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Bagg MK, Hellewell SC, Keeves J, Antonic-Baker A, McKimmie A, Hicks AJ, Gadowski A, Newcombe VFJ, Barlow KM, Balogh ZJ, Ross JP, Law M, Caeyenberghs K, Parizel PM, Thorne J, Papini M, Gill G, Jefferson A, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Cooper DJ, Rushworth N, Gabbe BJ, Fitzgerald M. The Australian Traumatic Brain Injury Initiative: Systematic Review of Predictive Value of Biological Markers for People With Moderate-Severe Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38115587 DOI: 10.1089/neu.2023.0464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to co-design a data resource to predict outcomes for people with moderate-severe traumatic brain injury (TBI) across Australia. Fundamental to this resource is the data dictionary, which is an ontology of data items. Here, we report the systematic review and consensus process for inclusion of biological markers in the data dictionary. Standardized database searches were implemented from inception through April 2022. English-language studies evaluating association between a fluid, tissue, or imaging marker and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Records were screened using a prioritization algorithm and saturation threshold in Research Screener. Full-length records were then screened in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association, and high-value predictors were discussed in a consensus process. Searches retrieved 106,593 records; 1,417 full-length records were screened, resulting in 546 included records. Two hundred thirty-nine individual markers were extracted, evaluated against 101 outcomes. Forty-one markers were judged to be high-value predictors of 15 outcomes. Fluid markers retained following the consensus process included ubiquitin C-terminal hydrolase L1 (UCH-L1), S100, and glial fibrillary acidic protein (GFAP). Imaging markers included computed tomography (CT) scores (e.g., Marshall scores), pathological observations (e.g., hemorrhage, midline shift), and magnetic resonance imaging (MRI) classification (e.g., diffuse axonal injury). Clinical context and time of sampling of potential predictive indicators are important considerations for utility. This systematic review and consensus process has identified fluid and imaging biomarkers with high predictive value of clinical and long-term outcomes following moderate-severe TBI.
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Affiliation(s)
- Matthew K Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- School of Health Sciences, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Sarah C Hellewell
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- School of Medicine, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
| | - Jemma Keeves
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ana Antonic-Baker
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Ancelin McKimmie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, VIC, Australia
- School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Adelle Gadowski
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Virginia F J Newcombe
- PACE Section, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Karen M Barlow
- Acquired Brain Injury in Children Research Program, Queensland Children's Hospital, Brisbane, QLD, Australia
- Centre for Children's Health Research, University of Queensland, Brisbane, QLD, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Jason P Ross
- Molecular Diagnostic Solutions, Health and Biosecurity, CSIRO, Australia
| | - Meng Law
- Alzheimer's Disease Research Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Neuroscience and Radiology, Monash University, Alfred Health, Melbourne, VIC, Australia
| | - Karen Caeyenberghs
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia
| | - Paul M Parizel
- University of Antwerp, Edegem, Belgium
- Department of Radiology, Royal Perth Hospital and University of Western Australia, Perth, WA, Australia
- West Australian National Imaging Facility Node, Nedlands, WA, Australia
| | - Jacinta Thorne
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
| | - Melissa Papini
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
| | - Geena Gill
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
| | - Amanda Jefferson
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, VIC, Australia
- School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- National Trauma Research Institute, Melbourne, VIC, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | | | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
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Niemeyer MJS, Jochems D, Van Ditshuizen JC, de Kanter J, Cremers L, van Hattem M, Den Hartog D, Houwert RM, Leenen LPH, van Wessem KJP. Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02407-5. [PMID: 38226991 DOI: 10.1007/s00068-023-02407-5] [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: 08/31/2023] [Accepted: 11/12/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE With an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers. METHODS From 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3-6 months post-discharge were collected. RESULTS The study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4-5] vs. UMC-U: 4 [4-5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up. DISCUSSION This study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Menco J S Niemeyer
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Denise Jochems
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan C Van Ditshuizen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Janneke de Kanter
- Department of Radiology, UMC Division Imaging and Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lotte Cremers
- Department of Radiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Martijn van Hattem
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roderick Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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van Erp IA, van Essen T, Kompanje EJ, van der Jagt M, Moojen WA, Peul WC, van Dijck JT. Treatment-limiting decisions in patients with severe traumatic brain injury in the Netherlands. BRAIN & SPINE 2024; 4:102746. [PMID: 38510637 PMCID: PMC10951765 DOI: 10.1016/j.bas.2024.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 01/03/2024] [Indexed: 03/22/2024]
Abstract
Introduction Treatment-limiting decisions (TLDs) can be inevitable severe traumatic brain injury (s-TBI) patients, but data on their use remain scarce. Research question To investigate the prevalence, timing and considerations of TLDs in s-TBI patients. Material and methods s-TBI patients between 2008 and 2017 were analysed retrospecively. Patient data, timing, location, involvement of proxies, and reasons for TLDs were collected. Baseline characteristics and in-hospital outcomes were compared between s-TBI patients with and without TLDs. Results TLDs were reported in 117 of 270 s-TBI patients (43.3%) and 95.9% of deaths after s-TBI were preceded by a TLD. The majority of TLDs (68.4%) were categorized as withdrawal of therapy, of which withdrawal of organ-support in 64.1%. Neurosurgical intervention was withheld in 29.9%. The median time from admission to TLD was 2 days [IQR, 0-8] and 50.4% of TLDs were made within 3 days of admission. The main reason for a TLD was that the patients were perceived as unsalvageable (66.7%). Nearly all decisions were made multidisciplinary (99.1%) with proxies involvement (75.2%). The predicted mortality (CRASH-score) between patients with and without TLDs were 72.6 vs. 70.6%. The percentage of TLDs in s-TBI patients increased from 20.0% in 2008 to 42.9% in 2012 and 64.3% in 2017. Discussion and conclusion TLDs occurred in almost half of s-TBI patients and were instituted more frequently over time. Half of TLDs were made within 3 days of admission in spite of baseline prognosis between groups being similar. Future research should address whether prognostic nihilism contributes to self-fulfilling prophecies.
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Affiliation(s)
- Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - T.A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Erwin J.O. Kompanje
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
- Department of Ethics and Philosophy of Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Wouter A. Moojen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
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van Essen TA, van Erp IA, Lingsma HF, Pisică D, Yue JK, Singh RD, van Dijck JT, Volovici V, Younsi A, Kolias A, Peppel LD, Heijenbrok-Kal M, Ribbers GM, Menon DK, Hutchinson PJ, Manley GT, Depreitere B, Steyerberg EW, Maas AI, de Ruiter GC, Peul WC. Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study. EClinicalMedicine 2023; 63:102161. [PMID: 37600483 PMCID: PMC10432786 DOI: 10.1016/j.eclinm.2023.102161] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023] Open
Abstract
Background Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. Methods We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Findings Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]). Interpretation We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Funding Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
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Affiliation(s)
- Thomas A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- Department of Surgery, Division of Neurosurgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Dana Pisică
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - John K. Yue
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Ranjit D. Singh
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lianne D. Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Gerard M. Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J.A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Godard C.W. de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Laic RAG, Verheyden J, Bruyninckx D, Lebegge P, Sloten JV, Depreitere B. Profound prospective assessment of radiological and functional outcome 6 months after TBI in elderly. Acta Neurochir (Wien) 2023; 165:849-864. [PMID: 36922467 DOI: 10.1007/s00701-023-05546-1] [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: 01/17/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Recovery after traumatic brain injury (TBI) in older adults is usually affected by the presence of comorbidities, leading to more severe sequelae in this age group than in younger patients. However, there are only few reports that prospectively perform in-depth assessment of outcome following TBI in elderly. OBJECTIVE This study aims at documenting structural brain characteristics and functional outcome and quality of life in elderly patients 6 months after TBI and comparing these data with healthy volunteers undergoing the same assessments. METHODS Thirteen TBI patients ≥ 65 years old, admitted to the University Hospitals Leuven (Belgium), between 2019 and 2022 due to TBI, including all injury severities, and a group of 13 healthy volunteers with similar demographic characteristics were prospectively included in the study. At admission, demographic, injury, and CT scan data were collected in our database. Six months after the accident, a brain MRI scan and standardized assessments of frailty, sleep quality, cognitive function, motor function, and quality of life were conducted. RESULTS A total of 13 patients and 13 volunteers were included in the study, with a median age of 74 and 73 years, respectively. Nine out of the 13 patients presented with a mild TBI. The patient group had a significantly higher level of frailty than the control group, presenting a mean Reported Edmonton Frailty Scale score of 5.8 (SD 2.7) vs 0.7 (SD 1.1) (p < 0.01). No statistically significant differences were found between patient and control brain volumes, fluid attenuated inversion recovery white matter hyperintensity volumes, number of lesions and blackholes, and fractional anisotropy values. Patients demonstrated a significantly higher median reaction time in the One Touch Stockings of Cambridge (22.3 s vs 17.6, p = 0.03) and Reaction Time (0.5 s vs 0.4 s, p < 0.01) subtests in the Cambridge Neuropsychological Test Automated Battery. Furthermore, patients had a lower mean score on the first Box and Blocks test with the right hand (46.6 vs 61.7, p < 0.01) and a significantly higher mean score in the Timed-Up & Go test (13.1 s vs 6.2 s, p = 0.02) and Timed Up & Go with cognitive dual task (16.0 s vs 10.2 s, p < 0.01). Substantially lower QOLIBRI total score (60.4 vs 85.4, p < 0.01) and QOLIBRI-OS total score (53.8 vs 88.5, p < 0.01) were also observed in the patients' group. CONCLUSION In this prospective study, TBI patients ≥ 65 years old when compared with elder controls showed slightly worse cognitive performance and poorer motor function, higher fall risk, but a substantially reduced QoL at 6 months FU, as well as significantly higher frailty, even when the TBI is classified as mild. No statistically significant differences were found in structural brain characteristics on MRI. Future studies with larger sample sizes are needed to refine the impact of TBI versus frailty on function and QoL in elderly.
