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Borazjani R, Ajdari MR, Niakan A, Yousefi O, Amoozandeh A, Sayadi M, Khalili H. Current Status and Outcomes of Critical Traumatic Brain Injury (GCS = 3-5) in a Developing Country: A Retrospective, Registry-Based Study. World J Surg 2022; 46:2335-2343. [PMID: 35789431 DOI: 10.1007/s00268-022-06645-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients sustaining critical TBI [initial Glasgow Coma Scale (GCS) ≤ 5] generally have poor outcomes. Little is known about the frequency, mortality rate, and functional outcomes of such patients in Iran. METHODS In this retrospective, registry-based cohort study, the demographic and clinicoradiological findings of TBI patients were queried from March 21, 2017, to March 21, 2020. We included TBI patients with initial GCS of 3-5. The functional outcome was assessed using the Glasgow Outcome Score-extended 6 (GOSE-6) months after the hospital discharge. Patients were classified as having unfavorable (GOSE-6 ≤ 4) and favorable (GOSE-6 > 4) outcomes. Gathered data were compared between groups. Multivariable logistic regression analysis was done to find factors affecting the outcome. RESULTS Four hundred ninety-seven patients (mean age = 37.59 ± 17.89) were enrolled, and 69.2% had unfavorable outcomes. Elderly patients (age ≥ 65 years) were highly overrepresented among the unfavorable group. 48.9% had bilateral fixed dilated pupils (BDFP), who mostly attained unfavorable outcomes. The overall in-hospital mortality rate was 50.3%. The in-hospital mortality rate was appalling among elderly patients with BFDP and GCS 3( 90%) and GCS 4(100%). Age ≥ 65 years [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.19-10.04], and BFDP (OR 4.48, 95% CI 2.60-7.73) increase the odds of unfavorable outcomes according to the regression analysis. CONCLUSION The survival rate and favorable outcomes of critical TBI patients are generally poor. However, we believe that the neurotrauma surgeons should discuss with patients' proxies and explain the clinical conditions and possible outcomes.
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Affiliation(s)
- Roham Borazjani
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Reza Ajdari
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Department of Neurosurgery, Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Chamran Blvd, Shiraz, 7194815711, Iran
| | - Omid Yousefi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arsham Amoozandeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Department of Biostatistics, Cardiovascular Research Center,, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hosseinali Khalili
- Department of Neurosurgery, Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Chamran Blvd, Shiraz, 7194815711, Iran.
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Salottolo K, Carrick M, Stewart Levy A, Morgan BC, Slone DS, Bar-Or D. The epidemiology, prognosis, and trends of severe traumatic brain injury with presenting Glasgow Coma Scale of 3. J Crit Care 2016; 38:197-201. [PMID: 27940095 DOI: 10.1016/j.jcrc.2016.11.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/08/2016] [Accepted: 11/23/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To characterize trends and prognosis of severe traumatic brain injury (TBI). METHODS This 5-year multicenter retrospective study included patients with TBI and Glasgow Coma Scale of 3. We analyzed demographic and clinical characteristics and mortality using Pearson χ2 tests, Cochran-Armitage trend tests, and stepwise logistic regression. Analyses were stratified by vehicular and fall etiologies; other etiologies were excluded (24%). RESULTS Included were 481 patients. Fall-related injuries increased 58% (P=.001) but vehicular etiology did not change (P=.63). The characteristics of the populations changed over time; with falls, the population became older and increasingly presented with normal vital signs, whereas with vehicular etiology, the population became younger, with more alcohol-related injury (P<.05 for all). Mortality from falls increased substantially from 25% to 63% (P<.001), whereas death from vehicular injures remained statistically unchanged but with a downward trend (50%-38%, P=.28). Predictors of mortality included injury severity and age at least 65 years for both groups. Additional variables that were prognostic were abnormal vital signs and subdural hematoma for vehicular injuries, and sex for fall injuries. CONCLUSIONS The epidemiology of severe TBI is changing. These epidemiologic data may be used for management and resource decisions, monitoring, and directing injury prevention measures.
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Affiliation(s)
- Kristin Salottolo
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113; Department of Trauma Research, St Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228; Department of Trauma Research, Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO 80907.
| | - Matthew Carrick
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075; Trauma Services Department, Medical Center of Plano, 3901 W 15th St, Plano, TX 75075.
| | - A Stewart Levy
- Intermountain Neurosurgery, 11700 W. 2nd Place, Lakewood, CO 80228; Trauma Services Department, St Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228.
| | - Brent C Morgan
- Trauma Services Department, Medical Center of Plano, 3901 W 15th St, Plano, TX 75075.
| | - Denetta S Slone
- Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113; Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113.
| | - David Bar-Or
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113; Department of Trauma Research, St Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228; Department of Trauma Research, Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO 80907.
