Traumatic brain injuries caused by traffic accidents in five European countries: outcome and public health consequences.

BACKGROUND: Road traffic accidents (RTAs) have been identified by public health organizations as being of major global concern. Traumatic brain injuries (TBIs) are among the most severe injuries and are in a large part caused by RTA. The objective of this article is to analyse the severity and outcome of TBI caused by RTA in different types of road users in five European countries. METHODS: The demographic, severity and outcome measures of 683 individuals with RTA-related TBI from Austria, Slovakia, Bosnia, Croatia and Macedonia were analysed. Five types of road users (car drivers, car passengers, motorcyclists, bicyclists and pedestrians) were compared using univariate and multivariate statistical methods. Short-term outcome [intensive care unit (ICU) survival] and last available long-term outcome of patients were analysed. RESULTS: In our data set, 44% of TBI were traffic related. The median age of patients was 32.5 years, being the lowest (25 years) in car passengers. The most severe and extensive injuries were reported in pedestrians. Pedestrians had the lowest rate of ICU survival (60%) and favourable long-term outcome (46%). Drivers had the highest ICU survival (73%) and car passengers had the best long-term outcome (59% favourable). No differences in the outcome were found between countries with different economy levels. CONCLUSION: TBI are significantly associated with RTA and thus, tackling them together could be more effective. The population at highest risk of RTA-related TBI are young males (in our sample median age: 32.5 years). Pedestrians have the most severe TBI with the worst outcome. Both groups should be a priority for public health action.

Outcome after severe brain trauma due to acute subdural hematoma.

OBJECT: In this paper, the authors' goal was to identify factors contributing to outcomes after severe traumatic brain injury (TBI) due to acute subdural hematoma (SDH). METHODS: Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data regarding accident, treatment, and outcomes were collected. Data sets from patients who had severe TBI (Glasgow Coma Scale score < 9) and acute SDH were selected. Six-month outcomes were classified as "favorable" if the Glasgow Outcome Scale (GOS) scores were 5 or 4, and they were classified as "unfavorable" if GOS scores were 3 or less. The Rotterdam score was used to classify CT findings, and the scores published by Hukkelhoven et al. were used to estimate the predicted rates of death and of unfavorable outcomes. Univariate (Fisher exact test, t-test, chi-square test) and multivariate (logistic regression) statistics were used to identify factors associated with hospital mortality and favorable outcome. RESULTS: Of the 738 patients with severe TBI, 360 (49%) had acute SDH. Of these, 168 (46.7%) died in the hospital, 67 (18.6%) survived with unfavorable outcome, and 116 (32.2%) survived with favorable outcome. Long-term outcome was unknown in 9 survivors (2.5%). Mortality rates predicted by the Rotterdam CT score showed good correlation with observed mortality rates. According to the Hukkelhoven scores, observed/predicted ratios for mortality and unfavorable outcome were 1.09 and 1.02, respectively. CONCLUSIONS: Age, severity of TBI, and neurological status were the main factors influencing outcomes after severe TBI due to acute SDH. Nonoperative management was associated with significantly higher mortality.

Effects of gender on outcomes after traumatic brain injury.

BACKGROUND: It has been reported that female gender may be an independent risk factor for poor outcome after traumatic brain injury (TBI). The goal of this study was to investigate gender differences in outcome after TBI. METHODS: Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on crash, treatment, and outcomes were collected. Data sets from patients who had isolated TBI were selected. Six-month outcomes were classified as "favorable" if Glasgow Outcome Scale scores were 5 or 4 and were classified as "unfavorable" if Glasgow Outcome Scale scores were 3 or less. The Rotterdam score was used to classify computed tomography (CT) findings. Univariate statistics (Fisher's exact test, t test, χ2 test) and logistic regression were used to identify factors associated with hospital mortality and favorable outcome. RESULTS: There were 134 female and 305 male patients. Hospital mortality was 39.6% for females and 32.5% for males (p = 0.16). Rates of unfavorable outcome were 58.7% for females and 53.4% for males (p = 0.09). There were no significant mortality differences between females and males for factors such as age groups, trauma mechanisms, Glasgow Coma Scale scores, lesions on the CT scan, or treatment factors. Logistic regression revealed that gender had no significant influence on mortality of unfavorable outcome. The differences in outcome were due to the higher mean age of females (61.4 vs. 50.4, p < 0.001) and possibly because of small differences in Glasgow Coma Scale scores and in CT scores. CONCLUSIONS: Female gender is not an independent risk factor for in-hospital mortality after TBI.

