Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours

A Geospatial Analysis of the Availability, Distribution, and Accessibility of Neurosurgical Facilities, Workforce, and Infrastructure in Nigeria; and Projection Towards 2050

OBJECTIVE

There has been a modest but progressive increase in the neurosurgical workforce, training, and service delivery in Nigeria in the last 2 decades. However, these resources are unevenly distributed. This study aimed to quantitatively assess the availability and distribution of neurosurgical resources in Nigeria while projecting the needed workforce capacity up to 2050.

METHODS

An online survey of Nigerian neurosurgeons and residents assessed the country's neurosurgical infrastructure, workforce, and resources. The results were analyzed descriptively, and geospatial analysis was used to map their distribution. A projection model was fitted to predict workforce targets for 2022-2050.

RESULTS

Out of 86 neurosurgery-capable health facilities, 65.1% were public hospitals, with only 17.4% accredited for residency training. Dedicated hospital beds and operating rooms for neurosurgery make up only 4.0% and 15.4% of the total, respectively. The population disease burden is estimated at 50.2 per 100,000, while the operative coverage was 153.2 cases per neurosurgeon. There are currently 132 neurosurgeons and 114 neurosurgery residents for a population of 218 million (ratio 1:1.65 million). There is an annual growth rate of 8.3%, resulting in a projected deficit of 1113 neurosurgeons by 2030 and 1104 by 2050. Timely access to neurosurgical care ranges from 21.6% to 86.7% of the population within different timeframes.

CONCLUSIONS

Collaborative interventions are needed to address gaps in Nigeria's neurosurgical capacity. Investments in training, infrastructure, and funding are necessary for sustainable development and optimized outcomes.

General surgeon performed emergency craniotomies in regional Queensland hospitals: a 20-year state-wide study on patient outcomes

BACKGROUND

Traumatic brain injuries account for up to 50% of trauma related deaths and if surgical intervention is indicated, consensus suggests a maximum of 4 hours to surgical decompression. The occurrence and outcomes of craniotomies performed by non-neurosurgeons in regional Queensland hospitals have never been reported previously in the literature.

METHODS

A retrospective review was performed at all regional Queensland hospitals without an on-site neurosurgical service from January 2001 to December 2022 to identify patients undergoing emergency craniotomy. Data recorded included basic demographics, history of anti-coagulant use, mechanism of injury, type of haemorrhage, Glasgow Coma Score and Glasgow Outcome Scale (GOS) on discharge. Radiological parameters measured included midline shift and maximal coronal depth of haematoma. The primary aim of this study was to assess the clinical and radiological outcomes of patients who underwent a craniotomy performed by general surgeons.

RESULTS

Over the past 20 years there have been 23 emergency decompressive procedures (one excluded) performed in regional Queensland. Preoperative imaging demonstrated 9 extradural haematomas and 13 subdural haematomas. Six of 17 transferred cases required reoperation after transfer to a neurosurgical centre. Survival was observed in 9 of 22 cases, with 'good' functional outcome (GOS ≥3) observed in 7 cases. In no cases were rurally performed burr holes effective.

DISCUSSION

Qualitatively, a larger craniotomy may be associated with better clinical and radiological outcomes. Although rare occurrences, our results demonstrate that general surgeon performed craniotomies are frequently efficacious in producing radiological and/or clinical improvement and should be considered as a potentially lifesaving procedure.

Human factor engineering of point-of-care near infrared spectroscopy device for intracranial hemorrhage detection in Traumatic Brain Injury: A multi-center comparative study using a hybrid methodology

OBJECTIVE

This study assessed machine learning powered Near-infrared spectroscopy based (mNIRS) device's usability and human factor ergonomics in four distinct healthcare provider groups.

BACKGROUND

Traumatic Brain Injury (TBI) is a global concern with significant well-being implications. Timely intracranial hemorrhage (ICH) detection is crucial. mNIRS offers efficient non-invasive TBI screening.

METHODS

Two device utilization stages involved operators (N = 21) and TBI-suspected subjects (n = 120). A hybrid approach used qualitative and quantitative methods, utilizing a 57-item survey and task completion time.

RESULTS

All groups positively perceived user-interface, physical, cognitive, and organizational ergonomics. The device's ease of use, calibration, size, cognitive support, and integration gained appreciation. Training reduced task completion time from 16.5 to 13.2 s.

CONCLUSION

mNIRS-based CEREBO® proves usable for TBI point-of-care assessment. Positive feedback from diverse healthcare groups validates design and cost-effectiveness alignment. A hybrid approach, training, and practice scans enhance usage and experience.

