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Pisică D, Volovici V, Yue JK, van Essen TA, den Boogert HF, Vande Vyvere T, Haitsma I, Nieboer D, Markowitz AJ, Yuh EL, Steyerberg EW, Peul WC, Dirven CMF, Menon DK, Manley GT, Maas AIR, Lingsma HF. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Neurosurgery 2024:00006123-990000000-01172. [PMID: 38771081 DOI: 10.1227/neu.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Guideline recommendations for surgical management of traumatic epidural hematomas (EDHs) do not directly address EDHs that co-occur with other intracranial hematomas; the relative rates of isolated vs nonisolated EDHs and guideline adherence are unknown. We describe characteristics of a contemporary cohort of patients with EDHs and identify factors influencing acute surgery. METHODS This research was conducted within the longitudinal, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury cohort study which prospectively enrolled patients with traumatic brain injury from 65 hospitals in 18 European countries from 2014 to 2017. All patients with EDH on the first scan were included. We describe clinical, imaging, management, and outcome characteristics and assess associations between site and baseline characteristics and acute EDH surgery, using regression modeling. RESULTS In 461 patients with EDH, median age was 41 years (IQR 24-56), 76% were male, and median EDH volume was 5 cm3 (IQR 2-20). Concomitant acute subdural hematomas (ASDHs) and/or intraparenchymal hemorrhages were present in 328/461 patients (71%). Acute surgery was performed in 99/461 patients (21%), including 70/86 with EDH volume ≥30 cm3 (81%). Larger EDH volumes (odds ratio [OR] 1.19 [95% CI 1.14-1.24] per cm3 below 30 cm3), smaller ASDH volumes (OR 0.93 [95% CI 0.88-0.97] per cm3), and midline shift (OR 6.63 [95% CI 1.99-22.15]) were associated with acute surgery; between-site variation was observed (median OR 2.08 [95% CI 1.01-3.48]). Six-month Glasgow Outcome Scale-Extended scores ≥5 occurred in 289/389 patients (74%); 41/389 (11%) died. CONCLUSION Isolated EDHs are relatively infrequent, and two-thirds of patients harbor concomitant ASDHs and/or intraparenchymal hemorrhages. EDHs ≥30 cm3 are generally evacuated early, adhering to Brain Trauma Foundation guidelines. For heterogeneous intracranial pathology, surgical decision-making is related to clinical status and overall lesion burden. Further research should examine the optimal surgical management of EDH with concomitant lesions in traumatic brain injury, to inform updated guidelines.
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Affiliation(s)
- Dana Pisică
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Victor Volovici
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - John K Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Division of Neurosurgery, Department of Surgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hugo F den Boogert
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Amy J Markowitz
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center and Haaglanden Medical Center, Leiden and The Hague, the Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
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Vreeburg RJG, Singh RD, van Erp IAM, Korhonen TK, Yue JK, Mee H, Timofeev I, Kolias A, Helmy A, Depreitere B, Moojen WA, Younsi A, Hutchinson P, Manley GT, Steyerberg EW, de Ruiter GCW, Maas AIR, Peul WC, van Dijck JTJM, den Boogert HF, Posti JP, van Essen TA. Early versus delayed cranioplasty after decompressive craniectomy in traumatic brain injury: a multicenter observational study within CENTER-TBI and Net-QuRe. J Neurosurg 2024:1-13. [PMID: 38669706 DOI: 10.3171/2024.1.jns232172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/26/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE The aim of this study was to compare the outcomes of early (≤ 90 days) and delayed (> 90 days) cranioplasty following decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). METHODS The authors analyzed participants enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and the Neurotraumatology Quality Registry (Net-QuRe) studies who were diagnosed with TBI and underwent DC and subsequent cranioplasty. These prospective, multicenter, observational cohort studies included 5091 patients enrolled from 2014 to 2020. The effect of cranioplasty timing on functional outcome was evaluated with multivariable ordinal regression and with propensity score matching (PSM) in a sensitivity analysis of functional outcome (Glasgow Outcome Scale-Extended [GOSE] score) and quality of life (Quality of Life After Brain Injury [QOLIBRI] instrument) at 12 months following DC. RESULTS Among 173 eligible patients, 73 (42%) underwent early cranioplasty and 100 (58%) underwent delayed cranioplasty. In the ordinal logistic regression and PSM, similar 12-month GOSE scores were found between the two groups (adjusted odds ratio [aOR] 0.87, 95% CI 0.61-1.21 and 0.88, 95% CI 0.48-1.65, respectively). In the ordinal logistic regression, early cranioplasty was associated with a higher risk for hydrocephalus than that with delayed cranioplasty (aOR 4.0, 95% CI 1.2-16). Postdischarge seizure rates (early cranioplasty: aOR 1.73, 95% CI 0.7-4.7) and QOLIBRI scores (β -1.9, 95% CI -9.1 to 9.6) were similar between the two groups. CONCLUSIONS Functional outcome and quality of life were similar between early and delayed cranioplasty in patients who had undergone DC for TBI. Neurosurgeons may consider performing cranioplasty during the index admission (early) to simplify the patient's chain of care and prevent readmission for cranioplasty but should be vigilant for an increased possibility of hydrocephalus. Clinical trial registration nos.: CENTER-TBI, NCT02210221 (clinicaltrials.gov); Net-QuRe, NTR6003 (trialsearch.who.int) and NL5761 (onderzoekmetmensen.nl).
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Affiliation(s)
- Rick J G Vreeburg
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Ranjit D Singh
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Inge A M van Erp
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Tommi K Korhonen
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- 3Neurocenter, Department of Neurosurgery and Research Unit of Clinical Neuroscience, Neurosurgery, Oulu University Hospital and University of Oulu, Finland
| | - John K Yue
- 4Department of Neurosurgery, University of California, San Francisco, California
| | - Harry Mee
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ivan Timofeev
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Angelos Kolias
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Adel Helmy
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Bart Depreitere
- 5Department of Neurosurgery, University Hospital Leuven, Belgium
| | - Wouter A Moojen
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Alexander Younsi
- 6Department of Neurosurgery, University Hospital Heidelberg, Germany
| | - Peter Hutchinson
- 2Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Geoffrey T Manley
- 4Department of Neurosurgery, University of California, San Francisco, California
| | - Ewout W Steyerberg
- 7Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Godard C W de Ruiter
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Andrew I R Maas
- 8Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- 9Department of Translational Neuroscience, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Wilco C Peul
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Jeroen T J M van Dijck
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Hugo F den Boogert
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Jussi P Posti
- 10Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Finland; and
| | - Thomas A van Essen
- 1University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
- 11Department of Surgery, Division of Neurosurgey, QEII Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
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Vande Vyvere T, Pisică D, Wilms G, Claes L, Van Dyck P, Snoeckx A, van den Hauwe L, Pullens P, Verheyden J, Wintermark M, Dekeyzer S, Mac Donald CL, Maas AIR, Parizel PM. Imaging Findings in Acute Traumatic Brain Injury: a National Institute of Neurological Disorders and Stroke Common Data Element-Based Pictorial Review and Analysis of Over 4000 Admission Brain Computed Tomography Scans from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2024. [PMID: 38482818 DOI: 10.1089/neu.2023.0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
In 2010, the National Institute of Neurological Disorders and Stroke (NINDS) created a set of common data elements (CDEs) to help standardize the assessment and reporting of imaging findings in traumatic brain injury (TBI). However, as opposed to other standardized radiology reporting systems, a visual overview and data to support the proposed standardized lexicon are lacking. We used over 4000 admission computed tomography (CT) scans of patients with TBI from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study to develop an extensive pictorial overview of the NINDS TBI CDEs, with visual examples and background information on individual pathoanatomical lesion types, up to the level of supplemental and emerging information (e.g., location and estimated volumes). We documented the frequency of lesion occurrence, aiming to quantify the relative importance of different CDEs for characterizing TBI, and performed a critical appraisal of our experience with the intent to inform updating of the CDEs. In addition, we investigated the co-occurrence and clustering of lesion types and the distribution of six CT classification systems. The median age of the 4087 patients in our dataset was 50 years (interquartile range, 29-66; range, 0-96), including 238 patients under 18 years old (5.8%). Traumatic subarachnoid hemorrhage (45.3%), skull fractures (37.4%), contusions (31.3%), and acute subdural hematoma (28.9%) were the most frequently occurring CT findings in acute TBI. The ranking of these lesions was the same in patients with mild TBI (baseline Glasgow Coma Scale [GCS] score 13-15) compared with those with moderate-severe TBI (baseline GCS score 3-12), but the frequency of occurrence was up to three times higher in moderate-severe TBI. In most TBI patients with CT abnormalities, there was co-occurrence and clustering of different lesion types, with significant differences between mild and moderate-severe TBI patients. More specifically, lesion patterns were more complex in moderate-severe TBI patients, with more co-existing lesions and more frequent signs of mass effect. These patients also had higher and more heterogeneous CT score distributions, associated with worse predicted outcomes. The critical appraisal of the NINDS CDEs was highly positive, but revealed that full assessment can be time consuming, that some CDEs had very low frequencies, and identified a few redundancies and ambiguity in some definitions. Whilst primarily developed for research, implementation of CDE templates for use in clinical practice is advocated, but this will require development of an abbreviated version. In conclusion, with this study, we provide an educational resource for clinicians and researchers to help assess, characterize, and report the vast and complex spectrum of imaging findings in patients with TBI. Our data provides a comprehensive overview of the contemporary landscape of TBI imaging pathology in Europe, and the findings can serve as empirical evidence for updating the current NINDS radiologic CDEs to version 3.0.
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Affiliation(s)
- Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Dana Pisică
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Guido Wilms
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Lene Claes
- icometrix, Research and Development, Leuven, Belgium
| | - Pieter Van Dyck
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Annemiek Snoeckx
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Luc van den Hauwe
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
| | - Pim Pullens
- Department of Imaging, University Hospital Ghent; IBITech/MEDISIP, Engineering and Architecture, Ghent University; Ghent Institute for Functional and Metabolic Imaging, Ghent University, Belgium
| | - Jan Verheyden
- icometrix, Research and Development, Leuven, Belgium
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Center, Houston, Texas, USA
| | - Sven Dekeyzer
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Radiology, University Hospital Ghent, Belgium
| | - Christine L Mac Donald
- Department of Neurological Surgery, School of Medicine, Harborview Medical Center, Seattle, Washington, USA
- Department of Neurological Surgery, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Paul M Parizel
- Department of Radiology, Royal Perth Hospital (RPH) and University of Western Australia (UWA), Perth, Australia; Western Australia National Imaging Facility (WA NIF) node, Australia
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Bhattacharyay S, Beqiri E, Zuercher P, Wilson L, Steyerberg EW, Nelson DW, Maas AIR, Menon DK, Ercole A. Therapy Intensity Level Scale for Traumatic Brain Injury: Clinimetric Assessment on Neuro-Monitored Patients Across 52 European Intensive Care Units. J Neurotrauma 2024; 41:887-909. [PMID: 37795563 PMCID: PMC11005383 DOI: 10.1089/neu.2023.0377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified-through expert consensus-during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL(Basic)) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL(Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients (n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL(Basic) scores (TIL24 and TIL(Basic)24, respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL(Basic) scores by taking the first-week maximum (TILmax and TIL(Basic)max) and first-week median (TILmedian and TIL(Basic)median) of TIL24 and TIL(Basic)24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL(Basic)) and integrates the widest range of modern ICP treatments. TILmedian outperforms both TILmax and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TILmedian ≥ 7.5 and TILmax ≥ 14. The TIL24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL24 ≥ 9. The median scores of each TIL component therapy over increasing TIL24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL(Basic)max suffers from a strong statistical ceiling effect and only covers 17% (95% confidence interval [CI]: 16-18%) of the information in TILmax, TIL(Basic) should not be used instead of TIL for rating maximum treatment intensity. TIL(Basic)24 and TIL(Basic)median can be suitable replacements for TIL24 and TILmedian, respectively (with up to 33% [95% CI: 31-35%] information coverage) when full TIL assessment is infeasible. Accordingly, we derive numerical ranges for categorising TIL24 scores into TIL(Basic)24 scores. In conclusion, our results validate TIL across a spectrum of ICP management and monitoring approaches. TIL is a more sensitive surrogate for pathophysiology than ICP and thus can be considered an intermediate outcome after TBI.
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Affiliation(s)
- Shubhayu Bhattacharyay
- Division of Anaesthesia, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - David W. Nelson
- Department of Physiology and Pharmacology, Section for Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - David K. Menon
- Division of Anaesthesia, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Cambridge Center for Artificial Intelligence in Medicine, Cambridge, United Kingdom
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5
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Yue JK, Lee YM, Sun X, van Essen TA, Elguindy MM, Belton PJ, Pisică D, Mikolic A, Deng H, Kanter JH, McCrea MA, Bodien YG, Satris GG, Wong JC, Ambati VS, Grandhi R, Puccio AM, Mukherjee P, Valadka AB, Tarapore PE, Huang MC, DiGiorgio AM, Markowitz AJ, Yuh EL, Okonkwo DO, Steyerberg EW, Lingsma HF, Menon DK, Maas AIR, Jain S, Manley GT. Performance of the IMPACT and CRASH prognostic models for traumatic brain injury in a contemporary multicenter cohort: a TRACK-TBI study. J Neurosurg 2024:1-13. [PMID: 38489823 PMCID: PMC11010725 DOI: 10.3171/2023.11.jns231425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 11/16/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization After Significant Head Injury (CRASH) prognostic models for mortality and outcome after traumatic brain injury (TBI) were developed using data from 1984 to 2004. This study examined IMPACT and CRASH model performances in a contemporary cohort of US patients. METHODS The prospective 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years 2014-2018) enrolled subjects aged ≥ 17 years who presented to level I trauma centers and received head CT within 24 hours of TBI. Data were extracted from the subjects who met the model criteria (for IMPACT, Glasgow Coma Scale [GCS] score 3-12 with 6-month Glasgow Outcome Scale-Extended [GOSE] data [n = 441]; for CRASH, GCS score 3-14 with 2-week mortality data and 6-month GOSE data [n = 831]). Analyses were conducted in the overall cohort and stratified on the basis of TBI severity (severe/moderate/mild TBI defined as GCS score 3-8/9-12/13-14), age (17-64 years or ≥ 65 years), and the 5 top enrolling sites. Unfavorable outcome was defined as GOSE score 1-4. Original IMPACT and CRASH model coefficients were applied, and model performances were assessed by calibration (intercept [< 0 indicated overprediction; > 0 indicated underprediction] and slope) and discrimination (c-statistic). RESULTS Overall, the IMPACT models overpredicted mortality (intercept -0.79 [95% CI -1.05 to -0.53], slope 1.37 [1.05-1.69]) and acceptably predicted unfavorable outcome (intercept 0.07 [-0.14 to 0.29], slope 1.19 [0.96-1.42]), with good discrimination (c-statistics 0.84 and 0.83, respectively). The CRASH models overpredicted mortality (intercept -1.06 [-1.36 to -0.75], slope 0.96 [0.79-1.14]) and unfavorable outcome (intercept -0.60 [-0.78 to -0.41], slope 1.20 [1.03-1.37]), with good discrimination (c-statistics 0.92 and 0.88, respectively). IMPACT overpredicted mortality and acceptably predicted unfavorable outcome in the severe and moderate TBI subgroups, with good discrimination (c-statistic ≥ 0.81). CRASH overpredicted mortality in the severe and moderate TBI subgroups and acceptably predicted mortality in the mild TBI subgroup, with good discrimination (c-statistic ≥ 0.86); unfavorable outcome was overpredicted in the severe and mild TBI subgroups with adequate discrimination (c-statistic ≥ 0.78), whereas calibration was nonlinear in the moderate TBI subgroup. In subjects ≥ 65 years of age, the models performed variably (IMPACT-mortality, intercept 0.28, slope 0.68, and c-statistic 0.68; CRASH-unfavorable outcome, intercept -0.97, slope 1.32, and c-statistic 0.88; nonlinear calibration for IMPACT-unfavorable outcome and CRASH-mortality). Model performance differences were observed across the top enrolling sites for mortality and unfavorable outcome. CONCLUSIONS The IMPACT and CRASH models adequately discriminated mortality and unfavorable outcome. Observed overestimations of mortality and unfavorable outcome underscore the need to update prognostic models to incorporate contemporary changes in TBI management and case-mix. Investigations to elucidate the relationships between increased survival, outcome, treatment intensity, and site-specific practices will be relevant to improve models in specific TBI subpopulations (e.g., older adults), which may benefit from the inclusion of blood-based biomarkers, neuroimaging features, and treatment data.
