Consensus paper on the assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13-15 at the emergency department: A multidisciplinary overview.

Traumatic brain injury (TBI) is a common reason for presenting to emergency departments (EDs). The assessment of these patients is frequently hampered by various confounders, and diagnostics is still often based on nonspecific clinical signs. Throughout Europe, there is wide variation in clinical practices, including the follow-up of those discharged from the ED. The objective is to present a practical recommendation for the assessment of adult patients with an acute TBI, focusing on milder cases not requiring in-hospital care. The aim is to advise on and harmonize practices for European settings. A multiprofessional expert panel, giving consensus recommendations based on recent scientific literature and clinical practices, is employed. The focus is on patients with a preserved consciousness (Glasgow Coma Scale 13-15) not requiring in-hospital care after ED assessment. The main results of this paper contain practical, clinically usable recommendations for acute clinical assessment, decision-making on acute head computerized tomography (CT), use of biomarkers, discharge options, and needs for follow-up, as well as a discussion of the main features and risk factors for prolonged recovery. In conclusion, this consensus paper provides a practical stepwise approach for the clinical assessment of patients with an acute TBI at the ED. Recommendations are given for the performance of acute head CT, use of brain biomarkers and disposition after ED care including careful patient information and organization of follow-up for those discharged.

Potential of heart fatty-acid binding protein, neurofilament light, interleukin-10 and S100 calcium-binding protein B in the acute diagnostics and severity assessment of traumatic brain injury.

BACKGROUND: There is substantial interest in blood biomarkers as fast and objective diagnostic tools for traumatic brain injury (TBI) in the acute setting. METHODS: Adult patients (≥18) with TBI of any severity and indications for CT scanning and orthopaedic injury controls were prospectively recruited during 2011-2013 at Turku University Hospital, Finland. The severity of TBI was classified with GCS: GCS 13-15 was classified as mild (mTBI); GCS 9-12 as moderate (moTBI) and GCS 3-8 as severe (sTBI). Serum samples were collected within 24 hours of admission and biomarker levels analysed with high-performance kits. The ability of biomarkers to distinguish between severity of TBI and CT-positive and CT-negative patients was assessed. RESULTS: Among 189 patients recruited, neurofilament light (NF-L) was obtained from 175 patients with TBI and 40 controls. S100 calcium-binding protein B (S100B), heart fatty-acid binding protein (H-FABP) and interleukin-10 (IL-10) were analysed for 184 patients with TBI and 39 controls. There were statistically significant differences between levels of all biomarkers between the severity classes, but none of the biomarkers distinguished patients with moTBI from patients with sTBI. Patients with mTBI discharged from the ED had lower levels of IL-10 (0.26, IQR=0.21, 0.39 pg/mL), H-FABP (4.15, IQR=2.72, 5.83 ng/mL) and NF-L (8.6, IQR=6.35, 15.98 pg/mL) compared with those admitted to the neurosurgical ward, IL-10 (0.55, IQR=0.31, 1.42 pg/mL), H-FABP (6.022, IQR=4.19, 20.72 ng/mL) and NF-L (13.95, IQR=8.33, 19.93 pg/mL). We observed higher levels of H-FABP and NF-L in older patients with mTBI. None of the biomarkers or their combinations was able to distinguish CT-positive (n=36) or CT-negative (n=58) patients with mTBI from controls. CONCLUSIONS: S100B, H-FABP, NF-L and IL-10 levels in patients with mTBI were significantly lower than in patients with moTBI and sTBI but alone or in combination, were unable to distinguish patients with mTBI from orthopaedic controls. This suggests these biomarkers cannot be used alone to diagnose mTBI in trauma patients in the acute setting.

Practitioners' opinions on traumatic brain injury care pathways in Finland and France: different organizations, common issues.

OBJECTIVE: In traumatic brain injury (TBI), differences in health-care contexts have profound effects on care pathways. Objectives were to compare TBI pathways of care and practitioners' views on quality of care issues in two large European areas: Varsinais-Suomi, Finland and Ile-de-France, France. METHODS: Thematic analysis of semi-structured interviews was conducted with TBI practitioners (n = 10) from all stages of TBI care. Interviews addressed organization and financing of care, decision-making on care transitions, and perceived issues. The structure-process-outcome model of Donabedian was used to classify findings related to quality of care issues. RESULTS: Main differences in organization of care pathways for people with TBI were related to financing modalities, number of pathway alternatives, inpatient versus outpatient rehabilitation, and indirect versus direct referrals to rehabilitation. Similar categories of issues were raised in the two settings. Issues in structures involved availability of services, financial access, and heterogeneity of expertise. Issues in processes involved diagnosis and follow-up, training regarding cognitive impairments, decision-making for referrals, transition delays, and care pathways of very severely affected patients. CONCLUSIONS: These findings provide clues to address care pathways in further comparative studies. Determinants of care pathway quality could be classified as direct or indirect, binding or adaptive organizational factors.

Usability of World Health Organization Disability Assessment Schedule in chronic traumatic brain injury.

