Severe traumatic brain lesions in Sweden. Part I: Aspects of management in non-neurosurgical clinics

Management and Outcome of Traumatic Intracerebral Hemorrhage in 79 Infants and Children from a Single Level 1 Trauma Center

OBJECTIVE

Traumatic brain injury is a leading form of pediatric trauma and a frequent cause of mortality and acquired neurological impairment in children. The aim of this study was to present the severity and outcomes of traumatic intracerebral bleeding in children and adolescence.

METHODS

Seventy-nine infants and children with intracerebral bleedings were treated between 1992 and 2020 at a single level 1 trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. The Glasgow Outcome Scale was used to classify the outcome at hospital discharge and at follow-up visits. CT scans of the brain were classified according to the Rotterdam score.

RESULTS

In total, 41 (52%) patients with intracerebral bleedings were treated surgically, and 38 (48%) patients were treated conservatively; in 15% of the included patients, delayed surgery was necessary. Patients presenting multiple trauma (p < 0.04), higher ISS (p < 0.01), poor initial neurological status (p < 0.001) and a higher Rotterdamscore (p = 0.038) were significantly more often treated surgically. Eighty-three percent of patients were able to leave the hospital, and out of these patients, about 60% showed good recovery at the latest follow-up visit. Overall, 11 patients (14%) died.

CONCLUSION

The findings in this study verified intracerebral bleeding as a rare but serious condition. Patients presenting with multiple traumas, higher initial ISS, poor initial neurological status and a higher Rotterdamscore were more likely treated by surgery.

TRIAL REGISTRATION

(researchregistry 2686).

Prevalence of persistent vegetative state compared to recovery, disability, and death in subjects with severe traumatic brain injury: A meta-analysis

BACKGROUND

The persistent vegetative state has drawn considerable attention since it is the poorest result apart from mortality in subjects with severe traumatic brain injury. This meta-analysis was performed to evaluate its prevalence compared to recovery, disability, and death 6 months post severe traumatic brain injury.

METHODS

A systematic-literature search up to May 2020 was performed and 19 studies were detected with 10 368 subjects. They contained data about the subject's status 6 months post severe traumatic brain injury (recovery, disability, persistent vegetative state, and death). Odds ratio (OR) with 95% confidence intervals (CIs) was calculated comparing the prevalence of persistent vegetative state to that of recovery, disability, and death; 6 months post severe traumatic brain injury using the dichotomous method with a random- or fixed-effect model.

RESULTS

Significantly higher prevalence was found of recovery (OR, 0.08; 95% CI, 0.03-0.20, P < .001); disability (OR, 0.09; 95% CI, 0.06-0.15, P < .001); and death (OR, 0.07; 95% CI, 0.04-0.11, P < .001) compared to the prevalence of persistent vegetative state. The prevalence of persistent vegetative state was variable over time. Also, the prevalence of persistent vegetative states in developing countries was much higher than in developed countries.

CONCLUSIONS

However, persistent vegetative state is the poorest result apart from mortality in subjects with severe traumatic brain injury. Its prevalence is lower than the recovery, disability, and death even in developing counties with its lower healthcare services. The prevalence was variable over time and higher in developing countries. This relationship forces us to recommend improving healthcare services to the extent that a persistent vegetative state could be avoided as much as possible.

[Guidelines for the management of severe traumatic brain injury. Part 3. Surgical management of severe traumatic brain injury (Options)]

Traumatic brain injury (TBI) is one of the main causes of mortality and severe disability in young and middle age patients. Patients with severe TBI, who are in coma, are of particular concern. Adequate diagnosis of primary brain injuries and timely prevention and treatment of secondary injury mechanisms markedly affect the possibility of reducing mortality and severe disability. The present guidelines are based on the authors' experience in developing international and national recommendations for the diagnosis and treatment of mild TBI, penetrating gunshot wounds of the skull and brain, severe TBI, and severe consequences of brain injury, including a vegetative state. In addition, we used the materials of international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe TBI, which were published in recent years. The proposed recommendations for surgical treatment of severe TBI in adults are addressed primarily to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in treating these patients.