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Affiliation(s)
- John K Yue
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Young M Lee
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Xiaoying Sun
- 3Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, California
| | - Thomas A van Essen
- 4University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, Leiden, The Hague, The Netherlands
| | - Mahmoud M Elguindy
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Patrick J Belton
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Dana Pisică
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ana Mikolic
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- 6Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hansen Deng
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John H Kanter
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael A McCrea
- 8Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yelena G Bodien
- 9Department of Neurological Surgery, University of Utah Health Center, Salt Lake City, Utah
- 10Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Gabriela G Satris
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Justin C Wong
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Vardhaan S Ambati
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Ramesh Grandhi
- 11Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Ava M Puccio
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pratik Mukherjee
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 12Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Alex B Valadka
- 13Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Phiroz E Tarapore
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael C Huang
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Anthony M DiGiorgio
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 14Institute of Health Policy Studies, University of California, San Francisco, California
| | - Amy J Markowitz
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Esther L Yuh
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 12Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - David O Okonkwo
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ewout W Steyerberg
- 15Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester F Lingsma
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David K Menon
- 16Division of Anesthesia, Department of Medicine, University of Cambridge, United Kingdom; and
| | - Andrew I R Maas
- 17Department of Neurological Surgery, Antwerp University Hospital and University of Antwerp, Belgium
| | - Sonia Jain
- 3Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, California
| | - Geoffrey T Manley
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
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6
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Picetti E, Demetriades AK, Catena F, Aarabi B, Abu-Zidan FM, Alves OL, Ansaloni L, Armonda RA, Badenes R, Bala M, Balogh ZJ, Barbanera A, Bertuccio A, Biffl WL, Bouzat P, Buki A, Castano-Leon AM, Cerasti D, Citerio G, Coccolini F, Coimbra R, Coniglio C, Costa F, De Iure F, Depreitere B, Fainardi E, Fehlings MJ, Gabrovsky N, Godoy DA, Gruen P, Gupta D, Hawryluk GWJ, Helbok R, Hossain I, Hutchinson PJ, Iaccarino C, Inaba K, Ivanov M, Kaprovoy S, Kirkpatrick AW, Klein S, Kolias A, Konovalov NA, Lagares A, Lippa L, Loza-Gomez A, Luoto TM, Maas AIR, Maciejczak A, Maier RV, Marklund N, Martin MJ, Melloni I, Mendoza-Lattes S, Meyfroidt G, Munari M, Napolitano LM, Okonkwo DO, Otomo Y, Papadopoulos MC, Petr O, Peul WC, Pudkrong AK, Qasim Z, Rasulo F, Reizinho C, Ringel F, Rizoli S, Rostami E, Rubiano AM, Russo E, Sarwal A, Schwab JM, Servadei F, Sharma D, Sharif S, Shiban E, Shutter L, Stahel PF, Taccone FS, Terpolilli NA, Thomé C, Toth P, Tsitsopoulos PP, Udy A, Vaccaro AR, Varon AJ, Vavilala MS, Younsi A, Zackova M, Zoerle T, Robba C. 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). World J Emerg Surg 2024; 19:4. [PMID: 38238783 PMCID: PMC10795357 DOI: 10.1186/s13017-023-00525-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/25/2023] [Indexed: 01/22/2024] Open
Abstract
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.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
| | - Andreas K Demetriades
- Department of Neurosurgery, Royal Infirmary Edinburgh, Edinburgh, UK
- Leiden University Neurosurgical Centre Holland, HMC-HAGA The Hague & LUMC Leiden, Leiden, The Netherlands
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Oscar L Alves
- Hospital Lusíadas Porto, Centro Hospitalar de Gaia/Espinho, Porto, Portugal
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, Pavia, Italy
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Andrea Barbanera
- Department of Neurosurgery, SS Antonio e Biagio e Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Alessandro Bertuccio
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Pierre Bouzat
- Universite Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Andras Buki
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Davide Cerasti
- Neuroradiology Unit, Parma University Hospital, Parma, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Neuroscience, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Division of Trauma and Acute Care Surgery, Riverside University Health System Medical Center, Riverside, CA, USA
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Francesco Costa
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | - Federico De Iure
- Department of Spine Surgery, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Louvain, Belgium
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Michael J Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, ON, Canada
| | - Nikolay Gabrovsky
- Clinic of Neurosurgery, University Hospital Pirogov, Sofia, Bulgaria
| | | | - Peter Gruen
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Gregory W J Hawryluk
- Neurological Institute, Cleveland Clinic, Akron General Hospital, Fairlawn, OH, USA
| | - Raimund Helbok
- Department of Neurology, Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Marcel Ivanov
- Neurosurgery Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Stanislav Kaprovoy
- Department of Spinal and Peripheral Nerve Surgery Burdenko Neurosurgical Center, Moscow, Russia
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Sam Klein
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- ANAPLASI Rehabilitation Centre, Athens, Greece
- 1St Neurosurgery Department, Henry Dunant Hospital Center, Athens, Greece
| | - Nikolay A Konovalov
- Department of Spinal and Peripheral Nerve Surgery Burdenko Neurosurgical Center, Moscow, Russia
| | - Alfonso Lagares
- Neurosurgery Department, University Hospital "12 de Octubre", Madrid, Spain
| | - Laura Lippa
- Department of Neurosurgery, Ospedale Niguarda, Milan, Italy
| | - Angelica Loza-Gomez
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Andrzej Maciejczak
- Department of Neurosurgery, St Luke Hospital, University of Rzeszow, Tarnow, Poland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | | | - Ilaria Melloni
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Louvain, Belgium
| | - Marina Munari
- Neuro-Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Lena M Napolitano
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Wilco C Peul
- Leiden University Neurosurgical Centre Holland, HMC-HAGA The Hague & LUMC Leiden, Leiden, The Netherlands
| | - Aichholz K Pudkrong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Zaffer Qasim
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Rasulo
- Department of Neuroanesthesia and Neurocritical Care, Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy
| | - Carla Reizinho
- Departamento de Neurocirurgia, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Sandro Rizoli
- Trauma Surgery Department, Hamad General Hospital, HMC, Doha, Qatar
| | - Elham Rostami
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Emanuele Russo
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Aarti Sarwal
- Department of Neurology, Atrium Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jan M Schwab
- Belford Center for Spinal Cord Injury and Departments of Neurology and Neuroscience, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Franco Servadei
- Humanitas Research Hospital-IRCCS & Humanitas University, Rozzano, Milan, Italy
| | - Deepak Sharma
- Neuroanesthesia & Perioperative Neuroscience, University of Washington, Seattle, WA, USA
| | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Fabio S Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicole A Terpolilli
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Toth
- Department of Neurosurgery, Medical School, University of Pecs, Pecs, Hungary
| | - Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloníki, Greece
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, 3004, Australia
| | - Alexander R Vaccaro
- Department of Orthopedic Surgery, Delaware Valley Spinal Cord Injury Center, Rothman Orthopedics, Sidney Kimmel Medical Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Albert J Varon
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine/Ryder Trauma Center, Miami, FL, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Monika Zackova
- Division of Intensive Care and Neurology Unit, Montecatone Rehabilitation Institute, Imola, Italy
| | - Tommaso Zoerle
- Department of Pathophysiology and Transplantation, University of Milan, Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Robba
- IRCCS Policlinico San Martino, Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, Università di Genova, Genoa, Italy
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7
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Ntikas M, Stewart W, Ietswaart M, Hunter AM, Maas AIR, Menon DK, Wilson L. Contrasting Characteristics and Outcomes of Sports-Related and Non-Sports-Related Traumatic Brain Injury. JAMA Netw Open 2024; 7:e2353318. [PMID: 38265796 PMCID: PMC10809021 DOI: 10.1001/jamanetworkopen.2023.53318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/01/2023] [Indexed: 01/25/2024] Open
Abstract
Importance Exposure to traumatic brain injury (TBI) has raised widespread concern over participation in sports, particularly over possible long-term consequences. However, little is known about the outcomes of individuals presenting to hospitals with sports-related TBI. Objective To compare the characteristics and outcomes of individuals presenting to hospitals with sports-related and non-sports-related TBI. Design, Setting, and Participants The CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) observational cohort study was conducted at hospitals in 18 countries. The study enrolled 4509 patients who had TBI and had an indication for computed tomography (CT), of whom 4360 were 16 years or older. Outcomes were assessed at 3 and 6 months, and groups were compared using regression analyses adjusting for clinical and demographic differences. Data were collected between December 9, 2014, and December 17, 2017, and analyzed from August 2022 to March 2023. Exposure Sports-related and non-sports-related TBI with subgroups selected by severity of injury. Main Outcomes and Measures The main outcome was the Glasgow Outcome Scale-Extended (GOSE) at 6 months, with secondary outcomes covering postconcussion symptoms, health-related quality of life, and mental health. Results A total of 4360 patients were studied, including 256 (6%) with sports-related TBI (mean [SD] age, 38.9 [18.1] years; 161 [63%] male) and 4104 with non-sports-related TBI (mean [SD] age, 51.0 [20.2] years; 2773 [68%] male). Compared with patients with non-sports-related TBI, patients with sports-related TBI were younger, more likely to have tertiary education, more likely to be previously healthy, and less likely to have a major extracranial injury. After adjustment, the groups did not differ in incomplete recovery (GOSE scores <8) at 6 months (odds ratio [OR], 1.27; 95% CI, 0.90-1.78; P = .22 for all patients; OR, 1.20; 95% CI, 0.83-1.73; P = .34 for those with mild TBI; and OR, 1.19; 95% CI, 0.74-1.92; P = .65 for those with mild TBI and negative CT findings). At 6 months, there was incomplete recovery in 103 of 223 patients (46%) with outcomes in the sports-related TBI group, 65 of 168 (39%) in those with mild sports-related TBI, and 30 of 98 (31%) in those with mild sports-related TBI and negative CT findings. In contrast, at 6 months, the sports-related TBI group had lower prevalence of anxiety, depression, posttraumatic stress disorder, and postconcussion symptoms than the non-sports-related group. Conclusions and Relevance In this cohort study of 4360 patients with TBI, functional limitations 6 months after injury were common after sports-related TBI, even mild sports-related TBI. Persisting impairment was evident in the sports-related TBI group despite better recovery compared with non-sports-related TBI on measures of mental health and postconcussion symptoms. These findings caution against taking an overoptimistic view of outcomes after sports-related TBI, even if the initial injury appears mild.
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Affiliation(s)
- Michail Ntikas
- Division of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - William Stewart
- Institute of Neuroscience and Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, United Kingdom
| | - Magdalena Ietswaart
- Division of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - Angus M. Hunter
- Sport Science, Nottingham Trent University, Nottingham, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Lindsay Wilson
- Division of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, United Kingdom
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8
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Maas AIR, Menon DK. Highlights in traumatic brain injury research in 2023. Lancet Neurol 2024; 23:15-17. [PMID: 38101885 DOI: 10.1016/s1474-4422(23)00458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem 2650, Belgium; Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium.
| | - David K Menon
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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9
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van Erp IAM, van Essen TA, Lingsma H, Pisica D, Singh RD, van Dijck JTJM, Volovici V, Kolias A, Peppel LD, Heijenbrok-Kal M, Ribbers GM, Menon DK, Hutchinson P, Depreitere B, Steyerberg EW, Maas AIR, de Ruiter GCW, Peul WC. Early surgery versus conservative treatment in patients with traumatic intracerebral hematoma: a CENTER-TBI study. Acta Neurochir (Wien) 2023; 165:3217-3227. [PMID: 37747570 PMCID: PMC10624744 DOI: 10.1007/s00701-023-05797-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Evidence regarding the effect of surgery in traumatic intracerebral hematoma (t-ICH) is limited and relies on the STITCH(Trauma) trial. This study is aimed at comparing the effectiveness of early surgery to conservative treatment in patients with a t-ICH. METHODS In a prospective cohort, we included patients with a large t-ICH (< 48 h of injury). Primary outcome was the Glasgow Outcome Scale Extended (GOSE) at 6 months, analyzed with multivariable proportional odds logistic regression. Subgroups included injury severity and isolated vs. non-isolated t-ICH. RESULTS A total of 367 patients with a large t-ICH were included, of whom 160 received early surgery and 207 received conservative treatment. Patients receiving early surgery were younger (median age 54 vs. 58 years) and more severely injured (median Glasgow Coma Scale 7 vs. 10) compared to those treated conservatively. In the overall cohort, early surgery was not associated with better functional outcome (adjusted odds ratio (AOR) 1.1, (95% CI, 0.6-1.7)) compared to conservative treatment. Early surgery was associated with better outcome for patients with moderate TBI and isolated t-ICH (AOR 1.5 (95% CI, 1.1-2.0); P value for interaction 0.71, and AOR 1.8 (95% CI, 1.3-2.5); P value for interaction 0.004). Conversely, in mild TBI and those with a smaller t-ICH (< 33 cc), conservative treatment was associated with better outcome (AOR 0.6 (95% CI, 0.4-0.9); P value for interaction 0.71, and AOR 0.8 (95% CI, 0.5-1.0); P value for interaction 0.32). CONCLUSIONS Early surgery in t-ICH might benefit those with moderate TBI and isolated t-ICH, comparable with results of the STITCH(Trauma) trial.
