Delayed Neurosurgical Intervention in Traumatic Brain Injury Patients Referred From Primary Hospitals Is Not Associated With an Unfavorable Outcome

Abstract

Background: Secondary transports of patients suffering from traumatic brain injury (TBI) may result in a delayed management and neurosurgical intervention, which is potentially detrimental. The aim of this study was to study the effect of triaging and delayed transfers on outcome, specifically studying time to diagnostics and neurosurgical management.Methods: This was a retrospective observational cohort study of TBI patients in need of neurosurgical care, 15 years and older, in the Stockholm Region, Sweden, from 2008 throughout 2014. Data were collected from pre-hospital and in-hospital charts. Known TBI outcome predictors, including the protein biomarker of brain injury S100B, were used to assess injury severity. Characteristics and outcomes of direct trauma center (TC) and those of secondary transfers were evaluated and compared. Functional outcome, using the Glasgow Outcome Scale, was assessed in survivors at 6–12 months after trauma. Regression models, including propensity score balanced models, were used for endpoint assessment.Results: A total of n = 457 TBI patients were included; n = 320 (70%) patients were direct TC transfers, whereas n = 137 (30%) were secondary referrals. In all, n = 295 required neurosurgery for the first 24 h after trauma (about 75% of each subgroup). Direct TC transfers were more severely injured (median Glasgow Coma Scale 8 vs. 13) and more often suffered a high energy trauma (31 vs. 2.9%) than secondary referrals. Admission S100B was higher in the TC transfer group, though S100B levels 12–36 h after trauma were similar between cohorts. Direct or indirect TC transfer could be predicted using propensity scoring. The secondary referrals had a shorter distance to the primary hospital, but had later radiology and surgery than the TC group (all p < 0.001). In adjusted multivariable analyses with and without propensity matching, direct or secondary transfers were not found to be significantly related to outcome. Time from trauma to surgery did not affect outcome.Conclusions: TBI patients secondary transported to a TC had surgical intervention performed hours later, though this did not affect outcome, presumably demonstrating that accurate pre-hospital triaging was performed. This indicates that for selected patients, a wait-and-see approach with delayed neurosurgical intervention is not necessarily detrimental, but warrants further research.

Correlation between Head Computed Tomography Scan, Pre-operative Blood Lactate, and Pre-operative Glucose Level in Acute Traumatic Subdural Hematoma

“…The mean value of blood lactate levels in this study exceeded the normal limit of blood lactate levels in adult patients, namely 0.9-1.7 mmol/L. The elevation in blood lactate levels is in accordance with the results of studies reported by Kawamata et al 13 and Cureton et al 6 that blood lactate levels could increase shortly after TBI and increase about 23.7% from baseline, then would be normal in 24-36 hours if the annoyance and damage was olved.…”

“…The average surgery time interval of this study is >8 hours, more than the golden hour,but still not past the silver day (<24 hours). 13 On the CT scan of the head, there were 50% with a hematoma thickness <15 mm and 50% with a hematoma thickness of 15-20 mm; whereas for other variables, about 62.5% with emphasis on basal cisterns and 37.5% without basal cisterns emphasis. The results of this study can be interpreted that the hematoma thickness of acute traumatic SDH can cause a focal effect on brain tissue in the form of brain superficial veins congestion and impaired brain perfusion so that it can progress to cerebral edema which results in compression of the basal cistern which indicates an elevated ICP.…”

Frontiers In Traumatic Brain Injury

“…More recently, the use of large animals in TBI research has increased. The effect of brain injury on lissencephalic animals as compared to larger ones with gyrencephalic structures differ, at least in part by differences in brain structure and mechanics related to the presence of large gyri [113,114]. The porcine model has been proposed as an ideal pre-clinical animal model based on feasibility and the anatomic and physiologic similarities to humans in comparison to rodents [115].…”

“…Several models of injury have been developed to resemble the pathophysiology of human TBI [113]. The most used ones are the lateral fluid percussion (LFP) model, the controlled cortical impact (CCI) model, the weight drop-impact (WD) model, and the blast model.…”

“…Elevated levels of S100B in the serum were observed in TBI patients as well as in patients suffering from neurodegenerative diseases [110]. The serum levels of the protein have been associated with clinical severity, radiological severity, and an unfavorable outcome [111][112][113][114] .…”