scholarly journals Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention

2019 ◽  
Vol 130 (5) ◽  
pp. 1616-1625 ◽  
Author(s):  
Alessandro Orlando ◽  
A. Stewart Levy ◽  
Benjamin A. Rubin ◽  
Allen Tanner ◽  
Matthew M. Carrick ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Scale Score ◽  
Mild Traumatic Brain Injury ◽  
Intervention Group ◽  
Stepwise Logistic Regression ◽  
Neurosurgical Procedures ◽  
Acute Hemorrhage ◽  
Subdural Hematomas ◽  
Neurosurgical Intervention

OBJECTIVEIsolated subdural hematomas (iSDHs) are one of the most common intracranial hemorrhage (ICH) types in the population with mild traumatic brain injury (mTBI; Glasgow Coma Scale score 13–15), account for 66%–75% of all neurosurgical procedures, and have one of the highest neurosurgical intervention rates. The objective of this study was to examine how quantitative hemorrhage characteristics of iSDHs in patients with mTBI at admission are associated with subsequent neurosurgical intervention.METHODSThis was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult trauma patients with mTBI and iSDHs were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic SDH, mass effect, and other hemorrhage-related variables were double–data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. The primary outcome was neurosurgical intervention (craniotomy, burr hole, catheter drainage of SDH, placement of intracranial pressure monitor, shunt, or ventriculostomy). Multivariate stepwise logistic regression was used to identify significant covariates and to assess interactions.RESULTSA total of 176 patients were included in our study: 28 patients did and 148 patients did not receive a neurosurgical intervention. Increasing head Abbreviated Injury Scale score was significantly associated with neurosurgical interventions. There was a strong correlation between the first 3 reviews on maximum hemorrhage length (R2 = 0.82) and maximum hemorrhage thickness (R2 = 0.80). The neurosurgical intervention group had a mean maximum SDH length and thickness that were 61 mm longer and 13 mm thicker than those of the nonneurosurgical intervention group (p < 0.001 for both). After adjusting for the presence of an acute-on-chronic hemorrhage, for every 1-mm increase in the thickness of an iSDH, the odds of a neurosurgical intervention increase by 32% (95% CI 1.16–1.50). There were no interventions for any SDH with a maximum thickness ≤ 5 mm on initial presenting scan.CONCLUSIONSThis is the first study to quantify the odds of a neurosurgical intervention based on hemorrhage characteristics in patients with an iSDH and mTBI. Once validated in a second population, these data can be used to better inform patients and families of the risk of future neurosurgical intervention, and to evaluate the necessity of interhospital transfers.

scholarly journals Isolated subdural hematomas in mild traumatic brain injury. Part 2: a preliminary clinical decision support tool for neurosurgical intervention

2019 ◽  
Vol 130 (5) ◽  
pp. 1626-1633 ◽  
Author(s):  
Alessandro Orlando ◽  
A. Stewart Levy ◽  
Benjamin A. Rubin ◽  
Allen Tanner ◽  
Matthew M. Carrick ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Logistic Regression ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Treatment Guidelines ◽  
Characteristic Curve ◽  
Stepwise Logistic Regression ◽  
Acute Hemorrhage ◽  
Subdural Hematomas ◽  
Neurosurgical Intervention

