1
|
Sampat V, Whitinger J, Flynn-O'Brien K, Kim I, Balakrishnan B, Mehta N, Sawdy R, Patel ND, Nallamothu R, Zhang L, Yan K, Zvara K, Farias-Moeller R. Accuracy of Early Neuroprognostication in Pediatric Severe Traumatic Brain Injury. Pediatr Neurol 2024; 155:36-43. [PMID: 38581727 DOI: 10.1016/j.pediatrneurol.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/15/2024] [Accepted: 03/12/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Children with severe traumatic brain injury (sTBI) are at risk for neurological sequelae impacting function. Clinicians are tasked with neuroprognostication to assist in decision-making. We describe a single-center study assessing clinicians' neuroprognostication accuracy. METHODS Clinicians of various specialties caring for children with sTBI were asked to predict their patients' functioning three to six months postinjury. Clinicians were asked to participate in the study if their patient had survived but not returned to baseline between day 4 and 7 postinjury. The outcome tool utilized was the functional status scale (FSS), ranging from 6 to 30 (best-worst function). Predicted scores were compared with actual scores three to six months postinjury. Lin concordance correlation coefficients were used to estimate agreement between predicted and actual FSS. Outcome was dichotomized as good (FSS 6 to 8) or poor (FSS ≥9). Positive and negative predictive values for poor outcome were calculated. Pessimistic prognostic prediction was defined as predicted worse outcome by ≥3 FSS points. Demographic and clinical variables were collected. RESULTS A total of 107 surveys were collected on 24 patients. Two children died. Fifteen children had complete (FSS = 6) or near-complete (FSS = 7) recovery. Mean predicted and actual FSS scores were 10.8 (S.D. 5.6) and 8.6 (S.D. 4.1), respectively. Predicted FSS scores were higher than actual scores (P < 0.001). Eight children had collective pessimistic prognostic prediction. CONCLUSIONS Clinicians predicted worse functional outcomes, despite high percentage of patients with near-normal function at follow-up clinic. Certain patient and provider factors were noted to impact accuracy and need to be studied in larger cohorts.
Collapse
Affiliation(s)
- Varun Sampat
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Whitinger
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katherine Flynn-O'Brien
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Irene Kim
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Binod Balakrishnan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Niyati Mehta
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel Sawdy
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Namrata D Patel
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rupa Nallamothu
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liyun Zhang
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ke Yan
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kimberley Zvara
- Division of Pediatric Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Raquel Farias-Moeller
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| |
Collapse
|
2
|
Toh EMS, Yan B, Lim IC, Yap DM, Wee WJ, Ng KJ, Nga VDW, Motani M, Lim MJR. The role of intracranial pressure variability as a predictor of intracranial hypertension and mortality in critically ill patients. J Neurosurg 2023; 139:1534-1541. [PMID: 37209075 DOI: 10.3171/2023.4.jns23123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/07/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Intracranial pressure (ICP) monitoring is a widely utilized and essential tool for tracking neurosurgical patients, but there are limitations to the use of a solely ICP-based paradigm for guiding management. It has been suggested that ICP variability (ICPV), in addition to mean ICP, may be a useful predictor of neurological outcomes, as it represents an indirect measure of intact cerebral pressure autoregulation. However, the current literature regarding the applicability of ICPV shows conflicting associations between ICPV and mortality. Thus, the authors aimed to investigate the effect of ICPV on intracranial hypertensive episodes and mortality using the eICU Collaborative Research Database version 2.0. METHODS The authors extracted from the eICU database 1,815,676 ICP readings from 868 patients with neurosurgical conditions. ICPV was computed using two methods: the rolling standard deviation (RSD) and the absolute deviation from the rolling mean (DRM). An episode of intracranial hypertension was defined as at least 25 minutes of ICP > 22 mm Hg in any 30-minute window. The effects of mean ICPV on intracranial hypertension and mortality were computed using multivariate logistic regression. A recurrent neural network with long short-term memory was used for time-series predictions of ICP and ICPV to prognosticate future episodes of intracranial hypertension. RESULTS A higher mean ICPV was significantly associated with intracranial hypertension using both ICPV definitions (RSD: aOR 2.82, 95% CI 2.07-3.90, p < 0.001; DRM: aOR 3.93, 95% CI 2.77-5.69, p < 0.001). ICPV was significantly associated with mortality in patients with intracranial hypertension (RSD: aOR 1.28, 95% CI 1.04-1.61, p = 0.026, DRM: aOR 1.39, 95% CI 1.10-1.79, p = 0.007). In the machine learning models, both definitions of ICPV achieved similarly good results, with the best F1 score of 0.685 ± 0.026 and an area under the curve of 0.980 ± 0.003 achieved with the DRM definition over 20 minutes. CONCLUSIONS ICPV may be useful as an adjunct for the prognostication of intracranial hypertensive episodes and mortality in neurosurgical critical care as part of neuromonitoring. Further research on predicting future intracranial hypertensive episodes with ICPV may help clinicians react expediently to ICP changes in patients.
