Traumatic Brain Injury

Osmolar therapy in pediatric traumatic brain injury

Authors: Bennett TD, Statler KD, Korgenski EK, Bratton SL.

OBJECTIVES: To describe patterns of use for mannitol and hypertonic saline in children with traumatic brain injury, to evaluate any potential associations between hypertonic saline and mannitol use and patient demographic, injury, and treatment hospital characteristics, and to determine whether the 2003 guidelines for severe pediatric traumatic brain injury impacted clinical practice regarding osmolar therapy.

DESIGN: Retrospective cohort study.

SETTING: Pediatric Health Information System database, January, 2001 to December, 2008.

PATIENTS: Children (age <18 yrs) with traumatic brain injury and head/neck Abbreviated Injury Scale score ≥3 who received mechanical ventilation and intensive care.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital billing for parenteral hypertonic saline and mannitol use, by day of service. Overall, 33% (2069 of 6238) of the patients received hypertonic saline, and 40% (2500 of 6238) received mannitol. Of the 1,854 patients who received hypertonic saline or mannitol for ≥2 days in the first week of therapy, 29% did not have intracranial pressure monitoring. After adjustment for hospital-level variation, primary insurance payer, and overall injury severity, use of both drugs was independently associated with older patient age, intracranial hemorrhage (other than epidural), skull fracture, and higher head/neck injury severity. Hypertonic saline use increased and mannitol use decreased with publication of the 2003 guidelines, and these trends continued through 2008.

CONCLUSIONS: Hypertonic saline and mannitol are used less in infants than in older children. The patient-level and hospital-level variation in osmolar therapy use and the substantial amount of sustained osmolar therapy without intracranial pressure monitoring suggest opportunities to improve the quality of pediatric traumatic brain injury care. With limited high-quality evidence available, published expert guidelines appear to significantly impact clinical practice in this area.

Acute clinical grading in pediatric severe traumatic brain injury and its association with subsequent intracranial pressure, cerebral perfusion pressure, and brain oxygenation

Authors: Figaji AA, Zwane E, Fieggen AG, Peter JC, Leroux PD.

OBJECT: The goal of this paper was to examine the relationship between methods of acute clinical assessment and measures of secondary cerebral insults in severe traumatic brain injury in children.

METHODS: Patients who underwent intracranial pressure (ICP), cerebral perfusion pressure (CPP), and brain oxygenation (PbtO(2)) monitoring and who had an initial Glasgow Coma Scale score, Pediatric Trauma Score, Pediatric Index of Mortality 2 score, and CT classification were evaluated. The relationship between these acute clinical scores and secondary cerebral insult measures, including ICP, CPP, PbtO(2), and systemic hypoxia were evaluated using univariate and multivariate analysis.

RESULTS: The authors found significant associations between individual acute clinical scores and select physiological markers of secondary injury. However, there was a large amount of variability in these results, and none of the scores evaluated predicted each and every insult. Furthermore, a number of physiological measures were not predicted by any of the scores.

CONCLUSIONS: Although they may guide initial treatment, grading systems used to classify initial injury severity appear to have a limited value in predicting who is at risk for secondary cerebral insults.

The impact of acquired brain damage in terms of epidemiology, economics and loss in quality of life

Authors: Javier Mar, Arantzazu Arrospide, José María Begiristain, Isabel Larrañaga, Elena Elosegui and Juan Oliva-Moreno.

Background: Patients with acquired brain damage (ABD) have suffered a brain lesion that interrupts vital development in the physical, psychological and social spheres. Stroke and traumatic brain injury (TBI) are the two main causes. The objectives of this study were to estimate the incidence and prevalence of ABD in the population of the Basque Country and Navarre in 2008, to calculate the associated cost of the care required and finally to assess the loss in health-related quality of life.

Methods: On the one hand, a cross-sectional survey was carried out, in order to estimate the incidence of ABD and its consequences in terms of costs and loss in quality of life from the evolution of a sample of patients diagnosed with stroke and TBI. On the other hand, a discrete event simulation model was built that enabled the prevalence of ABD to be estimated. Finally, a calculation was made of the formal and informal costs of ABD in the population of the Basque Country and Navarre (2,750,000 people).