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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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Castaño-Leon AM, Gómez PA, Paredes I, Munarriz PM, Panero I, Eiriz C, García-Pérez D, Lagares A. Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis. J Neurosurg Sci 2023; 67:83-92. [PMID: 32972116 DOI: 10.23736/s0390-5616.20.05034-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial. METHODS We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models. RESULTS The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC). CONCLUSIONS According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.
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Affiliation(s)
- Ana M Castaño-Leon
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain -
| | - Pedro A Gómez
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Irene Panero
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Carla Eiriz
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Daniel García-Pérez
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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8
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Orlando A, Coresh J, Carrick MM, Quan G, Berg GM, Dhakal L, Hamilton D, Madayag R, Lascano CHP, Bar-Or D. Characterizing Interhospital Variability in Neurosurgical Interventions for Patients with Mild Traumatic Brain Injury and Intracranial Hemorrhage. Neurotrauma Rep 2023; 4:149-158. [PMID: 36941879 PMCID: PMC10024575 DOI: 10.1089/neur.2022.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
The objective of this study was to quantify nation-wide interhospital variation in neurosurgical intervention risk by intracranial hemorrhage (ICH) type in the setting of mild traumatic brain injury (mTBI). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the National Trauma Data Bank from 2007 to 2019 with an emergency department Glasgow Coma Scale score 13-15, diagnosed ICH, no skull fracture. The primary outcome was neurosurgical intervention. Interhospital variation was assessed by examining the best linear unbiased predictors (BLUPs) obtained from mixed-effects logistic regression with random slopes and intercepts for hospitals and covariates for time and 14 demographic, injury, and hospital characteristics; one model per ICH type. Intercept BLUPs are estimates of how different each hospital is from the average hospital (after covariate adjustment). The study population included 49,220 (7%) neurosurgical interventions among 666,842 patients in 1060 hospitals. In 2019, after adjusting for patient case-mix and hospital characteristics, the percentage of hospitals with hemorrhage-specific neurosurgical intervention risk significantly different from the average hospital was as follows: isolated unspecified hemorrhage (0% of 995 hospitals); isolated contusion/laceration (0.54% of 929); isolated epidural hemorrhage (0.39% of 778); isolated subarachnoid hemorrhage (0.10% of 1002); multiple hemorrhages (2.49% of 963); and isolated subdural hemorrhage (16.25% of 1028). In the setting of mTBI, isolated subdural hemorrhages were the only ICH type to have considerable interhospital variability. Causes for this significant variation should be elucidated and might include changing hemorrhage characteristics and practice patterns over time.
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Affiliation(s)
- Alessandro Orlando
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Address correspondence to: Alessandro Orlando, PhD, MPH, Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 501 E. Hampden Avenue, Englewood, CO 80113, USA
| | - Josef Coresh
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Glenda Quan
- Department of Trauma Services, Swedish Medical Center, Englewood, Colorado, USA
| | - Gina M. Berg
- Department of Trauma Services, Wesley Medical Center, Wichita, Kansas, USA
| | - Laxmi Dhakal
- Department of Trauma Services, Wesley Medical Center, Wichita, Kansas, USA
| | - David Hamilton
- Department of Trauma Services, Penrose Hospital, Colorado Springs, Colorado, USA
| | - Robert Madayag
- Department of Trauma Services, St. Anthony Hospital, Lakewood, Colorado, USA
| | | | - David Bar-Or
- Injury Outcomes Network, Englewood, Colorado, USA
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9
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van Essen TA, Res L, Schoones J, de Ruiter G, Dekkers O, Maas A, Peul W, van der Gaag NA. Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute? J Neurotrauma 2023; 40:22-32. [PMID: 35699084 DOI: 10.1089/neu.2022.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.
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Affiliation(s)
- Thomas Arjan van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk Res
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Jan Schoones
- Directorate of Research Policy (Walaeus Library), and Leiden University Medical Center, Leiden, The Netherlands
| | - Godard de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Olaf Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Niels Anthony van der Gaag
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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10
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Hoogslag VDN, van Essen TA, Dijkman MD, Moudrous W, Schoonman GG, Peul WC. A multicentre retrospective cohort study on health-related quality of life after traumatic acute subdural haematoma: does cranial laterality affect long-term recovery? BMC Neurol 2022; 22:287. [PMID: 35915402 PMCID: PMC9341107 DOI: 10.1186/s12883-022-02790-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 06/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Traumatic acute subdural haematoma is a debilitating condition. Laterality intuitively influences management and outcome. However, in contrast to stroke, this research area is rarely studied. The aim is to investigate whether the hemisphere location of the ASDH influences patient outcome. Methods For this multicentre observational retrospective cohort study, patients were considered eligible when they were treated by a neurosurgeon for traumatic brain injury between 2008 and 2012, were > 16 years of age, had sustained brain injury with direct presentation to the emergency room and showed a hyperdense, crescent shaped lesion on the computed tomography scan. Patients were followed for a duration of 3-9 months post-trauma for functional outcome and 2-6 years for health-related quality of life. Main outcomes and measures included mortality, Glasgow Outcome Scale and the Quality of Life after Brain Injury score. The hypothesis was formulated after data collection. Results Of the 187 patients included, 90 had a left-sided ASDH and 97 had a right-sided haematoma. Both groups were comparable at baseline and with respect to the executed treatment. Furthermore, both groups showed no significant difference in mortality and Glasgow Outcome Scale score. Health-related quality of life, assessed 59 months (IQR 43-66) post-injury, was higher for patients with a right-sided haematoma (Quality of Life after Brain Injury score: 80 vs 61, P = 0.07). Conclusions This study suggests patients with a right-sided acute subdural haematoma have a better long-term health-related quality of life compared to patients with a left-sided acute subdural haematoma. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02790-3.
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11
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van den Brand CL, Foks KA, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MG, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Dippel DW, Jellema K. Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series. Injury 2022; 53:2979-2987. [PMID: 35831208 DOI: 10.1016/j.injury.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI). METHODS The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic. RESULTS Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%). CONCLUSIONS Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.
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Affiliation(s)
- Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands; Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Myriam Gm Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Centre for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Eef Reijners
- formerly Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Meriam Braaksma
- Department of Neurology, Bravis Hospital, PO Box 999, 4624 VT Bergen op Zoom, the Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
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12
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Liu Z, Du S, Wu Y, Chen T, Luo X, Bi C, Lan S, Chen X, Liu J. Intracranial pressure after closure of dura predicts decompressive craniectomy in patients with head trauma. J Neurotrauma 2022; 39:1231-1239. [PMID: 35538792 DOI: 10.1089/neu.2021.0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study aimed to address the risk factors of second decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) who initially underwent mass lesion evacuation, but no primary DC. Patients were enrolled if they had a hospital visit to Xiangya Hospital, Central South University with acute closed TBI from January 1, 2017, to December 31, 2019, and had undergone craniotomic mass lesion evacuation. Socio-demographic information, computed tomography (CT) information, clinical profiles, and surgical information were obtained from an electronic database. Twenty-four patients who had undergone a second DC (SDC) and 39 patients who did not (NSO) were included in the analysis. The prevailing lesions differed between the groups (P = 0.010). The SDC group had more compressed/obliterated basal cisterns than the NSO group (P = 0.028). After closure of dura, the SDC group also had higher intracranial pressure (ICP) than the NSO group (10.9 mmHg vs. 6.5 mmHg, P = 0.005). Binary logistic regression indicated that ICP after dura closure was an independent predictor of second DC (OR = 1.317, P = 0.011). A model using ICP after dura closure alone had an area under the curve value of 0.757 in its receiver operating characteristic curve. An ICP above 10.5 mmHg after closure of dura for the prediction of second DC had a sensitivity of 56.3% and specificity of 92.6%.
