Impact of decompressive craniectomy on functional outcome of severe acquired brain injuries patients, at discharge from intensive inpatient rehabilitation

The effect of decompressive craniectomy (DC) on survival and functional outcome in traumatic brain injuries (TBI) is far from satisfactory. Additional modalities including cisternal drainage (CD) that provides good control of refractory intracranial pressure (ICP) intraoperatively need careful scrutiny. Two centre retrospective superiority study with one centre offering only standard decompressive craniectomy (DC) i.e. Group 1 and the other centre supplementing cisternal drainage (CD) to standard DC i.e. Group 2 was conducted. Consecutive patients with traumatic brain injury with signs of brain herniation or CT scan showing mass lesion or diffuse brain edema or midline shift or with GCS less than 9 or rapid fall in GCS over 2 points with persistently raised ICP of 25 mmHg over 15 minutes between August 2012 and July 2017 were included. The primary outcome was rating on Glasgow Outcome Scale (GOS) at 6 months post operatively, with GOS (1-3) categorized as ‘Unfavorable’ and GOS (4,5) as ‘Favorable’. Patients either received DC alone (Group 1=73 patients, 48.7%) or DC with CD (Group 2=77 patients, 51.3%). 107 (71.3%) severe, 36 (24%) moderate, and 7 (4.7%) mild head injuries cases received 72 unilateral and 78 bilateral DC. GOS 1 was observed in 32 DC only group (43.8%) and 22 DC plus CD group (28.6%) (p=0.052), an absolute risk reduction of 15.2% was found. Outcome (favorable sun favorable) against all strata of head injury severity, predominant radiological feature, laterality of surgery, and patient characteristics across the two groups were statistically not significant, however the groups were statistically significantly different on age and GCS at presentation (p=0.016 & 0.034 consecutively). Distinct survival benefit in patients with traumatic brain injury receiving cisternal drainage during decompressive craniectomy did not translate to better functional outcome.

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Early versus late decompressive craniectomy in traumatic brain injury: A retrospective comparative case study

Trauma ◽

10.1177/1460408620935766 ◽

2020 ◽

pp. 146040862093576

Author(s):

Nida Fatima ◽

Mujeeb-Ur-Rehman ◽

Samia Shaukat ◽

Ashfaq Shuaib ◽

Ali Raza ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Regression Analysis ◽

Brain Injury ◽

Functional Outcome ◽

Decompressive Craniectomy ◽

Univariate Analysis ◽

Timing Of Surgery ◽

Comparative Case Study ◽

Outcome Parameters ◽

Good Functional Outcome

Objectives Decompressive craniectomy is a last-tier therapy in the treatment of raised intracranial pressure after traumatic brain injury. We report the association of demographic, radiographic, and injury characteristics with outcome parameters in early (<24 h) and late (≥24 h) decompressive craniectomy following traumatic brain injury. Methods We retrospectively identified 204 patients (158 (early decompressive craniectomy) and 46 (late decompressive craniectomy)), with a median age of 34 years (range 2–78 years) between 2015 and 2018. The primary endpoint was Glasgow Outcome Scale Extended (GOSE) at 60 days, while secondary endpoints included Glasgow Coma Score (GCS) at discharge, mortality at 30 days, and length of hospital stay. Regression analysis was used to assess the independent predictive variables of functional outcome. Results With a clinical follow-up of 60 days, the good functional outcome (GOSE = 5–8) was 73.5% versus 74.1% (p = 0.75) in early and late decompressive craniectomy, respectively. GCS ≥ 9 at discharge was 82.2% versus 91.3% (p = 0.21), mortality at 30 days was 10.8% versus 8.7% (p = 0.39), and length of stay in the hospital was 21 days versus 28 days (p = 0.20), respectively, in early and late decompressive craniectomy groups. Univariate analysis identified that GCS at admission (0.07 (0.32–0.18; < 0.05)) and indication for decompressive craniectomy (3.7 (1.3–11.01; 0.01)) are significantly associated with good functional outcome. Multivariate regression analysis revealed that GCS at admission (<9/≥9) (0.07 (0.03–0.16; <0.05)) and indication for decompressive craniectomy (extradural alone/ other hematoma) (1.75 (1.09–3.25; 0.02)) were significant independent predictors of good functional outcome irrespective of the timing of surgery. Conclusions Our results corroborate that the timing of surgery does not affect the outcome parameters. Furthermore, GCS ≥ 9 and/or extra dural hematoma are associated with relatively good clinical outcome after decompressive craniectomy.

