Improving mortality after extradural haematoma in England and Wales

Clinical Outcome of Patients Diagnosed Traumatic Intracranial Epidural Hematoma With Severe Brain Injury (Glasgow Coma Scale ≤8) Who Undergo Surgery: A Report From the Korean Neuro-Trauma Data Bank System

OBJECTIVE

To evaluate the clinical outcomes and prognostic factors in surgically treated patients with severe brain injury (Glasgow Coma Scale [GCS] score ≤8) diagnosed with traumatic epidural hematoma (EDH).

METHODS

From January 2018 to June 2021, 1,122 patients with an initial GCS score ≤8 were retrospectively enrolled in the Korean Neuro-Trauma Data Bank System. Clinical data of 79 surgically treated patients with EDH were compared between the unfavorable (scores of 1-4 on the Glasgow Outcome Scale-Extended [GOSE]) and favorable (score of 5-8 on the GOSE) outcome groups.

RESULTS

The overall mortality rate was 13.9%, and 60.8% of the patients had good outcomes at six months post-trauma. In the univariate analysis, increasing age (p=0.010), lower initial GCS score (p=0.001), higher Rotterdam computed tomography (CT) score (p=0.012), craniotomy rather than craniectomy (p=0.032), larger EDH volume (p=0.007), and loss of pupillary reactivity (unilateral unreactive pupil, p=0.026; bilateral unreactive pupils, p<0.001), were significantly correlated with unfavorable outcomes. Of these factors, increasing age (p=0.011) and bilateral unreactive pupils (p=0.002) were the most significant risk factors in the multivariate logistic regression analysis. The interval from admission to the brain CT scan was not correlated with the outcome; however, it was significantly longer in the unfavorable outcome group.

CONCLUSION

Despite severe brain injury, more than half of the patients with EDH had favorable outcomes after surgical treatment. Our findings suggest that prompt diagnosis and surgical treatment should be considered for such cases.

The unmet global burden of cranial epidural hematomas: A systematic review and meta-analysis

OBJECTIVE

Approximately 69 million people suffer from traumatic brain injury (TBI) annually. Patients with isolated epidural hematomas (EDH) with access to timely surgical intervention often sustain favorable outcomes. Efforts to ensure safe, timely, and affordable access to EDH treatment may offer tremendous benefits.

METHODS

A comprehensive literature search was conducted. A random-effects model was used to pool the outcomes. Studies were further categorized into groups by World Bank Income classification: high-income countries (HICs) and low- and middle-income countries (LMICs).

RESULTS

Forty-nine studies were included, including 36 from HICs, 12 from LMICs, and 1 from HIC / LMIC. Incidence of EDH amongst TBI patients 8.2 % (95 % CI: 5.9,11.2), including 9.2 % (95 %CI 6.4,13.2) in HICs and 5.8 % (95 % CI: 3.1,10.7) in LMICs (p = 0.20). The overall percent male was 73.7 % and 47.4 % were caused by road traffic accidents. Operative rate was 76.0 % (95 %CI: 67.9,82.6), with a numerically lower rate of 74.2 % (95 %CI: 64.0,81.8) in HICs than in LMICs 82.9 % (95 %CI: 65.4,92.5) (p = 0.33). This decreased to 55.5 % after adjustment for small study effect. The non-operative mortality (5.3 %, 95 %CI: 2.2,12.3) was lower than the operative mortality (8.3 %, 95 %CI: 4.6,14.6), with slightly higher rates in HICs than LMICs. This relationship remained after adjustment for small study effect, with 9.3 % operative mortality compared to 6.9 % non-operative mortality.

CONCLUSION

With an overall EDH incidence of 8.2 % and an operative rate of 55.5 %, 3.1 million people worldwide require surgery for traumatic EDH every year, most of whom are in prime working age. Given the favorable prognosis with treatment, traumatic EDH is a strong investment for neurosurgical capacity building.

Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia

To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1–3) (OR = 23.9, 95% CI: 3.1–184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level.