Simulating Cerebral Edema and Ischemia After Traumatic Acute Subdural Hematoma Using Triphasic Swelling Biomechanics

Poor outcome following traumatic acute subdural hematoma (ASDH) is associated with the severity of the primary injury and secondary injury including cerebral edema and ischemia. However, the underlying secondary injury mechanism contributing to elevated intracranial pressure (ICP) and high mortality rate remains unclear. Cerebral edema occurs in response to the exposure of the intracellular fixed charge density (FCD) after cell death, causing ICP to increase. The increased ICP from swollen tissue compresses blood vessels in adjacent tissue, restricting blood flow and leading to ischemic damage. We hypothesize that the mass occupying effect of ASDH exacerbates the ischemic injury, leading to ICP elevation, which is an indicator of high mortality rate in the clinic. Using FEBio (febio.org) and triphasic swelling biomechanics, this study modeled clinically relevant ASDHs and simulated post-traumatic brain swelling and ischemia to predict ICP. Results showed that common convexity ASDH significantly increased ICP by exacerbating ischemic injury, and surgical removal of the convexity ASDH may control ICP by preventing ischemia progression. However, in cases where the primary injury is very severe, surgical intervention alone may not effectively decrease ICP, as the contribution of the hematoma to the elevated ICP is insignificant. In addition, interhemispheric ASDH, located between the cerebral hemispheres, does not significantly exacerbate ischemia, supporting the conservative surgical management generally recommended for interhemispheric ASDH. The joint effect of the mass occupying effect of the blood clot and resulting ischemia contributes to elevated ICP which may increase mortality. Our novel approach may improve the fidelity of predicting patient outcome after motor vehicle crashes and traumatic brain injuries due to other causes.

Influence of Blood Components on Neuroinflammation, Blood-Brain Barrier Breakdown, and Functional Damage After Acute Subdural Hematoma in Rats

A central component of injury development after acute subdural hematoma (ASDH) is the increased intracranial pressure and consecutive mechanical reduction of cerebral blood flow (CBF). However, the role of different blood constituents in ASDH as additional lesioning factors remains unclear. This study examines the influence of blood components on neuroinflammation, blood-brain barrier (BBB) breakdown, and functional deficits in a rat model of ASDH. We infused corpuscular (whole blood, whole blood lysate, and red cell blood) and plasmatic (blood plasma, anticoagulated blood plasma, and aqueous isotonic solution) blood components into the subdural space while CBF was monitored. Rats then underwent behavioral testing. Lesion analysis and immunohistochemistry were performed 2 days after ASDH. Inflammatory reaction was assessed using staining for ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein, interleukin-1ß, tumor necrosis factor-alpha, and membrane attack complex. Integrity of the BBB was evaluated with albumin and matrix metalloproteinase 9 (MMP9) staining. We observed a significant drop in CBF in the corpuscular group (75% ± 7.5% of baseline) with distinct post-operative deficits and larger lesion volume compared to the plasmatic group (13.6 ± 5.4 vs. 1.3 ± 0.4 mm3). Further, inflammation was significantly increased in the corpuscular group with stronger immunoreaction. After whole blood infusion, albumin and MMP9 immunoreaction were significantly increased, pointing toward a disrupted BBB. The interaction between corpuscular and plasmatic blood components seems to be a key factor in the detrimental impact of ASDH. This interaction results in neuroinflammation and BBB leakage. These findings underscore the importance of performing surgery as early as possible and also provide indications for potential pharmacological targets.

The Efficacy of Traumatic Brain Injury Treatment by Neurotrauma Specialists

Objective

Since the establishment of Regional Trauma Centers (RTCs) in Korea, significant efforts have been made to improve the quality of care for patients with trauma. Simultaneously, the Department of Neurosurgery assigned neurotrauma specialists to RTCs to provide specialized care to patients with traumatic brain injury (TBI). In this study, we sought to determine whether neurotrauma specialists, compared to general neurosurgeons, could make a significant difference in treatment outcomes of patients with TBI.

Methods

In total, 156 patients with acute TBI who required decompression were included. We reviewed their records and compared the characteristics, outcomes, and prognosis of those who received surgical treatment from either neurotrauma specialists or general neurosurgeons at our institution.

Results

A significant difference was observed between treatment by trauma neurosurgery specialists and general neurosurgeons in time to surgery, with trauma specialists experiencing shorter surgical delays. However, no significant differences existed in mortality rates or Extended Glasgow Outcome Scale scores. Univariate and multivariable regression analyses revealed that lower Glasgow Coma Scale scores, an abnormal pupil reflex, larger transfusion volume, and prolonged time from emergency room admission to surgery were associated with high mortality rates.

Conclusion

Neurotrauma specialists can provide prompt surgical treatment to patients with TBI compared to general neurosurgeons. Our study did not reveal a significant difference in outcomes between the two groups. However, it is clear that rapid decompression is effective in patients with impending brain herniation. Therefore, the effectiveness of neurotrauma specialists needs to be confirmed through further systematic studies.

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.

Deadliness of Traumatic Subdural Hematomas in the First Quarter of the Year: A Measurement by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP)

Background Traumatic acute subdural hematoma (ASDH) is a surgical emergency and has been associated with high morbidity and mortality. However, it is not known whether mortality from ASDH occurs more frequently in a particular season. Methodology We queried the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) from 2016 to 2019. They were identified in the NSQIP using the International Classification of Diseases (ICD-10) code S06.5 to capture all admissions with a primary diagnosis of traumatic subdural hematoma. Mortality rates were reviewed per season, defined as three consecutive months in the year. Demographics such as age, race, ethnicity, height, and weight were reviewed. Comorbidities such as diabetes, risk factors, including smoking history, and hospitalization characteristics, such as admission year, operation year, and inpatient/outpatient treatment type, were also reviewed. Results A total of 1,656 patients were included in this study. The mean age of all participants was 70.6 years, with 37% (604/1,656) being female. The mortality rate was highest in January, February, and March at 24.5% (104/425, P = 0.045) of admitted patients compared to mortality rates of 18.8% (70/373) in April to June, 18.4% (81/441) in July to September, and 17.5% (73/417) in October to December. Conclusions Mortality is significantly greater during the winter months of January, February, and March among patients with ASDH. Despite better survival rates of ASDH over the past two decades, postoperative mortality rates still remain high.

