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1. Development of a Randomized Trial Comparing ICP-Monitor-Based Management of Severe Pediatric Traumatic Brain Injury to Management Based on Imaging and Clinical Examination Without ICP Monitoring-Study Protocol.

Author

Chesnut R, Temkin N, Pridgeon J, Sulzbacher S, Lujan S, Videtta W, Moya-Barquín L, Chaddock K, Bonow R, Petroni G, Guadagnoli N, Hendrickson P, Ramírez Cortez G, Carreazo NY, Vargas Aymituma A, Anchante D, Caqui P, Ramírez A, Munaico Abanto M, Ortiz Chicchon M, Cenzano Ramos J, Mazate-Mazariegos A, Castro Darce MDC, Sierra Morales R, Brol Lopez P, Menendez W, Posadas Gutierrez S, Kevin V, Mazariegos A, de Leon E, Rodas Barrios RE, Rodríguez S, Flores S, Alvarado O, Guzman Flores LJ, Moisa Martinez M, and Gonzalez P

Subjects
Adolescent, Humans, Child, Intracranial Pressure, Quality of Life, Glasgow Coma Scale, Monitoring, Physiologic methods, Randomized Controlled Trials as Topic, Multicenter Studies as Topic, Brain Injuries, Traumatic diagnostic imaging, Brain Injuries, Traumatic therapy, Brain Injuries, Intracranial Hypertension diagnostic imaging, Intracranial Hypertension etiology
Abstract

Background and Objectives: Traumatic brain injury (TBI) is a major global public health problem. It is a leading cause of death and disability in children and adolescents worldwide. Although increased intracranial pressure (ICP) is common and associated with death and poor outcome after pediatric TBI, the efficacy of current ICP-based management remains controversial. We intend to provide Class I evidence testing the efficacy of a protocol based on current ICP monitor-based management vs care based on imaging and clinical examination without ICP monitoring in pediatric severe TBI., Methods: A phase III, multicenter, parallel-group, randomized superiority trial performed in intensive care units in Central and South America to determine the impact on 6-month outcome of children aged 1-12 years with severe TBI (age-appropriate Glasgow Coma Scale score ≤8) randomized to ICP-based or non-ICP-based management., Expected Outcomes: Primary outcome is 6-month Pediatric Quality of Life. Secondary outcomes are 3-month Pediatric Quality of Life, mortality, 3-month and 6-month Pediatric extended Glasgow Outcome Score, intensive care unit length of stay, and number of interventions focused on treating measured or suspected intracranial hypertension., Discussion: This is not a study of the value of knowing the ICP in sTBI. This research question is protocol-based. We are investigating the added value of protocolized ICP management to treatment based on imaging and clinical examination in the global population of severe pediatric TBI. Demonstrating efficacy should standardize ICP monitoring in severe pediatric TBI. Alternate results should prompt reassessment of how and in which patients ICP data should be applied in neurotrauma care., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Published
2024
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2. Development of a Randomized Trial Comparing ICP-Monitor-Based Management of Severe Pediatric Traumatic Brain Injury to Management Based on Imaging and Clinical Examination Without ICP Monitoring-Research Algorithms.

Author

Chesnut R, Temkin N, Pridgeon J, Sulzbacher S, Lujan S, Videtta W, Moya-Barquín L, Chaddock K, Bonow RH, Petroni G, Guadagnoli N, Hendrickson P, Ramírez Cortez G, Carreazo NY, Vargas Aymituma A, Anchante D, Caqui P, Ramírez A, Munaico Abanto M, Ortiz Chicchon M, Cenzano Ramos J, Castro Darce MDC, Sierra Morales R, Brol Lopez P, Menendez W, Posadas Gutierrez S, Kevin V, Mazariegos A, de Leon E, Rodas Barrios RE, Rodríguez S, Flores S, Alvarado O, Guzman Flores LJ, Moisa Martinez M, and Gonzalez P

Subjects
Child, Humans, Algorithms, Intracranial Pressure, Monitoring, Physiologic methods, Prospective Studies, Randomized Controlled Trials as Topic, Multicenter Studies as Topic, Brain Injuries diagnostic imaging, Brain Injuries therapy, Brain Injuries, Traumatic diagnostic imaging, Brain Injuries, Traumatic therapy, Brain Injuries, Traumatic complications, Intracranial Hypertension diagnostic imaging, Intracranial Hypertension etiology
Abstract

Background and Objectives: The efficacy of our current approach to incorporating intracranial pressure (ICP) data into pediatric severe traumatic brain injury (sTBI) management is incompletely understood, lacking data from multicenter, prospective, randomized studies. The National Institutes of Health-supported Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial will compare outcomes from pediatric sTBI of a management protocol based on ICP monitoring vs 1 based on imaging and clinical examination without monitoring. Because no applicable comprehensive management algorithms for either cohort are available, it was necessary to develop them., Methods: A consensus conference involving the 21 intensivists and neurosurgeons from the 8 trial sites used Delphi-based methodology to formulate management algorithms for both study cohorts. We included recommendations from the latest Brain Trauma Foundation pediatric sTBI guidelines and the consensus-based adult algorithms (Seattle International Brain Injury Consensus Conference/Consensus Revised Imaging and Clinical Examination) wherever relevant. We used a consensus threshold of 80%., Results: We developed comprehensive management algorithms for monitored and nonmonitored cohort children with sTBI. We defined suspected intracranial hypertension for the nonmonitored group, set minimum number and timing of computed tomography scans, specified minimal age-adjusted mean arterial pressure and cerebral perfusion pressure targets, defined clinical neuroworsening, described minimal requisites for intensive care unit management, produced tiered management algorithms for both groups, and listed treatments not routinely used., Conclusion: We will study these protocols in the Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial in low- and middle-income countries. Second, we present them here for consideration as prototype pediatric sTBI management algorithms in the absence of published alternatives, acknowledging their limited evidentiary status. Therefore, herein, we describe our study design only, not recommended treatment protocols., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Published
2024
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3. Integrating, Harmonizing, and Curating Studies With High-Frequency and Hourly Physiological Data: Proof of Concept from Seven Traumatic Brain Injury Data Sets.

Author

Yaseen A, Robertson C, Cruz Navarro J, Chen J, Heckler B, DeSantis SM, Temkin N, Barber J, Foreman B, Diaz-Arrastia R, Chesnut R, Manley GT, Wright DW, Vassar M, Ferguson AR, Markowitz AJ, and Yamal JM

Subjects
Humans, Prospective Studies, Cytidine Diphosphate Choline therapeutic use, Information Dissemination, Brain Injuries, Traumatic drug therapy, Brain Injuries drug therapy
Abstract

Research in severe traumatic brain injury (TBI) has historically been limited by studies with relatively small sample sizes that result in low power to detect small, yet clinically meaningful outcomes. Data sharing and integration from existing sources hold promise to yield larger more robust sample sizes that improve the potential signal and generalizability of important research questions. However, curation and harmonization of data of different types and of disparate provenance is challenging. We report our approach and experience integrating multiple TBI data sets containing collected physiological data, including both expected and unexpected challenges encountered in the integration process. Our harmonized data set included data on 1536 patients from the Citicoline Brain Injury Treatment Trial (COBRIT), Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial (EPO Severe TBI), BEST-TRIP, Progesterone for the Treatment of Traumatic Brain Injury III Clinical Trial (ProTECT III), Transforming Research and Clinical Knowledge in Traumatic brain Injury (TRACK-TBI), Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II (BOOST-2), and Ben Taub General Hospital (BTGH) Research Database studies. We conclude with process recommendations for data acquisition for future prospective studies to aid integration of these data with existing studies. These recommendations include using common data elements whenever possible, a standardized recording system for labeling and timing of high-frequency physiological data, and secondary use of studies in systems such as Federal Interagency Traumatic Brain Injury Research Informatics System (FITBIR), to engage investigators who collected the original data.

Published
2023
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4. Comparative Effectiveness of Intracranial Pressure Monitoring on 6-Month Outcomes of Critically Ill Patients With Traumatic Brain Injury.

Author

Nattino G, Gamberini L, Brissy O, Carrara G, Chesnut R, Chiarini V, Chieregato A, Csomos A, Fleming JM, Gradisek P, Kaps R, Kyprianou T, Lazar I, Lemeshow S, Mikaszewska-Sokolewicz M, Paci G, Rossi C, Temkin N, Xirouchaki N, Giugni A, and Bertolini G

Subjects
Male, Female, Humans, Middle Aged, Aged, Cohort Studies, Prospective Studies, Critical Illness therapy, Intracranial Pressure, Brain Injuries, Traumatic complications
Abstract

Importance: While the relationship between persistent elevations in intracranial pressure (ICP) and poorer outcomes is well established for patients with traumatic brain injury (TBI), there is no consensus on how ICP measurements should drive treatment choices, and the effectiveness of ICP monitoring remains unknown., Objective: To evaluate the effectiveness of ICP monitoring on short- and mid-term outcomes of patients with TBI., Design, Setting, and Participants: CREACTIVE was a prospective cohort study that started in March 2014 and lasted 5 years. More than 8000 patients with TBI were enrolled at 83 intensive care units (ICUs) from 7 countries who joined the CREACTIVE Consortium. Patients with TBI who met the Brain Trauma Foundation guidelines for ICP monitoring were selected for the current analyses, which were performed from January to November 2022., Exposure: Patients who underwent ICP monitoring within 2 days of injury (exposure group) were propensity score-matched to patients who were not monitored or who underwent monitoring 2 days after the injury (control group)., Main Outcome and Measure: Functional disability at 6 months as indicated by Glasgow Outcome Scale-Extended (GOS-E) score., Results: A total of 1448 patients from 43 ICUs in Italy and Hungary were eligible for analysis. Of the patients satisfying the ICP-monitoring guidelines, 503 (34.7%) underwent ICP monitoring (median [IQR] age: 45 years [29-61 years]; 392 males [77.9%], 111 females [22.1%]) and 945 were not monitored (median [IQR] age: 66 years [48-78 years]; 656 males [69.4%], 289 females [30.6%]). After matching to balance the variables, worse 6-month recovery was observed for monitored patients compared with nonmonitored patients (death/vegetative state: 39.2% vs 40.6%; severe disability: 33.2% vs 25.4%; moderate disability: 15.7% vs 14.9%; good recovery: 11.9% vs 19.1%, respectively; P = .005). Monitored patients received medical therapies significantly more frequently., Conclusions and Relevance: In this cohort study, ICP monitoring was associated with poorer recovery and more frequent medical interventions with their relevant adverse effects. Optimizing the value of ICP monitoring for TBI requires further investigation on monitoring indications, clinical interventions, and management protocols.

Published
2023
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5. Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group.

Author

Sarigul B, Bell RS, Chesnut R, Aguilera S, Buki A, Citerio G, Cooper DJ, Diaz-Arrastia R, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer SA, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DD, Stocchetti N, Taccone FS, Timmons SD, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, and Hawryluk GWJ

Subjects
Humans, Prognosis, Consensus, Patient Care Planning, Brain Injuries, Traumatic diagnosis, Brain Injuries, Traumatic therapy, Disabled Persons
Abstract

Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the S eattle I nternational severe traumatic B rain I njury C onsensus C onference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.

Published
2023
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6. Intracranial pressure: current perspectives on physiology and monitoring.

Author

Hawryluk GWJ, Citerio G, Hutchinson P, Kolias A, Meyfroidt G, Robba C, Stocchetti N, and Chesnut R

Subjects
Cerebrovascular Circulation physiology, Humans, Intracranial Pressure physiology, Monitoring, Physiologic, Brain Injuries, Traumatic, Intracranial Hypertension diagnosis, Intracranial Hypertension etiology
Abstract

Intracranial pressure (ICP) monitoring is now viewed as integral to the clinical care of many life-threatening brain insults, such as severe traumatic brain injury, subarachnoid hemorrhage, and malignant stroke. It serves to warn of expanding intracranial mass lesions, to prevent or treat herniation events as well as pressure elevation which impedes nutrient delivery to the brain. It facilitates the calculation of cerebral perfusion pressure (CPP) and the estimation of cerebrovascular autoregulatory status. Despite advancements in our knowledge emanating from a half century of experience with this technology, important controversies remain related even to fundamental aspects of ICP measurements, including indications for monitoring, ICP treatment thresholds, and management of intracranial hypertension. Here, we review the history of ICP monitoring, the underlying pathophysiology as well as current perspectives on why, when and how ICP monitoring is best used. ICP is typically assessed invasively but a number of emerging, non-invasive technologies with inherently lower risk are showing promise. In selected cases, additional neuromonitoring can be used to assist in the interpretation of ICP monitoring information and adapt directed treatment accordingly. Additional efforts to expand the evidence base relevant to ICP monitoring, related technologies and management remain a high priority in neurosurgery and neurocritical care., (© 2022. Springer-Verlag GmbH Germany, part of Springer Nature.)

Published
2022
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7. Management of moderate to severe traumatic brain injury: an update for the intensivist.

Author

Meyfroidt G, Bouzat P, Casaer MP, Chesnut R, Hamada SR, Helbok R, Hutchinson P, Maas AIR, Manley G, Menon DK, Newcombe VFJ, Oddo M, Robba C, Shutter L, Smith M, Steyerberg EW, Stocchetti N, Taccone FS, Wilson L, Zanier ER, and Citerio G

Subjects
Adult, Humans, Intracranial Pressure physiology, Brain Injuries, Traumatic complications
Abstract

Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit., (© 2022. Springer-Verlag GmbH Germany, part of Springer Nature.)

Published
2022
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8. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study.