Collapse
Affiliation(s)
| | - Boshen Yan
- 2Faculty of Science, National University of Singapore
| | - Isis Claire Lim
- 1Yong Loo Lin School of Medicine, National University of Singapore
| | | | - Wen Jun Wee
- 2Faculty of Science, National University of Singapore
| | - Kai Jie Ng
- 1Yong Loo Lin School of Medicine, National University of Singapore
| | - Vincent Diong Weng Nga
- 3Division of Neurosurgery, University Surgical Cluster, National University Hospital, Singapore; and
| | - Mehul Motani
- 4Department of Electrical and Computer Engineering, National University of Singapore, Singapore
| | - Mervyn Jun Rui Lim
- 3Division of Neurosurgery, University Surgical Cluster, National University Hospital, Singapore; and
| |
Collapse
|
3
|
Secondary Cerebral Ischemia at Traumatic Brain Injury Is More Closely Related to Cerebrovascular Reactivity Impairment than to Intracranial Hypertension. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839838 DOI: 10.1007/978-3-030-59436-7_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
The purpose of this study was to investigate the relationship between the development of secondary cerebral ischemia (SCI), intracranial pressure (ICP) and cerebrovascular reactivity (CVR) after traumatic brain injury (TBI). METHODS 89 patients with severe TBI with ICP monitoring were studied retrospectively. The mean age was 36.3 ± 4.8 years, 53 men, 36 women. The median Glasgow Coma Score (GCS) was 6.2 ± 0.7. The median Injury Severity Score was 38.2 ± 12.5. To specify the degree of impact of changes in ICP and CVR on the SCI progression in TBI patients, logistic regression was performed. Significant p-values were <0.05. RESULTS The deterioration of CVR in combination with the severity of ICP has a significant impact on the increase in the prevalence rate of SCI. A logistic regression analysis for a model of SCI dependence on intracranial hypertension and CVR was performed. The results of the analysis showed that CVR was the most significant factor affecting SCI development in TBI. CONCLUSIONS The development of SCI in severe TBI depends largely on CVR impairment and to a lesser extent on ICP level. Treatment for severe TBI patients with SCI progression should not be aimed solely at intracranial hypertension correction but also at CVR recovery.
Collapse
|
4
|
Al-Hassani A, Strandvik G, Abayazeed S, Ahmed K, El-Menyar A, Mahmood I, Arumugam SK, Asim M, Nabir S, Ahmed N, Ahmed Z, Al-Thani H. Relationship of Optic Nerve Sheath Diameter and Intracranial Hypertension in Patients with Traumatic Brain Injury. J Emerg Trauma Shock 2020; 13:183-189. [PMID: 33304067 PMCID: PMC7717459 DOI: 10.4103/jets.jets_103_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/09/2019] [Accepted: 12/10/2019] [Indexed: 11/04/2022] Open
Abstract
Background to study the association between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in patients with moderate-to-severe brain injury. Patients and Methods A retrospective cohort study of traumatic brain injury (TBI) patients was conducted between 2010 and 2014. Data were analyzed and compared according to the ICP monitoring cutoff values. Outcomes included intracranial hypertension (ICH) and mortality. Results A total of 167 patients with a mean age of 33 ± 14 years, of them 96 had ICP monitored. ICP values correlated with ONSD measurement (r = 0.21, P = 0.04). Patients who developed ICH were more likely to have higher mean ONSD (P = 0.01) and subarachnoid hemorrhage (SAH) (P = 0.004). Receiver operating curve for ONSD showed a cutoff value of 5.6 mm to detect ICH with sensitivity 72.2% and specificity 50%. Age and ICP were independent predictors of inhospital mortality in multivariate model. Another model with same covariates showed ONSD and SAH to be independent predictors of ICH. Simple linear regression showed a significant association of ONSD with increased ICP (β = 0.21, 95% confidence interval 0.25-5.08, P = 0.03). Conclusions ONSD is a simple noninvasive measurement on initial CT in patients with TBI that could be a surrogate for ICP monitoring. However, further studies are warranted.