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Affiliation(s)
- Ziyuan Liu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Shan Du
- Xiangya Hospital Central South University, 159374, Department of Gastroenterology, Changsha, China;
| | - Yun Wu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Tiange Chen
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Xiangying Luo
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Changlong Bi
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Song Lan
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Xin Chen
- Xiangya Hospital Central South University, 159374, Neurosurgery, Changsha, Hunan, China.,Xiangya Hospital Central South University, 159374, National Clinical Medical Research Center for Geriatric Diseases, Changsha, Hunan, China;
| | - Jinfang Liu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, Hunan, China.,Xiangya Hospital Central South University, 159374, National Clinical Medical Research Center for Geriatric Diseases, Changsha, Hunan, China;
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13
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van Essen TA, Lingsma HF, Pisică D, Singh RD, Volovici V, den Boogert HF, Younsi A, Peppel LD, Heijenbrok-Kal MH, Ribbers GM, Walchenbach R, Menon DK, Hutchinson P, Depreitere B, Steyerberg EW, Maas AIR, de Ruiter GCW, Peul WC, Åkerlund C, Amrein K, Andelic N, Andreassen L, Anke A, Antoni A, Audibert G, Azouvi P, Azzolini ML, Bartels R, Barzó P, Beauvais R, Beer R, Bellander BM, Belli A, Benali H, Berardino M, Beretta L, Blaabjerg M, Bragge P, Brazinova A, Brinck V, Brooker J, Brorsson C, Buki A, Bullinger M, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Carbayo Lozano G, Carbonara M, Castaño-León AM, Cavallo S, Chevallard G, Chieregato A, Citerio G, Clusmann H, Coburn MS, Coles J, Cooper JD, Correia M, Čović A, Curry N, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, Dawes H, De Keyser V, Degos V, Della Corte F, Đilvesi Đ, Dixit A, Donoghue E, Dreier J, Dulière GL, Ercole A, Esser P, Ezer E, Fabricius M, Feigin VL, Foks K, Frisvold S, Furmanov A, Gagliardo P, Galanaud D, Gantner D, Gao G, George P, Ghuysen A, Giga L, Glocker B, Golubović J, Gomez PA, Gratz J, Gravesteijn B, Grossi F, Gruen RL, Gupta D, Haagsma JA, Haitsma I, Helbok R, Helseth E, Horton L, Huijben J, Jacobs B, Jankowski S, Jarrett M, Jiang JY, Johnson F, Jones K, Karan M, Kolias AG, Kompanje E, Kondziella D, Kornaropoulos E, Koskinen LO, Kovács N, Lagares A, Lanyon L, Laureys S, Lecky F, Ledoux D, Lefering R, Legrand V, Lejeune A, Levi L, Lightfoot R, Maegele M, Majdan M, Manara A, Manley G, Maréchal H, Martino C, Mattern J, McMahon C, Melegh B, Menovsky T, Mikolic A, Misset B, Muraleedharan V, Murray L, Nair N, Negru A, Nelson D, Newcombe V, Nieboer D, Nyirádi J, Oresic M, Ortolano F, Otesile O, Palotie A, Parizel PM, Payen JF, Perera N, Perlbarg V, Persona P, Piippo-Karjalainen A, Pirinen M, Ples H, Polinder S, Pomposo I, Posti JP, Puybasset L, Rădoi A, Ragauskas A, Raj R, Rambadagalla M, Rehorčíková V, Retel Helmrich I, Rhodes J, Richardson S, Richter S, Ripatti S, Rocka S, Roe C, Roise O, Rosand J, Rosenfeld J, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Rueckert D, Rusnák M, Sahuquillo J, Sakowitz O, Sanchez-Porras R, Sandor J, Schäfer N, Schmidt S, Schoechl H, Schoonman G, Schou RF, Schwendenwein E, Sewalt C, Skandsen T, Smielewski P, Sorinola A, Stamatakis E, Stanworth S, Kowark A, Stevens R, Stewart W, Stocchetti N, Sundström N, Takala R, Tamás V, Tamosuitis T, Taylor MS, Te Ao B, Tenovuo O, Theadom A, Thomas M, Tibboel D, Timmers M, Tolias C, Trapani T, Tudora CM, Unterberg A, Vajkoczy P, Valeinis E, Vallance S, Vámos Z, Van der Jagt M, van der Naalt J, Van der Steen G, van Dijck JT, Van Hecke W, van Heugten C, Van Praag D, Van Veen E, van Wijk R, Vande Vyvere T, Vargiolu A, Vega E, Velt K, Verheyden J, Vespa PM, Vik A, Vilcinis R, von Steinbüchel N, Voormolen D, Vulekovic P, Wang KK, Wiegers E, Williams G, Wilson L, Winzeck S, Wolf S, Yang Z, Ylén P, Zeiler FA, Ziverte A, Zoerle T. Surgery versus conservative treatment for traumatic acute subdural haematoma: a prospective, multicentre, observational, comparative effectiveness study. Lancet Neurol 2022; 21:620-631. [DOI: 10.1016/s1474-4422(22)00166-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 01/05/2023]
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14
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Singh RD, van Dijck JTJM, Maas AIR, Peul WC, van Essen TA. Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies. World Neurosurg 2022; 161:410-417. [PMID: 35505561 DOI: 10.1016/j.wneu.2021.11.092] [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: 10/18/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions. METHODS The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists. RESULTS Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments. CONCLUSIONS In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.
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Affiliation(s)
- Ranjit D Singh
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands.
| | - Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
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15
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Laic RAG, Vander Sloten J, Depreitere B. Traumatic brain injury in the elderly population: a 20-year experience in a tertiary neurosurgery center in Belgium. Acta Neurochir (Wien) 2022; 164:1407-1419. [PMID: 35267099 DOI: 10.1007/s00701-022-05159-0] [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: 01/13/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) rates in the elderly population are rapidly increasing worldwide. However, there are no clinical guidelines for the treatment of elderly TBI to date. This study aims at describing injury patterns and severity, clinical management, and outcomes in elderly TBI patients, which may contribute to specific prognostic tools and clinical guidelines in the future. METHODS Clinical records of 2999 TBI patients ≥ 65 years old admitted in the University Hospital Leuven (Belgium) between 1999 and 2019 were manually screened and 1480 cases could be included. Records were scrutinized for relevant clinical data. RESULTS The median age in the cohort was 78.0 years (IQR = 12). Falls represented the main accident mechanism (79.7%). The median Glasgow Coma Score on admission was 15 (range 3-15). Subdural hematomas were the most common lesion (28.4%). 90.1% of all patients were hospitalized and 27.0% were admitted to intensive care. 16.4% underwent a neurosurgical intervention. 11.0% of all patients died within 30 days post-TBI. Among the 521 patients with mild TBI, 28.6% were admitted to ICU and 13.1% had a neurosurgical intervention and 30-day mortality was 6.9%. CONCLUSION Over the 20-year study period, an increase of age and comorbidities and a reduction in neurosurgical interventions and ICU admissions were observed, along with a trend to less severe injuries but a higher proportion of treatment withdrawals, while at the same time mortality rates decreased. TBI is a life-changing event, leading to severe consequences in the elderly population, especially at higher ages. Even mild TBI is associated with substantial rates of hospitalization, surgery, and mortality in elderly. The characteristics of the elderly population with TBI are subject to changes over time.
