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

Predictors of withdrawal of life-sustaining therapies in older adults with TBI and a modified frailty index score

BACKGROUND

Withdrawal-of-life-sustaining-therapies (WLST) in patients with traumatic brain injury (TBI) is a complex decision-making process. The clinical factors related to WLST in older adults with TBI are currently poorly understood. The present study aims to determine the clinical predictors of WLST in older patients with TBI.

METHODS

All patients ≥ 65 years old with TBI (Head Abbreviated Injury Scale Score ≥ 3) were identified from the Geriatric TBI Database, a prospective registry of patients admitted to 45 trauma centers nationwide with TBI between 2017-2019. We collected factors related to past medical history, baseline demographic data, clinical presentation, TBI sub-type, neurosurgical interventions, and do-not-attempt-resuscitation (DNAR) orders. The primary outcome measure was WLST. Binary logistic regression was subsequently performed to determine factors independently associated with WLST.

RESULTS

A total of 1600 patients were identified. The median age was 80 years old and 48.6 % of patients were male. In this cohort, 120 patients (7.5 %) underwent WLST. A logistic regression model revealed that Glasgow Coma Scale (GCS) (OR 0.82; 95 %-CI 0.77--0.87), cerebral edema (3.2; 1.5-7.0), craniotomy/craniectomy (2.5; 1.4-4.4), and DNAR (8.8; 5.5-14.3) were all independently associated with WLST. This model demonstrated excellent discrimination ability with a concordance statistic of 0.935.

CONCLUSIONS

This study demonstrates that patients ≥ 65 years old with poor initial GCS, cerebral edema, craniotomy/craniectomy, and DNAR were all independently associated with WLST. Pre-injury frailty was not associated with WLST. Further studies are needed to evaluate the prognostic value of frailty indices in the management of patients with TBI.

Modified prediction model for poor short-term prognosis in patients with chronic subdural hematoma after burr hole drainage: a retrospective cohort study

To the Editor,I would like to acknowledge the valuable efforts taken to enhance the knowledge through the article "Prediction model for poor short-term prognosis in patients with chronic subdural hematoma (CSDH) after burr hole drainage: a retrospective cohort study" [1]. We thoroughly read this article published in your journal and learned the aim behind this study. This article has described every aspect of determining prognosis postoperatively in patients after evacuation of chronic subdural hematoma via a single burr hole. This research has immense potential to add valuable insights into preexisting literature. Nonetheless, we still have some uncertainties to address, for which I would like to offer a few critical reflections that could be very valuable in further research in this aspect. Incorporating these additional factors could significantly enhance the comprehensiveness of this model.

The impact of early surgery on mortality and functional recovery in older adults with traumatic intracranial lesions: a propensity score-based analysis

BACKGROUND

There is skepticism about the benefit of surgery in elderly patients affected by traumatic brain injury (TBI) due to the negative effect of age on the outcome and surgical complications. However, there are few studies that have investigated differences in patient's outcome between surgically and conservatively managed patients after adjusting for the imbalance in preinjury characteristics and clinical and radiological features. The primary aim of this study was to evaluate the effect of early surgery on mortality and functional recovery in a cohort of older adults with acute traumatic intracranial lesions after adjustment by Propensity Score (PS) matching.     MATERIALS AND METHODS: We conducted a retrospective cohort study on older adult patients (≥ 65 years) admitted for TBI between 2013 and 2023 to a single level 1 trauma center. Patients were categorized based on whether they underwent early surgery (< 48 h after TBI) for a space-occupying lesion evacuation. PS model was constructed based on age, frailty, comorbidities (Charlson comorbity index and American Society of Anaesthesiologists score), anticoagulants, hypoxia, shock, pupillary abnormalities and GCS motor response upon admission, midline shift, basal cistern effacement, volume of subdural and intracerebral hematomas, and limitation of life-sustaining treatment decisions.The effect of early surgery on 30-day mortality and unfavorable functional outcomes (GOSE 1-3) at 6 and 12 months were investigated after matching by paired test.

RESULTS

We identified and reviewed 301 patients who met all inclusion criteria and contained no exclusions. After matching, 62 patients (31 pairs of conservative and surgical patients) remained as the matched datasets. Our key finding was that older adult TBI patients who underwent early surgery had a statistically significant reduction in the risk of 30-day mortality (OR 0.313, 95% CI 0.114-0.853, p = 0.023) and unfaourable outcome at 12 months after TBI (OR 0.286, 95% CI 0.094-0.868, p = 0.027).

CONCLUSIONS

Early surgery was associated with decreased 30-day mortality and better functional outcome at 12 months after TBI in older adults with few comorbidities and good functionality when clinically affected by acute traumatic intracranial lesions with mass effect.

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.

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.

Diffuse Axonal Injury Pattern Predicts Timing of In-Hospital Neurologic Recovery: A Retrospective Case Series

BACKGROUND

Diffuse axonal injury (DAI) is a devastating traumatic neurologic injury with variable prognosis. Although outcomes such as mortality have been described, the time course of neurologic progression is poorly understood. We investigated the association between DAI neuroanatomic injury pattern and neurologic recovery timing.

METHODS

A retrospective review of our institution's trauma registry identified patients diagnosed with DAI from 2017-2021. The neuroradiologist's review of a head computed tomography scan was used to score DAI severity. In-hospital neurologic examinations were reviewed, and the Glasgow Coma Scale (GCS) was calculated for all patients throughout the hospital stay. Categorical variables were analyzed using the Fisher exact test, and continuous variables were analyzed using the Kruskal-Wallis test.

RESULTS

Nineteen DAI patients (grade 1 = 8; grade 2 = 1; grade 3 = 10) were included (mean age 31 years, 79% male). Mean Rotterdam computed tomography score, Injury Severity Scale, and admission GCS were comparable across DAI grades. Mean time in days to follow commands was shorter for those with grade 1 DAI (9.3) compared with grade 2 (17 days) or grade 3 (19 days) DAI (P = 0.02). Throughout hospitalization, patients with grade 1 DAI had higher motor (P = 0.006), eye (P = 0.001), and total GCS (P = 0.011) scores compared with those with grade 2 or 3 DAI. At the time of discharge, total GCS and the frequency of command following was similar across DAI grades.

CONCLUSIONS

Patients with grade 1 DAI demonstrated the fastest short-term neurologic recovery, although final discharge neurologic examination was comparable across DAI grades. DAI classification can provide useful short-term prognostic information regarding in-hospital neurologic improvement.

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.