Author

McCrea MA, Giacino JT, Barber J, Temkin NR, Nelson LD, Levin HS, Dikmen S, Stein M, Bodien YG, Boase K, Taylor SR, Vassar M, Mukherjee P, Robertson C, Diaz-Arrastia R, Okonkwo DO, Markowitz AJ, Manley GT, Adeoye O, Badjatia N, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Goldman D, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Keene CD, Korley FK, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Ngwenya LB, Noel F, Nolan A, Palacios E, Perl D, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Toga A, Valadka A, Wang K, Yue JK, Yuh E, and Zafonte R

Subjects
Activities of Daily Living, Adult, Cohort Studies, Disability Evaluation, Female, Glasgow Coma Scale, Glasgow Outcome Scale, Humans, Longitudinal Studies, Male, Middle Aged, Neuropsychological Tests, Persistent Vegetative State, Prognosis, Prospective Studies, Recovery of Function, Treatment Outcome, Withholding Treatment, Brain Injuries, Traumatic therapy
Abstract

Importance: Moderate to severe traumatic brain injury (msTBI) is a major cause of death and disability in the US and worldwide. Few studies have enabled prospective, longitudinal outcome data collection from the acute to chronic phases of recovery after msTBI., Objective: To prospectively assess outcomes in major areas of life function at 2 weeks and 3, 6, and 12 months after msTBI., Design, Setting, and Participants: This cohort study, as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, was conducted at 18 level 1 trauma centers in the US from February 2014 to August 2018 and prospectively assessed longitudinal outcomes, with follow-up to 12 months postinjury. Participants were patients with msTBI (Glasgow Coma Scale scores 3-12) extracted from a larger group of patients with mild, moderate, or severe TBI who were enrolled in TRACK-TBI. Data analysis took place from October 2019 to April 2021., Exposures: Moderate or severe TBI., Main Outcomes and Measures: The Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale (DRS) were used to assess global functional status 2 weeks and 3, 6, and 12 months postinjury. Scores on the GOSE were dichotomized to determine favorable (scores 4-8) vs unfavorable (scores 1-3) outcomes. Neurocognitive testing and patient reported outcomes at 12 months postinjury were analyzed., Results: A total of 484 eligible patients were included from the 2679 individuals in the TRACK-TBI study. Participants with severe TBI (n = 362; 283 men [78.2%]; median [interquartile range] age, 35.5 [25-53] years) and moderate TBI (n = 122; 98 men [80.3%]; median [interquartile range] age, 38 [25-53] years) were comparable on demographic and premorbid variables. At 2 weeks postinjury, 36 of 290 participants with severe TBI (12.4%) and 38 of 93 participants with moderate TBI (41%) had favorable outcomes (GOSE scores 4-8); 301 of 322 in the severe TBI group (93.5%) and 81 of 103 in the moderate TBI group (78.6%) had moderate disability or worse on the DRS (total score ≥4). By 12 months postinjury, 142 of 271 with severe TBI (52.4%) and 54 of 72 with moderate TBI (75%) achieved favorable outcomes. Nearly 1 in 5 participants with severe TBI (52 of 270 [19.3%]) and 1 in 3 with moderate TBI (23 of 71 [32%]) reported no disability (DRS score 0) at 12 months. Among participants in a vegetative state at 2 weeks, 62 of 79 (78%) regained consciousness and 14 of 56 with available data (25%) regained orientation by 12 months., Conclusions and Relevance: In this study, patients with msTBI frequently demonstrated major functional gains, including recovery of independence, between 2 weeks and 12 months postinjury. Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with msTBI. When discussing prognosis during the first 2 weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI.

Published
2021
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9. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians.

Author

Depreitere B, Citerio G, Smith M, Adelson PD, Aries MJ, Bleck TP, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein SP, Neumann JO, Robba C, Steiner L, Stocchetti N, Taccone FS, Valadka A, Wolf S, Zeiler FA, and Meyfroidt G

Subjects
Adult, Cerebrovascular Circulation, Consensus, Delphi Technique, Homeostasis, Humans, Prospective Studies, Reproducibility of Results, Brain Injuries, Traumatic therapy
Abstract

Background: Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty., Aim: To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities., Methods: A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants., Results: Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence., Conclusion: The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.

Published
2021
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10. Association of Sex and Age With Mild Traumatic Brain Injury-Related Symptoms: A TRACK-TBI Study.

Author

Levin HS, Temkin NR, Barber J, Nelson LD, Robertson C, Brennan J, Stein MB, Yue JK, Giacino JT, McCrea MA, Diaz-Arrastia R, Mukherjee P, Okonkwo DO, Boase K, Markowitz AJ, Bodien Y, Taylor S, Vassar MJ, Manley GT, Adeoye O, Badjatia N, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Keene CD, Korley FK, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Nolan A, Ngwenya LB, Noel F, Palacios E, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sun X, Toga A, Valadka A, Wang K, Yuh E, and Zafonte R

Subjects
Adult, Aged, Brain Concussion complications, Brain Injuries, Traumatic physiopathology, Brain Injuries, Traumatic psychology, Cognitive Dysfunction psychology, Female, Glasgow Coma Scale, Humans, Male, Middle Aged, Post-Concussion Syndrome psychology, Prospective Studies, Risk Assessment, Sex Distribution, Brain Injuries, Traumatic complications, Cognitive Dysfunction etiology, Post-Concussion Syndrome etiology, Severity of Illness Index
Abstract

Importance: Knowledge of differences in mild traumatic brain injury (mTBI) recovery by sex and age may inform individualized treatment of these patients., Objective: To identify sex-related differences in symptom recovery from mTBI; secondarily, to explore age differences within women, who demonstrate poorer outcomes after TBI., Design, Setting, and Participants: The prospective cohort study Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) recruited 2000 patients with mTBI from February 26, 2014, to July 3, 2018, and 299 patients with orthopedic trauma (who served as controls) from January 26, 2016, to July 27, 2018. Patients were recruited from 18 level I trauma centers and followed up for 12 months. Data were analyzed from August 19, 2020, to March 3, 2021., Exposures: Patients with mTBI (defined by a Glasgow Coma Scale score of 13-15) triaged to head computed tomography in 24 hours or less; patients with orthopedic trauma served as controls., Main Outcomes and Measures: Measured outcomes included (1) the Rivermead Post Concussion Symptoms Questionnaire (RPQ), a 16-item self-report scale that assesses postconcussion symptom severity over the past 7 days relative to preinjury; (2) the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5), a 20-item test that measures the severity of posttraumatic stress disorder symptoms; (3) the Patient Health Questionnaire-9 (PHQ-9), a 9-item scale that measures depression based on symptom frequency over the past 2 weeks; and (4) the Brief Symptom Inventory-18 (BSI-18), an 18-item scale of psychological distress (split into Depression and Anxiety subscales)., Results: A total of 2000 patients with mTBI (1331 men [67%; mean (SD) age, 41.0 (17.3) years; 1026 White (78%)] and 669 women [33%; mean (SD) age, 43.0 (18.5) years; 505 (76%) White]). After adjustment of multiple comparisons, significant TBI × sex interactions were observed for cognitive symptoms (B = 0.76; 5% false discovery rate-corrected P = .02) and somatic RPQ symptoms (B = 0.80; 5% false discovery rate-corrected P = .02), with worse symptoms in women with mTBI than men, but no sex difference in symptoms in control patients with orthopedic trauma. Within the female patients evaluated, there was a significant TBI × age interaction for somatic RPQ symptoms, which were worse in female patients with mTBI aged 35 to 49 years compared with those aged 17 to 34 years (B = 1.65; P = .02) or older than 50 years (B = 1.66; P = .02)., Conclusions and Relevance: This study found that women were more vulnerable than men to persistent mTBI-related cognitive and somatic symptoms, whereas no sex difference in symptom burden was seen after orthopedic injury. Postconcussion symptoms were also worse in women aged 35 to 49 years than in younger and older women, but further investigation is needed to corroborate these findings and to identify the mechanisms involved. Results suggest that individualized clinical management of mTBI should consider sex and age, as some women are especially predisposed to chronic postconcussion symptoms even 12 months after injury.

Published
2021
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11. Latent Profile Analysis of Neuropsychiatric Symptoms and Cognitive Function of Adults 2 Weeks After Traumatic Brain Injury: Findings From the TRACK-TBI Study.

Author

Brett BL, Kramer MD, Whyte J, McCrea MA, Stein MB, Giacino JT, Sherer M, Markowitz AJ, Manley GT, Nelson LD, Adeoye O, Badjatia N, Boase K, Barber J, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Diaz-Arrastia R, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Keene CD, Korley FK, Kramer J, Kreitzer N, Levin H, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Mukherjee P, Ngwenya LB, Noel F, Okonkwo D, Palacios E, Puccio A, Rabinowitz M, Robertson C, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Taylor S, Temkin N, Toga A, Valadka A, Vassar M, Wang K, Yue JK, Yuh E, and Zafonte R

Subjects
Adult, Brain Injuries, Traumatic physiopathology, Brain Injuries, Traumatic psychology, Female, Follow-Up Studies, Glasgow Coma Scale, Humans, Male, Prospective Studies, Time Factors, Brain Injuries, Traumatic diagnosis, Cognition physiology, Quality of Life
Abstract

Importance: Heterogeneity across patients with traumatic brain injury (TBI) presents challenges for clinical care and intervention design. Identifying distinct clinical phenotypes of TBI soon after injury may inform patient selection for precision medicine clinical trials., Objective: To investigate whether distinct neurobehavioral phenotypes can be identified 2 weeks after TBI and to characterize the degree to which early neurobehavioral phenotypes are associated with 6-month outcomes., Design, Setting, and Participants: This prospective cohort study included patients presenting to 18 US level 1 trauma centers within 24 hours of TBI from 2014 to 2019 as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. Data were analyzed from January 28, 2020, to January 11, 2021., Exposures: TBI., Main Outcomes and Measures: Latent profiles (LPs) were derived from common dimensions of neurobehavioral functioning at 2 weeks after injury, assessed through National Institutes of Health TBI Common Data Elements (ie, Brief Symptom Inventory-18, Patient Health Questionnaire-9 Depression checklist, Posttraumatic Stress Disorder Checklist for DSM-5, PROMIS Pain Intensity scale, Insomnia Severity Index, Rey Auditory Verbal Learning Test, Wechsler Adult Intelligence Scale-Fourth Edition Coding and Symbol Search subtests, Trail Making Test, and NIH Toolbox Cognitive Battery Pattern Comparison Processing Speed, Dimensional Change Card Sort, Flanker Inhibitory Control and Attention, and Picture Sequence Memory subtests). Six-month outcomes were the Satisfaction With Life Scale (SWLS), Quality of Life after Brain Injury-Overall Scale (QOLIBRI-OS), Glasgow Outcome Scale-Extended (GOSE), and Rivermead Post-Concussion Symptoms Questionnaire (RPQ)., Results: Among 1757 patients with TBI included, 1184 (67.4%) were men, and the mean (SD) age was 39.9 (17.0) years. LP analysis revealed 4 distinct neurobehavioral phenotypes at 2 weeks after injury: emotionally resilient (419 individuals [23.8%]), cognitively impaired (368 individuals [20.9%]), cognitively resilient (620 individuals [35.3%]), and neuropsychiatrically distressed (with cognitive weaknesses; 350 individuals [19.9%]). Adding LP group to models including demographic characteristics, medical history, Glasgow Coma Scale score, and other injury characteristics was associated with significantly improved estimation of association with 6-month outcome (GOSE R2 increase = 0.09-0.19; SWLS R2 increase = 0.12-0.22; QOLIBRI-OS R2 increase = 0.14-0.32; RPQ R2 = 0.13-0.34)., Conclusions and Relevance: In this cohort study of patients with TBI presenting to US level-1 trauma centers, qualitatively distinct profiles of symptoms and cognitive functioning were identified at 2 weeks after TBI. These distinct phenotypes may help optimize clinical decision-making regarding prognosis, as well as selection and stratification for randomized clinical trials.

Published
2021
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12. Consensus statement from the international consensus meeting on post-traumatic cranioplasty.

Author

Iaccarino C, Kolias A, Adelson PD, Rubiano AM, Viaroli E, Buki A, Cinalli G, Fountas K, Khan T, Signoretti S, Waran V, Adeleye AO, Amorim R, Bertuccio A, Cama A, Chesnut RM, De Bonis P, Estraneo A, Figaji A, Florian SI, Formisano R, Frassanito P, Gatos C, Germanò A, Giussani C, Hossain I, Kasprzak P, La Porta F, Lindner D, Maas AIR, Paiva W, Palma P, Park KB, Peretta P, Pompucci A, Posti J, Sengupta SK, Sinha A, Sinha V, Stefini R, Talamonti G, Tasiou A, Zona G, Zucchelli M, Hutchinson PJ, and Servadei F

Subjects
Humans, Hydrocephalus surgery, Italy, Brain Injuries, Traumatic surgery, Consensus Development Conferences as Topic, Craniotomy standards, Plastic Surgery Procedures standards
Abstract

Background: Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach., Methods: The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP., Results: The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations., Conclusions: This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Published
2021
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13. Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations.

Author

Hawryluk GWJ, Rubiano AM, Totten AM, O'Reilly C, Ullman JS, Bratton SL, Chesnut R, Harris OA, Kissoon N, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Lumba-Brown A, and Ghajar J

Subjects
Female, Humans, Treatment Outcome, Brain Injuries, Traumatic surgery, Decompressive Craniectomy methods
Abstract

When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of "living guidelines," whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/., (© Congress of Neurological Surgeons 2020.)

Published
2020
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14. A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC).

