In the Aftermath of Acute Hospitalization for Traumatic Brain Injury: Factors Associated with the Direct Pathway into Specialized Rehabilitation

Previous research has demonstrated that early initiation of rehabilitation and direct care pathways improve outcomes for patients with severe traumatic brain injury (TBI). Despite this knowledge, there is a concern that a number of patients are still not included in the direct care pathway. The study aim was to provide an updated overview of discharge to rehabilitation following acute care and identify factors associated with the direct pathway. We analyzed data from the Oslo TBI Registry—Neurosurgery over a five-year period (2015–2019) and included 1724 adults with intracranial injuries. We described the patient population and applied multivariable logistic regression to investigate factors associated with the probability of entering the direct pathway. In total, 289 patients followed the direct pathway. For patients with moderate–severe TBI, the proportion increased from 22% to 35% during the study period. Significant predictors were younger age, low preinjury comorbidities, moderate–severe TBI and disability due to TBI at the time of discharge. In patients aged 18–29 years, 53% followed the direct pathway, in contrast to 10% of patients aged 65–79 years (moderate–severe TBI). This study highlights the need for further emphasis on entering the direct pathway to rehabilitation, particularly for patients aged >64 years.

Download Full-text

P11 Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.91 ◽

2019 ◽

Vol 90 (3) ◽

pp. e29.1-e29

Author(s):

KM Rajwani ◽

JP Lavrador ◽

A Ansaripour ◽

E Maratos ◽

C Tolias

Keyword(s):

Traumatic Brain Injury ◽

Regression Analysis ◽

Brain Injury ◽

Anticoagulation Therapy ◽

Male Gender ◽

Trauma Network ◽

Transfer Distance ◽

Younger Age ◽

Number Of Patients ◽

Marshall Score

ObjectivesTo identify factors that influence the decision to transfer patients with traumatic brain injury (TBI) to a neurosurgical centre.DesignRetrospective data collected as part of TrIBAL study.SubjectsAll patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4 month period.MethodsOur primary outcome was transfer to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, anticoagulation therapy and severity of TBI (initial GCS and Marshall score). A multivariable logistic regression analysis was performed.ResultsA total of 347 patients were referred from regional hospitals with TBI and of these, 53 (15%) were transferred. The mean age of patients referred was 69.6 years, 62.5% were men and 43% on antiplatelets or anticoagulated. Similar number of patients were referred from hospitals within 30 miles (54%) and those more than 30miles away (46%). Eighty-four percent of patients had mild TBI (GCS 13–15) on initial assessment and 67% had a Marshall CT score of 2. After regression analysis, younger age, male gender and higher Marshall score predicted transfer to our neurosurgical centre (p<0.05).ConclusionsMany patients with TBI have relatively ‘minor’ injuries and remain at their local hospital. In our cohort higher Marshall score, younger age and male gender predicted transfer to a neurosurgicial centre. Transfer distance, anticoagulation therapy and initial GCS did not influence decision to transfer.

Download Full-text

Factors associated with shunt-dependent hydrocephalus after decompressive craniectomy for traumatic brain injury

Journal of Neurosurgery ◽

10.3171/2017.1.jns162721 ◽

2018 ◽

Vol 128 (5) ◽

pp. 1547-1552 ◽

Cited By ~ 16

Author(s):

Aditya Vedantam ◽

Jose-Miguel Yamal ◽

Hyunsoo Hwang ◽

Claudia S. Robertson ◽

Shankar P. Gopinath

Keyword(s):