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16
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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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Shao S, Guo T, Li F, Zhao Z, Li J, Wang X. Experimental study on the therapeutic effect of BDNF gene-carrying nanoparticles on traumatic brain injury. APPLIED NANOSCIENCE 2022. [DOI: 10.1007/s13204-022-02405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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18
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Mostert CQB, Singh RD, Gerritsen M, Kompanje EJO, Ribbers GM, Peul WC, van Dijck JTJM. Long-term outcome after severe traumatic brain injury: a systematic literature review. Acta Neurochir (Wien) 2022; 164:599-613. [PMID: 35098352 DOI: 10.1007/s00701-021-05086-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/07/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Expectation of long-term outcome is an important factor in treatment decision-making after severe traumatic brain injury (sTBI). Conclusive long-term outcome data substantiating these decisions is nowadays lacking. This systematic review aimed to provide an overview of the scientific literature on long-term outcome after sTBI. METHODS A systematic search was conducted using PubMed from 2008 to 2020. Studies were included when reporting long-term outcome ≥ 2 years after sTBI (GCS 3-8 or AIS head score ≥ 4), using standardized outcome measures. Study quality and risk of bias were assessed using the QUIPS tool. RESULTS Twenty observational studies were included. Studies showed substantial variation in study objectives and study methodology. GOS-E (n = 12) and GOS (n = 8) were the most frequently used outcome measures. Mortality was reported in 46% of patients (range 18-75%). Unfavourable outcome rates ranged from 29 to 100% and full recovery was seen in 21-27% of patients. Most surviving patients reported SF-36 scores lower than the general population. CONCLUSION Literature on long-term outcome after sTBI was limited and heterogeneous. Mortality and unfavourable outcome rates were high and persisting sequelae on multiple domains common. Nonetheless, a considerable proportion of survivors achieved favourable outcome. Future studies should incorporate standardized multidimensional and temporal long-term outcome measures to strengthen the evidence-base for acute and subacute decision-making. HIGHLIGHTS 1. Expectation of long-term outcome is an important factor in treatment decision-making for patients with severe traumatic brain injury (sTBI). 2. Favourable outcome and full recovery after sTBI are possible, but mortality and unfavourable outcome rates are high. 3. sTBI survivors are likely to suffer from a wide range of long-term consequences, underscoring the need for long-term and multi-modality outcome assessment in future studies. 4. The quality of the scientific literature on long-term outcome after sTBI can and should be improved to advance treatment decision-making.
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Affiliation(s)
- Cassidy Q B Mostert
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands.
| | - Ranjit D Singh
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Maxime Gerritsen
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
- Rijndam Rehabilitation, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
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19
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International practice variation in perioperative laboratory testing in glioblastoma patients-a retrospective cohort study. Acta Neurochir (Wien) 2022; 164:385-392. [PMID: 34997355 PMCID: PMC8854260 DOI: 10.1007/s00701-021-05090-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/02/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE Although standard-of-care has been defined for the treatment of glioblastoma patients, substantial practice variation exists in the day-to-day clinical management. This study aims to compare the use of laboratory tests in the perioperative care of glioblastoma patients between two tertiary academic centers-Brigham and Women's Hospital (BWH), Boston, USA, and University Medical Center Utrecht (UMCU), Utrecht, the Netherlands. METHODS All glioblastoma patients treated according to standard-of-care between 2005 and 2013 were included. We compared the number of blood drawings and laboratory tests performed during the 70-day perioperative period using a Poisson regression model, as well as the estimated laboratory costs per patient. Additionally, we compared the likelihood of an abnormal test result using a generalized linear mixed effects model. RESULTS After correction for age, sex, IDH1 status, postoperative KPS score, length of stay, and survival status, the number of blood drawings and laboratory tests during the perioperative period were 3.7-fold (p < 0.001) and 4.7-fold (p < 0.001) higher, respectively, in BWH compared to UMCU patients. The estimated median laboratory costs per patient were 82 euros in UMCU and 256 euros in BWH. Furthermore, the likelihood of an abnormal test result was lower in BWH (odds ratio [OR] 0.75, p < 0.001), except when the prior test result was abnormal as well (OR 2.09, p < 0.001). CONCLUSIONS Our results suggest a substantially lower clinical threshold for ordering laboratory tests in BWH compared to UMCU. Further investigating the clinical consequences of laboratory testing could identify over and underuse, decrease healthcare costs, and reduce unnecessary discomfort that patients are exposed to.
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Van der Straeten R, Peuskens D, Weyns F. Ethical attitudes in neurosurgery at the height of the COVID-19 pandemic. BRAIN AND SPINE 2022; 2:100925. [PMID: 36248163 PMCID: PMC9388278 DOI: 10.1016/j.bas.2022.100925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/23/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022]
Abstract
Pandemic conditions imposed withholding or withdrawing neurosurgical treatment. Variation exist in the management of intracranial haemorrhage or TBI during a pandemic. Triaging guidelines for neurosurgical patients need to be established.
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21
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Can We Cluster ICU Treatment Strategies for Traumatic Brain Injury by Hospital Treatment Preferences? Neurocrit Care 2021; 36:846-856. [PMID: 34873673 PMCID: PMC9110448 DOI: 10.1007/s12028-021-01386-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 10/20/2021] [Indexed: 11/29/2022]
Abstract
Background In traumatic brain injury (TBI), large between-center differences in treatment and outcome for patients managed in the intensive care unit (ICU) have been shown. The aim of this study is to explore if European neurotrauma centers can be clustered, based on their treatment preference in different domains of TBI care in the ICU. Methods Provider profiles of centers participating in the Collaborative European Neurotrauma Effectiveness Research in TBI study were used to assess correlations within and between the predefined domains: intracranial pressure monitoring, coagulation and transfusion, surgery, prophylactic antibiotics, and more general ICU treatment policies. Hierarchical clustering using Ward’s minimum variance method was applied to group data with the highest similarity. Heat maps were used to visualize whether hospitals could be grouped to uncover types of hospitals adhering to certain treatment strategies. Results Provider profiles were available from 66 centers in 20 different countries in Europe and Israel. Correlations within most of the predefined domains varied from low to high correlations (mean correlation coefficients 0.2–0.7). Correlations between domains were lower, with mean correlation coefficients of 0.2. Cluster analysis showed that policies could be grouped, but hospitals could not be grouped based on their preference. Conclusions Although correlations between treatment policies within domains were found, the failure to cluster hospitals indicates that a specific treatment choice within a domain is not a proxy for other treatment choices within or outside the domain. These results imply that studying the effects of specific TBI interventions on outcome can be based on between-center variation without being substantially confounded by other treatments. Trial registration We do not report the results of a health care intervention. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01386-y.
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22
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Sondag L, Jacobs FA, Schreuder FH, Boogaarts JD, Peter Vandertop W, Dammers R, Klijn CJ. Variation in medical management and neurosurgical treatment of patients with supratentorial spontaneous intracerebral haemorrhage. Eur Stroke J 2021; 6:134-142. [PMID: 34414288 PMCID: PMC8370071 DOI: 10.1177/23969873211005915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The role of surgery in spontaneous intracerebral haemorrhage (sICH) remains controversial. This leads to variation in the percentage of patients who are treated with surgery between countries. Patients and methods We sent an online survey to all neurosurgeons (n = 140) and to a sample of neurologists (n = 378) in Dutch hospitals, with questions on management in supratentorial sICH in general, and on treatment in six patients, to explore current variation in medical and neurosurgical management. We assessed patient and haemorrhage characteristics influencing treatment decisions. Results Twenty-nine (21%) neurosurgeons and 92 (24%) neurologists responded. Prior to surgery, neurosurgeons would more frequently administer platelet-transfusion in patients on clopidogrel (64% versus 13%; p = 0.000) or acetylsalicylic acid (61% versus 11%; p = 0.000) than neurologists. In the cases, neurosurgeons and neurologists were similar in their choice for surgery as initial treatment (24% and 31%; p = 0.12), however variation existed amongst physicians in specific cases. Neurosurgeons preferred craniotomy with haematoma evacuation (74%) above minimally-invasive techniques (5%). Age, Glasgow Coma Scale score and ICH location were important factors influencing decisions on treatment for neurosurgeons and neurologists. 69% of neurosurgeons and 80% of neurologists would randomise patients in a trial evaluating the effect of minimally-invasive surgery on functional outcome. Discussion Our results reflect the lack of evidence about the right treatment strategy in patients with sICH. Conclusion New high quality evidence is needed to guide treatment decisions for patients with ICH. The willingness to randomise patients into a clinical trial on minimally-invasive surgery, contributes to the feasibility of such studies in the future.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Floor Ae Jacobs
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Floris Hbm Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jeroen D Boogaarts
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - W Peter Vandertop
- Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, the Netherlands.,Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Academic Medical Centre, Amsterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Centre, Erasmus MC Stroke Centre, Rotterdam, the Netherlands
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
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23
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Truong EI, Stanley SP, DeMario BS, Tseng ES, Como JJ, Ho VP, Kelly ML. Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification. J Trauma Acute Care Surg 2021; 91:114-120. [PMID: 33605705 PMCID: PMC8505004 DOI: 10.1097/ta.0000000000003114] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution. METHODS We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval). RESULTS We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement. CONCLUSION Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification. LEVEL OF EVIDENCE Epidemiological, level III; Care management/Therapeutic level III.
