Time Course and Clinical Significance of Hematoma Expansion in Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study

Fletcher‐Sandersjöö, Alexander; Tatter, Charles; Tjerkaski, Jonathan; Bartek, Jiri; Maegele, Marc; Nelson, David W.; Svensson, Mikael; Thelin, Eric P.; Bellander, Bo‐Michael

doi:10.1007/s12028-022-01609-w

Cited by 9 publications

(10 citation statements)

References 33 publications

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“…Second, follow-up CT scan times varied. However, with a median time of 7.0 h to the second CT, a time point at which the majority of contusions have generally stopped expanding, 1 it is unlikely that scan timing altered our results in a significant way. Third, all patients who underwent their first CT scan within 12 h of injury were included, which is a larger time window than the 3 h used in the CRASH-3 trial 25 and could have reduced the amount of CE.…”

Section: Discussionmentioning

confidence: 79%

“…Contusion volumes were calculated using semi-automated threshold-guided planimetry, excluding the surrounding edema. In Center 1, this was performed using the IDS7 software, as previously described, 1 while the BrainLab ® elements software 16 was used in Center 2 (BrainLab Germany Headquarters, Munich, Germany). Each center had one assessor who was blinded to patient outcomes, but was made aware of whether the CT scan they were analyzing was the initial or follow-up one.…”

Section: Methodsmentioning

confidence: 99%

“…Contusion expansion (CE) is a potentially modifiable outcome predictor in traumatic brain injury (TBI), 1 making it an important surrogate end-point for hemostatic trials that are underpowered for patient-centric outcomes. Despite this, the research community is divided on the definition of clinically relevant CE, 2 which impacts interpretation and comparison of study results.…”

Section: Introductionmentioning

confidence: 99%

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Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study

Fletcher-Sandersjöö,

Svedung Wettervik,

Tatter

et al. 2024

Journal of Neurotrauma

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Contusion expansion (CE) is a potentially treatable outcome predictor in traumatic brain injury (TBI), and a suitable end-point for hemostatic therapy trials. However, there is no consensus on the definition of clinically relevant CE, both in terms of measurement criteria (absolute vs. relative volume increase) and cutoff values. In light of this, the aim of this study was to assess the predictive abilities of different CE definitions on outcome. We performed a multi-center observational cohort study of adults with moderate-to-severe TBI treated in an intensive care unit. The exposure of interest was CE, defined as the absolute and relative volume change between the first and second computed tomography scan. The primary outcome was the Glasgow Outcome Scale (GOS) at 6–12 months post-injury, dichotomized into unfavorable (GOS ≤3) or favorable (GOS ≥4). The secondary outcome was all-cause mortality. In total, 798 patients were included, with a median duration of 7.0 h between the first and second CT scan. The median absolute and relative CE was 1.5 mL (interquartile range [IQR] 0.1–8.3 mL) and 100% (IQR 10–530%), respectively. Both CE forms were independently associated with unfavorable GOS. Absolute CE outperformed relative CE in predicting both unfavorable GOS (area under the curve [AUC]: 0.65 vs. 0.60, p = 0.002) and all-cause mortality (AUC: 0.66 vs. 0.60, p = 0.003). For dichotomized CE, absolute cutoffs of 1–10 mL yielded the best results. We conclude that absolute CE demonstrates stronger outcome correlation than relative CE. In studies focusing on lesion progression in TBI, it may be advantageous to use absolute CE as the primary outcome metric. For dichotomized outcomes, cutoffs between 1 and 10 mL are suggested, depending on the desired sensitivity-specificity balance.

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Section: Discussionmentioning

confidence: 79%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study

Fletcher-Sandersjöö,

Svedung Wettervik,

Tatter

et al. 2024

Journal of Neurotrauma

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“…By POD5, most ICH will have stabilized in size. 7 12 27) Although delayed edema, hematoma expansion, or other complications can arise; most patients should have stable or improving neurologic status by POD 5. Importantly, POD 5 is early enough to allow for planning early tracheostomy by POD 10.…”

Section: Discussionmentioning

confidence: 99%

Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury

Guillotte,

Fry,

Gattozzi

et al. 2023

Korean J Neurotrauma

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Objective Many patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy. Methods The neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups. Results All patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101. Conclusion GCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.

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“…Cerebral contusions (Ccx) are common in sTBI and usually coexist with traumatic subarachnoid hemorrhage (tSAH) and ASDH. Many progress – “blossom” - within the first 24 h [62 ▪ ]. In localized Ccx, immediate craniotomy and hematoma removal is indicated in sTBI patients showing progressive neurological deterioration and significant mass effect on CT, with significant midline deviation and compressed basal cisterns.…”

Section: Surgical Perspectivesmentioning

confidence: 99%

The management of severe traumatic brain injury in the initial postinjury hours – current evidence and controversies

Hossain,

Rostami,

Marklund

2023

Current Opinion in Critical Care

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Purpose of review To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. Recent findings Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. Summary Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.

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Time Course and Clinical Significance of Hematoma Expansion in Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study

Cited by 9 publications

References 33 publications

Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study

Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study

Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury

The management of severe traumatic brain injury in the initial postinjury hours – current evidence and controversies

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