Association of Central Nervous System-Affecting Medications With Occurrence and Short-Term Mortality of Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

The use of medications commonly prescribed after traumatic brain injury (TBI) has been little studied before TBI. This study examined the association between the use of medications that affect the central nervous system (CNS) and the occurrence and short-term mortality of TBI.

METHODS

Mandatory Finnish registries were used to identify TBI admissions, fatal TBIs, and drug purchases during 2005-2018. Patients with TBI were 1:1 matched to nontrauma control patients to investigate the association between medications and the occurrence of TBI and 30-day mortality after TBI. Number needed to harm (NNH) was calculated for all medications.

RESULTS

The cohort included 59 606 patients with TBI and a similar number of control patients. CNS-affecting drugs were more common in patients with TBI than in controls [odds ratio = 2.07 (2.02-2.13), P < .001)]. Benzodiazepines were the most common type of medications in patients with TBI (17%) and in controls (11%). The lowest NNH for the occurrence of TBI was associated with benzodiazepines (15.4), selective serotonin uptake inhibitors (18.5), and second-generation antipsychotics (25.8). Eight percent of the patients with TBI died within 30 days. The highest hazard ratios (HR) and lowest NNHs associated with short-term mortality were observed with strong opioids [HR = 1.41 (1.26-1.59), NNH = 33.1], second-generation antipsychotics [HR = 1.36 (1.23-1.50), NNH = 37.1], and atypical antidepressants [HR = 1.17 (1.04-1.31), NNH = 77.7].

CONCLUSION

Thirty-seven percent of patients with TBI used at least 1 CNS-affecting drug. This proportion was significantly higher than in the control population (24%). The highest risk and lowest NNH for short-term mortality were observed with strong opioids, second-generation antipsychotics, and atypical antidepressants. The current risks underscore the importance of weighing the benefits and risks before prescribing CNS-affecting drugs in patients at risk of head injury.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS)

BACKGROUND

The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies.

METHODS

A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted.

RESULTS

A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak).

CONCLUSIONS

This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Preliminary Evaluation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries with Glial Fibrillary Acidic Protein

Glial fibrillary acidic protein (GFAP) has become the most promising biomarker for detecting traumatic abnormalities on head computed tomography (CT) in patients with traumatic brain injury (TBI), but most studies have not addressed the potential added value of combining the biomarker with clinical variables that confer risk for intracranial injuries. The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults were the first clinical decision rules in the field with an incorporated biomarker, the S100 astroglial calcium-binding protein B (S100B), which is used in the Mild (Low Risk) group defined by the guidelines. Our aim was to evaluate the performance of the guidelines when S100B was substituted with GFAP. The sample (N = 296) was recruited from the Tampere University Hospital's emergency department between November 2015 and November 2016, and there were 49 patients with available GFAP results who were stratified in the Mild (Low Risk) group (thus patients undergoing biomarker triaging). A previously reported cutoff of plasma GFAP ≥140 pg/mL was used. Within the Mild (Low Risk) group (n = 49), GFAP sensitivity (with 95% confidence intervals in parentheses) for detecting traumatic CT abnormalities was 1.0 (0.40-1.00), specificity 0.34 (0.19-0.53), the negative predictive value (NPV) 1.0 (0.68-1.00), and the positive predictive value (PPV) 0.16 (0.05-0.37). The sensitivity and specificity of the modified guidelines with GFAP, when applied to all imaged patients (n = 197) in the whole sample, were 0.94 (0.77-0.99) and 0.20 (0.15-0.28), respectively. NPV was 0.94 (0.80-0.99) and PPV 0.18 (0.13-0.25). In the Mild (Low Risk) group, none of the patients with GFAP results below 140 pg/mL had traumatic abnormalities on their head CT. These findings were derived from a small patient subgroup. Future researchers should replicate these findings in larger samples and assess whether GFAP has added or comparable value to S100B in acute TBI management.

Causes of fatal traumatic brain injury in Finland

OBJECTIVE

The phenotype of patients who suffer fatal traumatic brain injury (TBI) is poorly characterized. The authors examined the external causes, contributing diseases, and preinjury medication in adult patients with fatal TBI in a nationwide Finnish cohort.

METHODS

Deaths caused by TBIs in Finland were examined among decedents aged ≥ 16 years during 2005-2020 from the national Cause of Death Registry. Usage of prescription medications prior to TBI was studied using medication purchase data from the Social Insurance Institution of Finland.

RESULTS

The cohort consisted of 71,488,347 person-years, 821,259 total deaths, and 14,630 TBI-related deaths during 2005-2020, of which 67% (n = 9792) occurred in men. Women were older than men among those who suffered TBI-related death (mean age 77.2 ± 17.1 vs 64.5 ± 19.5 years, p < 0.0001). The overall crude incidence rate of fatal TBIs was 20.5/100,000 person-years (28.1/100,000 in men and 13.2/100,000 in women). TBI was the cause of death in 1.8% of all deaths in the Finnish population during the study years, but in patients aged 16-19 years, TBIs caused more than 17% of all deaths. The most common external cause of fatal TBI was a fall (70%), followed by poisoning or toxic effects (20%) and violence or self-harm (15%) overall. In men, the order of the most common causes of fatal TBI was similar to overall results (64%, 25%, and 19%, respectively), while in women, the most common cause was a fall (82%), followed by complications in healthcare (10%) and poisoning or toxic effects (9%). Cardiovascular diseases, psychiatric diseases, and infections were the most common diseases contributing to death. Blood pressure (lowering) medications were the most common type of medications used before fatal TBI. CNS medications were the second most common medication group. In the context of fatal TBI in Europe, Finland remains at the upper end of fatal TBI incidence.

CONCLUSIONS

TBI is a common cause of death in young adults, whereas the incidence of fatal TBI becomes increasingly higher with age in Finland. Cardiovascular diseases and psychiatric conditions were the most common diseases related to death, with opposite age trends. Healthcare facility complications were an alarmingly common cause of death in women with fatal TBI.

Increasing incidence of pediatric mild traumatic brain injury in Finland - a nationwide register study from 1998 to 2018

AIM

The purpose of this study is to document the annual incidence and incidence trends of pediatric traumatic brain injury (pTBI) in Finland over the course of 21 years.

METHODS

We conducted a retrospective nationwide register-based cohort study and used the Finnish Care Register and Population information statistics from 1998 to 2018. The patient group includes all patients aged <18 at the time of injury. We included all emergency department (ED) visits and subsequent inpatient admissions (meaning at least one night in the hospital) with International Classification of Diseases diagnostic code S06*. We calculated pTBI incidences per 100,000 person-years with 95% confidence intervals and the incidences were compared by incidence rate ratios (IRR), including age, diagnosis, and gender stratified analyses.

RESULTS

A total of 71,972 patients were included with 76,785 ED visits or hospitalizations for pTBI diagnoses. The annual incidence of diagnosed pTBI was 251 (CI: 241-260) per 100,000 in 1998 and 547 (CI: 533-561) per 100,000 in 2018, indicating a 118% increase in the incidence (IRR 2.18 CI: 2.09-2.28). Boys had 32% higher incidence (IRR 1.32 CI: 1.30-1.34) than girls. The highest cumulative incidence was observed among boys aged <1 years, 525 (CI: 507-543) per 100,000, and boys had higher incidences in all age groups. The most used diagnostic code was concussion, which included 92.1% of the diagnoses followed by diffuse brain injury, which included 2.3% of the diagnoses. The increase in the incidence of diagnosed pTBI was notably high after 2010. Concussion diagnoses and pTBI cases that were discharged directly from the ED had more than a two-fold increase from 2010 to 2018, whereas the incidence of inpatient admissions for pTBI increased by 53%.