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Affiliation(s)
- Inge A M van Erp
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands.
| | - Thomas A van Essen
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Hester Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Dana Pisica
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Ranjit D Singh
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Jeroen T J M van Dijck
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Victor Volovici
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Lianne D Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Gerard M Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Ewout W Steyerberg
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre and Haaglanden Medical Centre, Leiden and The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Antwerp, Belgium
| | - Godard C W de Ruiter
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Centre Holland, LUMC, HMC, HAGA, Leiden and The Hague, The Netherlands
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10
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Richter S, Czeiter E, Amrein K, Mikolic A, Verheyden J, Wang K, Maas AIR, Steyerberg E, Büki A, Menon DK, Newcombe VFJ. Prognostic Value of Serum Biomarkers in Patients With Moderate-Severe Traumatic Brain Injury, Differentiated by Marshall Computer Tomography Classification. J Neurotrauma 2023; 40:2297-2310. [PMID: 37376742 DOI: 10.1089/neu.2023.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Prognostication is challenging in patients with traumatic brain injury (TBI) in whom computed tomography (CT) fails to fully explain a low level of consciousness. Serum biomarkers reflect the extent of structural damage in a different way than CT does, but it is unclear whether biomarkers provide additional prognostic value across the range of CT abnormalities. This study aimed to determine the added predictive value of biomarkers, differentiated by imaging severity. This prognostic study used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study (2014-2017). The analysis included patients aged ≥16 years with a moderate-severe TBI (Glasgow Coma Scale [GCS] <13) who had an acute CT and serum biomarkers obtained ≤24h of injury. Of six protein biomarkers (GFAP, NFL, NSE, S100B, Tau, UCH-L1), the most prognostic panel was selected using lasso regression. The performance of established prognostic models (CRASH and IMPACT) was assessed before and after the addition of the biomarker panel and compared between patients with different CT Marshall scores (Marshall score <3 vs. Marshall score ≥3). Outcome was assessed at six months post-injury using the extended Glasgow Outcome Scale (GOSE), and dichotomized into favorable and unfavorable (GOSE <5). We included 872 patients with moderate-severe TBI. The mean age was 47 years (range 16-95); 647 (74%) were male and 438 (50%) had a Marshall CT score <3. The serum biomarkers GFAP, NFL, S100B and UCH-L1 provided complementary prognostic information; NSE and Tau showed no added value. The addition of the biomarker panel to established prognostic models increased the area under the curve (AUC) by 0.08 and 0.03, and the explained variation in outcome by 13-14% and 7-8%, for patients with a Marshall score of <3 and ≥3, respectively. The incremental AUC of biomarkers for individual models was significantly greater when the Marshall score was <3 compared with ≥3 (p < 0.001). Serum biomarkers improve outcome prediction after moderate-severe TBI across the range of imaging severities and especially in patients with a Marshall score <3.
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Affiliation(s)
- Sophie Richter
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
- ELKH-PTE Clinical Neuroscience MR Research Group, University of Pécs, Pécs, Hungary
| | - Krisztina Amrein
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
- ELKH-PTE Clinical Neuroscience MR Research Group, University of Pécs, Pécs, Hungary
| | - Ana Mikolic
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada
| | - Jan Verheyden
- Research and Development, icometrix, Leuven, Belgium
| | - Kevin Wang
- Program for Neurotrauma, Neuroproteomics and Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, Gainesville, Florida, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, University Medical Centre, Leiden, Netherlands
| | - András Büki
- Örebro University, School of Medical Sciences, Örebro, Sweden
| | - David K Menon
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Virginia F J Newcombe
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
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11
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Buh FC, Sumbele IUN, Maas AIR, Motah M, Pattisapu JV, Youm E, Meh BK, Kobeissy FH, Wang KW, Hutchinson PJA, Taiwe GS. Traumatic Brain Injury in Cameroon: A Prospective Observational Study in a Level I Trauma Centre. Medicina (Kaunas) 2023; 59:1558. [PMID: 37763678 PMCID: PMC10535664 DOI: 10.3390/medicina59091558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023]
Abstract
Background and Objective: About 14 million people will likely suffer a traumatic brain injury (TBI) per year by 2050 in sub-Saharan Africa. Studying TBI characteristics and their relation to outcomes can identify initiatives to improve TBI prevention and care. The objective of this study was to define the features and outcomes of TBI patients seen over a 1-year period in a level-I trauma centre in Cameroon. Materials and Methods: Data on demographics, causes, clinical aspects, and discharge status were collected over a period of 12 months. The Glasgow Outcome Scale-Extended (GOSE) and the Quality-of-Life Questionnaire after Brain Injury (QoLIBRI) were used to evaluate outcomes six months after TBI. Comparisons between two categorical variables were done using Pearson's chi-square test. Results: A total of 160 TBI patients participated in the study. The age group 15-45 years was most represented (78%). Males were more affected (90%). A low educational level was seen in 122 (76%) cases. Road traffic incidents (RTI) (85%), assaults (7.5%), and falls (2.5%) were the main causes of TBI, with professional bike riders being frequently involved (27%). Only 15 patients were transported to the hospital by ambulance, and 14 of these were from a referring hospital. CT-imaging was performed in 78% of cases, and intracranial traumatic abnormalities were identified in 64% of cases. Financial constraints (93%) was the main reason for not performing a CT scan. Forty-six (33%) patients were discharged against medical advice (DAMA) due to financial constraints. Mortality was 14% (22/160) and high in patients with severe TBI (46%). DAMA had poor outcomes with QoLIBRI. Only four patients received post-injury physical therapy services. Conclusions: TBI in Cameroon mainly results from RTIs and commonly affects young adult males. Lack of pre-hospital care, financial constraints limiting both CT scanning and medical care, and a lack of acute physiotherapy services likely influenced care and outcomes adversely.
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Affiliation(s)
- Franklin Chu Buh
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
| | - Irene Ule Ngole Sumbele
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, University of Antwerp, 2000 Edegem, Belgium;
| | - Mathieu Motah
- Department of Surgery, Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala P.O. Box 2701, Cameroon;
| | - Jogi V. Pattisapu
- Department of Pediatric Neurosurgery, University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA;
| | - Eric Youm
- Holo Healthcare, Nairobi 00400, Kenya;
| | - Basil Kum Meh
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
| | - Firas H. Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Riad El-Solh, Beirut P.O. Box 11-0236, Lebanon
| | - Kevin W. Wang
- Center for Neurotrauma, Multiomics & Biomarkers (CNMB), Department of Neurobiology, Neuroscience Institute, Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310-1458, USA;
| | | | - Germain Sotoing Taiwe
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
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12
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Maas AIR, Bragge P, Silverberg ND, Undén J, Lecky FE. French Guidelines for the Management of Patients with mild Traumatic Brain injury. Anaesth Crit Care Pain Med 2023:101261. [PMID: 37285920 DOI: 10.1016/j.accpm.2023.101261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Andrew I R Maas
- Antwerp University Hospital, Edegem, and University of Antwerp, Edegem, Belgium.
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Australia
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver Coastal Health Research Institute, Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada
| | - Johan Undén
- Dept. of Operation and Intensive Care, Hallands Hospital Halmstad, Lund University, Lund, Sweden
| | - Fiona E Lecky
- Emergency Department, Salford Royal Hospital, Salford, UK; Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
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13
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Wu X, Xie L, Lei J, Yao J, Li J, Ruan L, Hong J, Zheng G, Cheng Y, Long L, Wang J, Huang C, Xie Q, Zhang X, He J, Yu X, Lv S, Sun Z, Liu D, Li X, Zhu J, Yang X, Wang D, Bao Y, Maas AIR, Menon D, Xue Y, Jiang J, Feng J, Gao G. Acute traumatic coma awakening by right median nerve electrical stimulation: a randomised controlled trial. Intensive Care Med 2023; 49:633-644. [PMID: 37178149 PMCID: PMC10182548 DOI: 10.1007/s00134-023-07072-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/11/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Severe traumatic brain injury (TBI) leads to acute coma and may result in prolonged disorder of consciousness (pDOC). We aimed to determine whether right median nerve electrical stimulation is a safe and effective treatment for accelerating emergence from coma after TBI. METHODS This randomised controlled trial was performed in 22 centres in China. Participants with acute coma at 7-14 days after TBI were randomly assigned (1:1) to either routine therapy and right median nerve electrical stimulation (RMNS group) or routine treatment (control group). The RMNS group received 20 mA, 300 μs, 40 Hz stimulation pulses, lasting 20 s per minutes, 8 h per day, for 2 weeks. The primary outcome was the proportion of patients who regained consciousness 6 months post-injury. The secondary endpoints were Glasgow Coma Scale (GCS), Full Outline of Unresponsiveness scale (FOUR), Coma Recovery Scale-Revised (CRS-R), Disability Rating Scale (DRS) and Glasgow Outcome Scale Extended (GOSE) scores reported as medians on day 28, 3 months and 6 months after injury, and GCS and FOUR scores on day 1 and day 7 during stimulation. Primary analyses were based on the intention-to-treat set. RESULTS Between March 26, 2016, and October 18, 2020, 329 participants were recruited, of whom 167 were randomised to the RMNS group and 162 to the control group. At 6 months post-injury, a higher proportion of patients in the RMNS group regained consciousness compared with the control group (72.5%, n = 121, 95% confidence interval (CI) 65.2-78.7% vs. 56.8%, n = 92, 95% CI 49.1-64.2%, p = 0.004). GOSE at 3 months and 6 months (5 [interquartile range (IQR) 3-7] vs. 4 [IQR 2-6], p = 0.002; 6 [IQR 3-7] vs. 4 [IQR 2-7], p = 0.0005) and FOUR at 28 days (15 [IQR 13-16] vs. 13 [interquartile range (IQR) 11-16], p = 0.002) were significantly increased in the RMNS group compared with the control group. Trajectory analysis showed that significantly more patients in the RMNS group had faster GCS, CRS-R and DRS improvement (p = 0.01, 0.004 and 0.04, respectively). Adverse events were similar in both groups. No serious adverse events were associated with the stimulation device. CONCLUSION Right median nerve electrical stimulation is a possible effective treatment for patients with acute traumatic coma, that will require validation in a confirmatory trial.
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Affiliation(s)
- Xiang Wu
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College of HUST, Wuhan, China
| | - Jiemin Yao
- Department of Neurosurgery, The Second People's Hospital of Nanning, Nanning, China
| | - Jiarong Li
- Department of Neurosurgery, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, China
| | - Lixin Ruan
- Department of Neurosurgery, The People's Hospital of PingYang, Pingyang, China
| | - Jun Hong
- Department of Neurosurgery, Tangshan Gongren Hospital, Tangshan, China
| | - Guodong Zheng
- Department of Neurosurgery, Linyi People's Hospital, Linyi, China
| | - Yangyu Cheng
- Department of Neurosurgery, Changzhi Second People's Hospital, Changzhi, China
| | - Liansheng Long
- Department of Neurosurgery, South Taihu Hospital, Huzhou, China
| | - Jiancun Wang
- Department of Neurosurgery, The Third Affiliated Hospital of PLA Navy Military Medical University, Shanghai, China
| | - Chuanping Huang
- Department of Neurosurgery, The 421st Hospital of Chinese People's Liberation Army, Guangzhou, China
| | - Qiuyou Xie
- Department of Neurosurgery, Guangzhou General Hospital of Guangzhou Military Region, Guangzhou, China
| | - Xuelei Zhang
- Department of Neurosurgery, Lishui City People's Hospital, Lishui, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China
| | - Xuebin Yu
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing, China
| | - Shouhua Lv
- Department of Neurosurgery, Tengzhou City Center People's Hospital, Tengzhou, China
| | - Zhaosheng Sun
- Department of Neurosurgery, Harrison International Peace Hospital, Hengshui, China
| | - Dai Liu
- Department of Neurosurgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Xin Li
- Department of Neurosurgery, The Brain Hospital of Hunan Province, Changsha, China
| | - Jianxin Zhu
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng, China
| | - Xiaoliang Yang
- Department of Neurosurgery, Baoji 3rd Hospital of Chinese People's Liberation Army, Baoji, China
| | - Dongdong Wang
- Department of Neurosurgery, Yanjiao People's Hospital, Sanhe, China
| | - Yijun Bao
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, Edegem, Belgium
| | - David Menon
- Division of Anesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Yajun Xue
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiyao Jiang
- Brain Injury Centre, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Junfeng Feng
- Brain Injury Centre, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People's Republic of China.
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Institute of Head Trauma, Shanghai, China.
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14
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Silverberg ND, Iverson GL, Cogan A, Dams-O'Connor K, Delmonico R, Graf MJP, Iaccarino MA, Kajankova M, Kamins J, McCulloch KL, McKinney G, Nagele D, Panenka WJ, Rabinowitz AR, Reed N, Wethe JV, Whitehair V, Anderson V, Arciniegas DB, Bayley MT, Bazarian JJ, Bell KR, Broglio SP, Cifu D, Davis GA, Dvorak J, Echemendia RJ, Gioia GA, Giza CC, Hinds SR, Katz DI, Kurowski BG, Leddy JJ, Sage NL, Lumba-Brown A, Maas AIR, Manley GT, McCrea M, Menon DK, Ponsford J, Putukian M, Suskauer SJ, van der Naalt J, Walker WC, Yeates KO, Zafonte R, Zasler ND, Zemek R. The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury. Arch Phys Med Rehabil 2023:S0003-9993(23)00297-6. [PMID: 37211140 DOI: 10.1016/j.apmr.2023.03.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings. DESIGN Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus. PARTICIPANTS The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations. RESULTS The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.' CONCLUSIONS New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.
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Affiliation(s)
- Noah D Silverberg
- Department of Psychology, University of British Columbia; Vancouver Coastal Health Research Institute; Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada; 2136 West Mall, Vancouver, British Columbia, Canada, V6T 1Z4.
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital and the Schoen Adams Research Institute at Spaulding Rehabilitation; MassGeneral Hospital for Children Sports Concussion Program; & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts, USA; 79/96 Thirteenth Street, Charlestown Navy Yard, Charlestown, MA, 02129.
| | - Alison Cogan
- Center for the Study of Healthcare Innovation, Implementation & Policy; VA Greater Los Angeles Healthcare System; 11301 Wilshire Blvd, Los Angeles, CA 90073.
