Prognostic factors and clinical nomogram for in-hospital mortality in traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of death and functional disability in the general population. The nomogram is a clinical prediction tool that has been researched for a wide range of medical conditions. The purpose of this study was to identify prognostic factors associated with in-hospital mortality. The secondary objective was to develop a clinical nomogram for TBI patients' in-hospital mortality based on prognostic factors. METHODS: A retrospective cohort study was conducted to analyze 14,075 TBI patients who were admitted to a tertiary hospital in southern Thailand. The total dataset was divided into the training and validation datasets. Several clinical characteristics and imaging findings were analyzed for in-hospital mortality in both univariate and multivariable analyses using the training dataset. Based on binary logistic regression, the nomogram was developed and internally validated using the final predictive model. Therefore, the predictive performances of the nomogram were estimated by the validation dataset. RESULTS: Prognostic factors associated with in-hospital mortality comprised age, hypotension, antiplatelet, Glasgow coma scale score, pupillary light reflex, basilar skull fracture, acute subdural hematoma, subarachnoid hemorrhage, midline shift, and basal cistern obliteration that were used for building nomogram. The predictive performance of the nomogram was estimated by the training dataset; the area under the receiver operating characteristic curve (AUC) was 0.981. In addition, the AUCs of bootstrapping and cross-validation methods were 0.980 and 0.981, respectively. For the temporal validation with an unseen dataset, the sensitivity, specificity, accuracy, and AUC of the nomogram were 0.90, 0.88, 0.88, and 0.89, respectively. CONCLUSION: A nomogram developed from prognostic factors had excellent performance; thus, the tool had the potential to serve as a screening tool for prognostication in TBI patients. Furthermore, future research should involve geographic validation to examine the predictive performances of the clinical prediction tool.

Risk Factors for Intraoperative Hypotension During Decompressive Craniectomy in traumatic Brain Injury Patients.

BACKGROUND: Decompressive craniectomy (DC) is an important therapy for treating intracranial pressure elevation following traumatic brain injury (TBI). During this procedure, about one-third of patients become complicated with intraoperative hypotension (IH), which is associated with abruptly decreasing sympathetic activity resulting from brain decompression. This study aimed to identify factors associated with IH during DC procedures and the mortality rate in these patients. METHODS: The records of adult TBI patients aged 18 years and older who underwent DC at Songklanagarind Hospital between January 2014 and January 2021 were retrospectively reviewed. Using logistic regression analysis, various factors were analyzed for their associations with IH during the DC procedures. RESULTS: This study included 83 patients. The incidence of IH was 54%. Multivariate analysis showed that Glasgow Coma Scale motor response (GCS-M) 1-3 (vs. 4-6), higher preoperative heart rate (PHR), and larger amount of intraoperative blood loss were significantly associated with IH (P = 0.013, P < 0.001, and P < 0.001, respectively). Patients with GCS-M 1-3 and PHR ≥ 75 bpm had the highest chance of IH (77%), while patients with neither of these risk factors had the lowest chance (29%). The in-hospital mortality rate in the IH and non-IH groups was 44% and 26%, respectively (P = 0.138). CONCLUSIONS: GCS-M 1-3, higher PHR, and larger amount of intraoperative blood loss were the risk factors associated with IH during DC procedure in TBI patients. Patients who have these risk factors should be closely monitored and the attending physician be ready to apply prompt resuscitation and treatment for IH.

Comparison of intracranial injury predictability between machine learning algorithms and the nomogram in pediatric traumatic brain injury.

OBJECTIVE: The overuse of head CT examinations has been much discussed, especially those for minor traumatic brain injury (TBI). In the disruptive era, machine learning (ML) is one of the prediction tools that has been used and applied in various fields of neurosurgery. The objective of this study was to compare the predictive performance between ML and a nomogram, which is the other prediction tool for intracranial injury following cranial CT in children with TBI. METHODS: Data from 964 pediatric patients with TBI were randomly divided into a training data set (75%) for hyperparameter tuning and supervised learning from 14 clinical parameters, while the remaining data (25%) were used for validation purposes. Moreover, a nomogram was developed from the training data set with similar parameters. Therefore, models from various ML algorithms and the nomogram were built and deployed via web-based application. RESULTS: A random forest classifier (RFC) algorithm established the best performance for predicting intracranial injury following cranial CT of the brain. The area under the receiver operating characteristic curve for the performance of RFC algorithms was 0.80, with 0.34 sensitivity, 0.95 specificity, 0.73 positive predictive value, 0.80 negative predictive value, and 0.79 accuracy. CONCLUSIONS: The ML algorithms, particularly the RFC, indicated relatively excellent predictive performance that would have the ability to support physicians in balancing the overuse of head CT scans and reducing the treatment costs of pediatric TBI in general practice.

