The Long-Term Sequelae of Traumatic Brain Injury Over 10 Years of Follow-Up­A Matched Cohort Study Based on Routine Data of a Statutory Health Insurance Carrier

BACKGROUND: The acute effects of traumatic brain injury (TBI) are well documented, but there is no systematic quantification of its long-term sequelae in Germanlanguage literature. The purpose of this article is to compare the frequency of conditions linked to prior TBI with their frequency in the non-brain-injured population. METHODS: A matched cohort study was carried out on the basis of routine data from the BARMER statutory health insurance carrier. The exposure group consisted of patients treated over the period 2006-2009 for TBI at a variety of treatment intensities, including persons with multiple organ trauma. The control group consisted of BARMER insurees without prior TBI who were matched with the patients in the exposure group for age, sex, and pre-existing diseases. Late sequelae were sought in the routine data for a period of ten years after the injury. The outcome rates of the exposure and control groups were compared with Kaplan-Meier estimators and Poisson regression. RESULTS: 114 296 persons with TBI in the period 2006-2009 were included in the study. The mortality within ten years of TBI was 305 per 1000 individuals. The relative mortality in the exposure group was higher than that in control individuals of the same age and sex, with an incidence rate ratio (IRR) of 1.67 (95% confidence interval, [1.60; 1.74]). Immobility, dementia, epilepsy, endocrine disorders, functional disorders, depression, anxiety, cognitive deficits, headache, and sleep disorders were also more common in the exposure group. Persons with TBI requiring highintensity treatment displayed the highest relative incidence rates of the conditions studied over 10 years of follow-up. Persons who had been admitted to the hospital because of TBI had higher relative incidence rates for epilepsy and dementia than those who had been cared for on an outpatient basis. CONCLUSION: Adverse sequelae of TBI can still be seen ten years after the exposure. These patients die earlier than persons without TBI and suffer earlier and more frequently from associated conditions.

Health-related quality of life after spontaneous subarachnoid hemorrhage measured in a recent patient population.

OBJECTIVE: This study sought to determine the impact of spontaneous subarachnoid hemorrhage (SAH) on health-related quality of life (HRQOL). METHODS: Data were taken retrospectively from 601 patients (219 male, 382 female) treated between 1998 and 2008. Questionnaires concerning HRQOL were circulated prospectively, and the responses from 253 patients (81 male, 172 female) were analyzed. The questionnaires comprised the standardized Short-Form 36 (SF-36) and Short-Form 12 (SF-12) Health Surveys, a number of nonstandardized questions, and visual analogue scales. Statistical analysis of the results was exploratory, using unifactorial ANOVA (Scheffe), multivariate analyses of variance. RESULTS: The HRQOL is reduced considerably by SAH and remains so for a period of 10 years. Physical and emotional domains are primarily affected, but also cognitive functions, including memory and concentration in particular. Similarly, certain roles are affected that prove difficult to rehabilitate after acute care and cause serious debility in the long term. The Hunt and Hess Scale, Glasgow Outcome Scale, and seizures were found to have the greatest impact on HRQOL. CONCLUSIONS: Documentation of HRQOL after 6 to 12 months is useful because patients are often found to have a diminished HRQOL in the absence of a clear physical impairment. Because psychological, emotional, cognitive, and social functioning influence HRQOL in the long term, efforts at rehabilitation should focus in particular on improving such factors. Documentation of HRQOL is a useful, additive tool for consolidating and evaluating the outcome, and a treatment end point after SAH, respectively.

Analysis of intracranial pressure time series using wavelets (Haar basis functions).

PURPOSE: Transforming intracranial pressure (ICP) into frequency domain commenced in the early 1980s, arriving at the conclusion that cerebrospinal dynamics were mapped by ICP spectral composition. Classical analysis tools were not suitable for handling intrinsic signal non-stationarity. To overcome inherent obstacles we introduce a novel approach based upon wavelets. METHODS: During routine diagnostic volume pressure testing epidural ICP was acquired in 118 patients with suspected cerebrospinal fluid circulatory disorders. Pressure was digitised and conditioned to separate low frequent signal components (

Stationarity in neuromonitoring data.