Vocational outcome 6-15 years after a traumatic brain injury

PRIMARY OBJECTIVE

To describe vocational outcome 6-15 years after a traumatic brain injury (TBI) among individuals who were productive by working or studying at the time of their TBI and determine the associations with variables related to the time of injury and at follow-up.

METHODS AND PROCEDURES

Thirty-four individuals with a mild TBI and 45 with a moderate-to-severe TBI were assessed on average 10 years post-injury. Logistic regression was used to determine the association between their current vocational situation and variables related to the time of injury (gender, age, injury severity and educational level) and at follow-up (time since injury, marital status and overall disability).

RESULTS

A total of 67% were productive at follow-up. Age at injury, injury severity and the degree of disability at follow-up were strongly associated with being productive. Younger individuals with milder TBI and less severe disability were significantly more likely to be fully productive. No significant associations were found between productivity and gender, education, time since injury or marital status.

CONCLUSIONS

This study indicates that return to productivity in a long-term perspective after a TBI is possible, in particular when the individual is young, has sustained a mild TBI and has a milder form of overall disability.

150 years of treating severe traumatic brain injury: a systematic review of progress in mortality

Considerable effort and resources have been devoted to preserving life in patients with severe closed traumatic brain injury (TBI). We sought to identify temporal trends in mortality rates of these patients from the late 1800s to the present. We searched the literature for articles on severe TBI, abstracting numbers of patients studied, numbers of deaths, and years of patient entry. Mortality rates were calculated for each study, and meta-regression was used to pool data and to test for significant temporal trends. We reviewed 207 case series comprising more than 140,000 cases of severe closed TBI admitted to hospital over a span of almost 150 years. Since the late 1800s mortality has fallen by almost 50%. However, the rate has varied considerably among the four epochs chosen. Between 1885 and 1930, mortality decreased at a rate of 3% per decade. From 1970 to 1990, mortality declined at a rate of 9% per decade. Both changes are significant. There was no observed improvement in mortality between 1930 and 1970, nor is progress evident since 1990. The authors discuss possible reasons for the apparently intermittent progress in TBI survival over time.

Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury

OBJECT

Despite being common practice for decades and being recommended by national guidelines, aggressive monitoring and treatment of patients with severe traumatic brain injury (TBI) have not been supported by convincing evidence.

METHODS

The authors reviewed trials and case series reported after 1970 in which patients were treated for severe closed TBI, and mortality rates and favorable outcomes at 6 months after injury were analyzed. The patient groups were divided into those with and without intracranial pressure (ICP) monitoring and intensive therapy, and the authors performed a meta-analysis to assess the effects of treatment intensity on outcome.

RESULTS

Although the mortality rate fell during the years reviewed, it was consistently approximately 12% lower among patients in the intense treatment group (p < 0.001). Favorable outcomes did not change significantly over time, and were 6% higher among the aggressively treated patients (p = 0.0105).

CONCLUSIONS

Aggressive ICP monitoring and treatment of patients with severe TBI is associated with a statistically significant improvement in outcome. This improvement occurs independently of temporal effects.

Demographics, injury characteristics and outcome of traumatic brain injuries in northern Sweden

OBJECTIVES - To describe demographics, injury characteristics and outcome of traumatic brain injury (TBI) in northern Sweden over 10 years. MATERIAL AND METHODS - Data were retrospectively collected on those individuals (n = 332) in Norrbotten, northern Sweden, with a TBI who had been transferred for neurosurgical care from 1992 to 2001. RESULTS - A majority were older men with a mild TBI and an acute or chronic subdural hematoma following a fall. Younger individuals were fewer but had more often a severe TBI from a traffic accident. Most individuals received post-acute care and brain injury rehabilitation. A majority had a moderate or severe disability, but many were discharged back home with no major changes in their physical or social environment. CONCLUSIONS - Our data confirm the relationship between age, cause of injury, injury severity and outcome in relation to TBI and underscore the need for prevention as well as the importance of TBI as a cause of long-term disability.

