Elderly Traumatic Brain Injury Patients Research Articles

Nomogram for Predicting Central Nervous System Infection Following Traumatic Brain Injury in the Elderly

This study aims to identify risk factors for central nervous system (CNS) infection in elderly patients hospitalized with traumatic brain injury (TBI) and to develop a reliable predictive tool for assessing the likelihood of CNS infection in this population. We conducted a retrospective study on 742 elderly TBI patients treated at Tangdu Hospital, China. Clinical data was randomly split into training and validation sets (7:3 ratio). By conducting univariate and multivariate logistic regression analysis in the training set, we identified a list of variables to develop a nomogram for predicting the risk of CNS infection. We evaluated the performance of the predictive model in both cohorts respectively, using receiver operating characteristics curves, calibration curves, and decision curve analysis. Results of the logistic analysis in the training set indicated that surgical intervention (P= 0.007), red blood cell count (P= 0.019), C-reactive protein concentration (P < 0.001), and cerebrospinal fluid leakage (P < 0.001) significantly predicted the occurrence of CNS infection in elderly TBI patients. The model constructed based on these variables had high predictive capability (area under the curve-training= 0.832; area under the curve-validation= 0.824) as well as clinical utility. A nomogram constructed based on several key predictors reasonably predicts the risk of CNS infection in elderly TBI patients upon hospital admission. The model of the nanogram may contribute to timely interventions and improve health outcomes among affected individuals.

Traumatic brain injury in the elderly population: a 20-year experience in a tertiary neurosurgery center in Belgium.

Traumatic brain injury (TBI) rates in the elderly population are rapidly increasing worldwide. However, there are no clinical guidelines for the treatment of elderly TBI to date. This study aims at describing injury patterns and severity, clinical management, and outcomes in elderly TBI patients, which may contribute to specific prognostic tools and clinical guidelines in the future. Clinical records of 2999 TBI patients ≥ 65years old admitted in the University Hospital Leuven (Belgium) between 1999 and 2019 were manually screened and 1480 cases could be included. Records were scrutinized for relevant clinical data. The median age in the cohort was 78.0years (IQR = 12). Falls represented the main accident mechanism (79.7%). The median Glasgow Coma Score on admission was 15 (range 3-15). Subdural hematomas were the most common lesion (28.4%). 90.1% of all patients were hospitalized and 27.0% were admitted to intensive care. 16.4% underwent a neurosurgical intervention. 11.0% of all patients died within 30days post-TBI. Among the 521 patients with mild TBI, 28.6% were admitted to ICU and 13.1% had a neurosurgical intervention and 30-day mortality was 6.9%. Over the 20-year study period, an increase of age and comorbidities and a reduction in neurosurgical interventions and ICU admissions were observed, along with a trend to less severe injuries but a higher proportion of treatment withdrawals, while at the same time mortality rates decreased. TBI is a life-changing event, leading to severe consequences in the elderly population, especially at higher ages. Even mild TBI is associated with substantial rates of hospitalization, surgery, and mortality in elderly. The characteristics of the elderly population with TBI are subject to changes over time.

The prognostic value of cardiac troponin T in different age groups of traumatic brain injury patients.

The cardiac dysfunction has been confirmed as a common non-neurological complication and associated with increased mortality in traumatic brain injury (TBI) patients. As a biological marker of cardiac injury, the cardiac troponin T (TnT) has been verified correlated with the outcome of some non-traumatic brain injury patients. However, the prognostic value of TnT in TBI patients has not been clearly illustrated. We designed this study to explore the association between TnT and the outcome of TBI patients in different age subgroups. Patients diagnosed with TBI in a prospective critical care database were eligible for this study. Univariate logistic regression analysis was firstly performed to explore the relationship between included variables and mortality. Then, the real effect of TnT on the outcome of different age subgroups was analyzed by multivariate logistic regression analysis adjusting the confounding effects of other significant risk factors. Finally, we draw receiver operating characteristic (ROC) curves to evaluate the prognostic value of TnT in different age groups of TBI patients. 520 patients were included in this study with a mortality rate of 20.2%. There were 112 (21.5%) non-elderly patients (age < 65) and 408 (78.5%) elderly patients (age ≥ 65). Non-survivors had a higher percentage of previous acute myocardial infarction (p = 0.019) and pupil no-reaction (p = 0.028; p = 0.011) than survivors. Survivors had higher GCS (p < 0.001) and lower TnT than non-survivors (p < 0.001). TnT was significantly associated with mortality in non-elderly patients (p = 0.031) but not in overall patients (p = 0.143) and elderly patients (p = 0.456) in multivariate logistic regression analysis. The AUC (area under the ROC curve) value of TnT in overall, non-elderly and elderly patients was 0.644, 0.693 and 0.632, respectively. Combining TnT with GCS increased the sensitivity of predicting the poor outcome in both non-elderly and elderly TBI patients. The prognostic value of TnT differed between elderly and non-elderly TBI patients. Level of TnT was associated with mortality of non-elderly TBI patients but not elderly patients. Combining the TnT with GCS could increase the sensitivity of prognosisevaluation.

