Severe traumatic brain injury outcome

Severe traumatic brain injury outcome

Younger age, modified Fisher scale (mFS) score, and Intracerebral hemorrhage volume are associated with Intracranial pressure elevation in patients with a severe traumatic brain injury. Imaging features may stratify patients by their risk of subsequent ICP elevation 1).


There has been a secular trend towards reduced incidence of severe traumatic brain injury in the first world, driven by public health interventions such as seatbelt legislation, helmet use, and workplace health and safety regulations. This has paralleled improved outcomes following TBI delivered in a large part by the widespread establishment of specialised neurointensive care 2).

The impact of a moderate to severe brain injury depends on the following:

Severity of initial injury

Rate/completeness of physiological recovery

Functions affected

Meaning of dysfunction to the individual

Resources available to aid recovery

Areas of function not affected by TBI

see Effect of trauma center designation in severe traumatic brain injury outcome


Mortality or severe disability affects the majority of patients after severe traumatic brain injury (TBI). Adherence to the brain trauma foundation severe traumatic brain injury guidelines has overall improved outcomes; however, traditional as well as novel interventions towards intracranial hypertension and secondary brain injury have come under scrutiny after series of negative randomized controlled trials. In fact, it would not be unfair to say there has been no single major breakthrough in the management of severe TBI in the last two decades. One plausible hypothesis for the aforementioned failures is that by the time treatment is initiated for neuroprotection, or physiologic optimization, irreversible brain injury has already set in. Lazaridis et al., and others, have developed predictive models based on machine learning from continuous time series of intracranial pressure and partial pressure of brain tissue oxygen. These models provide accurate predictions of physiologic crises events in a timely fashion, offering the opportunity for an earlier application of targeted interventions. In a article, Lazaridis et al., review the rationale for prediction, discuss available predictive models with examples, and offer suggestions for their future prospective testing in conjunction with preventive clinical algorithms 3).


Determining the prognostic significance of clinical factors for patients with severe head injury can lead to an improved understanding of the pathophysiology of head injury and to improvement in therapy. A technique known as the sequential Bayes method has been used previously for the purpose of prognosis. The application of this method assumes that prognostic factors are statistically independent. It is now known that they are not. Violation of the assumption of independence may produce errors in determining prognosis. As an alternative technique for predicting the outcome of patients with severe head injury, a logistic regression model is proposed. A preliminary evaluation of the method using data from 115 patients with head injury shows the feasibility of using early data to predict outcome accurately and of being able to rank input variables in order of their prognostc significance. 4).


A prospective and consecutive series of 225 patients with severe head injuries who were managed in a uniform way was analyzed to relate outcome to several clinical variables. Good recovery or moderate disability were achieved by 56% of the patients, 10% remained severely disabled or vegetative, and 34% died. Factors important in predicting a poor outcome included the presence of intracranial hematoma, increasing age, motor impairment, impaired or absent eye movements or pupillary light reflexes, early hypotension, hypoxemia or hypercarbia, and raised intracranial pressure over 20 mm Hg despite artificial ventilation. Most of these predictive factors were assessed on admission, but a subset of 158 patients was identified in whom coma was present on admission and was known to have persisted at least until the following day. Although the mortality in this subset (40%) was higher than in the total series, it was lower than in several comparable reported series of patients with severe head injury. Predictive correlations were equally strong in the entire series and in the subset of 158 patients with coma. A plea is made for inclusion in the definition of “severe head injury” of all patients who do not obey commands or utter recognizable words on admission to the hospital after early resuscitation 5).


Survival rate of isolated severe TBI patients who required an emergent neurosurgical intervention could be time dependent. These patients might benefit from expedited process (computed tomographic scan, neurosurgical consultation, etc.) to shorten the time to surgical intervention 6).