Severity and outcome of traumatic brain injuries (TBI) with different causes of injury.

INTRODUCTION: Most epidemiological studies and reports have reached a consensus on the leading causes of traumatic brain injury (TBI). Despite the fact that the area of TBI is relatively well studied, reports on differences in severity and outcome of TBI with different causes are lacking. GOAL: This paper analyses the differences in severity and in short- and long-term outcome of TBIs with different causes. METHOD: This study analysed data on 1109 patients with severe TBI by dividing them into three injury-cause groups: 'traffic-related', 'falls' and 'other causes'. Severity and outcome was evaluated using chosen direct and indirect indicators. RESULTS: The most severe trauma occurred in the traffic-related group followed by falls and injuries with other causes. On the other hand, patients with traffic-related TBI had the best outcome. Age improves the outcome in the traffic-related group significantly. However, in the multivariate analysis after adjusting for age (and other important predictors including level of care) the odds for favourable long-term outcome stayed significantly higher in the traffic-related group. CONCLUSIONS: It is concluded that the causes of TBI should be considered by both clinicians and public health professionals as a lead in prognosis of outcome and policy planning.

Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65 years old.

The goal of this study was to investigate the outcomes of patients with traumatic brain injury (TBI) who had Glasgow Coma Scale (GCS) scores of 3 or 4, and were aged 66 years or older. Between January 2001 and December 2005, 13 European centers enrolled patients with severe brain trauma. Data sets of all patients who had a GCS score of 3 or 4 and were 66 years of age or older were analyzed. Outcomes were classified according to the Glasgow Outcome Scale (GOS) 12 months post-trauma as "favorable" (GOS score of 4 or 5), or "unfavorable" (GOS score of 1-3); relevant data for patients of the two groups were compared. Variables were analyzed by univariate analyses (chi-square, Wilcoxon-Mann-Whitney, and Fisher's exact tests), and a p value of <0.05 was considered significant. We analyzed 100 patients identified from the database as having GCS scores of 3 or 4 and age over 65 years. Factors having significant effects on outcomes were worse results of the Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), and Abbreviated Injury Scale (AIS) for the head. Closed or partially closed basal cisterns and/or midline shift >15 mm were also associated with unfavorable outcomes, as was subarachnoid hemorrhage (SAH). Patients with GCS scores of 3 or 4 who are older than 65 years have a poor, but not hopeless, prognosis. Confirmed factors predicting poor prognosis for this group of patients were closed basal cisterns and midline shift >15 mm on the first CT scan. Factors possibly related to favorable outcomes were female gender, lower trauma severity, open or partially open basal cisterns, and no midline shift on the first CT scan.

Outcome of brain trauma patients who have a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils in the field.

OBJECTIVE: To investigate the outcome of brain trauma patients who had a Glasgow Coma Scale score (GCS) of 3 and bilateral fixed and dilated pupils (BFDP) in the field. METHODS: Between January 2001 and December 2005, 13 European centres enrolled patients with severe brain trauma. Data sets of all patients who had a GCS of 3 as well as BFDP were analysed. Patients were classified according to the Glasgow Outcome Scale, 12 months after trauma as 'good' (Glasgow Outcome Scale of 5 or 4) or 'poor' functional recovery; relevant data for these two groups were compared. Variables that showed differences in univariate analyses (chi and Wilcoxon-Mann-Whitney tests) were then used as covariates in logistic regression models. A P value of less than 0.05 was considered significant. RESULTS: Ninety-two (7.8%) of 1172 patients had a GCS of 3 and BFDP; eight had 'good', 84 had 'poor' recovery. We found no significant differences in sex (79% male), age (median 32 years), and trauma mechanisms. Trauma was significantly less severe, probability of survival significantly higher (0.48 vs. 0.23) in the 'good' group. Only one of 39 patients who had closed basal cisterns on the first computed tomography scan, and none of the patients with midline shift greater than 15 mm had good outcomes. Logistic regression revealed that age, trauma severity, and status of basal cisterns on the first computed tomography scan were the factors determining outcomes. CONCLUSION: Patients with a GCS of 3 and BFDP in the field should be resuscitated aggressively, especially if the trauma seems to be not too severe.

