Need For Neurosurgical Intervention Research Articles

Outcomes of Traumatic Brain Injury Patients Managed in a Non–Intensive Care Unit Setting

IntroductionThe management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non–intensive care unit (ICU) setting after stratifying them using the mBIG criteria. MethodsA retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. ResultsOf the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. ConclusionsSelect patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

Traumatic brain injury outcomes at the “epicenter of the epicenter” of the united states COVID-19 pandemic amidst ongoing socio-demographic challenges

Abstract Introduction Traumatic brain injury (TBI) poses a significant public health challenge with profound impacts at individual, family, community, and societal levels. Early during the COVID-19 pandemic, the neighborhood of Elmhurst, Queens in New York City was a hotspot dubbed the “epicenter of the epicenter” of the crisis in the United States, requiring major changes in healthcare resource allocation. This study investigates how different phases of the COVID-19 pandemic affected the incidence, severity, and clinical outcomes of TBI in this geographical area. Methods TBI admissions to NYC Health + Hospitals/Elmhurst, a Level 1 Trauma Center, during the first six months of 2019, 2020, and 2021 were retrospectively analyzed. Data were grouped into three periods: pre-pandemic (1/1/19–6/30/19 and 1/1/20–2/29/20) [Group 1], first COVID-19 wave (3/1/20–6/30/20) [Group 2], and second COVID-19 wave (1/1/21–6/30/21) [Group 3]. Univariate analyses were conducted to explore factors potentially associated with TBI outcomes; variables that reached statistical significance (p < 0.05) were included in a binary logistic regression analysis dichotomized into good outcome (discharge to home or acute rehabilitation disposition) and poor outcome (discharge to skilled nursing facility/subacute rehabilitation, hospice, or in-hospital mortality). Results Analysis of 443 TBI patients (median age 56 [range 38, 73]; mean admissions/week 5.6 ± 2.7) demonstrated no significant variance in age (H = 0.92; p = 0.63), sex (χ2 = 1.4, p = 0.51), or ethnicity (χ2 = 17.1; p = 0.07) across groups. Group 2 had significantly fewer weekly admissions (3.9 ± 2.6) compared to Groups 1 (5.9 ± 2.2; p = 0.02) and 3 (6.1 ± 2.9; p = 0.01). Over the course of the pandemic, the proportion of uninsured patients decreased from 15 to 4%, while Medicaid and Medicare coverage rates rose from 25 to 41% and 20% to 28%, respectively (p < 0.001). A binary logistic regression model dichotomized by discharge outcome for all 443 TBI patients confirmed that increasing age (OR = 0.95; 95% CI 0.93–0.97; p < 0.001) and Injury Severity Score (OR = 0.88; 95% CI 0.83–0.93; p < 0.001) were inversely correlated with good outcome, while higher Glasgow Coma Scale (OR = 1.26; 95% CI 1.17–1.36; p < 0.001) was positively correlated. Of particular interest, Black/Hispanic ethnicity (OR = 0.36; 95% CI 0.19–0.66; p = 0.002) and public health insurance (Medicaid/Medicare) coverage (OR = 0.83; 95% CI 0.68–1.00; p = 0.05) were both associated with less favorable outcomes. Neither group designation, patient sex, COVID-19 status, or need for neurosurgical intervention was correlated with outcome (p > 0.05). Conclusion Despite the changes in TBI admission patterns throughout New York City during the COVID-19 pandemic, the quality of patient outcomes at our institution remained relatively consistent across the pandemic’s different phases, as assessed by discharge disposition. However, two important socioeconomic factors—ethnicity and health insurance status—were significantly associated with outcome, underscoring the need for systemic changes to address ongoing disparities in neurotrauma care.

Diagnostic Performance of GFAP, UCH-L1, and MAP-2 Within 30 and 60 Minutes of Traumatic Brain Injury.