CONCLUSIONS

The overall incidence of diagnosed pTBI has increased in Finland especially since 2010. Boys have higher incidence of diagnosed pTBI in all age groups. Most of the increase was due to increase in the concussion diagnoses, which may be due to the centralization of EDs into bigger units and increased diagnostic awareness of mild pTBI.

Risk for intracranial hemorrhage in individuals after mild traumatic brain injury who are taking serotonergic antidepressants

Background

Serotonergic antidepressants may predispose to bleeding, but little is known of the risk for traumatic intracranial bleeding.

Methods

This was a prospective case-control study of 218 patients with mild traumatic brain injuries (TBI) who were treated at a Finnish tertiary trauma hospital. Injury-related information and clinical findings were prospectively collected in the emergency department. Detailed pre-injury health history was collected from electronic medical records. Information on the use of serotonergic antidepressants was attained from the Finnish national prescription registry. All head CT scans were reviewed by a neuroradiologist based on the Common Data Elements. Cases were patients with traumatic intracranial hemorrhage on head CT. Controls were patients from the same cohort, but without traumatic intracranial lesions on CT. The proportion with traumatic intracranial bleeding for patients on serotonergic antidepressant medication was compared to the proportion for patients not on serotonergic medication.

Results

The study cohort consisted of 24 cases with traumatic intracranial bleeding and 194 injured controls. The median age of the sample was 70 years (interquartile range = 50-83). One fifth (21.6%) of all the patients were taking a serotonergic antidepressant. Of the patients on an antidepressant, 10.6% (5/47) had an acute hemorrhagic lesion compared to 11.1% (19/171) of those who were not on an antidepressant (p = 0.927). In the regression analysis, traumatic intracranial hemorrhage was not associated with antidepressant use.

Conclusion

Serotonergic antidepressant use was not associated with an increased risk of traumatic intracranial hemorrhage after a mild TBI. The patients in this relatively small cohort were mostly middle-aged and older adults. These factors limit the generalizability of the results in younger patients with mild TBI.

Examining four blood biomarkers for the detection of acute intracranial abnormalities following mild traumatic brain injury in older adults

Blood-based biomarkers have been increasingly studied for diagnostic and prognostic purposes in patients with mild traumatic brain injury (MTBI). Biomarker levels in blood have been shown to vary throughout age groups. Our aim was to study four blood biomarkers, glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neurofilament light (NF-L), and total tau (t-tau), in older adult patients with MTBI. The study sample was collected in the emergency department in Tampere University Hospital, Finland, between November 2015 and November 2016. All consecutive adult patients with head injury were eligible for inclusion. Serum samples were collected from the enrolled patients, which were frozen and later sent for biomarker analyses. Patients aged 60 years or older with MTBI, head computed tomography (CT) imaging, and available biomarker levels were eligible for this study. A total of 83 patients (mean age = 79.0, SD = 9.58, range = 60-100; 41.0% men) were included in the analysis. GFAP was the only biomarker to show statistically significant differentiation between patients with and without acute head CT abnormalities [U₍₈₃₎ = 280, p < 0.001, r = 0.44; area under the curve (AUC) = 0.79, 95% CI = 0.67-0.91]. The median UCH-L1 values were modestly greater in the abnormal head CT group vs. normal head CT group [U ₍₈₃₎ = 492, p = 0.065, r = 0.20; AUC = 0.63, 95% CI = 0.49-0.77]. Older age was associated with biomarker levels in the normal head CT group, with the most prominent age associations being with NF-L (r = 0.56) and GFAP (r = 0.54). The results support the use of GFAP in detecting abnormal head CT findings in older adults with MTBIs. However, small sample sizes run the risk for producing non-replicable findings that may not generalize to the population and do not translate well to clinical use. Further studies should consider the potential effect of age on biomarker levels when establishing clinical cut-off values for detecting head CT abnormalities.

Effect of Oral Anticoagulation and Adenosine Diphosphate Inhibitor Therapies on Short-term Outcome of Traumatic Brain Injury

OBJECTIVE

Usage of oral anticoagulants (OAC) or adenosine diphosphate inhibitors (ADPi) is known to increase the risk of bleeding. We aimed to investigate the impact of OAC and ADPi therapies on short-term outcomes after traumatic brain injury (TBI).

METHODS

All adult patients hospitalized for TBI in Finland during 2005-2018 were retrospectively studied using a combination of national registries. Usage of pharmacy-purchased OACs and ADPis at the time of TBI was analyzed with the pill-counting method (Social Insurance Institution of Finland). The primary outcome was 30-day case-fatality (Finnish Cause of Death Registry). The secondary outcomes were acute neurosurgical operation (ANO) and admission duration (Finnish Care Register for Health Care). Baseline characteristics were adjusted with multivariable regression including age, sex, comorbidities, skull or facial fracture, OAC/ADPi treatment, initial admission location, and the year of TBI admission.

RESULTS

The study population included 57,056 persons (mean age 66 years) of whom 0.9% used direct oral anticoagulants (DOAC), 7.1% Vitamin K antagonists (VKA), and 2.3% ADPis. Patients with VKAs had higher case-fatality than patients without OAC (15.4% vs. 7.1%; adjHR 1.35, CI 1.23-1.48; p<0.0001). Case-fatality was lower with DOACs (8.4%) than with VKAs (adjHR 0.62, CI 0.44-0.87; p=0.005) and was not different from patients without OACs (adjHR 0.93, CI 0.69-1.26; p=0.634). VKA usage was associated with higher neurosurgical operation rate compared to non-OAC patients (9.1% vs. 8.3%; adjOR 1.33, CI 1.17-1.52; p<0.0001). There was no difference in operation rate between DOAC and VKA. ADPi was not associated with case-fatality or operation rate in the adjusted analyses. VKAs and DOACs were not associated with longer admission length compared with the non-OAC group, whereas the admissions were longer in the ADPi group compared with the non-ADPi group.

CONCLUSION

Preinjury use of VKA is associated with increases in short-term mortality and in need for ANOs after TBI. DOACs are associated with lower fatality than VKAs after TBI. ADPis were not independently associated with the outcomes studied. These results point to relative safety of DOACs or ADPis in patients at risk of head trauma and encourage to choose DOACs when oral anticoagulation is required.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that among adults with TBI, mortality was significantly increased in those using VKAs but not in those using DOACs or ADPis.

Prognosis of patients with operated chronic subdural hematoma

Chronic subdural hematoma (cSDH), previously considered fairly benign and easy to treat, is now viewed a possible sign of incipient clinical decline. We investigated case-fatality, excess fatality and need for reoperations following operated cSDH in a nationwide setting focusing on patient-related characteristics. Finnish nationwide databases were searched for all admissions with operated cSDH as well as later deaths in adults (≥ 16 years) during 2004–2017. There were 8539 patients with an evacuated cSDH (68% men) with a mean age of 73.0 (± 12.8) years. During the follow-up, 3805 (45%) patients died. In-hospital case-fatality was 0.7% (n = 60) and 30-day case-fatality 4.2% (n = 358). The 1-year case-fatality was 14.3% (95% CI = 13.4–15.2%) among men and 15.3% (95% CI = 14.0–16.7%) among women. Comorbidity burden, older age, and alcoholism were significantly associated with fatality. One-year excess fatality rate compared to general Finnish population was 9.1% (95% CI = 8.4–9.9) among men and 10.3% (95% CI = 9.1–11.4) among women. Highest excess fatality was observed in the oldest age group in both genders. Reoperation was needed in 19.4% (n = 1588) of patients. Older age but not comorbidity burden or other patient-related characteristics were associated with increased risk for reoperation. The overall case-fatality and need for reoperations declined during the study era. Comorbidities should be considered when care and follow-up are planned in patients with cSDH. Our findings underpin the perception that the disease is more dangerous than previously thought and causes mortality in all exposed age groups: even a minor burden of comorbidities can be fatal in the post-operative period.