Author

Chesnut R, Aguilera S, Buki A, Bulger E, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin R, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo D, Patel M, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein D, Stocchetti N, Taccone FS, Timmons S, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, and Hawryluk GWJ

Subjects
Adult, Algorithms, Brain, Humans, Intracranial Pressure, Monitoring, Physiologic, Oxygen, Brain Injuries, Traumatic therapy, Intracranial Hypertension therapy
Abstract

Background: Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place., Methods: Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting., Results: We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms., Conclusions: These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference.

Published
2020
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15. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement.

Author

Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T, Bajamal AH, Barthélemy EJ, Devi BI, Bhat D, Bulters D, Chesnut R, Citerio G, Cooper DJ, Czosnyka M, Edem I, El-Ghandour NMF, Figaji A, Fountas KN, Gallagher C, Hawryluk GWJ, Iaccarino C, Joseph M, Khan T, Laeke T, Levchenko O, Liu B, Liu W, Maas A, Manley GT, Manson P, Mazzeo AT, Menon DK, Michael DB, Muehlschlegel S, Okonkwo DO, Park KB, Rosenfeld JV, Rosseau G, Rubiano AM, Shabani HK, Stocchetti N, Timmons SD, Timofeev I, Uff C, Ullman JS, Valadka A, Waran V, Wells A, Wilson MH, and Servadei F

Subjects
Brain Injuries, Traumatic complications, Consensus, Humans, Intracranial Hypertension etiology, Brain Injuries, Traumatic surgery, Decompressive Craniectomy methods, Intracranial Hypertension surgery
Abstract

Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach., Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries., Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval., Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Published
2019
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16. Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study.

Author

Stein MB, Jain S, Giacino JT, Levin H, Dikmen S, Nelson LD, Vassar MJ, Okonkwo DO, Diaz-Arrastia R, Robertson CS, Mukherjee P, McCrea M, Mac Donald CL, Yue JK, Yuh E, Sun X, Campbell-Sills L, Temkin N, Manley GT, Adeoye O, Badjatia N, Boase K, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Diaz-Arrastia R, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson A, Foreman B, Gardner R, Gaudette E, Giacino JT, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Korley F, Kramer J, Kreitzer N, Levin H, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, McCrea M, Merchant R, Mukherjee P, Nelson LD, Noel F, Okonkwo DO, Palacios E, Perl D, Puccio A, Rabinowitz M, Robertson CS, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Stein MB, Taylor S, Toga A, Temkin N, Valadka A, Vassar MJ, Vespa P, Wang K, Yue JK, Yuh E, and Zafonte R

Subjects
Adolescent, Adult, Case-Control Studies, Comorbidity, Emergency Service, Hospital, Female, Glasgow Coma Scale, Humans, Longitudinal Studies, Male, Prevalence, Prospective Studies, Risk Factors, Young Adult, Brain Injuries, Traumatic epidemiology, Depressive Disorder, Major epidemiology, Stress Disorders, Post-Traumatic epidemiology
Abstract

Importance: Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector., Objective: To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI)., Design, Setting, and Participants: Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study., Main Outcomes and Measures: Probable PTSD (PTSD Checklist for DSM-5 score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury., Results: Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk., Conclusions and Relevance: After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.

Published
2019
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17. Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study.

Author

Seabury SA, Gaudette É, Goldman DP, Markowitz AJ, Brooks J, McCrea MA, Okonkwo DO, Manley GT, Adeoye O, Badjatia N, Boase K, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Diaz-Arrastia R, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson A, Foreman B, Gardner R, Giacino J, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Korley F, Kramer J, Kreitzer N, Levin H, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Mukherjee P, Nelson L, Noel F, Palacios E, Perl D, Puccio A, Rabinowitz M, Robertson C, Rosand J, Sander A, Satris G, Schnyer D, Sherer M, Stein M, Taylor S, Temkin N, Toga A, Valadka A, Vassar M, Vespa P, Wang K, Yue J, Yuh E, and Zafonte R

Subjects
Adult, Aftercare methods, Brain Concussion, Emergency Service, Hospital, Female, Glasgow Coma Scale, Humans, Male, Middle Aged, Pamphlets, Prospective Studies, Trauma Centers, United States, Young Adult, Aftercare statistics & numerical data, Brain Injuries, Traumatic therapy
Abstract

Importance: Mild traumatic brain injury (mTBI) affects millions of Americans each year. Lack of consistent clinical practice raises concern that many patients with mTBI may not receive adequate follow-up care., Objective: To characterize the provision of follow-up care to patients with mTBI during the first 3 months after injury., Design, Setting, and Participants: This cohort study used data on patients with mTBI enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study between February 26, 2014, and August 25, 2016. We examined site-specific variations in follow-up care, the types of clinicians seen by patients receiving follow-up care, and patient and injury characteristics associated with a higher likelihood of receiving follow-up care. The TRACK-TBI study is a prospective, multicenter, longitudinal observational study of patients with TBI presenting to the emergency department of 1 of 11 level I US trauma centers. Study data included patients with head trauma who underwent a computed tomography (CT) scan within 24 hours of injury, had a Glasgow Coma Scale score of 13 to 15, were aged 17 years or older, and completed follow-up care surveys at 2 weeks and 3 months after injury (N = 831)., Main Outcomes and Measures: Follow-up care was defined as hospitals providing TBI educational material at discharge, hospitals calling patients to follow up, and patients seeing a physician or other medical practitioner within 3 months after the injury. Unfavorable outcomes were assessed with the Rivermead Post Concussion Symptoms Questionnaire., Results: Of 831 patients (289 [35%] female; 483 [58%] non-Hispanic white; mean [SD] age, 40.3 [16.9] years), less than half self-reported receiving TBI educational material at discharge (353 patients [42%]) or seeing a physician or other health care practitioner within 3 months after injury (367 patients [44%]). Follow-up care varied by study site; adjusting for patient characteristics, the provision of educational material varied from 19% to 72% across sites. Of 236 patients with a positive finding on a CT scan, 92 (39%) had not seen a medical practitioner 3 months after the injury. Adjusting for injury severity and demographics, patient admission to the hospital ward or intensive care unit, patient income, and insurance status were not associated with the probability of seeing a medical practitioner. Among the patients with 3 or more moderate to severe postconcussive symptoms, only 145 of 279 (52%) reported having seen a medical practitioner by 3 months., Conclusions and Relevance: There are gaps in follow-up care for patients with mTBI after hospital discharge, even those with a positive finding on CT or who continue to experience postconcussive symptoms.

Published
2018
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18. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.

Author

Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, and Ghajar J

Subjects
Evidence-Based Medicine, Humans, Neurosurgical Procedures, Practice Guidelines as Topic, Brain Injuries, Traumatic therapy, Critical Care
Abstract

The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines., (Copyright © 2016 Brain Trauma Foundation.)

Published
2017
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19. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

Author

Maas, A, Menon, D, Adelson, P, Andelic, N, Bell, M, Belli, A, Bragge, P, Brazinova, A, Büki, A, Chesnut, R, CITERIO, GIUSEPPE, Coburn, M, Cooper, D, Crowder, A, Czeiter, E, Czosnyka, M, Diaz arrastia, R, Dreier, J, Duhaime, A, Ercole, A, Van Essen, T, Feigin, V, Gao, G, Giacino, J, Gonzalez lara, L, Gruen, R, Gupta, D, Hartings, J, Hill, S, Jiang, J, Ketharanathan, N, Kompanje, E, Lanyon, L, Laureys, S, Lecky, F, Levin, H, Lingsma, H, Maegele, M, Majdan, M, Manley, G, Marsteller, J, Mascia, L, Mcfadyen, C, Mondello, S, Newcombe, V, Palotie, A, Parizel, P, Peul, W, Piercy, J, Polinder, S, Puybasset, L, Rasmussen, T, Rossaint, R, Smielewski, P, Söderberg, J, Stanworth, S, Stein, M, Von Steinbüchel, N, Stewart, W, Steyerberg, E, Stocchetti, N, Synnot, A, Te Ao, B, Tenovuo, O, Theadom, A, Tibboel, D, Videtta, W, Wang, K, Williams, W, Wilson, L, Yaffe, K, Adams, H, Agnoletti, V, Allanson, J, Amrein, K, Andaluz, N, Anke, A, Antoni, A, Van As, A, Audibert, G, Azaševac, A, Azouvi, P, Azzolini, M, Baciu, C, Badenes, R, Barlow, K, Bartels, R, Bauerfeind, U, Beauchamp, M, Beer, D, Beer, R, Belda, F, Bellander, B, Bellier, R, Benali, H, Benard, T, Beqiri, V, Beretta, L, Bernard, F, Bertolini, G, Bilotta, F, Blaabjerg, M, Den Boogert, H, Boutis, K, Bouzat, P, Brooks, B, Brorsson, C, Bullinger, M, Burns, E, Calappi, E, Cameron, P, Carise, E, Castaño león, A, Causin, F, Chevallard, G, Chieregato, A, Christie, B, Cnossen, M, Coles, J, Collett, J, Della Corte, F, Craig, W, Csato, G, Csomos, A, Curry, N, Dahyot fizelier, C, Dawes, H, Dematteo, C, Depreitere, B, Dewey, D, Van Dijck, J, Đilvesi, Đ, Dippel, D, Dizdarevic, K, Donoghue, E, Duek, O, Dulière, G, Dzeko, A, Eapen, G, Emery, C, English, S, Esser, P, Ezer, E, Fabricius, M, Feng, J, Fergusson, D, Figaji, A, Fleming, J, Foks, K, Francony, G, Freedman, S, Freo, U, Frisvold, S, Gagnon, I, Galanaud, D, Gantner, D, Giraud, B, Glocker, B, Golubovic, J, Gómez López, P, Gordon, W, Gradisek, P, Gravel, J, Griesdale, D, Grossi, F, Haagsma, J, Håberg, A, Haitsma, I, Van Hecke, W, Helbok, R, Helseth, E, Van Heugten, C, Hoedemaekers, C, Höfer, S, Horton, L, Hui, J, Huijben, J, Hutchinson, P, Jacobs, B, Van Der Jagt, M, Jankowski, S, Janssens, K, Jelaca, B, Jones, K, Kamnitsas, K, Kaps, R, Karan, M, Katila, A, Kaukonen, K, De Keyser, V, Kivisaari, R, Kolias, A, Kolumbán, B, Kolundžija, K, Kondziella, D, Koskinen, L, Kovács, N, Kramer, A, Kutsogiannis, D, Kyprianou, T, Lagares, A, Lamontagne, F, Latini, R, Lauzier, F, Lazar, I, Ledig, C, Lefering, R, Legrand, V, Levi, L, Lightfoot, R, Lozano, A, Macdonald, S, Major, S, Manara, A, Manhes, P, Maréchal, H, Martino, C, Masala, A, Masson, S, Mattern, J, Mcfadyen, B, Mcmahon, C, Meade, M, Melegh, B, Menovsky, T, Moore, L, Morgado Correia, M, Morganti kossmann, M, Muehlan, H, Mukherjee, P, Murray, L, Van Der Naalt, J, Negru, A, Nelson, D, Nieboer, D, Noirhomme, Q, Nyirádi, J, Oddo, M, Okonkwo, D, Oldenbeuving, A, Ortolano, F, Osmond, M, Payen, J, Perlbarg, V, Persona, P, Pichon, N, Piippo karjalainen, A, Pili floury, S, Pirinen, M, Ple, H, Poca, M, Posti, J, Van Praag, D, Ptito, A, Radoi, A, Ragauskas, A, Raj, R, Real, R, Reed, N, Rhodes, J, Robertson, C, Rocka, S, Røe, C, Røise, O, Roks, G, Rosand, J, Rosenfeld, J, Rosenlund, C, Rosenthal, G, Rossi, S, Rueckert, D, De Ruiter, G, Sacchi, M, Sahakian, B, Sahuquillo, J, Sakowitz, O, Salvato, G, Sánchez porras, R, Sándor, J, Sangha, G, Schäfer, N, Schmidt, S, Schneider, K, Schnyer, D, Schöhl, H, Schoonman, G, Schou, R, Sir, Ö, Skandsen, T, Smeets, D, Sorinola, A, Stamatakis, E, Stevanovic, A, Stevens, R, Sundström, N, Taccone, F, Takala, R, Tanskanen, P, Taylor, M, Telgmann, R, Temkin, N, Teodorani, G, Thomas, M, Tolias, C, Trapani, T, Turgeon, A, Vajkoczy, P, Valadka, A, Valeinis, E, Vallance, S, Vámos, Z, VARGIOLU, ALESSIA, Vega, E, Verheyden, J, Vik, A, Vilcinis, R, Vleggeert lankamp, C, Vogt, L, Volovici, V, Voormolen, D, Vulekovic, P, Vande Vyvere, T, Van Waesberghe, J, Wessels, L, Wildschut, E, Williams, G, Winkler, M, Wolf, S, Wood, G, Xirouchaki, N, Younsi, A, Zaaroor, M, Zelinkova, V, Zemek, R, Zumbo, F, Citerio, G, Vargiolu, A, Zumbo, F., Maas, Andrew I R, Menon, David K, Adelson, P David, Andelic, Nada, Bell, Michael J, Belli, Antonio, Bragge, Peter, Brazinova, Alexandra, Büki, Andrá, Chesnut, Randall M, Citerio, Giuseppe, Coburn, Mark, Cooper, D Jamie, Crowder, A Tamara, Czeiter, Endre, Czosnyka, Marek, Diaz-Arrastia, Ramon, Dreier, Jens P, Duhaime, Ann-Christine, Ercole, Ari, van Essen, Thomas A, Feigin, Valery L, Gao, Guoyi, Giacino, Joseph, Gonzalez-Lara, Laura E, Gruen, Russell L, Gupta, Deepak, Hartings, Jed A, Hill, Sean, Jiang, Ji-yao, Ketharanathan, Naomi, Kompanje, Erwin J O, Lanyon, Linda, Laureys, Steven, Lecky, Fiona, Levin, Harvey, Lingsma, Hester F, Maegele, Marc, Majdan, Marek, Manley, Geoffrey, Marsteller, Jill, Mascia, Luciana, Mcfadyen, Charle, Mondello, Stefania, Newcombe, Virginia, Palotie, Aarno, Parizel, Paul M, Peul, Wilco, Piercy, Jame, Polinder, Suzanne, Puybasset, Loui, Rasmussen, Todd E, Rossaint, Rolf, Smielewski, Peter, Söderberg, Jeannette, Stanworth, Simon J, Stein, Murray B, von Steinbüchel, Nicole, Stewart, William, Steyerberg, Ewout W, Stocchetti, Nino, Synnot, Anneliese, Te Ao, Braden, Tenovuo, Olli, Theadom, Alice, Tibboel, Dick, Videtta, Walter, Wang, Kevin K W, Williams, W Huw, Wilson, Lindsay, Yaffe, Kristine, InTBIR Participants, Investigator, Beretta, Luigi, InTBIR Participants Investigators, Menon, David [0000-0002-3228-9692], Czosnyka, Marek [0000-0003-2446-8006], Ercole, Ari [0000-0001-8350-8093], Newcombe, Virginia [0000-0001-6044-9035], Smielewski, Peter [0000-0001-5096-3938], Apollo - University of Cambridge Repository, Maas A.I.R., Menon D.K., David Adelson P.D., Andelic N., Bell M.J., Belli A., Bragge P., Brazinova A., Buki A., Chesnut R.M., Citerio G., Coburn M., Jamie Cooper D., Tamara Crowder A., Czeiter E., Czosnyka M., Diaz-Arrastia R., Dreier J.P., Duhaime A.-C., Ercole A., van Essen T.A., Feigin V.L., Gao G., Giacino J., Gonzalez-Lara L.E., Gruen R.L., Gupta D., Hartings J.A., Hill S., Jiang J.-Y., Ketharanathan N., Kompanje E.J.O., Lanyon L., Laureys S., Lecky F., Levin H., Lingsma H.F., Maegele M., Majdan M., Manley G., Marsteller J., Mascia L., McFadyen C., Mondello S., Newcombe V., Palotie A., Parizel P.M., Peul W., Piercy J., Polinder S., Puybasset L., Rasmussen T.E., Rossaint R., Smielewski P., Soderberg J., Stanworth S.J., Stein M.B., von Steinbuchel N., Stewart W., Steyerberg E.W., Stocchetti N., Synnot A., Te Ao B., Tenovuo O., Theadom A., Tibboel D., Videtta W., Wang K.K.W., Huw Williams W., Wilson L., Yaffe K., Adams H., Allanson J., Coles J., Hutchinson P.J., Kolias A.G., Sahakian B.J., Stamatakis E., Williams G., Agnoletti V., Martino C., Masala A., Teodorani G., Zumbo F., Amrein K., Ezer E., Kolumban B., Kovacs N., Melegh B., Nyiradi J., Sorinola A., Vamos Z., Andaluz N., Anke A., Frisvold S.K., Antoni A., van As A.B., Figaji A., Audibert G., Azasevac A., Dilvesi D., 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Lauzier F., Moore L., Turgeon A., Legrand V., Levi L., Zaaroor M., Lightfoot R., Macdonald S., Major S., Vajkoczy P., Wessels L., Winkler M.K.L., Wolf S., Manara A., Thomas M., Mattern J., Sakowitz O., Vogt L., Younsi A., McFadyen B., McMahon C., Correia M.M., Morganti-Kossmann M.C., Rosenfeld J.V., Muehlan H., Schmidt S., Mukherjee P., Noirhomme Q., Oddo M., Okonkwo D.O., Oldenbeuving A.W., Roks G., Schoonman G.G., Perlbarg V., Pichon N., Pili-Floury S., Pirinen M., Ples H., Poca M.A., Radoi A., Sahuquillo J., Ragauskas A., Rocka S., Real R.G.L., Telgmann R., Reed N., Rhodes J., Robertson C., Rosand J., Rosenthal G., Salvato G., Sanchez-Porras R., Sandor J., Sangha G., Schnyer D., Schohl H., Skandsen T., Stevanovic A., van Waesberghe J.V., Stevens R.D., Taccone F.S., Taylor M.S., Zelinkova V., Temkin N., Tolias C.M., Valadka A.B., Valeinis E., Vargiolu A., Vega E., Vik A., Vilcinis R., Wildschut E., Wood G., Xirouchaki N., Zemek R., Maas, A, Menon, D, Adelson, P, Andelic, N, Bell, M, 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Zaaroor, M, Zelinkova, V, Zemek, R, Zumbo, F, Pediatric Surgery, Intensive Care, and Public Health