Data on the performance of traumatic brain injury (TBI) biomarkers within minutes of injury are lacking. To examine the performance of glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and microtubule-associated protein 2 (MAP-2) within 30 and 60 minutes of TBI in identifying intracranial lesions on computed tomography (CT) scan, need for neurosurgical intervention (NSI), and clinically important early outcomes (CIEO). This cohort study is a biomarker analysis of a multicenter prehospital TBI cohort from the Prehospital Tranexamic Acid Use for TBI clinical trial conducted across 20 centers and 39 emergency medical systems in North America from May 2015 to March 2017. Prehospital hemodynamically stable adult patients with traumatic injury and suspected moderate to severe TBI were included. Blood samples were measured for GFAP, UCH-L1, and MAP-2. Data were analyzed from December 1, 2023, to March 15, 2024. The presence of CT lesions, diffuse injury severity on CT, NSI within 24 hours of injury, and CIEO (composite outcome including early death, neurosurgery, or prolonged mechanical ventilation ≥7 days) within 7 days of injury. Of 966 patients enrolled, 804 patients (mean [SD] age, 41 [19] years; 418 [74.2%] male) had blood samples, including 563 within 60 minutes and 375 within 30 minutes of injury. Among patients with blood drawn within 30 minutes of injury, 212 patients (56.5%) had CT lesions, 61 patients (16.3%) had NSI, and 112 patients (30.0%) had CIEO. Among those with blood drawn within 60 minutes, 316 patients (56.1%) had CT lesions, 95 patients (16.9%) had NSI, and 172 patients (30.6%) had CIEO. All biomarkers showed significant elevations with worsening diffuse injury on CT within 30 and 60 minutes of injury. Among blood samples taken within 30 minutes, GFAP had the highest area under the receiver operating characteristic curve (AUC) to detect CT lesions, at 0.88 (95% CI, 0.85-0.92), followed by MAP-2 (AUC, 0.78; 95% CI, 0.73-0.83) and UCH-L1 (AUC, 0.75; 95% CI, 0.70-0.80). Among blood samples taken within 60 minutes, AUCs for CT lesions were 0.89 (95% CI, 0.86-0.92) for GFAP, 0.76 (95% CI, 0.72-0.80) for MAP-2, and 0.73 (95% CI, 0.69-0.77) for UCH-L1. Among blood samples taken within 30 minutes, AUCs for NSI were 0.78 (95% CI, 0.72-0.84) for GFAP, 0.75 (95% CI, 0.68-0.81) for MAP-2, and 0.69 (95% CI, 0.63-0.75) for UCH-L1; and for CIEO, AUCs were 0.89 (95% CI, 0.85-0.93) for GFAP, 0.83 (95% CI, 0.78-0.87) for MAP-2, and 0.77 (95% CI, 0.72-0.82) for UCH-L1. Combining the biomarkers was no better than GFAP alone for all outcomes. At GFAP of 30 pg/mL within 30 minutes, sensitivity for CT lesions was 98.1% (95% CI, 94.9%-99.4%) and specificity was 34.4% (95% CI, 27.2%-42.2%). GFAP levels greater than 6200 pg/mL were associated with high risk of NSI and CIEO. In this cohort study of prehospital patients with TBI, GFAP, UCH-L1, and MAP-2 measured within 30 and 60 minutes of injury were significantly associated with traumatic intracranial lesions and diffuse injury severity on CT scan, 24-hour NSI, and 7-day CIEO. GFAP was the strongest independent marker associated with all outcomes. This study sets a precedent for the early utility of GFAP in the first 30 minutes from injury in future clinical and research endeavors.

The Florida Geriatric Head Trauma CT Clinical Decision Rule.

Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

The Effect of 4-Factor Prothrombin Complex Concentrate to Reverse Factor Xa Inhibitors in Patients With Traumatic Intracranial Hemorrhage.

The utility of 4-factor prothrombin complex concentrate (4F-PCC) for reversal in patients on factor Xa inhibitors (XaI) is unclear, specifically in mild traumatic brain injury (mTBI). This is a retrospective review over 6 years at a level 1 trauma center of patients presenting with mTBI on XaI comparing outcomes for those that received 4F-PCC to those that did not. 140 patients were included, 103 (74%) of these patients received 4F-PCC while 37 (26%) did not. There was no significant difference in neurologic decline within 48 hours of admission or need for neurosurgical intervention. Interestingly, there was no difference in ICH progression (16% vs 14%, P = .77). In this study, 4F-PCC given after mild traumatic brain injury did not impact ICH progression, neurologic decline, or need for neurosurgical intervention. Although limited in numbers, this study suggests that 4F-PCC is not necessarily required in mTBI and further studies are indicated.

Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls.

The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF. Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method. A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease. When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac risk, and measures of injury severity. This may allow for better identification of at-risk patients, and at the same time resulting in a more equitable allocation of resources.