Comparative effectiveness of different surgical procedures for traumatic acute epidural haematoma: study protocol for Prospective, Observational Real-world Treatments of AEDH in Large-scale Surgical Cases (PORTALS-AEDH)

INTRODUCTION

Controversy and variation exist in surgical management for acute epidural haematoma (AEDH). Although craniotomy for AEDH is conventionally employed, no specific evaluation on the necessity of decompressive craniectomy (DC) followed by AEDH evacuation has been performed.

METHODS AND ANALYSIS

This is a multicentre prospective, phase III observational study that evaluates different surgical managements for the AEDH. Patients of both genders, aged 18-65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH, complying with other inclusion and exclusion criteria, are enrolled. Clinical information, including diagnosis of AEDH, radiological information, treatment procedures and follow-up data of 1, 3 and 6 months post-injury, is collected on 2000 eligible patients among 263 hospitals in China. Recruitment for the study started in April 2021, and inclusion will be continued until the sample size is obtained, expected is an inclusion period of 24 months. The interventions of concern are surgical treatments for AEDH, including craniotomy and DC. The primary outcome is the Glasgow Outcome Score-Extended 6 months post-injury. Secondary outcomes include the incidence of postoperative cerebral infarction, the incidence of additional craniocerebral surgery and other evaluation indicators within 6 months post-injury.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethics committee and institutional review board of Renji Hospital, School of Medicine, Shanghai Jiao Tong University. All study investigators strictly follow the Declaration of Helsinki and Human Biomedical Research Ethical Issues. Signed written informed consent will be obtained from all enrolled patients. The trial results will be disseminated through academic conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04229966.

Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial

Background

The expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy.

Methods/design

Patients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury.

Discussion

This study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice.

Trial registration

ClinicalTrials.govNCT 04261673. Registered on 04 February 2020

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Minicraniotomy Under Local Anesthesia and Monitored Sedation for the Operative Treatment of Uncomplicated Traumatic Acute Extradural Hematoma

BACKGROUND

Major craniotomy is currently the de facto operative treatment for traumatic acute extradural hematoma (AEDH). This craniotomy, involving extensive scalp dissection (the trauma flap) and major cranial bone opening, can be impracticable in the remote regions of some Western countries, and even more so in the low-resource health systems of most developing countries.

METHODS

We describe the surgical technique of minicraniotomy under local anesthesia plus monitored sedation as a much less invasive operative treatment for AEDH. The results of its use in a preliminary patient group are also presented.

RESULTS

The procedure has been carried out in 10 consecutive patients (7 men), including an infant 4 months of age. The age range was 4 months to 56 years. The patients suffered varying severity of head injury, with a median Glasgow Coma Scale (GCS) score of 11 out of 15 (range, 4-15). The median trauma to surgery time was 25 hours (range, 13-192 hours). The surgery was successfully completed, with hematoma evacuated and hemostasis achieved. The median duration of surgery was 90 minutes. The in-hospital outcome was Glasgow Outcome Scale score of normal status in 6 patients, moderate deficit in 2 patients, and vegetative state in the patient whose preoperative GCS score was 4. One other patient, admitted with a GCS score of 11, died 5 days postoperatively from extracranial causes. The surviving patients have been followed-up for a median time of 15 months with no new deficits.

CONCLUSIONS

Compared with full craniotomy under general anesthesia, minicraniotomy under local anesthesia plus sedation may be a more pragmatic, less invasive, and low-cost surgical treatment option for uncomplicated traumatic acute extradural hematoma.

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

OBJECTIVE

Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)-bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI -directly into SNCs-producing a measurable effect.

SETTING

Two English Ambulance Services.

PARTICIPANTS

74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults-injured nearest to an NSAH-with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC.

INTERVENTIONS

Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC.

OUTCOMES

Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes.

RESULTS

56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7-14.0)% vs intervention=9.4(2.3-14.0)%).

CONCLUSION

Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely.

TRIAL REGISTRATION NUMBER

ISRCTN68087745.

Survival Trends After Surgery for Acute Subdural Hematoma in Adults Over a 20-year Period

OBJECTIVE

We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period.

SUMMARY OF BACKGROUND DATA

ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time.