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance & Department of Neurology, Brain Injury Research Center of Mount Sinai, Box 1163, Icahn School of Medicine at Mount Sinai, New York, NY, USA 10029. kristen.dams-o'
| | - Richard Delmonico
- Kaiser Foundation Rehabilitation Center, The Permanente Medical Group, Kaiser Permanente, Northern California, 975 Sereno Drive, Vallejo, CA, USA 94589.
| | - Min Jeong P Graf
- Department of Physical Medicine and Rehabilitation, Hennepin Healthcare; Department of Rehabilitation Medicine, University of Minnesota, 701 Park Ave, Minneapolis, MN, USA 55415.
| | - Mary Alexis Iaccarino
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, 300 1(st) Ave, Charlestown, MA, USA 02129; Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1(st) Ave, Charlestown, MA, USA 02129.
| | - Maria Kajankova
- Department of Rehabilitation and Human Performance, Brain Injury Research Center of Mount Sinai, Box 1163, Icahn School of Medicine at Mount Sinai, New York, NY, USA 10029.
| | - Joshua Kamins
- UCLA Steve Tisch BrainSPORT Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA, 300 Medical Plaza Ste B-200 Los Angeles, CA, USA 90095.
| | - Karen L McCulloch
- Division of Physical Therapy, Department of Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, 3030 Bondurant Hall, CB# 7135, Chapel Hill, NC, USA 27599-7135.
| | - Gary McKinney
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, 1335 East West Highway, Silver Spring, MD, USA 20910.
| | - Drew Nagele
- School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, 4170 City Ave, Philadelphia, PA, USA 19131.
| | - William J Panenka
- British Columbia Neuropsychiatry Program; Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, UBC, Vancouver, BC, Canada, V6T2A1.
| | - Amanda R Rabinowitz
- Moss Rehabilitation Research Institute, 50 Township Line Rd., Elkins Park, PA, USA, 19027.
| | - Nick Reed
- Department of Occupational Science & Occupational Therapy, University of Toronto, 160-500 University Ave, Toronto, ON, Canada, M5G1V7.
| | - Jennifer V Wethe
- Mayo Clinic School of Medicine, 13400 E Shea Blvd, Scottsdale, AZ, USA 85259.
| | - Victoria Whitehair
- MetroHealth Rehabilitation Institute and Case Western Reserve University; 2500 MetroHealth Drive, Cleveland, OH, USA 44109.
| | - Vicki Anderson
- Murdoch Children's Research Institute; The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052 Australia.
| | - David B Arciniegas
- University of New Mexico School of Medicine; University of Colorado School of Medicine; 1635 Aurora Ct, Aurora, CO, USA 80045.
| | - Mark T Bayley
- Toronto Rehabilitation Institute, University Health Network; University of Toronto; Room 3-102-12, 550 University Avenue, Toronto, Ontario, Canada, M5G2A2.
| | - Jeffrey J Bazarian
- University of Rochester School of Medicine and Dentistry; 265 Crittenden Blvd Box 655c, Rochester, NY, USA 14642.
| | - Kathleen R Bell
- University of Texas Southwestern Medical Center; 5323 Harry Hines Blvd, Dallas, TX, USA, 75390.
| | - Steven P Broglio
- University of Michigan, Michigan Concussion Center; 830 N University Ave., Ann Arbor, MI, USA 48109.
| | - David Cifu
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine; U.S. Department of Veterans Affairs; 1223 East Marshall Street, Richmond, VA, USA 23298.
| | - Gavin A Davis
- Cabrini Health; Suite 53 - Neurosurgery, Cabrini Malvern, Victoria, 3144, Australia.
| | - Jiri Dvorak
- Schulthess Clinic, Department of Neurology, Swiss Concussion Center; Lengghalde 2, CH-8008, Switzerland.
| | - Ruben J Echemendia
- University Orthopedics Center, Concussion Care Clinic; University of Missouri-Kansas City, Kansas City, Missouri, USA. 107 Picadilly Rd., Port Matilda, PA, USA 16870.
| | - Gerard A Gioia
- Division of Neuropsychology/ SCORE Concussion Program, Children's National Hospital, George Washington University School of Medicine; 15245 Shady Grove Road #350, Rockville, MD, USA 20850.
| | - Christopher C Giza
- University of California at Los Angeles, Departments of Neurosurgery and Pediatrics, Steve Tisch BrainSPORT Program; Room 557 Wasserman, Department of Neurosurgery, 300 Stein Plaza, UCLA, Los Angeles, CA, USA 90095.
| | - Sidney R Hinds
- Uniformed Services University, Department of Neurology and Radiology, 4301 Jones Bridge Rd, Bethesda, MD 20814.
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine; 72 E. Concord St. Robinson (B3), Boston University School of Medicine, Boston, MA, USA 02118.
| | - Brad G Kurowski
- Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Departments of Pediatrics, Neurology, and Rehabilitation Medicine, University of Cincinnati College of Medicine; 3333 Burnet Avenue, MLC 4009, Cincinnati, OH, USA 45229.
| | - John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine; SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences; 160 Farber Hall, Buffalo, NY, USA 14214.
| | - Natalie Le Sage
- Population Health and Optimal Health Practices Axis, CHU de Québec-Université Laval Research Centre; VITAM-Centre de recherche en santé durable; 1401, 18e rue, Québec, Canada, G1J 1Z4.
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University; 900 Welch Road, Stanford, CA, USA 94303.
| | - Andrew I R Maas
- Antwerp University Hospital, Edegem, and University of Antwerp; Drie Eikenstraat 655, 2650 Edegem, Belgium.
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California, San Francisco; 1001 Potrero Ave, San Francisco, CA, USA 94110.
| | - Michael McCrea
- Medical College of Wisconsin; 8701 Watertown Plank Road, Milwaukee, WI, USA 53226.
| | - David K Menon
- University of Cambridge; Box 93, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK.
| | - Jennie Ponsford
- Monash University; 18 Innovation Walk, Clayton campus, VIC 3800, Australia.
| | | | - Stacy J Suskauer
- Kennedy Krieger Institute and Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine; 707 North Broadway, Baltimore, MD, USA 21205.
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen; Netherlands.
| | - William C Walker
- Virginia Commonwealth University; 1223 East Marshall Street, 4(th) Fl., Box 980677, Richmond, VA, USA 23298-0677.
| | - Keith Owen Yeates
- Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary; 2500 University Dr NW, Calgary, AB T2N 1N4, Canada.
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation Spaulding Rehabilitation Hospital/Massachusetts General Hospital/Brigham and Women's Hospital/Harvard Medical School; 300 First Avenue, Boston, MA, USA 02129.
| | - Nathan D Zasler
- Concussion Care Centre of Virginia, Ltd.; 3721 Westerre Parkway, Suite B, Henrico, VA, USA 23233.
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa; Children's Hospital of Eastern Ontario; 401 Smyth Road, Ottawa, ON, Canada, K1H 8L1.
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15
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Maas AIR, Hemphill JC, Wilson L, Manley GT. Managing outcome expectations after Traumatic Brain Injury. Injury 2023; 54:1233-1235. [PMID: 37055145 DOI: 10.1016/j.injury.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Affiliation(s)
- Andrew I R Maas
- Antwerp University Hospital, Edegem, and University of Antwerp, Edegem, Belgium.
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco; Building 1, Room 101, 1001 Potrero Avenue, San Francisco, CA, 94110, United States of America; Department of Neurological Surgery, University of California, San Francisco, Brain & Spinal Injury Center, 1001 Potrero Avenue, San Francisco, CA, 94110, United States of America
| | - Lindsay Wilson
- Division of Psychology, School of Natural Sciences, University of Stirling, Stirling FK9 4LA, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, Brain & Spinal Injury Center, 1001 Potrero Avenue, San Francisco, CA, 94110, United States of America
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von Steinbuechel N, Hahm S, Muehlan H, Arango-Lasprilla JC, Bockhop F, Covic A, Schmidt S, Steyerberg EW, Maas AIR, Menon D, Andelic N, Zeldovich M. Impact of Sociodemographic, Premorbid, and Injury-Related Factors on Patient-Reported Outcome Trajectories after Traumatic Brain Injury (TBI). J Clin Med 2023; 12:jcm12062246. [PMID: 36983247 PMCID: PMC10052290 DOI: 10.3390/jcm12062246] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/08/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
Traumatic brain injury (TBI) remains one of the leading causes of death and disability worldwide. To better understand its impact on various outcome domains, this study pursues the following: (1) longitudinal outcome assessments at three, six, and twelve months post-injury; (2) an evaluation of sociodemographic, premorbid, and injury-related factors, and functional recovery contributing to worsening or improving outcomes after TBI. Using patient-reported outcome measures, recuperation trends after TBI were identified by applying Multivariate Latent Class Mixed Models (MLCMM). Instruments were grouped into TBI-specific and generic health-related quality of life (HRQoL; QOLIBRI-OS, SF-12v2), and psychological and post-concussion symptoms (GAD-7, PHQ-9, PCL-5, RPQ). Multinomial logistic regressions were carried out to identify contributing factors. For both outcome sets, the four-class solution provided the best match between goodness of fit indices and meaningful clinical interpretability. Both models revealed similar trajectory classes: stable good health status (HRQoL: n = 1944; symptoms: n = 1963), persistent health impairments (HRQoL: n = 442; symptoms: n = 179), improving health status (HRQoL: n = 83; symptoms: n = 243), and deteriorating health status (HRQoL: n = 86; symptoms: n = 170). Compared to individuals with stable good health status, the other groups were more likely to have a lower functional recovery status at three months after TBI (i.e., the GOSE), psychological problems, and a lower educational attainment. Outcome trajectories after TBI show clearly distinguishable patterns which are reproducible across different measures. Individuals characterized by persistent health impairments and deterioration require special attention and long-term clinical monitoring and therapy.
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Affiliation(s)
- Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
- Correspondence:
| | - Stefanie Hahm
- Department Health & Prevention, Institute of Psychology, University of Greifswald, Robert-Blum-Str. 13, 17489 Greifswald, Germany
| | - Holger Muehlan
- Department Health & Prevention, Institute of Psychology, University of Greifswald, Robert-Blum-Str. 13, 17489 Greifswald, Germany
| | - Juan Carlos Arango-Lasprilla
- Departments of Psychology and Physical Medicine and Rehabilitation, Virginia Commonwealth University, 907 Floyd Ave., Richmond, VA 23284, USA
| | - Fabian Bockhop
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
| | - Silke Schmidt
- Department Health & Prevention, Institute of Psychology, University of Greifswald, Robert-Blum-Str. 13, 17489 Greifswald, Germany
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 RC Leiden, The Netherlands
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium
| | - David Menon
- Division of Anaesthesia, University of Cambridge/Addenbrooke’s Hospital, Box 157, Cambridge CB2 0QQ, UK
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, 0450 Oslo, Norway
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models, Faculty of Medicine, Univeristy of Oslo, 0373 Oslo, Norway
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
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Maas AIR, Menon DK, Manley GT. Towards further progress in traumatic brain injury - Authors' reply. Lancet Neurol 2023; 22:110. [PMID: 36681441 DOI: 10.1016/s1474-4422(22)00516-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem 2650, Belgium.
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Maas AIR, Steyerberg EW. Commentary: Prognostic Models for Traumatic Brain Injury Have Good Discrimination But Poor Overall Model Performance for Predicting Mortality and Unfavorable Outcomes. Neurosurgery 2022; 91:e164-e165. [PMID: 36269564 DOI: 10.1227/neu.0000000000002177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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van Essen TA, Lingsma HF, Steyerberg EW, de Ruiter GCW, Maas AIR, Peul WC. Treatment of acute subdural haematoma – Authors' reply. Lancet Neurol 2022; 21:1080-1081. [DOI: 10.1016/s1474-4422(22)00433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022]
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Affiliation(s)
- Thomas A van Essen
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre, and Haga Teaching Hospital, Leiden and The Hague, 2333 ZA Leiden, Netherlands.
| | - Hester F Lingsma
- Centre for Medical Decision Sciences, Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Godard C W de Ruiter
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre, and Haga Teaching Hospital, Leiden and The Hague, 2333 ZA Leiden, Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, and University of Antwerp, Belgium
| | - Wilco C Peul
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre, and Haga Teaching Hospital, Leiden and The Hague, 2333 ZA Leiden, Netherlands
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21
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Rezoagli E, Petrosino M, Rebora P, Menon DK, Mondello S, Cooper DJ, Maas AIR, Wiegers EJA, Galimberti S, Citerio G. High arterial oxygen levels and supplemental oxygen administration in traumatic brain injury: insights from CENTER-TBI and OzENTER-TBI. Intensive Care Med 2022; 48:1709-1725. [PMID: 36264365 PMCID: PMC9705485 DOI: 10.1007/s00134-022-06884-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/17/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE The effect of high arterial oxygen levels and supplemental oxygen administration on outcomes in traumatic brain injury (TBI) is debated, and data from large cohorts of TBI patients are limited. We investigated whether exposure to high blood oxygen levels and high oxygen supplementation is independently associated with outcomes in TBI patients admitted to the intensive care unit (ICU) and undergoing mechanical ventilation. METHODS This is a secondary analysis of two multicenter, prospective, observational, cohort studies performed in Europe and Australia. In TBI patients admitted to ICU, we describe the arterial partial pressure of oxygen (PaO2) and the oxygen inspired fraction (FiO2). We explored the association between high PaO2 and FiO2 levels within the first week with clinical outcomes. Furthermore, in the CENTER-TBI cohort, we investigate whether PaO2 and FiO2 levels may have differential relationships with outcome in the presence of varying levels of brain injury severity (as quantified by levels of glial fibrillary acidic protein (GFAP) in blood samples obtained within 24 h of injury). RESULTS The analysis included 1084 patients (11,577 measurements) in the CENTER-TBI cohort, of whom 55% had an unfavorable outcome, and 26% died at a 6-month follow-up. Median PaO2 ranged from 93 to 166 mmHg. Exposure to higher PaO2 and FiO2 in the first seven days after ICU admission was independently associated with a higher mortality rate. A trend of a higher mortality rate was partially confirmed in the OzENTER-TBI cohort (n = 159). GFAP was independently associated with mortality and functional neurologic outcome at follow-up, but it did not modulate the outcome impact of high PaO2 levels, which remained independently associated with 6-month mortality. CONCLUSIONS In two large prospective multicenter cohorts of critically ill patients with TBI, levels of PaO2 and FiO2 varied widely across centers during the first seven days after ICU admission. Exposure to high arterial blood oxygen or high supplemental oxygen was independently associated with 6-month mortality in the CENTER-TBI cohort, and the severity of brain injury did not modulate this relationship. Due to the limited sample size, the findings were not wholly validated in the external OzENTER-TBI cohort. We cannot exclude the possibility that the worse outcomes associated with higher PaO2 were due to use of higher FiO2 in patients with more severe injury or physiological compromise. Further, these findings may not apply to patients in whom FiO2 and PaO2 are titrated to brain tissue oxygen monitoring (PbtO2) levels. However, at minimum, these findings support the need for caution with oxygen therapy in TBI, particularly since titration of supplemental oxygen is immediately applicable at the bedside.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Extracorporeal Membrane Oxygenation (ECMO) Center, Azienda Socio-Sanitaria Territoriale (ASST) di Monza, Monza, Italy
| | - Matteo Petrosino
- Department of Medicine and Surgery, Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Paola Rebora
- Department of Medicine and Surgery, Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - D James Cooper
- Intensive Care Department, Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew I R Maas
- Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefania Galimberti
- Department of Medicine and Surgery, Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy. .,NeuroIntensive Care Unit, Neuroscience Department, Hospital San Gerardo, ASST Monza, Monza, Italy.
