Actualización epidemiológica: tasa de mortalidad por Hemorragia Subdural Traumática entre los años 2018-2022 en Chile / Epidemiological update: traumatic Subdural Hemorrhage mortality rate between 2018-2022 in Chile

Traumatic subdural hemorrhage (TSH) is an injury between the meningeal membranes, caused by traumas, especially traffic accidents. OBJECTIVE: To describe the mortality rate (MR) due to TSH in the period 2018-2022 in Chile. MATERIALS AND METHODS: Descriptive, observational, and cross-sectional study on MR due to TSH in the period 2018-2022 in Chile, according to gender, age group, regional distribution, place of death, and month of death. Anonymous and public databases were used. No ethics committee approval was required. RESULTS: The average MR due to TSH in Chile from 2018 to 2022 was 0.45/100,000 inhabitants, with a peak in 2018 (0.75) and a minimum in 2021 (0.31). Men had higher rates. Mortality increased with age, especially in those over 80 years. The Metropolitan Region accounted for 35.2% of TSH-related deaths. Hospitals and clinics were the main places of death (67.1%), with more deaths in March, July, and August. DISCUSSION: The MR due to TSH progressively decreased due to medical improvements. Men have higher rates, possibly due to risk factors or biological differences. The reduction in MR in hospitals is linked to changes in the severity and categorization of the place of death. The connection with traffic accidents is significant, especially between March and August, due to the return to academic activities and weather conditions. Additionally, TSH-related deaths are concentrated in densely populated regions with more traffic accidents.

Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. METHODS: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. CONCLUSION: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Exosomes from Bone Marrow Mesenchymal Stem Cells Can Alleviate Early Brain Injury After Subarachnoid Hemorrhage Through miRNA129-5p-HMGB1 Pathway.

In this study, the roles of exosomes (Exo) from bone marrow mesenchymal stem cells (BMSCs) in attenuating early brain injury (EBI) in rat brain after subarachnoid hemorrhage (SAH) had been investigated. The male Sprague-Dawley rats (300-350 g) were used to establish the SAH model using endovascular perforation method. The animals were randomly divided into three groups: sham (n = 25), SAH+PBS (n = 42), and SAH+Exo groups (n = 33). At 1 h after SAH, Exo or phosphate-buffered saline (PBS) was administered by femoral vein injection. The effects of Exo on the mortality, neurological function, brain water content, and blood-brain barrier (BBB) were explored. Furthermore, the expressions of miRNA129-5p and high-mobility group box 1 protein (HMGB1) after Exo treatment were also detected. In addition, immunohistochemistry and western blot were applied to investigate the mechanism of Exo's effects. The results indicated that Exo could improve the neurological functions, reduce brain water content and maintain BBB integrity after SAH. After Exo treatment, the expression of miRNA129-5p was significantly increased, whereas the RNA level of HMGB1 was decreased. The protein levels of proinflammatory and proapoptosis factors, such as HMGB1, Toll-like receptor-4 (TLR4), tumor necrosis factor-α, and p53, were increased after SAH, which were significantly declined after Exo application. The results indicated that Exo from BMSCs could alleviate EBI after SAH through miRNA129-5p's anti-inflammation and antiapoptosis effects through quenching the activity of HMGB1-TLR4 pathway.

