Outcome in Patients with Isolated Moderate to Severe Traumatic Brain Injury

Introduction. Traumatic brain injury (TBI) remains a major cause of death. Withdrawal of life-sustaining treatment (WLST) can be initiated if there is little anticipated chance of recovery to an acceptable quality of life. The aim of this study was firstly to investigate WLST rates in patients with moderate to severe isolated TBI and secondly to assess outcome data in the survivor group. Material and Methods. A retrospective cohort study was performed. Patients aged ≥ 18 years with moderate or severe isolated TBI admitted to the ICU of a single academic hospital between 2011 and 2015 were included. Exclusion criteria were isolated spinal cord injury and referrals to and from other hospitals. Gathered data included demographics, mortality, cause of death, WLST, and Glasgow Outcome Scale (GOS) score after three months. Good functional outcome was defined as GOS > 3. Results. Of 367 patients, 179 patients were included after applying inclusion and exclusion criteria. 55 died during admission (33%), of whom 45 (82%) after WLST. Patients undergoing WLST were older, had worse neurological performance at presentation, and had more radiological abnormalities than patients without WLST. The decision to withdraw life-sustaining treatment was made on the day of admission in 40% of patients. In 33% of these patients, this decision was made while the patient was in the Emergency Department. 71% of survivors had a good functional outcome after three months. No patient left hospital with an unresponsive wakefulness syndrome (UWS) or suffered from UWS after three months. One patient died within three months of discharge. Conclusion. In-hospital mortality in isolated brain injured patients was 33%. The vast majority died after a decision to withdraw life-sustaining treatment. None of the patients were discharged with an unresponsive wakefulness syndrome.

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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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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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One-year costs of intensive care in pediatric patients with traumatic brain injury

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.6.peds20189 ◽

2021 ◽

Vol 27 (1) ◽

pp. 79-86

Author(s):

Era D. Mikkonen ◽

Markus B. Skrifvars ◽

Matti Reinikainen ◽

Stepani Bendel ◽

Ruut Laitio ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Intensive Care ◽

Brain Injury ◽

Social Security ◽

Functional Outcome ◽

Injury Severity ◽

Pediatric Population ◽

Favorable Outcome ◽

Index Hospitalization ◽

Pediatric Tbi

OBJECTIVETraumatic brain injury (TBI) is a major cause of death and disability in the pediatric population. The authors assessed 1-year costs of intensive care in pediatric TBI patients.METHODSIn this retrospective multicenter cohort study of four academic ICUs in Finland, the authors used the Finnish Intensive Care Consortium database to identify children aged 0–17 years treated for TBI in ICUs between 2003 and 2013. The authors reviewed all patient health records and head CT scans for admission, treatment, and follow-up data. Patient outcomes included functional outcome (favorable outcome defined as a Glasgow Outcome Scale score of 4–5) and death within 6 months. Costs included those for the index hospitalization, rehabilitation, and social security up to 1 year after injury. To assess costs, the authors calculated the effective cost per favorable outcome (ECPFO).RESULTSIn total, 293 patients were included, of whom 61% had moderate to severe TBI (Glasgow Coma Scale [GCS] score 3–12) and 40% were ≥ 13 years of age. Of all patients, 82% had a favorable outcome and 9% died within 6 months of injury. The mean cost per patient was €48,719 ($54,557) (95% CI €41,326–€56,112). The index hospitalization accounted for 66%, rehabilitation costs for 27%, and social security costs for 7% of total healthcare costs. The ECPFO was €59,727 ($66,884) (95% CI €52,335–€67,120). A higher ECPFO was observed among patients with clinical and treatment-related variables indicative of parenchymal swelling and high intracranial pressure. Lower ECPFO was observed among patients with higher admission GCS scores and those who had epidural hematomas.CONCLUSIONSGreater injury severity increases ECPFO and is associated with higher postdischarge costs in pediatric TBI patients. In this pediatric cohort, over two-thirds of all resources were spent on patients with favorable functional outcome, indicating appropriate resource allocation.

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Faculty Opinions recommendation of Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.7264956.7513054 ◽

2010 ◽

Author(s):

Jonathan Rhodes

Keyword(s):

Traumatic Brain Injury ◽

Randomized Controlled Trial ◽

Brain Injury ◽

Functional Outcome ◽

Severe Traumatic Brain Injury ◽

Controlled Trial ◽

Rapid Sequence Intubation ◽

Randomized Controlled ◽

Rapid Sequence

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GCS-Pupil Score Has a Stronger Association with Mortality and Poor Functional Outcome than GCS Alone in Pediatric Severe Traumatic Brain Injury

Pediatric Neurosurgery ◽

10.1159/000517330 ◽

2021 ◽

pp. 1-8

Author(s):

Binod Balakrishnan ◽

Heather VanDongen-Trimmer ◽

Irene Kim ◽

Sheila J. Hanson ◽

Liyun Zhang ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Functional Outcome ◽

