The Influence of Age on the Outcomes of Traumatic Brain Injury: Findings from a Japanese Nationwide Survey (J-ASPECT Study-Traumatic Brain Injury)

Incidence of rare malignant transformation in vestibular schwannomas treated with stereotactic radiosurgery: a single-institution analysis of 1,061 cases

PURPOSE

This study assesses the incidence of malignant transformation (MT) in vestibular schwannomas (VSs) treated with stereotactic radiosurgery (SRS) over a 30-year period, with a median follow-up of 12 years.

METHODS

A retrospective analysis was performed on 1,051 individuals who underwent gamma knife surgery (GKS) for VS between May 1991 and March 2023. The cohort comprised 1,013 individuals with sporadic VSs and 38 with neurofibromatosis type 2-related schwannomatosis (NF2-SWN), totaling 1,061 treated VSs. The annual MT risk was calculated based on lesion-years at risk.

RESULTS

Among the 1,061 VSs treated with GKS, MT occurred in 2 cases (0.19%), both in individuals with sporadic VSs. Over 12,940 lesion-years from GKS to the latest follow-up, the annual MT risk was 0.016% for all VSs, with no cases observed within the first 5 years post-GKS. However, the risk increased to 0.025% beyond 5 years. No instances of MT were identified in individuals with NF2-SWN.

CONCLUSIONS

This study represents the most extensive investigation specifically examining the incidence of MT in VSs treated with SRS, leveraging the largest case series and longest observation period to date. The findings indicate that MT following SRS for VSs is exceedingly rare. Although the overall risk remains minimal, it may increase slightly with extended follow-up. These results support the continued use of SRS as a safe and effective treatment for VS while emphasizing the need for long-term monitoring.

A machine learning model to predict neurological deterioration after mild traumatic brain injury in older adults

Objective

Neurological deterioration after mild traumatic brain injury (TBI) has been recognized as a poor prognostic factor. Early detection of neurological deterioration would allow appropriate monitoring and timely therapeutic interventions to improve patient outcomes. In this study, we developed a machine learning model to predict the occurrence of neurological deterioration after mild TBI using information obtained on admission.

Methods

This was a retrospective cohort study of data from the Think FAST registry, a multicenter prospective observational study of elderly TBI patients in Japan. Patients with an admission Glasgow Coma Scale (GCS) score of 12 or below or who underwent surgical treatment immediately upon admission were excluded. Neurological deterioration was defined as a decrease of 2 or more points from a GCS score of 13 or more within 24 h of hospital admission. The model predictive accuracy was judged with the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC), and the Youden index was used to determine the cutoff value.

Results

A total of 421 of 721 patients registered in the Think FAST registry between December 2019 and May 2021 were included in our study, among whom 25 demonstrated neurological deterioration. Among several machine learning algorithms, eXtreme Gradient Boosting (XGBoost) demonstrated the highest predictive accuracy in cross-validation, with an AUROC of 0.81 (±0.07) and an AUPRC of 0.33 (±0.08). Through SHapley Additive exPlanations (SHAP) analysis, five important features (D-dimer, fibrinogen, acute subdural hematoma thickness, cerebral contusion size, and systolic blood pressure) were identified and used to construct a better performing model (cross-validation AUROC of 0.84 and AUPRC of 0.34; testing data AUROC of 0.77 and AUPRC of 0.19). At the cutoff value from the Youden index, the model showed a sensitivity, specificity, and positive predictive value of 60, 96, and 38%, respectively. When neurosurgeons attempted to predict neurological deterioration using the same testing data, their values were 20, 94, and 19%, respectively.

Conclusion

In this study, our predictive model showed an acceptable performance in detecting neurological deterioration after mild TBI. Further validation through prospective studies is necessary to confirm these results.

A national perspective of ambulance clinicians' perceptions, experiences and decision-making processes when assessing older adults with a head injury: a mixed-methods study

Introduction

UK ambulance services employ diverse models of care, resulting in 40-60% emergency department (ED) conveyance rates. Head injury conveyance rates for older adults (60 years and over) remain high (60-70%), despite most being mild. This research aimed to explore ambulance clinicians' perceptions, experiences and decision-making processes when assessing older adults with head injuries, considering the various factors influencing their clinical decisions.

