Comparison of Two Predictive Models for Short-Term Mortality in Patients after Severe Traumatic Brain Injury

Kesmarky, Klara; Delhumeau, Cécile; Zenobi, Marie; Walder, Bernhard

doi:10.1089/neu.2016.4606

Cited by 9 publications

(6 citation statements)

References 52 publications

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“…Monitoring of pupillary function helps provide insight into secondary insults (e.g., high ICP), as sustained or new-onset pupillary abnormalities are associated with worse outcome [8]. Pupillary light reactivity is a known prognostic predictor in patients with TBI [21] and is a validated variable used in both the CRASH (Corticosteroid Randomization after Significant Head Injury) and the IMPACT (International Mission of Prognosis and Analysis of Clinical Trials) prognostic models [9]. Somewhat surprisingly, previous studies and both the CRASH and IMPACT models are based on the standard manual qualitative pupillary examination, and there are only limited data regarding the potential value of quantitative pupillometry in the monitoring of TBI complications and outcome.…”

Section: Discussionmentioning

confidence: 99%

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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Background: Elevated intracranial pressure (ICP) is frequent after traumatic brain injury (TBI) and may cause abnormal pupillary reactivity, which in turn is associated with a worse prognosis. Using automated infrared pupillometry, we examined the relationship between the Neurological Pupil index (NPi) and invasive ICP in patients with severe TBI. Methods: This was an observational cohort of consecutive subjects with severe TBI (Glasgow Coma Scale [GCS] < 9 with abnormal lesions on head CT) who underwent parenchymal ICP monitoring and repeated NPi assessment with the NPi-200® pupillometer. We examined NPi trends over time (four consecutive measurements over intervals of 6 h) prior to sustained elevated ICP > 20 mmHg. We further analyzed the relationship of cumulative abnormal NPi burden (%NPi values < 3 during total ICP monitoring time) with intracranial hypertension (ICHT)-categorized as refractory (ICHT-r; requiring surgical decompression) vs. non-refractory (ICHT-nr; responsive to medical therapy)-and with the 6-month Glasgow Outcome Score (GOS). Results: A total of 54 patients were studied (mean age 54 ± 21 years, 74% with focal injuries on CT), of whom 32 (59%) had ICHT. Among subjects with ICHT, episodes of sustained elevated ICP (n = 43, 172 matched ICP-NPi samples; baseline ICP [T − 6 h ] 14 ± 5 mmHg vs. ICPmax [T 0 h ] 30 ± 9 mmHg) were associated with a concomitant decrease of the NPi (baseline 4.2 ± 0.5 vs. 2.8 ± 1.6, p < 0.0001 ANOVA for repeated measures). Abnormal NPi values were more frequent in patients with ICHT-r (n = 17; 38 [3-96]% of monitored time vs. 1 [0-9]% in patients with ICHT-nr [n = 15] and 0.5 [0-10]% in those without ICHT [n = 22]; p = 0.007) and were associated with an unfavorable 6-month outcome (15 [1-80]% in GOS 1-3 vs. 0 [0-7]% in GOS 4-5 patients; p = 0.002). Conclusions: In a selected cohort of severe TBI patients with abnormal head CT lesions and predominantly focal cerebral injury, elevated ICP episodes correlated with a concomitant decrease of NPi. Sustained abnormal NPi was in turn associated with a more complicated ICP course and worse outcome.

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Section: Discussionmentioning

confidence: 99%

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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“…A large epidemiological cohort multi-center study compared the predictive performance of such an extended predictive model, including M-GSC, pupil reaction, age, HAIS, and the presence of multiple trauma, for short term mortality against a reference predictive model, including M-GCS, pupil reaction and age (IMPACT core model). This study, which included 808 severe adult TBI, observed that the extended predictive model had a statistically significant higher predictive performance [54].…”

Section: Prehospital and Emergency Carementioning

confidence: 99%

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

2019

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Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

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“…While it is important to estimate the influence of each risk factor individually, one has to bear in mind that about 75% of an elderly TBI cohort did not have an isolated TBI [25] and many have comorbidities [10,24]. A combination of different risk factors such as age (including frailty (60) and nursing home residency), GCS, abbreviated injury score of head (AIS head), and cranial CT scoring might predict with high discrimination and high calibration certain outcomes such as mortality, posttraumatic complications, and disability [61,62]. Further research is needed to elucidate whether specific biomarkers might improve prediction after TBI in general and, particularly, in older TBI patients [63][64][65].…”

Section: In-hospital Acute Care Managementmentioning

confidence: 99%

Integrated Health Care Management of Moderate to Severe TBI in Older Patients—A Narrative Review

Schumacher

Müri

Walder

2017

Curr Neurol Neurosci Rep

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The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.

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Comparison of Two Predictive Models for Short-Term Mortality in Patients after Severe Traumatic Brain Injury

Cited by 9 publications

References 52 publications

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Integrated Health Care Management of Moderate to Severe TBI in Older Patients—A Narrative Review

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