Outcome and survival of surgically treated acute subdural hematomas and postcraniotomy hematomas - A retrospective cohort study

Background

The morbidity and mortality of acute subdural hematoma (aSDH) remains high. Several factors have been reported to affect the outcome and survival of these patients. In this study, we explored factors potentially associated with the outcome and survival of surgically treated acute subdural hematoma (aSDH), including postcraniotomy hematomas (PCHs).

Methods

This retrospective cohort study was conducted in a single tertiary university hospital between 2008 and 2012 and all aSDH patients that underwent surgical intervention were included. A total of 132 cases were identified for collection of demographics, clinical, laboratory, and imaging data. Univariate and multivariable analyses were performed to assess factors associated with three-month Glasgow Outcome Scale (GOS) and survival at one- and five-year.

Results

In this study, PCH (n = 14, 10.6%) was not associated with a worse outcome according to the 3- month GOS (p = 0.37) or one (p = 0.34) and five-year (p = 0.37) survival. The multivariable analysis showed that the volume of initial hematoma (p = 0.009) and Abbreviated Injury Scale score (p = 0.016) were independent predictors of the three-month GOS. Glasgow Coma Scale (GCS) score (p < 0.001 and p = 0.037) and age (p = 0.048 and p = 0.003) were predictors for one and five-year survival, while use of antiplatelet drug (p = 0.030), neuroworsening (p = 0.005) and smoking (p = 0.026) were significant factors impacting one year survival. In addition, blood alcohol level on admission was a predictor for five-year survival (p = 0.025).

Conclusions

These elucidations underscore that, although PCHs are pertinent, a comprehensive appreciation of multifarious variables is indispensable in aSDH prognosis. These findings are observational, not causal. Expanded research endeavors are advocated to corroborate these insights.

Early Onset of Rapid Lesion Growth in an Acute Subdural Hematoma Model in Rats

OBJECTIVE

Acute subdural hematoma (ASDH) leads to the highest mortality rates of all head injuries with secondary brain damage playing a pivotal role in terms of morbidity and mortality. In patients with ASDH, a delay in surgery leads to disproportional mortality. The benefit of (very) early therapy is therefore, a target of ongoing research. As the process of delayed brain damage in ASDH has not yet been described, this study therefore aimed to examine secondary lesion growth in an experimental rat model of ASDH to define the ideal timing for testing potential neuroprotective therapies.

METHODS

Cerebral blood flow was monitored during ASDH induction with 300 μl of autologous blood. Lesion growth was characterized using Hematoxylin-Eosin- , Cresyl-Violet-, and Fluoro-Jade B-staining for early signs of neuronal degeneration. Histological evaluations were performed between 15 minutes and 24 hours after ASDH.

RESULTS

There was a significant reduction of cerebral blood flow after ASDH. Fluoro-Jade B-positive cells were visible 15 minutes after ASDH in the lesioned hemisphere. Nonlinear growth of lesion volume from 3.7 ± 0.4 mm3 to 17.5 ± 0.6 mm3 was observed at 24 hours in Hematoxylin-Eosin-staining.

CONCLUSIONS

The most damage develops between 15 minutes and 1 hour and again between 2 and 6 hours after ASDH. The time course of lesion growth supports the approach of early surgery for patients. It furthermore constitutes a basis for further ASDH research with more clearly defined time windows for therapy in animal models.

Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article

Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.

Milestones in the history of neurocritical care

Over the last century, significant milestones have been achieved in managing critical illness and diagnosing and treating neurological diseases. Building upon these milestones, the field of neurocritical care emerged in the 1980 and 1990 s at the convergence of critical care medicine and acute neurological treatment. This comprehensive review presents a historical account of key developments in neurocritical care in both the United States and Europe, with a special emphasis on German contributions. The scope of the review encompasses: the foundations of neurocritical care, including post-operative units in the 1920s and 30s, respiratory support during the poliomyelitis epidemics in the 40 and 50 s, cardiac and hemodynamic care in the 60 and 70 s, and stroke units in the 80 and 90 s; key innovations including cerebral angiography, computed tomography, and intracranial pressure and multi-modal monitoring; and advances in stroke, traumatic brain injury, cardiac arrest, neuromuscular disorders, meningitis and encephalitis. These advances have revolutionized the management of neurological emergencies, emphasizing interdisciplinary teamwork, evidence-based protocols, and personalized approaches to care.

Door-to-Skin Time in Patient Undergoing Emergency Trauma Craniotomy

Background

Traumatic brain injury (TBI) is the third leading cause of death and disability worldwide in 2020. For patients with TBI with significant intracranial bleeds, urgent surgical intervention remains the mainstay treatment. This study aims to evaluate the time to definite surgical intervention since admission and its association with patient outcomes in a neurosurgery referral centre in Malaysia.

Methods

This retrospective study was conducted at Hospital Sultanah Aminah Johor Bahru from 1 January 2019 to 31 December 2019. All patients with TBI requiring urgent craniotomy were identified from the operating theatre registry, and the required data were extracted from their clinical notes, including the Glasgow Outcome Score (GCS) at discharge and 6 months later. Logistic regression was performed to identify the factors associated with poor outcomes.