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22
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Chen L, Xu H, He J, Zhang C, Maas AIR, Nieboer D, Raj R, Sun H, Wang Y. Performance of the IMPACT and Helsinki models for predicting 6-month outcomes in a cohort of patients with traumatic brain injury undergoing cranial surgery. Front Neurol 2022; 13:1031865. [DOI: 10.3389/fneur.2022.1031865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aimPrediction models for patients with traumatic brain injury (TBI) require generalizability and should apply to different settings. We aimed to validate the IMPACT and Helsinki prognostic models in patients with TBI who underwent cranial surgery in a Chinese center.MethodsThis validation study included 607 surgical patients with moderate to severe TBI (Glasgow Coma Scale [GCS] score ≤12) who were consecutively admitted to the Neurotrauma Center of People's Liberation Army (PLANC), China, between 2009 and 2021. The IMPACT models (core, extended and lab) and the Helsinki CT clinical model were used to estimate 6-month mortality and unfavorable outcomes. To assess performance, we studied discrimination and calibration.ResultsIn the PLANC database, the observed 6-month mortality rate was 28%, and the 6-month unfavorable outcome was 52%. Significant differences in case mix existed between the PLANC cohort and the development populations for the IMPACT and, to a lesser extent, for the Helsinki models. Discrimination of the IMPACT and Helsinki models was excellent, with most AUC values ≥0.80. The highest values were found for the IMPACT lab model (AUC 0.87) and the Helsinki CT clinical model (AUC 0.86) for the prediction of unfavorable outcomes. Overestimation was found for all models, but the degree of miscalibration was lower in the Helsinki CT clinical model.ConclusionIn our population of surgical TBI patients, the IMPACT and Helsinki CT clinical models demonstrated good performance, with excellent discrimination but suboptimal calibration. The good discrimination confirms the validity of the predictors, but the poorer calibration suggests a need to recalibrate the models to specific settings.
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Maas AIR, Fitzgerald M, Gao G, Gupta D, Hutchinson P, Manley GT, Menon DK. Traumatic brain injury over the past 20 years: research and clinical progress. Lancet Neurol 2022; 21:768-770. [DOI: 10.1016/s1474-4422(22)00307-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022]
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Helmrich IRAR, Czeiter E, Amrein K, Büki A, Lingsma HF, Menon DK, Mondello S, Steyerberg EW, von Steinbüchel N, Wang KKW, Wilson L, Xu H, Yang Z, van Klaveren D, Maas AIR. Incremental prognostic value of acute serum biomarkers for functional outcome after traumatic brain injury (CENTER-TBI): an observational cohort study. Lancet Neurol 2022; 21:792-802. [DOI: 10.1016/s1474-4422(22)00218-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/20/2022] [Accepted: 05/16/2022] [Indexed: 12/23/2022]
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van der Vlegel M, Mikolić A, Lee Hee Q, Kaplan ZLR, Retel Helmrich IRA, van Veen E, Andelic N, Steinbuechel NV, Plass AM, Zeldovich M, Wilson L, Maas AIR, Haagsma JA, Polinder S. Health care utilization and outcomes in older adults after Traumatic Brain Injury: A CENTER-TBI study. Injury 2022; 53:2774-2782. [PMID: 35725508 DOI: 10.1016/j.injury.2022.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/11/2022] [Accepted: 05/08/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The incidence of Traumatic Brain Injury (TBI) is increasingly common in older adults aged ≥65 years, forming a growing public health problem. However, older adults are underrepresented in TBI research. Therefore, we aimed to provide an overview of health-care utilization, and of six-month outcomes after TBI and their determinants in older adults who sustained a TBI. METHODS We used data from the prospective multi-center Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. In-hospital and post-hospital health care utilization and outcomes were described for patients aged ≥65 years. Ordinal and linear regression analyses were performed to identify determinants of the Glasgow Outcome Scale Extended (GOSE), health-related quality of life (HRQoL), and mental health symptoms six-months post-injury. RESULTS Of 1254 older patients, 45% were admitted to an ICU with a mean length of stay of 9 days. Nearly 30% of the patients received inpatient rehabilitation. In total, 554/1254 older patients completed the six-month follow-up questionnaires. The mortality rate was 9% after mild and 60% after moderate/severe TBI, and full recovery based on GOSE was reported for 44% of patients after mild and 6% after moderate/severe TBI. Higher age and increased injury severity were primarily associated with functional impairment, while pre-injury systemic disease, psychiatric conditions and lower educational level were associated with functional impairment, lower generic and disease-specific HRQoL and mental health symptoms. CONCLUSION The rate of impairment and disability following TBI in older adults is substantial, and poorer outcomes across domains are associated with worse preinjury health. Nonetheless, a considerable number of patients fully or partially returns to their preinjury functioning. There should not be pessimism about outcomes in older adults who survive.
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Affiliation(s)
- Marjolein van der Vlegel
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands.
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Quentin Lee Hee
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Z L Rana Kaplan
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Isabel R A Retel Helmrich
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands; Department of Intensive Care Adults, Rotterdam, the Netherlands
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, 0424 Oslo, Norway
| | - Nicole V Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen (UMG)/ Georg-August-University, Göttingen, Germany
| | - Anne Marie Plass
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen (UMG)/ Georg-August-University, Göttingen, Germany
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen (UMG)/ Georg-August-University, Göttingen, Germany
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, CA 3000, The Netherlands
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Volovici V, Pisică D, Gravesteijn BY, Dirven CMF, Steyerberg EW, Ercole A, Stocchetti N, Nelson D, Menon DK, Citerio G, van der Jagt M, Maas AIR, Haitsma IK, Lingsma HF, Åkerlund C, Amrein K, Andelic N, Andreassen L, Audibert G, Azouvi P, Azzolini ML, Bartels R, Beer R, Bellander BM, Benali H, Berardino M, Beretta L, Beqiri E, Blaabjerg M, Lund SB, Brorsson C, Buki A, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Lozano GC, Castaño-León AM, Cavallo S, Chevallard G, Chieregato A, Coburn M, Coles J, Cooper JD, Correia M, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, De Keyser V, Degos V, Corte FD, Boogert HD, Depreitere B, Dilvesi D, Dixit A, Dreier J, Dulière GL, Ezer E, Fabricius M, Foks K, Frisvold S, Furmanov A, Galanaud D, Gantner D, Ghuysen A, Giga L, Golubovic J, Gomez PA, Grossi F, Gupta D, Haitsma I, Helseth E, Hutchinson PJ, Jankowski S, Johnson F, Karan M, Kolias AG, Kondziella D, Koraropoulos E, Koskinen LO, Kovács N, Kowark A, Lagares A, Laureys S, Ledoux D, Lejeune A, Lightfoot R, Manara A, Martino C, Maréchal H, Mattern J, McMahon C, Menovsky T, Misset B, Muraleedharan V, Murray L, Negru A, Newcombe V, Nyirádi J, Ortolano F, Payen JF, Perlbarg V, Persona P, Piippo-Karjalainen A, Ples H, Pomposo I, Posti JP, Puybasset L, Radoi A, Ragauskas A, Raj R, Rhodes J, Richter S, Rocka S, Roe C, Roise O, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Sahuquillo J, Sandrød O, Sakowitz O, Sanchez-Porras R, Schirmer-Mikalsen K, Schou RF, Smielewski P, Sorinola A, Stamatakis E, Sundström N, Takala R, Tamás V, Tamosuitis T, Tenovuo O, Thomas M, Tibboel D, Tolias C, Trapani T, Tudora CM, Vajkoczy P, Vallance S, Valeinis E, Vámos Z, Van der Steen G, van Wijk RPJ, Vargiolu A, Vega E, Vik A, Vilcinis R, Vulekovic P, Williams G, Winzeck S, Wolf S, Younsi A, Zeiler FA, Ziverte A, Clusmann H, Voormolen D, van Dijck JTJM, van Essen TA. Comparative effectiveness of intracranial hypertension management guided by ventricular versus intraparenchymal pressure monitoring: a CENTER-TBI study. Acta Neurochir (Wien) 2022; 164:1693-1705. [PMID: 35648213 PMCID: PMC9233652 DOI: 10.1007/s00701-022-05257-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/11/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To compare outcomes between patients with primary external ventricular device (EVD)-driven treatment of intracranial hypertension and those with primary intraparenchymal monitor (IP)-driven treatment. METHODS The CENTER-TBI study is a prospective, multicenter, longitudinal observational cohort study that enrolled patients of all TBI severities from 62 participating centers (mainly level I trauma centers) across Europe between 2015 and 2017. Functional outcome was assessed at 6 months and a year. We used multivariable adjusted instrumental variable (IV) analysis with "center" as instrument and logistic regression with covariate adjustment to determine the effect estimate of EVD on 6-month functional outcome. RESULTS A total of 878 patients of all TBI severities with an indication for intracranial pressure (ICP) monitoring were included in the present study, of whom 739 (84%) patients had an IP monitor and 139 (16%) an EVD. Patients included were predominantly male (74% in the IP monitor and 76% in the EVD group), with a median age of 46 years in the IP group and 48 in the EVD group. Six-month GOS-E was similar between IP and EVD patients (adjusted odds ratio (aOR) and 95% confidence interval [CI] OR 0.74 and 95% CI [0.36-1.52], adjusted IV analysis). The length of intensive care unit stay was greater in the EVD group than in the IP group (adjusted rate ratio [95% CI] 1.70 [1.34-2.12], IV analysis). One hundred eighty-seven of the 739 patients in the IP group (25%) required an EVD due to refractory ICPs. CONCLUSION We found no major differences in outcomes of patients with TBI when comparing EVD-guided and IP monitor-guided ICP management. In our cohort, a quarter of patients that initially received an IP monitor required an EVD later for ICP control. The prevalence of complications was higher in the EVD group. PROTOCOL The core study is registered with ClinicalTrials.gov , number NCT02210221, and the Resource Identification Portal (RRID: SCR_015582).
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Thomas I, Dickens AM, Posti JP, Czeiter E, Duberg D, Sinioja T, Kråkström M, Retel Helmrich IRA, Wang KKW, Maas AIR, Steyerberg EW, Menon DK, Tenovuo O, Hyötyläinen T, Büki A, Orešič M. Serum metabolome associated with severity of acute traumatic brain injury. Nat Commun 2022; 13:2545. [PMID: 35538079 PMCID: PMC9090763 DOI: 10.1038/s41467-022-30227-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 04/21/2022] [Indexed: 12/12/2022] Open
Abstract
Complex metabolic disruption is a crucial aspect of the pathophysiology of traumatic brain injury (TBI). Associations between this and systemic metabolism and their potential prognostic value are poorly understood. Here, we aimed to describe the serum metabolome (including lipidome) associated with acute TBI within 24 h post-injury, and its relationship to severity of injury and patient outcome. We performed a comprehensive metabolomics study in a cohort of 716 patients with TBI and non-TBI reference patients (orthopedic, internal medicine, and other neurological patients) from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) cohort. We identified panels of metabolites specifically associated with TBI severity and patient outcomes. Choline phospholipids (lysophosphatidylcholines, ether phosphatidylcholines and sphingomyelins) were inversely associated with TBI severity and were among the strongest predictors of TBI patient outcomes, which was further confirmed in a separate validation dataset of 558 patients. The observed metabolic patterns may reflect different pathophysiological mechanisms, including protective changes of systemic lipid metabolism aiming to maintain lipid homeostasis in the brain.
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Affiliation(s)
- Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Alex M Dickens
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, Finland.,Department of Chemistry, University of Turku, Turku, Finland
| | - Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.,Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary
| | - Daniel Duberg
- Department of Chemistry, Örebro University, Örebro, Sweden
| | - Tim Sinioja
- Department of Chemistry, Örebro University, Örebro, Sweden
| | - Matilda Kråkström
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, Finland
| | - Isabel R A Retel Helmrich
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Olli Tenovuo
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - András Büki
- School of Medical Sciences, Örebro University, Örebro, Sweden.,Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.,Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden. .,Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, Finland.