Changing epidemiology of traumatic brain injury among the working-aged in Finland: Admissions and neurosurgical operations

BACKGROUND

Recent studies from Finland have highlighted an increase in the incidence of traumatic brain injuries (TBI) in older age groups and high overall mortality. We performed a comprehensive study on the changing epidemiology of TBI focusing on the acute events in the Finnish working-age population.

METHODS

Nationwide databases were searched for all emergency ward admissions with a TBI diagnosis for persons of 16-69 years of age during 2004-2018.

RESULTS

In the Finnish working-age population, there were 52,487,099 person-years, 38,810 TBI-related hospital admissions, 4664 acute neurosurgical operations (ANO), and 2247 cases of in-hospital mortality (IHM). The TBI-related hospital admission incidence was 94/100,000 person-years in men, 44/100,000 in women, and 69/100,000 overall. The incidence rate of admissions increased in women, while in men and overall, the rate decreased. The incidence rate increased in the group of 60-69 years in both genders. Lowest incidence rates were observed in the age group of 30-39 years. Occurrence risk for TBI admission was higher in men in all age groups. Trends of ANOs decreased overall, while decompressive craniectomy was the only operation type in which a rise in incidence was found. Evacuation of acute subdural hematoma was the most common ANO. Mean length of stay and IHM rate halved during the study years.

CONCLUSIONS

In Finland, the epidemiology of acute working-aged TBI has significantly changed. The rates of admission incidences, ANOs, and IHM nowadays represent the lower end of the range of these acute events reported in the western world.

Craniotomies following acute traumatic brain injury in Finland-a national study between 1997 and 2018

Background

A number of patients who sustain a traumatic brain injury (TBI) require surgical intervention due to acute intracranial bleeding. The aim of this retrospective study was to assess the national trends of acute craniotomies following TBI in the Finnish adult population.

Methods

The data were collected retrospectively from the Finnish Care Register for Health Care (1997–2018). The study cohort covered all first-time registered craniotomies following TBI in patients aged 18 years or older. A total of 7627 patients (median age = 59 years, men = 72%) were identified.

Results

The total annual incidence of acute trauma craniotomies decreased by 33%, from 8.6/100,000 in 1997 to 5.7/100,000 in 2018. The decrease was seen in both genders and all age groups, as well as all operation subgroups (subdural hematoma, SDH; epidural hematoma, EDH; intracerebral hematoma, ICH). The greatest incidence rate of 15.4/100,000 was found in patients 70 years or older requiring an acute trauma craniotomy. The majority of surgeries were due to an acute SDH and the patients were more often men. The difference between genders decreased with age (18–39 years = 84% men, 40–69 = 78% men, 70 + years = 55% men). The median age of the patients increased from 58 to 65 years during the 22-year study period.

Conclusions

The number of trauma craniotomies is gradually decreasing; nonetheless, the incidence of TBI-related craniotomies remains high among geriatric patients. Further studies are needed to determine the indications and derive evidence-based guidelines for the neurosurgical care of older adults with TBIs to meet the challenges of the growing elderly population.

Serotonergic Antidepressants and Risk for Traumatic Intracranial Bleeding

Background: Serotonergic antidepressants may predispose to bleeding but the effect on traumatic intracranial bleeding is unknown. Methods: The rate of intracranial bleeding in patients with antidepressant medication was compared to patients not antidepressants in a cohort of patients with acute head injury. This association was examined by using a consecutive cohort of head trauma patients from a Finnish tertiary center emergency department (Tampere University Hospital, Tampere, Finland). All consecutive (2010-2012) adult patients (n = 2,890; median age = 58; male = 56%, CT-positive = 22%, antithrombotic medication users = 25%, antidepressant users = 10%) who underwent head CT due to head trauma in the emergency department were included. Results: Male gender, GCS <15, older age, and anticoagulation were associated with an increased risk for traumatic intracranial bleeding. There were 17.8% of patients not taking antidepressants and 18.3% of patients on an antidepressant who had traumatic intracranial bleeding (p = 0.830). Among patients who were taking antithrombotic medication, 16.6% of the patients not taking antidepressant medication, and 22.5% of the patients taking antidepressant medication, had bleeding (p = 0.239). In a regression analysis, traumatic intracranial hemorrhage was not associated with antidepressant use. Conclusions: Serotonergic antidepressant use was not associated with an increased risk of traumatic intracranial hemorrhage.

Reliability of the freehand region-of-interest method in quantitative cerebral diffusion tensor imaging

Background

Diffusion tensor imaging (DTI) is a magnetic resonance imaging (MRI) technique used for evaluating changes in the white matter in brain parenchyma. The reliability of quantitative DTI analysis is influenced by several factors, such as the imaging protocol, pre-processing and post-processing methods, and selected diffusion parameters. The region-of-interest (ROI) method is most widely used of the post-processing methods because it is found in commercial software. The focus of our research was to study the reliability of the freehand ROI method using various intra- and inter-observer analyses.

Methods

This study included 40 neurologically healthy participants who underwent diffusion MRI of the brain with a 3 T scanner. The measurements were performed at nine different anatomical locations using a freehand ROI method. The data extracted from the ROIs included the regional mean values, intra- and inter-observer variability and reliability. The used DTI parameters were fractional anisotropy (FA), the apparent diffusion coefficient (ADC), and axial (AD) and radial (RD) diffusivity.

Results

The average intra-class correlation coefficient (ICC) of the intra-observer was found to be 0.9 (excellent). The single ICC results were excellent (> 0.8) or adequate (> 0.69) in eight out of the nine regions in terms of FA and ADC. The most reliable results were found in the frontobasal regions. Significant differences between age groups were also found in the frontobasal regions. Specifically, the FA and AD values were significantly higher and the RD values lower in the youngest age group (18–30 years) compared to the other age groups.

Conclusions

The quantitative freehand ROI method can be considered highly reliable for the average ICC and mostly adequate for the single ICC. The freehand method is suitable for research work with a well-experienced observer. Measurements should be performed at least twice in the same region to ensure that the results are sufficiently reliable. In our study, reliability was slightly undermined by artifacts in some regions such as the cerebral peduncle and centrum semiovale. From a clinical point of view, the results are most reliable in adults under the age of 30, when age-related changes in brain white matter have not yet occurred.

Preexisting conditions in older adults with mild traumatic brain injuries

OBJECTIVE

This study examined the prevalence of preexisting conditions that could affect premorbid brain health, cognition, and functional independence among older adults with mild traumatic brain injury (MTBI), and the relationship between preexisting conditions, injury characteristics, and emergency department (ED) discharge location (home versus continued care).

METHODS

Older adults (N = 1,427; 55-104 years-old; 47.4% men) who underwent head computed tomography (CT) after acute head trauma were recruited from the ED. Researchers documented preexisting medical conditions retrospectively from hospital records.

RESULTS

Multiple preexisting conditions increased in frequency with greater age, including circulatory and nervous system diseases and preexisting abnormalities on head CT. Psychiatric and substance use disorders (SUDs) decreased in frequency with greater age. Among participants with uncomplicated MTBI and GCS = 15, preexisting nervous system diseases and preexisting CT abnormalities were associated with higher odds of continued care for all participants, whereas psychiatric disorders and SUDs were only associated with higher odds of continued care among participants <70 years-old. Preexisting circulatory diseases, loss of consciousness, and amnesia were unassociated with discharge location.

