Managing Severe Traumatic Brain Injury Across Resource Settings: Latin American Perspectives.

Severe traumatic brain injury (sTBI) is a condition of increasing epidemiologic concern worldwide. Outcomes are worse as observed in low- and middle-income countries (LMICs) versus high-income countries. Global targets are in place to address the surgical burden of disease. At the same time, most of the published literature and evidence on the clinical approach to sTBI comes from wealthy areas with an abundance of resources. The available paradigms, including the Brain Trauma Foundation guidelines, the Seattle International Severe Traumatic Brain Injury Consensus Conference, Consensus Revised Imaging and Clinical Examination, and multimodality approaches, may fit differently depending on local resources, expertise, and sociocultural factors. A first step toward addressing heterogeneity in practice is to consider comparative effectiveness approaches that can capture actual practice patterns and record short-term and long-term outcomes of interest. Decompressive craniectomy (DC) decreases intracranial pressure burden and can be lifesaving. Nevertheless, completed randomized controlled trials took place within high-income settings, leaving important questions unanswered and making extrapolations to LMICs questionable. The concept of preemptive DC specifically to address limited neuromonitoring resources may warrant further study to establish a benefit/risk profile for the procedure and its role within local protocols of care.

Household income is associated with functional outcomes in a multi-institutional cohort of patients with ischemic stroke and COVID-19.

OBJECTIVES: The COVID-19 pandemic has heightened awareness of health disparities associated with socioeconomic status (SES) across the United States. We examined whether household income is associated with functional outcomes after stroke and COVID-19. MATERIALS AND METHODS: This was a multi-institutional, retrospective cohort study of consecutively hospitalized patients with SARS-CoV-2 and radiographically confirmed stroke presenting from March through November 2020 to any of five comprehensive stroke centers in metropolitan Chicago, Illinois, USA. Zip-code-derived household income was dichotomized at the Chicago median. Logistic regression was used to examine the relationship between household income and good functional outcome (modified Rankin Scale 0-3 at discharge, after ischemic stroke). RESULTS: Across five hospitals, 159 patients were included. Black patients comprised 48.1%, White patients 38.6%, and Hispanic patients 27.7%. Median household income was $46,938 [IQR: $32,460-63,219]. Ischemic stroke occurred in 115 (72.3%) patients (median NIHSS 7, IQR: 0.5-18.5) and hemorrhagic stroke in 37 (23.7%). When controlling for age, sex, severe COVID-19, and NIHSS, patients with ischemic stroke and household income above the Chicago median were more likely to have a good functional outcome at discharge (OR 7.53, 95% CI 1.61 - 45.73; P=0.016). Race/ethnicity were not included in final adjusted models given collinearity with income. CONCLUSIONS: In this multi-institutional study of hospitalized patients with stroke, those residing in higher SES zip codes were more likely to have better functional outcomes, despite controlling for stroke severity and COVID-19 severity. This suggests that area-based SES factors may play a role in outcomes from stroke and COVID-19.

Frequency, Risk Factors, and Outcomes of Unplanned Readmission to the Neurological Intensive Care Unit after Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Unplanned readmission to the neurological intensive care unit (ICU) is an underinvestigated topic in patients admitted after spontaneous intracerebral hemorrhage (ICH). The purpose of this study is to investigate the frequency, clinical risk factors, and outcome of bounce back to the neurological ICU in a cohort of patients admitted after ICH. METHODS: This is a retrospective observational study inspecting bounce back to the neurological ICU in patients admitted with spontaneous ICH over an 8-year period. For each patient, demographics, medical history, clinical presentation, length of ICU stay, unplanned readmission to neurological ICU, cause of readmission, and mortality were reviewed. Bounce back to the neurological ICU was defined as an unplanned readmission to the neurological ICU from a general floor service during the same hospitalization. A multivariable analysis was used to define independent variables associated with bounce back to the neurological ICU as well as association between bounce back to the neurological ICU and mortality. The significance level was set at p < 0.05. RESULTS: A total of 221 patients were included. Among those, 20 (9%) had a bounce back to the neurological ICU. Respiratory complications (n = 11) was the most common reason for bounce back to the neurological ICU, followed by neurological (n = 5) and cardiological (n = 4) complications. In a multivariable logistic regression, location of hemorrhage in the basal ganglia (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.0-8.9, p = 0.03) and dysphagia at the time of transfer (OR: 3.9, 95% CI: 1.0-15.4, p = 0.04) were significantly associated with bounce back to the neurological ICU. After we controlled for ICH score, readmission to the ICU was also independently associated with higher mortality (OR: 14.1, 95% CI: 2.8-71.7, p < 0.01). CONCLUSIONS: Bounce back to the neurological ICU is not an infrequent complication in patients with spontaneous ICH and is associated with higher hospital length of stay and mortality. We identified relevant and potentially modifiable risk factors associated with bounce back to the neurological ICU. Future prospective studies are necessary to develop patient-centered strategies that may improve transition from the neurological ICU to the general floor.