Machine learning-based models to predict the need for neurosurgical intervention after moderate traumatic brain injury.

Traumatic brain injury (TBI) is a widespread global health issue with significant economic consequences. However, no existing model exists to predict the need for neurosurgical intervention in moderate TBI patients with positive initial computed tomographyscans. This study determines the efficacy of machine learning (ML)-based models in predicting the need for neurosurgical intervention. This is a retrospective study of patients admitted to the neuro-intensive care unit of Emtiaz Hospital, Shiraz, Iran, between January 2018 and December 2020. The most clinically important variables from patients that met our inclusion and exclusion criteria were collected and used as predictors. We developed models using multilayer perceptron,random forest,support vector machines (SVM), and logistic regression. To evaluate the models, their F1-score, sensitivity, specificity, and accuracy were assessed using a fourfold cross-validation method. Based on predictive models, SVM showed the highest performance in predicting the need for neurosurgical intervention, with an F1-score of 0.83, an area under curveof 0.93, sensitivity of 0.82, specificity of 0.84, a positive predictive valueof 0.83, and a negative predictive valueof 0.83. The use of ML-based models as decision-making tools can be effective in predicting with high accuracy whether neurosurgery will be necessary after moderate TBIs. These models may ultimately be used as decision-support tools to evaluate early intervention in TBI patients.

In old anticoagulated patients with mild traumatic brain injury, a 24-h observation period should not be recommended without evidence of a clear benefit: a retrospective study of delayed hemorrhagic versus iatrogenic complications.

Mild traumatic brain injury (mTBI) is a common cause of admission to the Emergency Department (ED). Many patients are elderly on oral anticoagulant therapy (OAT) at increased risk of immediate and delayed intracranial hemorrhage (ICH). To investigate the frequency of delayed ICH (DICH) in old patients with mTBI in OAT and the occurrence of complications related to the ED stay. In this single-center retrospective study, we recruited all patients in OAT aged 65 and over, admitted for mTBI to the ED of our Hospital in Florence from March 2019 to February 2021. Clinical variables were collected and cranial computed tomography (CT) scans reviewed. The primary outcome was the frequency of DICH occurring within 30days since the trauma after a first negative CT. Secondary outcomes included need of neurosurgical intervention and death for DICH, and hospital-related complications. Statistical analyses were conducted using IBM SPSS Statistics (version 22). Among 363 enrolled patients, there were 31 acute ICH (8.5%) at the first CT scan, while in the 316 negative included patients, 10 DICH (3.2%) were identified. Among the latter, no neurosurgical treatment, or death due to ICH occurred. Overall, 25 cases (6.9%) had iatrogenic complications during the 24-h observation period, often serious, such as respiratory failure after sedation due to restlessness, or COVID-19 infection. The low frequency of DICH and the occurrence of several iatrogenic complications suggest that the risk-benefit ratio of a 24-h ED observation is not advantageous in elderly with mTBI.

Key Findings on Computed Tomography of the Head that Predict Death or the Need for Neurosurgical Intervention From Traumatic Brain Injury.

Traumatic brain injury (TBI) requires rapid management to avoid secondary injury or death. This study evaluated if a simple schema for quickly interpreting CT head (CTH) imaging by trauma surgeons and trainees could be validated to predict need for neurosurgical intervention (NSI) or death from TBI within 24 hours. We retrospectively reviewed TBI patients presenting to our trauma center in 2020 with blunt mechanism and GCS ≤ 12. Primary independent variables were presence of 7 normal findings on CTH (CSF at foramen magnum, open fourth ventricle, CSF around quadrigeminal plate, CSF around cerebral peduncles, absence of midline shift, visible sulci/gyri, and gray-white differentiation). Trauma surgeons and trainees separately evaluated each patient's CTH, scoring findings as normal or abnormal. Primary outcome was NSI/death in 24hours. Our population consisted of 444 patients; 21.4% received NSI or died within 24hours. By trainees' interpretation, 5.8% of patients without abnormal findings had NSI/death vs 52.0% of patients with ≥1 abnormality; attending interpretation was 8.7% and 54.9%, respectively (P < .001). Sulci/gyri effacement, midline shift, and cerebral peduncle effacement maximized sensitivity and specificity for predicting NSI/death. Considering pooled results, when ≥1 of those 3 findings was abnormal, sensitivity was 77.89%, specificity was 80.80%, positive predictive value was 52.48%, and negative predictive value was 93.07%. Any single abnormality in this schema significantly predicted a large increase in NSI/death in 24hours in TBI patients, and three particular findings were most predictive. This schema may help predict need for intervention and expedite management of moderate/severe TBI.