Epidemiology, treatment and outcome of patients after severe traumatic brain injury in European regions with different economic status.

BACKGROUND: We hypothesized that the economic status of a region might influence quality of care and outcome of patients with severe brain trauma. METHODS: Between January 2001 and December 2005, 13 centres enrolled patients with severe brain trauma. Data on accident, treatment and outcomes were collected prospectively. The regions were classified as 'high income' (Austria, five centres), 'upper middle income' (UMI) (Croatia, Slovakia, six centres) or 'lower middle income' (LMI) (Bosnia, Macedonia, two centres). Data on epidemiology, treatment and outcomes were compared according to this classification. Quality of care was assessed using a new scoring system. RESULTS: A total of 1172 data sets were analysed. Patients from the wealthier regions were significantly older. Low-level falls and traffic accidents contributed to more than two-third of all cases. Violence-related trauma was significantly more frequent in 'middle income' regions. Treatment quality was significantly different; treatment according to guidelines for brain trauma management was provided most frequently for patients from high-income regions. Compared with expected mortality rates, mortality was 6.5% lower in the 'high-income' centres, 2.4% lower in the 'UMI' centres and 13% higher in the 'LMI' centres. Advanced age, poor neurological status, high trauma severity and poor quality of care were associated with significantly lower odds for survival. CONCLUSIONS: The association between the economic status and outcome of brain trauma patients was due to the quality of care. Successful implementation of guidelines for brain trauma management requires a well-funded health care system.

Severe traumatic brain injury in Austria I: introduction to the study.

OBJECTIVES: The goals of the Austrian Severe Traumatic Brain Injury Study were to investigate the current management of patients with severe traumatic brain injury in Austria and to assess the effects of introducing guidelines for the management of severe traumatic brain injury upon the outcome of these patients. The purpose of this paper is to give a detailed description of the goals, methods, and overall results of the study, and to provide an introduction to a series of papers where the results of the study will be presented and discussed. STUDY DESIGN: The study included patients with severe traumatic brain injury from five centers in Austria. Data on accident, pre-hospital treatment, hospital treatment, and patient status were collected prospectively. Patient data was entered daily for the first 10 days in hospital and then up to a year after discharge from intensive care. All data was entered into an internet-based database. The data was evaluated to describe epidemiology, pre-hospital treatment, medical management, and surgical management; the evaluation also assessed the effects of guideline-based management on traumatic brain injury patients. RESULTS: The data set comprises a total of 492 patient records from the 5 participating hospitals; this data was collected over a 3-year period. Data quality is considered good; the number of missing data items is low. ICU mortality was 31.6%. Final outcome: 23% of the patients had a good recovery, 10% had moderate disabilities, 8% had severe disabilities, 6% were persistent vegetative, and 38% died. Final outcome was unknown in 16% of patients. CONCLUSIONS: This study proved that an internet-based database may be a valuable tool for prospective multicenter studies if many variables have to be collected for a high number of patients. The results of our study provide enough evidence to initiate further research on many aspects of the management of traumatic brain injury patients.

Severe traumatic brain injury in Austria II: epidemiology of hospital admissions.

OBJECTIVES: The goal of this paper is to describe the hospital-based epidemiology of severe TBI in Austria. PATIENTS AND METHODS: Data sets from 492 patients included in the study by 5 Austrian hospitals were available. Age and gender distribution, education, occupation, location of trauma, mechanism of injury, alcohol use, type and severity of injury, associated injuries, length of intensive care unit stay, and intensive care unit outcome were evaluated for each of the 5 centers. RESULTS: The sample represents roughly 13% of all cases with severe TBI which were treated in Austrian hospitals during the study period. Mean age was 48 +/- 21 years, and most patients were male (72%). The most important trauma locations were roads (50%), home (24%), outdoors (10%), and workplace (7%). Transportrelated trauma was the most important mechanism (44%) followed by falls < 3 m (30%), falls > 3 m (11%), and sports injuries (5%). Detailed analysis of transport-related trauma showed that car accidents (45%) were most common, followed by pedestrian (20%), motorbike (19%), and bicycle (16%) accidents. Significant differences between the centers were found for most of the variables analyzed. The severe traumatic brain injury was associated with spinal cord injury in 10%, and with severe multiple trauma in 38% of cases. Intensive care mortality was 31.7%. There were no significant correlations between mechanisms of injury and severity of trauma, nor between mechanisms and ICU outcome. CONCLUSIONS: Epidemiology of severe traumatic brain injuries in Austria is not much different from other industrialized countries. Traffic accidents are responsible for the majority of traumas, stressing the importance of road injury prevention. Attention should also be paid to the specific risks of older people and to prevent injuries at home.