Subjects
medicine.medical_specialty, EVIDENCE-BASED MEDICINE, Treatment outcome, Poison control, Other Research Radboud Institute for Molecular Life Sciences [Radboudumc 0], EMERGENCY-DEPARTMENT VISITS, Review, PLACEBO-CONTROLLED TRIAL, Middle income country, Healthcare improvement science Radboud Institute for Health Sciences [Radboudumc 18], 03 medical and health sciences, 0302 clinical medicine, Intensive care, Brain Injuries, Traumatic, Journal Article, medicine, traumatic barin injury, Humans, 030212 general & internal medicine, Clinical care, Neurologic disease, Psychiatry, DIAGNOSTIC MANAGEMENT STRATEGIES, business.industry, RANDOMIZED CONTROLLED-TRIAL, ACUTE SUBDURAL-HEMATOMA, SEVERE HEAD-INJURY, ROAD TRAFFIC INJURIES, brain injury, Hospital care, 3. Good health, Reconstructive and regenerative medicine Radboud Institute for Health Sciences [Radboudumc 10], Brain Injuries, Health care cost, PATIENT-REPORTED OUTCOMES, Human medicine, Neurology (clinical), business, Humanities, 030217 neurology & neurosurgery, GLASGOW COMA SCALE
Abstract

Executive summary A concerted effort to tackle the global health problem posed by traumatic brain injury (TBI) is long overdue. TBI is a public health challenge of vast, but insufficiently recognised, proportions. Worldwide, more than 50 million people have a TBI each year, and it is estimated that about half the world’s population will have one or more TBIs over their lifetime. TBI is the leading cause of mortality in young adults and a major cause of death and disability across all ages in all countries, with a disproportionate burden of disability and death occurring in low-income and middle-income countries (LMICs). It has been estimated that TBI costs the global economy approximately $US400 billion annually. Deficiencies in prevention, care, and research urgently need to be addressed to reduce the huge burden and societal costs of TBI. This Commission highlights priorities and provides expert recommendations for all stakeholders— policy makers, funders, health-care professionals, researchers, and patient representatives—on clinical and research strategies to reduce this growing public health problem and improve the lives of people with TBI. The epidemiology of TBI is changing: in high-income countries, the number of elderly people with TBI is increasing, mainly due to falls, while in LMICs, the burden of TBI from road traffic incidents is increasing. Data on the frequency of TBI and TBI-related deaths and on the economic impact of brain trauma are often incomplete and vary between countries. Improved, accurate epidemiological monitoring and robust healtheconomic data collection are needed to inform healthcare policy and prevention programmes. Highly developed and coordinated systems of care are crucial for management of patients with TBI. However, in practice, implementation of such frameworks varies greatly and disconnects exist in the chain of care. Optimisation of systems of care should be high on the policy agenda and could yield substantial gains in terms of both patient outcomes and costs to society. TBI is a complex condition, and strong evidence to support treatment guidelines and recommendations is scarce. Most multicentre clinical trials of medical and surgical interventions have failed to show efficacy, despite promising preclinical results. At the bedside, treatment strategies are generally based on guidelines that promote a one-size-fits-all approach and are insufficiently targeted to the needs of individual patients. Attempts to individualise treatment are challenging owing to the diversity of TBI, and are hampered by the use of simplistic methods to characterise its initial type and severity. Advances in genomics, blood biomarkers, magnetic resonance imaging (MRI), and pathophysiological monitoring, combined with informatics to integrate data from multiple sources, offer new research avenues to improve disease characterisation and monitoring of disease evolution. These tools can also aid understanding of disease mechanisms and facilitate targeted treatment strategies for individual patients. Individualised management in the postacute phase and evaluation of the effectiveness of treatment and care processes depend on accurate quantification of outcomes. In practice, however, the use of simplistic methods hinders efforts to quantify outcomes after TBI of all severities. Development and validation of multidimensional approaches will be essential to improve measurement of clinical outcomes, for both research and patient care. In particular, we need to find better ways to characterise the currently under-recognised risk of long-term disabling sequelae in patients with relatively mild injuries. Prognostic models are important to help clinicians to provide reliable information to patients and relatives, and to facilitate comparative audit of care between centres and countries. There is an urgent need for further development, validation, and implementation of prognostic models in TBI, particularly for less severe TBI. This multitude of challenges in TBI—encompassing systems of care, clinical management, and research strategy—demands novel approaches to the generation of new evidence and its implementation in clinical practice. Comparative effectiveness research (CER) offers opportunities to capitalise on the diversity of TBI and systems of care and enables assessment of therapies in real-world conditions; high-quality CER studies can provide strong evidence to support guideline recommendations. The global challenges posed by TBI necessitate global collaborations and a change in research culture to endorse broad data sharing. This Commission covers a range of topics that need to be addressed to confront the global burden of TBI and reduce its effects on individuals and society: epidemiology (section 1); health economics (section 2); prevention (section 3); systems of care (section 4); clinical management (section 5); characterisation of TBI (section 6); outcome assessment (section 7); prognosis (section 8); and new directions for acquiring and implementing evidence (section 9). Table 1 summarises key messages from the Commission and provides recommendations to advance clinical care and research in TBI. We must increase awareness of the scale of the challenge posed by TBI. If we are to tackle the individual and societal burden of TBI, these efforts need to go beyond a clinical and research audience and address the public, politicians, and other stakeholders. We need to develop and implement policies for better prevention and systems of care in order to improve outcomes for individuals with TBI. We also need a commitment to substantial long-term investment in TBI research across a range of disciplines to determine best practice and facilitate individualised management strategies. A combination of innovative research methods and global collaboration, and ways to effectively translate progress in basic and clinical research into clinical practice and public health policy, will be vital for progress in the field.

Published
2017

20. Effect of frailty on 6-month outcome after traumatic brain injury: a multicentre cohort study with external validation