Predictors and Time-Based Hospital Mortality in Patients with Isolated and Polytrauma Brain Injuries.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. We studied the predictors and time-based mortality in patients with isolated and polytrauma brain injuries in a rapidly developing country. We hypothesized that TBI-related 30-day mortality is decreasing over time. METHODS: A retrospective analysis was conducted for all patients with moderate-to-severe TBI who were admitted directly to a level 1 trauma center between 2010 and 2014. Patient's data were analyzed and compared according to survival (survived vs. not survived), time (early death [2 days], intermediate [3-7 days] versus late [>7 days]) post-injury, and type (polytrauma vs. isolated TBI). Cox proportional hazards models were performed for the predictors of mortality. RESULTS: A total of 810 patients were admitted with moderate-to-severe TBI with a median age of 27 years. Traffic-related injury was the main mechanism of TBI (65%). Isolated TBIs represented 22.6% of cases and 56% had head AIS >3. The overall mortality rate was 27%, and most of deaths occurred in the intermediate (40%) and early period (38%). The incidence of TBI was greater in patients aged 21-30 years but the mortality was proportionately higher among elderly. The average annual incidence was 8.43 per 100,000 population with an overall mortality of 2.28 per 100,000 population. Kaplan-Meier curves showed that polytrauma had greater mortality than isolated TBI. However, Cox survival analysis showed that age [Hazard ratio (HR) 1.02], scene GCS (HR 0.86),subarachnoid hemorrhage (HR 1.7), and blood transfusion amount (HR 1.03) were the predictors of mortality regardless of being polytrauma or isolated TBI after controlling for 14 relevant covariates. CONCLUSIONS: The 30-day survival in patients with TBI is improving over the years in Qatar; however, the mortality remains high in the elderly males. The majority of deaths occurred within a week after the injury. Further studies are needed to assess the long-term survival in patients with moderate-to-severe TBI.

Traumatic subarachnoid hemorrhage due to motor vehicle crash versus fall from height: a 4-year epidemiologic study.

BACKGROUND: Traumatic brain injury (TBI) is a common cause of morbidity and mortality worldwide. It is difficult to estimate the real incidence of traumatic subarachnoid hemorrhage (TSAH). Although TSAH after trauma is associated with poor prognoses, the impact of mechanism of injury (MOI) and the pathophysiology remains unknown. We hypothesized that outcome of TSAH caused by motor vehicle crash (MVC) or fall from height (FFH) varies based on the MOI. METHODS: Data were collected retrospectively from a prospectively created database registry in the section of Trauma Surgery at Hamad General Hospital between January 2008 and July 2012. All patients presented with head trauma and TSAH were included. Patient data included age, gender, nationality, mechanism of injury, injury severity score (ISS), types of head injuries, and associated injuries. Ventilator days, intensive care unit length of stay, pneumonia, and mortality were also studied. RESULTS: A total of 1665 patients with TBI were identified, of them 403 had TSAH with a mean age of 35 ± 15 years. Of them 93% were male patients and 86% were expatriates. MVC (53%) and FFH (35%) were the major mechanisms of injury. The overall mean ISS and head abbreviated injury score were 19 ± 10.6 and 3.4 ± 0.96, respectively. Patients in MVC group sustained severe TSAH, had significantly greater head abbreviated injury score (3.5 ± 0.9 vs. 3.2 ± 0.9; P = 0.009) and ISS (21.6 ± 10.6 vs. 15.9 ± 9.5; P = 0.001), and lower scene Glasgow coma scale (10.8 ± 4.8 vs. 13.2 ± 3.4; P = 0.001) compared with the FFH group. In addition, the MVC group sustained more intraventricular hemorrhage (4.7 vs. 0.7; P = 0.001) and diffuse axonal injury (4.2 vs. 2.9; P = 0.001). In contrast, extradural hemorrhage (14.3% vs. 11.6%; P = 0.008) was higher in the FFH group. Lower extremities (14% vs. 4.3%; P = 0.004) injury was mainly associated with the MVC group. The overall mortality was 19 % among patients with TSAH. The mortality rate was higher in the MVC group when compared with the FFH group (24% vs. 10%; P = 0.001). In both groups, ISS and Glasgow coma scale at the scene were independent predictors of mortality. CONCLUSIONS: Patients with TSAH have a higher mortality rate. In this population, MVCs are associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can reduce the incidence and severity of TBI in Qatar.

The prognosis of the traumatic subarachnoid hemorrhage: a prospective report of 121 patients.