Critical care of neurotrauma

Traumatic brain injury often affects people in their most productive years, inflicting a significant burden on families and society. The advances in modern critical care have improved survival of patients; thus more patients live after traumatic brain injury, which raises an important issue about their neurologic outcome. At the present time, there are limited data regarding methods to optimize neurologic recovery. In this review, we try to bring information from different sources to show new approaches to achieve that goal. Some of the techniques employed are investigational and some are waiting to find broader application in intensive care units across the country.

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring

OBJECT

The early pathophysiological features of traumatic brain injury observed in the intensive care unit (ICU) have been described in terms of altered cerebral blood flow, altered brain metabolism, and neurochemical excitotoxicity. Seizures occur in animal models of brain injury and in human brain injury. Previous studies of posttraumatic seizures in humans have been based principally on clinical observations without a systematic approach to electroencephalographic (EEG) recording of seizures. The purpose of this study was to determine prospectively the incidence of convulsive and nonconvulsive seizures by using continuous EEG monitoring in patients in the ICU during the initial 14 days post-injury.

METHODS

Ninety-four patients with moderate-to-severe brain injuries underwent continuous EEG monitoring begin-ning at admission to the ICU (mean delay 9.6+/-5.4 hours) and extending up to 14 days postinjury. Convulsive and nonconvulsive seizures occurred in 21 (22%) of the 94 patients, with six of them displaying status epilepticus. In more than half of the patients (52%) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone. All six patients with status epilepticus died, compared with a mortality rate of 24% (18 of 73) in the nonseizure group (p<0.001). The patients with status epilepticus had a shorter mean length of stay (9.14+/-5.9 days compared with 14+/-9 days [t-test, p<0.031). Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room, with maintenance at mean levels of 16.6+/-2.8 mg/dl. No differences in key prognostic factors (such as the Glasgow Coma Scale score, early hypoxemia, early hypotension, or 1-month Glasgow Outcome Scale score) were found between the patients with seizures and those without.

CONCLUSIONS

Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury.

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring

Object

The early pathophysiological features of traumatic brain injury observed in the intensive care unit (ICU) have been described in terms of altered cerebral blood flow, altered brain metabolism, and neurochemical excitotoxicity. Seizures occur in animal models of brain injury and in human brain injury. Previous studies of posttraumatic seizures in humans have been based principally on clinical observations without a systematic approach to electroencephalographic (EEG) recording of seizures. The purpose of this study was to determine prospectively the incidence of convulsive and nonconvulsive seizures by using continuous EEG monitoring in patients in the ICU during the initial 14 days postinjury.

Methods

Ninety-four patients with moderate-to-severe brain injuries underwent continuous EEG monitoring beginning at admission to the ICU (mean delay 9.6 ± 5.4 hours) and extending up to 14 days postinjury. Convulsive and nonconvulsive seizures occurred in 21 (22%) of the 94 patients, with six of them displaying status epilepticus. In more than half of the patients (52%) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone. All six patients with status epilepticus died, compared with a mortality rate of 18 (24%) of 73 in the nonseizure group (p < 0.001). The patients with status epilepticus had a shorter mean length of stay (9.14 ± 5.9 days compared with 14 ± 9 days (t-test, p < 0.03). Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room, with maintenance at mean levels of 16.6 ± 2.8 mg/dl. No differences in key prognostic factors (such as the Glasgow Coma Scale score, early hypoxemia, early hypotension, or 1-month Glasgow Outcome Scale score) were found between the patients with seizures and those without.

Conclusions

Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury.