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Abstract
The "brain death" standard as a criterion of death is closely associated with the need for transplantable organs from heart-beating donors. Are all of these potential donors really dead, or does the documented evidence of patients destined for organ harvesting who improve, or even recover to live normal lives, call into question the premise underlying "brain death"? The aim of this paper is to re-examine the notion of "brain death," especially its clinical test-criteria, in light of a broad framework, including medical knowledge in the field of neuro-intensive care and the traditional ethics of the medical profession. I will argue that both the empirical medical evidence and the ethics of the doctor-patient relationship point to an alternative approach toward the severely comatose patient (potential brain-dead donor). Lay Summary: Though legally accepted and widely practiced, the "brain death" standard for the determination of death has remained a controversial issue, especially in view of the occurrence of "chronic brain death" survivors. This paper critically re-evaluates the clinical test-criteria for "brain death," taking into account what is known about the neuro-critical care of severe brain injury. The medical evidence, together with the understanding of the moral role of the physician toward the patient present before him or her, indicate that an alternative approach should be offered to the deeply comatose patient.
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Affiliation(s)
- Doyen Nguyen
- Pontifical University of St. Thomas Aquinas, Rome, Italy
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4
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Salottolo K, Carrick M, Levy AS, Morgan BC, Mains CW, Slone DS, Bar-Or D. Aggressive operative neurosurgical management in patients with extra-axial mass lesion and Glasgow Coma Scale of 3 is associated with survival benefit: A propensity matched analysis. Injury 2016; 47:70-6. [PMID: 26499227 DOI: 10.1016/j.injury.2015.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/01/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI). METHODS We conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications. RESULTS There were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6-10.5) p<0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99-6.3, p=0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7-3.4), p=0.30). CONCLUSIONS Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive.
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Affiliation(s)
- Kristin Salottolo
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States.
| | - Matthew Carrick
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States.
| | - A Stewart Levy
- Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Intermountain Neurosurgery, 11700 W. 2nd Place, Lakewood, CO 80228, United States.
| | - Brent C Morgan
- Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States.
| | - Charles W Mains
- Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States.
| | - Denetta S Slone
- Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States.
| | - David Bar-Or
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States.
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Dang Q, Simon J, Catino J, Puente I, Habib F, Zucker L, Bukur M. More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes. J Surg Res 2015; 198:482-8. [PMID: 25972315 DOI: 10.1016/j.jss.2015.03.092] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/16/2015] [Accepted: 03/27/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND In an expanding elderly population, traumatic brain injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI, according to the Brain Trauma Foundation (BTF), include intracranial pressure (ICP) monitoring. Whether ICP monitoring contributes to outcomes in the elderly patients with TBI has not been explored. METHODS This is a retrospective study extracted from the National Trauma Database 2007-2008 research datasets. Patients were included if aged >55 y and they met BTF indications for ICP monitoring. Patients that had nonsurvivable injuries (any body region, abbreviated injury score = 6), were dead on arrival, had withdrawal of care, or length of stay <48 h were excluded. Outcomes were then stratified based on ICP monitoring. The primary outcomes were inhospital mortality and favorable discharge. Logistic regression was used to analyze the effect of ICP monitoring on outcomes. RESULTS A total of 4437 patients were included with 11.2% having an ICP monitor placed. Patients requiring an ICP monitor were younger overall, more likely to present hypertensive, had higher injury severity, and more likely to require operative intervention. Median initial Glasgow coma scale (3) was similar between groups. Of those patients with ICP monitoring, overall mortality was significantly higher, and they were less likely to have favorable discharge status. Craniotomy itself was not associated with increased mortality (P = 0.450). CONCLUSIONS Our findings suggest that the use of ICP monitoring according to BTF guidelines in elderly TBI patients does not provide outcomes superior to treatment without monitoring. The ideal group to benefit from ICP monitor placement remains to be elucidated.
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Affiliation(s)
- Quoc Dang
- Department of Surgery, Larkin Community Hospital, South Miami, Florida; Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida.
| | - Joshua Simon
- Department of Surgery, Larkin Community Hospital, South Miami, Florida; Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Joe Catino
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
| | - Fahim Habib
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
| | - Lloyd Zucker
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Marko Bukur
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
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