Severe traumatic brain injury in Austria IV: intensive care management.

OBJECTIVES: The goal of this paper is to describe the ICU management of severe traumatic brain injury (TBI) in Austria. PATIENTS AND METHODS: Data sets from 415 patients included by 5 Austrian hospitals were available. The analysis focused on complications and outcomes of intensive care, monitoring of intracranial pressure (ICP), efficacy of interventions to control ICP, management of hemodynamics and cerebral perfusion pressure (CPP), ventilation, and effects of hyperglycaemia. RESULTS: Overall ICU mortality was 30.8%; 90-day mortality was 35.7%. Final outcome was favorable in 33%, unfavorable in 51%, and in 16% the final outcome was unknown. An ICP monitoring device was used in 64%; most patients received intraparenchymal sensors (77%). Events associated with mortality > 50% were CPP < 50 mm Hg for > 12 hours/day, ICP > 25 mm Hg for > 12 hours/day, and MAP < 70 mm Hg for > 18 hours/day. The use of ICP monitoring was associated with significantly reduced ICU mortality. Interventions that may have improved the outcome included the use of barbiturates (short-term), hypertonic saline, moderate hyperventilation (33 < pCO2 < 37; p < 0.001 vs. aggressive hyper-and normoventilation), and normothermia. Hyperglycaemia was associated with poor outcome. CONCLUSIONS: Our study showed that ICU management of patients with severe TBI mostly follows international guidelines, and that outcome was comparable to or even better than that reported by other authors. Low CPP was associated with poor outcome, and was more often due to low MAP than to elevated ICP. The use of barbiturates and hypertonic saline was more common than expected. CPP should be maintained > 50 mm Hg, the use of catecholamines, fluid loading, barbiturates (short-term), moderate hyperventilation, hypertonic saline, and insulin may improve outcome after severe TBI.

Severe traumatic brain injury in Austria III: prehospital status and treatment.

OBJECTIVES: The goal of this paper is to describe prehospital status and treatment of patients with severe TBI in Austria. PATIENTS AND METHODS: Data sets from 396 patients with severe TBI (Glasgow Coma Scale score < 9) included by 5 Austrian hospitals were available. The analysis focused on incidence and/or degree of severity of typical clinical signs, frequency of use of different management options, and association with outcomes for both. ICU mortality, 90-day mortality, final outcome (favorable = good recovery or moderate disability; unfavorable = severe disability, vegetative state, or death) after 6 or 12 months, and ratio of observed (90-day) to predicted mortality (O/E ratio) are reported for the selected parameters. Chi2 -test, t-test, Fisher's exact test, and logistic regression were used to identify significant (p < 0.05) differences for association with survival and favorable outcome (both coded as 1). RESULTS: The majority of patients were male (72%), mean age was 49 +/- 21 years, mean injury severity score (ISS) was 27 +/- 17, mean first GCS score was 5.6 +/- 2.9, and expected hospital survival was 63 +/- 30%. ICU mortality was 32%, 90-day mortality was 37%, and final outcome was favorable in 35%, unfavorable in 53%, unknown in 12%. We found that age > 60 years, ISS > 50 points, GCS score < 4, bilateral changes in pupil size and reactivity, respiratory rate < 10/min, systolic blood pressure (SBP) < 90 mm Hg, and heart rate < 60/min were associated with significantly higher ICU and 90-day mortality rates, and lower rates of favorable outcome. With regard to prognostic value the GCS motor response score is identical to the full GCS score. Administration of > 1000 ml of fluid and helicopter transport were associated with better outcomes than expected, while endotracheal intubation in the field had neither a positive nor a negative effect on outcomes. Administration of no or < 500 ml of fluids was associated with worse outcomes than expected. Outcomes were better than expected in the few patients (5%) who received hypertonic saline. CONCLUSIONS: Age, ISS, and initial neuro status are the factors most closely associated with outcome. Hypotension must be avoided. Fluids should be given to restore and/or maintain SBP > 110 mm Hg. Helicopter transport should be arranged for more seriously injured patients.

