Abstract
BACKGROUND
Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically ...classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments.
OBJECTIVE
To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury.
METHODS
A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD).
RESULTS
The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI = 0.37, 0.67) and cognitive (0.40; 95% CI = 0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI = 0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P < .05). Children and adults with concussion showed significantly more cognitive symptoms than their respective controls (SMD = 0.66 and 0.24; P < .001). Furthermore, ocular-motor in adult patients (SMD = 0.72; P < .001) and vestibular symptoms in both pediatric and adult patients (SMD = 0.18 and 0.36; P < .05) were significantly worse in concussion patients than in controls.
CONCLUSION
Five concussion subtypes with varying prevalence within 3 d following injury are commonly seen clinically and identifiable upon systematic literature review. Sleep disturbance, a concussion-associated condition, is also common. There was insufficient information available for analysis of cervical strain. A comprehensive acute concussion assessment defines and characterizes the injury and, therefore, should incorporate evaluations of all 5 subtypes and associated conditions.
Background. Traumatic brain injury (TBI) can result in significant morbidity and mortality if not diagnosed in a timely manner. Brain computed tomography (CT) is the diagnostic gold standard but is ...of limited availability in most South African public hospitals, resulting in transfer of TBI patients to tertiary hospitals. Objective. To describe the referral patterns and outcomes of patients with TBI referred to Groote Schuur Hospital Trauma Centre. Methods. This was a retrospective audit of all patients admitted to the Trauma Centre who had a brain CT scan for suspected TBI between 1 February 2022 and 31 March 2022. Demographic data (age, sex), mechanism of injury and Glasgow Coma Score were recorded. Referral pathways were determined, and final disposition of patients was recorded. Results. A total of 522 patients had a brain CT for TBI. Of these, 314 (60.1%) were referred from other hospitals. CT scan was abnormal in 178 (34.1%) patients. Three hundred and two (58.6%) were discharged home within 24 hours. The mean time between referral and CT scan was 13 hours. Conclusion. More than half of patients referred for a CT scan were discharged from the Trauma Centre within 24 hours of admission, which indicates additional costs and inefficiencies in the health system. These data are useful to guide resource planning and allocation for district hospitals, since less expensive point-of-care modalities now exist to diagnose TBI, and which are useful in indicating the prognosis of patients.
Biomarkers can be broadly defined as qualitative or quantitative measurements that convey information on the physiopathological state of a subject at a certain time point or disease state. Biomarkers ...can indicate health, pathology, or response to treatment, including unwanted side effects. When used as outcomes in clinical trials, biomarkers act as surrogates or substitutes for clinically meaningful endpoints. Biomarkers of disease can be diagnostic (the identification of the nature and cause of a condition) or prognostic (predicting the likelihood of a person's survival or outcome of a disease). In addition, genetic biomarkers can be used to quantify the risk of developing a certain disease. In the specific case of traumatic brain injury, surrogate blood biomarkers of imaging can improve the standard of care and reduce the costs of diagnosis. In addition, a prognostic role for biomarkers has been suggested in the case of post-traumatic epilepsy. Given the extensive literature on clinical biomarkers, we will focus herein on biomarkers which are present in peripheral body fluids such as saliva and blood. In particular, blood biomarkers, such as glial fibrillary acidic protein and salivary/blood S100B, will be discussed together with the use of nucleic acids (eg, DNA) collected from peripheral cells.
Traumatic brain injury (TBI) affects 1.6 million Americans annually. The injury severity impacts the overall outcome and likelihood for survival. Current treatment of acute TBI includes surgical ...intervention and supportive care therapies. Treatment of elevated intracranial pressure and optimizing cerebral perfusion are cornerstones of current therapy. These approaches do not directly address the secondary neurological sequelae that lead to continued brain injury after TBI. Depending on injury severity, a complex cascade of processes are activated and generate continued endogenous changes affecting cellular systems and overall outcome from the initial insult to the brain. Homeostatic cellular processes governing calcium influx, mitochondrial function, membrane stability, redox balance, blood flow and cytoskeletal structure often become dysfunctional after TBI. Interruption of this cascade has been the target of numerous pharmacotherapeutic agents investigated over the last two decades. Many agents such as selfotel, pegorgotein (PEG-SOD), magnesium, deltibant and dexanabinol were ineffective in clinical trials. While progesterone and ciclosporin have shown promise in phase II studies, success in larger phase III, randomized, multicentre, clinical trials is pending. Consequently, no neuroprotective treatment options currently exist that improve neurological outcome after TBI. Investigations to date have extended understanding of the injury mechanisms and sites for intervention. Examination of novel strategies addressing both pathological and pharmacological factors affecting outcome, employing novel trial design methods and utilizing biomarkers validated to be reflective of the prognosis for TBI will facilitate progress in overcoming the obstacles identified from previous clinical trials.
Repetitive brain trauma is associated with a progressive neurological deterioration, now termed as chronic traumatic encephalopathy (CTE). Most instances of CTE occur in association with the play of ...sports, but CTE has also been reported in association with blast injuries and other neurotrauma. Symptoms of CTE include behavioral and mood changes, memory loss, cognitive impairment and dementia. Like many other neurodegenerative diseases, CTE is diagnosed with certainty only by neuropathological examination of brain tissue. CTE is a tauopathy characterized by the deposition of hyperphosphorylated tau (p‐tau) protein as neurofibrillary tangles, astrocytic tangles and neurites in striking clusters around small blood vessels of the cortex, typically at the sulcal depths. Severely affected cases show p‐tau pathology throughout the brain. Abnormalities in phosphorylated 43 kDa TAR DNA‐binding protein are found in most cases of CTE; beta‐amyloid is identified in 43%, associated with age. Given the importance of sports participation and physical exercise to physical and psychological health as well as disease resilience, it is critical to identify the genetic risk factors for CTE as well as to understand how other variables, such as stress, age at exposure, gender, substance abuse and other exposures, contribute to the development of CTE.