Civilian Firearm-Inflicted Brain Injury: Coagulopathy, Vascular Injuries, and Triage.

PURPOSE OF REVIEW: Civilian firearm-inflicted penetrating brain injury (PBI) carries high morbidity and mortality. Concurrently, the evidence base guiding management decisions remains limited. Faced with large volume of PBI patients, we have made observations in relation to coagulopathy and cerebrovascular injuries. We here review this literature in addition to the question about early prognostication as it may inform neurosurgical decision-making. RECENT FINDINGS: The triad of coagulopathy, low motor score, and radiographic compression of basal cisterns comprises a phenotype of injury with exceedingly high mortality. PBI leads to high rates of cerebral arterial and venous injuries, and projectile trajectory is emerging as an independent predictor of outcome. The combination of coagulopathy with cerebrovascular injury creates a specific endophenotype. The nature and role of coagulopathy remain to be deciphered, and consideration to the use of tranexamic acid should be given. Prospective controlled trials are needed to create clinical evidence free of patient selection bias.

Post-Trial Enhanced Deployment and Technical Performance with the MISTIE Procedure per Lessons Learned.

OBJECTIVE: We hypothesize that procedure deployment rates and technical performance with minimally invasive surgery and thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE) can be enhanced in post-trial clinical practice, per Phase III trial results and lessons learned. MATERIALS AND METHODS: We identified ICH patients and those who underwent MISTIE procedure between 2017-2021 at a single site, after completed enrollments in the Phase III trial. Deployment rates, complications and technical outcomes were compared to those observed in the trial. Initial and final hematoma volume were compared between site measurements using ABC/2, MISTIE trial reading center utilizing manual segmentation, and a novel Artificial Intelligence (AI) based volume assessment. RESULTS: Nineteen of 286 patients were eligible for MISTIE. All 19 received the procedure (6.6% enrollment to screening rate 6.6% compared to 1.6% at our center in the trial; p=0.0018). Sixteen patients (84%) achieved evaculation target < 15 mL residual ICH or > 70% removal, compared to 59.7% in the trial surgical cohort (p=0.034). No poor catheter placement occurred and no surgical protocol deviations. Limitations of ICH volume assessments using the ABC/2 method were shown, while AI based methodology of ICH volume assessments had excellent correlation with manual segmentation by experienced reading centers. CONCLUSIONS: Greater procedure deployment and higher technical success rates can be achieved in post-trial clinical practice than in the MISTIE III trial. AI based measurements can be deployed to enhance clinician estimated ICH volume. Clinical outcome implications of this enhanced technical performance cannot be surmised, and will need assessment in future trials.

Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management.

BACKGROUND AND OBJECTIVES: To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI). METHODS: We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome. RESULTS: The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05). CONCLUSION: Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.

Comparative Analysis of Clinical Severity and Outcomes in Penetrating Versus Blunt Traumatic Brain Injury Propensity Matched Cohorts.