Severe traumatic brain injury in Austria V: CT findings and surgical management.

OBJECTIVES: The aim of this paper is to describe CT findings and surgical management of patients with severe traumatic brain injury (TBI) in Austria. PATIENTS AND METHODS: Data sets from 415 patients treated by 5 Austrian hospitals were available. The analysis focused on incidence, surgical management, and outcome of different types of intracranial lesions, and outcome of surgical interventions with and without monitoring of intracranial pressure (ICP). For the first analysis we assigned the patients to 16 groups based on the type of lesion as evaluated by CT scan. For the second analysis we created 4 groups based on surgical treatment (yes/no) and ICP monitoring (yes/no). RESULTS: The mean age was 48.9 years with a male to female ratio of 299:116. The most frequent single lesions were contusions (CONT) and diffuse brain edema. Combined lesions were far more common than single lesions; the most frequently observed combinations included CONT and subarachnoid hemorrhage (SAH) with or without subdural hematoma (SDH). Surgery was done in 276 (66.5%) patients. Osteoplastic surgery (OPS; n = 221) was the most common method followed by osteoclastic surgery (OCS; n = 91) and decompressive craniectomy (DEC; n = 15). ICU mortality was 29.7% for all patients who had any kind of surgery, which was lower than that of patients who were treated non-operatively (33.1%). The ICU mortality of patients with SDH was lower with OCS (18.8%) than with OPS (36.0%). Patients who received ICP monitoring but did not require surgery had the lowest 90 day mortality (17.5%). CONCLUSIONS: ICP monitoring seems to be beneficial in both operatively and non-operatively treated patients with severe TBI. Patients with SDH who were operated on had significantly better outcomes. In patients with SDH, their outcome after osteoclastic surgery was significantly better than after osteoplastic procedures.

Severe traumatic brain injury in Austria VI: effects of guideline-based management.

OBJECTIVES: The goal of this paper is to report relations between health outcomes and implementation of individual recommendations of the guidelines. PATIENTS AND METHODS: Data sets from 405 patients included by 5 Austrian hospitals were available. The analysis focused on the compliance of treatment modalities to TBI guidelines recommendations. Compliance was evaluated based on scores developed specifically for this purpose. To evaluate the relations between the TBI guidelines compliance and outcomes the estimation of odds ratios was computed using multiple as well as logistic regression with age, ISS and initial GCS used to control confounding. RESULTS: The option on prehospital resuscitation was followed in 84%, the guideline on early resuscitation was followed in 79%. The guideline on intracranial pressure treatment threshold was the most closely followed one (89%). The option on cerebral perfusion pressure was followed in less than 30% of patients. Only the scores on resuscitation of blood pressure and oxygenation and on cerebral perfusion pressure were positively and statistically significantly related to ICU survival. Positive relations were also found for adherence to the recommendations on the type of monitoring, hyperventilation (guideline), prophylactic use of anti-seizure drugs, and the total of scores. The other recommendations were negatively related to ICU survival, but computed odds ratios were statistically not significant. Analysis of relations between compliance scores and length of ICU and hospitals stay in survivors showed that adherence to the recommendations on type of monitoring was related to a reduction of length of stay in ICU and hospital, adherence to the hyperventilation guideline was related to shortened ICU, but increased hospital stay, and adherence to the guideline on mannitol was related to reduced days in hospital, but not to days in ICU. Implementing the standard on corticosteroid use was related to a reduction of days both in hospital and ICU. Using the standard on prophylactic use of anti-seizure drugs was related to a reduction in ICU days. If all the recommendations were closely followed an increase of days in ICU would be observed, while the length of stay in hospital would be reduced. CONCLUSIONS: The relatively strong relation between initial resuscitation in the hospital and ICU survival provides a firm basis for future efforts of emergency teams. The positive influence of some of the recommendations on reduction of ICU or hospital days may provide economic incentives to promote guidelines implementation.