Results

A total of 154 patients were included in this study. The median door-to-skin time was 605 (interquartile range = 494-766) min. At discharge, 105 patients (68.2%) had poor outcomes. At the 6-month follow-up, only 58 patients (37.7%) remained to have poor outcomes. Simple logistic regression showed that polytrauma, hypotensive episode, ventilation, severe TBI, and the door-to-skin time were significantly associated with poor outcomes. After adjustments for the clinical characteristics in the analysis, the likelihood of having poor outcomes for every minute delay in the door-to-skin time increased at discharge (adjusted odds ratio [AOR] = 1.005; 95% confidence interval [CI] = 1.002-1.008) and the 6-month follow-up (AOR = 1.008; 95% CI = 1.005-1.011).

Conclusion

The door-to-skin time is directly proportional to poor outcomes in patients with TBI. Concerted efforts from all parties involved in trauma care are essential in eliminating delays in surgical interventions and improving outcomes.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Emergency department burr hole simulation using 3D-printed model

BACKGROUND

Traumatic epidural hematoma (EDH) with the potential to displace the brain tissue and increase intracranial pressure (ICP), is a life-threatening condition that requires emergent intervention. In rare circumstances, Emergency Physician (EP) may have to do skull trephination to reduce the ICP as a temporary measure.

SPECIFIC AIMS

To evaluate emergency medicine (EM) residents' comfort in performing emergency department (ED) burr holes and to assess their difficulties and evaluate comfort level before and after simulated EDH cases.

MATERIALS AND METHODS

A 3D-printed skull and electrical and manual drills were used for the simulation. Subjective comfort level pre and post-procedure, as well as objective procedural skills and time to complete the drill, were recorded.

RESULTS

Twenty EM residents participated in the simulation study. The median time to perforate through the skull was 4 s for the electric drill and 10 s for the manual drill. A comfort level of 5 and above was reported by 12 participants for the manual drill and by 17 participants for the electric drill. Six participants had mild and 2 participants had moderate observed difficulty in handling the manual and electric drill. Most participants performed both procedures successfully with one attempt only. Three participants have an overall comfort level above 5 before the simulation and 13 participants had a post-simulation.

CONCLUSION

The 3D-printed model assisted the ED burr hole simulation and the residents could perform the procedure with minimum difficulties.

Time to evacuation of acute subdural and extradural haematoma: prospective study before and after implementation of a major trauma centre

Purpose: Patients with Extradural (EDH) and Acute Subdural Haematomas (ASDH) represent a subgroup of head-injured patients that gain the most from timely treatment. While treatment times for head injury overall improved since the introduction of Major Trauma Centres (MTCs), no data exists describing how the time to treatment of EDH and ASDH has changed. We, therefore, compared the evacuation of ASDH and EDH before and after the implementation of a major trauma network.Methods: Data was collected prospectively between 1 May 2006 to 31 May 2007 and 1 March 2014 to 31 March 2016. The study was carried out at University Hospital Southampton, designated MTC in 2012. Patients over 18 with ASDH or EDH requiring emergency surgery were included.Results: The median time (IQR) for decompression was 4.8h (3.9-6.6) in 2006-7 and 4.4h (3.4-5.9) in 2014-16, p = 0.386. The proportion treated within 4 hours was 32% in 2006-7, and 33% in 2014-16 (p = 1.000). Analysis showed a decrease in time for CT scan (p = 0.01) and acceptance by neurosurgery (p < 0.001). There were increases in time for transferring to hospital (p = 0.005), awaiting operating theatre (p = 0.005), and operative time (p = 0.018).Conclusions: Since the introduction of MTCs, there has been no significant reduction in time to treat this select group of patients despite reductions in time to treatment of most other trauma and head-injured patients. This may be because parts of the pathway have improved, but others haven't. It is also possible that while previously head injury was poorly served, resources were prioritised to this group so finding further gains is difficult.

Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis

BACKGROUND

Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial.

METHODS

We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models.

RESULTS

The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC).

CONCLUSIONS

According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

Effect of Pre-Management Antithrombotic Agent Use on Outcome after Traumatic Acute Subdural Hematoma in the Elderly: A Systematic Review

Traumatic acute subdural hematomas (ASDH) are common in elderly patients (age ≥65 years) and are associated with a poorer prognosis compared with younger populations. Antithrombotic agent (ATA) use is also common in the elderly; however, the influence that pre-morbid ATA has on outcome in ASDH is poorly understood. We hypothesized that pre-morbid ATA use significantly worsens outcomes in elderly patients presenting with traumatic ASDH. English language medical literature was searched for articles relating to ATA use in the elderly with ASDH. Data were collated and appraised where possible. Analyses of study bias were performed. Twelve articles encompassing 2038 patients were included; controls were poorly described in the included studies. Pre-morbid ATA use was seen in 1042 (51.1%) patients and 18 different ATA combination therapies were identified, with coumarins being the most common single agent used. The newer direct oral anticoagulants were evaluated in only two studies. ATA use was associated with a lower presenting Glasgow Coma Scale (GCS) score but not hematoma volume on computed tomography (CT) or post-operative hematoma re-accumulation. No studies connected ATA use with patient outcomes without the presence of confounders and bias. Reversal strategies, bridging therapy, recommencement of ATA, and comparison groups were poorly described; accordingly, our hypothesis was rejected. ATA reversal methods, identification of surgical candidates, optimal surgery methods, and when or whether ATA should be recommenced following ASDH resolution remain topics of debate. This study defines our current understanding on this topic, revealing clear deficiencies in the literature with recommendations for future research.

Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute?

The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.

Relevance of Routine Postoperative CT Scans Following Aneurysm Clipping-A Retrospective Multicenter Analysis of 423 Cases

AIM

Postoperative head computed tomography (POCT) is routinely performed in numerous medical institutions, mainly to identify possible postsurgical complications. This study sought to assess the clinical appropriateness of POCT in asymptomatic and symptomatic patients after ruptured or unruptured aneurysm clipping.

METHODS

This is a retrospective multicenter study involving microsurgical procedures of ruptured (RA) and unruptured intracranial aneurysm (UA) surgeries performed in the Centers associated with the Pomeranian Department of the Polish Society of Neurosurgeons. A database of surgical procedures of intracranial aneurysms from 2017 to 2020 was created. Only patients after a CT scan within 24 h were included.

RESULTS

A total of 423 cases met the inclusion criteria for the analysis. Age was the only significant factor associated with postoperative blood occurrence on POCT. A total of 37 (8.75%) cases of deterioration within 24 h with urgent POCT were noted, 3 (8.1%) required recraniotomy. The highest number necessary to predict (NNP) one recraniotomy based on patient deterioration was 50 in the RA group.

CONCLUSION

We do not recommend POCTs in asymptomatic patients after planned clipping. New symptom onset requires radiological evaluation. Simultaneous practice of POCT after ruptured aneurysm treatment within 24 h is recommended.

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities

The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.

‘Burr holes in the bush’: Clinician preparedness for undertaking emergency intracranial haematoma evacuation surgery in rural and regional Queensland

OBJECTIVES

Delayed inter-hospital transfers of deteriorating neurotrauma patients from rural and regional hospitals to tertiary centres have seen the need for non-neurosurgeons to undertake emergency intracranial haematoma evacuation surgery locally. In the present study, the authors contributed to the paucity in the literature regarding the widespread availability of cranial access equipment in non-tertiary centres and patient outcomes in Queensland.

METHODS

We surveyed delegates (senior theatre nurses or surgical service directors) from rural and regional Queensland hospitals if they were located outside the local catchment of a tertiary centre and had a CT scanner. Questions regarded availability, location and storage conditions of mechanical cranial access kits, as well as last usage, and associated patient outcomes.

RESULTS

Twenty-six delegates from eligible hospitals responded. Eighteen hospitals offered surgical services. Eleven hospitals housed complete mechanical cranial access kits. Five hospitals housed incomplete kits. Thirteen hospitals housed their equipment sterile in the operating theatre or ED. Eleven hospitals reported using the equipment, with last usage ranging from 4 months to over 30 years. Two hospitals reported using the equipment within 12 months while a further five reported using it within 10 years. Two hospitals reported 'good' outcomes, two 'ok' and one 'poor'.

CONCLUSIONS

The availability of cranial access equipment outside Queensland tertiary centres has been limited. Inter-hospital transfers are likely to persist in Queensland and haematoma evacuation surgery has been a life-saving endeavour, so improving access to cranial access equipment in hospitals where it is currently lacking is highly warranted.

Closure intracranial pressure is an objective intraoperative determinant of the adequacy of surgical decompression in traumatic acute subdural haematoma: a multicentre observational study

PURPOSE

Acute subdural haematoma (ASDH) is associated with severe traumatic brain injury and poor outcomes. Although guidelines exist for the decompression of ASDH, the question of adequate decompression remains unanswered. The authors examined the relationship of intracranial pressure (ICP) on closure with outcomes to determine its utility in the determination of adequate ASDH decompression.

METHODS

A multicentre retrospective review of 105 consecutive patients with ASDH who underwent decompressive surgery was performed. Receiver operating characteristic (ROC) analysis with internal validation was performed to determine an ICP threshold for the division of patients into the inadequate and good ICP groups. Multivariable analyses were performed for both inpatient and long-term outcomes.

RESULTS

An ICP threshold of 10 mmHg was identified with a 91.5% specificity, 45.7% sensitivity, and a positive and negative predictive value of 80.8% and 68.4%. There were 26 patients (24.8%) and 79 patients (75.2%) in the inadequate and good ICP groups, respectively. After adjustment, the inadequate ICP group was associated with increased postoperative usage of mannitol (OR 14.2, p < 0.001) and barbiturates (OR 150, p = 0.001). Inadequate ICP was also associated with increased inpatient mortality (OR 24.9, p < 0.001), and a lower rate of favourable MRS at 1 year (OR 0.08, p = 0.008). The complication rate was similar amongst the groups.

CONCLUSIONS

Closure ICP is a novel, objective, and actionable intraoperative biomarker that correlates with inpatient and long-term outcomes in ASDH. Various surgical manoeuvres can be undertaken to achieve this target safely. Large-scale prospective studies should be performed to validate this ICP threshold.

Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept

Objectives

Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH).

Materials and Methods

A scoping review was conducted on Medline database from inception to September 2021.

Results

The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D).

Conclusion

This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.