Clinical decision rules in predicting computed tomography scan findings and need for neurosurgical intervention in mild traumatic brain injury: a prospective observational study.

In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran. The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes. In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models. The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria havehigher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.

Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma

BackgroundAlthough clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging. ObjectiveThis study evaluated risk factors and outcomes of geriatric patients with uncertain head injury. MethodsThis prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15. ResultsWe enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67–13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67–13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15–12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24–1.99), alcohol use (OR 1.62; 95% CI 1.25–2.09), antiplatelet use (OR 1.84; 95% CI 1.46–2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54–4.13). Patients with uncertain trauma had no characteristics associated with increased ICH. ConclusionsAlthough ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.

Not all traumatic brain injury patients on preinjury anticoagulation are the same

BackgroundPrognostic significance of different anticoagulants in TBI patients remains unanswered. We aimed to compare effects of different anticoagulants on outcomes of TBI patients. MethodsA secondary analysis of AAST BIG MIT. Blunt TBI patients ≥50 years using anticoagulants presenting ICH were identified. Outcomes were progression of ICH and need for neurosurgical intervention (NSI). Results393 patients were identified. Mean age was 74 and most common anticoagulant was aspirin (30%), followed by Plavix (28%), and coumadin (20%). 20% had progression of ICH and 10% underwent NSI. On multivariate regression for ICH progression, warfarin, SDH, IPH, SAH, alcohol intoxication and neurologic exam deterioration were associated with increased odds. Warfarin, abnormal neurologic exam on presentation, and SDH were independent predictors of NSI. ConclusionsOur findings reflect a dynamic interaction between type of anticoagulants, bleeding pattern & outcomes. Future modifications of BIG may need to take the type of anticoagulant into consideration.

Impact of a Femoral Fracture on Outcome after Traumatic Brain Injury-A Matched-Pair Analysis of the TraumaRegister DGU®.

Traumatic brain injury (TBI) is the leading cause of death and disability in polytrauma and is often accompanied by concomitant injuries. We conducted a retrospective matched-pair analysis of data from a 10-year period from the multicenter database TraumaRegister DGU® to analyze the impact of a concomitant femoral fracture on the outcome of TBI patients. A total of 4508 patients with moderate to critical TBI were included and matched by severity of TBI, American Society of Anesthesiologists (ASA) risk classification, initial Glasgow Coma Scale (GCS), age, and sex. Patients who suffered combined TBI and femoral fracture showed increased mortality and worse outcome at the time of discharge, a higher chance of multi-organ failure, and a rate of neurosurgical intervention. Especially those with moderate TBI showed enhanced in-hospital mortality when presenting with a concomitant femoral fracture (p = 0.037). The choice of fracture treatment (damage control orthopedics vs. early total care) did not impact mortality. In summary, patients with combined TBI and femoral fracture have higher mortality, more in-hospital complications, an increased need for neurosurgical intervention, and inferior outcome compared to patients with TBI solely. More investigations are needed to decipher the pathophysiological consequences of a long-bone fracture on the outcome after TBI.

Prevalence, severity, and neurosurgical management of abusive head trauma during the COVID-19 pandemic.

