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Podell JE, Morris NA. Traumatic Brain Injury and Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:721-756. [PMID: 38830069 DOI: 10.1212/con.0000000000001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury. LATEST DEVELOPMENTS Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated. ESSENTIAL POINTS Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.
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Chen JW, Yengo-Kahn A, Chotai S, Bhamidipati A, Smith C, Davis P, Reynolds RA, Boyd MP, Barrett TW, Compton ES, Dennis BM, Norris MS, Patel MB, Schwarz JP, Thomason NR, Thompson RC, Guillamondegui OD. Assessment of safety and effectiveness of non-neurosurgical management for minimal traumatic brain injury (TBI). Injury 2023; 54:82-86. [PMID: 36028374 DOI: 10.1016/j.injury.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile. METHODS A non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation. RESULTS A total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001). CONCLUSION A protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.
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Affiliation(s)
- Jeffrey W Chen
- Vanderbilt University School of Medicine, Nashville, TN, United States.
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States.
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | | | - Candice Smith
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Philip Davis
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Rebecca A Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | - Mary Peyton Boyd
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Tyler W Barrett
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Elizabeth S Compton
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Bradley M Dennis
- Vanderbilt University School of Medicine, Nashville, TN, United States; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Michael S Norris
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Mayur B Patel
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States; Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States; Surgical Services, Geriatric Research Education and Clinical Centers, Tennessee Valley Healthcare System, United States Department of Veterans Affairs, Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt Brain Institute, United States
| | - Jacob P Schwarz
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | - Nicholas R Thomason
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
| | - Reid C Thompson
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
| | - Oscar D Guillamondegui
- Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States; Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States.
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Vestlund S, Tryggmo S, Vedin T, Larsson PA, Edelhamre M. Comparison of the predictive value of two international guidelines for safe discharge of patients with mild traumatic brain injuries and associated intracranial pathology. Eur J Trauma Emerg Surg 2022; 48:4489-4497. [PMID: 34859266 PMCID: PMC9712145 DOI: 10.1007/s00068-021-01842-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine and compare the sensitivity, specificity, and proportion of patients eligible for discharge by the Brain Injury Guidelines and the Mild TBI Risk Score in patients with mild traumatic brain injury and concomitant intracranial injury. METHODS Retrospective review of the medical records of adult patients with traumatic intracranial injuries and an initial Glasgow Coma Scale score of 14-15, who sought care at Helsingborg Hospital between 2014/01/01 and 2019/12/31. Both guidelines were theoretically applied. The sensitivity, specificity, and percentage of the cohort that theoretically could have been discharged by either guideline were calculated. The outcome was defined as death, in-hospital intervention, admission to the intensive care unit, requiring emergency intubation due to intracranial injury, decreased consciousness, or seizure within 30 days of presentation. RESULTS Of the 538 patients included, 8 (1.5%) and 10 (1.9%) were eligible for discharge according to the Brain Injury Guidelines and the Mild TBI Risk Score, respectively. Both guidelines had a sensitivity of 100%. The Brain Injury Guidelines had a specificity of 2.3% and the Mild TBI Risk Score had a specificity of 2.9%. CONCLUSION There was no difference between the two guidelines in sensitivity, specificity, or proportion of the cohort eligible for discharge. Specificity and proportion of cohort eligible for discharge were lower than each guideline's original study. At present, neither guideline can be recommended for implementation in the current or similar settings.
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Affiliation(s)
- Sebastian Vestlund
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Sebastian Tryggmo
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Tomas Vedin
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | | | - Marcus Edelhamre
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Hanalioglu S, Hanalioglu D, Elbir C, Gulmez A, Sahin OS, Sahin B, Turkoglu ME, Kertmen HH. A Novel Decision-Support Tool (IniCT Score) for Repeat Head Computed Tomography in Pediatric Mild Traumatic Brain Injury. World Neurosurg 2022; 165:e102-e109. [PMID: 35654329 DOI: 10.1016/j.wneu.2022.05.103] [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: 01/22/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The necessity of computed tomography (CT) has been questioned in pediatric mild traumatic brain injury (mTBI) because of concerns related to radiation exposure. Distinguishing patients with lower and higher risk of clinically important TBI (ciTBI) is paramount to the optimal management of these patients. OBJECTIVE This study aimed to analyze the imaging predictors of ciTBI and develop an algorithm to identify patients at low and high risk for ciTBI to inform clinical decision making using a large single-center cohort of pediatric patients with mTBI. METHODS We retrospectively identified pediatric patients with mTBI with repeat CT within 48 hours of injury using an institutional database. RESULTS Among 3867 pediatric patients, 219 patients with mTBI with repeat CT were included. Thirty-eight had ciTBI (17%), 16 (7%) required intensive care unit admission, and 6 (3%) underwent surgery. Median time interval between initial and repeat CT was 7 hours (range, 4-10). Clinical worsening and radiologic progression were evident in 36 (16%) and 24 (11%) patients, respectively. Multivariate analysis showed that 5 pathologic findings (depressed skull fracture, pneumocephalus, epidural hematoma, subdural hematoma, and contusion) on initial CT and radiologic progression on repeat CT were independent predictors of ciTBI. A new scoring system based on these 5 factors on initial CT (IniCT [Initial CT scoring system] score) had excellent discrimination for ciTBI, need for intensive care unit admission, and neurosurgery (area under the curve >0.8). CONCLUSIONS The IniCT scoring system can successfully differentiate low-risk and high-risk patients based on initial CT scan. Zero score can eliminate the need for a routine repeat CT, whereas scores ≥2 should prompt serial neurologic examinations and/or repeat CT depending on the clinical situation.