Collapse
Affiliation(s)
| | | | | | - Khalid Ahmed
- Department of Surgery and, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar.,Department of Surgery, Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Ismail Mahmood
- Department of Surgery and, Hamad General Hospital, Doha, Qatar
| | | | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Syed Nabir
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Nadeem Ahmed
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Zahoor Ahmed
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery and, Hamad General Hospital, Doha, Qatar
| |
Collapse
|
5
|
|
6
|
Oppelt K, Hähnlein D, Boschert J, Küffer M, Grützner PA, Münzberg M, Kreinest M. Influence of demographic factors and clinical status parameters on long-term neurological, psychological and vegetative outcome following traumatic brain injury. Brain Inj 2018; 32:1500-1509. [PMID: 30024773 DOI: 10.1080/02699052.2018.1499963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PRIMARY OBJECTIVE We evaluated the neurologic, psychological and vegetative outcome, the health status and changes of the personal and occupational status of patients after traumatic brain injuries (TBIs). Correlations between outcome parameters and basic demographic factors and initial clinical status parameters of the patients were assessed. RESEARCH DESIGN Monocentric, retrospective follow-up analysis. METHODS AND PROCEDURES We evaluated the neurologic, psychological and vegetative outcome and health status of patients, who survived TBI with a mean follow-up time of 54 months. Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS) and a questionnaire on Quality of Life were used for outcome measurement. The personal and occupational status, trauma-derived changes to that status and medical and demographic factors that have an impact on the health condition of patients after TBI were assessed. MAIN OUTCOMES AND RESULTS With a median GOS of 5.0 and median DRS of 3.0, our patients showed just moderate disabilities. Fifty-six per cent of the patients felt 'very good' or 'good'. Age, gender, the preclinical Glasgow Coma Scale (GCS), state of pupil reaction and surgical treatment did not seem to affect the GOS or DRS. Correlations between body mass index, age and gender and distinct neurologic, psychological and vegetative symptoms were found. The personal status did not change significantly after TBI. Changes to occupational and socioeconomic status were evident. CONCLUSIONS One-third of the patients are heavily affected by neurological, psychological and vegetative symptoms after surviving TBI. Some demographic factors affected this integrity.
Collapse
Affiliation(s)
- Konrad Oppelt
- a Klinik für Unfallchirurgie und Orthopädie , BG Klinik Ludwigshafen , Ludwigshafen , Germany
| | - Doreen Hähnlein
- a Klinik für Unfallchirurgie und Orthopädie , BG Klinik Ludwigshafen , Ludwigshafen , Germany.,b Abteilung für Anästhesie und Intensivmedizin , GRN-Klinik Sinsheim , Sinsheim , Germany
| | - Jürgen Boschert
- c Abteilung für Neurochirurgie , BG Klinik Ludwigshafen , Ludwigshafen , Germany
| | | | - Paul Alfred Grützner
- a Klinik für Unfallchirurgie und Orthopädie , BG Klinik Ludwigshafen , Ludwigshafen , Germany
| | - Matthias Münzberg
- a Klinik für Unfallchirurgie und Orthopädie , BG Klinik Ludwigshafen , Ludwigshafen , Germany
| | - Michael Kreinest
- a Klinik für Unfallchirurgie und Orthopädie , BG Klinik Ludwigshafen , Ludwigshafen , Germany
| |
Collapse
|