CONCLUSIONS

Preexisting medical conditions that could affect brain and cognitive health occur commonly among older adults who sustain MTBIs. These conditions can confound research examining post-injury outcomes within this age group.

Mortality After Trauma Craniotomy Is Decreasing in Older Adults-A Nationwide Population-Based Study

OBJECTIVE

No evidence-based guidelines are available for operative neurosurgical treatment of older patients with traumatic brain injuries (TBIs), and no population-based results of current practice have been reported. The objective of the present study was to investigate the rates of trauma craniotomy operations and later mortality in older adults with TBI in Finland.

METHODS

Nationwide databases were searched for all admissions with a TBI diagnosis and after trauma craniotomy, and later deaths for persons aged ≥60 years from 2004 to 2018.

RESULTS

The study period included 2166 patients (64% men; mean age, 70.3 years) who had undergone TBI-related craniotomy. The incidence rate of operations decreased with a concomitant decrease in adjusted mortality (30-day mortality, P < 0.001; 1-year mortality, P < 0.001) and increase in mean patient age (R² = 0.005; P < 0.001) during the study period. The cumulative mortality was 25% at 30 days and 38% at 1 year. The comorbidities increasing the hazard for 30-day mortality were diabetes, a history of malignancy, peripheral vascular disease, and a history of myocardial infarction. For 1-year mortality, the comorbidities were heart failure and a history of myocardial infarction. Evacuation of an epidural hematoma decreased the hazard for mortality. In contrast, evacuation of an intracerebral hematoma and decompressive craniectomy increased the risk at both 30 days and 1 year.

CONCLUSIONS

Among older adults in Finland, the rate of trauma craniotomy and later mortality has been decreasing although the mean age of operated patients has been increasing. This can be expected to be related to an improved understanding of geriatric TBIs and, consequently, improved selection of patients for targeted therapy.

High-Risk Periods for Adult Traumatic Brain Injuries: A Nationwide Population-Based Study

INTRODUCTION

There is minimal existing available information on nationwide seasonal peaks in traumatic brain injuries (TBIs). This lack of information is an impediment to the effective development of prevention programs, societal policies, and hinders the resourcing of medical emergency services. Our current aim is to study nationwide population-based high-risk periods TBI over a 15-year study period in Finland.

METHODS

Nationwide databases were searched for all admissions with a TBI diagnosis and later for deaths of persons ≥16 years of age during 2004-2018. The search included all hospitals that provide acute TBI care in Finland.

RESULTS

The study period included 69,231 TBI-related hospital admissions (men = 62%). We found that for men, the highest rate of TBIs occurred on Saturdays, whereas women experience the highest rate of TBIs on Mondays. The highest rate of TBIs in men occurred in July, while women experienced the highest rate of TBIs in January. TBI-related hospital admissions (incidence risk ratio [IRR] 1.090, 95% CI 1.07-1.11, p < 0.0001) and mortality within 30 days after TBI (hazard ratio [HR] 1.057, 95% CI 1.001-1.116, p = 0.0455) were more common on public holidays and weekends than on weekdays. There was an increasing trend in the proportion of TBI-related hospital admissions occurring on public holidays and weekends from 2004 (31.5%) to 2018 (33.4%) (p = 0.0007). In summer months, TBI-related hospital admissions (IRR 1.10, 95% CI 1.08-1.12, p < 0.0001) and 30-day mortality (HR 1.069, 95% CI 1.010-1.131, p = 0.0211) were more common than in other months. TBIs occurred more often in younger and healthier individuals on these index days and times. In terms of specific public holidays, the TBI risk was overall higher on New Year's Eves and Days (IRR 1.40, 95% CI 1.25-1.58, p < 0.0001) and Midsummer's Eves and Days (IRR 1.36, 95% CI 1.20-1.54, p < 0.0001), compared to nonworking days. This finding was significant in both genders.

CONCLUSIONS

TBI-related hospital admissions and mortality were more common on public holidays, weekends, and in summer months in Finland. People who sustained TBIs on these days were on average younger and healthier. The occurrence of TBIs on public holidays and weekends is increasing at an alarming rate.

Epidemiology of traumatic spinal cord injury in Finland

Study design

Prospective cohort study.

Objectives

To determine the incidence and evaluate the characteristics of newly injured patients admitted to two spinal cord injury (SCI) centers during a 4-year period.

Setting

Oulu and Tampere University Hospital, Finland.

Methods

A dedicated multidisciplinary team evaluated all of the patients with new traumatic SCI (TSCI). The data were recorded according to the International Spinal Cord Injury Core Data Sets.

Results

In a 4-year period, 346 new patients with TSCI were admitted to the study centers. In the Oulu and Tampere University Hospitals’ catchment areas, the mean annual incidence of TSCI was 36.6 per million. The leading causes of injury were low-level falls (36.2%), high-level falls (25.5%), and transport-related accidents (19.2%). In the patients >60 years, 72.6% were injured by falling and the proportion of low-level falls was 49.7%. In the patients ≤60 years old, 47.4% were alcohol-related. The proportion of cervical injuries in the patients >60 years was 77.1%, while in the patients ≤60 years the proportion was 59.6%. The incidence of TSCI was higher during the Summer and Autumn months.

Conclusion

The mean annual incidence of TSCI was 36.6 per million corresponding to 200 new annual cases in Finland. Incomplete tetraplegia due to falling among elderly was overrepresented in the study population. Alcohol-consumption preceded injury in nearly half of the cases in the younger population. The prevention should focus on alcohol-related injuries and falls in the elderly.

Admission Levels of Interleukin 10 and Amyloid β 1-40 Improve the Outcome Prediction Performance of the Helsinki Computed Tomography Score in Traumatic Brain Injury

Background: Blood biomarkers may enhance outcome prediction performance of head computed tomography scores in traumatic brain injury (TBI).

Objective: To investigate whether admission levels of eight different protein biomarkers can improve the outcome prediction performance of the Helsinki computed tomography score (HCTS) without clinical covariates in TBI.

Materials and methods: Eighty-two patients with computed tomography positive TBIs were included in this study. Plasma levels of β-amyloid isoforms 1–40 (Aβ40) and 1–42 (Aβ42), glial fibrillary acidic protein, heart fatty acid-binding protein, interleukin 10 (IL-10), neurofilament light, S100 calcium-binding protein B, and total tau were measured within 24 h from admission. The patients were divided into favorable (Glasgow Outcome Scale—Extended 5–8, n = 49) and unfavorable (Glasgow Outcome Scale—Extended 1–4, n = 33) groups. The outcome was assessed 6–12 months after injury. An optimal predictive panel was investigated with the sensitivity set at 90–100%.

Results: The HCTS alone yielded a sensitivity of 97.0% (95% CI: 90.9–100) and specificity of 22.4% (95% CI: 10.2–32.7) and partial area under the curve of the receiver operating characteristic of 2.5% (95% CI: 1.1–4.7), in discriminating patients with favorable and unfavorable outcomes. The threshold to detect a patient with unfavorable outcome was an HCTS > 1. The three best individually performing biomarkers in outcome prediction were Aβ40, Aβ42, and neurofilament light. The optimal panel included IL-10, Aβ40, and the HCTS reaching a partial area under the curve of the receiver operating characteristic of 3.4% (95% CI: 1.7–6.2) with a sensitivity of 90.9% (95% CI: 81.8–100) and specificity of 59.2% (95% CI: 40.8–69.4).