The impact of a moderate to severe brain injury can include:

Cognitive deficits including difficulties with:

Attention Concentration Distractibility Memory Speed of Processing Confusion Perseveration Impulsiveness Language Processing “Executive functions” Speech and Language

not understanding the spoken word (receptive aphasia) difficulty speaking and being understood (expressive aphasia) slurred speech speaking very fast or very slow problems reading problems writing Sensory

difficulties with interpretation of touch, temperature, movement, limb position and fine discrimination Perceptual

the integration or patterning of sensory impressions into psychologically meaningful data Vision

partial or total loss of vision weakness of eye muscles and double vision (diplopia) blurred vision problems judging distance involuntary eye movements (nystagmus) intolerance of light (photophobia) Hearing

decrease or loss of hearing ringing in the ears (tinnitus) increased sensitivity to sounds Smell

loss or diminished sense of smell (anosmia) Taste

loss or diminished sense of taste Seizures

the convulsions associated with epilepsy that can be several types and can involve disruption in consciousness, sensory perception, or motor movements Physical Changes

Physical paralysis/spasticity Chronic pain Control of bowel and bladder Sleep disorders Loss of stamina Appetite changes Regulation of body temperature Menstrual difficulties Social-Emotional

Dependent behaviors Emotional ability Lack of motivation Irritability Aggression Depression Disinhibition Denial/lack of awareness


Both single predictors from early clinical examination and multiple hospitalization variables/parameters can be used to determine the long-term prognosis of TBI. Predictive models like the IMPACT or CRASH prognosis calculator (based on large sample sizes) can predict mortality and unfavorable outcomes. Moreover, imaging techniques like MRI (Magnetic Resonance Imaging) can also predict consciousness recovery and mental recovery in severe TBI, while biomarkers associated with stress correlate with, and hence can be used to predict, severity and mortality. All predictors have limitations in clinical application. Further studies comparing different predictors and models are required to resolve limitations of current predictors 7).


1)

Murray NM, Wolman DN, Mlynash M, Threlkeld ZD, Christensen S, Heit JJ, Harris OA, Hirsch KG. Early Head Computed Tomography Abnormalities Associated with Elevated Intracranial Pressure in Severe Traumatic Brain Injury. J Neuroimaging. 2020 Nov 4. doi: 10.1111/jon.12799. Epub ahead of print. PMID: 33146933.
2)

Khellaf A, Khan DZ, Helmy A. Recent advances in traumatic brain injury. J Neurol. 2019 Sep 28. doi: 10.1007/s00415-019-09541-4. [Epub ahead of print] PubMed PMID: 31563989.
3)

Lazaridis C, Rusin CG, Robertson CS. Secondary Brain Injury: Predicting and Preventing Insults. Neuropharmacology. 2018 Jun 6. pii: S0028-3908(18)30279-X. doi: 10.1016/j.neuropharm.2018.06.005. [Epub ahead of print] Review. PubMed PMID: 29885419.
4)

Stablein DM, Miller JD, Choi SC, Becker DP. Statistical methods for determining prognosis in severe head injury. Neurosurgery. 1980 Mar;6(3):243-8. PubMed PMID: 6770283.
5)

Miller JD, Butterworth JF, Gudeman SK, Faulkner JE, Choi SC, Selhorst JB, Harbison JW, Lutz HA, Young HF, Becker DP. Further experience in the management of severe head injury. J Neurosurg. 1981 Mar;54(3):289-99. PubMed PMID: 7463128.
6)

Matsushima K, Inaba K, Siboni S, Skiada D, Strumwasser AM, Magee GA, Sung GY, Benjaminm ER, Lam L, Demetriades D. Emergent operation for isolated severe traumatic brain injury: Does time matter? J Trauma Acute Care Surg. 2015 Aug 28. [Epub ahead of print] PubMed PMID: 26317818.
7)

Gao L, Wu X. Prediction of clinical outcome in severe traumatic brain injury. Front Biosci (Landmark Ed). 2015 Jan 1;20:763-771. PubMed PMID: 25553477.

