Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study

Abstract

Introduction: Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization. Methods: Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported. Results: In 481 subjects, 91.1% had ED admission GCS 13–15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02–21.19]), ICP monitoring (mOR = 15.48 [2.92–81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13–25.36]; mOR = 5.68 [1.18–27.35]). Conclusions: Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Effect of perioperative anticoagulant prophylaxis in patients with traumatic subdural hematoma and a history of anticoagulant use: a propensity-matched National Trauma Data Bank analysis

“…These findings are consistent with those in the current literature. [38][39][40][41] In these patients at higher risk for death, therapy with UH and LMWH may be especially beneficial despite the risk of increased hospital complications, due to the mortality benefit they confer. Conversely, higher GCS score and, surprisingly, a history of dementia were associated with lower odds of death.…”

Mortality Predictors for Adult Patients with Mild-to-Moderate Traumatic Brain Injury: A Literature Review

“…Mortality rates that are directly associated with TBI include death resulting from the initial injury in the acute phase, within hours to days of the incident. Research studies have investigated the predictors for immediate impact of TBI on mortality such as the severity of injury, GCS, neuroimaging findings and type of injury [12,13]. For example, studies have shown that subjects with penetrating TBI show higher mortality rates in comparison to blunt TBI [14].…”

Traumatic Brain Injury: Contemporary Challenges and the Path to Progress

“…While rates of neurosurgical procedural interventions and mortality are low for GCS 13-15 TBI (3-9% and 1-2%, respectively) [27,28], neurologic deterioration can occur acutely in this population and patients with GCS deficits or intracranial neuroimaging findings should receive vigilant clinical monitoring and treatment [29]. Recent studies have bolstered the recognition of non-"mild" TBI symptomatology and sequelae that compromise the return to baseline function.…”