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Affiliation(s)
- Evelyn I Truong
- From the Department of Surgery (E.I.T., S.P.S., B.S.D., E.S.T., J.J.C., V.P.H.) MetroHealth Medical Center; Department of Population and Quantitative Health Sciences (V.P.H.), Case Western Reserve University School of Medicine; Department of Neurological Surgery, MetroHealth Medical Center, Cleveland, Ohio (M.L.K.)
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24
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Craniotomy size for traumatic acute subdural hematomas in elderly patients-same procedure for every age? Neurosurg Rev 2021; 45:459-465. [PMID: 33900496 PMCID: PMC8827226 DOI: 10.1007/s10143-021-01548-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 12/03/2022]
Abstract
Surgical treatment of acute subdural hematoma (aSDH) is still matter of debate, especially in the elderly. A retrospective study to compare two different surgical approaches, namely standard (SC, craniotomy size > 8 cm) and limited craniotomy (LC, craniotomy size < 8 cm), was conducted in elderly patients with traumatic aSDH to identify the role of craniotomy size in terms of clinical and radiological outcome. Sixty-four patients aged 75 or older with aSDH as sole lesion were retrospectively analyzed. Data were collected pre- and postoperatively including clinical and radiological criteria. The primary outcome parameter was 30-day mortality. Secondary outcome parameters were radiological. The mean age was 79.2 (± 3.1) years with no difference between groups and almost equal distribution of craniotomy size. Mortality rate was significantly higher in the SC group in comparison to the LC group (68.4% vs. 31.6%; p = 0.045). The preoperative HD (p = 0.08) and the MLS (p = 0.09) were significantly higher in the SC group, whereas postoperative radiological evaluation showed no significant difference in HD or MLS. A limited craniotomy is sufficient for adequate evacuation of an aSDH in the elderly achieving the same radiological and clinical outcome.
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25
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Ahmed N, Greenberg P, Shin S. Mortality Outcome of Emergency Decompressive Craniectomy and Craniotomy in the Management of Acute Subdural Hematoma: A National Data Analysis. Am Surg 2020; 87:347-353. [PMID: 32972240 DOI: 10.1177/0003134820951463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of the study is to evaluate the in-hospital mortality of patients who presented with acute subdural hematoma (SDH) and underwent emergency decompressive craniectomy (DC) or craniotomy (CO) within 4 hours of hospital arrival. METHOD The National Trauma Data Bank (NTDB) dataset of the calendar year of 2007 through 2010 was accessed for the study. All blunt severe head injury patients who presented with acute SDH were included in the study. Severe head injury is defined as a head Abbreviated Injury Scale (AIS) score ≥3 and a Glasgow Coma Scale (GCS) score ≤8. Univariate followed by propensity-matched analyses were performed to compare the two procedure groups: DC and CO. RESULTS Out of 2370 patients, 518, (21.9%) patients underwent DC. There were significant differences found in the univariate analysis between the DC and CO groups for median age (38 (IQR: 22.0, 55.0) vs 49 (IQR: 27, 67), P < .001), mechanism of injury (fall: 33.2% vs 50.7%; motor vehicle crashes: 58.3% vs 40.9%, P < .001), and median injury severity score (ISS: 26.0 (IQR: 25, 38) vs 26 (IQR: 25.0, 33.0), P < .001). After propensity score matching and pair-matched analysis, no differences were found with any of the above characteristics. The pair-matched analysis also showed no significant difference in in-hospital mortality (42.7% vs 37.5%, P = .10) between the DC vs CO groups. CONCLUSION The overall in-hospital mortality for emergency CO or DC for the evacuation of SDH remains high. The preference of one operative procedure over the other did not impact overall mortality.
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Affiliation(s)
- Nasim Ahmed
- 23498 Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA.,Department of Surgery, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Patricia Greenberg
- 23498 Department of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - SeungHoon Shin
- 23498 Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA
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26
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Gao G, Wu X, Feng J, Hui J, Mao Q, Lecky F, Lingsma H, Maas AIR, Jiang J. Clinical characteristics and outcomes in patients with traumatic brain injury in China: a prospective, multicentre, longitudinal, observational study. Lancet Neurol 2020; 19:670-677. [PMID: 32702336 DOI: 10.1016/s1474-4422(20)30182-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Large-scale studies are required to better characterise traumatic brain injury (TBI) and to identify the most effective treatment approaches for TBI. However, evidence is scarce and mostly originates from high-income countries. We aimed to describe the existing care for patients with TBI and the outcomes in China. METHODS The Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) China registry is a prospective, multicentre, longitudinal, observational study done in 56 neurosurgical centres across China. We collected data of patients who were admitted to hospital with a clinical diagnosis of TBI and an indication for CT. Patients who were discharged directly from the emergency room were excluded. The primary endpoint was survival on discharge. Prognostic analyses were applied to identify predictors of mortality. Variations in mortality were compared between centres and provinces within China. Mortality was compared with expected mortality, estimated using the CRASH basic model. This study was registered with ClinicalTrials.gov, NCT02210221. FINDINGS From Dec 22, 2014, to Aug 1, 2017, 13 627 patients with TBI from 56 centres were enrolled in the registry. Data from 13 138 patients from 52 hospitals in 22 provinces of China were analysed. Most patients were male (9782 [74%]), with a median age of 48 years (IQR 33-61). The median Glasgow Coma Scale (GCS) score was 13 (IQR 9-15), and the leading cause of injury was road-traffic incident (6548 [50%]). Overall, 637 (5%) patients died, including 552 (20%) patients with severe TBI. Age, GCS score, injury severity score, pupillary light reflex, CT findings (compressed basal cistern and midline shift ≥5 mm), presence of hypoxia, systemic hypotension, altitude higher than >500 m, and GDP per capita were significantly associated with survival in all patients with TBI. Variation in mortality existed between centres and regions. The expected 14-day mortality was 1116 (13%), but 544 (7%) deaths within 14 days were observed (observed to expected ratio 0·49 [95% CI 0·45-0·53]). INTERPRETATION The results show differences in mortality between centres and regions across China, which indicates potential for identifying best practices through comparative effectiveness research. The risk factors identified in prognostic analyses might contribute to developing benchmarks for assessing quality of care. FUNDING None.
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Affiliation(s)
- Guoyi Gao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Xiang Wu
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Junfeng Feng
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyuan Hui
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Qing Mao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester Lingsma
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium; University of Antwerp, Edegem, Belgium
| | - Jiyao Jiang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China; Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China; Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China.
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27
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Zhang W, Qin Z, Xian K, Tang S. Assessment of plasma homocysteine levels in patients with craniocerebral injury and prognosis. J Int Med Res 2019; 48:300060519882202. [PMID: 31852292 PMCID: PMC7607269 DOI: 10.1177/0300060519882202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To investigate the effect of plasma homocysteine (Hcy) and C-reactive protein
(CRP) levels in patients with craniocerebral injury. Methods A retrospective analysis of data from patients with craniocerebral injury who
underwent surgery. Patients were stratified according to the extent of the
craniocerebral injury into severe, moderate and mild craniocerebral injury
groups. Serum Hcy and CRP levels were determined at admission, at 7 days
after treatment and at 3 months after injury. Univariate and multivariate
Cox regression analyses were undertaken to identify prognostic factors. Results The study enrolled 96 patients: 29 patients with mild injury; 33 patients
with moderate injury; and 34 patients with severe injury. Serum Hcy and CRP
levels at admission were significantly higher in the severe craniocerebral
injury group than in the other two groups; and they were significantly
higher the moderate craniocerebral injury group compared with the mild
craniocerebral injury group. Serum Hcy and CRP levels of the three groups of
patients were significantly lower after 7 days of treatment than those
before treatment. The levels of Hcy and CRP were positively correlated in
all three groups. Conclusion Serum Hcy and CRP levels in patients could be used to monitor the condition
and prognosis of patients with craniocerebral injury.