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van Essen TA, Lingsma HF, Pisică D, Singh RD, Volovici V, den Boogert HF, Younsi A, Peppel LD, Heijenbrok-Kal MH, Ribbers GM, Walchenbach R, Menon DK, Hutchinson P, Depreitere B, Steyerberg EW, Maas AIR, de Ruiter GCW, Peul WC, Åkerlund C, Amrein K, Andelic N, Andreassen L, Anke A, Antoni A, Audibert G, Azouvi P, Azzolini ML, Bartels R, Barzó P, Beauvais R, Beer R, Bellander BM, Belli A, Benali H, Berardino M, Beretta L, Blaabjerg M, Bragge P, Brazinova A, Brinck V, Brooker J, Brorsson C, Buki A, Bullinger M, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Carbayo Lozano G, Carbonara M, Castaño-León AM, Cavallo S, Chevallard G, Chieregato A, Citerio G, Clusmann H, Coburn MS, Coles J, Cooper JD, Correia M, Čović A, Curry N, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, Dawes H, De Keyser V, Degos V, Della Corte F, Đilvesi Đ, Dixit A, Donoghue E, Dreier J, Dulière GL, Ercole A, Esser P, Ezer E, Fabricius M, Feigin VL, Foks K, Frisvold S, Furmanov A, Gagliardo P, Galanaud D, Gantner D, Gao G, George P, Ghuysen A, Giga L, Glocker B, Golubović J, Gomez PA, Gratz J, Gravesteijn B, Grossi F, Gruen RL, Gupta D, Haagsma JA, Haitsma I, Helbok R, Helseth E, Horton L, Huijben J, Jacobs B, Jankowski S, Jarrett M, Jiang JY, Johnson F, Jones K, Karan M, Kolias AG, Kompanje E, Kondziella D, Kornaropoulos E, Koskinen LO, Kovács N, Lagares A, Lanyon L, Laureys S, Lecky F, Ledoux D, Lefering R, Legrand V, Lejeune A, Levi L, Lightfoot R, Maegele M, Majdan M, Manara A, Manley G, Maréchal H, Martino C, Mattern J, McMahon C, Melegh B, Menovsky T, Mikolic A, Misset B, Muraleedharan V, Murray L, Nair N, Negru A, Nelson D, Newcombe V, Nieboer D, Nyirádi J, Oresic M, Ortolano F, Otesile O, Palotie A, Parizel PM, Payen JF, Perera N, Perlbarg V, Persona P, Piippo-Karjalainen A, Pirinen M, Ples H, Polinder S, Pomposo I, Posti JP, Puybasset L, Rădoi A, Ragauskas A, Raj R, Rambadagalla M, Rehorčíková V, Retel Helmrich I, Rhodes J, Richardson S, Richter S, Ripatti S, Rocka S, Roe C, Roise O, Rosand J, Rosenfeld J, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Rueckert D, Rusnák M, Sahuquillo J, Sakowitz O, Sanchez-Porras R, Sandor J, Schäfer N, Schmidt S, Schoechl H, Schoonman G, Schou RF, Schwendenwein E, Sewalt C, Skandsen T, Smielewski P, Sorinola A, Stamatakis E, Stanworth S, Kowark A, Stevens R, Stewart W, Stocchetti N, Sundström N, Takala R, Tamás V, Tamosuitis T, Taylor MS, Te Ao B, Tenovuo O, Theadom A, Thomas M, Tibboel D, Timmers M, Tolias C, Trapani T, Tudora CM, Unterberg A, Vajkoczy P, Valeinis E, Vallance S, Vámos Z, Van der Jagt M, van der Naalt J, Van der Steen G, van Dijck JT, Van Hecke W, van Heugten C, Van Praag D, Van Veen E, van Wijk R, Vande Vyvere T, Vargiolu A, Vega E, Velt K, Verheyden J, Vespa PM, Vik A, Vilcinis R, von Steinbüchel N, Voormolen D, Vulekovic P, Wang KK, Wiegers E, Williams G, Wilson L, Winzeck S, Wolf S, Yang Z, Ylén P, Zeiler FA, Ziverte A, Zoerle T. Surgery versus conservative treatment for traumatic acute subdural haematoma: a prospective, multicentre, observational, comparative effectiveness study. Lancet Neurol 2022; 21:620-631. [DOI: 10.1016/s1474-4422(22)00166-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 01/05/2023]
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Singh RD, van Dijck JTJM, Maas AIR, Peul WC, van Essen TA. Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies. World Neurosurg 2022; 161:410-417. [PMID: 35505561 DOI: 10.1016/j.wneu.2021.11.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions. METHODS The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists. RESULTS Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments. CONCLUSIONS In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.
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Affiliation(s)
- Ranjit D Singh
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands.
| | - Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
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Maas AIR, Ercole A, De Keyser V, Menon DK, Steyerberg EW. Opportunities and Challenges in High-Quality Contemporary Data Collection in Traumatic Brain Injury: The CENTER-TBI Experience. Neurocrit Care 2022; 37:192-201. [PMID: 35303262 DOI: 10.1007/s12028-022-01471-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/11/2022] [Indexed: 11/29/2022]
Abstract
Strong evidence in support of guidelines for traumatic brain injury (TBI) is lacking. Large-scale observational studies may offer a complementary source of evidence to clinical trials to improve the care and outcome for patients with TBI. They are, however, challenging to execute. In this review, we aim to characterize opportunities and challenges of large-scale collaborative research in neurotrauma. We use the setup and conduct of Collaborative European Neurotrauma Effectiveness Research in TBI (CENTER-TBI) as an illustrative example. We highlight the importance of building a team and of developing a network for younger researchers, thus investing toward the future. We involved investigators early in the design phase and recognized their efforts in a group contributor list on all publications. We found, however, that translation to academic credits often failed, and we suggest that the current system of academic credits be critically appraised. We found substantial variability in consent procedures for participant enrollment within and between countries. Overall, obtaining approvals typically required 4-6 months, with outliers up to 18 months. Research costs varied considerably across Europe and should be defined by center. We substantially underestimated costs of data curation, and we suggest that 15-20% of the budget be reserved for this purpose. Streamlining analyses and accommodating external research proposals demanded a structured approach. We implemented a systematic inventory of study plans and found this effective in maintaining oversight and in promoting collaboration between research groups. Ensuring good use of the data was a prominent feature in the review of external proposals. Multiple interactions occurred with industrial partners, mainly related to biomarkers and neuroimaging, and resulted in various formal collaborations, substantially extending the scope of CENTER-TBI. Overall, CENTER-TBI has been productive, with over 250 international peer-reviewed publications. We have ensured mechanisms to maintain the infrastructure and continued analyses. We see potential for individual patient data meta-analyses in connection to other large-scale projects. Our collaboration with Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) has taught us that although standardized data collection and coding according to common data elements can facilitate such meta-analyses, further data harmonization is required for meaningful results. Both CENTER-TBI and TRACK-TBI have demonstrated the complexity of the conduct of large-scale collaborative studies that produce high-quality science and new insights.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium.
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Box 93, Cambridge, CB2 0QQ, UK
| | - Veronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Box 93, Cambridge, CB2 0QQ, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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Maas AIR. Commentary: The Richmond Acute Subdural Hematoma Score: A Validated Grading Scale to Predict Postoperative Mortality. Neurosurgery 2022; 90:e60. [PMID: 35113834 DOI: 10.1227/neu.0000000000001801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Manley GT, Lingsma HF, Maas AIR. ADAPTing to a New Era of Comparative Effectiveness Research in Traumatic Brain Injury-Generating Evidence From Observational Data. JAMA Netw Open 2022; 5:e220899. [PMID: 35267038 DOI: 10.1001/jamanetworkopen.2022.0899] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Whitehouse DP, Vile AR, Adatia K, Herlekar R, Roy AS, Mondello S, Czeiter E, Amrein K, Büki A, Maas AIR, Menon DK, Newcombe VFJ. Blood Biomarkers and Structural Imaging Correlations Post-Traumatic Brain Injury: A Systematic Review. Neurosurgery 2022; 90:170-179. [PMID: 34995235 DOI: 10.1227/neu.0000000000001776] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Blood biomarkers are of increasing importance in the diagnosis and assessment of traumatic brain injury (TBI). However, the relationship between them and lesions seen on imaging remains unclear. OBJECTIVE To perform a systematic review of the relationship between blood biomarkers and intracranial lesion types, intracranial lesion injury patterns, volume/number of intracranial lesions, and imaging classification systems. METHODS We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, and Cumulative Index to Nursing and Allied Health Literature from inception to May 2021, and the references of included studies were also screened. Heterogeneity in study design, biomarker types, imaging modalities, and analyses inhibited quantitative analysis, with a qualitative synthesis presented. RESULTS Fifty-nine papers were included assessing one or more biomarker to imaging comparisons per paper: 30 assessed imaging classifications or injury patterns, 28 assessed lesion type, and 11 assessed lesion volume or number. Biomarker concentrations were associated with the burden of brain injury, as assessed by increasing intracranial lesion volume, increasing numbers of traumatic intracranial lesions, and positive correlations with imaging classification scores. There were inconsistent findings associating different biomarkers with specific imaging phenotypes including diffuse axonal injury, cerebral edema, and intracranial hemorrhage. CONCLUSION Blood-based biomarker concentrations after TBI are consistently demonstrated to correlate burden of intracranial disease. The relation with specific injury types is unclear suggesting a lack of diagnostic specificity and/or is the result of the complex and heterogeneous nature of TBI.
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Affiliation(s)
- Daniel P Whitehouse
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | | | - Krishma Adatia
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Rahul Herlekar
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Akangsha Sur Roy
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
- MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary
| | - Krisztina Amrein
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - András Büki
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
- Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Virginia F J Newcombe
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Whitehouse DP, Monteiro M, Czeiter E, Vyvere TV, Valerio F, Ye Z, Amrein K, Kamnitsas K, Xu H, Yang Z, Verheyden J, Das T, Kornaropoulos EN, Steyerberg E, Maas AIR, Wang KKW, Büki A, Glocker B, Menon DK, Newcombe VFJ. Relationship of admission blood proteomic biomarkers levels to lesion type and lesion burden in traumatic brain injury: A CENTER-TBI study. EBioMedicine 2022; 75:103777. [PMID: 34959133 PMCID: PMC8718895 DOI: 10.1016/j.ebiom.2021.103777] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/12/2021] [Accepted: 12/10/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We aimed to understand the relationship between serum biomarker concentration and lesion type and volume found on computed tomography (CT) following all severities of TBI. METHODS Concentrations of six serum biomarkers (GFAP, NFL, NSE, S100B, t-tau and UCH-L1) were measured in samples obtained <24 hours post-injury from 2869 patients with all severities of TBI, enrolled in the CENTER-TBI prospective cohort study (NCT02210221). Imaging phenotypes were defined as intraparenchymal haemorrhage (IPH), oedema, subdural haematoma (SDH), extradural haematoma (EDH), traumatic subarachnoid haemorrhage (tSAH), diffuse axonal injury (DAI), and intraventricular haemorrhage (IVH). Multivariable polynomial regression was performed to examine the association between biomarker levels and both distinct lesion types and lesion volumes. Hierarchical clustering was used to explore imaging phenotypes; and principal component analysis and k-means clustering of acute biomarker concentrations to explore patterns of biomarker clustering. FINDINGS 2869 patient were included, 68% (n=1946) male with a median age of 49 years (range 2-96). All severities of TBI (mild, moderate and severe) were included for analysis with majority (n=1946, 68%) having a mild injury (GCS 13-15). Patients with severe diffuse injury (Marshall III/IV) showed significantly higher levels of all measured biomarkers, with the exception of NFL, than patients with focal mass lesions (Marshall grades V/VI). Patients with either DAI+IVH or SDH+IPH+tSAH, had significantly higher biomarker concentrations than patients with EDH. Higher biomarker concentrations were associated with greater volume of IPH (GFAP, S100B, t-tau;adj r2 range:0·48-0·49; p<0·05), oedema (GFAP, NFL, NSE, t-tau, UCH-L1;adj r2 range:0·44-0·44; p<0·01), IVH (S100B;adj r2 range:0.48-0.49; p<0.05), Unsupervised k-means biomarker clustering revealed two clusters explaining 83·9% of variance, with phenotyping characteristics related to clinical injury severity. INTERPRETATION Interpretation: Biomarker concentration within 24 hours of TBI is primarily related to severity of injury and intracranial disease burden, rather than pathoanatomical type of injury. FUNDING CENTER-TBI is funded by the European Union 7th Framework programme (EC grant 602150).
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Affiliation(s)
- Daniel P Whitehouse
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Department of Computing, Imperial College, London, UK
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Rét u. 2, H-7623 Pécs, Hungary; Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Ifjúság útja 20, H-7624 Pécs, Hungary; MTA-PTE Clinical Neuroscience MR Research Group; Pécs, Hungary
| | - Thijs Vande Vyvere
- Research and Development, Icometrix, Leuven, Belgium; Department of Radiology, Antwerp University Hospital and University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Fernanda Valerio
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Zheng Ye
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Krisztina Amrein
- Department of Neurosurgery, Medical School, University of Pécs, Rét u. 2, H-7623 Pécs, Hungary; Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Ifjúság útja 20, H-7624 Pécs, Hungary
| | | | - Haiyan Xu
- Program for Neurotrauma, Neuroproteomics and Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, McKnight Brain Institute, L4-100L 1149 South Newell Drive, Gainesville, FL 32611, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroproteomics and Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, McKnight Brain Institute, L4-100L 1149 South Newell Drive, Gainesville, FL 32611, USA
| | - Jan Verheyden
- Research and Development, Icometrix, Leuven, Belgium
| | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | | | - Ewout Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Wijlrijkstraat 10, 2650 Edegem, Belgium
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics and Biomarker Research, Departments of Emergency Medicine, Psychiatry and Neuroscience, University of Florida, McKnight Brain Institute, L4-100L 1149 South Newell Drive, Gainesville, FL 32611, USA; Brain Rehabilitation Research Center, Malcom Randall Veterans Affairs Medical Center (VAMC), 1601 SW, Archer Rd. Gainesville FL 32608, USA
| | - András Büki
- Department of Neurosurgery, Medical School, University of Pécs, Rét u. 2, H-7623 Pécs, Hungary; Neurotrauma Research Group, Szentágothai Research Centre, University of Pécs, Ifjúság útja 20, H-7624 Pécs, Hungary
| | - Ben Glocker
- Biomedical Image Analysis Group, Department of Computing, Imperial College, London, UK
| | - David K Menon
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Virginia F J Newcombe
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK.
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Abstract
IMPORTANCE An interview is considered the gold standard method of assessing global functional outcomes in clinical trials among patients with acute traumatic brain injury (TBI). However, several multicenter clinical trials have used questionnaires completed by a patient or caregiver to assess the primary end point. OBJECTIVE To examine agreement between interview and questionnaire formats for assessing TBI outcomes and to consider whether an interview has advantages. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from patients enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) project from December 2014 to December 2017. Data were analyzed from December 2020 to April 2021. Included patients were aged 16 years or older with TBI and a clinical indication for computed tomography imaging. Outcome assessments were completed using both an interview and a questionnaire at follow-up 3 and 6 months after injury. EXPOSURES Traumatic brain injury of all severities. MAIN OUTCOMES AND MEASURES Ratings on the Glasgow Outcome Scale-Extended (GOSE) administered as a structured interview rated by an investigator and as a questionnaire completed by patients or caregivers and scored centrally were compared, and the strength of agreement was evaluated using weighted κ statistics. Secondary outcomes included comparison of different sections of the GOSE assessments and the association of GOSE ratings with baseline factors and patient-reported mental health, health-related quality of life, and TBI symptoms. RESULTS Among the 3691 eligible individuals in the CENTER-TBI study, both GOSE assessment formats (interview and questionnaire) were completed by 994 individuals (26.9%) at 3 months after TBI (654 [65.8%] male; median age, 53 years [IQR, 33-66 years]) and 628 (17.0%) at 6 months (409 [65.1%] male; median age, 51 years [IQR, 31-64 years]). Outcomes of the 2 assessment methods agreed well at both 3 months (weighted κ, 0.77; 95% CI, 0.73-0.80) and 6 months (weighted κ, 0.82; 95% CI, 0.78-0.86). Furthermore, item-level agreement between the 2 methods was good for sections regarding independence in everyday activities (κ, 0.70-0.79 across both time points) and moderate for sections regarding subjective aspects of functioning such as relationships and symptoms (κ, 0.41-0.51 across both time points). Compared with questionnaires, interviews recorded more problems with work (294 [30.5%] vs 233 [24.2%] at 3 months and 161 [26.8%] vs 136 [22.7%] at 6 months), fewer limitations in social and leisure activities (330 [33.8%] vs 431 [44.1%] at 3 months and 179 [29.7%] vs 219 [36.4%] at 6 months), and more symptoms (524 [53.6%] vs 324 [33.1%] at 3 months and 291 [48.4%] vs 179 [29.8%] at 6 months). Interviewers sometimes assigned an overall rating based on judgment rather than interview scoring rules, particularly for patients with potentially unfavorable TBI outcomes. However, for both formats, correlations with baseline factors (ρ, -0.13 to 0.42) and patient-reported outcomes (ρ, 0.29 to 0.65) were similar in strength. CONCLUSIONS AND RELEVANCE In this cohort study, GOSE ratings obtained by questionnaire and interview methods were in good agreement. The similarity of associations of the ratings obtained by both GOSE methods with baseline factors and other TBI outcome measures suggests that despite some apparent differences, the core information collected by both interviews and questionnaires was similar. The findings support the use of questionnaires in studies in which this form of contact may offer substantial practical advantages compared with interviews.
