Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Higher age is a major driver of in-hospital adverse events independent of comorbid diseases among patients with isolated mild traumatic brain injury

PURPOSE

The goal of this study was to investigate if and to what extent age, independent of comorbid diseases, is a risk factor for negative in-hospital outcome with mTBI.

METHODS

In a retrospective cohort study, we identified 1589 adult patients treated for isolated mTBI in our level-1 trauma center between 2008 and 2015. We used logistic regression analyses to assess the odds of any adverse event by age group (< 65, 65-75, 76-85, and 85+), adjusting for gender and chronic diseases.

RESULTS

The prevalence of any adverse event during in-hospital care among mTBI patients was 3.2% overall, 1.8% among those younger than age 65 years, 2.1% among those age 65-75 years, 8% among those age 75-85 years, and 19% among those age 85+ years. The odds of any adverse event were similar in patients aged 65-75 years, but increased among senior patients 4.4-fold for age 75-85 years (OR 4.4, 95%CI 2.0-9.8, p < 0.001), and 18-fold for age 85+ years (OR 18.0, 95%CI 8.7-37, p < 0.001). Additionally, chronic alcohol abuse (OR 7.0, 95%CI 3.2-15, p < 0.001), diseases of the musculoskeletal system (OR 4.3, 95%CI 1.5-13, p = 0.008), and diabetes mellitus (OR 2.7, 95%CI 1.2-6.5, p = 0.023) increased the odds of any adverse events independent of age and all other covariates.

CONCLUSIONS

The odds of sustaining an adverse event increased exponentially after age 75 independent of gender and any comorbid diseases. Our data support international efforts to manage senior patients in interdisciplinary geriatric trauma units.

Hydrocephalus communicans after traumatic upper cervical spine injury with a cerebrospinal fluid fistula: a rare complication

Secondary hydrocephalus communicans after traumatic upper cervical spine injuries with leakage of cerebrospinal fluid is a rare and hardly described complication. A case of a 75-year-old woman sustained a type II dens axis without other injuries, especially without evidence of a hydrocephalus in the primary CT scan. Dorsal atlanto-axial fusion was performed. Postoperative drainage was prolonged and positive for β2-transferrin. Wound revision with an attempt to seal the leakage was not successful. Secondary CT scans of the brain were performed due to neurological deterioration and showed a hydrocephalus with typical EEG findings. No anatomical reason for a circulative obstruction was found in the CT scan. After application of a ventriculo-peritoneal shunt the neurological status improved and the patient could be discharged to neurological rehabilitation.