Methods

This study used a mixed-methods sequential explanatory design comprising an online survey and one-to-one interviews with patient-facing ambulance clinicians in the UK. The survey, distributed through nine ambulance services and via social media, gathered data about clinicians' experiences, confidence levels and perceptions when assessing older adults with head injuries. It focused on exposure frequency, confidence in assessing asymptomatic patients, perceived risks of medications and confidence in available decision tools. The subsequent interviews delved deeper into the survey responses.

Results

A total of 385 participants were recruited, predominantly male paramedics (61%), with a median age of 35 years and a median of eight years of ambulance service experience. Participants reported frequent encounters with older adults with head injuries, and expressed high confidence in assessing visible injuries but lower confidence in conducting neurological examinations. Participants found NICE and JRCALC guidelines satisfactory, and reported confidence in conveying patients to the ED but less confidence in alternative referrals or discharges. The interviews revealed two overarching themes: guideline-based care and patient-centred care, with sub-themes emphasising the importance of shared decision making, collaboration with other healthcare professionals and safety-netting strategies.

Conclusion

Although clinicians express confidence in using clinical guidelines for ED conveyances, they often find such guidance overly prescriptive and struggle to translate them for individual cases. There is a need for more patient-centred, holistic decision making, especially considering the unique aspects of head injuries in older adults. Challenges include fear of poor outcomes, limited feedback on patient outcomes and low confidence in making referral or discharge decisions. Specific guidelines tailored to this demographic, as well as improved support services, may aid in reducing unnecessary ED conveyances.

Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals

BACKGROUND

Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population.

METHODS

We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses.

FINDINGS

We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality.

CONCLUSIONS

In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population.

REVIEW REGISTRATION

PROSPERO CRD42022323231.

Serum Caffeine Concentration at the Time of Traumatic Brain Injury and Its Long-Term Clinical Outcomes

Caffeine is one of the most widely consumed psychoactive drugs in the general population. It has a neuroprotective effect in degenerative neurological disorders; however, the association between caffeine and traumatic brain injury (TBI) outcomes is contradictory. The objective of this study was to evaluate the association between serum caffeine concentration at the time of injury and long-term functional outcomes of patients with TBI visiting the emergency department (ED). This was a prospective multi-center cohort study including adult patients with intracranial injury confirmed by radiological examination, who visited five participating EDs within 72 h after TBI. The main exposure was the serum caffeine level within 4 h after injury, and the study outcome was a favorable functional recovery at 6 months after injury. Multi-variable logistic regression analysis adjusted for potential confounders was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Among the 334 study participants, caffeine was not detected in 102 patients (30.5 %). In patients with identifiable caffeine level, serum caffeine level was categorized into tercile groups; low (0.01-0.58 μg/mL), intermediate (0.59-1.66 μg/mL), and high (1.67-10.00 μg/mL). The proportions of patients with a 6-month favorable functional recovery were 56.9% in the no-caffeine group, 79.2% in the low-caffeine group, 75.3% in the intermediate-caffeine group, and 66.7% in the high-caffeine group (p = 0.006). In multi-variable logistic regression analysis, the low- and intermediate-caffeine groups were significantly associated with a higher probability of 6-month favorable functional recovery compared with the no-caffeine group [AORs (95% CI): 2.82 (1.32-6.02) and 2.18 (1.06-4.47], respectively. This study showed a significant association between a serum caffeine concentration of 0.01 to 1.66 μg/mL and good functional recovery at 6 months after injury compared with the no-caffeine group of patients with TBI with intracranial injury. These results suggest the possibility of using serum caffeine level as a potential biomarker for TBI outcome prediction and of using caffeine as a therapeutic agent in the clinical care of patients with TBI.