Reports published during the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) pandemic suggest that hospitals potentially experienced an increased incidence in the presentation of abusive head trauma (AHT) in children; however, it remains unknown if the pandemic influenced the severity or need for neurosurgical intervention during this time. This study is a post hoc analysis of a prospectively collected database of pediatric patients who sustained traumatic head injuries from 2018 to 2021 and were treated at the Children's Hospital of Pittsburgh that was screened for concern of AHT at the time of presentation. Pairwise univariate analysis of AHT prevalence, Glasgow Coma Scale (GCS) score, intracranial pathology, and neurosurgical interventions was performed to investigate differences before, during, and after the initial lockdown in Pennsylvania, which was defined as March 23, 2020, to August 26, 2020. Of 2181 pediatric patients who presented with head trauma, 263 (12.1%) with AHT were identified. Prevalence of AHT did not differ during (12.4% before vs 10.0% during, p = 0.31) or following (12.2% after, p = 0.92) lockdown. Need for neurosurgery after AHT remained unchanged during lockdown (10.7% before vs 8.3% during, p = 0.72) and after (10.5% after, p = 0.97). Patients did not differ in terms of sex, age, or race between periods. Average GCS score was lower after lockdown (13.9 before vs 11.9 after, p = 0.008) but not during (12.3, p = 0.062). In this cohort, mortality associated with AHT was 4.8 times higher during lockdown (4.3% before vs 20.8% during, p = 0.002) and returned to pre-lockdown rates thereafter (7.8%, p = 0.27). The primary contributor to mortality was ischemic brain injury (5% before vs 20.8% during, p = 0.005). Patients were 5.5 times more likely to undergo decompressive hemicraniectomy in the months after lockdown compared with prior (1.2% vs 6.6%, p = 0.035). The authors have presented the findings of the first study to examine the prevalence and neurosurgical management of AHT during the Sars-Cov-2 lockdown in Pennsylvania. The overall prevalence of AHT was not affected by lockdown; however, patients were more likely to experience mortality or traumatic ischemia during lockdown. The GCS score of AHT patients was significantly lower, and these patients were more likely to require decompressive hemicraniectomy after the initial lockdown period.

Clinical characteristics and outcomes of traumatic brain injury patients admitted to tertiary level surgical intensive care unit of Kashmir, India

Background: Traumatic brain injury (TBI) is a leading cause of mortality, morbidity, disability, and socioeconomic losses in the Indian subcontinent. For policy making, there is a lack of reliable and larger data regarding traumatic brain injuries in our setting. Aim: In our study an attempt was made to analyze and assess the clinical characteristics of patients with traumatic brain injuries admitted in Surgical Intensive Care Unit of SMHS hospital Srinagar. Materials and Methods: In this observational study, 89 patients of TBI admitted in SICU during study period were enrolled, after obtaining ethical clearance from institutional ethical clearancecommittee. All the study patients were followed up in SICU on daily basis. All thedata required for study was recorded from the patient’s clinical notes as per studyprotocol. Outcome of patients was assessed in terms of survival at discharge from SICU. Results: Majority of the TBI patients requiring ICU admission had Severe TBI (64%). Allthe patients required CT Brain on arrival to hospital and brain contusions (65.2%) were the most common findings on CT brain. Check CT brain was required in53.9% of patients. There was need for neurosurgical intervention in 49.4% ofpatients and 21.3% required blood transfusions.

Pre-Injury Antiplatelet Therapy and Risk of Adverse Outcomes after Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

There is an increasing number of trauma patients presenting on pre-injury antiplatelet (AP) agents attributable to an aging population and expanding cardio- or cerebrovascular indications for antithrombotic therapy. The effects of different AP regimens on outcomes after traumatic brain injury (TBI) have yet to be elucidated, despite the implications on patient/family counseling and the potential need for better reversal strategies. The goal of this systematic review and meta-analysis was to assess the impact of different pre-injury AP regimens on outcomes after TBI. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the OVID Medline, Embase, BIOSIS, Scopus, and Cochrane databases were searched from inception to February 2022 using a combination of terms pertaining to TBI and use of AP agents. Baseline demographics and study characteristics as well as outcome data pertaining to intracerebral hematoma (ICH) progression, need for neurosurgical intervention, hospital length of stay, mortality, and functional outcome were extracted. Pooled odds ratios (ORs) and mean differences comparing groups were calculated using random-effects models. Thirteen observational studies, totaling 1244 patients receiving single AP therapy with acetylsalicylic acid or clopidogrel, 413 patients on dual AP therapy, and 3027 non-AP users were included. No randomized controlled trials were identified. There were significant associations between dual AP use and ICH progression (OR, 2.81; 95% confidence interval [CI], 1.19–6.61; I2, 85%; p = 0.02) and need for neurosurgical intervention post-TBI (OR, 1.61; 95% CI, 1.15–2.28; I2, 15%; p = 0.006) compared to non-users, but not between single AP therapy and non-users. There were no associations between AP use and hospital length of stay or mortality after trauma. Pre-injury dual AP use, but not single AP use, is associated with higher rates of ICH progression and neurosurgical intervention post-TBI. However, the overall quality of studies was low, and this association should be further investigated in larger studies.