Traumatic Brain Injury ◽

Logistic Regression ◽

Brain Injury ◽

Decompressive Craniectomy ◽

Controlled Trial ◽

Statistical Significance ◽

Ventriculoperitoneal Shunting ◽

Younger Age ◽

Frontal Horn ◽

Severe Tbi

OBJECTIVEPosttraumatic hydrocephalus (PTH) affects 11.9%–36% of patients undergoing decompressive craniectomy (DC) and is an important cause of morbidity after traumatic brain injury (TBI). Early diagnosis and treatment of PTH can prevent further neurological compromise in patients who are recovering from TBI. There is limited data on predictors of shunting for PTH after DC for TBI.METHODSProspectively collected data from the erythropoietin severe TBI randomized controlled trial were studied. Demographic, clinical, and imaging data were analyzed for enrolled patients who underwent a DC. All head CT scans during admission were reviewed and assessed for PTH by the Gudeman criteria or the modified Frontal Horn Index ≥ 33%. The presence of subdural hygromas was categorized as unilateral/bilateral hemispheric or interhemispheric. Using L1-regularized logistic regression to select variables, a multiple logistic regression model was created with ventriculoperitoneal shunting as the binary outcome. Statistical significance was set at p < 0.05.RESULTSA total of 60 patients who underwent DC were studied. Fifteen patients (25%) underwent placement of a ventriculoperitoneal shunt for PTH. The majority of patients underwent unilateral decompressive hemicraniectomy (n = 46, 77%). Seven patients (12%) underwent bifrontal DC. Unilateral and bilateral hemispheric hygromas were noted in 31 (52%) and 7 (11%) patients, respectively. Interhemispheric hygromas were observed in 19 patients (32%). The mean duration from injury to first CT scan showing hemispheric subdural hygroma and interhemispheric hygroma was 7.9 ± 6.5 days and 14.9 ± 11.7 days, respectively. The median duration from injury to shunt placement was 43.7 days. Multivariate analysis showed that the presence of interhemispheric hygroma (OR 63.6, p = 0.001) and younger age (OR 0.78, p = 0.009) were significantly associated with the need for a shunt after DC.CONCLUSIONSThe presence of interhemispheric subdural hygromas and younger age were associated with shunt-dependent hydrocephalus after DC in patients with severe TBI.

Download Full-text

Risk Factors for Withdrawal of Life-Sustaining Treatment in Severe Traumatic Brain Injury

The American Surgeon ◽

10.1177/000313482008600106 ◽

2020 ◽

Vol 86 (1) ◽

pp. 8-14

Author(s):

Sahil Gambhir ◽

Areg Grigorian ◽

Divya Ramakrishnan ◽

Catherine M. Kuza ◽

Brian Sheehan ◽

...

Keyword(s):

Risk Factors ◽

Traumatic Brain Injury ◽

Risk Factor ◽

Brain Injury ◽

Confidence Interval ◽

Odds Ratio ◽

Independent Risk Factor ◽

Factors Associated ◽

Severe Tbi ◽

Life Sustaining Treatment

Studies demonstrate a significant variation in decision-making regarding withdrawal of life-sustaining treatment (WLST) practices for patients with severe traumatic brain injury (TBI). We investigated risk factors associated with WLST in severe TBI. We hypothesized age ≥65 years would be an independent risk factor. In addition, we compared survivors with patients who died in hospital after WLST to identify potential factors associated with in-hospital mortality. The Trauma Quality Improvement Program (2010–2016) was queried for patients with severe TBI of the head. Patients were compared by age (age < 65 and age ≥ 65 years) and survival after WLST (survivors versus non-survivors) at hospitalization discharge. A multivariable logistic regression model was used for analysis. From 1,403,466 trauma admissions, 328,588 (23.4%) patients had severe TBI. Age ≥ 65 years was associated with increased WLST (odds ratio: 1.76, confidence interval: 1.59–1.94, P < 0.001), whereas nonwhite race was associated with decreased WLST (odds ratio: 0.60, confidence interval: 0.55–0.65, P < 0.001). Compared with non-survivors of WLST, survivors were older (74 vs 61 years, P < 0.001) and more likely to have comorbidities such as hypertension (57% vs 38.5%, P < 0.001). Age ≥ 65 years was an independent risk factor for WLST, and nonwhite race was associated with decreased WLST. Patients surviving until discharge after WLST decision were older (≥74 years) and had multiple comorbidities.

Download Full-text

Challenges and Opportunities for Neuroimaging in Young Patients with Traumatic Brain Injury: a Coordinated Effort towards Advancing Discovery from the ENIGMA Pediatric Moderate/Severe TBI Group

10.31234/osf.io/y2txh ◽

2019 ◽

Cited By ~ 4

Author(s):

Emily L. Dennis ◽

Karen Caeyenberghs ◽

Robert F. Asarnow ◽

Talin Babikian ◽

Brenda Bartnik-Olson ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Meta Analysis ◽