In-hospital mortality and risk factors among elderly patients with traumatic brain injury: protocol for a systematic review and meta-analysis

INTRODUCTION

The elderly population is more vulnerable to traumatic brain injury (TBI) compared with younger adults, and there is an increasing trend in TBI-related hospitalisations and deaths in the elderly due to the ageing global population. This is a thorough update to a previous meta-analysis on the mortality of elderly TBI patients. Our review will include more recent studies and provide a comprehensive analysis of risk factors.

METHODS AND ANALYSIS

The protocol of our systematic review and meta-analysis is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will search the following databases: PubMed, Cochrane Library and Embase from inception to 1 February 2023 reporting in-hospital mortality and/or risk factors predicting in-hospital mortality among elderly patients with TBI. We will perform a quantitative synthesis for in-hospital mortality data combined with meta-regression and subgroup analysis to determine whether there is a trend or source of heterogeneity. Pooled estimates for risk factors will be presented in the form of ORs and 95% CIs. Examples of risk factors include age, gender, cause of injury, severity of injury, neurosurgical intervention and preinjury antithrombotic therapy. Dose-response meta-analysis for age and risk of in-hospital mortality will be performed if sufficient studies are included. We will perform a narrative analysis if quantitative synthesis is not appropriate.

ETHICS AND DISSEMINATION

Ethics approval is not required; we will publish findings from this study in a peer-reviewed journal and present results at national and international conferences. This study will promote a better understanding and management of elderly/geriatric TBI.

PROSPERO REGISTRATION NUMBER

CRD42022323231.

Hypertension and advanced age increase the risk of cognitive impairment after mild traumatic brain injury: A registry-based study

OBJECTIVE

As the global population ages, the incidence of traumatic brain injury (TBI) increases. While mild TBI can impair the cognitive function of older adults, the cause and background of mild TBI-induced cognitive impairment remains unclear, and the evaluation of risk factors for cognitive impairment after mild TBI remain open for consideration especially in the current aging society. This study aimed to evaluate the risks associated with cognitive impairment following mild TBI.

METHODS

Between January 2006 and December 2018, 2,209 patients with TBI required hospitalization in Shimane Prefectural Central Hospital. Mild TBI was defined as a Japan coma scale ≤ 10 at admission. The cognitive function of the patients was measured with the Hasegawa Dementia Rating Scale-revised or Mini-mental state examination at least twice during the patients' hospital stays. The odds ratio (OR) and 95% confidence interval (CI) of each considered risk factor was calculated with multivariable logistic regression analysis after univariate analysis.

RESULTS

Among 1,674 patients with mild TBI, 172 patients underwent cognitive function examinations, and 145 patients (84.3%) were found to have cognitive impairment at discharge. Significant risk factors for cognitive impairment included age (P = 0.008) and hypertension (P = 0.013) in univariate analysis; and age (OR 1.04: 95% CI 1.01-1.07) and hypertension (OR 5.81: 95% CI 1.22-27.68) by multivariable analysis.

CONCLUSIONS

Older patients with hypertension displayed significantly higher cognitive impairment risk after even mild TBI. For these patients, we should take carefully management even after mild TBI.

Validation of the Japan Coma Scale for the prediction of mortality in children: analysis of a nationwide trauma database

Objective

The Japan Coma Scale (JCS) is widely used in clinical practice to evaluate levels of consciousness in Japan. There have been several studies on the usefulness of JCS in adults. However, its usefulness in evaluating children has not been reported. Therefore, this study aimed to assess the usefulness of the JCS for the prediction of mortality in children.

Methods

This is a multicenter cohort study which used data from a national trauma registry (Japan Trauma Data Bank). This study included patients under 16 years of age who were treated between 2004 and 2015.

The primary outcome measure was in-hospital mortality. Two models were used to examine each item of the Glasgow Coma Scale (GCS) and the JCS. Model A included the discrete levels of each index. In model B, data regarding age, sex, vital signs on arrival to hospital, the Injury Severity Score, and blunt trauma were added to each index. The effectivity of the JCS score was then evaluated using the area under the curve (AUC) for discrimination, a calibration plot, and the Hosmer-Lemeshow test for calibration.