METHODS

Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data.

RESULTS

The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors.

CONCLUSIONS

A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

BACKGROUND

Reconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence - with regard to 'early neurosurgery' in this cohort - which we sought to address.

METHODS

Pilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters).

PRIMARY OUTCOMES

recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. 'Open-label' secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.

RESULTS

Overall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%; p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.

CONCLUSIONS

Current NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating 'early neurosurgery through bypass' and address the challenge of reliable TBI diagnosis at the scene of injury.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68087745.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

The impact of major trauma centre implementation on the pathways and outcome of traumatic intracranial extradural haematoma in a regional centre

INTRODUCTION

A new trauma care system with regional major trauma centres (MTC) was implemented on 1st April 2012 across England. We aimed to assess whether this has affected the referral pathways and mortality of patients undergoing emergency craniotomy for extradural haematoma (EDH), where clinical outcome is correlated with the time to intervention.

MATERIALS AND METHODS

This was a retrospective cohort comparison study. All patients who had undergone evacuation of EDH from January 2011 to December 2013 were identified. Only those in whom a decision for emergency craniotomy had been made at the time of referral to the on-call neurosurgeon were included. The CRASH predicted risk of mortality was calculated for individual patients. Mortality was assessed at 14 days in order to compute standardised mortality ratios (SMR).

RESULTS

Overall, 65 patients underwent EDH evacuation during the study period (21 pre-MTC and 44 post-MTC). Of those, 43 emergency procedures according to the aforementioned definition were included for further analysis (13 pre-MTC, 30 post-MTC). The mean CRASH predicted risk of mortality was 0.21 for the pre-MTC cohort (95% CI: 0.07-0.34) and 0.094 for the post-MTC cohort (95% CI: 0.039-0.15; p = 0.052). There was no significant difference in the rate of secondary transfers before and after MTC implementation (9/13 vs. 23/30, p = 0.71). The mean interval from referral to operation was 198 min for the pre-MTC cohort (95% CI: 123-273) and 201 min for the post-MTC cohort (95% CI: 141-262; p = 0.95). The SMR was 0.37 for the pre-MTC cohort (95% CI: 0.02-1.81; 1 death) and 0.71 for the post-MTC cohort (95% CI: 0.12-2.34; 2 deaths).

CONCLUSIONS

MTC implementation has not affected the time to operation or the mortality following EDH evacuation.

Traumatic acute extradural haematoma - Indications for surgery revisited

Extradural haematomas (EDH) occur in approximately 2% of all head injuries but account for a significant proportion of fatal head injuries with mortality rates ranging from 1.2 to 33%. The expeditious surgical evacuation of EDH is associated with an excellent prognosis and is considered the most cost-effective operation performed by neurosurgeons. The Brain Trauma Foundation (BTF) has produced informative guidance on the management of EDH. The criteria laid out for conservative management comprises non-comatose patients with EDH less than 30 cm in volume, less than 15 mm thick and causing less than 5 mm midline shift. The BTF recommends that all patients with an EDH volume of greater than 30 cm(3) should undergo surgical evacuation regardless of Glasgow Coma Scale. This recommendation was based upon early case series and cohort studies from two decades. Within an ageing population, we now see many older patients who may accommodate greater extra-axial blood volumes. With this in mind, we believe the indications for surgical evacuation of EDH merit renewed consideration.

Role of neuroimaging in management of traumatic brain injury

Traumatic brain injury is a significant cause of morbidity and mortality in the UK with substantial associated economic costs to the healthcare system. This article explores the role of neuroimaging in both acute and long-term management of traumatic brain injury patients. We discuss the indications for urgent cross-section imaging as well as radiological features of both primary insults and secondary injuries. The role of neuroimaging in guiding surgical therapy and monitoring post-operative traumatic brain injury patients has also been described. Following initial injury, traumatic brain injury patients can suffer from a wide variety of physical, social and psychological difficulties. New techniques such as diffusion tensor imaging in combination with conventional magnetic resonance imaging sequences may provide useful information in predicting long-term prognosis and guiding rehabilitation.