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Affiliation(s)
- Lindsay Horton
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Jonathan Rhodes
- Department of Anaesthesia, University of Edinburgh, Western General, Edinburgh, United Kingdom
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
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Van Praag DLG, Van Den Eede F, Wouters K, Wilson L, Maas AIR. The Impact of Neurocognitive Functioning on the Course of Posttraumatic Stress Symptoms following Civilian Traumatic Brain Injury. J Clin Med 2021; 10:jcm10215109. [PMID: 34768628 PMCID: PMC8584567 DOI: 10.3390/jcm10215109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/15/2021] [Accepted: 10/28/2021] [Indexed: 11/18/2022] Open
Abstract
Background: One out of seven individuals who have suffered a traumatic brain injury (TBI) develops a posttraumatic stress disorder (PTSD), which is often associated with neurocognitive impairment. The present study explores the impact of neurocognitive functioning after mild, moderate, and severe TBI on the course of PTSD symptoms. Methods: The data of 671 adults admitted to hospital for a TBI was drawn from the Collaborative European Neurotrauma Effectiveness Research (CENTER-TBI) study. After six- and 12-months post-injury, participants completed the PTSD Checklist-5 (PCL-5), from which change scores were calculated. At six months, participants also completed a neurocognitive assessment including the Rey Auditory Verbal Learning Test, the Trail Making Test, and the Cambridge Neuropsychological Test Automated Battery (CANTAB). Linear regressions were performed to identify associations between cognitive functioning and PCL-5 change scores. Results: Overall, mean PCL-5 change scores showed no clear change (−0.20 ± 9.88), but 87 improved and 80 deteriorated by a change score of 10 or more. CANTAB Rapid Visual Information Processing scores were significantly associated with PCL-5 change scores. Conclusions: Strong sustained attention was associated with improvement in PTSD symptoms. Assessing cognitive performance may help identify individuals at risk of developing (persisting) PTSD post-TBI and offer opportunities for informing treatment strategies.
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Affiliation(s)
- Dominique L. G. Van Praag
- Department of Psychology, Antwerp University Hospital, 2650 Edegem, Belgium
- Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, 2610 Wilrijk, Belgium
- Correspondence: ; Tel.: +32-3-821-56-14
| | - Filip Van Den Eede
- Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, 2610 Wilrijk, Belgium
- Department of Psychiatry, Antwerp University Hospital, 2650 Edegem, Belgium;
| | - Kristien Wouters
- Clinical Trial Center, Clinical Research Center Antwerp, Antwerp University Hospital, 2650 Edegem, Belgium;
- Antwerp Research Center, Faculty of Medicine, University of Antwerp, 2610 Wilrijk, Belgium
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling FK9 4LA, UK;
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, 2650 Edegem, Belgium;
- Translational Neurosciences, University of Antwerp, 2610 Wilrijk, Belgium
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Lecky FE, Otesile O, Marincowitz C, Majdan M, Nieboer D, Lingsma HF, Maegele M, Citerio G, Stocchetti N, Steyerberg EW, Menon DK, Maas AIR. The burden of traumatic brain injury from low-energy falls among patients from 18 countries in the CENTER-TBI Registry: A comparative cohort study. PLoS Med 2021; 18:e1003761. [PMID: 34520460 PMCID: PMC8509890 DOI: 10.1371/journal.pmed.1003761] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 10/12/2021] [Accepted: 08/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is an important global public health burden, where those injured by high-energy transfer (e.g., road traffic collisions) are assumed to have more severe injury and are prioritised by emergency medical service trauma triage tools. However recent studies suggest an increasing TBI disease burden in older people injured through low-energy falls. We aimed to assess the prevalence of low-energy falls among patients presenting to hospital with TBI, and to compare their characteristics, care pathways, and outcomes to TBI caused by high-energy trauma. METHODS AND FINDINGS We conducted a comparative cohort study utilising the CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) Registry, which recorded patient demographics, injury, care pathway, and acute care outcome data in 56 acute trauma receiving hospitals across 18 countries (17 countries in Europe and Israel). Patients presenting with TBI and indications for computed tomography (CT) brain scan between 2014 to 2018 were purposively sampled. The main study outcomes were (i) the prevalence of low-energy falls causing TBI within the overall cohort and (ii) comparisons of TBI patients injured by low-energy falls to TBI patients injured by high-energy transfer-in terms of demographic and injury characteristics, care pathways, and hospital mortality. In total, 22,782 eligible patients were enrolled, and study outcomes were analysed for 21,681 TBI patients with known injury mechanism; 40% (95% CI 39% to 41%) (8,622/21,681) of patients with TBI were injured by low-energy falls. Compared to 13,059 patients injured by high-energy transfer (HE cohort), the those injured through low-energy falls (LE cohort) were older (LE cohort, median 74 [IQR 56 to 84] years, versus HE cohort, median 42 [IQR 25 to 60] years; p < 0.001), more often female (LE cohort, 50% [95% CI 48% to 51%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001), more frequently taking pre-injury anticoagulants or/and platelet aggregation inhibitors (LE cohort, 44% [95% CI 42% to 45%], versus HE cohort, 13% [95% CI 11% to 14%]; p < 0.001), and less often presenting with moderately or severely impaired conscious level (LE cohort, 7.8% [95% CI 5.6% to 9.8%], versus HE cohort, 10% [95% CI 8.7% to 12%]; p < 0.001), but had similar in-hospital mortality (LE cohort, 6.3% [95% CI 4.2% to 8.3%], versus HE cohort, 7.0% [95% CI 5.3% to 8.6%]; p = 0.83). The CT brain scan traumatic abnormality rate was 3% lower in the LE cohort (LE cohort, 29% [95% CI 27% to 31%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001); individuals in the LE cohort were 50% less likely to receive critical care (LE cohort, 12% [95% CI 9.5% to 13%], versus HE cohort, 24% [95% CI 23% to 26%]; p < 0.001) or emergency interventions (LE cohort, 7.5% [95% CI 5.4% to 9.5%], versus HE cohort, 13% [95% CI 12% to 15%]; p < 0.001) than patients injured by high-energy transfer. The purposive sampling strategy and censorship of patient outcomes beyond hospital discharge are the main study limitations. CONCLUSIONS We observed that patients sustaining TBI from low-energy falls are an important component of the TBI disease burden and a distinct demographic cohort; further, our findings suggest that energy transfer may not predict intracranial injury or acute care mortality in patients with TBI presenting to hospital. This suggests that factors beyond energy transfer level may be more relevant to prehospital and emergency department TBI triage in older people. A specific focus to improve prevention and care for patients sustaining TBI from low-energy falls is required.
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Affiliation(s)
- Fiona E. Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Emergency Department, Salford Royal Hospital, Salford, United Kingdom
- * E-mail:
| | - Olubukola Otesile
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Carl Marincowitz
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Marek Majdan
- Department of Public Health, University of Trnava, Trnava, Slovakia
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marc Maegele
- Institute for Research in Operative Medicine, Witten/Herdecke University, Köln, Germany
| | - Giuseppe Citerio
- Neurointensive Care, Azienda Socio Sanitaria Territoriale di Monza, Monza, Italy
- School of Medicine and Surgery, Università degli Studi di Milano–Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - David K. Menon
- University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, Edegem, Belgium
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Wiegers EJA, Trapani T, Gabbe BJ, Gantner D, Lecky F, Maas AIR, Menon DK, Murray L, Rosenfeld JV, Vallance S, Lingsma HF, Steyerberg EW, Cooper DJ. Characteristics, management and outcomes of patients with severe traumatic brain injury in Victoria, Australia compared to United Kingdom and Europe: A comparison between two harmonised prospective cohort studies. Injury 2021; 52:2576-2587. [PMID: 33910683 DOI: 10.1016/j.injury.2021.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this manuscript is to compare characteristics, management, and outcomes of patients with severe Traumatic Brain Injury (TBI) between Australia, the United Kingdom (UK) and Europe. METHODS We enrolled patients with severe TBI in Victoria, Australia (OzENTER-TBI), in the UK and Europe (CENTER-TBI) from 2015 to 2017. Main outcome measures were mortality and unfavourable outcome (Glasgow Outcome Scale Extended <5) 6 months after injury. Expected outcomes were compared according to the IMPACT-CT prognostic model, with observed to expected (O/E) ratios and 95% confidence intervals. RESULTS We included 107 patients from Australia, 171 from UK, and 596 from Europe. Compared to the UK and Europe, patients in Australia were younger (median 32 vs 44 vs 44 years), a larger proportion had secondary brain insults including hypotension (30% vs 17% vs 21%) and a larger proportion received ICP monitoring (75% vs 74% vs 58%). Hospital length of stay was shorter in Australia than in the UK (median: 17 vs 23 vs 16 days), and a higher proportion of patients were discharged to a rehabilitation unit in Australia than in the UK and Europe (64% vs 26% vs 28%). Mortality overall was lower than expected (27% vs 35%, O/E ratio 0.77 [95% CI: 0.64 - 0.87]. O/E ratios were comparable between regions for mortality in Australia 0.86 [95% CI: 0.49-1.23] vs UK 0.82 [0.51-1.15] vs Europe 0.76 [0.60-0.87]). Unfavourable outcome rates overall were in line with historic expectations (O/E ratio 1.32 [0.96-1.68] vs 1.13 [0.84-1.42] vs 0.96 [0.85-1.09]). CONCLUSIONS There are major differences in case-mix between Australia, UK, and Europe; Australian patients are younger and have a higher rate of secondary brain insults. Despite some differences in management and discharge policies, mortality was less than expected overall, and did not differ between regions. Functional outcomes were similar between regions, but worse than expected, emphasizing the need to improve treatment for patients with severe TBI.
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Affiliation(s)
- Eveline J A Wiegers
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Tony Trapani
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Health Data Research UK, Swansea University, United Kingdom
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, Alfred Hospital, Melbourne, Australia
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK; Emergency Department, Salford Royal Hospital, Salford, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Shirley Vallance
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, Alfred Hospital, Melbourne, Australia
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Ercole A, Dixit A, Nelson DW, Bhattacharyay S, Zeiler FA, Nieboer D, Bouamra O, Menon DK, Maas AIR, Dijkland SA, Lingsma HF, Wilson L, Lecky F, Steyerberg EW. Imputation strategies for missing baseline neurological assessment covariates after traumatic brain injury: A CENTER-TBI study. PLoS One 2021; 16:e0253425. [PMID: 34358231 PMCID: PMC8345855 DOI: 10.1371/journal.pone.0253425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/03/2021] [Indexed: 12/02/2022] Open
Abstract
Statistical models for outcome prediction are central to traumatic brain injury research and critical to baseline risk adjustment. Glasgow coma score (GCS) and pupil reactivity are crucial covariates in all such models but may be measured at multiple time points between the time of injury and hospital and are subject to a variable degree of unreliability and/or missingness. Imputation of missing data may be undertaken using full multiple imputation or by simple substitution of measurements from other time points. However, it is unknown which strategy is best or which time points are more predictive. We evaluated the pseudo-R2 of logistic regression models (dichotomous survival) and proportional odds models (Glasgow Outcome Score—extended) using different imputation strategies on the The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset. Substitution strategies were easy to implement, achieved low levels of missingness (<< 10%) and could outperform multiple imputation without the need for computationally costly calculations and pooling multiple final models. While model performance was sensitive to imputation strategy, this effect was small in absolute terms and clinical relevance. A strategy of using the emergency department discharge assessments and working back in time when these were missing generally performed well. Full multiple imputation had the advantage of preserving time-dependence in the models: the pre-hospital assessments were found to be relatively unreliable predictors of survival or outcome. The predictive performance of later assessments was model-dependent. In conclusion, simple substitution strategies for imputing baseline GCS and pupil response can perform well and may be a simple alternative to full multiple imputation in many cases.
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Affiliation(s)
- Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - David W. Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Omar Bouamra
- Trauma Audit Research Network, University of Manchester, Salford, United Kingdom
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Simone A. Dijkland
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Center for Medical Decision Making, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Center for Medical Decision Making, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Center for Medical Decision Making, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, Netherlands
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Sewalt CA, Gravesteijn BY, Menon D, Lingsma HF, Maas AIR, Stocchetti N, Venema E, Lecky FE. Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study. Scand J Trauma Resusc Emerg Med 2021; 29:113. [PMID: 34348784 PMCID: PMC8340517 DOI: 10.1186/s13049-021-00930-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00930-1.