Conclusion: Admission plasma levels of IL-10 and Aβ40 significantly improve the prognostication ability of the HCTS after TBI.

Comparing Glial Fibrillary Acidic Protein (GFAP) in Serum and Plasma Following Mild Traumatic Brain Injury in Older Adults

Objective: Identification and validation of blood-based biomarkers for the diagnosis and prognosis of mild traumatic brain injury (mTBI) is of critical importance. There have been calls for more research on mTBI in older adults. We compared blood-based protein marker glial fibrillary acidic protein (GFAP) concentrations in serum and in plasma within the same cohort of older adults and assessed their ability to discriminate between individuals based on intracranial abnormalities and functional outcome following mTBI.

Methods: A sample of 121 older adults [≥50 years old with head computed tomography (CT), n = 92] seeking medical care for a head injury [Glasgow Coma Scale scores of 14 (n = 6; 5.0%) or 15 (n = 115; 95.0%)] were enrolled from the emergency department (ED). The mean time between injury and blood sampling was 3.4 h (SD = 2.1; range = 0.5–11.7). Serum GFAP concentration was measured first using the Human Neurology 4-Plex Assay, while plasma GFAP concentration was later measured using the GFAP Discovery Kit, both on an HD-1 Single molecule array (Simoa) instrument. Glasgow Outcome Scale-Extended was assessed 1 week after injury.

Results: Both serum and plasma GFAP levels were significantly higher in those with abnormal CT scans compared to those with normal head CT scans (plasma: U = 1,198, p < 0.001; serum: U = 1,253, p < 0.001). The ability to discriminate those with and without intracranial abnormalities was comparable between serum (AUC = 0.814) and plasma (AUC = 0.778). In the total sample, GFAP concentrations were considerably higher in plasma than in serum (Wilcoxon signed-rank test z = 0.42, p < 0.001, r = 0.42). Serum and plasma GFAP levels were highly correlated in the total sample and within all subgroups (Spearman's rho range: 0.826–0.907). Both serum and plasma GFAP levels were significantly higher in those with poor compared to good functional outcome (serum: U = 1,625, p = 0.002; plasma: U = 1,539, p = 0.013). Neither plasma (AUC = 0.653) nor serum (AUC = 0.690) GFAP were adequate predictors of functional outcome 1 week after injury.

Conclusions: Despite differences in concentration, serum and plasma GFAP levels were highly correlated and had similar discriminability between those with and without intracranial abnormalities on head CT following an mTBI. Neither serum nor plasma GFAP had adequate discriminability to identify patients who would have poor functional outcome.

Reliability of the Sport Concussion Assessment Tool 5 baseline testing: A 2-week test-retest study

OBJECTIVES

To examine short-term test-retest reliability of the Sport Concussion Assessment Tool 5 (SCAT5).

DESIGN

Longitudinal study.

METHODS

Sixty-two professional male ice hockey players (mean age=22.5, SD=3.2) completed a preseason baseline test twice over a two-week interval. Half of the players were tested by the same assessor on both testing sessions. Spearman's correlations (rs) were used to determine linear agreements, and Wilcoxon signed rank tests (sig r) were used to determine mean differences, between testing sessions.

RESULTS

Symptoms had high test-retest reliability (Score: rs=0.85, p<0.001, sig r p<0.001; Severity: rs=0.84, p<0.001, sig r p<0.001). The reliability coefficients for the SAC (rs=0.58, p<0.001, sig r: p=0.412), and mBESS (rs=0.40, p=0.001, sig r: p=0.607) were considerably lower than symptoms. More than half (52%) of the athletes reported at least one baseline symptom (Md=1, M=2.2, SD=3.3). The most commonly reported symptoms were fatigue or low energy and neck pain. The broad ranges of SAC total scores (range=28-45, Md=35, M=35.4, SD=4.2) and SAC test-retest change scores (range -7 to +11) were mostly due to variability on the memory performance, tested using 10-item word lists. The number of mBESS single leg stance errors (Md=1, Md 3.2, SD=4.0) was greater than Tandem stance errors (Md=0, Md=2.0, SD=3.6).

CONCLUSIONS

The two-week test-retest reliability of the SCAT5 baseline scores varied from moderate to high. However, there was considerable individual variability on the SAC and mBESS scores and most players have notable short-term fluctuation on performance even if uninjured. Recommendations for interpreting change on the SCAT5 are provided.

Chronic subdural hematoma-incidence, complications, and financial impact

OBJECTIVE

To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT).

METHODS

A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland).

RESULTS

The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia.

CONCLUSIONS

Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

A decade of geriatric traumatic brain injuries in Finland: population-based trends

BACKGROUND

we investigated trends of traumatic brain injury (TBI)-related hospitalisations, deaths, acute neurosurgical operations (ANO), and lengths of hospital stay (LOS) in patients aged ≥70 years in Finland using a population-based cohort.

METHODS

nationwide databases were searched for all admissions with a TBI diagnosis as well as later deaths for persons ≥70 years of age during 2004-2014.

RESULTS

the study period included 20,259 TBI-related hospitalisations (mean age = 80.7 years, men = 48.9%). The incidence of TBI-related hospitalisations was 283/100,000 person-years with an estimated overall annual increase of 2.9% (95% CI: 0.4-5.9%). There was an annual decrease of 2.2% in in-hospital mortality (IHM) in men (95% CI: 0.1-4.3%), with no change in women or overall. There was an annual decrease of 1.1% in odds for ANOs among hospitalised overall (95% CI: 0.1-2.1%) and of 1.4% in men (95% CI: 0.0-2.7%), while no change was observed in women. LOS decreased annually by 2.5% (95% CI: 2.1-2.9%). The incidence of TBI-related deaths was 70/100,000 person-years with an estimated annual increase of 1.6% in women (95% CI: 0.2-2.9%), but no change in men or overall. Mean ages of TBI-related admissions and deaths increased (P < 0.001).

INTERPRETATION

the incidence rate of geriatric TBI-related hospitalisations increased, especially in women, but LOS and the rate of ANOs among hospitalised decreased. The overall TBI-related mortality remained stable, and IHM decreased in men, while in women, the overall mortality increased and IHM remained stable. However, the overall incidence rates of TBI-related hospitalisations and deaths and the number of cases of IHM were still higher in men.

Finnish study of intraoperative irrigation versus drain alone after evacuation of chronic subdural haematoma (FINISH): a study protocol for a multicentre randomised controlled trial

INTRODUCTION

Chronic subdural haematomas (CSDHs) are one of the most common neurosurgical conditions. The goal of surgery is to alleviate symptoms and minimise the risk of symptomatic recurrences. In the past, reoperation rates as high as 20%-30% were described for CSDH recurrences. However, following the introduction of subdural drainage, reoperation rates dropped to approximately 10%. The standard surgical technique includes burr-hole craniostomy, followed by intraoperative irrigation and placement of subdural drainage. Yet, the role of intraoperative irrigation has not been established. If there is no difference in recurrence rates between intraoperative irrigation and no irrigation, CSDH surgery could be carried out faster and more safely by omitting the step of irrigation. The aim of this multicentre randomised controlled trial is to study whether no intraoperative irrigation and subdural drainage results in non-inferior outcome compared with intraoperative irrigation and subdural drainage following burr-hole craniostomy of CSDH.

METHODS AND ANALYSIS

This is a prospective, randomised, controlled, parallel group, non-inferiority multicentre trial comparing single burr-hole evacuation of CSDH with intraoperative irrigation and evacuation of CSDH without irrigation. In both groups, a passive subdural drain is used for 48 hours as a standard of treatment. The primary outcome is symptomatic CSDH recurrence requiring reoperation within 6 months. The predefined non-inferiority margin for the primary outcome is 7.5%. To achieve a 2.5% level of significance and 80% power, we will randomise 270 patients per group. Secondary outcomes include modified Rankin Scale, rate of mortality, duration of operation, length of hospital stay, adverse events and change in volume of CSDH.