Clinical Nomogram Predicting Intracranial Injury in Pediatric Traumatic Brain Injury.

BACKGROUND: There are differences in injured mechanisms among pediatric traumatic brain injury (TBI) in developing countries. This study aimed to develop and validate clinical nomogram for predicting intracranial injury in pediatric TBI that will be implicated in balancing the unnecessary investigation in the general practice. MATERIALS AND METHODS: The retrospective study was conducted in all patients who were younger than 15 years old and underwent computed tomography (CT) of the brain after TBI in southern Thailand. Injured mechanisms and clinical characteristics were identified and analyzed with binary logistic regression for predicting intracranial injury. Using random sampling without replacement, the total data was split into nomogram developing dataset (80%) and testing dataset (20%). Therefore, a nomogram was constructed and applied via the web-based application from the developing dataset. Using testing dataset, validation as binary classifiers was performed by various probabilities levels. RESULTS: A total of 900 victims were enrolled. The mean age was 87.2 (standard deviation [SD] 57.4) months, and 65.3% of all patients injured were from road traffic accidents. The rate of positive findings in CT of the brain was 32.8%. A nomogram was developed from the significant variables, including age groups, road traffic accidents, loss of consciousness, scalp hematoma/laceration, motor weakness, signs of basilar skull fraction, low Glasgow Coma Scale score, and pupillary light reflex.Therefore, a nomogram was developed from 80% of data and was validated from 20% of data. The accuracy, sensitivity, specificity, positive, and negative predictive values of the nomogram were 0.83, 0.42, 1.00, 1.00, and 0.81 at a cutoff value of 0.5 probability. CONCLUSION: This study provides a clinical nomogram that will be applied to making decisions in general practice as a diagnostic tool from high specificity.

Traumatic cerebrovascular injury: Prevalence and risk factors.

BACKGROUND: Traumatic cerebrovascular injury (TCVI) is uncommon in traumatic brain injury (TBI). Although TCVI is a rare condition, this complication is serious. A missed or delayed diagnosis may lead to an unexpected life-threatening hemorrhagic event or persistent neurological deficit. The object of this study was to determine the prevalence and risk factors associated with TCVI. METHODS: The authors retrospectively reviewed medical records and neuroimaging studies of 5178 patients with TBI. The association of various factors was investigated using time-to-event statistical analysis. A TCVI which resulted in an occlusion, arteriovenous fistula, pseudoaneurysm or cerebral artery transection was defined as an event. RESULTS: Forty-two patients developed a TCVI after injuries with an overall prevalence of 0.8%. The risk factors for an intracranial arterial injury based on univariate analysis using the Cox proportional hazard regression were penetrating injury, severe head injury, orbitofacial injury, basilar skull fracture, subdural hematoma, and cerebral contusion. In multivariable analysis, the two variables that were independently associated with TCVI were basilar skull fracture (odds ratio [OR] 22.1, 95% confidence interval [CI] 11.5-42.2) followed by orbitofacial fracture (OR 13.6, 95% CI 6.8-27.3). CONCLUSIONS: Although TCVI is a rare complication of TBI, early investigation in high-risk patients may be necessary for early treatment before an unexpected fatal event occurs.

Traumatic cerebrovascular injury: clinical characteristics and illustrative cases.