Author

Stefania Galimberti, Francesca Graziano, Andrew I R Maas, Giulia Isernia, Fiona Lecky, Sonia Jain, Xiaoying Sun, Raquel C Gardner, Sabrina R Taylor, Amy J Markowitz, Geoffrey T Manley, Maria Grazia Valsecchi, Giuseppe Bellelli, Giuseppe Citerio, Cecilia Ackerlund, Hadie Adams, Krisztina Amrein, Nada Andelic, Lasse Andreassen, Audny Anke, Anna Antoni, Gérard Audibert, Philippe Azouvi, Maria Luisa Azzolini, Ronald Bartels, Pál Barzó, Romuald Beauvais, Ronny Beer, Bo-Michael Bellander, Antonio Belli, Habib Benali, Maurizio Berardino, Luigi Beretta, Morten Blaabjerg, Peter Bragge, Alexandra Brazinova, Vibeke Brinck, Joanne Brooker, Camilla Brorsson, Andras Buki, Monika Bullinger, Manuel Cabeleira, Alessio Caccioppola, Emiliana Calappi, Maria Rosa Calvi, Peter Cameron, Guillermo Carbayo Lozano, Marco Carbonara, Ana M. Castaño-León, Simona Cavallo, Giorgio Chevallard, Arturo Chieregato, Hans Clusmann, Mark Steven Coburn, Jonathan Coles, Jamie D. Cooper, Marta Correia, Amra Covic, Nicola Curry, Endre Czeiter, Marek Czosnyka, Claire Dahyot-Fizelier, Paul Dark, Helen Dawes, Véronique De Keyser, Vincent Degos, Francesco Della Corte, Hugo den Boogert, Bart Depreitere, Đula Đilvesi, Abhishek Dixit, Emma Donoghue, Jens Dreier, Guy-Loup Dulière, Ari Ercole, Patrick Esser, Erzsébet Ezer, Martin Fabricius, Valery L. Feigin, Kelly Foks, Shirin Frisvold, Alex Furmanov, Pablo Gagliardo, Damien Galanaud, Dashiell Gantner, Guoyi Gao, Pradeep George, Alexandre Ghuysen, Lelde Giga, Ben Glocker, Jagoš Golubovic, Pedro A. Gomez, Johannes Gratz, Benjamin Gravesteijn, Francesca Grossi, Russell L. Gruen, Deepak Gupta, Juanita A. Haagsma, Iain Haitsma, Raimund Helbok, Eirik Helseth, Lindsay Horton, Jilske Huijben, Peter J. Hutchinson, Bram Jacobs, Stefan Jankowski, Mike Jarrett, Ji-yao Jiang, Faye Johnson, Kelly Jones, Mladen Karan, Angelos G. Kolias, Erwin Kompanje, Daniel Kondziella, Lars-Owe Koskinen, Noémi Kovács, Ana Kowark, Alfonso Lagares, Linda Lanyon, Steven Laureys, Didier Ledoux, Rolf Lefering, Valerie Legrand, Aurelie Lejeune, Leon Levi, Roger Lightfoot, Hester Lingsma, Marc Maegele, Marek Majdan, Alex Manara, Hugues Maréchal, Costanza Martino, Julia Mattern, Charles McFadyen, Catherine McMahon, Béla Melegh, David Menon, Tomas Menovsky, Ana Mikolic, Benoit Misset, Visakh Muraleedharan, Lynnette Murray, Ancuta Negru, David Nelson, Virginia Newcombe, Daan Nieboer, József Nyirádi, Matej Oresic, Fabrizio Ortolano, Olubukola Otesile, Aarno Palotie, Paul M. Parizel, Jean-François Payen, Natascha Perera, Vincent Perlbarg, Paolo Persona, Wilco Peul, Anna Piippo-Karjalainen, Matti Pirinen, Dana Pisica, Horia Ples, Suzanne Polinder, Inigo Pomposo, Jussi P. Posti, Louis Puybasset, Andreea Radoi, Arminas Ragauskas, Rahul Raj, Malinka Rambadagalla, Veronika Rehorčíková, Isabel Retel Helmrich, Jonathan Rhodes, Sylvia Richardson, Sophie Richter, Samuli Ripatti, Saulius Rocka, Cecilie Roe, Olav Roise, Jeffrey Rosenfeld, Christina Rosenlund, Guy Rosenthal, Rolf Rossaint, Sandra Rossi, Daniel Rueckert, Martin Rusnák, Juan Sahuquillo, Oliver Sakowitz, Renan Sanchez-Porras, Janos Sandor, Nadine Schäfer, Silke Schmidt, Herbert Schoechl, Guus Schoonman, Rico Frederik Schou, Elisabeth Schwendenwein, Charlie Sewalt, Ranjit D. Singh, Toril Skandsen, Peter Smielewski, Abayomi Sorinola, Emmanuel Stamatakis, Simon Stanworth, Robert Stevens, William Stewart, Ewout W. Steyerberg, Nino Stocchetti, Nina Sundström, Riikka Takala, Viktória Tamás, Tomas Tamosuitis, Mark Steven Taylor, Braden Te Ao, Olli Tenovuo, Alice Theadom, Matt Thomas, Dick Tibboel, Marjolijn Timmers, Christos Tolias, Tony Trapani, Cristina Maria Tudora, Andreas Unterberg, Peter Vajkoczy, Egils Valeinis, Shirley Vallance, Zoltán Vámos, Mathieu van der Jagt, Joukje van der Naalt, Gregory Van der Steen, Jeroen T.J.M. van Dijck, Inge A. van Erp, Thomas A. van Essen, Wim Van Hecke, Caroline van Heugten, Dominique Van Praag, Ernest van Veen, Roel van Wijk, Thijs Vande Vyvere, Alessia Vargiolu, Emmanuel Vega, Kimberley Velt, Jan Verheyden, Paul M. Vespa, Anne Vik, Rimantas Vilcinis, Victor Volovici, Nicole von Steinbüchel, Daphne Voormolen, Peter Vulekovic, Kevin K.W. Wang, Eveline Wiegers, Guy Williams, Lindsay Wilson, Stefan Wolf, Zhihui Yang, Peter Ylén, Alexander Younsi, Frederick A. Zeiler, Agate Ziverte, Tommaso Zoerle, Opeolu Adeoye, Neeraj Badjatia, Jason Barber, Michael Bergin, Kim Boase, Yelena Bodien, Randall Chesnut, John Corrigan, Karen Crawford, Ramon Diaz-Arrastia, Sureyya Dikmen, Ann-Christine Duhaime, Richard Ellenbogen, Venkata Feeser, Adam R Ferguson, Brandon Foreman, Etienne Gaudette, Joseph Giacino, Luis Gonzalez, Shankar Gopinath, Ramesh Grandhi, Rao Gullapalli, Claude Hemphill, Gillian Hotz, Russell Huie, Ruchira Jha, C. Dirk Keene, Ryan Kitagawa, Frederick Korley, Joel Kramer, Natalie Kreitzer, Harvey Levin, Chris Lindsell, Joan Machamer, Christopher Madden, Alastair Martin, Thomas McAllister, Michael McCrea, Randall Merchant, Pratik Mukherjee, Lindsay Nelson, Laura B. Ngwenya, Florence Noel, Amber Nolan, David Okonkwo, Eva Palacios, Daniel Perl, Ava Puccio, Miri Rabinowitz, Claudia Robertson, Richard Ben Rodgers, Jonathan Rosand, Eric Rosenthal, Angelle Sander, Danielle Sandsmark, Gabriella Sugar, Andrea Schneider, David Schnyer, Seth Seabury, Mark Sherer, Murray Stein, Nancy Temkin, Arthur Toga, Abel Torres-Espin, Alex Valadka, Mary Vassar, Kevin Wang, Vincent Wang, John K. Yue, Esther Yuh, Ross Zafonte, Galimberti, S, Graziano, F, Maas, A, Isernia, G, Lecky, F, Jain, S, Sun, X, Gardner, R, Taylor, S, Markowitz, A, Manley, G, Valsecchi, M, Bellelli, G, Citerio, G, Ackerlund, C, Adams, H, Amrein, K, Andelic, N, Andreassen, L, Anke, A, Antoni, A, Audibert, G, Azouvi, P, Azzolini, M, Bartels, R, Barzo, P, Beauvais, R, Beer, R, Bellander, B, Belli, A, Benali, H, Berardino, M, Beretta, L, Blaabjerg, M, Bragge, P, Brazinova, A, Brinck, V, Brooker, J, Brorsson, C, Buki, A, Bullinger, M, Cabeleira, M, Caccioppola, A, Calappi, E, Calvi, M, Cameron, P, Carbayo Lozano, G, Carbonara, M, Castano-Leon, A, Cavallo, S, Chevallard, G, Chieregato, A, Clusmann, H, Coburn, M, Coles, J, Cooper, J, Correia, M, Covic, A, Curry, N, Czeiter, E, Czosnyka, M, Dahyot-Fizelier, C, Dark, P, Dawes, H, De Keyser, V, Degos, V, Della Corte, F, den Boogert, H, Depreitere, B, Dilvesi, D, Dixit, A, Donoghue, E, Dreier, J, Duliere, G, Ercole, A, Esser, P, Ezer, E, Fabricius, M, Feigin, V, Foks, K, Frisvold, S, Furmanov, A, Gagliardo, P, Galanaud, D, Gantner, D, Gao, G, George, P, Ghuysen, A, Giga, L, Glocker, B, Golubovic, J, Gomez, P, Gratz, J, Gravesteijn, B, Grossi, F, Gruen, R, Gupta, D, Haagsma, J, Haitsma, I, Helbok, R, Helseth, E, Horton, L, Huijben, J, Hutchinson, P, Jacobs, B, Jankowski, S, Jarrett, M, Jiang, J, Johnson, F, Jones, K, Karan, M, Kolias, A, Kompanje, E, Kondziella, D, Koskinen, L, Kovacs, N, Kowark, A, Lagares, A, Lanyon, L, Laureys, S, Ledoux, D, Lefering, R, Legrand, V, Lejeune, A, Levi, L, Lightfoot, R, Lingsma, H, Maegele, M, Majdan, M, Manara, A, Marechal, H, Martino, C, Mattern, J, Mcfadyen, C, Mcmahon, C, Melegh, B, Menon, D, Menovsky, T, Mikolic, A, Misset, B, Muraleedharan, V, Murray, L, Negru, A, Nelson, D, Newcombe, V, Nieboer, D, Nyiradi, J, Oresic, M, Ortolano, F, Otesile, O, Palotie, A, Parizel, P, Payen, J, Perera, N, Perlbarg, V, Persona, P, Peul, W, Piippo-Karjalainen, A, Pirinen, M, Pisica, D, Ples, H, Polinder, S, Pomposo, I, Posti, J, Puybasset, L, Radoi, A, Ragauskas, A, Raj, R, Rambadagalla, M, Rehorcikova, V, Retel Helmrich, I, Rhodes, J, Richardson, S, Richter, S, Ripatti, S, Rocka, S, Roe, C, Roise, O, Rosenfeld, J, Rosenlund, C, Rosenthal, G, Rossaint, R, Rossi, S, Rueckert, D, Rusnak, M, Sahuquillo, J, Sakowitz, O, Sanchez-Porras, R, Sandor, J, Schafer, N, Schmidt, S, Schoechl, H, Schoonman, G, Schou, R, Schwendenwein, E, Sewalt, C, Singh, R, Skandsen, T, Smielewski, P, Sorinola, A, Stamatakis, E, Stanworth, S, Stevens, R, Stewart, W, Steyerberg, E, Stocchetti, N, Sundstrom, N, Takala, R, Tamas, V, Tamosuitis, T, Taylor, M, Te Ao, B, Tenovuo, O, Theadom, A, Thomas, M, Tibboel, D, Timmers, M, Tolias, C, Trapani, T, Tudora, C, Unterberg, A, Vajkoczy, P, Valeinis, E, Vallance, S, Vamos, Z, van der Jagt, M, van der Naalt, J, Van der Steen, G, van Dijck, J, van Erp, I, van Essen, T, Van Hecke, W, van Heugten, C, Van Praag, D, van Veen, E, van Wijk, R, Vande Vyvere, T, Vargiolu, A, Vega, E, Velt, K, Verheyden, J, Vespa, P, Vik, A, Vilcinis, R, Volovici, V, von Steinbuchel, N, Voormolen, D, Vulekovic, P, Wang, K, Wiegers, E, Williams, G, Wilson, L, Wolf, S, Yang, Z, Ylen, P, Younsi, A, Zeiler, F, Ziverte, A, Zoerle, T, Adeoye, O, Badjatia, N, Barber, J, Bergin, M, Boase, K, Bodien, Y, Chesnut, R, Corrigan, J, Crawford, K, Diaz-Arrastia, R, Dikmen, S, Duhaime, A, Ellenbogen, R, Feeser, V, Ferguson, A, Foreman, B, Gaudette, E, Giacino, J, Gonzalez, L, Gopinath, S, Grandhi, R, Gullapalli, R, Hemphill, C, Hotz, G, Huie, R, Jha, R, Keene, C, Kitagawa, R, Korley, F, Kramer, J, Kreitzer, N, Levin, H, Lindsell, C, Machamer, J, Madden, C, Martin, A, Mcallister, T, Mccrea, M, Merchant, R, Mukherjee, P, Nelson, L, Ngwenya, L, Noel, F, Nolan, A, Okonkwo, D, Palacios, E, Perl, D, Puccio, A, Rabinowitz, M, Robertson, C, Rodgers, R, Rosand, J, Rosenthal, E, Sander, A, Sandsmark, D, Sugar, G, Schneider, A, Schnyer, D, Seabury, S, Sherer, M, Stein, M, Temkin, N, Toga, A, Torres-Espin, A, Valadka, A, Vassar, M, Wang, V, Yue, J, Yuh, E, Zafonte, R, Molecular Neuroscience and Ageing Research (MOLAR), CENTER-TBI TRACK-TBI Participants and Investigators, Galimberti, S., Graziano, F., Maas, A. I. R., Isernia, G., Lecky, F., Jain, S., Sun, X., Gardner, R. C., Taylor, S. R., Markowitz, A. J., Manley, G. T., Valsecchi, M. G., Bellelli, G., Citerio, G., Ackerlund, C., Adams, H., Amrein, K., Andelic, N., Andreassen, L., Anke, A., Antoni, A., Audibert, G., Azouvi, P., Azzolini, M. L., Bartels, R., Barzo, P., Beauvais, R., Beer, R., Bellander, B. -M., Belli, A., Benali, H., Berardino, M., Beretta, L., Blaabjerg, M., Bragge, P., Brazinova, A., Brinck, V., Brooker, J., Brorsson, C., Buki, A., Bullinger, M., Cabeleira, M., Caccioppola, A., Calappi, E., Calvi, M. R., Cameron, P., Carbayo Lozano, G., Carbonara, M., Castano-Leon, A. M., Cavallo, S., Chevallard, G., Chieregato, A., Clusmann, H., Coburn, M. S., Coles, J., Cooper, J. D., Correia, M., Covic, A., Curry, N., Czeiter, E., Czosnyka, M., Dahyot-Fizelier, C., Dark, P., Dawes, H., De Keyser, V., Degos, V., Della Corte, F., den Boogert, H., Depreitere, B., Dilvesi, D., Dixit, A., Donoghue, E., Dreier, J., Duliere, G. -L., Ercole, A., Esser, P., Ezer, E., Fabricius, M., Feigin, V. L., Foks, K., Frisvold, S., Furmanov, A., Gagliardo, P., Galanaud, D., Gantner, D., Gao, G., George, P., Ghuysen, A., Giga, L., Glocker, B., Golubovic, J., Gomez, P. A., Gratz, J., Gravesteijn, B., Grossi, F., Gruen, R. L., Gupta, D., Haagsma, J. A., Haitsma, I., Helbok, R., Helseth, E., Horton, L., Huijben, J., Hutchinson, P. J., Jacobs, B., Jankowski, S., Jarrett, M., Jiang, J. -Y., Johnson, F., Jones, K., Karan, M., Kolias, A. G., Kompanje, E., Kondziella, D., Koskinen, L. -O., Kovacs, N., Kowark, A., Lagares, A., Lanyon, L., Laureys, S., Ledoux, D., Lefering, R., Legrand, V., Lejeune, A., Levi, L., Lightfoot, R., Lingsma, H., Maegele, M., Majdan, M., Manara, A., Marechal, H., Martino, C., Mattern, J., Mcfadyen, C., Mcmahon, C., Melegh, B., Menon, D., Menovsky, T., Mikolic, A., Misset, B., Muraleedharan, V., Murray, L., Negru, A., Nelson, D., Newcombe, V., Nieboer, D., Nyiradi, J., Oresic, M., Ortolano, F., Otesile, O., Palotie, A., Parizel, P. M., Payen, J. -F., Perera, N., Perlbarg, V., Persona, P., Peul, W., Piippo-Karjalainen, A., Pirinen, M., Pisica, D., Ples, H., Polinder, S., Pomposo, I., Posti, J. P., Puybasset, L., Radoi, A., Ragauskas, A., Raj, R., Rambadagalla, M., Rehorcikova, V., Retel Helmrich, I., Rhodes, J., Richardson, S., Richter, S., Ripatti, S., Rocka, S., Roe, C., Roise, O., Rosenfeld, J., Rosenlund, C., Rosenthal, G., Rossaint, R., Rossi, S., Rueckert, D., Rusnak, M., Sahuquillo, J., Sakowitz, O., Sanchez-Porras, R., Sandor, J., Schafer, N., Schmidt, S., Schoechl, H., Schoonman, G., Schou, R. F., Schwendenwein, E., Sewalt, C., Singh, R. D., Skandsen, T., Smielewski, P., Sorinola, A., Stamatakis, E., Stanworth, S., Stevens, R., Stewart, W., Steyerberg, E. W., Stocchetti, N., Sundstrom, N., Takala, R., Tamas, V., Tamosuitis, T., Taylor, M. S., Te Ao, B., Tenovuo, O., Theadom, A., Thomas, M., Tibboel, D., Timmers, M., Tolias, C., Trapani, T., Tudora, C. M., Unterberg, A., Vajkoczy, P., Valeinis, E., Vallance, S., Vamos, Z., van der Jagt, M., van der Naalt, J., Van der Steen, G., van Dijck, J. T. J. M., van Erp, I. A., van Essen, T. A., Van Hecke, W., van Heugten, C., Van Praag, D., van Veen, E., van Wijk, R., Vande Vyvere, T., Vargiolu, A., Vega, E., Velt, K., Verheyden, J., Vespa, P. M., Vik, A., Vilcinis, R., Volovici, V., von Steinbuchel, N., Voormolen, D., Vulekovic, P., Wang, K. K. W., Wiegers, E., Williams, G., Wilson, L., Wolf, S., Yang, Z., Ylen, P., Younsi, A., Zeiler, F. A., Ziverte, A., Zoerle, T., Adeoye, O., Badjatia, N., Barber, J., Bergin, M., Boase, K., Bodien, Y., Chesnut, R., Corrigan, J., Crawford, K., Diaz-Arrastia, R., Dikmen, S., Duhaime, A. -C., Ellenbogen, R., Feeser, V., Ferguson, A. R., Foreman, B., Gaudette, E., Giacino, J., Gonzalez, L., Gopinath, S., Grandhi, R., Gullapalli, R., Hemphill, C., Hotz, G., Huie, R., Jha, R., Keene, C. D., Kitagawa, R., Korley, F., Kramer, J., Kreitzer, N., Levin, H., Lindsell, C., Machamer, J., Madden, C., Martin, A., Mcallister, T., Mccrea, M., Merchant, R., Mukherjee, P., Nelson, L., Ngwenya, L. B., Noel, F., Nolan, A., Okonkwo, D., Palacios, E., Perl, D., Puccio, A., Rabinowitz, M., Robertson, C., Rodgers, R. B., Rosand, J., Rosenthal, E., Sander, A., Sandsmark, D., Sugar, G., Schneider, A., Schnyer, D., Seabury, S., Sherer, M., Stein, M., Temkin, N., Toga, A., Torres-Espin, A., Valadka, A., Vassar, M., Wang, K., Wang, V., Yue, J. K., Yuh, E., and Zafonte, R.