Results

A total of 9045 patients were identified. The AUCs of the GCS and JCS were 0.929 (95% confidence interval (CI) 0.904 to 0.954) and 0.930 (95% CI 0.906 to 0.954) in model A and 0.975 (95% CI 0.963 to 0.987) and 0.974 (95% CI 0.963 to 0.985) in model B, respectively. The results of the Hosmer-Lemeshow test were 0.00 (p=1.00) and 0.00 (p=1.00) in model A and 4.14 (p=0.84) and 8.55 (p=0.38) in model B for the GCS and JCS, respectively.

Conclusions

We demonstrated that the JCS is as valid as the GCS for predicting mortality. The findings of this study indicate that the JCS is a useful and relevant tool for pediatric trauma care and future research.

Sex-specific analysis of traumatic brain injury events: applying computational and data visualization techniques to inform prevention and management

BACKGROUND

The interplay of host, agent, and environment implicated in traumatic brain injury (TBI) events is difficult to account for in hypothesis-driven research. Data-driven analysis of injury data can enable insight into injury events in novel ways. This research dissected complex and multidimensional data at the time of the TBI event by exploiting data mining and information visualization methods.

METHODS

We drew upon population-based decade-long health administrative data collected through the routine operation of the publicly funded health system in Ontario, Canada. We applied a computational approach to categorize health records of 235,003 patients with TBI versus the same number of reference patients without TBI, individually matched based on sex, age, place of residence, and neighbourhood income quantile. We adopted the basic concepts of the Haddon Matrix (host, agent, environment) to organize emerging factors significantly related to TBI versus non-TBI events. To explore sex differences, the data of male and female patients with TBI were plotted on heatmaps and clustered using hierarchical clustering algorithms.

RESULTS

Based on detected similarities, the computational technique yielded 34 factors on which individual TBI-event codes were loaded, allowing observation of a set of definable patterns within the host, the agent, and the environment. Differences in the patterns of host, agent and environment were found between male and female patients with TBI, which are currently not identified based on data from injury surveillance databases. The results were internally validated.

CONCLUSIONS

The study outlines novel areas for research relevant to TBI and offers insight into how computational and visual techniques can be applied to advance the understanding of TBI event. Results highlight unique aspects of sex differences of the host and agent at the injury event, as well as differences in exposure to adverse social and environmental circumstances, which can be a function of gender, aiding in future studies of injury prevention and gender-transformative care.

Current trend in treatment of glioblastoma in Japan: a national survey using the diagnostic procedure combination database (J-ASPECT study-glioblastoma)

Background

In the treatment for glioblastoma (GBM), treatment modalities, such as bevacizumab (BEV) and carmustine wafers implants have been approved in Japan since 2013. However, it is unclear whether such a trend in treatment complexity can accelerate treatment centralization. The aim of this study was to reveal the current trend in the treatment of GBM in Japan.

Methods

We used diagnostic procedure combination (DPC) database to analyze the data of 1,774 patients from 305 institutions between April 2016 and March 2019. To analyze the situations associated with first-line BEV use during concurrent TMZ (temozolomide)-radiotherapy, we compared TMZ alone and TMZ–BEV groups.

Results

Of the 1,774 patients with GBM, tumor removal by craniotomy was performed in 1,572 (88.6%) patients, and stereotactic biopsy was performed in 156 (8.8%) patients. A total of 1,229 (69.3%) patients underwent radiotherapy, and 1,287 (72.5%) patients underwent chemotherapy. TMZ alone was administered to 878 (68.2%) and TMZ combined with BEV in 381 (29.6%) patients. In the TMZ–BEV group, as compared to the TMZ-alone group, the rate of discharge to home was significantly lower (P = 0.0044), and the rate of stereotactic biopsy was significantly higher (P < 0.0001). No significant difference was observed in the distribution of patients between the TMZ alone and TMZ–BEV groups depending on the scale of institution (P = 0.1240).

Conclusion

First-line BEV administration seems to be selected properly regardless of the institutional scale. This Japan-wide study of GBM treatment revealed that high level and newly introduced treatments have been steadily generalized in Japanese institutions.