OBJECTIVES: To investigate functioning measured with the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) in patients with mild, moderate and severe traumatic brain injury, and to compare patients' experiences with assessments made by their significant others and by consultant neurologists. METHODS: A total of 112 consecutive patients with traumatic brain injury (29 mild, 43 moderate, 40 severe) and their significant others completed a 12-item WHODAS 2.0 survey. A neurologist assessed functioning with the International Classification of Functioning, Disability and Health minimal generic set. RESULTS: The total patient and proxy WHODAS 2.0 sum score was rated as severe, and impairments in household tasks, learning, community life, emotional functions, concentrating, dealing with strangers, maintaining friendships, and working ability as around moderate in all 3 severity groups. In standing, walking, washing, and dressing oneself the reported impairments increased from mild in mild traumatic brain injury to moderate in severe traumatic brain injury. A neurologist rated the overall functioning, working ability, and motor activities most impaired in severe traumatic brain injury, while there were no between-group differences in energy and drive functions and emotional functions. CONCLUSION: Patients with chronic traumatic brain injury perceive a diversity of significant difficulties in activities and participation irrespective of the severity of the injury. We recommend assessing disability in traumatic brain injury with the short and understandable WHODAS 2.0 scale, when planning client-oriented services.

Sport concussion assessment tool 2 in a civilian trauma sample with mild traumatic brain injury.

The aim of the study was to evaluate the validity of the Sport Concussion Assessment Tool-Second Edition (SCAT2) in patients with acute mild traumatic brain injuries (mTBIs) in a civilian trauma setting. In addition, the SCAT2 was compared to the Military Acute Concussion Evaluation (MACE). All the participants of the study were prospectively recruited from the emergency department of Tampere University Hospital (Tampere, Finland). Patients (n=49) between the ages of 18 and 60 years, with no premorbid medical or psychiatric conditions, who met the World Health Organization criteria for mTBI, were enrolled. Trauma controls (n=33) were recruited using similar study criteria. The main measures of the study consisted of SCAT2, MACE, and mTBI severity markers, including neuroimaging (computed tomography and conventional magnetic resonance imaging [MRI]), and 1-month clinical outcomes (postconcussion syndrome diagnosis and return to work status). The scoreable components of the SCAT2 performed variably across five dimensions of validity (diagnostic, criterion, divergent, predictive, and responsiveness). The Standardized Assessment of Concussion component reasonably discriminated mTBI patients from controls, was associated with MRI lesions, improved over time, and predicted return to work. Symptom scores differentiated patients with mTBIs from controls, and elevated initial symptom scores in patients with mTBI were associated with a greater risk of persistent postconcussion symptoms. The SCAT2 was superior to the MACE. The SCAT2 appears useful for detecting acute mTBI-related symptoms and cognitive impairment, refining prognosis, and monitoring recovery.

Acute assessment of brain injuries in ground-level falls.

OBJECTIVE: The purpose of this study was to characterize traumatic brain injuries (TBI) sustained in ground-level falls (GLFs). The focus was on factors associated with acute computed tomographic (CT) findings. METHODS: The sample included 575 subjects examined and treated at the Tampere University Hospital emergency department (ED). Retrospective data collection consisted of subject- and injury-related data and clinical information from the emergency department. All CT scans were analyzed and systematically coded. RESULTS: Ground-level falls were the mechanism of injury in 48.3% (n = 278) of the subjects. In the GLF group, independent risk factors for acute traumatic CT findings were long-term alcohol abuse, older age, being found on the ground, and left temporoparietal and occipital location of direct head impact. There were no significant differences in the incidence of any intracranial traumatic lesion type between those with GLFs and other causes of TBI. None of the classic clinical TBI severity markers studied were associated with acute traumatic CT findings in patients with GLFs. CONCLUSIONS: Older age and long-term alcohol abuse increase the likelihood of acute intracranial CT abnormalities. The pattern of intracranial traumatic CT findings does not differ from other causes of TBI. Clinical signs and indices of TBI severity did not predict traumatic CT findings.

Treatment costs and productivity losses caused by traumatic brain injuries.

OBJECTIVE: To estimate the magnitude and relative importance of hospital treatment costs and productivity losses caused by traumatic brain injuries (TBIs). PATIENTS: A total of 155 patients with new TBI diagnoses admitted to Turku University Hospital were systematically sampled. METHODS: Hospital costs were determined by collecting detailed data from patient records and applying the actual cost from the hospital administration. For estimating the productivity losses, the age of retirement was adjusted according to the age- and sex-specific retirement probability. RESULTS: Median treatment costs per TBI patient were €5429, surgery €1600 and other costs €3651. Overall treatment costs for severe brain injuries were significantly (p < 0.01) higher than for less severe cases. Median production losses due to early retirement were estimated to be €1.19 million per TBI patient, significantly (p < 0.03) lower among less severe than among the severe cases. Age, sex and severity of TBI could explain only 9% of the variation in treatment costs, but explained 73% of the variation in production losses. CONCLUSIONS: Indirect productivity losses form the great majority of the overall economic burden of TBI to society. The direct treatment costs in tertiary level hospitals also impose a considerable burden on the healthcare sector.

Clinical assessment of hemispatial neglect: evaluation of different measures and dimensions.

The multidimensional nature of the neglect syndrome constitutes a challenge for clinical assessments. This study evaluates the sensitivity of different clinical measures to detect neglect and explores ways to evaluate the diversity of the syndrome in a clinical sample. An extensive battery of tests was used to examine aspects of visuospatial, representational, and personal neglect. A total of 31 normal control participants and 34 patients with right hemisphere stroke were examined 16.8 days post-stroke, on average. Of the patients, 24 showed neglect in at least one task. The Random shape cancellation test, Star cancellation, and two line bisection tasks appeared to be the most sensitive tests of visuospatial neglect. Personal neglect and neglect in far space occurred only together with extrapersonal neglect. Besides near space, other spatial aspects of neglect are important to consider in clinical assessments, but standardized methods are needed. In this patient group a minimum of 10 tests were needed to cover various aspects of detection, dissociations, and severity of neglect. A multifactorial approach in clinical testing of neglect is recommended.