A porcine model for evaluation of cerebral haemodynamics and metabolism during increased intracranial pressure

In patients with severe head injuries raised intracranial pressure (ICP) constitutes the most important cause of mortality. Several new therapies for increased ICP have recently been suggested and it is of importance to study the physiological effects of these treatments in animal experiments during steady state conditions. A porcine model for evaluation of cerebral haemodynamics and metabolism during increased ICP is presented. Intracranial hypertension was induced by inflation of two tonometric gastric balloons placed extradurally covering a major part of the parietooccipital region bilaterally. The distribution of the blood flow supplied by the carotid artery used for the cerebral blood flow (CBF) measurements was studied by intraarterial (i.a.) injection of 99mTc-HMPAO. The measurements showed that following ligation of the external carotid and the occipital artery no accumulation of tracer substance occurred in extracranial tissues during normal or increased ICP. Cerebral physiological variables (CBF, Cavo2, and ICP) were measured 5, 20 and 60 min after induction of intracranial hypertension. The results confirm that the experimental situation gives a reproducible increase in ICP (25-28 mm Hg) and that the physiological variables remain stable during the period of intracranial hypertension. We conclude that the model simulates the effects of an acute intracranial focal mass and is well suited for the evaluation of different pharmacological therapies of increased ICP.

Re-examining the concept of severity in traumatic brain injury

This paper re-examines the theoretical concept of severe brain injury focusing on the duration of coma as a precise indicator of the clinical profile. A retrospective hospital chart study of 361 traumatic brain-injured patients was undertaken to determine the homogeneity of the subsample of the severely brain-injured (defined as 2 or more days of coma) with respect to the probability of four types of impairment: ataxia, contractures, paralysis and speech impairment. The current concept of severity assumes homogeneity among the 'severely brain-injured'. However, our results indicate significant differences in impairment within this population. The authors feel strongly that future studies must describe coma duration in finer gradations, and test for homogeneity within samples before inferences are made. Improvements in life-sustaining technologies have resulted in longer coma durations. The need to use coma days as an indicator of impairment rather than a broad category of severity is emphasized.

Economic aspects of capacity for work after severe traumatic brain lesions

During 1981-84,310 patients with severe traumatic brain lesions were treated at the Department of Neurosurgery in Lund, Sweden. A total of 161 patients were treated after the introduction of a more aggressive management protocol in 1983. In this first part of a long-term follow-up study we concentrate on the economic aspects. Two questions were addressed: first, what was the vocational outcome after severe head injuries? and second, what were the long-term effects of the new protocol? Out of 147 patients classified as good recovery/moderate disability (GR/MD) 6-months after injury, 106 patients agreed to participate in the study. Five to 8 years after injury 70 patients were classified as capable of working: 57 of these patients were actually at work, nine were studying and four were unemployed. Twenty-two patients had received disability pension and 14 patients had retired because of old age. In the age groups up to 60 years, 70% of patients had returned to work or school. The number of patients who returned to work was significantly higher after introduction of the more aggressive management protocol: 38 of 57 patients who had returned to work were in the group treated between 1983 and 1984. Mean income for patients who had returned to work was close to the average for the corresponding age groups in Sweden. Mean sick leave 5-8 years after severe head injuries was only slightly higher than average in Sweden. Our data show that a majority of the patients classified as GR/MD 6 months after severe traumatic brain lesions have the capacity to return to work. The improvements in the primary management of patients with severe head injuries introduced in 1983 increased the number of patients who work and thus increased the number of patients who favourably contributed to the economy of the community.