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Affiliation(s)
- Wenjia Zhang
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
| | - Zhongqiao Qin
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
| | - Kecong Xian
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
| | - Shuhong Tang
- Department of Neurosurgery, Guigang People's Hospital, Guigang City, Guangxi Zhuang Autonomous Region, China
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Robinson D, Khoury JC, Kleindorfer D. Regional Variation in the Management of Nontraumatic Subdural Hematomas Across the United States. World Neurosurg 2019; 135:e418-e423. [PMID: 31862343 DOI: 10.1016/j.wneu.2019.12.011] [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: 10/13/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGOUND Nontraumatic subdural hematomas are a common indication for inpatient hospitalization in the United States, yet there is little high-quality evidence regarding which patients should receive surgical or medical treatment. We sought to assess variation in surgical management and medical treatment with steroids for nontraumatic subdural hematomas across the United States. METHODS Using the Premier database, we analyzed patients with a primary discharge diagnosis of nontraumatic subdural hematoma in 2014. International Classification of Diseases, Ninth Revision, procedure codes were used to identify patients who underwent surgical management, and pharmacy data were used to identify patients treated with dexamethasone. Univariable and multivariable analyses were used to examine the association of age, race, sex, academic versus nonacademic center, and regions of the United States with conservative or surgical management. RESULTS There were 3915 inpatient hospitalizations for nontraumatic subdural hematomas in 2014 in the Premier database, of whom 1860 (47.5%) underwent surgery, and 360 (9.2%) underwent treatment with dexamethasone, either as a primary treatment or as an adjuvant to surgery. Older age, female sex, and being managed outside of the Western U.S. region were associated with a lower likelihood of undergoing surgical management on multivariable analysis; only younger age was associated with a greater likelihood of being treated with dexamethasone. CONCLUSIONS There is considerable variability in surgical management of nontraumatic subdural hematomas across the United States based on age, sex, and region. Future studies should explore the reasons for the variability and attempt to better clarify indications for surgical management of subdural hematomas.
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Affiliation(s)
- David Robinson
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Van Essen TA, Volovici V, Cnossen MC, Kolias A, Ceyisakar I, Nieboer D, Peppel LD, Heijenbrok-Kal M, Ribbers G, Menon D, Hutchinson P, Depreitere B, de Ruiter GCW, Lingsma HF, Steyerberg EW, Maas AI, Peul WC. Comparative effectiveness of surgery in traumatic acute subdural and intracerebral haematoma: study protocol for a prospective observational study within CENTER-TBI and Net-QuRe. BMJ Open 2019; 9:e033513. [PMID: 31619435 PMCID: PMC6797419 DOI: 10.1136/bmjopen-2019-033513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Controversy exists about the optimal treatment for patients with a traumatic acute subdural haematoma (ASDH) and an intracerebral haematoma/contusion (t-ICH). Treatment varies largely between different regions. The effect of this practice variation on patient outcome is unknown. Here, we present the protocol for a prospective multicentre observational study aimed at comparing the effectiveness of different treatment strategies in patients with ASDH and/or t-ICH. Specifically, the aims are to compare (1) an acute surgical approach to an expectant approach and (2) craniotomy to decompressive craniectomy when evacuating the haematoma. METHODS AND ANALYSIS Patients presenting to the emergency room with an ASDH and/or an t-ICH are eligible for inclusion. Standardised prospective data on patient and injury characteristics, treatment and outcome will be collected on 1000 ASDH and 750 t-ICH patients in 60-70 centres within two multicentre prospective observational cohort studies: the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Neurotraumatology Quality Registry (Net-QuRe). The interventions of interest are acute surgery, defined as surgery directly after the first CT at presentation versus late or no surgery and craniotomy versus decompressive craniectomy. The primary outcome measure is the Glasgow Outcome Score-Extended at 6 months. Secondary outcome measures include in-hospital mortality, quality of life and neuropsychological tests. In the primary analysis, the effect of treatment preference (eg, proportion of patients in which the intervention under study is preferred) per hospital will be analysed with random effects ordinal regression models, adjusted for casemix and stratified by study. Such a hospital-level approach reduces confounding by the indication. Sensitivity analyses will include propensity score matching, with treatment defined on patient level. This study is designed to determine the best acute management strategy for ASDH and t-ICH by exploiting the existing between-hospital variability in surgical management. ETHICS AND DISSEMINATION Ethics approval was obtained in all participating countries. Results of surgical management of ASDH and t-ICH/contusion will separately be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02210221 and NL 5761.
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Affiliation(s)
- Thomas A Van Essen
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Victor Volovici
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Neurosurgery, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Maryse C Cnossen
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Iris Ceyisakar
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Daan Nieboer
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Lianne D Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, ErasmusMC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, ErasmusMC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gerard Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, ErasmusMC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Godard C W de Ruiter
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Hester F Lingsma
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre and Haaglanden Medical Centre, Leiden and The Hague, The Netherlands
| | - Andrew I Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
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van Dijck JTJM, Dijkman MD, Ophuis RH, de Ruiter GCW, Peul WC, Polinder S. In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment. PLoS One 2019; 14:e0216743. [PMID: 31071199 PMCID: PMC6508680 DOI: 10.1371/journal.pone.0216743] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/28/2019] [Indexed: 12/19/2022] Open
Abstract
Background The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology. Methods A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement. Results Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported. Conclusions Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.
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Affiliation(s)
- Jeroen T. J. M. van Dijck
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
- * E-mail:
| | - Mark D. Dijkman
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Robbin H. Ophuis
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C. W. de Ruiter
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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31
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van Dijck JTJM, van Essen TA, Dijkman MD, Mostert CQB, Polinder S, Peul WC, de Ruiter GCW. Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox? Acta Neurochir (Wien) 2019; 161:875-884. [PMID: 30923919 PMCID: PMC6483942 DOI: 10.1007/s00701-019-03878-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness. METHODS This study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)-specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation. RESULTS Out of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13-15), 19 a moderate (GCS 9-12), and 49 a severe (GCS 3-8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4-5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580). CONCLUSIONS Although this study confirms that outcome is often "unfavorable" after t-ASDH, it also shows that "favorable" outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.
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Affiliation(s)
- Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands.
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Mark D Dijkman
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Cassidy Q B Mostert
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
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32
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van Essen TA, den Boogert HF, Cnossen MC, de Ruiter GCW, Haitsma I, Polinder S, Steyerberg EW, Menon D, Maas AIR, Lingsma HF, Peul WC. Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study. Acta Neurochir (Wien) 2019; 161:435-449. [PMID: 30569224 PMCID: PMC6407836 DOI: 10.1007/s00701-018-3761-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/30/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. METHODS A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). RESULTS The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. CONCLUSION Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.
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Affiliation(s)
- Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, The Netherlands.
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands.
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maryse C Cnossen
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands
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van Essen TA, Dijkman MD, Cnossen MC, Moudrous W, Ardon H, Schoonman GG, Steyerberg EW, Peul WC, Lingsma HF, de Ruiter GCW. Comparative Effectiveness of Surgery for Traumatic Acute Subdural Hematoma in an Aging Population. J Neurotrauma 2018; 36:1184-1191. [PMID: 30234429 DOI: 10.1089/neu.2018.5869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
There is uncertainty as to the optimal initial management of patients with traumatic acute subdural hematoma, leading to regional variation in surgical policy. This can be exploited to compare the effect of various management strategies and determine best practices. This article reports such a comparative effectiveness analysis of a retrospective observational cohort of traumatic acute subdural hematoma patients in two geographically distinct neurosurgical departments chosen for their - a-priori defined - diverging treatment preferences. Region A favored a strategy focused on surgical hematoma evacuation, whereas region B employed a more conservative approach, performing primary surgery less often. Region was used as a proxy for preferred treatment strategy to compare outcomes between groups, adjusted for potential confounders using multivariable logistic regression with imputation of missing data. In total, 190 patients were included: 108 from region A and 82 from region B. There were 104 males (54.7%). Matching current epidemiological developments, the median age was relatively high at 68 years (interquartile range [IQR], 54-76). Baseline characteristics were comparable between regions. Primary evacuation was performed in 84% of patients in region A and in 65% of patients in region B (p < 0.01). Mortality was lower in region A (37% vs. 45%, p = 0.29), as was unfavorable outcome (53% vs. 62%, p = 0.23). The strategy favoring surgical evacuation was associated with significantly lower odds of mortality (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.21-0.88) and unfavorable outcome (OR: 0.53; 95% CI: 0.27-1.02) 3-9 months post-injury. Therefore, in the aging population of patients with acute subdural hematoma, a treatment strategy favoring emergency hematoma evacuation might be associated with lower odds of mortality and unfavorable outcome.