The Effect of Cerebrolysin on the Predictive Value of Baseline Prognostic Risk Score in Moderate and Severe Traumatic Brain Injury

Cognitive dysfunction is a significant complaint among patients after moderate to severe traumatic brain injury (TBI), with devastating consequences on functional recovery and quality of life. Prognostic models allow a better assessment and management of neurotrauma patients.

The aim of the study was to demonstrate the predictive value of the Baseline Prognostic Risk Score (BPRS) in moderate to severe TBI, in a sample of patients treated with neurotrophic factors.

Eighty patients with moderate-severe TBI from the CAPTAIN II study were included in secondary data analysis. Patients received active treatment with Cerebrolysin, 50 mL per day for ten days, followed by two treatment cycles with 10 mL per day for ten days. BPRS was determined on admission; the age was recorded, and patients were evaluated using the following neurocognitive tests: Mini-Mental State Essay (MMSE), Wechsler Adult Intelligence Scale-Third Edition Processing Speed Index (WAIS-III PSI) and Stroop Colour Word Test-Victoria Version at 10, 30 and 90 days. Hierarchical regression analysis was performed to investigate the unique predictive value of BPRS on cognitive evolution, independent of age. BPRS independently predicted scores on the WAIS-III PSI DSCales and the Word subscale of the Stroop Colour Word Test at 90 days. Age was a significant predictor for all the investigated scales at 10, 30, and 90 days.

This study demonstrates the predictive value of a validated prognostic model (BPRS) for medium-term neurocognitive outcomes in a sample of moderate-severe traumatic brain injury treated with neurotrophic factors.

Association between physician-staffed helicopter versus ground emergency medical services and mortality for pediatric trauma patients: A retrospective nationwide cohort study

Background

Helicopter emergency medical services’ (HEMS) effectiveness for pediatric trauma patients remains unclear. We aimed to examine the relation between HEMS and reduced mortality in pediatric trauma patients.

Methods

This retrospective cohort study utilized data from the Japan Trauma Data Bank, a national multicenter clinical trauma database. Participants were aged <18 years, admitted between 2004 and 2015, and transported from the scene to the hospital by HEMS or ground emergency medical services (GEMS). We used a standardized mortality ratio (SMR) weight method, and fitted a marginal structural model to adjust for measured confounders. The SMR weight was calculated using the estimation of the propensity scores. A logistic regression model was used with the baseline independent variables to estimate the propensity score.

Results

Overall, 5,947 patients were identified in our study: 453 were transported by HEMS and 5,494 by GEMS. The mean injury severity score in the HEMS group was significantly higher than that in the GEMS group17.0 (Standard deviation = 11.0) vs 12.2 (Standard deviation = 9.2), p < .001. In-hospital mortality was higher in the HEMS group than that in the GEMS group in the unadjusted analysis (3.8% vs 1.3%, respectively; p < .001). After adjusting for covariates, HEMS transport was not associated with reduced hospital mortality. (odds ratio = 0.82, 95% confidence interval = 0.42–1.58).

Conclusions

HEMS was not associated with reduced mortality among pediatric trauma patients compared with GEMS in this nationwide study. Further investigation is necessary to determine who clearly benefits from HEMS as compared to GEMS.

The Effect of Frailty and Patient Comorbidities on Outcomes After Acute Subdural Hemorrhage: A Preliminary Analysis

BACKGROUND

Frailty is associated with worse outcomes across a variety of neurosurgical diseases. However, its effect on acute subdural hemorrhage (aSDH) outcomes is unclear. The goal of this study is to compare 3 measures of frailty with the gold standard (i.e., initial Glasgow Coma Scale [iGCS] score) for predicting outcomes after aSDH.

METHODS

Patients who presented between January 2016 and June 2018 were retrospectively identified based on International Classification of Diseases codes for aSDH. Patients' modified Frailty Index (mFI), temporalis muscle thickness (TMT), and age-adjusted Charlson Comorbidity Index (CCI) were calculated. Primary end points were death and discharge home.