Does the Timing of the Surgery Have a Major Role in Influencing the Outcome in Elders with Acute Subdural Hematomas?

BACKGROUND

The incidence of traumatic acute subdural hematomas (ASDH) in the elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays no clear role as a predictor. We investigated whether the timing of surgery had a major role in influencing the outcome in these patients.

METHODS

We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 year period in five Italian hospitals. Patients were divided into three surgical timing groups from hospital arrival: ultra-early (within 6 h); early (6-24 h); and delayed (after 24 h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at the Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed.

RESULTS

We included 136 patients. About 33% died as a result of the consequences of ASDH and among the survivors, only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting the Glasgow Outcome Scale (GCS), which was on average lower in the ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared to be neither associated with survival nor with functional outcome, also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor.

CONCLUSIONS

An earlier surgery was offered to patients with worse clinical-radiological findings. Additionally, after stratification for GCS, it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor.

A Brief Review of Bolus Osmotherapy Use for Managing Severe Traumatic Brain Injuries in the Pre-Hospital and Emergency Department Settings

Background: Severe traumatic brain injury (TBI) management begins in the pre-hospital setting, but clinicians are left with limited options for stabilisation during retrieval due to time and space constraints, as well as a lack of access to monitoring equipment. Bolus osmotherapy with hypertonic substances is commonly utilised as a temporising measure for life-threatening brain herniation, but much contention persists around its use, largely stemming from a limited evidence base. Method: The authors conducted a brief review of hypertonic substance use in patients with TBI, with a particular focus on studies involving the pre-hospital and emergency department (ED) settings. We aimed to report pragmatic information useful for clinicians involved in the early management of this patient group. Results: We reviewed the literature around the pharmacology of bolus osmotherapy, commercially available agents, potential pitfalls, supporting evidence and guideline recommendations. We further reviewed what the ideal agent is, when it should be administered, dosing and treatment endpoints and/or whether it confers meaningful long-term outcome benefits. Conclusions: There is a limited evidence-based argument in support of the implementation of bolus osmotherapy in the pre-hospital or ED settings for patients who sustain a TBI. However, decades’ worth of positive clinician experiences with osmotherapy for TBI will likely continue to drive its on-going use. Choices regarding osmotherapy will likely continue to be led by local policies, individual patient characteristics and clinician preferences.

Emergent craniotomy in rural and regional settings: recommendations from a tertiary neurosurgery unit: diagnosis and surgical decision-making

Largely attributed to the tyranny of distance, timely transfer of patients with major traumatic brain injuries (TBI) from rural or regional hospitals to metropolitan trauma centres is not always feasible. This has warranted emergent craniotomies to be undertaken by non-neurosurgeons at their local hospitals with previous acceptable results reported in regional Australia. Our institution endorses this ongoing potentially life-saving practice when necessary and emphasize the need for neurosurgical units to provide ongoing TBI education to peripheral hospitals. In this first of a two-part narrative review, the authors describe the recommended diagnostic pathway for patients with a suspected TBI presenting to rural or regional hospitals and discuss local surgical management options in the presence or absence of a CT scanner.

Are bilaterally fixed and dilated pupils the kiss of death in patients with transtentorial herniation? Systematic review and pooled analysis

OBJECTIVE

Bilaterally fixed and dilated pupils (BFDP) in the setting of transtentorial herniation due to a space-occupying lesion have traditionally been considered a sign of futility. As a result, such patients may be denied life-saving decompressive surgery, resulting in very high mortality rates. We sought to determine survival rate and functional outcomes in patients with transtentorial herniation and BFDP following emergency decompressive surgery.

METHODS

Systematic review of MEDLINE, EMBASE, Cochrane, and Google Scholar databases, using a combination of 15 prespecified keywords, according to PRISMA methodology. Individual patient data were extracted, pooled, and analyzed.

RESULTS

Twenty-two studies totaling 503 patients were included. Study designs were: prospective cohort (n=1), retrospective cohort (n=15), case report (n=6). Nearly two-thirds of patients (67.7%) were male. Mean age was 41 years (range 3-82). Median preoperative Glasgow coma score (GCS) was 3 (range 3-6). Nearly two-thirds (66.9%) underwent surgical decompression within 2 hours of pupillary changes. Mean follow-up was 7 months (range 1-40). Two-thirds (67%) died. Among survivors, 50.5% had severe disability (GOS 2-3), while 49.5% had good outcome (GOS 4-5), representing 17% of the whole population. Given the methodological limitations, the prognostic value of age, GCS, and time to surgery could not be determined.

CONCLUSION

The literature suggests a rate of favorable recovery approaching 17% following decompressive surgery in patients with transtentorial herniation and BFDP, secondary to space-occupying lesions. In the setting of stroke or trauma, the clinical finding of BFDP should not be solely relied on as an indicator of futility. Prospective studies are warranted.