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Affiliation(s)
- Thomas A van Essen
- 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,2 Department of Neurosurgery, Medial Center Haaglanden, The Hague, The Netherlands
| | - Mark D Dijkman
- 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Maryse C Cnossen
- 3 Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Walid Moudrous
- 4 Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,5 Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Hilko Ardon
- 6 Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Guus G Schoonman
- 4 Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Ewout W Steyerberg
- 3 Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.,7 Department of Medical Statistics and Bioinformatics,, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilco C Peul
- 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,2 Department of Neurosurgery, Medial Center Haaglanden, The Hague, The Netherlands
| | - Hester F Lingsma
- 3 Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C W de Ruiter
- 2 Department of Neurosurgery, Medial Center Haaglanden, The Hague, The Netherlands
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Kolias AG, Viaroli E, Rubiano AM, Adams H, Khan T, Gupta D, Adeleye A, Iaccarino C, Servadei F, Devi BI, Hutchinson PJ. The current status of decompressive craniectomy in traumatic brain injury. CURRENT TRAUMA REPORTS 2018; 4:326-332. [PMID: 30473990 PMCID: PMC6244550 DOI: 10.1007/s40719-018-0147-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI). RECENT FINDINGS The publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about 1) the indications for DC in various TBI subtypes, 2) alternative techniques (e.g. hinge craniotomy), 3) optimal time and material for cranial reconstruction, and 4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial. SUMMARY This review provides an overview of the current evidence base, discusses its limitations and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low- and middle-income countries due to their much greater TBI burden.
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Affiliation(s)
- Angelos G. Kolias
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Cambridge, CB2 0QQ UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Edoardo Viaroli
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Andres M. Rubiano
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Neuroscience Institute, INUB-MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Hadie Adams
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Cambridge, CB2 0QQ UK
| | - Tariq Khan
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Deepak Gupta
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amos Adeleye
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Surgery, Division of Neurological Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
| | - Bhagavatula Indira Devi
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Peter J. Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Cambridge, CB2 0QQ UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
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Foks KA, van den Brand CL, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MGM, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Jellema K, Dippel DWJ. External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands. BMJ 2018; 362:k3527. [PMID: 30143521 PMCID: PMC6108278 DOI: 10.1136/bmj.k3527] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To externally validate four commonly used rules in computed tomography (CT) for minor head injury. DESIGN Prospective, multicentre cohort study. SETTING Three university and six non-university hospitals in the Netherlands. PARTICIPANTS Consecutive adult patients aged 16 years and over who presented with minor head injury at the emergency department with a Glasgow coma scale score of 13-15 between March 2015 and December 2016. MAIN OUTCOME MEASURES The primary outcome was any intracranial traumatic finding on CT; the secondary outcome was a potential neurosurgical lesion on CT, which was defined as an intracranial traumatic finding on CT that could lead to a neurosurgical intervention or death. The sensitivity, specificity, and clinical usefulness (defined as net proportional benefit, a weighted sum of true positive classifications) of the four CT decision rules. The rules included the CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and National Institute for Health and Care Excellence (NICE) guideline for head injury. RESULTS For the primary analysis, only six centres that included patients with and without CT were selected. Of 4557 eligible patients who presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for performing CT scanning: the NOC rule was preferable at a low threshold, the NICE rule was preferable at a higher threshold, whereas the CHIP rule was preferable for an intermediate threshold. CONCLUSIONS Application of the CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT scanning among patients with minor head injury, resulting in many unnecessary CT scans and some missed intracranial traumatic findings. Until an existing decision rule has been updated, any of the four rules can be used for patients presenting minor head injuries at the emergency department. Use of the CHIP rule is recommended because it leads to a substantial reduction in CT scans while missing few potential neurosurgical lesions.
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Affiliation(s)
- Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Myriam G M Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Centre for Health Decision Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Eef Reijners
- Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Meriam Braaksma
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
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Cnossen MC, van Essen TA, Ceyisakar IE, Polinder S, Andriessen TM, van der Naalt J, Haitsma I, Horn J, Franschman G, Vos PE, Peul WC, Menon DK, Maas AI, Steyerberg EW, Lingsma HF. Adjusting for confounding by indication in observational studies: a case study in traumatic brain injury. Clin Epidemiol 2018; 10:841-852. [PMID: 30050328 PMCID: PMC6055622 DOI: 10.2147/clep.s154500] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Observational studies of interventions are at risk for confounding by indication. The objective of the current study was to define the circumstances for the validity of methods to adjust for confounding by indication in observational studies. PATIENTS AND METHODS We performed post hoc analyses of data prospectively collected from three European and North American traumatic brain injury studies including 1,725 patients. The effects of three interventions (intracranial pressure [ICP] monitoring, intracranial operation and primary referral) were estimated in a proportional odds regression model with the Glasgow Outcome Scale as ordinal outcome variable. Three analytical methods were compared: classical covariate adjustment, propensity score matching and instrumental variable (IV) analysis in which the percentage exposed to an intervention in each hospital was added as an independent variable, together with a random intercept for each hospital. In addition, a simulation study was performed in which the effect of a hypothetical beneficial intervention (OR 1.65) was simulated for scenarios with and without unmeasured confounders. RESULTS For all three interventions, covariate adjustment and propensity score matching resulted in negative estimates of the treatment effect (OR ranging from 0.80 to 0.92), whereas the IV approach indicated that both ICP monitoring and intracranial operation might be beneficial (OR per 10% change 1.17, 95% CI 1.01-1.42 and 1.42, 95% CI 0.95-1.97). In our simulation study, we found that covariate adjustment and propensity score matching resulted in an invalid estimate of the treatment effect in case of unmeasured confounders (OR ranging from 0.90 to 1.03). The IV approach provided an estimate in the similar direction as the simulated effect (OR per 10% change 1.04-1.05) but was statistically inefficient. CONCLUSION The effect estimation of interventions in observational studies strongly depends on the analytical method used. When unobserved confounding and practice variation are expected in observational multicenter studies, IV analysis should be considered.
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Affiliation(s)
- Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,
| | - Thomas A van Essen
- Neurosurgical Cooperative Holland, Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Iris E Ceyisakar
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,
| | | | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Janneke Horn
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Gaby Franschman
- Department of Anesthesiology, VU University Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Pieter E Vos
- Department of Neurology, Slingeland Hospital, Doetinchem, the Netherlands
| | - Wilco C Peul
- Neurosurgical Cooperative Holland, Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge/Addenbrooke's Hospital, Cambridge, UK
| | - Andrew Ir Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,
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Orlando A, Levy AS, Rubin BA, Tanner A, Carrick MM, Lieser M, Hamilton D, Mains CW, Bar-Or D. Isolated subdural hematomas in mild traumatic brain injury. Part 2: a preliminary clinical decision support tool for neurosurgical intervention. J Neurosurg 2018; 130:1626-1633. [PMID: 29905511 DOI: 10.3171/2018.1.jns171906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 01/04/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A paucity of studies have examined neurosurgical interventions in the mild traumatic brain injury (mTBI) population with intracranial hemorrhage (ICH). Furthermore, it is not understood how the dimensions of an ICH relate to the risk of a neurosurgical intervention. These limitations contribute to a lack of treatment guidelines. Isolated subdural hematomas (iSDHs) are the most prevalent ICH in mTBI, carry the highest neurosurgical intervention rate, and account for an overwhelming majority of all neurosurgical interventions. Decision criteria in this population could benefit from understanding the risk of requiring neurosurgical intervention. The aim of this study was to quantify the risk of neurosurgical intervention based on the dimensions of an iSDH in the setting of mTBI. METHODS This was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult (≥ 18 years) trauma patients with mTBI and iSDH were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic (AOC) SDH, mass effect, and other hemorrhage-related variables were double-data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. Tentorial SDHs were not measured. The primary outcome was neurosurgical intervention (craniotomy, burr holes, intracranial pressure monitor placement, shunt, ventriculostomy, or SDH evacuation). Multivariate stepwise logistic regression was used to identify significant covariates, to assess interactions, and to create the scoring system. RESULTS There were a total of 176 patients included in our study: 28 patients did and 148 did not receive a neurosurgical intervention. There were no significant differences between neurosurgical intervention groups in 11 demographic and 22 comorbid variables. Patients with neurosurgical intervention had significantly longer and thicker SDHs than nonsurgical controls. Logistic regression identified thickness and AOC hemorrhage as being the most important variables in predicting neurosurgical intervention; SDH length was not. Risk of neurosurgical intervention was calculated based on the SDH thickness and presence of an AOC hemorrhage from a multivariable logistic regression model (area under the receiver operating characteristic curve 0.94, 95% CI 0.90-0.97; p < 0.001). With a decision point of 2.35% risk, we predicted neurosurgical intervention with 100% sensitivity, 100% negative predictive value, and 53% specificity. CONCLUSIONS This is the first study to quantify the risk of neurosurgical intervention based on hemorrhage characteristics in patients with mTBI and iSDH. Once validated in a second population, these data can be used to inform the necessity of interhospital transfers and neurosurgical consultations.
