Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians with Subdural Hematomas

Mortality Predictors for Adult Patients with Mild-to-Moderate Traumatic Brain Injury: A Literature Review

Traumatic brain injuries (TBIs) represent a significant public health concern, with mild-to-moderate cases comprising a substantial portion of incidents. Understanding the predictors of mortality among adult patients with mild-to-moderate TBIs is crucial for optimizing clinical management and improving outcomes. This literature review examines the existing research to identify and analyze the mortality predictors in this patient population. Through a comprehensive review of peer-reviewed articles and clinical studies, key prognostic factors, such as age, Glasgow Coma Scale (GCS) score, the presence of intracranial hemorrhage, pupillary reactivity, and coexisting medical conditions, are explored. Additionally, this review investigates the role of advanced imaging modalities, biomarkers, and scoring systems in predicting mortality following a mild-to-moderate TBI. By synthesizing the findings from diverse studies, this review aims to provide clinicians and researchers with valuable insights into the factors influencing mortality outcomes in adult patients with a mild-to-moderate TBI, thus facilitating more informed decision making and targeted interventions in clinical practice.

Outcomes After the Surgical Evacuation of Traumatic Acute Subdural Hematomas: The tASDH Risk Score

BACKGROUND

Acute subdural hematoma (ASDH) is a common pathology following traumatic brain injury (TBI). There is sparse data on the prediction of clinical outcomes following traumatic ASDH (tASDH) evacuation. We investigated prognosticators of outcome following evacuation of tASDHs, with subset analysis in a cohort of octogenarians. We developed a scoring system for stratifying the risk of in-hospital mortality for patients undergoing tASDH evacuation.

METHODS

A retrospective chart review was performed to identify all patients who underwent tASDH evacuation. Baseline clinical and demographic data including age, traumatic brain injury mechanism, admission Glasgow Coma Scale (GCS), and Rotterdam computed tomography Scale (RCS) were collected. In-hospital outcomes such as mortality and discharge disposition were collected. A scoring system (tASDH Score) which incorporates RCS (1-2 points), admissions GCS (0-1 points), and age (0-1 point) was created to predict the risk of in-hospital mortality following tASDH evacuation.

RESULTS

Being an octogenarian (OR = 6.91 [2.20-21.71], P = 0.0009), having a GCS of 9-12 (OR = 1.58 [1.32-4.12], P = 0.027) or 3-8 (OR = 2.07 [1.41-10.38], P = 0.018), and having an RCS of 4-6 (OR = 3.49 [1.45-8.44], P = 0.0055) were independently predictive of in-hospital mortality. The in-hospital mortality rate was lower for those with a tASDH score of 1 (10%), compared to those with a score of 2 (12%), 3 (42%), and 4 (100%).

CONCLUSIONS

Octogenarians with an RCS of 4-6 and an admission GCS <13 have a high risk of mortality following tASDH evacuation. Knowledge of which patients are unlikely to survive ASDH evacuation may help guide neurosurgeons in prognostication and goals of care discussions.

Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients

Objective

We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management.

Background

Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation.

Methods

A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability.

Results

Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata.

Conclusion

Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.

Novel application of the Rotterdam CT score in the prediction of intracranial hypertension following severe traumatic brain injury

OBJECTIVE

Severe traumatic brain injury (TBI) is associated with intracranial hypertension (ICHTN). The Rotterdam CT score (RS) can predict clinical outcomes following TBI, but the relationship between the RS and ICHTN is unknown. The purpose of this study was to investigate clinical and radiological factors that predict ICHTN in patients with severe TBI.

METHODS

The authors performed a single-center retrospective review of patients who, between 2018 and 2021, had an intracranial pressure (ICP) monitor placed following TBI. Radiological and clinical characteristics related to the TBI and ICP monitoring were collected. The main outcome of interest was ICHTN, which was a dichotomous outcome (yes or no) defined on a per-patient basis as an ICP > 22 mm Hg that persisted for at least 5 minutes and required an escalation of treatment. ICHTN included both elevated opening pressure on initial monitor placement and ICP elevations later during hospitalization. Multivariate logistic regression was performed to determine variables associated with ICHTN. Diagnostic accuracy was evaluated using the area under the receiver operating characteristic curve (AUROC).

RESULTS

Seventy patients with severe TBI and an ICP monitor were included in this study. There was a predominance of male patients (94.0%), and the mean patient age was 40 years old. Most patients (67%) had an intraparenchymal catheter placed, whereas 33% of patients had a ventriculostomy catheter placed. In the multivariate logistic regression analysis, the RS was an independent predictor of ICHTN (OR 2.0, 95% CI 1.2-3.5, p = 0.014). No instances of ICHTN were observed in patients with an RS of 2 or less and no sulcal effacement. The AUROC of the RS and sulcal effacement was higher than the AUROC of the RS alone for predicting ICHTN (0.76 vs 0.71, p = 0.003, z-test).

CONCLUSIONS

The RS was predictive of ICHTN in patients with severe TBI, and the diagnostic accuracy of the model was improved with the inclusion of sulcal effacement at the vertex on CT of the head. Patients with a low RS and no sulcal effacement are likely at low risk for the development of ICHTN.

Establishment of relapse risk model and multivariate logistic regression analysis on risk factors of relapse in children with primary nephrotic syndrome

This study aimed to investigate relapse risk factors in children with primary nephrotic syndrome (PNS) for prevention and early intervention via logistic regression. One hundred thirty-seven children with PNS were enrolled in this study. Clinical variables were analyzed by single-factor and multiple regression analysis to establish the regression equation. The predictive ability of the regression equation was investigated by the receiver operating characteristic curve (ROC). Files of 17 patients were lost, and 120 patients were enrolled finally in the study, among whom 55 cases (45.8%) had frequently relapsed. Single-factor analysis and multiple regression analysis revealed that concurrent infection on first onset, irregular glucocorticoid therapy, severe hypoalbuminemia, and persistent severe hyperlipidemia were the significant risk factors for frequent relapse on PNS (P < .05), among which infection remained to be the main inductive factor. Among the 4 indicators, serum albumin had the best diagnostic efficacy based on the area under the ROC curve (0.933), sensitivity (89.09%), and specificity (81.54%). The area under curve, sensitivity, and specificity for the combined diagnostic model of the 4 indices were 97.8%, 98.18%, and 90.77%, respectively, which had good predictive power for the relapse of patients. Concurrent infection, irregular glucocorticoid therapy, severe hypoalbuminemia, and persistent severe hyperlipemia were all the risk factors for PNS relapse. The established logistic regression model based on these factors above is reliable for predicting frequent PNS relapse. Much attention should be paid to these critical factors, and early intervention should be taken to reduce the incidence of relapse.