RESULTS

Of 167 patients included, the mean age was 63.4 ± 1.9 years, the average CCI was 3.4 ± 0.2, mFI was 1.4 ± 0.1, TMT was 7.1 ± 0.2 mm, and iGCS score was 11.9 ± 0.3. Sixty-nine patients (41.3%) were discharged home and 32 (19.2%) died during hospitalization. In multivariate analysis, decreasing iGCS score (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.96; P = 0.0112) and midline shift (OR, 1.27; 95% CI, 1.08-1.50; P = 0.0048), but not age or frailty, predicted mortality. In addition to iGCS score (OR, 1.26; 95% CI, 1.10-1.44; P = 0.0011), lower CCI (OR, 0.32; 95% CI, 0.14-0.74; P = 0.0071) and larger TMT (OR, 2.63; 95% CI, 1.16-5.99; P = 0.0210) independently predicted increased rates of discharge home. mFI was not independently associated with either primary end point in multivariate analysis.

CONCLUSIONS

iGCS score predicts both mortality and discharge location after aSDH better than do age or frailty. However, CCI and TMT, but not mFI, are useful prognostic indicators of discharge to home after aSDH. The iGCS score should continue to be the primary prediction tool for patients with aSDH; however, frailty may be useful for resource allocation, especially when nearing discharge.

Baseline Predictors of Survival, Neurological Recovery, Cognitive Function, Neuropsychiatric Outcomes, and Return to Work in Patients after a Severe Traumatic Brain Injury: an Updated Review

Introduction

Severe traumatic brain injury (sTBI) is a common cause of death and disability worldwide, with long-term squeal among survivors that include cognitive deficits, psychosocial and neuropsychiatric dysfunction, failure to return to pre-injury levels of work, school and inter-personal relationships, and overall reduced quality of and satisfaction with life.

Aim

The aim of this work is to review the current literature on baseline predictors of outcomes in adults post sTBI.

Method

Most of available literature on baseline predictors of outcomes in adults post sTBI were reviewed and summarized in this work.

Results

Currently, a sizeable number of composite predictors of mortality and overall function exists; however, these instruments tend to over-estimate poor outcomes and fail to address issues like cognition, psychosocial/ neuropsychiatric dysfunction, and return to work or school.

Conclusion

This article reviews currently-identified predictors of all these outcomes.

Serum caspase-3 levels during the first week of traumatic brain injury

OBJECTIVE

Confluence between the intrinsic and extrinsic apoptosis pathways is reached at the point of caspase-3 activation, which induces death cell. Higher serum caspase-3 levels have been recorded on day 1 of traumatic brain injury (TBI) in 30-day non-survivors compared to survivors. The objectives of this study therefore were to determine whether serum caspase-3 levels are persistently higher in non-survivors than in survivors, and whether these levels may be used to predict 30-day mortality.

DESIGN

A prospective observational study was carried out.

SETTING

Six Spanish Intensive Care Units.

PATIENTS

Patients with severe isolated TBI (defined as Glasgow Coma Scale <9 points and non-cranial Injury Severity Score <10 points).

INTERVENTIONS

Serum caspase-3 concentrations were measured on days 1, 4 and 8 of TBI.

MAIN VARIABLES OF INTEREST

Thirty-day mortality was considered as the study endpoint.

RESULTS

In comparison with non-survivors (n=34), 30-day survivors (n=90) showed lower serum caspase-3 levels on days 1 (p=0.001), 4 (p<0.001) and 8 (p<0.001) of TBI. Analysis of the ROC curves showed serum caspase-3 concentrations on days 1, 4 and 8 of TBI to have an AUC (95% CI) in predicting 30-day mortality of 0.70 (0.61-0.78; p=0.001), 0.83 (0.74-0.89; p<0.001) and 0.87 (0.79-0.93; p<0.001), respectively.

CONCLUSIONS

The novel findings of our study were that serum caspase-3 levels during the first week of TBI were lower in survivors and could predict 30-day mortality.