PURPOSE: Signals reflecting the metabolic and circulatory status of an injured central nervous system are normally corrupted systematically. The patient is part of a therapeutic control-loop and the signals acquired are rather determined by the quality of control (stationarity of signals) than by the underlying pathological process. METHODS: To verify the control-loop hypothesis, neuromonitoring data from 12 randomly selected severely head injured patients (initial GCS ≤ 8, 7 men, 5 women) were analysed for circulatory (blood pressure, intracranial pressure [ICP], cerebral perfusion pressure [CPP]) and metabolic (arterial blood gases, jugular bulb oxygenation [SjvO(2)], brain tissue oxygen partial pressure [ptiO(2)]) variables (n = 10). A total of 120 time series of generally not equidistant sample intervals were assessed for stationarity by Wallis & Moore's runs test. RESULTS: Non-stationarity could only be proven in 23 time series, i.e. the control-loop hypothesis was violated. Trends were mainly found in CPP (n = 5) and ICP (n = 4). The remaining cases spread out on all but one (temperature) signal. Nine patients showed at least one time series with a trend. One patient had clear trends in five out of ten variables that focused on SjvO(2), ptiO(2), ICP and CPP. CONCLUSIONS: Absence of stationarity in about 20% of time series is credited to an effective therapeutic control-loop. For analytical purposes, however, the benefit seems to be overestimated. Consequently, neuromonitoring should be considered the analysis of short-term disturbances that are intentionally compensated for by a short response time. Information content is thus reduced even if the number of sensor devices increases.

Head injury in Germany: A population-based prospective study on epidemiology, causes, treatment and outcome of all degrees of head-injury severity in two distinct areas.

INTRODUCTION: Little is known about the ratio of mild traumatic brain injury (TBI) to moderate and severe TBI, about the time that elapses until primary care is given, about the number of patients requiring immediate surgery and about the early outcome and the costs. METHOD: In a prospective study two regions taken as model examples were investigated: the City of Hanover with its surrounding catchment area and Münster with its regions. RESULTS: From 1 March 2000 until 28 February 2001 all patients were recruited who were admitted to a hospital emergency department due to a TBI; 6783 patients (58.4% male, 41.6% female; 29.7% children < 16 years) were included; 5220 (73%) received in-hospital treatment; and 258 were given early rehabilitation. The incidence of TBI is 332 per 100 000 head of population. The GCS (Glasgow Coma Scale) or other forms of neurological examinations were performed in only 56% of all cases. According to the GCS status, 90.2% are classified as mild, 3.9% as moderate and 5.2% as severe. Intubation is given only to 76.1% of patients with severe TBI. Lethality was 1%. The predominant cause of TBI is falls, with 52.5% of all cases, while 26.3% were due to road accidents. The time elapsing between the accident event and initial examination at the hospital is less than 1 hour in 63% of all cases. X-rays were taken in 82% of all cases of TBI, with 19.3% of the patients receiving a CT scan; 58.7% of all TBI patients have additional injuries of the facial skull, 8.8% of the vertebral column, 7.2% of the thorax, 2.6% of the abdomen, 3.4% of the pelvis and 19.6% of one or more extremities. One year after the accident, 50% of all patients still required treatment even after mild TBI. CONCLUSION: It is necessary to follow the TBI guidelines, e.g. regarding intubation and neurological examination. The indication for cranial x-rays and CT should be reconsidered.

Head trauma in children, part 3: clinical and psychosocial outcome after head trauma in children.