Penetrating head injury outcome

Penetrating head injury outcome

Surgical intervention in penetrating head injury patients with GCS 3-5 results in improved mortality but comes at a cost of increased resource utilization in the form of longer LOS and higher infection rate. On the other hand, in patients with GCS ≥6, surgery does not provide significant benefits in patient survival. Future prospective studies providing insight as to the impact of surgery on the resource utilization and quality of survival would be beneficial in determining the need for surgical intervention in this population 1).


Reports from civilian cohorts are small because of the high reported mortality rates (as high as 90%). Data from military populations suggest a better prognosis for penetrating brain injury, but previous reports are hampered by analyses that exclude the point of injury.

The purpose of a study was to provide a description of the long-term functional outcomes of those who sustain a combat-related penetrating brain injury (from the initial point of injury to 24 months afterward).

This study is a retrospective review of cases of penetrating brain injury in patients who presented to the Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan, from January 2010 to March 2013. The primary outcome of interest was Glasgow Outcome Scale (GOS) score at 6, 12, and 24 months from date of injury.

A total of 908 cases required neurosurgical consultation during the study period, and 80 of these cases involved US service members with penetrating brain injury. The mean admission Glasgow Coma Scale (GCS) score was 8.5 (SD 5.56), and the mean admission Injury Severity Score (ISS) was 26.6 (SD 10.2). The GOS score for the cohort trended toward improvement at each time point (3.6 at 6 months, 3.96 at 24 months, p > 0.05). In subgroup analysis, admission GCS score ≤ 5, gunshot wound as the injury mechanism, admission ISS ≥ 26, and brain herniation on admission CT head were all associated with worse GOS scores at all time points. Excluding those who died, functional improvement occurred regardless of admission GCS score (p < 0.05). The overall mortality rate for the cohort was 21%.

Good functional outcomes were achieved in this population of severe penetrating brain injury in those who survived their initial resuscitation. The mortality rate was lower than observed in civilian cohorts 2).


At the time of the Boer War in 1899 penetrating head injuries, which formed a large proportion of the battlefield casualties, resulted in almost 100% mortality. Since that time up to the present day, significant improvements in technique, equipment and organisation have reduced the mortality to about 10% 3).

References

1)

D’Agostino R, Kursinskis A, Parikh P, Letarte P, Harmon L, Semon G. Management of Penetrating Traumatic Brain Injury: Operative versus Non-Operative Intervention [published online ahead of print, 2020 Aug 17]. J Surg Res. 2020;257:101-106. doi:10.1016/j.jss.2020.07.046
2)

Two-year mortality and functional outcomes in combat-related penetrating brain injury: battlefield through rehabilitation. Neurosurg Focus. 2018 Dec 1;45(6):E4. doi: 10.3171/2018.9.FOCUS18359. PubMed PMID: 30544304.
3)

Stanworth PA. A century of British military neurosurgery. J R Army Med Corps. 2015 Aug 4. pii: jramc-2015-000477. doi: 10.1136/jramc-2015-000477. [Epub ahead of print] Review. PubMed PMID: 26243803.

Iatrogenic peripheral nerve injury

Iatrogenic peripheral nerve injury

Treatment

Iatrogenic peripheral nerve injury is a considerable social and economic concern and the majority of cases are preventable. Complications should be referred to and dealt with promptly by experienced surgeons, to ensure the best chances for optimal functional recovery. Their prevention should be emphasized. Their management should include ensuring early diagnosis, administering an appropriate treatment with rehabilitation, rendering psychological support, and providing control of pain 1).


The combination of morphological assessment (neurosonography) with functional assessment (nerve conduction studies) is of paramount importance in the management of traumatic peripheral nerve injuries. If on sonography, the nerve appears intact, then intraoperative nerve conduction studies the functionality of the nerve. If conduction is impaired (signifying the presence of a neuroma-in-continuity), then nerve grafting is done. If the conduction is somewhat preserved, neurolysis is performed 2).