ETHICS AND DISSEMINATION

The study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District (HUS/3035/2019 §238) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04203550.

Mild Chronic Traumatic Encephalopathy Neuropathology in People With No Known Participation in Contact Sports or History of Repetitive Neurotrauma

It has been asserted that chronic traumatic encephalopathy (CTE) pathology is only present in former athletes and others who have been exposed to repetitive concussions, subconcussive blows, or both. We hypothesized that CTE pathology would be present in men who had no known history of repetitive neurotrauma. Comprehensive medical record reviews and health surveys completed by a family member were available for the 8 men in this case series, none of whom had known exposure to repetitive neurotrauma but 2 of whom had a history of traumatic brain injury (TBI). Postmortem tissue was immunostained for hyperphosphorylated tau (p-tau) to assess for CTE pathology, Braak stage, and aging-related p-tau. The neuropathologist was blind to age, personal history, and clinical history. Six of the 8 cases (75%) showed p-tau in neurons, astrocytes, and cell processes around small blood vessels in an irregular pattern at the depths of the cortical sulci. The changes were focal and limited in terms of overall extent, and some of the cases had a clearer pattern of pathology and some could be considered equivocal. Two of the 8 cases had a history of TBI and one of them showed CTE pathology. Five of the 6 cases with no known history of neurotrauma appeared to meet consensus criteria for CTE. This study adds to the emerging literature indicating that CTE pathology is present in people not known to have experienced multiple concussions or subconcussive blows to the head.

The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population

OBJECTIVE

The aim of this study was to determine the population-based epidemiology of chronic subdural hematoma (CSDH) over a 26-year period.

METHODS

A retrospective study was conducted of all adult patients (≥ 18 years and residents of Pirkanmaa [Finland]) with a diagnosis of CSDH between 1990 and 2015. The cases were identified using ICD codes. Detailed data collection was performed using medical records and death certificates. All patients were monitored until death or the end of year 2017. The annual number of inhabitants in the Pirkanmaa region was obtained from Statistics Finland (Helsinki, Finland).

RESULTS

A total of 1168 patients with CSDH were identified from hospital records and death certificates; patients were considered as new-incidence cases if 2 years had elapsed following primary treatment and in cases involving a new contralateral CSDH. From 1990 to 2015, the overall incidence of CSDH doubled from 8.2 to 17.6/100,000/year. Among adults younger than 70 years, the incidence remained quite stable, whereas the incidence clearly increased among the ≥ 80-year-old population, from 46.9 to 129.5/100,000/year. The median age for a CSDH diagnosis increased from 73 to 79 years during the 26-year period. Head trauma was documented in 59% of cases. A ground-level fall was related to the CSDH in 31% of patients younger than 60 years and in 54% of those 80 years or older. The proportion of alcohol-related cases decreased toward the end of the study period (1990–1995: 16% and 2011–2015: 7%), because alcohol abuse was less frequent among the growing group of elderly patients. In contrast, the percentage of patients receiving anticoagulant or antiplatelet medication almost doubled toward 2015 (1990–1995, 27%; and 2011–2015, 49%). The patients’ neurological condition on admission, based on both Glasgow Coma Scale score (score < 13: 1990–1995, 18%; and 2011–2015, 7%; p < 0.001) and the modified Rankin Scale score (score 0–2: 1990–1995, 8%; and 2011–2015, 19%; p < 0.001), was better in recent years than in the early 1990s.

CONCLUSIONS

From 1990 to 2015, the incidence of CSDH has increased markedly. The incidence of CSDH among the population 80 years or older has nearly tripled since 1990. The use of anticoagulants has increased, but there has been no change regarding the ratio between a traumatic and a spontaneous CSDH etiology. As the world population becomes progressively older, the increasing incidence of CSDH will be a burden to patients and a future challenge for neurosurgical clinics.

Age, symptoms, and functional outcome after mild traumatic brain injury

OBJECTIVES

Previous older adult studies have examined outcome from moderate-to-severe traumatic brain injury (TBI), but fewer have focused on the effects of milder brain injuries. This study examined age-related differences in symptom reporting and whether symptoms are differentially related to functional outcome based on age.

MATERIALS & METHODS

Patients presenting with a head injury at the Tampere University Hospital emergency department (N = 325, aged 18-100) were evaluated at 1 week post injury on the Modified Rankin Scale and Rivermead Post Concussion Symptoms Questionnaire (RPQ).

RESULTS

A quarter of participants had missing RPQ data, with missingness associated with greater age and strongly associated with pre-existing functional impairment, dementia, and/or neurological conditions. Among participants with complete data, participants <65 years old endorsed headaches, noise/light sensitivity, irritability, and frustration/impatience at a greater frequency than participants ≥65 years old. However, no differences were found in the number of symptoms endorsed or the total symptom severity score. The correlations between the severity of symptoms and change in function were similar between the two age groups.

CONCLUSIONS

Older adults tended to report fewer symptoms, but symptoms had a roughly equivalent relationship with declines in functioning across age groups. A large percentage of older adults in this study had pre-injury dementia or neurological disease that contributed to missing data on the 1-week outcome measures. The results provide insight into the impact of mild spectrum TBI on older adults compared to younger patients.

Characterizing the type and location of intracranial abnormalities in mild traumatic brain injury

OBJECTIVEThe incidence of intracranial abnormalities after mild traumatic brain injury (TBI) varies widely across studies. This study describes the characteristics of intracranial abnormalities (acute/preexisting) in a large representative sample of head-injured patients who underwent CT imaging in an emergency department.METHODSCT scans were systematically analyzed/coded in the TBI Common Data Elements framework. Logistic regression modeling was used to quantify risk factors for traumatic intracranial abnormalities in patients with mild TBIs. This cohort included all patients who were treated at the emergency department of the Tampere University Hospital (between 2010 and 2012) and who had undergone head CT imaging after suffering a suspected TBI (n = 3023), including 2766 with mild TBI and a reference group with moderate to severe TBI.RESULTSThe most common traumatic lesions seen on CT scans obtained in patients with mild TBIs and those with moderate to severe TBIs were subdural hematomas, subarachnoid hemorrhages, and contusions. Every sixth patient (16.1%) with mild TBI had an intracranial lesion compared with 5 of 6 patients (85.6%) in the group with moderate to severe TBI. The distribution of different types of acute traumatic lesions was similar among mild and moderate/severe TBI groups. Preexisting brain lesions were a more common CT finding among patients with mild TBIs than those with moderate to severe TBIs. Having a past traumatic lesion was associated with increased risk for an acute traumatic lesion but neurodegenerative and ischemic lesions were not. A lower Glasgow Coma Scale score, male sex, older age, falls, and chronic alcohol abuse were associated with higher risk of acute intracranial lesion in patients with mild TBI.CONCLUSIONSThese findings underscore the heterogeneity of neuropathology associated with the mild TBI classification. Preexisting brain lesions are common in patients with mild TBI, and the incidence of preexisting lesions increases with age. Acute traumatic lesions are fairly common in patients with mild TBI; every sixth patient had a positive CT scan. Older adults (especially men) who fall represent a susceptible group for acute CT-positive TBI.