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Affiliation(s)
- Charlie Aletta Sewalt
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Benjamin Yaël Gravesteijn
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Anesthesiology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Esmee Venema
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - Fiona E Lecky
- Center for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Yuh EL, Jain S, Sun X, Pisica D, Harris MH, Taylor SR, Markowitz AJ, Mukherjee P, Verheyden J, Giacino JT, Levin HS, McCrea M, Stein MB, Temkin NR, Diaz-Arrastia R, Robertson CS, Lingsma HF, Okonkwo DO, Maas AIR, Manley GT, Adeoye O, Badjatia N, Boase K, Bodien Y, Corrigan JD, Crawford K, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Keene CD, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Nelson L, Ngwenya LB, Noel F, Nolan A, Palacios E, Perl D, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Toga A, Valadka A, Vassar M, Zafonte R. Pathological Computed Tomography Features Associated With Adverse Outcomes After Mild Traumatic Brain Injury: A TRACK-TBI Study With External Validation in CENTER-TBI. JAMA Neurol 2021; 78:1137-1148. [PMID: 34279565 PMCID: PMC8290344 DOI: 10.1001/jamaneurol.2021.2120] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Question Are different patterns of intracranial injury on head computed tomography associated with prognosis after mild traumatic brain injury (mTBI)? Findings In this cohort study, subarachnoid hemorrhage, subdural hematoma, and contusion often co-occurred and were associated with both incomplete recovery and more severe impairment out to 12 months after injury, while intraventricular and/or petechial hemorrhage co-occurred and were associated with more severe impairment up to 12 months after injury; epidural hematoma was associated with incomplete recovery at some points but not with more severe impairment. Some intracranial hemorrhage patterns were more strongly associated with outcomes than previously validated demographic and clinical variables. Meaning In this study, different pathological features on head computed tomography carried different implications for mild traumatic brain injury prognosis to 1 year. Importance A head computed tomography (CT) with positive results for acute intracranial hemorrhage is the gold-standard diagnostic biomarker for acute traumatic brain injury (TBI). In moderate to severe TBI (Glasgow Coma Scale [GCS] scores 3-12), some CT features have been shown to be associated with outcomes. In mild TBI (mTBI; GCS scores 13-15), distribution and co-occurrence of pathological CT features and their prognostic importance are not well understood. Objective To identify pathological CT features associated with adverse outcomes after mTBI. Design, Setting, and Participants The longitudinal, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study enrolled patients with TBI, including those 17 years and older with GCS scores of 13 to 15 who presented to emergency departments at 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018, and underwent head CT imaging within 24 hours of TBI. Evaluations of CT imaging used TBI Common Data Elements. Glasgow Outcome Scale–Extended (GOSE) scores were assessed at 2 weeks and 3, 6, and 12 months postinjury. External validation of results was performed via the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Data analyses were completed from February 2020 to February 2021. Exposures Acute nonpenetrating head trauma. Main Outcomes and Measures Frequency, co-occurrence, and clustering of CT features; incomplete recovery (GOSE scores <8 vs 8); and an unfavorable outcome (GOSE scores <5 vs ≥5) at 2 weeks and 3, 6, and 12 months. Results In 1935 patients with mTBI (mean [SD] age, 41.5 [17.6] years; 1286 men [66.5%]) in the TRACK-TBI cohort and 2594 patients with mTBI (mean [SD] age, 51.8 [20.3] years; 1658 men [63.9%]) in an external validation cohort, hierarchical cluster analysis identified 3 major clusters of CT features: contusion, subarachnoid hemorrhage, and/or subdural hematoma; intraventricular and/or petechial hemorrhage; and epidural hematoma. Contusion, subarachnoid hemorrhage, and/or subdural hematoma features were associated with incomplete recovery (odds ratios [ORs] for GOSE scores <8 at 1 year: TRACK-TBI, 1.80 [95% CI, 1.39-2.33]; CENTER-TBI, 2.73 [95% CI, 2.18-3.41]) and greater degrees of unfavorable outcomes (ORs for GOSE scores <5 at 1 year: TRACK-TBI, 3.23 [95% CI, 1.59-6.58]; CENTER-TBI, 1.68 [95% CI, 1.13-2.49]) out to 12 months after injury, but epidural hematoma was not. Intraventricular and/or petechial hemorrhage was associated with greater degrees of unfavorable outcomes up to 12 months after injury (eg, OR for GOSE scores <5 at 1 year in TRACK-TBI: 3.47 [95% CI, 1.66-7.26]). Some CT features were more strongly associated with outcomes than previously validated variables (eg, ORs for GOSE scores <5 at 1 year in TRACK-TBI: neuropsychiatric history, 1.43 [95% CI .98-2.10] vs contusion, subarachnoid hemorrhage, and/or subdural hematoma, 3.23 [95% CI 1.59-6.58]). Findings were externally validated in 2594 patients with mTBI enrolled in the CENTER-TBI study. Conclusions and Relevance In this study, pathological CT features carried different prognostic implications after mTBI to 1 year postinjury. Some patterns of injury were associated with worse outcomes than others. These results support that patients with mTBI and these CT features need TBI-specific education and systematic follow-up.
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Affiliation(s)
- Esther L Yuh
- Brain and Spinal Injury Center, San Francisco, California.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
| | - Dana Pisica
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Mark H Harris
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Amy J Markowitz
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, San Francisco, California.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco
| | - Jan Verheyden
- Research and Development, Icometrix, Leuven, Belgium
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Harvey S Levin
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla.,Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle
| | | | | | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Geoffrey T Manley
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joel Kramer
- University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | - Amber Nolan
- University of California, San Francisco, San Francisco
| | - Eva Palacios
- University of California, San Francisco, San Francisco
| | - Daniel Perl
- Uniformed Services University, Bethesda, Maryland
| | | | | | | | | | | | | | - Arthur Toga
- University of Southern California, Los Angeles
| | | | - Mary Vassar
- University of California, San Francisco, San Francisco
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von Steinbuechel N, Rauen K, Krenz U, Wu YJ, Covic A, Plass AM, Cunitz K, Mueller I, Bockhop F, Polinder S, Wilson L, Steyerberg EW, Maas AIR, Menon D, Zeldovich M. Translation and Linguistic Validation of Outcome Instruments for Traumatic Brain Injury Research and Clinical Practice: A Step-by-Step Approach within the Observational CENTER-TBI Study. J Clin Med 2021; 10:2863. [PMID: 34203325 PMCID: PMC8269004 DOI: 10.3390/jcm10132863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/16/2022] Open
Abstract
Assessing outcomes in multinational studies on traumatic brain injury (TBI) poses major challenges and requires relevant instruments in languages other than English. Of the 19 outcome instruments selected for use in the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, 17 measures lacked translations in at least one target language. To fill this gap, we aimed to develop well-translated linguistically and psychometrically validated instruments. We performed translations and linguistic validations of patient-reported measures (PROMs), clinician-reported (ClinRO), and performance-based (PerfO) outcome instruments, using forward and backward translations, reconciliations, cognitive debriefings with up to 10 participants, iterative revisions, and international harmonization with input from over 150 international collaborators. In total, 237 translations and 211 linguistic validations were carried out in up to 20 languages. Translations were evaluated at the linguistic and cultural level by coding changes when the original versions are compared with subsequent translation steps, using the output of cognitive debriefings, and using comprehension rates. The average comprehension rate per instrument varied from 88% to 98%, indicating a good quality of the translations. These outcome instruments provide a solid basis for future TBI research and clinical practice and allow the aggregation and analysis of data across different countries and languages.
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Affiliation(s)
- Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Katrin Rauen
- Department of Geriatric Psychiatry, Psychiatric Hospital Zurich, University of Zurich, Minervastrasse 145, 8032 Zurich, Switzerland; or
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Feodor-Lynen-Straße 17, 81377 Munich, Germany
| | - Ugne Krenz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Yi-Jhen Wu
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Anne Marie Plass
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Katrin Cunitz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Isabelle Mueller
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Fabian Bockhop
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.P.); (E.W.S.)
| | - Lindsay Wilson
- Department of Psychology, University of Stirling, Stirling FK9 4LJ, UK;
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.P.); (E.W.S.)
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 RC Leiden, The Netherlands
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium;
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Box 157, Cambridge CB2 0QQ, UK;
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
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von Steinbuechel N, Rauen K, Bockhop F, Covic A, Krenz U, Plass AM, Cunitz K, Polinder S, Wilson L, Steyerberg EW, Maas AIR, Menon D, Wu YJ, Zeldovich M, Investigators TCENTERTBIPA. Psychometric Characteristics of the Patient-Reported Outcome Measures Applied in the CENTER-TBI Study. J Clin Med 2021; 10:2396. [PMID: 34071667 PMCID: PMC8199160 DOI: 10.3390/jcm10112396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 01/31/2023] Open
Abstract
Traumatic brain injury (TBI) may lead to impairments in various outcome domains. Since most instruments assessing these are only available in a limited number of languages, psychometrically validated translations are important for research and clinical practice. Thus, our aim was to investigate the psychometric properties of the patient-reported outcome measures (PROM) applied in the CENTER-TBI study. The study sample comprised individuals who filled in the six-months assessments (GAD-7, PHQ-9, PCL-5, RPQ, QOLIBRI/-OS, SF-36v2/-12v2). Classical psychometric characteristics were investigated and compared with those of the original English versions. The reliability was satisfactory to excellent; the instruments were comparable to each other and to the original versions. Validity analyses demonstrated medium to high correlations with well-established measures. The original factor structure was replicated by all the translations, except for the RPQ, SF-36v2/-12v2 and some language samples for the PCL-5, most probably due to the factor structure of the original instruments. The translation of one to two items of the PHQ-9, RPQ, PCL-5, and QOLIBRI in three languages could be improved in the future to enhance scoring and application at the individual level. Researchers and clinicians now have access to reliable and valid instruments to improve outcome assessment after TBI in national and international health care.
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Affiliation(s)
- Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
| | - Katrin Rauen
- Department of Geriatric Psychiatry, Psychiatric Hospital Zurich, University of Zurich, Minervastrasse 145, 8032 Zurich, Switzerland; or
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Feodor-Lynen-Straße 17, 81377 Munich, Germany
| | - Fabian Bockhop
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
| | - Ugne Krenz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
| | - Anne Marie Plass
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
| | - Katrin Cunitz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.P.); (E.W.S.)
| | - Lindsay Wilson
- Department of Psychology, University of Stirling, Stirling FK9 4LJ, UK;
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.P.); (E.W.S.)
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 RC Leiden, The Netherlands
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium;
| | - David Menon
- Division of Anaesthesia, University of Cambridge/Addenbrooke’s Hospital, Box 157, Cambridge CB2 0QQ, UK;
| | - Yi-Jhen Wu
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (F.B.); (A.C.); (U.K.); (A.M.P.); (K.C.); (Y.-J.W.); (M.Z.)
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Maas AIR, Steyerberg EW. Commentary: Disability Rating Scale in the First Few Weeks After a Severe Traumatic Brain Injury as a Predictor of 6-Month Functional Outcome. Neurosurgery 2021; 88:E242-E243. [PMID: 33428755 DOI: 10.1093/neuros/nyaa488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.,Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
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Huijben JA, Dixit A, Stocchetti N, Maas AIR, Lingsma HF, van der Jagt M, Nelson D, Citerio G, Wilson L, Menon DK, Ercole A. Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis. Crit Care 2021; 25:78. [PMID: 33622371 PMCID: PMC7901510 DOI: 10.1186/s13054-020-03370-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs). METHODS We studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP. RESULTS 313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0-2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome. CONCLUSION Substantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies. TAKE HOME MESSAGE Substantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments. TRIAL REGISTRATION The core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).
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Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
- Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Maas AIR, Peul W, Thomé C. Surgical decompression in acute spinal cord injury: earlier is better. Lancet Neurol 2020; 20:84-86. [PMID: 33357515 DOI: 10.1016/s1474-4422(20)30478-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem 2650, Belgium.
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, Netherlands; Department of Neurosurgery, Haaglanden Medical Centre, The Hague, Netherlands
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
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Dijkland SA, Helmrich IRAR, Nieboer D, van der Jagt M, Dippel DWJ, Menon DK, Stocchetti N, Maas AIR, Lingsma HF, Steyerberg EW. Outcome Prediction after Moderate and Severe Traumatic Brain Injury: External Validation of Two Established Prognostic Models in 1742 European Patients. J Neurotrauma 2020; 38:1377-1388. [PMID: 33161840 DOI: 10.1089/neu.2020.7300] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models predict functional outcome after moderate and severe traumatic brain injury (TBI). We aimed to assess their performance in a contemporary cohort of patients across Europe. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core study is a prospective, observational cohort study in patients presenting with TBI and an indication for brain computed tomography. The CENTER-TBI core cohort consists of 4509 TBI patients available for analyses from 59 centers in 18 countries across Europe and Israel. The IMPACT validation cohort included 1173 patients with GCS ≤12, age ≥14, and 6-month Glasgow Outcome Scale-Extended (GOSE) available. The CRASH validation cohort contained 1742 patients with GCS ≤14, age ≥16, and 14-day mortality or 6-month GOSE available. Performance of the three IMPACT and two CRASH model variants was assessed with discrimination (area under the receiver operating characteristic curve; AUC) and calibration (comparison of observed vs. predicted outcome rates). For IMPACT, model discrimination was good, with AUCs ranging between 0.77 and 0.85 in 1173 patients and between 0.80 and 0.88 in the broader CRASH selection (n = 1742). For CRASH, AUCs ranged between 0.82 and 0.88 in 1742 patients and between 0.66 and 0.80 in the stricter IMPACT selection (n = 1173). Calibration of the IMPACT and CRASH models was generally moderate, with calibration-in-the-large and calibration slopes ranging between -2.02 and 0.61 and between 0.48 and 1.39, respectively. The IMPACT and CRASH models adequately identify patients at high risk for mortality or unfavorable outcome, which supports their use in research settings and for benchmarking in the context of quality-of-care assessment.
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Affiliation(s)
- Simone A Dijkland
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Isabel R A Retel Helmrich
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - David K Menon
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
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Mikolić A, Polinder S, Steyerberg EW, Retel Helmrich IRA, Giacino JT, Maas AIR, van der Naalt J, Voormolen DC, von Steinbüchel N, Wilson L, Lingsma HF, van Klaveren D. Prediction of Global Functional Outcome and Post-Concussive Symptoms after Mild Traumatic Brain Injury: External Validation of Prognostic Models in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2020; 38:196-209. [PMID: 32977737 DOI: 10.1089/neu.2020.7074] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The majority of traumatic brain injuries (TBIs) are categorized as mild, according to a baseline Glasgow Coma Scale (GCS) score of 13-15. Prognostic models that were developed to predict functional outcome and persistent post-concussive symptoms (PPCS) after mild TBI have rarely been externally validated. We aimed to externally validate models predicting 3-12-month Glasgow Outcome Scale Extended (GOSE) or PPCS in adults with mild TBI. We analyzed data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) project, which included 2862 adults with mild TBI, with 6-month GOSE available for 2374 and Rivermead Post-Concussion Symptoms Questionnaire (RPQ) results available for 1605 participants. Model performance was evaluated based on calibration (graphically and characterized by slope and intercept) and discrimination (C-index). We validated five published models for 6-month GOSE and three for 6-month PPCS scores. The models used different cutoffs for outcome and some included symptoms measured 2 weeks post-injury. Discriminative ability varied substantially (C-index between 0.58 and 0.79). The models developed in the Corticosteroid Randomisation After Significant Head Injury (CRASH) trial for prediction of GOSE <5 discriminated best (C-index 0.78 and 0.79), but were poorly calibrated. The best performing models for PPCS included 2-week symptoms (C-index 0.75 and 0.76). In conclusion, none of the prognostic models for early prediction of GOSE and PPCS has both good calibration and discrimination in persons with mild TBI. In future studies, prognostic models should be tailored to the population with mild TBI, predicting relevant end-points based on readily available predictors.
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Affiliation(s)
- Ana Mikolić
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Isabel R A Retel Helmrich
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Daphne C Voormolen
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David van Klaveren
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.,Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies/Tufts Medical Center, Boston, Massachusetts, USA
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