OBJECTIVEA paucity of studies have examined neurosurgical interventions in the mild traumatic brain injury (mTBI) population with intracranial hemorrhage (ICH). Furthermore, it is not understood how the dimensions of an ICH relate to the risk of a neurosurgical intervention. These limitations contribute to a lack of treatment guidelines. Isolated subdural hematomas (iSDHs) are the most prevalent ICH in mTBI, carry the highest neurosurgical intervention rate, and account for an overwhelming majority of all neurosurgical interventions. Decision criteria in this population could benefit from understanding the risk of requiring neurosurgical intervention. The aim of this study was to quantify the risk of neurosurgical intervention based on the dimensions of an iSDH in the setting of mTBI.METHODSThis was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult (≥ 18 years) trauma patients with mTBI and iSDH were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic (AOC) SDH, mass effect, and other hemorrhage-related variables were double–data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. Tentorial SDHs were not measured. The primary outcome was neurosurgical intervention (craniotomy, burr holes, intracranial pressure monitor placement, shunt, ventriculostomy, or SDH evacuation). Multivariate stepwise logistic regression was used to identify significant covariates, to assess interactions, and to create the scoring system.RESULTSThere were a total of 176 patients included in our study: 28 patients did and 148 did not receive a neurosurgical intervention. There were no significant differences between neurosurgical intervention groups in 11 demographic and 22 comorbid variables. Patients with neurosurgical intervention had significantly longer and thicker SDHs than nonsurgical controls. Logistic regression identified thickness and AOC hemorrhage as being the most important variables in predicting neurosurgical intervention; SDH length was not. Risk of neurosurgical intervention was calculated based on the SDH thickness and presence of an AOC hemorrhage from a multivariable logistic regression model (area under the receiver operating characteristic curve 0.94, 95% CI 0.90–0.97; p < 0.001). With a decision point of 2.35% risk, we predicted neurosurgical intervention with 100% sensitivity, 100% negative predictive value, and 53% specificity.CONCLUSIONSThis is the first study to quantify the risk of neurosurgical intervention based on hemorrhage characteristics in patients with mTBI and iSDH. Once validated in a second population, these data can be used to inform the necessity of interhospital transfers and neurosurgical consultations.

scholarly journals Neurosurgical intervention in patients with mild traumatic brain injury and its effect on neurological outcomes

2016 ◽  
Vol 124 (2) ◽  
pp. 538-545 ◽  
Author(s):  
Kevin James Tierney ◽  
Natasha V. Nayak ◽  
Charles J. Prestigiacomo ◽  
Ziad C. Sifri
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Nonoperative Management ◽  
Intervention Group ◽  
Clinical Predictors ◽  
Neurological Outcomes ◽  
Cranial Ct ◽  
Delayed Intervention ◽  
Neurosurgical Intervention

OBJECT The object of this study was to determine the mortality and neurological outcome of patients with mild traumatic brain injury (mTBI) who require neurosurgical intervention (NSI), identify clinical predictors of a poor outcome, and investigate the effect of failed nonoperative management and delayed NSI on outcome. METHODS A cross-sectional study of 10 years was performed, capturing all adults with mTBI and NSI. Primary outcome variables were mortality and Glasgow Outcome Scale (GOS) score. Patients were divided into an immediate intervention group, which received an NSI after the initial cranial CT scan, and a delayed intervention group, which had failed nonoperative management and received an NSI after 2 or more cranial CT scans. RESULTS The mortality rate in mTBI patients requiring NSI was 13%, and the mean GOS score was 3.6 ± 1.2. An age > 60 years was independently predictive of a worse outcome, and epidural hematoma was independently predictive of a good outcome. Logistic regression analysis using independent variables was calculated to create a model for predicting poor neurological outcomes in patients with mTBI undergoing NSI and had 74.1% accuracy. Patients in the delayed intervention group had worse mortality (25% vs 9%) and worse mean GOS scores (2.9 ± 1.3 vs 3.7 ± 1.2) than those in the immediate intervention group. CONCLUSIONS Data in this study demonstrate that patients with mTBI requiring NSI have higher mortality rates and worse neurological outcomes and should therefore be classified separately from mTBI patients not requiring NSI. Additionally, mTBI patients requiring NSI after the failure of nonoperative management have worse outcomes than those receiving immediate intervention and should be considered separately.

Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention

JAMA Surgery ◽  
2016 ◽  
Vol 151 (10) ◽  
pp. 954 ◽  
Author(s):  
Itamar Ashkenazi ◽  
William P. Schecter ◽  
Kobi Peleg ◽  
Adi Givon ◽  
Oded Olsha ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Scale Score ◽  
Glasgow Coma Scale Score ◽  
Coma Scale ◽  
Neurosurgical Intervention

scholarly journals Facial Fractures: Independent Prediction of Neurosurgical Intervention

2021 ◽  
Author(s):  
Brandon Lucke-Wold ◽  
Kevin Pierre ◽  
Sina Aghili-Mehrizi ◽  
Gregory Murad
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
External Ventricular Drain ◽  
Intervention Group ◽  
Facial Fracture ◽  
Pressure Monitor ◽  
Significant Difference ◽  
Neurosurgical Intervention

Abstract Background:Over half of patients with facial fractures have associated traumatic brain injury. Based on previous force dynamic cadaveric studies, Lefort type 2 and 3 fractures are more associated with severe injury. Whether this correlates to neurosurgical intervention have not been well characterized. The purpose of this retrospective data analysis is to characterize fracture pattern types in patients requiring neurosurgical intervention and to see if this is different from those not requiring intervention. Methods:Retrospective data was collected from the trauma registry from 2010-2019. Inclusion criteria: adults over 18, confirmed facial fracture with available neuroimaging, reported traumatic brain injury, and admission to ICU or floor bed. Exclusion criteria: patients less than 18 years old, patients with no neuroimaging, and patients that were deceased prior to initiation of neurosurgical intervention. Data included: basic demographic data, presenting Glasgow Coma Scale (GCS) score, mechanism of injury, type of traumatic brain injury, neurosurgical intervention, and facial fracture type. Retrospective Contingency Analysis with Fraction of Total Comparison was used with Chi-Square analysis for demographic and injury characteristic data.Results:1172 patients met inclusion criteria. 1001 required no neurosurgical intervention and 171 required intervention. No significant difference was seen between the non-intervention group and intervention group in terms of demographic data or baseline injury characteristics except for presenting GCS. A significant difference was seen between groups for presenting Glasgow Coma Scale (c2=67.71, p<0.001). The intervention group had greater number of patients with GCS<8 compared to the non-intervention group. Fracture patterns were overall similar between the non-intervention group compared to intervention group (c2=4.518, p=0.92), however subset analysis did reveal a 2 fold increase in Lefort type 2 fractures and notable increase in Lefort type 3 and panfacial fractures in the intervention group. The intervention group was further divided into those requiring external ventricular drain or intracranial pressure monitor only vs. patients requiring craniectomy, craniotomy, or burr holes with or with external ventricular drain or intracranial pressure monitor. A significant difference was seen between groups (c2=20.02, p=0.03). The craniectomy, craniotomy, or burr hole group was much more likely to have Lefort type 2 or 3 fractures compared to the external ventricular drain or intracranial pressure monitor group only. Conclusions:Lefort type 2 and type 3 fractures are significantly associated with requiring neurosurgical intervention. An improved algorithm for managing these patients has been proposed in the discussion. Ongoing work will focus on validating and refining the algorithm in order to improve patient care for trauma patients with facial fracture and traumatic brain injury.

Epidemiology of Mild Traumatic Brain Injury with Intracranial Hemorrhage: Focusing Predictive Models for Neurosurgical Intervention

2017 ◽  
Vol 107 ◽  
pp. 94-102 ◽  
Author(s):  
Alessandro Orlando ◽  
A. Stewart Levy ◽  
Matthew M. Carrick ◽  
Allen Tanner ◽  
Charles W. Mains ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Intracranial Hemorrhage ◽  
Predictive Models ◽  
Neurosurgical Intervention

scholarly journals Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury

2010 ◽  
Vol 29 (5) ◽  
pp. E3 ◽  
Author(s):  
Andrew P. Carlson ◽  
Pedro Ramirez ◽  
George Kennedy ◽  
A. Robb McLean ◽  
Cristina Murray-Krezan ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Care Center ◽  
Demographic Data ◽  
Tertiary Care ◽  
High Resource ◽  
Interhospital Transfer ◽  
Neurosurgical Intervention

Object Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need. Methods The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded. Results During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6–131.8; OR 9.7 for SDH, 95% CI 2.4–39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15. Conclusions Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.

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