Inter-hospital transfer of polytrauma and severe traumatic brain injury patients: Retrospective nationwide cohort study using data from the Swiss Trauma Register

IntroductionPolytrauma and traumatic brain injury (TBI) patients are among the most vulnerable patients in trauma care and exhibit increased morbidity and mortality. Timely care is essential for their outcome. Severe TBI with initially high scores on the Glasgow Coma (GCS) scores is difficult to recognise on scene and referral to a Major Trauma Center (MTC) might be delayed. Therefore, we examined current referral practice, injury patterns and mortality in these patients.Materials and methodsRetrospective, nationwide cohort study with Swiss Trauma Register (STR) data between 01/012015 and 31/12/2018. STR includes patients ≥16 years with an Injury Severity Score (ISS) >15 and/or an Abbreviated Injury Scale (AIS) for head >2. We performed Cox proportional hazard models with injury type as the primary outcome and mortality as the dependent variable. Secondary outcomes were inter-hospital transfer and age.Results9,595 patients were included. Mortality was 12%. 2,800 patients suffered from isolated TBI. 69% were men. Median age was 61 years and median ISS 21. Two thirds of TBI patients had a GCS of 13–15 on admission to the Emergency Department (ED). 26% of patients were secondarily transferred to an MTC. Patients with isolated TBI and those aged ≥65 years were transferred more often. Crude analysis showed a significantly elevated hazard for death of 1.48 (95%CI 1.28–1.70) for polytrauma patients with severe TBI and a hazard ratio (HR) of 1.82 (95%CI 1.58–2.09) for isolated severe TBI, compared to polytrauma patients without TBI. Patients directly admitted to the MTC had a significantly elevated HR for death of 1.63 (95%CI 1.40–1.89), compared to those with secondary transfer.ConclusionsA high initial GCS does not exclude the presence of severe TBI and triage to an MTC should be seriously considered for elderly TBI patients.

Traumatic brain injury\u2014the effects of patient age on treatment intensity and mortality

BackgroundAgeing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a self-fulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI.MethodsIncluded in this study was consecutively admitted patients with TBI, aged ≥ 15 years, with a cerebral CT showing intracranial signs of trauma, during the time-period between 2015–2018. Data were extracted from our prospective quality control registry for admitted TBI patients. As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Uni- and multivariate survival analyses were performed using logistic multinomial regression.ResultsA total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years (range 15–98), 70% were men, and 39% were ≥ 65 years. Head injury severity was mild in 706 patients (45%), moderate in 437 (28%), and severe in 428 (27%). Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score ≥ 3, and low management intensity.ConclusionThe present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of treatment bias and could in the future be limited with a more aggressive management regime.

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

BackgroundThe probability of favorable outcome after traumatic brain injury (TBI) decreases with age. Elderly, ≥ 60 years, are an increasing part of our population. Recent studies have shown an increase of favorable outcome in elderly over time. However, the optimal patient selection and neurointensive care (NIC) treatments may differ in the elderly and the young. The aims of this study were to examine outcome in a larger group of elderly TBI patients receiving NIC and to identify demographic and treatment related prognostic factors.MethodsPatients with TBI ≥ 60 years receiving NIC at our department between 2008 and 2014 were included. Demographics, co-morbidity, admission characteristics, and type of treatments were collected. Clinical outcome at around 6 months was assessed. Potential prognostic factors were included in univariate and multivariate regression analysis with favorable outcome as dependent variable.ResultsTwo hundred twenty patients with mean age 70 years (median 69; range 60–87) were studied. Overall, favorable outcome was 46% (Extended Glasgow Outcome Scale (GOSE) 5–8), unfavorable outcome 27% (GOSE 2–4), and mortality 27% (GOSE 1). Significant independent negative prognostic variables were high age (p < 0.05), multiple injuries (p < 0.05), GCS M ≤ 3 on admission (p < 0.05), and mechanical ventilation (p < 0.001).ConclusionsOverall, the elderly TBI patients > 60 years receiving modern NIC in this study had a fair chance of favorable outcome without large risks for severe deficits and vegetative state, also in patients over 75 years of age. High age, multiple injuries, GCS M ≤ 3 on admission, and mechanical ventilation proved to be independent negative prognostic factors. The results underline that a selected group of elderly with TBI should have access to NIC.