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BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Outcome Prediction in Patients with Severe Traumatic Brain Injury Using Deep Learning from Head CT Scans

Background After severe traumatic brain injury (sTBI), physicians use long-term prognostication to guide acute clinical care yet struggle to predict outcomes in comatose patients. Purpose To develop and evaluate a prognostic model combining deep learning of head CT scans and clinical information to predict long-term outcomes after sTBI. Materials and Methods This was a retrospective analysis of two prospectively collected databases. The model-building set included 537 patients (mean age, 40 years ± 17 [SD]; 422 men) from one institution from November 2002 to December 2018. Transfer learning and curriculum learning were applied to a convolutional neural network using admission head CT to predict mortality and unfavorable outcomes (Glasgow Outcomes Scale scores 1-3) at 6 months. This was combined with clinical input for a holistic fusion model. The models were evaluated using an independent internal test set and an external cohort of 220 patients with sTBI (mean age, 39 years ± 17; 166 men) from 18 institutions in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study from February 2014 to April 2018. The models were compared with the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model and the predictions of three neurosurgeons. Area under the receiver operating characteristic curve (AUC) was used as the main model performance metric. Results The fusion model had higher AUCs than did the IMPACT model in the prediction of mortality (AUC, 0.92 [95% CI: 0.86, 0.97] vs 0.80 [95% CI: 0.71, 0.88]; P < .001) and unfavorable outcomes (AUC, 0.88 [95% CI: 0.82, 0.94] vs 0.82 [95% CI: 0.75, 0.90]; P = .04) on the internal data set. For external TRACK-TBI testing, there was no evidence of a significant difference in the performance of any models compared with the IMPACT model (AUC, 0.83; 95% CI: 0.77, 0.90) in the prediction of mortality. The Imaging model (AUC, 0.73; 95% CI: 0.66-0.81; P = .02) and the fusion model (AUC, 0.68; 95% CI: 0.60, 0.76; P = .02) underperformed as compared with the IMPACT model (AUC, 0.83; 95% CI: 0.77, 0.89) in the prediction of unfavorable outcomes. The fusion model outperformed the predictions of the neurosurgeons. Conclusion A deep learning model of head CT and clinical information can be used to predict 6-month outcomes after severe traumatic brain injury. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Haller in this issue.

Surgical significance of prolonged fixed and dilated pupils in a case of non-traumatic, spontaneously regressing, acute subdural haemorrhage

Bilaterally fixed and dilated pupils (BFDP) in traumatic acute subdural haematoma (ASDH) patients represent an ominous sign that portends irreversible brainstem injury and death. Whether patients with spontaneous ASDH and BFDP follow similar outcomes is unknown. We present a mid-60s man, found unconscious, with a Glasgow Coma Scale (GCS) of 4 following 8 days of headaches. Emergency CT imaging demonstrated a large right ASDH and the patient exhibited BFDP for >3 hours despite sedation and mannitol. Neurological improvement and spontaneously reduced SDH thickness were observed 10 hours postadmission, and he was later transferred for craniotomy and ASDH evacuation. His long-term outcomes were good: achieving independence in his activities of daily living and a GCS of 15. To the best of our knowledge, this is the first reported patient with a spontaneous, regressing ASDH and prolonged BFDP who clinically improved. This case raises important questions regarding factors used to determine prognosis and surgical viability for ASDH.

Multifactorial Interventions to Reduce Duration and Variability in Delays to Identification of Serious Injury After Falls in Hospital Inpatients

OBJECTIVES

Inpatient falls are the most commonly reported safety incidents and are associated with serious injuries. This study aimed to use multifactorial interventions to reduce the delays to the diagnosis of serious injury in a time series analysis after serious incidents relating to falls within a central London Trust.

METHODS

A multiprofessional project team undertook process mapping to identify opportunities for improvement at different stages in the management of a fall. The interventions included an educational teaching session aimed at doctors, a lanyard card designed by doctors using the plan-do-study-act methodology, a falls-specific pager for radiographers, and a new system to refer to portering. Quantitative data were obtained using an serious incident database where serious injury occurred (SI data; n = 65) and routinely collected incident reporting database on falls regardless of injury (IR data; n = 178). Qualitative questionnaire data (n = 70) were also used to evaluate doctors' confidence in falls assessment before and after interventions.

RESULTS

Results in the IR data demonstrated a significant reduction in the median (interquartile range) minutes delay in the time to review a patient after a fall from 81 (43-180) to 51 (26-112; P = 0.003) and the time to order imaging from 102 (45-370) to 50 (33-96; P = 0.04). Analysis of the SI database demonstrated a nonstatistically significant reduction in the overall time taken to detect serious injury after a fall from 348 (126-756) to 192 (108-384) minutes (P = 0.070). Furthermore, analysis using statistical process control charts showed evidence of special cause variation and a shift in the process in detecting serious harm after a fall. Junior doctors' confidence in investigations improved from 53% to 76% (P = 0.04) after the intervention.

CONCLUSIONS

The cumulative application of multiple interventions with small individual effects resulted in a substantial positive effect on delays and variability in diagnosis of serious harm. Given a similar institutional context, the more effective interventions in our study could be adopted elsewhere.

The Richmond Acute Subdural Hematoma Score: A Validated Grading Scale to Predict Postoperative Mortality

BACKGROUND

Traumatic acute subdural hematomas (aSDHs) are common, life-threatening injuries often requiring emergency surgery.

OBJECTIVE

To develop and validate the Richmond acute subdural hematoma (RASH) score to stratify patients by risk of mortality after aSDH evacuation.