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Affiliation(s)
- Sahin Hanalioglu
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey; Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Damla Hanalioglu
- Division of Pediatric Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Cagri Elbir
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ahmet Gulmez
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Omer Selcuk Sahin
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Balkan Sahin
- Department of Neurosurgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Erhan Turkoglu
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Huseyin Hayri Kertmen
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Ward CL, Cohen RB, Olafson SN, Goetz AB, Leung P, Moran BJ, Strain JJ, Parsikia A, Kaplan MJ. Impact of Repeat Head Computed Tomography on Mild Traumatic Brain Injury Patients With Abbreviated Injury Score 1-2 Injuries. Am Surg 2022; 88:1946-1953. [PMID: 35225007 DOI: 10.1177/00031348221075763] [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: 11/17/2022]
Abstract
BACKGROUND Patients presenting with traumatic intracranial hemorrhage (ICH) routinely undergo repeat head Computed Tomography (CT) scans with the goal of identifying progressing hemorrhage early and providing timely intervention. Glasgow Coma Scale (GCS) score and Abbreviated Injury Score (AIS) are typically used to grade the severity of traumatic brain injury (TBI) and triage subsequent management. However, most patients receive a repeat head CT scan within 6 hours of the initial insult, regardless of these clinical scores. We investigated the yield of a repeat CT scan for mild blunt TBI (GCS 13-15, AIS 1-2). METHODS This was a single-center retrospective chart review at a level 1 trauma center between 2009 and 2019. Our primary outcome was medical or surgical intervention directly resulted from change in CT head findings. We used multivariate regression to identify predictors of surgical and medical intervention. RESULTS 234 mild TBI patients met inclusion criteria. 33.7% of all patients had worsening ICH. 7.7% of patients required a surgical intervention, and 27.4% received a medical intervention. Multivariate analysis found that a decline in GCS (OR 8.64), and polytrauma (Injury Severity Score >15; OR 3.32) predicted surgical intervention. Worsening ICH did not predict surgical or medical intervention. Patients requiring medical intervention were more likely to have a decline in GCS (OR 2.53, P = .02) and be older (age >65, OR 2.06, P = .02). CONCLUSION In the population of blunt traumatic injury, worsening ICH did not predict surgical or medical intervention. Routine repeat imaging for this population is low yield, and clinical exam should guide the decision to reimage.
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Affiliation(s)
- Candace L Ward
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
| | - Ryan B Cohen
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
| | - Samantha N Olafson
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
| | | | - Pak Leung
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
| | - Benjamin J Moran
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
| | - Jay J Strain
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
| | - Afshin Parsikia
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
| | - Mark J Kaplan
- Department of Trauma and Critical Care, 6528Einstein Healthcare Network, Philadelphia, PA, USA
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Krueger EM, DiGiorgio AM, Jagid J, Cordeiro JG, Farhat H. Current Trends in Mild Traumatic Brain Injury. Cureus 2021; 13:e18434. [PMID: 34737902 PMCID: PMC8559421 DOI: 10.7759/cureus.18434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/02/2021] [Indexed: 12/12/2022] Open
Abstract
In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed.
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Affiliation(s)
- Evan M Krueger
- Neurological Surgery, Carle Foundation Hospital, Urbana, USA
| | - Anthony M DiGiorgio
- Neurological Surgery, University of California San Francisco, San Francisco, USA
| | - Jonathan Jagid
- Neurological Surgery, University of Miami, Coral Gables, USA
| | | | - Hamad Farhat
- Neurological Surgery, Advocate Aurora Health Care, Downers Grove, USA
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