Clinical characteristics analysis of 2 368 patients with traumatic brain injury

Objective To understand the clinical characteristics of traumatic brain injury (TBI) patients and provide fundamental data for reducing the incidence of TBI and improving its treatment efficacy. Methods Medical histories of TBI inpatients from January 2011 to December 2016 were collected from the TBI database of Neurosurgical Department at Tianjin Medical University General Hospital. Information including gender, age, causes of TBI, injury severity, sources of the inpatients, interval from injury to treatment, diagnosis, and treatment were analyzed retrospectively. Results A total of 2 368 TBI patients were enrolled, aged mainly 30-60 years. There were more male patients (n=1 741) than female patients (n=627) (2.78 ∶1), while the gender ratio was reversed among patients above 60 years old (2.09 ∶1) (P<0.05). Traffic accident (60.14%) remained the major cause of TBI, while the proportion of electric motorcycle accident was 17.35%, followed by fall from height (13.64%). The proportion of mild TBI patients from suburb counties was lower than that of patients from the six urban areas (P<0.05), while the proportion of heavy TBI patients from other provinces was higher than those of both urban and suburb counties (P<0.05). The average interval from injury to specialist treatment was 7.53 hours. Patients who received treatment within 3 hours had better improvement than those who were treated 3 hours after TBI (P<0.05). The main injuries were skull fracture (33.07%) and brain contusion (30.32%). A total of 783 patients (33.07%) underwent surgery, among which 693 patients received the most common procedure of craniotomy hematoma evacuation (including decompressive craniectomy). The improvement rate of patients with intracranial pressure monitoring was higher than those without intracranial pressure monitoring (P<0.05). The improvement rate of the surgery group was significantly higher than that of the non surgery group (P<0.05). Conclusions The ratio of elderly female TBI patients is on the rise; TBI presents an increase in traffic accidents; mild TBI patients choose to receive treatment in close hospitals while those with severe TBI choose comprehensive hospitals; and the interval from injury to treatment is long. The following strategies including improving the traffic facilities, strengthening the education of traffic safety on elderly females and pedestrians, and optimizing the TBI medical treatment process would reduce the incidence of TBI and improve the efficiency of treatment. Key words: Brain injuries; Database; Inpatients; Clinical characteristics

Clinical efficacy of compound Ipratropium bromide atomization inhalation combined with Ambroxol intravenous treatment in traumatic brain injury patients with tracheotomy

Objective To investigate the clinical value of compound ipratropium bromide atomization inhalation combined with ambroxol intravenous treatment in traumatic brain injury patients with tracheotomy. Methods Totally 58 elderly patients undergoing tracheotomy for traumatic brain injury admitted to our hospital from April 2014 to April 2015 were selected, and they were randomly divided into the observation group and the control group. The control group was treated with a pure ambroxol intravenous injection, and the observation group was treated with compound Ipratropium bromide atomization inhalation combined with Ambroxol intravenous treatment. Pulmonary infection time, the indwelling time for tracheotomy tube, the incidences of airway mucosal bleeding and other complications and the positive rate of sputum culture at 3, 7, 14 days after treatment were compared between the two groups. Results Pulmonary infection time and the indwelling time for tracheotomy tube were shorter in the observation group than in the control group 〔(16.8±7.2) d vs. (24.5±14.1) d, (19.0±5.9) d vs. (27.4±6.5) d, both P 0.05). The positive rate of sputum culture at 5 and 7 days after treatment were lower in the observation group than in the control group (48.3% vs. 55.2%, 34.5% vs. 51.7%, P<0.05). Conclusions The compound Ipratropium bromide atomization inhalation combined with Ambroxol intravenous treatment versus a pure Ambroxol intravenous treatment has a significant clinical efficacy in elderly traumatic brain injury patients with tracheotomy, and it can reduce the incidence of adverse reactions, which is worthy of clinical application. Key words: Cholinergic antagonists; Ambroxol; Craniocerebral trauma