OBJECTIVE: Traumatic cerebrovascular injury (TCVI) is a rare and serious complication of traumatic brain injury (TBI). Various forms of TCVIs have been reported, including occlusions, arteriovenous fistulas, pseudoaneurysms, and transections. They can present at a variety of intervals after TBI and may manifest as sudden episodes, progressive symptoms, and even delayed fatal events. The purpose of this study was to analyze cases of TCVI identified at a single institution and further explore types and characteristics of these complications of TBI in order to improve recognition and treatment of these injuries. METHODS: The authors performed a retrospective review of cases of TCVI identified at their institution between 2013 and 2016. A total of 5178 patients presented with TBI during this time period, and 42 of these patients qualified for a diagnosis of TCVI and had adequate medical and imaging records for analysis. Data from their cases were analyzed, and 3 illustrative cases are presented in detail. RESULTS: The most common type of TCVI was arteriovenous fistula (86.4%), followed by pseudoaneurysm (11.9%), occlusion (2.4%), and transection (2.4%). The mortality rate of patients with TCVI was 7.1%. CONCLUSIONS: The authors describe the clinical characteristics of patients with TCVI and provide data from a series of 42 cases. It is important to recognize TCVI in order to facilitate early diagnosis and treatment.

Blast-induced traumatic brain injury: the experience from a level I trauma center in southern Thailand.

OBJECTIVEIn the ongoing conflict in southern Thailand, the improvised explosive device (IED) has been a common cause of blast-induced traumatic brain injury (bTBI). The authors investigated the particular characteristics of bTBI and the factors associated with its clinical outcome.METHODSA retrospective cohort study was conducted on all patients who had sustained bTBI between 2009 and 2017. Collected data included clinical characteristics, intracranial injuries, and outcomes. Factors analysis was conducted using a forest plot.RESULTSDuring the study period, 70 patients met the inclusion criteria. Fifty individuals (71.4%) were military personnel. One-third of the patients (32.9%) suffered moderate to severe bTBI, and the rate of intracerebral injuries on brain CT was 65.7%. Coup contusion was the most common finding, and primary blast injury was the most common mechanism of blast injury. Seventeen individuals had an unfavorable outcome (Glasgow Outcome Scale score 1-3), and the overall mortality rate for bTBI was 11.4%. In the univariate analysis, factors associated with an unfavorable outcome were preoperative coagulopathy, midline shift of the brain ≥ 5 mm, basal cistern effacement, moderate to severe TBI, hypotension, fixed and dilated pupils, surgical site infection, hematocrit < 30% on admission, coup contusion, and subdural hematoma. In the multivariable analysis, midline shift ≥ 5 mm (OR 29.1, 95% CI 2.5-328.1) and coagulopathy (OR 28.7, 95% CI 4.5-180.3) were the only factors predicting a poor outcome of bTBI.CONCLUSIONSbTBIs range from mild to severe. Midline shift and coagulopathy are treatable factors associated with an unfavorable outcome. Hence, in cases of bTBI, reversing an abnormal coagulogram is required as soon as possible to improve clinical outcomes. The management of brain shift needs further study.

The Optimal Operative Timing of Traumatic Intracranial Acute Subdural Hematoma Correlated with Outcome.

OBJECTIVE: Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH. MATERIALS AND METHODS: The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups. RESULTS: The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome. CONCLUSIONS: The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.

Multiple, Primary Brain Tumors with Diverse Origins and Different Localizations: Case Series and Review of the Literature.

BACKGROUND: Multiple, primary brain tumors with different histological types occurring in the same patient are extremely rare. Several hypotheses have been proposed, and the pathophysiology of coexisting tumors has long been debated; however, due to low incidence, standard practices for this scenario are still inconclusive. CASE DESCRIPTION: The authors describe 6 cases of coexisting tumors. By conducting a literature research focused on the computed tomography (CT) era and patients without prior radiation or phakomatosis. Sixty-five such reported cases were identified. In addition, the authors summarize their experience in 6 patients including histopathological features, chronological presentations, outcomes, mortality, and management from their series as well as from previous cases from the reported literature. CONCLUSION: The coexistence of multiple, primary brain tumors is an interesting condition. Surgical management remains the major treatment; malignant histology has a poor prognostic factor.

Impact of Road Traffic Injury to Pediatric Traumatic Brain Injury in Southern Thailand.