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Functional outcome of inpatient rehabilitation in persons with brain tumors

Archives of Physical Medicine and Rehabilitation ◽

10.1016/s0003-9993(98)90414-2 ◽

1998 ◽

Vol 79 (12) ◽

pp. 1530-1534 ◽

Cited By ~ 101

Author(s):

Michael W. O'Dell ◽

Karen Barr ◽

David Spanier ◽

Ronald E. Warnick

Keyword(s):

Brain Tumors ◽

Functional Outcome ◽

Inpatient Rehabilitation

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Long-Term Effects of Decompressive Craniectomy on Functional Outcomes after Traumatic Brain Injury: A Multicenter Study

The American Surgeon ◽

10.1177/000313481808400844 ◽

2018 ◽

Vol 84 (8) ◽

pp. 1314-1318 ◽

Cited By ~ 1

Author(s):

Eliza Moskowitz ◽

Claudia I. Melendez ◽

Julie Dunn ◽

Abid D. Khan ◽

Richard Gonzalez ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Confidence Interval ◽

Functional Outcome ◽

Decompressive Craniectomy ◽

Functional Outcomes ◽

Structured Interview ◽

Good Functional Outcome

Decompressive craniectomy (DC) is a surgical modality sometimes used in the management of elevated intracranial pressure. Questions remain as to its long-term benefits in traumatic brain injury patients. The extended Glasgow Outcome Scale (eGOS) is a scoring system based on a structured interview that allows for consistent and reproducible measurement of long-term functional outcomes. The purpose of this study was to determine the eGOS score of post-craniectomy patients after discharge and stratify survivors based on outcome. A multicenter review of patients who underwent DC was performed. Survivors underwent a phone survey at which time the eGOS was calculated. Patients with an eGOS ≥ 5 were considered to have a good functional outcome. Fifty-four patients underwent DC. Age (OR 1.038; confidence interval 1.003–1.074) and Glasgow Coma Scale (OR 0677; confidence interval 0.527–0.870) were predictors of mortality. Patients who were available for follow-up (n = 13) had poor functional outcomes at discharge (eGOS = 3); however, this improved at the time of follow-up survey (eGOS = 5; P = 0.005). DC is a controversial operation with high mortality and uncertain benefit. Among our cohort, the eGOS score was significantly higher at follow-up survey than it was at discharge. Although the mortality was high, if patients survived to discharge, most had a good functional outcome at follow-up survey.

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Functional Outcome Trajectories Following Inpatient Rehabilitation for TBI in the United States: A NIDILRR TBIMS and CDC Interagency Collaboration

Journal of Head Trauma Rehabilitation ◽

10.1097/htr.0000000000000484 ◽

2020 ◽

Vol 35 (2) ◽

pp. 127-139 ◽

Cited By ~ 1

Author(s):

Kristen Dams-O'Connor ◽

Jessica M. Ketchum ◽

Jeffrey P. Cuthbert ◽

John D. Corrigan ◽

Flora M. Hammond ◽

...

Keyword(s):

United States ◽

Functional Outcome ◽

Interagency Collaboration ◽

Inpatient Rehabilitation ◽

The United States

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The Impact of Level of Physical Therapist Assistant Involvement on Patient Outcomes Following Stroke

Physical Therapy ◽

10.1093/ptj/pzaa158 ◽

2020 ◽

Vol 100 (12) ◽

pp. 2165-2173

Author(s):

Jennifer Biggs

Keyword(s):