Association between the outcome of traumatic brain injury patients and cerebrovascular autoregulation, cerebral perfusion pressure, age, and injury grades

Background and objectiveThe aim of this study was to explore the association of cerebrovascular autoregulation (CA) and optimal cerebral perfusion pressure (CPP) managing conditions with the outcome of traumatic brain injury (TBI) patients including additional information about the patients’ age and grade of diffuse axonal injury (DAI). Materials and methodsThe CA monitoring of 28 TBI patients was performed by using ICM+ software (Cambridge, UK). The CA status estimating pressure reactivity indexes (PRx) and CPP data were processed in order to obtain information on the patient-specific treatment conditions by calculating the optimal CPP. ResultsThere was a negative correlation between the Glasgow outcome scale (GOS) score and PRx (r=−0.448 at hospital discharge and r=−0.402 after 6 months). The estimated threshold value PRx of >0.24 was associated with mortality. The correlation coefficients between the GOS score and the difference CPP-optimal CPP were 0.549 at hospital discharge and 0.484 after 6 months. The threshold value of CPP declination from ΔCPPopt per −6mmHg was associated with mortality. Poorer outcome was predicted for elderly TBI patients (aged >47 years) and patients having a DAI grade of 3. ConclusionsThe association of the GOS score with CPP, CA impairment conditions, age and diffuse axonal injury (DAI) grade showed that the outcomes of TBI patients were associated with patient-specific CPP management and better outcomes were obtained for younger patients, for patients having lower DAI grade and for patients whose CPP was kept within the range from the optimal CPP to the optimal CPP+10mmHg.

Promising clinical outcome of elderly with TBI after modern neurointensive care.

The increasing number of elderly patients with traumatic brain injury (TBI) leads to specific neurointensive care (NIC) challenges. Therefore, elderly subjects with TBI need to be further studied. In this study we evaluated the demographics, management and outcome of elderly TBI patients receiving modern NIC. Patients referred to our NIC unit between 2008 and 2010 were included. Patients were divided in two age groups, elderly (E) ≥65years and younger (Y) 64-15 years. Parameters studied were the dominant finding on CT scans, neurological motor skills and consciousness, type of monitoring, neurosurgical procedures/treatments and Glasgow Outcome Scale Extended score at 6 months after injury. Sixty-two E (22%) and 222 Y (78%) patients were included. Falls were more common in E (81%) and vehicle accidents were more common in Y patients (37%). Acute subdural hematoma was significantly more common in E (50% of cases) compared to Y patients (18%). Intracranial pressure was monitored in 44% of E and 57% of Y patients. Evacuation of significant mass lesions was performed more common in the E group. The NIC mortality was similar in both groups (4-6%). Favorable outcome was observed in 72% of Y and 51% of E patients. At the time of follow-up 25% of E and 7% of Y patients had died. The outcome of elderly patients with TBI was significantly worse than in younger patients, as expected. However, as much as 51% of the elderly patients showed a favorable outcome after NIC. We believe that these results encourage modern NIC in elderly patients with TBI. We need to study how secondary brain injury mechanisms differ in the older patients and to identify specific outcome predictors for elderly patients with TBI.

Damage Control Cultures in Elderly Patients with Traumatic Brain Injury

INTRODUCTION: Traumatic brain injury (TBI) in elderly patients compromises immune function, increasing the risk for delayed death. How early infections alter mortality compared with later infections is not well described, and if mortality is increased, sending empiric cultures at admission, termeddamage control cultures,maybetter diagnose and treat these patients. The purpose of this study was to determine if an early infection predicts higher mortality in elderly TBI patients.

More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes

BackgroundIn an expanding elderly population, traumatic brain injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI, according to the Brain Trauma Foundation (BTF), include intracranial pressure (ICP) monitoring. Whether ICP monitoring contributes to outcomes in the elderly patients with TBI has not been explored. MethodsThis is a retrospective study extracted from the National Trauma Database 2007–2008 research datasets. Patients were included if aged >55 y and they met BTF indications for ICP monitoring. Patients that had nonsurvivable injuries (any body region, abbreviated injury score = 6), were dead on arrival, had withdrawal of care, or length of stay <48 h were excluded. Outcomes were then stratified based on ICP monitoring. The primary outcomes were inhospital mortality and favorable discharge. Logistic regression was used to analyze the effect of ICP monitoring on outcomes. ResultsA total of 4437 patients were included with 11.2% having an ICP monitor placed. Patients requiring an ICP monitor were younger overall, more likely to present hypertensive, had higher injury severity, and more likely to require operative intervention. Median initial Glasgow coma scale (3) was similar between groups. Of those patients with ICP monitoring, overall mortality was significantly higher, and they were less likely to have favorable discharge status. Craniotomy itself was not associated with increased mortality (P = 0.450). ConclusionsOur findings suggest that the use of ICP monitoring according to BTF guidelines in elderly TBI patients does not provide outcomes superior to treatment without monitoring. The ideal group to benefit from ICP monitor placement remains to be elucidated.

Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients.

Previous studies of traumatic brain injury (TBI) outcomes in elderly patients on oral antithrombotic (OAT) therapies have yielded conflicting results. Our objective was to examine the effect of premorbid OAT medications on outcomes among elderly TBI patients with intracranial hemorrhage. We performed a retrospective analysis of elderly TBI patients (≥65 years) with closed head injury and evidence of brain hemorrhage on computed tomography scan from 2006 to 2010. Patient demographics, injury severity, clinical course, hospital and intensive care unit length of stay, and disposition were collected. Comparison of patients stratified by premorbid OAT use was performed using nonparametric Kruskal-Wallis and Fisher's exact tests. Multivariable logistic regression was used to compare groups and identify predictors of primary outcomes, including mortality, neurosurgical intervention, hemorrhage progression, complications, and infection. A total of 1,552 patients were identified: 543 on aspirin only, 97 on clopidogrel only, 218 on warfarin only, 193 on clopidogrel and aspirin, and 501 on no antithrombotic agent. Blood products were administered to reverse coagulopathy in 77.3% of patients on antithrombotic medications. After adjusting for covariates, including medication reversal, OAT use was associated with increased mortality (p = 0.04). Warfarin use was identified as a key predictor (odds ratio, 2.27; p = 0.05), in contrast to the preinjury use of antiplatelet medications, which was not associated with increased risk of in-hospital death. Rates of neurosurgical intervention differed between groups, with patients on warfarin undergoing intervention more frequently. Survivor subset analysis demonstrated that hemorrhage progression was not associated with preinjury antithrombotic therapy, nor were rates of complication or infection, hospital and intensive care unit lengths of stay, or ventilator days. Preinjury use of warfarin, but not antiplatelet medications, influences survival and need for neurosurgical intervention in elderly TBI patients with intracranial hemorrhage; hemorrhage progression and morbidity are not affected. The importance of antithrombotic therapy may lie in its impact on initial injury severity. Epidemiologic study, level III.

Traumatic Brain Injury in an Aging Population

The epidemiology of traumatic brain injury (TBI) is changing in several Western countries, with an increasing proportion of elderly TBI patients admitted to the intensive care unit (ICU). We describe a series of 1366 adult patients admitted to three neuro-ICUs in which 44% of cases were 50 years of age or older. The health status before trauma (rated using the APACHE score) was worse in older patients. In all 604 patients had emergency removal of intracranial masses, with extradural hematomas more frequent in young cases and subdural hematomas more frequent in older patients. Outcomes were classified according to the Glasgow Outcome Scale (GOS) 6 months post-trauma, as favorable (GOS score 4-5), or unfavorable (GOS score 1-3). Favorable outcomes were achieved by 50% of patients, but the proportions of unfavorable outcomes rose with age. Mortality was the main cause of unfavorable outcomes 6 months after injury in older patients. Logistic regression analysis indicates that several parameters independently contributed to outcome, including the motor component of the Glasgow Coma Scale (GCS), pupils, CT findings, and early hypotension. Additionally, the odds ratios were very high for age and health status before TBI. Patients admitted to the ICU are increasingly older, have co-morbidities, and have specific types of intracranial lesions. Early rescue, surgical treatment, and intensive care of these patients may produce excellent results up to the age of 59 years, with favorable outcomes still possible for 39% of cases aged 60-69 years, without an excessive burden of severely disabled patients.

Depression as a Secondary Condition Following Mild and Moderate Traumatic Brain Injury.

This article reviews literature on the prevalence, course, risk factors, and functional impact associated with depression following mild and moderate traumatic brain injury (TBI). Research conducted by the authors on depression in both young and elderly TBI patients is presented, supporting previous findings on the high frequency of affective disturbance and its adverse effects on activities of daily living. Treatment approaches emphasizing early patient education and counseling are discussed as potential strategies to mitigate the development of posttraumatic depression.