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Affiliation(s)
- Alessandro Orlando
- 1Trauma Research Department and
- 4Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado
- 5Trauma Research Department, Medical City Plano, Plano, Texas
- 6Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado
| | | | - Benjamin A Rubin
- 2Department of Neurosurgery, Swedish Medical Center, Englewood, Colorado
| | - Allen Tanner
- 6Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado
| | | | - Mark Lieser
- 7Trauma Services Department, Research Medical Center, Kansas City, Missouri; and
| | - David Hamilton
- 6Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado
| | - Charles W Mains
- 4Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado
| | - David Bar-Or
- 1Trauma Research Department and
- 4Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado
- 5Trauma Research Department, Medical City Plano, Plano, Texas
- 6Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado
- 8Rocky Vista University College of Osteopathic Medicine, Parker, Colorado
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38
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Won YD, Na MK, Ryu JI, Cheong JH, Kim JM, Kim CH, Han MH. Radiologic Factors Predicting Deterioration of Mental Status in Patients with Acute Traumatic Subdural Hematoma. World Neurosurg 2017; 111:e120-e134. [PMID: 29248778 DOI: 10.1016/j.wneu.2017.12.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/30/2017] [Accepted: 12/04/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate whether subdural hematoma (SDH) volume and other radiologic factors predict deterioration of mental status in patients with acute traumatic SDH. METHODS SDH volumes were measured with a semiautomated tool. The area under the receiver operating characteristic curve was used to determine optimal cutoff values for mental deterioration, including the variables midline shift, SDH volume, hematoma thickness, and Sylvian fissure ratio. Multivariate logistic regression was used to calculate the odds ratio for mental deterioration based on several predictive factors. RESULTS We enrolled 103 consecutive patients admitted to our hospital with acute traumatic SDH over an 8-year period. We observed an increase in SDH volume of approximately 7.2 mL as SDH thickness increased by 1 mm. A steeper slope for midline shift was observed in patients with SDH volumes of approximately 75 mL in the younger age group compared with patients in the older age group. When comparing cutoff values used to predict poor mental status at time of admission between the 2 age groups, we observed smaller midline shifts in the older patients. CONCLUSIONS Among younger patients, an overall tendency for more rapid midline shift progression was observed in patients with relatively low SDH volumes compared with older patients. Older patients seem to tolerate larger hematoma volumes owing to brain atrophy compared with younger patients. When there is a midline shift, older patients seem to be more vulnerable to mental deterioration than younger patients.
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Affiliation(s)
- Yu Deok Won
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyonggi-do, Korea
| | - Min Kyun Na
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyonggi-do, Korea
| | - Je-Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyonggi-do, Korea
| | - Jin-Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyonggi-do, Korea
| | - Jae-Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyonggi-do, Korea
| | - Choong-Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyonggi-do, Korea
| | - Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyonggi-do, Korea.
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Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Büki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Söderberg J, Stanworth SJ, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K, Adams H, Agnoletti V, Allanson J, Amrein K, Andaluz N, Anke A, Antoni A, van As AB, Audibert G, Azaševac A, Azouvi P, Azzolini ML, Baciu C, Badenes R, Barlow KM, Bartels R, Bauerfeind U, Beauchamp M, Beer D, Beer R, Belda FJ, Bellander BM, Bellier R, Benali H, Benard T, Beqiri V, Beretta L, Bernard F, Bertolini G, Bilotta F, Blaabjerg M, den Boogert H, Boutis K, Bouzat P, Brooks B, Brorsson C, Bullinger M, Burns E, Calappi E, Cameron P, Carise E, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Christie B, Cnossen M, Coles J, Collett J, Della Corte F, Craig W, Csato G, Csomos A, Curry N, Dahyot-Fizelier C, Dawes H, DeMatteo C, Depreitere B, Dewey D, van Dijck J, Đilvesi Đ, Dippel D, Dizdarevic K, Donoghue E, Duek O, Dulière GL, Dzeko A, Eapen G, Emery CA, English S, Esser P, Ezer E, Fabricius M, Feng J, Fergusson D, Figaji A, Fleming J, Foks K, Francony G, Freedman S, Freo U, Frisvold SK, Gagnon I, Galanaud D, Gantner D, Giraud B, Glocker B, Golubovic J, Gómez López PA, Gordon WA, Gradisek P, Gravel J, Griesdale D, Grossi F, Haagsma JA, Håberg AK, Haitsma I, Van Hecke W, Helbok R, Helseth E, van Heugten C, Hoedemaekers C, Höfer S, Horton L, Hui J, Huijben JA, Hutchinson PJ, Jacobs B, van der Jagt M, Jankowski S, Janssens K, Jelaca B, Jones KM, Kamnitsas K, Kaps R, Karan M, Katila A, Kaukonen KM, De Keyser V, Kivisaari R, Kolias AG, Kolumbán B, Kolundžija K, Kondziella D, Koskinen LO, Kovács N, Kramer A, Kutsogiannis D, Kyprianou T, Lagares A, Lamontagne F, Latini R, Lauzier F, Lazar I, Ledig C, Lefering R, Legrand V, Levi L, Lightfoot R, Lozano A, MacDonald S, Major S, Manara A, Manhes P, Maréchal H, Martino C, Masala A, Masson S, Mattern J, McFadyen B, McMahon C, Meade M, Melegh B, Menovsky T, Moore L, Morgado Correia M, Morganti-Kossmann MC, Muehlan H, Mukherjee P, Murray L, van der Naalt J, Negru A, Nelson D, Nieboer D, Noirhomme Q, Nyirádi J, Oddo M, Okonkwo DO, Oldenbeuving AW, Ortolano F, Osmond M, Payen JF, Perlbarg V, Persona P, Pichon N, Piippo-Karjalainen A, Pili-Floury S, Pirinen M, Ple H, Poca MA, Posti J, Van Praag D, Ptito A, Radoi A, Ragauskas A, Raj R, Real RGL, Reed N, Rhodes J, Robertson C, Rocka S, Røe C, Røise O, Roks G, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossi S, Rueckert D, de Ruiter GCW, Sacchi M, Sahakian BJ, Sahuquillo J, Sakowitz O, Salvato G, Sánchez-Porras R, Sándor J, Sangha G, Schäfer N, Schmidt S, Schneider KJ, Schnyer D, Schöhl H, Schoonman GG, Schou RF, Sir Ö, Skandsen T, Smeets D, Sorinola A, Stamatakis E, Stevanovic A, Stevens RD, Sundström N, Taccone FS, Takala R, Tanskanen P, Taylor MS, Telgmann R, Temkin N, Teodorani G, Thomas M, Tolias CM, Trapani T, Turgeon A, Vajkoczy P, Valadka AB, Valeinis E, Vallance S, Vámos Z, Vargiolu A, Vega E, Verheyden J, Vik A, Vilcinis R, Vleggeert-Lankamp C, Vogt L, Volovici V, Voormolen DC, Vulekovic P, Vande Vyvere T, Van Waesberghe J, Wessels L, Wildschut E, Williams G, Winkler MKL, Wolf S, Wood G, Xirouchaki N, Younsi A, Zaaroor M, Zelinkova V, Zemek R, Zumbo F. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16:987-1048. [DOI: 10.1016/s1474-4422(17)30371-x] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
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40
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Cnossen MC, Huijben JA, van der Jagt M, Volovici V, van Essen T, Polinder S, Nelson D, Ercole A, Stocchetti N, Citerio G, Peul WC, Maas AIR, Menon D, Steyerberg EW, Lingsma HF. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:233. [PMID: 28874206 PMCID: PMC5586023 DOI: 10.1186/s13054-017-1816-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/10/2017] [Indexed: 11/23/2022]
Abstract
Background No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI. Methods A 29-item survey on ICP monitoring and treatment was developed on the basis of literature and expert opinion, and it was pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Results The survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately 90% of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomographic abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as using a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%). Conclusions Substantial variation was found regarding monitoring and treatment policies in patients with TBI and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1816-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
| | - Jilske A Huijben
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | - Thomas van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David Menon
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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