Abstract
INTRODUCTION
Following traumatic brain injury (TBI), midline shift is often caused by space occupying lesions leading to increased intracranial pressure and worsened morbidity and mortality. ...Outcome has been studied in this population; recovery trajectory in these patients has not been reported. We utilized the COBRIT trial to analyze subject recovery over time depending on degree of midline shift at presentation.
METHODS
Subject data from the COBRIT trial were stratified into groups of midline shift, and outcome measures were analyzed at 30, 90, and 180 d after injury. Recovery trajectory analysis was performed identifying patients with outcome measures at all time points, analyzing the degree of recovery based on midline shift at presentation.
RESULTS
There were 896, 1196, and 895 subjects with adequate outcome data at 30, 90, and 180 d, respectively. Rates of favorable outcome (GOS-E 4-8) at 6 mo after injury were 87% (no midline shift), 79% (1-5 mm shift), 64% (6-10 mm shift), and 47% (>10 mm shift). The mean improvement from unfavorable outcome (GOS-E 2-3) to favorable outcome (GOS-E 4-8) from 1 to 6 mo in all groups was 20%. The mean GOS-E of subjects in the 6 to 10 mm group crosses from unfavorable outcome into favorable outcome at 90 d, and the mean GOS-E of subjects in the >10 mm group nearly reaches the threshold of favorable outcome by 180 d after injury.
CONCLUSION
In this secondary analysis of the COBRIT trial, TBI subjects with <10mm of midline shift on admission head CT had significantly improved functional outcomes through 180 d after injury compared to those with greater than 10 mm of midline shift; however, nearly 50% of patients with 10 mm of midline shift will achieve a favorable outcome (GOS-E 4-8) by 6 mo after injury. Subjects with a unfavorable outcome (GOS-E 2-3) at 30 d should continue close observation as approximately 20% will improve to a favorable outcome by 6 mo after injury.
Abstract
INTRODUCTION
Transfer of stable patients who might otherwise be safely observed at a community hospital adds to the ever-increasing cost of healthcare in the United States. This study aims ...to show that overtriage of complicated mild traumatic brain injury (mTBI) patients leads to substantial costs to a healthcare system. Secondary outcomes are predictors of overtriage and transfer times.
METHODS
A 9-yr retrospective analysis of patients admitted to our tertiary care center who had mTBI with evidence of intracranial hemorrhage on computed tomography scan. Patients were dichotomized based on their mode of transfer (helicopter vs ambulance) and admission status (primary admission vs secondary admission). Secondary overtriage was defined as patients with an injury severity score less than 15, no surgical interventions performed, and hospital stay less than 48 h. Charges were calculated for each cohort, and multivariate linear regression analysis was used to determine predictors of overtriage.
RESULTS
A total of 1447 patients met the inclusion criteria for this study. A total of 115 patients met the criteria for secondary overtriage. Secondary overtriaged patients are younger (median: 41 yr vs 60.5 yr, P < .001), had lower ISS (9 vs 16, P < .001), had a shorter hospital stay (1 d vs 3 d, P < .001) and a shorter intensive care unit stay (P < .001), had lower proportion of comorbidities (38.9% vs 58.0%, P < .001) and complications (0.9% vs 7.2%, P < .001). Secondary overtriaged patients had a higher chance of being discharged home and an average transfer time of 51 min. Lack of insurance was a major predictor of overtriage. Secondary overtriaged patients had an average cost of $13 294.
CONCLUSION
Significant overtriage of complicated mTBI patients leads to a cost of approximately $13 000 per patient. Eliminating these transfers is another way to save on healthcare costs.
Abstract
INTRODUCTION
There is paucity of research addressing how health care decisions are made in cases of severe traumatic brain injury. This study aims to identify the demographic and clinical ...factors associated with withdrawal care in the setting of severe traumatic brain injury.
METHODS
This is a retrospective study using the Trauma Quality Improvement Program database from 2013 to 2015. Patients with severe traumatic brain injury (GCS 3-8, AIS 2-5) were included. Univariate and multivariate analyses with adjusted P-values were performed for descriptive statistics. A logistic regression analysis was used to identify demographic and clinical factors associated with withdrawal of care.
RESULTS
The analysis included 7869 (21%) patients who withdrew and 30 080 (79%) who did not. More than half of those withdrawn were at a University hospital. Patients undergoing withdrawal of care were older (57.6 ± 20.6 vs 42.9 ± 18.8 yr) and 69% were male, 82% were white, 43% were from the Southern United States and 31% had private insurance. Black or other races were less likely to undergo withdrawal of care as compared to white (odds ratio OR 0.7, 95% confidence interval CI 0.6-0.7 and 0.8, 95% CI 0.8-0.9, respectively). Injury severity score (ISS) was significantly different between those who underwent withdrawal and those who did not, 28.2 ± 12.3 vs 26.1 ± 12.1. The presence of epidural or subdural hematoma was also significantly different between the 2 groups (78% vs 72%). Those who did not have a craniotomy were less likely to undergo withdrawal and those who did not have a hematoma were less likely to undergo withdrawal (OR 0.7, 95% CI 0.7-0.8 and 0.8, 95% CI 0.7-0.9, respectively). The average ICU length of stay and ventilation days were shorter for patients who underwent withdrawal.
CONCLUSION
Age, ISS, craniotomy, race (white), and type of insurance (Medicare) were each positive predictors for withdrawal of care. By contrast, region (Southern United States), race (black), and being functionally independent were negative predictors.
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