Psychosocial outcome 5-8 years after severe traumatic brain lesions and the impact of rehabilitation services

This study addresses three questions. First, what is the long-term psychosocial outcome for severely head-injured patients? Second, is an increased survival rate associated with an increase in the number of patients with a poor quality of life? Third, do rehabilitation services affect the final outcome? The long-term outcome was assessed by means of questionnaires for self-ratings, interviews with patients and relatives and neurophysical examinations. One hundred and six patients initially judged as good recovery/moderate disability (GR/MD) 6 months post-injury participated in the study. Forty to 50% of these patients showed co-ordination disturbances; more than 20% had speech disorders and cranial nerve deficits. Twenty-eight per cent had psychiatric symptom scores on the Hopkins Symptom Checklist (HSCL) indicating need of treatment. Social function according to the Social Adjustment Scale--Self-Report (SAS--SR) showed that 40% had problems concerning interpersonal relations and 20-30% had problems within the field of leisure activities, but few problems were reported on work activities and economy. The Comprehensive Psychopathological Rating Scale (CPRS) revealed that hostile feelings, failing memory and fatiguability were common symptoms and were reported by relatives in 71%, 52% and 48%, respectively, but the mean distress levels were moderate. A correlation was seen between quality of life reported by relatives and the degree of mental and social disability according to the Bond Outcome Scale, but the correlation to neurophysical handicap was rather weak. The majority of patients were able to return to a productive social life. The proportion of patients with a poor long-term outcome did not increase after introduction of an aggressive management protocol for head injuries. Data indicated that improvements in facilities for rehabilitation may positively affect psychosocial adjustment.

Statistical profile of traumatic brain injury: a Canadian rehabilitation population

A retrospective clinical hospital chart study was undertaken to prepare a statistical profile of traumatic brain-injured patients in rehabilitation. It included 498 consecutive admissions to the Traumatic Brain Injury Rehabilitation Program of the Queen Elizabeth Hospital (Toronto, Canada) from 1978 to 1991. Descriptive statistics were obtained for age, gender, marital status, educational status, occupational status, history of drug and alcohol use, cause of injury, month of injury and length of coma. Comparisons are made between the studied population and several Canadian centres, as well as international brain injury demographics in the literature. Results are discussed in terms of the gender differences and lifestyle parameters associated with brain injury.

Clinical outcome and cognitive impairment in patients with severe head injuries treated with barbiturate coma

This study reports on clinical outcome in 38 patients with severe head injuries (posttraumatic coma for 6 hours or more) treated with barbiturate coma because of intracranial hypertension. Eighteen patients died, 4 patients remained in a severely disabled or a chronic vegetative state, and 16 patients reached the levels good recovery/moderate disability. Six of these patients returned to work or school full time, 4 for half time and 3 were in a rehabilitation program. Fourteen patients were subjected to a comprehensive neuropsychological assessment. All patients except one exhibited varying degrees of cognitive dysfunction and 6 patients had signs of personality change. The quality of life for the majority of surviving patients was relatively good but the positive effects of barbiturate coma therapy in the age groups over 40 years appeared to be limited.

Complications and side effects during thiopentone therapy in patients with severe head injuries

This study reports all complications and side effects occurring in 38 patients with severe traumatic brain lesions treated with barbiturate coma because of a dangerous increase in intracranial pressure. The treatment was induced by intravenous infusion of thiopentone (5-11 mg.kg-1) followed by a continuous infusion of 4-8 mg.kg-1.h-1. The subsequent rate of thiopentone infusion was governed by the level of the intracranial pressure with the intention of keeping ICP below 20 mmHg (2.7 kPa). The duration of treatment was 1-15 days. Arterial hypotension occurred in 58%, hypokalemia in 82%, respiratory complications in 76%, infections in 55%, hepatic dysfunction in 87% and renal dysfunction in 47% of the patients. Twenty patients survived. Mortality in 17 patients was caused by an untreatable increase in intracranial pressure. In one patient complications due to barbiturate treatment may have contributed to the fatal outcome. In none of the other cases were the noted complications and side effects associated with any permanent symptoms or dysfunctions.