Violence-related traumatic brain injury

Objectives: The purpose of this study was to determine the unique characteristics of violence-related traumatic brain injuries (TBI). Methods: All consecutive patients who underwent head CT due to an acute head injury (n = 3023) at the Emergency Department of Tampere University Hospital (Aug 2010-Jul 2012) were included. A detailed retrospective data collection was conducted in relation to demographics, injury-related data, premorbid health, clinical characteristics, and neuroimaging findings. Results: Patients with violence-related TBIs (n = 222) were compared to patients who sustained a TBI by other mechanisms (n = 2801). Statistically significant differences were found on age, gender, prior circulatory system disease, prior mental or behavioral disorders, chronic alcohol abuse, regular substance abuse, regular medication, alcohol intoxication at the time of injury, narcotics intoxication at the time of injury, and acute traumatic lesion on head CT. The groups did not differ on clinical signs of TBI severity. Conclusions: Young adult males with premorbid mental health history and chronic alcohol abuse are most prone to sustain a TBI due to a violence-related incident. Incidents are often related to alcohol intoxication. However, violence was not consistently associated with more severe TBIs than other mechanisms of injury.

Serum Neurofilament Light Is Elevated Differentially in Older Adults with Uncomplicated Mild Traumatic Brain Injuries

Neurofilament light (NF-L) might have diagnostic and prognostic potential as a blood biomarker for mild traumatic brain injury (mTBI). However, elevated NF-L is associated with several neurological disorders associated with older age, which could confound its usefulness as a traumatic brain injury biomarker. We examined whether NF-L is elevated differentially following uncomplicated mTBI in older adults with pre-injury neurological disorders. In a case-control study, a sample of 118 adults (mean age = 62.3 years, standard deviation [SD] = 22.5, range = 18-100; 52.5% women) presenting to the emergency department (ED) with an uncomplicated mTBI were enrolled. All participants underwent head computed tomography in the ED and showed no macroscopic evidence of injury. The mean time between injury and blood sampling was 8.3 h (median [Md] = 3.5; SD = 13.5; interquartile range [IQR] = 1.9-6.0, range = 0.8-67.4, and 90% collected within 19 h). A sample of 40 orthopedically-injured trauma control subjects recruited from a second ED also were examined. Serum NF-L levels were measured and analyzed using Human Neurology 4-Plex A assay on a HD-1 Single Molecule Array (Simoa) instrument. A high correlation was found between age and NF-L levels in the total mTBI sample (r = 0.80), within the subgroups without pre-injury neurological diseases (r = 0.76) and with pre-injury neurological diseases (r = 0.68), and in the trauma control subjects (r = 0.76). Those with mTBIs and pre-injury neurological conditions had higher NF-L levels than those with no pre-injury neurological conditions (p < 0.001, Cohen's d = 1.01). Older age and pre-injury neurological diseases are associated with elevated serum NF-L levels in patients with head trauma and in orthopedically-injured control subjects.

Risk factors for laryngeal penetration-aspiration in patients with acute traumatic cervical spinal cord injury

BACKGROUND CONTEXT

Laryngeal penetration-aspiration, the entry of material into the airways, is considered the most severe subtype of dysphagia and is common among patients with acute cervical spinal cord injury (SCI).

PURPOSE

The aim of this study was to investigate risk factors for penetration-aspiration in patients with acute traumatic cervical spinal cord injury (TCSCI).

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

Thirty-seven patients with TCSCI were included in the study.

OUTCOME MEASURES

The highest Rosenbek penetration-aspiration scale (PAS; range 1-8) score of each patient was the primary outcome measure. The risk factors consisted of patient characteristics, demographics, and clinical signs observed during a clinical swallowing trial.

MATERIALS AND METHODS

A clinical swallowing trial and videofluoroscopic swallowing study (VFSS) was performed on all patients within 28 days post injury. For group comparisons, the patients were divided into two groups: (1) penetrator-aspirators (PAS score ≥3) and (2) non-penetrator-aspirators (PAS score ≤2).

RESULTS

Of the 37 patients, 83.8% were male. The mean age at the time of the injury was 61.2 years. Most patients had an incomplete TCSCI (78.4%) caused by a fall (75.7%). In the VFSS, 51.4% of the patients were penetrator-aspirators, and 71.4% had silent aspiration. The risk factors for predicting penetration-aspiration were (1) necessity of bronchoscopies, (2) lower level of anterior cervical operation, (3) coughing, throat clearing, choking related to swallowing, and (4) changes in voice quality related to swallowing. Binary logistic regression identified coughing, throat clearing, choking, and changes in voice quality related to swallowing as independent risk factors for penetration-aspiration.

CONCLUSIONS

The necessity of bronchoscopies, postinjury lower cervical spine anterior surgery, coughing, throat clearing, choking, and changes in voice quality related to swallowing was a markedrisk factor for aspiration and penetration following a cervical SCI. These factors and signs should be used to suspect injury-related pharyngeal dysfunction and to initiate preventive measures to avoid complications. The clinical swallowing evaluation is a relevant adjunct in the management of these patients and can improve the detection of penetration and aspiration.

Sport Concussion Assessment Tool: Interpreting day-of-injury scores in professional ice hockey players

OBJECTIVES

To characterize the clinical utility of Sport Concussion Assessment Tool 3 (SCAT3) baseline and normative reference values for the assessment of acute concussion; and to identify the sensitivity of each SCAT3 subcomponent to the acute effects of concussion.

DESIGN

Prospective cohort.

METHODS

The day-of-concussion SCAT3 results (n=27) of professional male ice hockey players (mean age=27, SD=4) were compared to athlete's individual baseline and to the league's normative reference values. Normative cutoffs corresponding to 10th percentile and natural distribution change cutoffs corresponding to 90th percentile cumulative frequency were considered uncommon.

RESULTS

The percentages of the players with uncommon day-of-injury performance, when post-injury scores were compared to individual baseline versus (vs.) normative values, were as follows: symptoms: 96% vs. 100% (post-injury score: M=12, Md=12, SD=4; severity M=26, Md=23, SD=13); Standardized Assessment of Concussion (SAC): 33% vs. 27% (post-injury M=25, Md=26, SD=3); modified-BESS (M-BESS): 46% vs. 46% (post-injury M=7, Md=5, SD=7); Tandem Gait: 18% vs. 31% (post-injury M=11, Md=12, SD=4); coordination: both 8%. The number and severity of post-injury symptoms were significantly greater, with extremely large effect sizes (Cohen's d=2.44-3.92), than normative values and individual baseline scores. The post-injury SAC score was significantly lower relative to both baseline (d=0.68) and normative values (d=0.88). The post-injury M-BESS performance was significantly worse when compared to both individual baseline (d=1.06) and league normative values (d=1.46). No significant day-of-injury Tandem Gait deficits were observed using either comparison method.

CONCLUSIONS

SCAT3 league normative values were as sensitive as individual baseline scores during day-of-injury assessments. Symptoms were the most sensitive post-concussion component of the SCAT3.

A Systematic Review of the Usefulness of Glial Fibrillary Acidic Protein for Predicting Acute Intracranial Lesions following Head Trauma

Background

The extensive use of computed tomography (CT) after acute head injury is costly and carries potential iatrogenic risk. This systematic review examined the usefulness of blood-based glial fibrillary acidic protein (GFAP) for predicting acute trauma-related CT-positive intracranial lesions following head trauma. The main objective was to summarize the current evidence on blood-based GFAP as a potential screening test for acute CT-positive intracranial lesions following head trauma.

Methods

We screened MEDLINE, EMBASE, PsychInfo, CINAHL, Web of Science, the Cochrane Database, Scopus, Clinical Trials, OpenGrey, ResearchGate, and the reference lists of eligible publications for original contributions published between January 1980 and January 2017. Eligibility criteria included: (i) population: human head and brain injuries of all severities and ages; (ii) intervention: blood-based GFAP measurement ≤24 h post-injury; and (iii) outcome: acute traumatic lesion on non-contrast head CT ≤24 h post-injury. Three authors completed the publication screening, data extraction, and quality assessment of eligible articles.

