Management of traumatic brain injury in China versus Europe

Abstract

It was a pleasure to read the extremely detailed study reported in The Lancet Neurology by Gao and colleagues1Gao G Wu X Feng J et al.Clinical characteristics and outcomes in paţients with traumatic brain injury in China: a prospective, multicentre, longitudinal, observational study.Lancet Neurol. 2020; 19: 670-677Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar on the clinical characteristics and outcomes of patients with traumatic brain injury in China. The dataset encompasses a total of 13 627 patients with traumatic brain injury collected over 2·5 years, which slightly exceeds the numbers of many European studies, such as the CRASH trial,2Perel P Arango M et al.Medical Research Council CRASH Trial CollaboratorsPredicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients.BMJ. 2008; 336: 425-429Crossref PubMed Scopus (770) Google Scholar which enrolled about 8500 patients. I agree with the authors that the strengths of the study are its large size, the prospective data collection, and the multicentre collaboration to cover over two-thirds of all neurosurgical centres in China (a country that has a population of over 1·5 billion). Ultimately, Gao and colleagues have modelled a Chinese registry based on the Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) registry,3Maas AI Menon DK Steyerberg EW et al.Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI): a prospective longitudinal observational study.Neurosurgery. 2015; 76: 67-80Crossref PubMed Scopus (298) Google Scholar allowing the potential for accurate comparative analysis between the management of traumatic brain injury in China and Europe. Although the authors mention limitations of the study—eg, the under-representation of patients with major extracranial injury owing to these patients being commonly treated in non-neurosurgical (ie, general) intensive care units in China, the study can nevertheless serve as a benchmark for future inquiry into assessing outcomes of traumatic brain injury in China, which, courtesy of the large number of patients, can inform collaborative practices between European and Chinese centres. However, several important variables in the study by Gao and colleagues seem at odds with those cited in previous literature. For example, the proportion of patients with (presumably isolated) systemic hypotension in the cohort is stated to be between 1% and 3%. This statistic greatly conflicts with the estimated incidence of systemic hypotension of 4·6% by Spaite and colleagues,4Spaite DW Hu C Bobrow BJ et al.The impact of combined prehospital hypotension and hypoxia on mortality in major traumatic brain injury.Ann Emerg Med. 2017; 69: 62-72Summary Full Text Full Text PDF PubMed Scopus (89) Google Scholar as per their prospective pre-implementation cohort analysing patient and injury characteristics by survival status of 13 151 patients enrolled from Jan 1, 2007, to March 31, 2014. In addition, Stassen and colleagues5Stassen W Welzel T The prevalence of hypotension and hypoxaemia in blunt traumatic brain injury in the prehospital setting of Johannesburg, South Africa: a retrospective chart review.S Afr Med J. 2014; 104: 424-427Crossref PubMed Google Scholar reported an incidence of 33% on their retrospective cross-sectional descriptive study of 66 patients enrolled from Jan 1, 2011, to Dec 31, 2011. Therefore, even if regional variations are considered, the dataset by Gao and colleagues seems unusually small at 1%. Furthermore, Gao and colleagues incorrectly assume that, unlike for patients in Japan, the USA or the UK, the median age of 48 years in their cohort is unique. A look at the study by Spaite and colleagues4Spaite DW Hu C Bobrow BJ et al.The impact of combined prehospital hypotension and hypoxia on mortality in major traumatic brain injury.Ann Emerg Med. 2017; 69: 62-72Summary Full Text Full Text PDF PubMed Scopus (89) Google Scholar suggests that the median age in a dataset of 13 151 patients is similar, at 45 years. Therefore, traumatic brain injury in China afflicts a similar patient demographic regarding age if compared with the USA and some European countries. Another point is the geographical variation in traumatic brain injury mortality in neurosurgical centres across China, and subsequent morbidity and access to rehabilitation services. It is this geographical variation that distinguishes Gao and colleagues' study from the European traumatic brain injury studies, because many European countries have not comparatively analysed outcomes on the basis of regional differences within each country. Further research is urgently needed to address how best to improve resources, for both neurosurgical and non-neurosurgical interventions. I declare no competing interests. Management of traumatic brain injury in China versus Europe – Authors' replyWe thank Simon Lammy for his interest in our large size, multicentre, observational study that reveals the clinical characteristics and outcomes of patients with traumatic brain injury in China.1 The data have been prospectively collected following the methods of the Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) registry, which paved a practical way for comparative analysis in the care of traumatic brain injury between China and Europe, as reported in August, 2020, by Feng and colleagues. Full-Text PDF Clinical characteristics and outcomes in patients with traumatic brain injury in China: a prospective, multicentre, longitudinal, observational studyThe results show differences in mortality between centres and regions across China, which indicates potential for identifying best practices through comparative effectiveness research. The risk factors identified in prognostic analyses might contribute to developing benchmarks for assessing quality of care. Full-Text PDF