Traumatic brain injury (TBI) is a global health challenge; however, penetrating brain injury (PBI) remains under-represented in evidence-based knowledge and research efforts. This study utilized data from the Trauma Quality Improvement Program (TQIP) of the National Trauma Data Bank (NTDB) to investigate outcomes of PBI as compared with clinical-severity-matched non-penetrating or blunt TBI. A total of 1765 patients with PBI were 1:1 propensity score-matched for clinical severity with blunt TBI patients. The intent of PBI was self-inflicted in 34.1% of the cases, and the mechanism was firearm-inflicted in 89.1%. Mortality was found to be significantly more common in PBI than in the severity- matched TBI cohort (33.9% vs. 14.3 %, p < 0.001) as was unfavorable outcome. Mortality was mediated by withdrawal of life-sustaining therapies (WOLST) 30% of the time, and WOLST occurred earlier (median 3 days vs. 6 days, p < 0.001) in PBI. Increased rate of mortality was observed with a Glasgow Coma Scale (GCS) of <11 in PBI as compared with <7 in blunt TBI. In conclusion, PBI patients exhibited higher mortality rates and unfavorable outcomes; one third of excess mortality was mediated by WOLST. The study also brings into question the applicability of the conventional TBI classification, based on GCS, in PBI. We emphasize the need to address the observed disparities and better understand the distinctive characteristics and mechanisms underlying PBI outcomes to improve patient care and reduce mortality.

Impact of Covid-19 on Stroke Code Activations, Process Metrics, and Diagnostic Error.

BACKGROUND AND PURPOSE: In a comprehensive stroke center, we analyzed the stroke code activations (SCA), assessed the impact of Covid-19, and the measures taken by the local government to lessen the spread of the disease. METHODS: We retrospectively reviewed SCA and classified them into 2 groups: pre-pandemic activations (February 15 to March 10) and Covid-19 pandemic activations (March 11 to April 30). The primary outcome was the ratio of true positive diagnoses of stroke relative to the total number of SCA in the 2 time periods. RESULTS: Among the 212 SCA, 83 (39.2%) were from the pre-pandemic period, whereas 129 (60.8%) were from the pandemic period, 147 (69.3%) in the Emergency Department (ED) versus 65 (30.7%) in the inpatient service. In the ED cohort, a rapid decrease in the number of SCA at the beginning of the pandemic was followed by a gradual increase to pre-pandemic levels and a significant increase in the number of true positive strokes over time (44.2% vs 61.1%, p = 0.037). An increase in door-to-CT time (p = 0.001) and an increase in the rate of diagnostic error in patients admitted from the ED (p = 0.016) were also seen. The in-hospital cohort had a sustained decrease in the number of SCA following the pandemic declaration, with no difference in the rate of true positive stroke. CONCLUSIONS: We observed a rapid decline and slow recovery in ED SCA with a shift toward increased true positive cases following the Covid-19 pandemic. Also, delays in obtaining CT and diagnostic error was increased, however, no difference in early clinical outcomes were seen between groups.

Safer Stroke-Dx Instrument: Identifying Stroke Misdiagnosis in the Emergency Department.

BACKGROUND: Missed or delayed diagnosis of acute stroke, or false-negative stroke (FNS), at initial emergency department (ED) presentation occurs in ≈9% of confirmed stroke patients. Failure to rapidly diagnose stroke can preclude time-sensitive treatments, resulting in higher risks of severe sequelae and disability. In this study, we developed and tested a modified version of a structured medical record review tool, the Safer Dx Instrument, to identify FNS in a subgroup of hospitalized patients with stroke to gain insight into sources of ED stroke misdiagnosis. METHODS: We conducted a retrospective cohort study at 2 unaffiliated comprehensive stroke centers. In the development and confirmatory cohorts, we applied the Safer Stroke-Dx Instrument to report the prevalence and documented sources of ED diagnostic error in FNS cases among confirmed stroke patients upon whom an acute stroke was suspected by the inpatient team, as evidenced by stroke code activation or urgent neurological consultation, but not by the ED team. Inter-rater reliability and agreement were assessed using interclass coefficient and kappa values (κ). RESULTS: Among 183 cases in the development cohort, the prevalence of FNS was 20.2% (95% CI, 15.0-26.7). Too narrow a differential diagnosis and limited neurological examination were common potential sources of error. The interclass coefficient for the Safer Stroke-Dx Instrument items ranged from 0.42 to 0.91, and items were highly correlated with each other. The κ for diagnostic error identification was 0.90 (95% CI, 0.821-0.978) using the Safer Stroke-Dx Instrument. In the confirmatory cohort of 99 cases, the prevalence of FNS was 21.2% (95% CI, 14.2-30.3) with similar sources of diagnostic error identified. CONCLUSIONS: Hospitalized patients identified by stroke codes and requests for urgent neurological consultation represent an enriched population for the study of diagnostic error in the ED. The Safer Stroke-Dx Instrument is a reliable tool for identifying FNS and sources of diagnostic error.