METHODS

The 2016 National Trauma Data Bank (NTDB) was queried to identify adult patients with traumatic aSDHs who underwent craniectomy or craniotomy within 4 h of arrival to an emergency department. Multivariate logistic regression modeling identified risk factors independently associated with mortality. The RASH score was developed based on a factor's strength and level of association with mortality. The model was validated using the 2017 NTDB and the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 2516 cases met study criteria. The patients were 69.3% male with a mean age of 55.7 yr and overall mortality rate of 36.4%. Factors associated with mortality included age between 61 and 79 yr (odds ratio [OR] = 2.3, P < .001), age ≥80 yr (OR = 6.3, P < .001), loss of consciousness (OR = 2.3, P < .001), Glasgow Coma Scale score of ≤8 (OR = 2.6, P < .001), unilateral (OR = 2.8, P < .001) or bilateral (OR = 3.9, P < .001) unresponsive pupils, and midline shift >5 mm (OR = 1.7, P < .001). Using these risk factors, the RASH score predicted progressively increasing mortality ranging from 0% to 94% for scores of 0 to 8, respectively (AUC = 0.72). Application of the RASH score to 3091 cases from 2017 resulted in similar accuracy (AUC = 0.74).

CONCLUSION

The RASH score is a simple and validated grading scale that uses easily accessible preoperative factors to predict estimated mortality rates in patients with traumatic aSDHs who undergo surgical evacuation.

Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study

INTRODUCTION

To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome.

MATERIALS AND METHODS

We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting.

RESULTS

The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%).

CONCLUSION

Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.

Clinical and Laboratory Markers in Determination of Treatment Modalities and Short-Term Prognosis in Patients with Traumatic Acute Subdural Hematoma: Original Study

Objective In patients with traumatic acute subdural hematoma (ASH), it has not been yet fully elucidated which patients can benefit from surgery or from clinical follow-up. This study was constructed to predict treatment modality and short-term prognosis in patients with ASH using their clinical, radiological, and biochemical laboratory findings during admission to hospital.

Methods Findings of patients with ASH determined on their CT scan between 2015 and 2018 were evaluated. Patients were grouped in terms of ASH-FOL (patients followed-up without surgery, n = 13), ASH-OP (patients treated surgically, n = 10), and ASH-INOP (patients considered as inoperable, n = 5) groups. They also were divided into “survived (n = 14)” and “nonsurvived (n = 14)” groups.

Results ASH developed as a result of fall from a height in 15 patients and traffic accidents in 13 patients. In deciding for surgery, it was determined that Glasgow coma scale (GCS) scores < 8, midline shift (MLS) level > 5 mm, MLS-hematoma thickness ratio > 0.22, leukocyte count > 12730 uL, and presence of anisocoria could be used as predictive markers. It was determined that GCS scores < 8, hematoma thickness value > 8 mm, and the presence of anisocoria could be considered as biomarkers in prediction of mortality likelihood.

Conclusion It could be suggested that GCS scores, MLS level, MLS-hematoma thickness ratio, presence of anisocoria, and leukocyte count value could help in determination of the treatment modality in patients with ASH. Additionally, GCS scores, hematoma thickness value, and presence of anisocoria could each be used as a marker in the prediction of early-stage prognosis and mortality likelihood of these patients.

Analysis of Brain Natriuretic Peptide Levels after Traumatic Acute Subdural Hematoma and the Risk of Post-Operative Cerebral Infarction

Traumatic acute subdural hematoma (aSDH) is associated with a high mortality rate caused by post-operative cerebral infarction. Recently, brain natriuretic peptide (BNP) was considered a reliable biomarker in the acute phase of traumatic brain injuries. We therefore aimed in this study to analyze BNP levels on admission, identify the predictors of their elevation, and assess the relationship between BNP and the risk of post-operative cerebral infarction. Patients with isolated, unilateral, traumatic aSDH who were admitted to our department between July 2017 and May 2020 were enrolled in this study. On admission, cranial computer tomography (CCT) and BNP sampling were simultaneously performed. Additionally, the time between head trauma and BNP sampling (TTS) was assessed. Admission radiographic variables included hematoma volumes, midline shift, and degree of brain edema. Cerebral infarction was detected on postoperative CCT. In total, 130 patients were included in this study. Surgical treatment was performed in 82.3% (n = 107) of cases. The multiple regression analysis showed that larger hematoma volumes (p = 0.032) and advanced age (p = 0.005) were independent predictors of elevated BNP when TTS <24 h. The binomial logistical regression analysis identified BNP with a cutoff value of <29.4 pg/mL (TTS = 3-12 h, adjusted odds ratio [aOR] = 16.5, p = 0.023) as an independent predictor of post-operative cerebral infarction. Elevated BNP levels in the first 24 h post-trauma were related to larger hematoma volumes and advanced age. Further, an increased risk of post-operative cerebral infarction was identified in patients with lower BNP levels in the post-traumatic period 3-12 h.

Decompressive craniectomy in traumatic brain injury: The intensivist's point of view

OBJETIVE

To perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC.

METHOD

Observational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014-2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer-Lemeshow and a bootstrapping analysis with 1000 re-samples respectively.

RESULTS

37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78-0.91) and Hosmer-Lemeshow p=0.71. The developed score detected well those patients who were going to need an early DC (first 24h) after a TBI (2.5±0.5) but not those who would need it in a later stage of their disease (1.7±0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24h vs. do not require DC, 1.7±0.8 vs. 1±0.7; p=0.002).

CONCLUSION

We have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.

Perioperative management of severe brain injured patients

Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.