Subjects
Male, Traumatic/therapy, Frailty, Brain Injuries, Traumatic/therapy, traumatic brain injury, Reproducibility of Results, Middle Aged, Cohort Studies, Brain Injuries, Brain Injuries, Traumatic, outcome, Humans, Glasgow Coma Scale, Neurology (clinical), Human medicine, Prospective Studies, Aged
Abstract

Background: Frailty is known to be associated with poorer outcomes in individuals admitted to hospital for medical conditions requiring intensive care. However, little evidence is available for the effect of frailty on patients’ outcomes after traumatic brain injury. Many frailty indices have been validated for clinical practice and show good performance to predict clinical outcomes. However, each is specific to a particular clinical context. We aimed to develop a frailty index to predict 6-month outcomes in patients after a traumatic brain injury. Methods: A cumulative deficit approach was used to create a novel frailty index based on 30 items dealing with disease states, current medications, and laboratory values derived from data available from CENTER-TBI, a prospective, longitudinal observational study of patients with traumatic brain injury presenting within 24 h of injury and admitted to a ward or an intensive care unit at 65 centres in Europe between Dec 19, 2014, and Dec 17, 2017. From the individual cumulative CENTER-TBI frailty index (range 0–30), we obtained a standardised value (range 0–1), with high scores indicating higher levels of frailty. The effect of frailty on 6-month outcome evaluated with the extended Glasgow Outcome Scale (GOSE) was assessed through a proportional odds logistic model adjusted for known outcome predictors. An unfavourable outcome was defined as death or severe disability (GOSE score ≤4). External validation was performed on data from TRACK-TBI, a prospective observational study co-designed with CENTER-TBI, which enrolled patients with traumatic brain injury at 18 level I trauma centres in the USA from Feb 26, 2014, to July 27, 2018. CENTER-TBI is registered with ClinicalTrials.gov, NCT02210221; TRACK-TBI is registered at ClinicalTrials.gov, NCT02119182. Findings: 2993 participants (median age was 51 years [IQR 30–67], 2058 [69%] were men) were included in this analysis. The overall median CENTER-TBI frailty index score was 0·07 (IQR 0·03–0·15), with a median score of 0·17 (0·08–0·27) in older adults (aged ≥65 years). The CENTER-TBI frailty index score was significantly associated with the probability of an increasingly unfavourable outcome (cumulative odds ratio [OR] 1·03, 95% CI 1·02–1·04; p

Published
2022

21. Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

Author

Edoardo Picetti, Fausto Catena, Fikri Abu-Zidan, Luca Ansaloni, Rocco A. Armonda, Miklosh Bala, Zsolt J. Balogh, Alessandro Bertuccio, Walt L. Biffl, Pierre Bouzat, Andras Buki, Davide Cerasti, Randall M. Chesnut, Giuseppe Citerio, Federico Coccolini, Raul Coimbra, Carlo Coniglio, Enrico Fainardi, Deepak Gupta, Jennifer M. Gurney, Gregory W. J. Hawryluk, Raimund Helbok, Peter J. A. Hutchinson, Corrado Iaccarino, Angelos Kolias, Ronald W. Maier, Matthew J. Martin, Geert Meyfroidt, David O. Okonkwo, Frank Rasulo, Sandro Rizoli, Andres Rubiano, Juan Sahuquillo, Valerie G. Sams, Franco Servadei, Deepak Sharma, Lori Shutter, Philip F. Stahel, Fabio S. Taccone, Andrew Udy, Tommaso Zoerle, Vanni Agnoletti, Francesca Bravi, Belinda De Simone, Yoram Kluger, Costanza Martino, Ernest E. Moore, Massimo Sartelli, Dieter Weber, Chiara Robba, Apollo - University of Cambridge Repository, Picetti, E, Catena, F, Abu-Zidan, F, Ansaloni, L, Armonda, R, Bala, M, Balogh, Z, Bertuccio, A, Biffl, W, Bouzat, P, Buki, A, Cerasti, D, Chesnut, R, Citerio, G, Coccolini, F, Coimbra, R, Coniglio, C, Fainardi, E, Gupta, D, Gurney, J, Hawrylux, G, Helbok, R, Hutchinson, P, Iaccarino, C, Kolias, A, Maier, R, Martin, M, Meyfroidt, G, Okonkwo, D, Rasulo, F, Rizoli, S, Rubiano, A, Sahuquillo, J, Sams, V, Servadei, F, Sharma, D, Shutter, L, Stahel, P, Taccone, F, Udy, A, Zoerle, T, Agnoletti, V, Bravi, F, De Simone, B, Kluger, Y, Martino, C, Moore, E, Sartelli, M, Weber, D, Robba, C, Institut Català de la Salut, [Picetti E] Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy. [Catena F] Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy. [Abu-Zidan F] The Research Ofce, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates. [Ansaloni L] Unit of General Surgery, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy. [Armonda RA] Department of Neurosurgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA. Department of Neurosurgery, 8405MedStar Washington Hospital Center, Washington, DC, USA. [Bala M] Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, Jerusalem, Israel. [Sahuquillo J] Servei de Neurocirurgia, Vall d’Hebron Hospital Universitari, Barcelona, Spain. Universitat Autònoma de Barcelona, Bellaterra, Spain, Vall d'Hebron Barcelona Hospital Campus, and Citerio, Giuseppe [0000-0002-5374-3161]

Subjects
Hub, Health Occupations::Medicine::Specialties, Surgical::Neurosurgery [DISCIPLINES AND OCCUPATIONS], profesiones sanitarias::medicina::especialidades quirúrgicas::neurocirugía [DISCIPLINAS Y OCUPACIONES], Dany cerebral, Behavior and Behavior Mechanisms::Psychology, Social::Group Processes::Consensus [PSYCHIATRY AND PSYCHOLOGY], conducta y mecanismos de la conducta::psicología social::procesos de grupo::consenso [PSIQUIATRÍA Y PSICOLOGÍA], Neurosurgical Procedures, Wounds and Injuries::Trauma, Nervous System::Craniocerebral Trauma::Brain Injuries::Brain Injuries, Traumatic [DISEASES], Traumatic brain injury, heridas y lesiones::traumatismos del sistema nervioso::traumatismos craneocerebrales::lesiones encefálicas::lesiones encefálicas traumáticas [ENFERMEDADES], Brain Injuries, Traumatic, Humans, Cervell - Ferides i lesions, Research, Presa de decisions, Brain, Otros calificadores::Otros calificadores::/cirugía [Otros calificadores], Management, Spoke, Transfer, Hospitals, Other subheadings::Other subheadings::/surgery [Other subheadings], Hospitalization, Emergency Medicine, Surgery, Sistema nerviós - Cirurgia
Abstract

Acknowledgements: We would like to thank WSES for the support., BACKGROUND: Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. METHODS: A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. RESULTS: A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. CONCLUSIONS: This consensus provides practical recommendations to support clinician's decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

Published
2023

22. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury

Author

Raimund Helbok, FS Taccone, J. Dureanteau, Ari Ercole, Michael N. Diringer, V. De Sloovere, Alex B. Valadka, Geert Meyfroidt, Michael D. Smith, Pierre Bouzat, Thomas P. Bleck, Frederick A. Zeiler, Nino Stocchetti, C. Hawthorne, Bart Depreitere, C. Robba, Luzius A. Steiner, Samuel Klein, Marcel J. H. Aries, Giuseppe Citerio, Jan-Oliver Neumann, Gregory W.J. Hawryluk, P. David Adelson, Stefan Wolf, Randall M. Chesnut, Depreitere, B. [0000-0002-7458-0648], Apollo - University of Cambridge Repository, Depreitere, B [0000-0002-7458-0648], Intensive Care, RS: MHeNs - R1 - Cognitive Neuropsychiatry and Clinical Neuroscience, MUMC+: MA Medische Staf IC (9), Depreitere, B, Citerio, G, Smith, M, Adelson, P, Aries, M, Bleck, T, Bouzat, P, Chesnut, R, De Sloovere, V, Diringer, M, Dureanteau, J, Ercole, A, Hawryluk, G, Hawthorne, C, Helbok, R, Klein, S, Neumann, J, Robba, C, Steiner, L, Stocchetti, N, Taccone, F, Valadka, A, Wolf, S, Zeiler, F, and Meyfroidt, G

Subjects
Adult, DYNAMICS, medicine.medical_specialty, Consensus, Neurology, Delphi Technique, Traumatic brain injury, INTRACRANIAL-PRESSURE, Delphi method, Critical Care and Intensive Care Medicine, OXYGEN, 03 medical and health sciences, 0302 clinical medicine, Homeostasi, Brain Injuries, Traumatic, medicine, Humans, Homeostasis, CRITICAL THRESHOLDS, Autoregulation, Prospective Studies, Cerebral perfusion pressure, Intensive care medicine, Multiple choice, BLOOD-FLOW, HYPERTENSION, business.industry, Gold standard, Reproducibility of Results, 030208 emergency & critical care medicine, Cerebral blood flow, Consensus development, medicine.disease, REACTIVITY, CEREBRAL PERFUSION-PRESSURE, Cerebrovascular Circulation, INSULTS, Neurology (clinical), Neurosurgery, business, Original Work, 030217 neurology & neurosurgery
Abstract

Background Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty. Aim To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities. Methods A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants. Results Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence. Conclusion The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.