If it is noted during an operation that a nerve has been severed, it should be repaired immediately during the same operation (primary repair) or within 2–3 weeks (early secondary repair) 3).

The same is true when the nerve is torn or damaged but not cleanly cut. The same operative approach is used as for any other nerve injury. The repair ideally is done with microsurgical tools and magnifying devices, insuring maximal visualization for the repair.

Once again, this ideal situation with the immediate repair is seldom achieved. Usually, the cause of the damage is unknown. In our experience, the operative report rarely provides useful information. When the mechanism for the damage is unknown but there is reason to think that the nerve may regenerate itself, we prefer to wait 3 months with monthly neurological examinations. If at this time, the deficit has not changed or only minimally improved, the nerve should be surgically explored in the next month. If the neurosonographic examination after exposure of the nerve identifies a neuroma, one should not delay. The operation should ideally occur within 3 weeks 4).

A severed nerve should be reconstructed, if possible. Usually, this requires nerve grafting. The sural nerve on the lateral calf is usually used as a source. Other cutaneous nerves such as the saphenous nerve and the medial antebrachial cutaneous nerve can also be used 5). If the nerve appears to be intact, then intraoperative nerve conduction studies help assess how functional it is in the area of damage. If conductivity is impaired, then the affected segment of the nerve surrounded by scar tissue—usually thickened and diagnosed as a neuroma in continuity—is excised and replaced by a transplant. In other cases, when conductivity studies are more promising, it suffices to free the nerve up from the surrounding reactive tissues (neurolysis). In recent years intraoperative neuro sonography has been employed, facilitating the evaluation of individual nerve fascicles, helping distinguish between a complete neuroma in continuity without any residual fascicles and a partial lesion still containing functioning fascicles 6).

The combination of the functional evaluation (nerve conduction studies) and the morphologic assessment (neuro sonography) is very helpful in the surgical management of traumatic injuries in peripheral nerve surgery. The exact approach is documented in the interdisciplinary guidelines of the AWMF “Versorgung peripherer Nervenverletzungen” 7).

A key factor in improving the prognosis is physical therapy, both after the deficit is identified and then post-operatively until re-innervation of the affected muscles has occurred. Electric stimulation therapy is also worthwhile in our option. In this way, the muscle structures can be better maintained until nerve regeneration has occurred.

Case series

Dubuisson et al. analyzed the management of iatrogenic peripheral nerve injury (iNI) in 42 patients.

The iNI occurred mostly during a surgical procedure (n = 39), either on a nerve or plexus (n = 13), on bone, joint, vessel, or soft tissue (n = 24) or because of malpositioning (n = 2). The most commonly injured nerves were the brachial plexusradial nervesciatic nervefemoral nerve, or peroneal nerves. 42.9% of the patients were referred to later than 6 months. A neurological deficit was present in 37 patients and neuropathic pain in 17. Two patients were lost to follow-up. Conservative treatment was applied in 23 patients because of good spontaneous recovery or compensation or because of expected bad prognosis whatever the treatment. Surgical treatment was performed in 17 patients because of known nerve section (n = 2), persistent neurological deficit (n = 12) or invalidating neuropathic pain (n = 3); nerve reconstruction with grafts (n = 8) and neurolysis (n = 8) were the most common procedures. The outcome was satisfactory in 50%. Potential reasons for poor outcomes were a very proximal injury, placement of very long grafts, delayed referral, and predominance of neuropathic pain. According to the literature, delayed referral of iNI for treatment is frequent. They provides an illustrative case of a young girl operated on at 6.5 months for femoral nerve reconstruction with grafts while the nerve section was obvious from the operative note and pathological tissue analysis. Litigation claims (n = 10) resulted in malpractice (n = 2) or therapeutic area (n = 5) (3 unavailable conclusions).