Results

The initial search identified 4,706 articles, with 51 eligible for subsequent full-text assessment. Twenty-seven articles were ultimately included. Twenty-four (89%) studies reported a positive association between GFAP level and acute trauma-related intracranial lesions on head CT. The area under the receiver operating characteristic curve for GFAP prediction of intracranial pathology ranged from 0.74 to 0.98 indicating good to excellent discrimination. GFAP seemed to discriminate mass lesions and diffuse injury, with mass lesions having significantly higher GFAP levels. There was considerable variability between the measured GFAP averages between studies and assays. No well-designed diagnostic studies with specific GFAP cutoff values predictive of acute traumatic intracranial lesions have been published.

Conclusion

Intracranial CT-positive trauma lesions were associated with elevated GFAP levels in the majority of studies. Methodological heterogeneity in GFAP assessments and the lack of well-designed diagnostic studies with commercially validated GFAP platforms hinder the level of evidence, and variability in levels of GFAP with no clearly established cutoff for abnormality limit the clinical usefulness of the biomarker. However, blood-based GFAP holds promise as a means of screening for acute traumatic CT-positive lesion following head trauma.

Traumatic cervical spinal cord injury: a prospective clinical study of laryngeal penetration and aspiration

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Dysphagia is a relatively common secondary complication in patients with traumatic cervical spinal cord injuries (TCSCI). The purpose of this study was to determine the incidence of aspiration and penetration in patients with acute TCSCI.

SETTING

Tampere University Hospital, Tampere, Finland.

METHODS

A total of 46 patients with TCSCI were evaluated with a videofluoroscopic swallowing study (VFSS). Rosenbek's penetration-aspiration scale (PAS) was used to classify the degree of penetration or aspiration. The medical records of each patient were systematically reviewed.

RESULTS

Of the 46 patients, 85% were male. The mean age at the time of the injury was 62.1 years. Most patients had an incomplete injury (78%), and most of them due to a fall (78%). In the VFSS 19 (41%) patients penetrated and 15 (33%) aspirated. Only 12 (26%) of the patients had a PAS score of 1 indicating that swallowed material did not enter the airway. Of the patients who aspirated, 73% had silent aspiration.

CONCLUSION

The incidence of penetration or aspiration according to VFSS is high in this cohort of patients with TCSCI. Therefore, the swallowing function of patients with acute TCSCI should be routinely evaluated before initiating oral feeding. VFSS is highly recommended, particularly to rule out the possibility of silent aspiration and to achieve information on safe nutrition consistency.

Recovery from Mild Traumatic Brain Injury in Previously Healthy Adults

This prospective longitudinal study reports recovery from mild traumatic brain injury (MTBI) across multiple domains in a carefully selected consecutive sample of 74 previously healthy adults. The patients with MTBI and 40 orthopedic controls (i.e., ankle injuries) completed assessments at 1, 6, and 12 months after injury. Outcome measures included cognition, post-concussion symptoms, depression, traumatic stress, quality of life, satisfaction with life, resilience, and return to work. Patients with MTBI reported more post-concussion symptoms and fatigue than the controls at the beginning of recovery, but by 6 months after injury, did not differ as a group from nonhead injury trauma controls on cognition, fatigue, or mental health, and by 12 months, their level of post-concussion symptoms and quality of life was similar to that of controls. Almost all (96%) patients with MTBI returned to work/normal activities (RTW) within the follow-up of 1 year. A subgroup of those with MTBIs and controls reported mild post-concussion-like symptoms at 1 year. A large percentage of the subgroup who had persistent symptoms had a modifiable psychological risk factor at 1 month (i.e., depression, traumatic stress, and/or low resilience), and at 6 months, they had greater post-concussion symptoms, fatigue, insomnia, traumatic stress, and depression, and worse quality of life. All of the control subjects who had mild post-concussion-like symptoms at 12 months also had a mental health problem (i.e., depression, traumatic stress, or both). This illustrates the importance of providing evidence-supported treatment and rehabilitation services early in the recovery period.

Who Gets Head Trauma or Recruited in Mild Traumatic Brain Injury Research?

Mild traumatic brain injury (mTBI) is a public health problem. Outcome from mTBI is heterogeneous in part due to pre-injury individual differences that typically are not well described or understood. Pre-injury health characteristics of all consecutive patients (n=3023) who underwent head computed tomography due to acute head trauma in the emergency department of Tampere University Hospital, Finland, between August 2010 and July 2012 were examined. Patients were screened to obtain a sample of working age adults with no pre-injury medical or mental health problems who had sustained a "pure" mTBI. Of all patients screened, 1990 (65.8%) fulfilled the mTBI criteria, 257 (8.5%) had a more severe TBI, and 776 (25.7%) had a head trauma without obvious signs of brain injury. Injury-related data and participant-related data (e.g., age, sex, diagnosed diseases, and medications) were collected from hospital records. The most common pre-injury diseases were circulatory (39.4%-43.2%), neurological (23.7%-25.2%), and psychiatric (25.8%-27.5%) disorders. Alcohol abuse was present in 18.4%-26.8%. The most common medications were for cardiovascular (33.1%-36.6%), central nervous system (21.4%-30.8%), and blood clotting and anemia indications (21.5%-22.6%). Of the screened patients, only 2.5% met all the enrollment criteria. Age, neurological conditions, and psychiatric problems were the most common reasons for exclusion. Most of the patients sustaining an mTBI have some pre-injury diseases or conditions that could affect clinical outcome. By excluding patients with pre-existing conditions, the patients with known risk factors for poor outcome remain poorly studied.

Possible confounding factors on cerebral diffusion tensor imaging measurements

BACKGROUND

Diffusion tensor imaging (DTI) is prone to numerous systemic confounding factors that should be acknowledged to avoid false conclusions.

PURPOSE

To investigate the possible effects of age, gender, smoking, alcohol consumption, and education on cerebral DTI parameters in a generally healthy homogenous sample with no neurological or psychiatric diseases.

MATERIAL AND METHODS

Forty (n = 40) subjects (mean age, 40.3 years; SD, 12.3) underwent brain DTI with 3 T magnetic resonance imaging (MRI). At enrolment, all the subjects were interviewed with respect to general health, education, history of smoking, and alcohol consumption. Studied DTI parameters included: (i) fractional anisotropy (FA); and (ii) apparent diffusion coefficient (ADC). Region-of-interest (ROI)-based measurements were estimated at 13 anatomical locations bilaterally on the axial images, except for the corpus callosum in which the ROIs were placed on the sagittal images. Circular ROI measurements were mainly used. Freehand ROI method was used with the forceps minor, uncinate fasciculus, and thalamus. Intra-observer variability and repeatability were assessed.

RESULTS

The most consistent finding was that aging decreased FA values in the frontal brain regions. Regarding the other confounding factors, the results were discontinuous and no concrete conclusions could be drawn from these findings. In general, intra-observer repeatability of the DTI measurement was considered relatively good.

CONCLUSION

Age should be noted as considerable confounding factors in ROI-based DTI analysis. More research on the effects of gender, smoking, alcohol consumption, and education is needed.

Necessity of monitoring after negative head CT in acute head injury

OBJECTIVE

The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT).

MATERIALS AND METHODS

This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010-July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n=2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication.

RESULTS

The majority (n=1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n=27) of these patients returned to ED within 72h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%.

CONCLUSION

In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.