Published
2021

23. Traumatic brain injury : progress and challenges in prevention, clinical care, and research

Author

Andrew I R Maas, David K Menon, Geoffrey T Manley, Mathew Abrams, Cecilia Åkerlund, Nada Andelic, Marcel Aries, Tom Bashford, Michael J Bell, Yelena G Bodien, Benjamin L Brett, András Büki, Randall M Chesnut, Giuseppe Citerio, David Clark, Betony Clasby, D Jamie Cooper, Endre Czeiter, Marek Czosnyka, Kristen Dams-O'Connor, Véronique De Keyser, Ramon Diaz-Arrastia, Ari Ercole, Thomas A van Essen, Éanna Falvey, Adam R Ferguson, Anthony Figaji, Melinda Fitzgerald, Brandon Foreman, Dashiell Gantner, Guoyi Gao, Joseph Giacino, Benjamin Gravesteijn, Fabian Guiza, Deepak Gupta, Mark Gurnell, Juanita A Haagsma, Flora M Hammond, Gregory Hawryluk, Peter Hutchinson, Mathieu van der Jagt, Sonia Jain, Swati Jain, Ji-yao Jiang, Hope Kent, Angelos Kolias, Erwin J O Kompanje, Fiona Lecky, Hester F Lingsma, Marc Maegele, Marek Majdan, Amy Markowitz, Michael McCrea, Geert Meyfroidt, Ana Mikolić, Stefania Mondello, Pratik Mukherjee, David Nelson, Lindsay D Nelson, Virginia Newcombe, David Okonkwo, Matej Orešič, Wilco Peul, Dana Pisică, Suzanne Polinder, Jennie Ponsford, Louis Puybasset, Rahul Raj, Chiara Robba, Cecilie Røe, Jonathan Rosand, Peter Schueler, David J Sharp, Peter Smielewski, Murray B Stein, Nicole von Steinbüchel, William Stewart, Ewout W Steyerberg, Nino Stocchetti, Nancy Temkin, Olli Tenovuo, Alice Theadom, Ilias Thomas, Abel Torres Espin, Alexis F Turgeon, Andreas Unterberg, Dominique Van Praag, Ernest van Veen, Jan Verheyden, Thijs Vande Vyvere, Kevin K W Wang, Eveline J A Wiegers, W Huw Williams, Lindsay Wilson, Stephen R Wisniewski, Alexander Younsi, John K Yue, Esther L Yuh, Frederick A Zeiler, Marina Zeldovich, Roger Zemek, InTBIR Participants and Investigators, Maas, A, Menon, D, Manley, G, Abrams, M, Åkerlund, C, Andelic, N, Aries, M, Bashford, T, Bell, M, Bodien, Y, Brett, B, Büki, A, Chesnut, R, Citerio, G, Clark, D, Clasby, B, Cooper, D, Czeiter, E, Czosnyka, M, Dams-O'Connor, K, De Keyser, V, Diaz-Arrastia, R, Ercole, A, van Essen, T, Falvey, É, Ferguson, A, Figaji, A, Fitzgerald, M, Foreman, B, Gantner, D, Gao, G, Giacino, J, Gravesteijn, B, Guiza, F, Gupta, D, Gurnell, M, Haagsma, J, Hammond, F, Hawryluk, G, Hutchinson, P, van der Jagt, M, Jain, S, Jiang, J, Kent, H, Kolias, A, Kompanje, E, Lecky, F, Lingsma, H, Maegele, M, Majdan, M, Markowitz, A, Mccrea, M, Meyfroidt, G, Mikolić, A, Mondello, S, Mukherjee, P, Nelson, D, Nelson, L, Newcombe, V, Okonkwo, D, Orešič, M, Peul, W, Pisică, D, Polinder, S, Ponsford, J, Puybasset, L, Raj, R, Robba, C, Røe, C, Rosand, J, Schueler, P, Sharp, D, Smielewski, P, Stein, M, von Steinbüchel, N, Stewart, W, Steyerberg, E, Stocchetti, N, Temkin, N, Tenovuo, O, Theadom, A, Thomas, I, Espin, A, Turgeon, A, Unterberg, A, Van Praag, D, van Veen, E, Verheyden, J, Vyvere, T, Wang, K, Wiegers, E, Williams, W, Wilson, L, Wisniewski, S, Younsi, A, Yue, J, Yuh, E, Zeiler, F, Zeldovich, M, Zemek, R, RS: MHeNs - R1 - Cognitive Neuropsychiatry and Clinical Neuroscience, Intensive Care, and MUMC+: MA Medische Staf IC (9)

Subjects
NEUROTRAUMA EFFECTIVENESS RESEARCH, OUTCOME PREDICTION, PREHOSPITAL TRIAGE TOOLS, COMMON DATA ELEMENTS, Violence, INTENSIVE-CARE, CEREBRAL PERFUSION-PRESSURE, POSTTRAUMATIC-STRESS-DISORDER, Cost of Illness, LIFE-SUSTAINING THERAPY, CT HEAD RULE, Brain Injuries, Traumatic, Humans, Neurology (clinical), MAJOR TRAUMA, Human medicine, Sports
Abstract

Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research.

Published
2022

24. Intracranial pressure: current perspectives on physiology and monitoring

Author

Gregory W. J. Hawryluk, Giuseppe Citerio, Peter Hutchinson, Angelos Kolias, Geert Meyfroidt, Chiara Robba, Nino Stocchetti, Randall Chesnut, Hawryluk, G, Citerio, G, Hutchinson, P, Kolias, A, Meyfroidt, G, Robba, C, Stocchetti, N, and Chesnut, R

Subjects
Critical care, Traumatic brain injury, Monitoring, Intracranial pressure, Physiology, Cerebrovascular Circulation, Brain Injuries, Traumatic, Humans, Non-invasive, Critical Care and Intensive Care Medicine, Monitoring, Physiologic, Intracranial hypertension
Abstract

Intracranial pressure (ICP) monitoring is now viewed as integral to the clinical care of many life-threatening brain insults, such as severe traumatic brain injury, subarachnoid hemorrhage, and malignant stroke. It serves to warn of expanding intracranial mass lesions, to prevent or treat herniation events as well as pressure elevation which impedes nutrient delivery to the brain. It facilitates the calculation of cerebral perfusion pressure (CPP) and the estimation of cerebrovascular autoregulatory status. Despite advancements in our knowledge emanating from a half century of experience with this technology, important controversies remain related even to fundamental aspects of ICP measurements, including indications for monitoring, ICP treatment thresholds, and management of intracranial hypertension. Here, we review the history of ICP monitoring, the underlying pathophysiology as well as current perspectives on why, when and how ICP monitoring is best used. ICP is typically assessed invasively but a number of emerging, non-invasive technologies with inherently lower risk are showing promise. In selected cases, additional neuromonitoring can be used to assist in the interpretation of ICP monitoring information and adapt directed treatment accordingly. Additional efforts to expand the evidence base relevant to ICP monitoring, related technologies and management remain a high priority in neurosurgery and neurocritical care.

Published
2022

25. Consensus statement from the international consensus meeting on post-traumatic cranioplasty

Author

F. La Porta, A. Cama, Konstantinos Fountas, Jussi P. Posti, Giuseppe Talamonti, Anna Estraneo, Amos Olufemi Adeleye, Andrew I R Maas, Kee B. Park, P. Palma, Tariq Khan, Mino Zucchelli, Gianluigi Zona, Andres M. Rubiano, E. Viaroli, Vicknes Waran, Robson Luis Oliveira de Amorim, Franco Servadei, Stefano Signoretti, Roberto Stefini, Corrado Iaccarino, I. Hossain, Alessandro Bertuccio, Rita Formisano, Andras Buki, Peter J. Hutchinson, Giuseppe Cinalli, Anthony Figaji, Randall M. Chesnut, Angelo Pompucci, P. De Bonis, Carlo Giussani, V. Sinha, Charalabos Gatos, Dirk Lindner, P. Peretta, Anastasia Tasiou, Angelos G. Kolias, S. K. Sengupta, P. D. Adelson, S. I. Florian, Wellingson Silva Paiva, A. Sinha, Antonino Germanò, P. Kasprzak, Paolo Frassanito, Apollo - University of Cambridge Repository, Kolias, Angelos [0000-0003-3992-0587], Hutchinson, Peter [0000-0002-2796-1835], Iaccarino, C, Kolias, A, Adelson, P, Rubiano, A, Viaroli, E, Buki, A, Cinalli, G, Fountas, K, Khan, T, Signoretti, S, Waran, V, Adeleye, A, Amorim, R, Bertuccio, A, Cama, A, Chesnut, R, De Bonis, P, Estraneo, A, Figaji, A, Florian, S, Formisano, R, Frassanito, P, Gatos, C, Germano, A, Giussani, C, Hossain, I, Kasprzak, P, La Porta, F, Lindner, D, Maas, A, Paiva, W, Palma, P, Park, K, Peretta, P, Pompucci, A, Posti, J, Sengupta, S, Sinha, A, Sinha, V, Stefini, R, Talamonti, G, Tasiou, A, Zona, G, Zucchelli, M, Hutchinson, P, and Servadei, F

Subjects
medicine.medical_specialty, Statement (logic), medicine.medical_treatment, media_common.quotation_subject, Consensus Development Conferences as Topic, Neurosurgery, Decompressive craniectomy, Brain tumors, NO, Cranioplasty, Voting, Brain Injuries, Traumatic, Global health, medicine, Humans, Ratification, media_common, Rehabilitation, business.industry, Subject (documents), Conference Report, Plastic Surgery Procedures, Italy, Review Article - Conference Report, Family medicine, hydrocephalu, Surgery, hydrocephalus, Neurology (clinical), Human medicine, business, Inclusion (education), Craniotomy, Hydrocephalus
Abstract

Background Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. Methods The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. Results The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. Conclusions This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Published
2021

26. A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Author

Gregory W.J. Hawryluk, Andres M. Rubiano, Michael N. Diringer, Geoffrey T. Manley, David K. Menon, Juan Sahuquillo, Eve C. Tsai, Franco Servadei, Odette A. Harris, Ramon Diaz Arrastia, Alan Hoffer, Fabio Silvio Taccone, Romer Geocadin, Nino Stocchetti, Geert Meyfroidt, Sergio Aguilera, Lori Shutter, Jeffrey V. Rosenfeld, Stephan A. Mayer, Guoyi Gao, D. Jamie Cooper, David W. Wright, Peter J. Hutchinson, Deborah M. Stein, Ryan S. Kitagawa, Giuseppe Citerio, Jamshid Ghajar, Daniel B. Michael, Claudia S. Robertson, David O. Okonkwo, Paul M. Vespa, Shelly D. Timmons, Eileen M. Bulger, Mathew Joseph, Mauro Oddo, Jamie S. Ullman, Anthony Figaji, Randall M. Chesnut, Christopher Zammit, Andras Buki, Mayur B. Patel, Walter Videtta, Chesnut, R, Aguilera, S, Buki, A, Bulger, E, Citerio, G, Cooper, D, Arrastia, R, Diringer, M, Figaji, A, Gao, G, Geocadin, R, Ghajar, J, Harris, O, Hoffer, A, Hutchinson, P, Joseph, M, Kitagawa, R, Manley, G, Mayer, S, Menon, D, Meyfroidt, G, Michael, D, Oddo, M, Okonkwo, D, Patel, M, Robertson, C, Rosenfeld, J, Rubiano, A, Sahuquillo, J, Servadei, F, Shutter, L, Stein, D, Stocchetti, N, Taccone, F, Timmons, S, Tsai, E, Ullman, J, Vespa, P, Videtta, W, Wright, D, Zammit, C, and Hawryluk, G

Subjects
Traumatic, Intracranial Pressure, Conference Reports and Expert Panel, Critical Care and Intensive Care Medicine, 0302 clinical medicine, Brain Injuries, Traumatic, Protocol, Brain injury, Adult, Algorithms, Brain, Brain Injuries, Traumatic/therapy, Humans, Intracranial Hypertension/therapy, Monitoring, Physiologic, Oxygen, Algorithm, Brain oxygen, Consensus, Head trauma, Intracranial pressure, PbtO2, SIBICC, Seattle, Tiers, Consensus conference, Management algorithm, Public Health and Health Services, Intracranial pressure monitoring, medicine.medical_specialty, Physical Injury - Accidents and Adverse Effects, Monitoring, Traumatic brain injury, Clinical Sciences, Consensu, Traumatic Brain Injury (TBI), 03 medical and health sciences, Anesthesiology, medicine, Physiologic, Intensive care medicine, bt, Traumatic Head and Spine Injury, Protocol (science), Adult patients, business.industry, Neurosciences, 030208 emergency & critical care medicine, medicine.disease, Emergency & Critical Care Medicine, Brain Disorders, Tier, 030228 respiratory system, Brain Injuries, Intracranial Hypertension, business
Abstract

Background Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place. Methods Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting. Results We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms. Conclusions These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference. Electronic supplementary material The online version of this article (10.1007/s00134-019-05900-x) contains supplementary material, which is available to authorized users.