Young Patients ◽

Future Research ◽

Childhood And Adolescence ◽

Developmental Issues ◽

Challenges And Opportunities ◽

Severe Tbi ◽

Advance Research

Traumatic brain injury (TBI) is a major cause of death and disability in children in both developed and developing nations. Children and adolescents suffer from TBI at a higher rate than the general population; however, research in this population lags behind research in adults. This may be due, in part, to the smaller number of investigators engaged in research with this population and may also be related to changes in safety laws and clinical practice that have altered length of hospital stays, treatment, and access to this population. Specific developmental issues also warrant attention in studies of children, and the ever-changing context of childhood and adolescence may require larger sample sizes than are commonly available to adequately address remaining questions related to TBI. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric Moderate-Severe TBI (msTBI) group aims to advance research in this area through global collaborative meta-analysis. In this paper we discuss important challenges in pediatric TBI research and opportunities that we believe the ENIGMA Pediatric msTBI group can provide to address them. We conclude with recommendations for future research in this field of study.

Download Full-text

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.

Download Full-text

Prehospital Factors Associated with Discharge Outcomes: Baseline Data from the Andhra Pradesh Traumatic Brain Injury Project

World Neurosurgery X ◽

10.1016/j.wnsx.2019.100020 ◽

2019 ◽

Vol 2 ◽

pp. 100020 ◽

Cited By ~ 2

Author(s):

Kodanda Ram ◽

Kadali VaraPrasad ◽

Murali K. Krishna ◽

Nithya Kannan ◽

Venkataraman Sundar ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Andhra Pradesh ◽

Baseline Data ◽

Factors Associated ◽

Discharge Outcomes

Download Full-text

Self-awareness four years after severe traumatic brain injury: discordance between the patient’s and relative’s complaints. Results from the PariS-TBI study

Clinical Rehabilitation ◽

10.1177/0269215517734294 ◽

2017 ◽

Vol 32 (5) ◽

pp. 692-704 ◽

Cited By ~ 6

Author(s):

Camille Chesnel ◽

Claire Jourdan ◽

Eleonore Bayen ◽

Idir Ghout ◽

Emmanuelle Darnoux ◽

...

Keyword(s):

Quality Of Life ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Significant Relationship ◽

Injury Severity ◽

Chronic Phase ◽

Functional Independence ◽

Severe Tbi

Objective: To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness. Design/Setting/Subjects: This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study). Intervention/Main measures: Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life. Results: A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)). Conclusion: Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

Download Full-text

Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study

BMJ Open ◽

10.1136/bmjopen-2020-047305 ◽

2021 ◽

Vol 11 (6) ◽

pp. e047305

Author(s):

Susan Alcock ◽

Divjeet Batoo ◽

Sudharsana Rao Ande ◽

Rob Grierson ◽

Marco Essig ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Cohort Study ◽

Brain Injury ◽

Early Diagnosis ◽

Hospital Mortality ◽

Brain Death ◽

Severe Traumatic Brain Injury ◽

Health Research ◽

Ct Perfusion ◽

Severe Tbi

IntroductionSevere traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (<48 hours) with severe TBI is estimated at 50%. Several clinical examinations exist to determine brain death; however, most are difficult to elicit in the acute setting in patients with severe TBI. Having a definitive assessment tool would help predict early in-hospital mortality in this population. CT perfusion (CTP) has shown promise diagnosing early in-hospital mortality in patients with severe TBI and other populations. The purpose of this study is to validate admission CTP features of brain death relative to the clinical examination outcome for characterizing early in-hospital mortality in patients with severe TBI.Methods and analysisThe Early Diagnosis of Mortality using Admission CT Perfusion in Severe Traumatic Brain Injury Patients study, is a prospective cohort study in patients with severe TBI funded by a grant from the Canadian Institute of Health Research. Adults aged 18 or older, with evidence of a severe TBI (Glasgow Coma Scale score ≤8 before initial resuscitation) and, on mechanical ventilation at the time of imaging are eligible. Patients will undergo CTP at the time of first imaging on their hospital admission. Admission CTP compares with the reference standard of an accepted bedside clinical assessment for brainstem function. Deferred consent will be used. The primary outcome is a binary outcome of mortality (dead) or survival (not dead) in the first 48 hours of admission. The planned sample size for achieving a sensitivity of 75% and a specificity of 95% with a CI of ±5% is 200 patients.Ethics and disseminationThis study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed through forums at the end of the study.Trial registration numberNCT04318665

Download Full-text