With the aim of determining long-term outcome, the authors approached 38 families (average 2.1 years after trauma) with a questionnaire, following the acute-clinical treatment of head trauma of their children. Long-term damage was restricted almost exclusively to patients presenting with a Glasgow Coma Score < or =8. Paresis (16%), cranial nerve damage (13%), incontinence (5%), or coordinative disturbances (18%) continued. The older children stated that they influenced their life to a great extent (11%). Furthermore, many had mental and cognitive problems that occur quite frequently even in children with light head trauma and often only manifest after release from hospital. This causes problems and results in inferior performance (26%), especially at school, which is further complicated through lengthy periods of absence. The parents, especially, mentioned behavioral problems such as social withdrawal or aggressive demeanor, which led to tension also inside the family. A persistent vegetative state is rare after head trauma in children.

Head trauma in children, part 1: admission, diagnostics, and findings.

The objective of this study is to describe and to determine the preclinical situation and early in-clinical situation, diagnostic findings, and factors influencing the outcome of severe head trauma in children. Records of 48 children (0-16 years) were analyzed during a 3-year interval. Correlations with the outcome (Glasgow Outcome Scale) were determined by focusing on different scales, clinical findings, biochemistry, and clinical course features. The initial shock index had a major relevance (P = .0089). Systolic blood pressure (P = .0002) and bradycardia (P = .035) were important factors. Assessing the severity of trauma according to the Glasgow Coma Score, the most accurate parameter for outcome is based on the detailed quality of ''eye opening'' (P = .0155). Pupillary motoricity at the accident site (P = .002) and emergency room (P = .0004) are strong predictors. Preclinical measurements of stabilization and oxygenation have the same impact as the in-clinical management.

Head trauma in children, part 2: course and discharge with outcome.

To minimize the secondary brain damage, we analyzed the effect of cerebral perfusion pressure-orientated management and tried to find factors of clinical management and biochemical findings that influence clinical, cognitive, and psychosocial outcome. Management at intensive care unit was standardized. A standardized (short form 36 health survey) and nonstandardized split questionnaire explored long-term outcome. Glutamic-oxaloacetic-transaminase, creatine kinase MB or glucose are markers for bad outcome (P < .05). Patients with cerebral perfusion pressure values below the recommended standard for just a single occurrence had significantly worse outcome (P = .0132). Mean arterial pressure, central venous pressure, and heart rate alone do not correlate with outcome. At least 1 occurrence of mean arterial pressure and central venous pressure below the lower limits resulted in a poor outcome (P = .035). Cerebral perfusion pressure-guided therapy seems to prevent further brain damage and results in outcome scores that are comparable to those children with head trauma exhibiting symptoms of mild brain edema.

The use of recombinant activated factor VII in neurosurgery.

BACKGROUND: Bleeding complications in neurosurgery often take alarming proportions without major hemodynamic effect or impairment of coagulation physiology because severe neurologic deficits are to be expected. Any measures used to stabilize or normalize coagulation are therefore of great interest. Administration of packed red cells, fresh frozen plasma, and platelet concentrates is associated with volume loading, which is suspected to multiply the secondary brain damage, for example, by the development of an edema. In this respect, the administration of rFVIIa may develop into a new option associated with low-volume administration. CASE DESCRIPTIONS: We report on 5 neurosurgical patients to whom rFVIIa was given at doses of 51 to 202 microg/kg of body weight for the treatment of severe intraoperative bleeding (n = 3) or as prophylaxis of bleeding (n = 2). The operation was completed successfully in all patients after administration of rFVIIa, with stabilization of the coagulation status. CONCLUSION: Therefore, reported cases constitute an approach in treatment and prophylaxis of bleeding complications in neurosurgery. There are reports of thromboembolic events in use of rFVIIa, particularly in unlabeled use. But according to our findings and current literature, there is no evidence of higher risk of thromboembolic adverse events in treatment with rFVIIa. However, the number of patients presented does not allow any final assessment to be made as to whether the properties of rFVIIa are of particular benefit for neurosurgical patients. Further studies with appropriate study design are required to verify effects observed in this investigation.