Results: The cross-sectional study showed that the incidences of ABD caused by stroke and TBI were 61.8 and 12.5 cases per 100,000 per year respectively, while the overall prevalence was 657 cases per 100,000 people. The SF-36 physical and mental component scores were 28.9 and 44.5 respectively. The total economic burden was calculated to be 382.14 million euro per year, distributed between 215.27 and 166.87 of formal and informal burden respectively. The average cost per individual was 21,040 € per year.

Conclusions: The main conclusion of this study is that ABD has a high impact in both epidemiological and economic terms as well as loss in quality of life. The overall prevalence obtained is equivalent to 0.7% of the total population. The substantial economic burden is distributed nearly evenly between formal and informal costs. Specifically, it was found that the physical dimensions of quality of life are the most severely affected. The prevalence-based approach showed adequate to estimate the population impact of ABD and the resources needed to compensate the disability.

Prevalence, management and outcomes of traumatic brain injury patients admitted to an Irish intensive care unit

Authors: S. Frohlich, P. Johnson and J. Moriarty.

Background: Traumatic brain injury is one of the leading causes of death and disability among young people. However outcomes from traumatic brain injury can be improved by use of parameters such as intracranial pressure monitoring (ICP) to guide treatment, early surgical intervention and management of these patients in a neurosurgical centre.
Aims: To examine the incidence of traumatic brain injury, compliance with best practice guidelines and outcomes in patients admitted to an intensive care unit in a major teaching hospital in Ireland.
Methods: Retrospective chart review.
Results: Forty-six patients were admitted over a 3-year period, half of whom had GCS <8. Medical management was appropriate but only two patients were transferred to a neurosurgical centre and none received ICP monitoring. Overall mortality of 37% was higher than international norms.
Conclusions: Irish patients with severe head injury do not currently receive care in accordance with international evidence-based guidelines.

Head impact exposure in collegiate football players

Authors: Crisco JJ, Wilcox BJ, Beckwith JG, Chu JJ, Duhaime AC, Rowson S, Duma SM, Maerlender AC, McAllister TW, Greenwald RM.

In American football, impacts to the helmet and the resulting head accelerations are the primary cause of concussion injury and potentially chronic brain injury. The purpose of this study was to quantify exposures to impacts to the head (frequency, location and magnitude) for individual collegiate football players and to investigate differences in head impact exposure by player position. A total of 314 players were enrolled at three institutions and 286,636 head impacts were recorded over three seasons. The 95th percentile peak linear and rotational acceleration and HITsp (a composite severity measure) were 62.7g, 4378rad/s(2) and 32.6, respectively. These exposure measures as well as the frequency of impacts varied significantly by player position and by helmet impact location. Running backs (RB) and quarter backs (QB) received the greatest magnitude head impacts, while defensive line (DL), offensive line (OL) and line backers (LB) received the most frequent head impacts (more than twice as many than any other position). Impacts to the top of the helmet had the lowest peak rotational acceleration (2387rad/s(2)), but the greatest peak linear acceleration (72.4g), and were the least frequent of all locations (13.7%) among all positions. OL and QB had the highest (49.2%) and the lowest (23.7%) frequency, respectively, of front impacts. QB received the greatest magnitude (70.8g and 5428rad/s(2)) and the most frequent (44% and 38.9%) impacts to the back of the helmet. This study quantified head impact exposure in collegiate football, providing data that is critical to advancing the understanding of the biomechanics of concussive injuries and sub-concussive head impacts.

Mild traumatic brain injury: Impairment and disability assessment caveats

Authors: Zasler ND, Martelli MF.

Mild traumatic brain injury (MTBI) accounts for approximately 80% of all brain injuries, and persistent sequelae can impede physical, emotional, social, marital, vocational, and avocational functioning. Evaluation of impairment and disability following MTBI typically can involve such contexts as social security disability application, personal injury litigation, worker's compensation claims, disability insurance policy application, other health care insurance policy coverage issues, and the determination of vocational and occupational competencies and limitations. MTBI is still poorly understood and impairment and disability assessment in MTBI can present a significant diagnostic challenge. There are currently no ideal systems for rating impairment and disability for MTBI residua. As a result, medicolegal examiners and clinicians must necessarily familiarise themselves with the variety of disability and impairment evaluation protocols and understand their limitations. The current paper reviews recommended procedures and potential obstacles and confounding issues.

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