Published
2020

27. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Author

Juan Sahuquillo, Paul M. Vespa, Alan Hoffer, Fabio Silvio Taccone, Geert Meyfroidt, Odette A. Harris, Shelly D. Timmons, Eve C. Tsai, David K. Menon, David W. Wright, Sergio Aguilera, Lori Shutter, Walter Videtta, Christopher Zammit, Franco Servadei, Romergryko G. Geocadin, Andres M. Rubiano, Jamshid Ghajar, Jeffrey V. Rosenfeld, Daniel B. Michael, Deborah M. Stein, Anthony Figaji, Mauro Oddo, David O. Okonkwo, Andras Buki, Geoffrey T. Manley, Nino Stocchetti, D. Jamie Cooper, Mayur B. Patel, Eileen M. Bulger, Stephan A. Mayer, Guoyi Gao, Claudia S. Robertson, Mathew Joseph, Jamie S. Ullman, Peter Hutchinson, Randall M. Chesnut, Gregory W.J. Hawryluk, Giuseppe Citerio, Ramon Diaz Arrastia, Michael N. Diringer, Ryan S. Kitagawa, [Hawryluk GWJ] Section of Neurosurgery, University of Manitoba, Winnipeg, Canada. [Aguilera S] Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile. Valparaiso University, Valparaiso, Chile. [Buki A] Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság Útja, Pécs, Hungary. University of Pécs, Pécs, Hungary. [Bulger E] Department of Surgery, Harborview Medical Center, University of Washington, Seattle, USA. [Citerio G] School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, Monza, Italy. [Cooper DJ] Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia. Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia. [Sahuquillo J] Servei de Neurocirurgia, Vall d'Hebron Hospital Universitari, Barcelona, Spain, Vall d'Hebron Barcelona Hospital Campus, Rubiano, Andrés M. [0000-0001-8931-3254], Hawryluk, G, Aguilera, S, Buki, A, Bulger, E, Citerio, G, Cooper, D, Arrastia, R, Diringer, M, Figaji, A, Gao, G, Geocadin, R, Ghajar, J, Harris, O, Hoffer, A, Hutchinson, P, Joseph, M, Kitagawa, R, Manley, G, Mayer, S, Menon, D, Meyfroidt, G, Michael, D, Oddo, M, Okonkwo, D, Patel, M, Robertson, C, Rosenfeld, J, Rubiano, A, Sahuquillo, J, Servadei, F, Shutter, L, Stein, D, Stocchetti, N, Taccone, F, Timmons, S, Tsai, E, Ullman, J, Vespa, P, Videtta, W, Wright, D, Zammit, C, and Chesnut, R

Subjects
Male, Traumatic, Consensus Development Conferences as Topic, Psychological intervention, Critical Care and Intensive Care Medicine, 0302 clinical medicine, Brain Injuries, Traumatic, 80 and over, Protocol, Brain injury, Traumatismos craneocerebrales, Intracranial pressure, Aged, 80 and over, medicine.diagnostic_test, Middle Aged, AUTOREGULATION, Management algorithm, Algorithm, Ciencias de la información::análisis de sistemas::técnica Delfos [CIENCIA DE LA INFORMACIÓN], Practice Guidelines as Topic, Public Health and Health Services, Intracranial pressure monitoring, Nervous System Diseases::Nervous System Diseases::Trauma, Nervous System::Craniocerebral Trauma::Brain Injuries::Brain Injuries, Traumatic [DISEASES], Information Science::Systems Analysis::Delphi Technique [INFORMATION SCIENCE], Female, TRIAL, medicine.symptom, Life Sciences & Biomedicine, Algorithms, intracranial pressure, monitoring Severe Traumatic Brain Injury, Adult, medicine.medical_specialty, Physical Injury - Accidents and Adverse Effects, Consensus, Monitoring, Musculoskeletal and Neural Physiological Phenomena::Nervous System Physiological Phenomena::Cerebrospinal Fluid Pressure::Intracranial Pressure [PHENOMENA AND PROCESSES], Traumatic brain injury, Aged, Brain Injuries, Traumatic/diagnosis, Brain Injuries, Traumatic/physiopathology, Humans, Intracranial Hypertension/diagnosis, Intracranial Hypertension/physiopathology, Monitoring, Physiologic/methods, Monitoring, Physiologic/standards, Head trauma, SIBICC, Seattle, Tiers, Sedation, Clinical Sciences, Consensu, Neurological examination, Presión intracraneal, and over, Traumatic Brain Injury (TBI), 03 medical and health sciences, Critical Care Medicine, Equips d'especialistes, General & Internal Medicine, DECOMPRESSIVE CRANIECTOMY, medicine, enfermedades del sistema nervioso::enfermedades del sistema nervioso::traumatismos del sistema nervioso::traumatismos craneocerebrales::lesiones encefálicas::lesiones encefálicas traumáticas [ENFERMEDADES], Physiologic, Intensive care medicine, Cervell - Ferides i lesions, Traumatic Head and Spine Injury, Monitoring, Physiologic, Lesiones traumáticas del encéfalo, Protocol (science), Science & Technology, business.industry, Neurosciences, 030208 emergency & critical care medicine, medicine.disease, Emergency & Critical Care Medicine, Brain Disorders, fenómenos fisiológicos nerviosos y musculoesqueléticos::fenómenos fisiológicos del sistema nervioso::presión del líquido cefalorraquídeo::presión intracraneal [FENÓMENOS Y PROCESOS], Tier, 030228 respiratory system, Brain Injuries, Intracranial Hypertension, business, Pressió intracranial
Abstract

Brain injury; Head trauma; Algorithm Daño cerebral; Trauma en la cabeza; Algoritmo Lesió cerebral; Trauma al cap; Algoritme Background: Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation’s sTBI Management Guidelines, as they were not evidence-based. Methods: We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole- and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists’ decision tendencies were the focus of recommendations. Results: We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination. Conclusions: Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management recommendations based on combined expert opinion. It reflects neither a standard-of-care nor a substitute for thoughtful individualized management. We thank our financial supporters who include Adler/Geirsch Attorney at Law, the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Neurotrauma and Critical Care, Bard, the Brain Trauma Foundation, DePuy, Hemedex, Integra, the Neurointensive Care Section of the European Society of Intensive Care Medicine, Neurosurgical Society of Australasia, Medtronic, Moberg Research, Natus, Neuroptics, Raumedic, Sophysa, Stryker, and Zoll.

Published
2019

28. WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

Author

Andrew W Kirkpatrick, Juan Sahuquillo, Federico Coccolini, Luca Ansaloni, Raul Coimbra, George C. Velmahos, Raimund Helbok, Edoardo Picetti, Philip F. Stahel, Rocco Armonda, Deepak Gupta, Sandra Rossi, Franco Servadei, Zsolt J. Balogh, Thomas M. Scalea, Francesco Minardi, Andrew I.R. Maas, Ari Leppäniemi, Sandro Rizoli, Maurizio Berardino, Ronald V. Maier, Marco Ceresoli, Pierre Bouzat, Fausto Catena, Massimo Sartelli, Randall M. Chesnut, Giuseppe Citerio, Gian Luca Baiocchi, Yasuhiro Otomo, Yoram Kluger, Gustavo Pereira Fraga, Peter J. Hutchinson, Fikri M. Abu-Zidan, Osvaldo Chiara, Dieter G. Weber, Andres M. Rubiano, Nino Stocchetti, Andras Buki, Ernest E. Moore, Salomone Di Saverio, Takahiro Kinoshita, Fabio Silvio Taccone, Walter L. Biffl, David O. Okonkwo, John Myburgh, Miklosh Bala, Tommaso Tonetti, Rubiano, Andrés M. [0000-0001-8931-3254], Hutchinson, Peter [0000-0002-2796-1835], Apollo - University of Cambridge Repository, Picetti, E, Rossi, S, Abu-Zidan, F, Ansaloni, L, Armonda, R, Baiocchi, G, Bala, M, Balogh, Z, Berardino, M, Biffl, W, Bouzat, P, Buki, A, Ceresoli, M, Chesnut, R, Chiara, O, Citerio, G, Coccolini, F, Coimbra, R, Di Saverio, S, Fraga, G, Gupta, D, Helbok, R, Hutchinson, P, Kirkpatrick, A, Kinoshita, T, Kluger, Y, Leppaniemi, A, Maas, A, Maier, R, Minardi, F, Moore, E, Myburgh, J, Okonkwo, D, Otomo, Y, Rizoli, S, Rubiano, A, Sahuquillo, J, Sartelli, M, Scalea, T, Servadei, F, Stahel, P, Stocchetti, N, Taccone, F, Tonetti, T, Velmahos, G, Weber, D, Catena, F, Citerio, Giuseppe [0000-0002-5374-3161], and Edoardo Picetti, Sandra Rossi, Fikri M. Abu-Zidan, Luca Ansaloni, Rocco Armonda, Gian Luca Baiocchi, Miklosh Bala, Zsolt J. Balogh, Maurizio Berardino, Walter L. Biffl, Pierre Bouzat, Andras Buki, Marco Ceresoli, Randall M. Chesnut, Osvaldo Chiara, Giuseppe Citerio, Federico Coccolini, Raul Coimbra, Salomone Di Saverio, Gustavo P. Fraga, Deepak Gupta, Raimund Helbok, Peter J. Hutchinson, Andrew W. Kirkpatrick, Takahiro Kinoshita, Yoram Kluger, Ari Leppaniemi, Andrew I. R. Maas, Ronald V. Maier, Francesco Minardi, Ernest E. Moore, John A. Myburgh, David O. Okonkwo, Yasuhiro Otomo, Sandro Rizoli, Andres M. Rubiano, Juan Sahuquillo, Massimo Sartelli, Thomas M. Scalea, Franco Servadei, Philip F. Stahel, Nino Stocchetti, Fabio S. Taccone, Tommaso Tonetti, George Velmahos, Dieter Weber, Fausto Catena

Subjects
Adult, medicine.medical_specialty, Delphi Technique, Monitoring, Traumatic brain injury, Bleeding, Hemorrhage, Management, Polytrauma, Consensus Development Conferences as Topic, lcsh:Surgery, Poison control, Guidelines as Topic, Review, Suicide prevention, Occupational safety and health, 03 medical and health sciences, Traumatic brain injury, Polytrauma, Bleeding, Hemorrhage, Monitoring, Management, 0302 clinical medicine, Injury prevention, Brain Injuries, Traumatic, medicine, Humans, Monitoring, Physiologic, Lesiones traumáticas del encéfalo, business.industry, Multiple Trauma, Head injury, lcsh:Medical emergencies. Critical care. Intensive care. First aid, Human factors and ergonomics, 030208 emergency & critical care medicine, lcsh:RD1-811, lcsh:RC86-88.9, medicine.disease, Hipotensión, 3. Good health, Patient Care Management, General Surgery, Emergency medicine, Emergency Medicine, Surgery, Human medicine, Encefalopatía traumática crónica, business, 030217 neurology & neurosurgery
Abstract

The acute phase management of patients with severe traumatic brain injury (TBI) and polytrauma represents a major challenge. Guidelines for the care of these complex patients are lacking, and worldwide variability in clinical practice has been documented in recent studies. Consequently, the World Society of Emergency Surgery (WSES) decided to organize an international consensus conference regarding the monitoring and management of severe adult TBI polytrauma patients during the first 24 hours after injury. A modified Delphi approach was adopted, with an agreement cut-off of 70%. Forty experts in this field (emergency surgeons, neurosurgeons, and intensivists) participated in the online consensus process. Sixteen recommendations were generated, with the aim of promoting rational care in this difficult setting.

Published
2019

29. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury: Consensus statement

Author

Giuseppe Citerio, Angelos G. Kolias, Anthony Figaji, Mathew Joseph, Andres M. Rubiano, Paul N. Manson, Chris Uff, Dhananjaya I Bhat, Weiming Liu, Franco Servadei, Kostas N. Fountas, Idara Edem, Nasser M F El-Ghandour, Adam J. Wells, Kee B. Park, Ivan Timofeev, Oleg V. Levchenko, Marek Czosnyka, Tsegazeab Laeke, David K. Menon, Abenezer Tirsit Aklilu, Geoffrey T. Manley, Mark Wilson, Ernest J. Barthélemy, Clare N. Gallagher, Nino Stocchetti, Gail Rosseau, Anna Teresa Mazzeo, Gregory W.J. Hawryluk, Alex B. Valadka, Diederik Bulters, Daniel B. Michael, B Indira Devi, Vicknes Waran, Andrew I R Maas, Shelly D. Timmons, Jeffrey V. Rosenfeld, Tamara Tajsic, Jamie S. Ullman, Baiyun Liu, D. Jamie Cooper, David O. Okonkwo, Tedy Apriawan, Hamisi K. Shabani, Randall M. Chesnut, Peter J. Hutchinson, Amos Olufemi Adeleye, Corrado Iaccarino, Susanne Muehlschlegel, Tariq Khan, Abdul Hafid Bajamal, Hutchinson, P, Kolias, A, Tajsic, T, Adeleye, A, Aklilu, A, Apriawan, T, Bajamal, A, Barthélemy, E, Devi, B, Bhat, D, Bulters, D, Chesnut, R, Citerio, G, Cooper, D, Czosnyka, M, Edem, I, El-Ghandour, N, Figaji, A, Fountas, K, Gallagher, C, Hawryluk, G, Iaccarino, C, Joseph, M, Khan, T, Laeke, T, Levchenko, O, Liu, B, Liu, W, Maas, A, Manley, G, Manson, P, Mazzeo, A, Menon, D, Michael, D, Muehlschlegel, S, Okonkwo, D, Park, K, Rosenfeld, J, Rosseau, G, Rubiano, A, Shabani, H, Stocchetti, N, Timmons, S, Timofeev, I, Uff, C, Ullman, J, Valadka, A, Waran, V, Wells, A, Wilson, M, Servadei, F, Hutchinson, Peter [0000-0002-2796-1835], Kolias, Angelos [0000-0003-3992-0587], Menon, David [0000-0002-3228-9692], and Apollo - University of Cambridge Repository

Subjects
Traumatic, Decompression, medicine.medical_specialty, Decompressive Craniectomy, Physical Injury - Accidents and Adverse Effects, Consensus, Traumatic brain injury, Statement (logic), medicine.medical_treatment, Clinical Sciences, Neurosurgery, Cranioplasty, Decompression, Neurosurgery, Neurotrauma, Cranioplasty, Neurotrauma, Brain Injuries, Traumatic, Humans, Intracranial Hypertension, Traumatic Brain Injury (TBI), 030218 nuclear medicine & medical imaging, 03 medical and health sciences, 0302 clinical medicine, Medicine, Intensive care medicine, Traumatic Head and Spine Injury, Neurology & Neurosurgery, business.industry, Neurosciences, Injuries and accidents, medicine.disease, Brain Disorders, nervous system diseases, 3. Good health, Good Health and Well Being, Brain Injuries, Surgery, Decompressive craniectomy, Neurology (clinical), Human medicine, business, 030217 neurology & neurosurgery
Abstract

Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction. publishedVersion

Published
2019

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