higher plasma FCN2, FCN3, and, in particular, MASP-2 levels early after injury were associated with an unfavorable outcome at 90 days (death, vegetative state, and severe disability) which may be related to an increased activation of the lectin pathway.

Comparison of Two Predictive Models for Short-Term Mortality in Patients after Severe Traumatic Brain Injury

The Glasgow Coma Scale (GCS) and the Abbreviated Injury Score of the head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim of this study was to compare the prognostic performance of an alternative predictive model including motor GCS, pupillary reactivity, age, HAIS, and presence of multi-trauma for short-term mortality with a reference predictive model including motor GCS, pupil reaction, and age (IMPACT core model). A secondary analysis of a prospective epidemiological cohort study in Switzerland including patients after severe TBI (HAIS >3) with the outcome death at 14 days was performed. Performance of prediction, accuracy of discrimination (area under the receiver operating characteristic curve [AUROC]), calibration, and validity of the two predictive models were investigated. The cohort included 808 patients (median age, 56; interquartile range, 33-71), median GCS at hospital admission 3 (3-14), abnormal pupil reaction 29%, with a death rate of 29.7% at 14 days. The alternative predictive model had a higher accuracy of discrimination to predict death at 14 days than the reference predictive model (AUROC 0.852, 95% confidence interval [CI] 0.824-0.880 vs. AUROC 0.826, 95% CI 0.795-0.857; p < 0.0001). The alternative predictive model had an equivalent calibration, compared with the reference predictive model Hosmer-Lemeshow p values (Chi2 8.52, Hosmer-Lemeshow p = 0.345 vs. Chi2 8.66, Hosmer-Lemeshow p = 0.372). The optimism-corrected value of AUROC for the alternative predictive model was 0.845. After severe TBI, a higher performance of prediction for short-term mortality was observed with the alternative predictive model, compared with the reference predictive model.

Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality

OBJECTIVES

To provide a comprehensive assessment of the management of traumatic brain injury (TBI) relating to epidemiology, complications and standardised mortality across specialist units.

DESIGN

The Trauma Audit and Research Network collects data prospectively on patients suffering trauma across England and Wales. We analysed all data collected on patients with TBI between April 2014 and June 2015.

SETTING

Data were collected on patients presenting to emergency departments across 187 hospitals including 26 with specialist neurosurgical services, incorporating factors previously identified in the Ps14 multivariate logistic regression (Ps14n) model multivariate TBI outcome prediction model. The frequency and timing of secondary transfer to neurosurgical centres was assessed.

RESULTS

We identified 15 820 patients with TBI presenting to neurosurgical centres directly (6258), transferred from a district hospital to a neurosurgical centre (3682) and remaining in a district general hospital (5880). The commonest mechanisms of injury were falls in the elderly and road traffic collisions in the young, which were more likely to present in coma. In severe TBI (Glasgow Coma Score (GCS) ≤8), the median time from admission to imaging with CT scan is 0.5 hours. Median time to craniotomy from admission is 2.6 hours and median time to intracranial pressure monitoring is 3 hours. The most frequently documented complication of severe TBI is bronchopneumonia in 5% of patients. Risk-adjusted W scores derived from the Ps14n model indicate that no neurosurgical unit fell outside the 3 SD limits on a funnel plot.

CONCLUSIONS

We provide the first comprehensive report of the management of TBI in England and Wales, including data from all neurosurgical units. These data provide transparency and suggests equity of access to high-quality TBI management provided in England and Wales.

Visually-guided gait training in paretic patients during the first rehabilitation phase: study protocol for a randomized controlled trial

Background

After a lesion to the central nervous system, many patients suffer from reduced walking capability. In the first rehabilitation phase, repeated walking exercises facilitate muscular strength and stimulate brain plasticity and motor relearning. However, marked limping, an unsteady gait, and poor management of obstacle clearance may persist, which increases a patient’s risk of falling. Gait training with augmented reality has been recommended to improve gait coordination. The objective of this study is to test whether a gait rehabilitation program using augmented reality is superior to a conventional treadmill training program of equivalent intensity.