Cerebral Performance Category ◽

Regression Tree ◽

Classification And Regression Tree ◽

Continuous Variables ◽

Poor Functional Outcome ◽

Severity Scores ◽

Pupil Reactivity

Background: The Glasgow Coma Scale (GCS), used to classify the severity of traumatic brain injury (TBI), is associated with mortality and functional outcomes. However, GCS can be affected by sedation and neuromuscular blockade. GCS-Pupil (GCS-P) score, calculated as GCS minus Pupil Reactivity Score (PRS), was shown to better predict outcomes in a retrospective cohort of adult TBI patients. We evaluated the applicability of GCS-P to a large retrospective pediatric severe TBI (sTBI) cohort. Methods: Admissions to pediatric intensive care units in the Virtual Pediatric Systems (VPS, LLC) database from 2010 to 2015 with sTBI were included. We collected GCS, PRS (number of nonreactive pupils), cardiac arrest, abusive head trauma status, illness severity scores, pediatric cerebral performance category (PCPC) score, and mortality. GCS-P was calculated as GCS minus PRS. χ2 or Fisher’s exact test and Mann-Whitney U test compared categorical and continuous variables, respectively. Classification and regression tree analysis identified thresholds of GCS-P and GCS along with other independent factors which were further examined using multivariable regression analysis to identify factors independently associated with mortality and unfavorable PCPC at PICU discharge. Results: Among the 2,682 patients included in the study, mortality was 23%, increasing from 4.7% for PRS = 0 to 80% for PRS = 2. GCS-P identified more severely injured patients with GCS-P scores 1 and 2 who had worse outcomes. GCS-P ≤ 2 had higher odds for mortality, OR = 68.4 (95% CI = 50.6–92.4) and unfavorable PCPC, OR = 17.3 (8.1, 37.0) compared to GCS ≤ 5. GCS-P ≤ 2 also had higher specificity and positive predictive value for both mortality and unfavorable PCPC compared to GCS ≤ 5. Conclusions: GCS-P, by incorporating pupil reactivity to GCS scoring, is more strongly associated with mortality and poor functional outcome at PICU discharge in children with sTBI.

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Mixture Model Framework for Traumatic Brain Injury Prognosis Using Heterogeneous Clinical and Outcome Data

IEEE Journal of Biomedical and Health Informatics ◽

10.1109/jbhi.2021.3099745 ◽

2021 ◽

pp. 1-1

Author(s):

Alan D. Kaplan ◽

Qi Cheng ◽

Kadri Aditya Mohan ◽

Lindsay D. Nelson ◽

Sonia Jain ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Mixture Model ◽

Outcome Data ◽

Model Framework

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Modulated Neuroprotection in Unresponsive Wakefulness Syndrome after Severe Traumatic Brain Injury

Brain Sciences ◽

10.3390/brainsci11081044 ◽

2021 ◽

Vol 11 (8) ◽

pp. 1044

Author(s):

Cristina Daia ◽

Cristian Scheau ◽

Aura Spinu ◽

Ioana Andone ◽

Cristina Popescu ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Glasgow Coma Scale ◽

Severe Traumatic Brain Injury ◽

Functional Independence ◽

Unresponsive Wakefulness Syndrome ◽

Coma Scale ◽

Severe Tbi ◽

Neuroprotective Treatment ◽

Gcs Score

Background: We aimed to assess the effects of modulated neuroprotection with intermittent administration in patients with unresponsive wakefulness syndrome (UWS) after severe traumatic brain injury (TBI). Methods: Retrospective analysis of 60 patients divided into two groups, with and without neuroprotective treatment with Actovegin, Cerebrolysin, pyritinol, L-phosphothreonine, L-glutamine, hydroxocobalamin, alpha-lipoic acid, carotene, DL-α-tocopherol, ascorbic acid, thiamine, pyridoxine, cyanocobalamin, Q 10 coenzyme, and L-carnitine alongside standard treatment. Main outcome measures: Glasgow Coma Scale (GCS) after TBI, Extended Glasgow Coma Scale (GOS E), Disability Rankin Scale (DRS), Functional Independence Measurement (FIM), and Montreal Cognitive Assessment (MOCA), all assessed at 1, 3, 6, 12, and 24 months after TBI. Results: Patients receiving neuroprotective treatment recovered more rapidly from UWS than controls (p = 0.007) passing through a state of minimal consciousness and gradually progressing until the final evaluation (p = 0.000), towards a high cognitive level MOCA = 22 ± 6 points, upper moderate disability GOS-E = 6 ± 1, DRS = 6 ± 4, and an assisted gait, FIM =101 ± 25. The improvement in cognitive and physical functioning was strongly correlated with lower UWS duration (−0.8532) and higher GCS score (0.9803). Conclusion: Modulated long-term neuroprotection may be the therapeutic key for patients to overcome UWS after severe TBI.

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Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

BMC Medical Ethics ◽

10.1186/s12910-021-00612-8 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Annette Robertsen ◽

Eirik Helseth ◽

Reidun Førde

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Ethical Issues ◽

Ethical Reasoning ◽

Depth Information ◽

Worst Case ◽

Life Sustaining Treatment ◽

Wait And See ◽

Prognostic Uncertainty

Abstract Background Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making. Results A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team—family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. Conclusions Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.

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