NI can result in considerable disability, pain, and litigation. Optimal management is required 8).


Rasulić et al. describe and analyze iatrogenic nerve injuries in a total of 122 consecutive patients who received surgical treatment at there institution during a period of 10 years, from January 1, 2003, to December 31, 2013. The final outcome evaluation was performed 2 years after surgical treatment.

The most common causes of iatrogenic nerve injuries among patients in the study were the operations of bone fractures (23.9%), lymph node biopsy (19.7%), and carpal tunnel release (18%). The most affected nerves were median nerve (21.3%), accessory nerve (18%), radial nerve (15.6%), and peroneal nerve (11.5%). In 74 (60.7%) patients, surgery was performed 6 months after the injury, and in 48 (39.3%) surgery was performed within 6 months after the injury. In 80 (65.6%) patients, we found lesion in discontinuity, and in 42 (34.4%) patients lesion in continuity. The distribution of surgical procedures performed was as follows: autotransplantation (51.6%), neurolysis (23.8%), nerve transfer (13.9%), direct suture (8.2%), and resection of neuroma (2.5%). In total, we achieved satisfactory recovery in 91 (74.6%), whereas the result was dissatisfactory in 31 (25.4%) patients.

Patients with iatrogenic nerve injuries should be examined as soon as possible by experts with experience in traumatic nerve injuries so that the correct diagnosis can be reached and the appropriate therapy planned. The timing of reconstructive surgery and the technique used are the crucial factors for functional recover 9).


340 patients underwent surgery for iatrogenic nerve injuries over a 23-year period in the District Hospital of Günzburg (Neurosurgical Department of the University of Ulm). In a study published by the authors in 2001, 17.4% of the traumatic nerve lesions treated were iatrogenic. 94% of iatrogenic nerve injuries occurred during surgical procedures 10).

References

1)

Kumar A, Shukla D, Bhat DI, Devi BI. Iatrogenic peripheral nerve injuries. Neurol India. 2019;67(Supplement):S135-S139. doi:10.4103/0028-3886.250700
2)

Sinha S. Management protocol in the case of iatrogenic peripheral nerve injuries. Neurol India. 2019;67(Supplement):S140-S141. doi:10.4103/0028-3886.250696
3) , 4) , 5) , 7)

Deutsche Gesellschaft für Handchirurgie (DGH), Deutsche Gesellschaft für Neurologie (DGN), Deutsche Gesellschaft für Neurochirurgie (DGNC), Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC), Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC), Deutsche Gesellschaft für Unfallchirurgie (DGU) Leitlinen: Versorgung peripherer Nervenverletzungen. http://www.awmf.org/leitlinien/detail/ll/005-010.html Stand 30.06.2013
6)

Koenig RW, Schmidt TE, Heinen CPG, et al. Intraoperative high-resolution ultrasound: a new technique in the management of peripheral nerve disorders. Clinical article Journal of Neurosurgery. 2011;114:514–521
8)

Dubuisson A, Kaschten B, Steinmetz M, et al. Iatrogenic nerve injuries: a potentially serious medical and medicolegal problem. About a series of 42 patients and review of the literature [published online ahead of print, 2020 Jul 11]. Acta Neurol Belg. 2020;10.1007/s13760-020-01424-0. doi:10.1007/s13760-020-01424-0
9)

Rasulić L, Savić A, Vitošević F, et al. Iatrogenic Peripheral Nerve Injuries-Surgical Treatment and Outcome: 10 Years’ Experience. World Neurosurg. 2017;103:841-851.e6. doi:10.1016/j.wneu.2017.04.099
10)

Antoniadis G, Kretschmer T, Pedro MT, König RW, Heinen CP, Richter HP. Iatrogenic nerve injuries: prevalence, diagnosis and treatment. Dtsch Arztebl Int. 2014;111(16):273-279. doi:10.3238/arztebl.2014.0273
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