Methods/design

The GASPAR trial (Gait Adaptation for Stroke Patients with Augmented Reality) is a pragmatic, parallel-arm, single-center, nonblind, superiority randomized control trial in neurorehabilitation. The setting is a rehabilitation clinic in Switzerland. The planned number of participants is 70–100. The intervention uses instrumented treadmills equipped with projectors that display shapes on the walking surface. The principle is that patients must adapt their gait to the image that unfolds in front of them. Specific exercises for gait symmetry, coordination enhancement, and gait agility are provided. The program includes twenty 30-min sessions spanning 4 weeks. The comparator group receives standard treadmill training of a similar frequency and intensity. The main outcome to be measured in the trial is walking speed, which is assessed with the 2-min Walk Test. Moreover, gait parameters are recorded during the gait training sessions. Other outcomes are balance control (Berg Balance Scale) and the fear of falling (Falls Efficacy Scale). The statistical analyses will compare the baseline assessment for each participant (before the intervention) with a post-intervention assessment (taken a few days after the end of the program). Furthermore, a follow-up assessment will take place 3 months after discharge.

Discussion

The study results will provide new knowledge about recovery in neurological patients and will contribute to the design of better rehabilitation programs to accompany this process. The findings will also help health care funders to decide whether treadmills equipped with augmented reality capabilities are a worthwhile investment.

Trial registration

ClinicalTrials.gov ID: NCT02808078, registered on 16 June 2016.

Prehospital management of traumatic brain injury patients--a gender perspective

BACKGROUND

Studies show that there are differences between men and women when it comes to several aspects of health care. But the research on equal care in a prehospital setting for patients with severe traumatic brain injury (TBI) has been sparsely investigated. The aim of this study is to describe prehospital care from a gender perspective.

METHOD

This is a retrospective study of (n = 651) patients (>15 years) with severe TBI requiring intensive care at a University Hospital in Sweden during the years 2000-2010. Outcome was measured by survival and Glasgow Outcome Scale (GOS) scores at discharge.

RESULT

Our results show differences, though not significant, in the initial assessments and performed interventions between male and female TBI patients. Female patients received more assessments and performed interventions compared to men during prehospital care. Men received more interventions with I.V. fluid but significantly less airway interventions (endotracheal intubation) compared to female patients. More men were transported directly to neurosurgical specialist care as compared to females. No difference in outcome was found.

CONCLUSION

Our results show differences, however not significant in the assessments and performed interventions between gender, with female patients receiving more assessments and interventions compared to male patients during prehospital care. Future research should focus on gender differences in initial early signs of TBI to improve early identification.

Prehospital risk factors of mortality and impaired consciousness after severe traumatic brain injury: an epidemiological study

Background

Severe traumatic brain injury (TBI) is a significant health concern and a major burden for society. The period between trauma event and hospital admission in an emergency department (ED) could be a determinant for secondary brain injury and early survival. The aim was to investigate the relationship between prehospital factors associated with secondary brain injury (arterial hypotension, hypoxemia, hypothermia) and the outcomes of mortality and impaired consciousness of survivors at 14 days.

Methods

A multicenter, prospective cohort study was performed in dedicated trauma centres of Switzerland. Adults with severe TBI (Abbreviated Injury Scale score of head region (HAIS) >3) were included. Main outcome measures were death and impaired consciousness (Glasgow Coma Scale (GCS) ≤13) at 14 days. The associations between risk factors and outcome were assessed with univariate and multivariate regression models.

Results

589 patients were included, median age was 55 years (IQR 33, 70). The median GCS in ED was 4 (IQR 3-14), with abnormal pupil reaction in 167 patients (29.2%). Median ISS was 25 (IQR 21, 34). Three hundred seven patients sustained their TBI from falls (52.1%) and 190 from a road traffic accidents (32.3%). Median time from Out-of-hospital Emergency Medical Service (OHEMS) departure on scene to arrival in ED was 50 minutes (IQR 37-72); 451 patients had a direct admission (76.6%). Prehospital hypotension was observed in 24 (4.1%) patients, hypoxemia in 73 (12.6%) patients and hypothermia in 146 (24.8%). Prehospital hypotension and hypothermia (apart of age and trauma severity) was associated with mortality. Prehospital hypoxemia (apart of trauma severity) was associated with impaired consciousness; indirect admission was a protective factor.

Conclusion

Mortality and impaired consciousness at 14 days do not have the same prehospital risk factors; prehospital hypotension and hypothermia is associated with mortality, and prehospital hypoxemia with impaired consciousness.

The management of severe traumatic brain injury

An approach to the initial evaluation, resuscitation, and treatment of the patient with severe traumatic brain injury is presented in terms of the underlying physiology and literature support. The primary importance of rapid and complete systemic resuscitation in terms of the "ABCs" is stressed, with the goal of optimizing cerebral perfusion and preventing secondary insults to the injured brain. The integration of brain-specific treatments and diagnostic maneuvers into resuscitation protocols is discussed, including the role of mannitol and hyperventilation as well as the prioritization of CT imaging of the brain.