Length Of Stay ◽

Functional Outcome ◽

Patient Outcomes ◽

Physical Therapist ◽

Inpatient Rehabilitation ◽

Scoring Methods ◽

Regression Analyses ◽

Rehabilitation Facility ◽

Physical Therapist Assistant ◽

Discharge Location

Abstract Objective This study investigates if higher utilization of physical therapist assistants adversely affects patient outcomes in the acute rehabilitation setting for patients following a cerebrovascular accident (CVA). Methods Participants were admitted to 1 of 5 inpatient rehabilitation facilities following a CVA from 2008 to 2010. High physical therapist assistant use was defined as ≥20% of the physical therapist visits being provided by the physical therapist assistant for an episode of care. Multivariable regression techniques examined differences in functional outcome, discharge location, and length of stay between high and low physical therapist assistant use groups. Propensity scoring methods supplemented findings of the regression analyses. Results Of the 1561 participants, 496 (32%) had high physical therapist assistant involvement. Baseline participant characteristics such as age, sex, baseline motor function, and comorbidities did not differ between high and low physical therapist assistant use groups. After adjusting for patient characteristics, rehabilitation facility, and year, higher physical therapist assistant use did not adversely affect functional outcome or length of stay. Fewer conclusions can be drawn regarding discharge location, although there was no significant difference in discharge location between groups with high and low physical therapist assistant utilization. Propensity scoring methods supported the findings of the regression analyses. Conclusions Higher physical therapist assistant involvement in the rehabilitation of patients following CVA did not adversely affect functional outcome, increase length of stay, or reduce the likelihood of discharge to home from an inpatient rehabilitation facility. Impact The results demonstrate the value of the physical therapist assistant in the provision of physical therapy for patients with stroke in the inpatient rehabilitation setting. Higher involvement of the physical therapist assistant may provide cost savings while maintaining patient outcomes for this setting and population.

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Mortality and One-Year Functional Outcome in Elderly and Very Old Patients with Severe Traumatic Brain Injuries: Observed and Predicted

Behavioural Neurology ◽

10.1155/2015/845491 ◽

2015 ◽

Vol 2015 ◽

pp. 1-7 ◽

Cited By ~ 12

Author(s):

Cecilie Røe ◽

Toril Skandsen ◽

Unn Manskow ◽

Tiina Ader ◽

Audny Anke

Keyword(s):

Functional Outcome ◽

Brain Injuries ◽

Clinical Information ◽

Unfavorable Outcome ◽

Old Patients ◽

Very Old ◽

Severe Tbi ◽

One Year ◽

Very Old Patients

The aim of the present study was to evaluate mortality and functional outcome in old and very old patients with severe traumatic brain injury (TBI) and compare to the predicted outcome according to the internet based CRASH (Corticosteroid Randomization After Significant Head injury) model based prediction, from the Medical Research Council (MRC).Methods.Prospective, national multicenter study including patients with severe TBI ≥65 years. Predicted mortality and outcome were calculated based on clinical information (CRASH basic) (age, GCS score, and pupil reactivity to light), as well as with additional CT findings (CRASH CT). Observed 14-day mortality and favorable/unfavorable outcome according to the Glasgow Outcome Scale at one year was compared to the predicted outcome according to the CRASH models.Results.97 patients, mean age 75 (SD 7) years, 64% men, were included. Two patients were lost to follow-up; 48 died within 14 days. The predicted versus the observed odds ratio (OR) for mortality was 2.65. Unfavorable outcome (GOSE < 5) was observed at one year follow-up in 72% of patients. The CRASH models predicted unfavorable outcome in all patients.Conclusion.The CRASH model overestimated mortality and unfavorable outcome in old and very old Norwegian patients with severe TBI.

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Severe Disability After Stroke: Outcome After Inpatient Rehabilitation

Neurorehabilitation and Neural Repair ◽

10.1177/154596839901300310 ◽

1999 ◽

Vol 13 (3) ◽

pp. 199-203 ◽

Cited By ~ 9

Author(s):

John G. Schmidt ◽

Jessie Drew-Cates ◽

Mary L. Dombovy

Keyword(s):

Functional Outcome ◽

Hemorrhagic Stroke ◽

Inpatient Rehabilitation ◽

Functional Independence ◽

Efficiency Score ◽

Poor Functional Outcome ◽

Rehabilitation Unit ◽

Home Setting ◽

Severe Stroke ◽

Acute Rehabilitation

Objective: To determine the functional outcome following acute rehabilitation of patients with severe and very severe stroke using the Functional Independence Mea sure (FIM). Background: Most patients with severe and very severe stroke are reported in the literature to have a poor functional outcome. However, there are few studies that specifically address severity and their conclusions are confounding. Methods: We retrospectively reviewed charts of 41 consecutive patients with the primary diag nosis of ischemic or hemorrhagic stroke admitted to an inpatient rehabilitation unit with a admission FIM score of <60. Outcome measures included discharge residence, length of stay, and FIM score. Results: Over 63 percent (26 patients) were discharged to home. Discharge mean FIM scores (61.24) were significantly improved over the admission mean FIM (34.12) for self-care, mobility, communication, and social cog nition. The FIM Efficiency score was 0.356/day (mean[FIMdis-FIMadm]/mean LOS) as compared with previous reports of FIM Efficiency of 0.97/day for all stroke. Con clusion: Patients with severe stroke can experience improvement during inpatient rehabilitation and be discharged to a home setting, although the rate of improvement is less than that of more moderate stroke.

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