BACKGROUND: Motor vehicle is a major transportation in Southern Thailand as the result of road traffic injury and death. Consequently, severe disability and mortality in pediatric traumatic brain injury (TBI) were observed from traffic accident, particularly motorcycle accident. To identify the risk of intracranial injury in children, the association of treatment outcome with various factors including mechanisms of injury, clinical characteristics, and intracranial pathology can be assessed. MATERIALS AND METHODS: This was a retrospective study conducted on children, who were younger than 15 years old with TBI and were enrolled from 2004 to 2015. Several clinically relevant issues were reviewed and statistically analyzed. RESULTS: A total of 948 casualties were enrolled. Compared with falling down, the motorcycle accident was significantly associated with intracranial injury (odds ratio 1.73, 95% confidence interval [CI] 1.08-2.76). Other factors associated with intracranial injury were hemiparesis (odds ratio 5.69, 95% CI 1.44-22.36), positive of basal skull fracture signs (odds ratio 15.66, 95% CI 3.44-71.28), and fixed reaction to light of both pupils (odds ratio 5.74, 95% CI 1.71-19.23). Mortality found in thirty cases (3.2%). Furthermore, the risk of death correlated with motorcycle accident (P = 0.02) and severe head injury (P < 0.001). Neurosurgical intervention was not associated with outcome, but severe head injury, hemorrhagic shock, epidural, and subdural hematoma were impact factors. CONCLUSION: The findings demonstrate road traffic injury, especially motorcycle accident leading to brain injury and death. Prevention program is a necessary key to decrease mortality and disability in pediatric TBI.

Tranexamic acid for patients with traumatic brain injury: a randomized, double-blinded, placebo-controlled trial.

BACKGROUND: Traumatic brain injury (TBI) is commonly accompanied by intracranial bleeding which can worsen after hospital admission. Tranexamic acid (TXA) has been shown to reduce bleeding in elective surgery and there is evidence that short courses of TXA can reduce rebleeding in spontaneous intracranial haemorrhage. We aimed to determine the effectiveness and safety of TXA in preventing progressive intracranial haemorrhage in TBI. METHODS: This is a double blinded, placebo controlled randomized trial. We enrolled 238 patients older than 16 years with moderate to severe TBI (post-resuscitation Glasgow Coma Scale (GCS) 4 to 12) who had a computerized tomography (CT) brain scan within eight hours of injury and in whom there was no immediate indication for surgery. We excluded patients if they had a coagulopathy or a serum creatinine over than 2.0 milligrams%. The treatment was a single dose of 2 grams of TXA in addition to other standard treatments. The primary outcome was progressive intracranial haemorrhage (PIH) which was defined as an intracranial haemorrhage seen on the second CT scan that was not seen on the first CT scan, or an intracranial haemorrhage seen on the first scan that had expanded by 25% or more on any dimension (height, length, or width) on the second scan. RESULTS: Progressive intracranial haemorrhage was present in 21 (18%) of 120 patients allocated to TXA and in 32 (27%) of 118 patients allocated to placebo. The difference was not statistically significant [RR = 0.65 (95% CI 0.40 to 1.05)]. There were no significant difference in the risk of death from all causes in patients allocated to TXA compared with placebo [RR = 0.69 (95% CI 0.35 to 1.39)] and the risk of unfavourable outcome on the Glasgow Outcome Scale [RR = 0.76 (95% CI 0.46 to 1.27)]. There was no evidence of increased risk of thromboembolic events in those patients allocated to TXA. CONCLUSIONS: TXA may reduce PIH in patients with TBI; however, the difference was not statistically significant in this trial. Large clinical trials are needed to confirm and to assess the effect of TXA on death or disability after TBI.

Free survival time of recurrence and malignant transformation and associated factors in patients with supratentorial low-grade gliomas.

OBJECTIVE: To determine the recurrence and malignancy free survival time and associated factors with recurrence and malignant transformation of patients with low-grade gliomas after primary surgical resection. MATERIAL AND METHOD: The present study was retrospective. Patients who underwent surgery and were diagnosed with low-grade gliomas between January 2000 and October 2009 were recruited. Time to recurrence and malignant transformation were analyzed using Kaplan-Meier method and multivariate Cox proportional hazard regression models. RESULTS: Seventy-seven patients underwent surgery for low-grade glioma. The pathological reports were diffuse astrocytoma in 55 patients (71%), oligodendroglioma in 19 patients (25%), and oligoastrocytoma in three patients (40%). The types of tumor resection were biopsy in 39 patients (50%), subtotal resection 34 patients (44%), and total resection in four patients (5%). The overall mean time to follow-up was 40 months, the median recurrence and malignant transformation times were 14 and 24 months. The 5-year recurrence-free and malignant-free survival rate was 50% and 68%. Factors associated with tumor recurrence were age, sex, presenting symptoms, preoperative Karnofsky performance status (KPS) score, tumor volume, and contrast enhancement. None of these factors showed statistically significant association with malignant transformation. CONCLUSION: One fourth of the patients had tumor recurrence and malignant transformation in a short period of time. Delayed recurrence and malignant transformation after primary resection are associated with several factors. The type of surgery especially total-subtotal resection might favor prognosis.