Extradural haemorrhage in infancy and childhood. A review of 35 years' experience in South Australia

One hundred and two paediatric cases of extradural haemorrhage (EDH) were treated in Adelaide, South Australia, during the period 1954-1988; 10 were infants (0-2 years) and 92 were children (2-14 years). There were 9 deaths (mortality 8.8%). Long-term disabilities severe enough to interfere with school and/or employment were seen in 8 (7.8%) survivors. This relatively low number of adverse outcomes is partly an expression of a low incidence (5.9%) of associated intradural haematomas and few high-velocity impacts due to vehicular accidents. There is reason to believe that the results of treatment have improved in the decade 1977-1988. We attribute this in part to early diagnosis by computed tomography (CT), but a contributory factor may be earlier referrals from country centres to a paediatric trauma centre and rapid transfer, by air or road, by medical retrieval teams.

Non-neurosurgical operative intervention in head-injured patients

Guidelines relating to non neurosurgical operative intervention in head-injured patients are not available for the British Isles. We present a series of seven patients with extradural haematoma operated upon in the referring hospital prior to transfer to our unit. The cases were analysed in an attempt to elucidate the efficacy of the emergency procedures and the associated problems. Recommendations are made in order to generate discussion on this aspect of head injury management.

Severe traumatic brain lesions in Sweden. Part 2: Impact of aggressive neurosurgical intensive care

During a 6 year period (1977-1982), 425 patients were treated in the Department of Neurosurgery, University Hospital of Lund, for severe traumatic brain lesions (coma greater than 6 hours). From 1983 a more aggressive management protocol was introduced including early recording of intracranial pressure (ICP) and 162 patients were included in the study 1983-1984. A dangerous increase in ICP in spite of adequate surgical treatment and moderately controlled hyperventilation was the incentive for barbiturate coma therapy in selected patients. In the first part of the study overall mortality was 48% whereas 39% of the patients reached good recovery/moderate disability 6 months after injury. During the second part of the study the corresponding figures were 35% and 54%, respectively (in both cases p less than or equal to 0.01). In the group of patients with focal intracranial mass lesions mortality decreased from 59% to 46% (p less than or equal to 0.05) and good recovery/moderate disability increased from 30% to 42% (p less than or equal to 0.05). Improvement in outcome was even more pronounced in patients with no-mass lesions, mortality decreased from 30% to 12% and good recovery/moderate disability increased from 56% to 80% (p less than or equal to 0.05 and p less than or equal to 0.01, respectively). No change occurred in age distribution or in the types of intracranial lesions that could explain these improvements. It is concluded that aggressive neurosurgical intensive care significantly improves outcome in patients with severe traumatic brain lesions.

Severe traumatic brain lesions in Sweden. Part 3: Economic aspects of aggressive neurosurgical intensive care

The present study had two main objectives: Firstly, to document the economic differences between 'ordinary' and 'aggressive' neurosurgical intensive care and secondly, to evaluate the medical benefits in relation to costs for different subgroups of head-injured patients. The study compares patients injured in traffic accidents and treated in the Department of Neurosurgery, University Hospital of Lund, during 1977-1978 (n = 67) with similar patients treated during 1983-1984 (n = 87) after introduction of more vigorous neurosurgical intensive care. The economic analysis was performed by means of the CRISE-method (Cost Related Index Score Evaluation) and all costs were related to the monetary value in 1984. Adoption of a program for 'aggressive' neurosurgical intensive care increased the costs per treated patient by about 46% (from 70.887 Swedish Crowns (SEK) to 103.452 SEK). Mortality decreased significantly after the change in intensive care and the cost per surviving patient remained virtually unaffected (131.928 SEK vs. 132.357 SEK). Further, after introduction of the 'aggressive' programme a larger proportion of the economic expenditures were spent on patients who ultimately recovered well. It is concluded that the increase in costs following introduction of a more vigorous intensive care programme in patients with severe traumatic brain lesions is very reasonable in relation to the documented medical benefits.