Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

Traumatic subdural haematoma: integrating case-based clinical judgement with guidelines.

Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity with a significant loss of functional capacity and a huge socioeconomic burden. Road traffic accidents are the most common (60%) cause followed by falls and violence in India and worldwide. This case discusses the story of a 23-year-old man with severe TBI-subdural haematoma, who presented in a comatose state. The patient was a purported candidate for emergency decompressive surgery as per Brain Trauma Foundation (BTF) guidelines but was managed conservatively. This case questions the plausibility of the BTF guidelines for severe TBI, particularly in rural hospitals in India and how such cases are often managed with clinical judgement based on the review of literature. The patient recovered well with a perfect 8/8 on Glasgow Outcome Scale Extended Score.

Hospital costs, incidence, and inhospital mortality rates of traumatic subdural hematoma in the United States.

OBJECT: This study provides the first US national data regarding frequency, cost, and mortality rate of traumatic subdural hematoma (SDH), and identifies demographic factors affecting morbidity and death in patients with traumatic SDH undergoing surgical drainage. METHODS: A retrospective analysis was conducted by querying the Nationwide Inpatient Sample, the largest all-payer database of nonfederal community hospitals. All cases of traumatic SDH were identified using ICD-9 codes. The study consisted of 2 parts: 1) trends data, which were abstracted from the years 1993-2006, and 2) univariate analysis and multivariate logistic regression of demographic variables on inhospital complications and deaths for the years 1993-2002. RESULTS: Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006. Inhospital deaths decreased from 16.4% to 11.6% for traumatic SDH. Average costs increased 67% to $47,315 per admission. For the multivariate regression analysis, between 1993 and 2002, 67,864 patients with traumatic SDH underwent operative treatment. The inhospital mortality rate was 14.9% for traumatic SDH drainage, with an 18% inhospital complication rate. Factors affecting inhospital deaths included presence of coma (OR = 2.45) and more than 2 comorbidities (OR = 1.60). Increased age did not worsen the inhospital mortality rate. CONCLUSIONS: Nationally, frequency and cost of traumatic SDH cases are increasing rapidly.

National trend in prevalence, cost, and discharge disposition after subdural hematoma from 1998-2007.

OBJECTIVES: Subdural hematoma is a common type of intracranial hemorrhage, particularly among the elderly, yet, despite the aging U.S. population, little has been published in the last 10 yrs. This study aimed to determine national trends in prevalence, discharge disposition, length of stay, and cost of subdural hematoma over time. DESIGN: Retrospective cohort study. SETTING: Adult patients hospitalized in the United States between 1998 and 2007 identified in the Nationwide Inpatient Sample. PARTICIPANTS: Seven hundred twenty thousand, two hundred ninety-seven adult patients hospitalized in subdural hematoma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Discharge disposition, hospital length of stay, and national cost (adjusted to 2007 dollars) were examined. Hospitalizations for subdural hematoma increased from 59,373 (30 per 100,000 hospitalizations) in 1998 to 91,935 (42 per 100,000) in 2007, constituting a 39% per-capita increase. The prevalence of subdural hematoma increased with age (p < .001), particularly among those >80 yrs of age (36% of subdural hematoma cohort), in lower income patients, in patients with acquired abnormalities of the coagulation cascade, and in patients with trauma. Inhospital mortality decreased from 15% to 12% (p = .001), but unsatisfactory discharge disposition increased from 17% to 20% (p < .001). National cost increased from $1.0 to $1.6 billion (p < .001). Unsatisfactory discharge disposition and cost were both independently predicted by higher comorbidity index, alcohol abuse, history of trauma, and acquired abnormal coagulation or platelet factors (p < .05). Neurosurgical intervention for subdural hematoma decreased from 41% in 1998 to 31% in 2007 (p < .001). Subdural hematoma evacuation was associated with decreased mortality but did not significantly protect against poor discharge disposition and was associated with significantly higher cost. CONCLUSIONS: The prevalence and total cost for subdural hematoma has increased significantly in the last decade nationwide. Health resource consumption for subdural hematoma is increasing without clear evidence that management practices are leading to improved outcomes.

Trend in outcome and financial impact of subdural hemorrhage.

BACKGROUND: Little current data exists regarding outcome, cost, and length of stay (LOS) after subdural hemorrhage (SDH). We sought to examine predictors of discharge disposition, ICU and hospital LOS and direct, indirect, ICU, surgical, and diagnostic costs for SDH. METHODS: A retrospective review was conducted of 216 SDH patients, aged >18 years admitted to our hospital between 1/2001 and 12/2008. Discharge disposition was characterized as dead, poor or good. Multivariable logistic regression analysis was performed to identify predictors of disposition, LOS, and cost. RESULTS: Of 216 SDH patients, the median age was 74 (19-95), and the median admission Glasgow Coma Scale (GCS) was 14 (3-15). The SDH was characterized as acute in 14%, subacute in 44%, chronic in 12%, and mixed in 30%. Surgical evacuation was performed in 139 (64%) patients. Death occurred in 29 (13%) patients and poor disposition in 43 (20%). Significant predictors of death included age, admission GCS, and hospital LOS (P < 0.05). Longer hospital LOS was associated with poor disposition, while shorter ICU LOS was associated with good disposition (P < 0.01). Median hospital LOS was 8 (1-99) days. Median total direct costs for hospitalization were $10,670 ($907-238,856). ICU and hospital LOS were significant predictors of all measures of cost (P < 0.05). SDH size, chronicity, and surgical intervention were not predictors of any outcome. There was no significant change in any outcome variable between 2001 and 2008. CONCLUSIONS: Despite good admission neurological status, death or poor discharge disposition is common after SDH. LOS and costs remain high and have not improved in the last decade.

The use of recombinant factor VIIa (NovoSeven) for treatment of active or impending bleeding in brain injury: broadening the indications.

We report three patients with severe traumatic brain injury, both open and closed, who were treated with recombinant activated factor VII. This treatment was given in a desperate, last-ditch effort to save the life of patient 1, as a preventive or early treatment of a developing hematoma in patient 2, and as treatment of a threatening hematoma in patient 3. One of the three patients survived. During the past few years we have broadened the indications for recombinant activated factor VII and started using it as a preventive measure rather than as a "last line of defense." However, the potential complications of disseminated intravascular coagulation and thrombotic events, as well as the cost-effectiveness in view of the available evidence-based medicine, should be considered.