Haemostatic drugs for traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability. Intracranial bleeding is a common complication of TBI, and intracranial bleeding can develop or worsen after hospital admission. Haemostatic drugs may reduce the occurrence or size of intracranial bleeds and consequently lower the morbidity and mortality associated with TBI. OBJECTIVES: To assess the effects of haemostatic drugs on mortality, disability and thrombotic complications in patients with traumatic brain injury. SEARCH STRATEGY: We searched the electronic databases: Cochrane Injuries Group Specialised Register (3 February 2009), CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (1950 to Week 3 2009), PubMed (searched 3 February 2009 (last 180 days)), EMBASE (1980 to Week 4 2009), CINAHL (1982 to January 2009), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to January 2009), ISI Web of Science: Conference Proceedings Citation Index - Science (CPCI-S) (1990 to January 2009). SELECTION CRITERIA: We included published and unpublished randomised controlled trials comparing haemostatic drugs (antifibrinolytics: aprotinin, tranexamic acid (TXA), aminocaproic acid or recombined activated factor VIIa (rFVIIa)) with placebo, no treatment, or other treatment in patients with acute traumatic brain injury. DATA COLLECTION AND ANALYSIS: Two review authors independently examined all electronic records, and extracted the data. We judged that there was clinical heterogeneity between trials so we did not attempt to pool the results of the included trials. The results are reported separately. MAIN RESULTS: We included two trials. One was a post-hoc analysis of 30 TBI patients from a randomised controlled trial of rFVIIa in blunt trauma patients. The risk ratio for mortality at 30 days was 0.64 (95% CI 0.25 to 1.63) for rFVIIa compared to placebo. This result should be considered with caution as the subgroup analysis was not pre-specified for the trial. The other trial evaluated the effect of rFVIIa in 97 TBI patients with evidence of intracerebral bleeding in a computed tomography (CT) scan. The corresponding risk ratio for mortality at the last follow up was 1.08 (95% CI 0.44 to 2.68). The quality of the reporting of both trials was poor so it was difficult to assess the risk of bias. AUTHORS' CONCLUSIONS: There is no reliable evidence from randomised controlled trials to support the effectiveness of haemostatic drugs in reducing mortality or disability in patients with TBI. New randomised controlled trials assessing the effects of haemostatic drugs in TBI patients should be conducted. These trials should be large enough to detect clinically plausible treatment effects.

ICP threshold in CPP management of severe head injury patients.

BACKGROUND: Elevated intracranial pressure (ICP) is significantly associated with high mortality rate in severe head injury (SHI) patients. However, there is no absolute agreement regarding the level at which ICP must be treated. The objective of this study was to compare the outcomes of severe head injury patients treated by setting the ICP threshold at >or=20 mm Hg or >or=25 mm Hg. METHODS: Treatment protocol in this study consisted of therapeutic maneuvers designed to maximize cerebral profusion pressure (CPP) and control ICP. Twenty-seven patients with severe head injury and intracranial hypertension (ICP >or=20 mm Hg) were enrolled and fourteen cases were allocated to the group of ICP threshold >or=25 mm Hg. Six-month clinical outcomes were evaluated using the Glasgow Outcome Score (GOS). RESULTS: There were no statistically significant differences in clinical parameters between the groups. Logistic regression identified the presence of basal cisterns on the initial computed tomography (CT) scan as a significant predictor of good outcome. ICP threshold did not influence outcome. CONCLUSIONS: This study supported a recommended ICP threshold of 20 to 25 mm Hg in SHI management. However, in cases with an absence of basal cisterns on initial CT scan, the probability of good outcome may be higher using an ICP threshold of >or=20 mm Hg.