64-Year-Old Woman With Aphasia and Troponin Elevation

64-Year-Old Woman With Aphasia and Troponin Elevation

Skull Base Regeneration During Treatment With Chemoradiation for Nasopharyngeal Carcinoma: A Case Report.

Advanced cases of nasopharyngal carcinoma can present with skull base invasion. Treatment of these advanced cases with radiotherapy poses a challenge given proximity of tumor to critical neural structures as well as concern that a skull base defect and associated complications could develop with tumor regression. A 34-year-old male patient presented with a 7-cm nasopharyngeal tumor invading the skull base with destruction of the clivus and intracranial extension. He underwent a course of definitive chemoradiation, requiring use of adaptive radiotherapy, that resulted in complete tumor regression and is free of disease 5 years posttreatment. Imaging done during treatment demonstrated that significant regeneration of bone occurred simultaneously with tumor regression. This case demonstrates that it is possible for bony regeneration to occur simultaneously with tumor regression in a patient with skull base invasion by tumor, precluding the need for neurosurgical intervention.

Traumatic brain injury patients with platelet inhibition receiving platelet transfusion demonstrate decreased need for neurosurgical intervention and decreased mortality.

Platelet dysfunction is known to occur in patients with traumatic brain injury (TBI), and the correction of platelet dysfunction may prevent hemorrhagic progression in TBI. Thromboelastography with platelet mapping (TEG-PM; Haemonetics) evaluates the degree of platelet function inhibition through the adenosine diphosphate (ADP) and arachidonic acid (AA) pathways. We hypothesized that ADP and AA inhibition would improve with the transfusion of platelets in patients with TBI. A retrospective review was conducted at a Level I trauma center of all patients presenting with TBI from December 2019 to December 2020. Per a practice management guideline, a platelet mapping assay was obtained on all patients with TBI upon admission. If ADP or AA was found to be inhibited (>60%), the patient was transfused 1 unit of platelets and a repeat platelet mapping assay was ordered. Demographic data, laboratory values, and outcomes were analyzed. Over the 13-month study period, 453 patients with TBI underwent TEG-PM with a protocol adherence rate of 66.5% resulting in a total of 147 patients who received platelets for ADP and/or AA inhibition; of those, 107 underwent repeat TEG-PM after platelets were administered. With the administration of platelets, ADP (p < 0.0001), AA (p < 0.0001), and MA (p = 0.0002) all significantly improved. Of 330 patients with TBI not taking antiplatelet medications, 50.9% showed inhibition in ADP and/or AA. If AA or ADP inhibition was noted on admission, mortality was increased (p = 0.0108). If ADP improved with platelet administration, the need for neurosurgical intervention was noted to decrease (p = 0.0182). Patients with TBI and platelet inhibition may benefit from the administration of platelets to correct platelet dysfunction. Thromboelastography with platelet mapping may be implemented in the initial workup of patients presenting with TBI to assess platelet dysfunction and provide prognostic information, which may guide treatment. Therapeutic / Care Management, level III.

476 Does Anticoagulation or Antiplatelet Therapy Increase Risk of Traumatic Subarachnoid Hemorrhage Progression?

INTRODUCTION: Isolated traumatic subarachnoid hemorrhage (tSAH) is a common finding of mild traumatic brain injury that often results in the transfer to a tertiary center. This is often done out of concern for patients on blood thinners (BT) who are thought to be at higher risk of clinical worsening. METHODS: A retrospective analysis identified patients over the age of 18 with isolated tSAH and a GCS of 15 on admission. Clinical information including use of BT, administration of reversal agents, radiographic progression, and need for neurosurgical intervention were collected. Patients on BT were divided into AP, AC and AP/AC groups based on drug type. RESULTS: 384 patients were included with 203 in the non-BT group and 181 in the BT group. 2.1% had worsening scans and none required neurosurgical intervention. There was no difference in radiographic worsening between the non-BT and BT group (2.4% vs. 1.6%; p = 1.00). Crosswise comparison revealed no difference between the non-BT group and each BT subtype (AP, AP/AC, AC). The non-BT group was more likely to have radiographic improvement than the BT group (45.8% vs. 30.9%; p = 0.002). CONCLUSION: Neurologically intact patients on BT with isolated tSAH are not at increased risk of radiographic progression or need for neurosurgical management. Consequently, the presence of BT should not influence management decisions for increased surveillance.