Recent investigations have shown the significance of subarachnoid bleeding on computed tomography scans first taken after admission for head injuries. In our study, we describe a prospective follow-up of 121 patients with traumatic subarachnoid hemorrhage (tSAH). From January 2004 to January 2007 we collected data prospectively from 121 patients admitted with diagnosis of tSAH to our trauma intensive care unit, on the basis of admission with a computed tomography scan. The classification of tSAH was performed using the Fisher scale with modification, and the follow-up was performed using the Glasgow Outcome Scale (GOS). The minimum period for a follow-up was established 6 months after the injury. Traffic accident was the main cause of head injuries (72% in total; 48% involving cars and 24% involving motorcycles), followed by falls (23%) and aggression (5%). Twenty-eight percent of patients sustained major multiple injuries, with spinal injury as the main associated trauma. The outcome was favorable (GOS score 4 or 5) in 54 patients (45%) and unfavorable (GOS score 1, 2, or 3) in 67 patients (55%). The mortality rate was proportionally greater in patients who had cisternal clots >1 mm (P < 0.001), assessed by the Fisher scale with modification. When functional recovery was evaluated using the GOS, the recovery rate and the daily life activities were lower in patients with intraventricular bleeding (P = 0.001). Our results showed that patients with severe tSAH had the worst prognosis.

Head injury caused by tear gas cartridge in teenage population.

OBJECTIVES: The aim of this study was to assess the head injury in children caused by an unusual projectile, a tear gas cartridge. The study is the only one on this subject which has been done in a teenage population. METHOD: This was a prospective study conducted over a period of 4 years in which all the patients aged less than or equal to 18 years and who had a head injury due to a tear gas cartridge were included. RESULTS: We had 5 patients in our study group. All the patients were males. Commonest CT scan finding was brain contusion with skull fracture. One of our patients died. One patient continues to be in vegetative state whereas 3 had a good outcome. CONCLUSION: Tear gas cartridge, though considered as one of the benign modalities of controlling agitated crowds, is not really benign. It can cause serious injuries and mortality. The personnel using them might be trained in a better way so that the people do not receive direct hits. In addition some changes in the design of tear gas cartridge can be done to decrease the impact to the skull.

[Traumatic subarachnoid hemorrhage: a prospective study of 58 cases]. / Travmatik subaraknoid kanamalar: 58 olguluk prospektif çalisma.

BACKGROUND: We evaluated the prognostic factors in traumatic subarachnoid hemorrhage (tSAH). METHODS: This study was conducted with 58 patients (44 males, 14 females; mean age 39.2; range 17 to 79 years) with tSAH, between 2001 and 2003. The patients who were admitted to the hospital within in the first 6 hours of head injury were included, whereas patients with gun shot wounds, multiple injured patients and postoperative patients were excluded. Fifty-eight patients with tSAH were prospectively followed. The neurological status of the patients and the outcomes were evaluated using Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS), respectively and computed tomography (CT) examinations were done according to the grading criteria by Hijdra and Fisher. RESULTS: The etiology of tSAH included traffic accidents (73%), falls (20%) and others (7%). The GCS scores of patients at admission were mild (9%), moderate (39%) and severe (52%). In the CT scans, the amount and distribution of bleeding was grade 1 (small SAH) in 21 patients, grade 2 (moderate SAH) in 17 patients, and grade 3 (extensive SAH) in 20 patients according to Hijdra grading system and according to Fisher's criteria. The thickness of blood layer was grade 1 (no blood) in 6 patients, grade 2 (bleeding layer less than 1 mm) in 21 patients, grade 3 (bleeding layer more than 1 mm) in 15 patients and grade 4 (ventricular bleeding) in 16 patients. Neurological outcomes of patients were favorable (good recovery or moderate disability) in 59%, and unfavorable (severe disability, persistent vegetative state or death) in 41% according to GOS. CONCLUSION: We have found in our series that the prognosis was poor in patients with poor admission scores of GCS, cysternal or fissural hemorrhage, tSAH with cerebral contusion or acute subdural hematoma, higher than 13 points according to Hidjra's classification and patients of grade 3 or 4 in Fisher's criteria.