Shelly D. Timmons

Comparative effectiveness research in neurotrauma.

Comparative effectiveness research (CER) is emerging as a commonly applied technique to determine the usefulness of medical interventions. Such research aims to compare various treatments for specific disease entities for overall effectiveness and potential for harm. According to the Centers for Disease Control, an estimated 1.7 million patients sustain a traumatic brain injury (TBI) annually in the US. In this review the authors examine the existence of CER reports in the area of neurotrauma to date and consider the context in which clinical research and evidence-based guidelines have and will continue to inform such analyses, with special attention to TBI.

Mild traumatic brain injury

MTBI may be caused by diffuse (affecting the whole brain) or focal (affecting a specific area) injury. In diffuse injuries, a blow to the head leading to temporary loss of consciousness can result in stretching and tearing of nerve fibres throughout the brain. Most stretched nerve cells will return to normal, but some may be permanently damaged, either functioning abnormally or not functioning at all. This causes the symptoms of MTBI.

Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children

Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

Importance In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control’s (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. Objective To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. Evidence Review Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. Findings Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. Conclusions and Relevance This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

Prehospital Transportation and Optimal Utilization of Resources

Prehospital guidelines for the management of severe traumatic brain injury (sTBI) outline issues of injury prevention, initial evaluation, early treatment goals, and triage concerns and call for specific resuscitative efforts and neurologic assessments. All of these measures are aimed at the avoidance of secondary insults contributing to secondary injury cascades in the brain following TBI. Several factors including regional geography, topography, weather patterns, available modes of transportation, and the locales of health-care institutions and trauma centers must all be taken into account when devising transportation and prehospital treatment strategies to improve patient outcomes. Controversies regarding best type of transportation, direct-to-trauma center versus closest hospital transport, still exist, but data are emerging to support transporting sTBI patients to the highest-level trauma center available as soon as possible. Telemedicine services will aid better coordination of care in the future.

Comorbidities and Positioning: Morbid Obesity and Multiple Trauma

Neurosurgical positioning is challenging even in a controlled environment. Comorbidities such as morbid obesity and polytrauma make operative positioning even more challenging. Prone positioning requires extra thought and preparation, especially in the obese patient. Extensive preoperative workup may be required. Intra-abdominal pressure should be minimized. Great care must be taken when positioning to avoid peripheral nerve injury, pressure points sores, and ischemic optic neuropathy. Positioning of the polytrauma patient is equally challenging and requires cooperation between the anesthesia team and multiple surgical teams in time-pressured emergency situations. Protection of the spine during intubation and positioning is key.

Use of Multimodality Neuromonitoring in the Management of Traumatic Brain Injury

Multimodality neuromonitoring has become an essential part of neurocritical care over the past several decades. Ideally, the management strategies employed based on the information provided by multimodality monitoring should minimize secondary injury and not instigate deleterious effects. The aim of this chapter is to discuss available advanced neuromonitoring techniques, to review evidence for patient outcomes in the setting of multimodality monitoring, and to discuss in brief the logistical implications of implementing these techniques in the neurocritical care unit.

Use of Consciousness-Enhancing Medications in the Traumatic Brain Injury Patient

After traumatic brain injury (TBI), patients often experience an altered level of consciousness for some period of time, and deeply altered levels of consciousness may be classified as comatose or vegetative states. Some patients do not fit either of these categories, due to some level of preservation of self-awareness, and are defined as being in a minimally conscious state; patients may progress to this state from coma or vegetative state after a TBI. Understanding the criteria for each of these altered states is important for prognostication purposes. While a large proportion of patients with prolonged coma after a TBI will “awaken” within 1 year, many researchers have focused on utilization of pharmaceutical agents to hasten recovery of consciousness due to the propensity for complications and other deleterious issues associated with prolonged coma. However, as with all medications, the medications used have a side-effect profile that could certainly play a harmful role in recovery. In addition, limited data are available to suggest that these medications actually do aid TBI patients in their recovery. The goal of this chapter is to discuss the available evidence for conscious-enhancing medications for this use.

Editorial. The challenges of estimating the cost of traumatic brain injury worldwide

ACCOMPANYING ARTICLE DOI: 10.3171/2018.1.FOCUS17796. INCLUDE WHEN CITING DOI: 10.3171/2018.2.FOCUS1888. In their investigation entitled “The Estimated Cost of Surgically Managed Isolated Traumatic Head Injury Secondary to Road Traffic Accidents,”5 X. You et al. have highlighted many of the challenges inherent in estimating costs of care in general. This group studied the direct costs of traumatic brain injury (TBI) over a finite period in a very well circumscribed group of TBI patients in what was admittedly only a beginning effort to understand costs of care and the societal financial impact of TBI in Malaysia. Given the authors’ citation that 7.54% of hospital admissions to Ministry of Health and private hospitals in Malaysia in 2015 were due to injury, making it the fourth leading cause of hospital admissions, economic analyses are justified. TBI is a massive global problem causing death and disability to millions annually. Despite the social and financial ramifications of TBI,2 studies on the cost of TBI care are relatively few in number. The literature has revealed that cost estimates are widely variable, dependent upon severity, comorbidities, and a variety of socioeconomic issues, such as race, ethnicity, geography, income, and other markers of social status. Although this study represents an incremental step forward in our understanding of the burden of TBI, it is nonetheless an important one. Malaysia is considered by the World Bank to be an upper middle–income country (MIC) at present, and economically stable MICs are considered to have positive effects on other parts of the world in terms of international financial stability. In-country health care expenditures, therefore, have ramifications not only for Malaysia, but if they are detrimental to the country’s overall economy, they may have negative downstream consequences to other countries. It is also important for the government and the medical community to understand the impact of costs of care provided to its citizens, because much of that care is funded by the government (Ministry of Health).5 Furthermore, according to the World Bank, the nation has identified the poorest 40% of the population as an important segment on which to focus aid efforts, which have been provided (at least in part) in the form of direct material financial support to individuals. This group, like the lowest income segment of any population, is particularly vulnerable to unforeseen events causing economic hardship, such as an injury or illness requiring unexpected expenditures. Certainly, sustaining a TBI can financially challenge or even bankrupt an individual or a family, and for those already at financial risk, it can be ruinous. The financial obligation from the government may be additionally burdened by a large population of both survivors and family members who can no longer earn because they must forego gainful employment to care for the injured person. This vicious cycle can contribute to an ongoing public health burden in any country, and while beyond the scope of the You study, it will be important in the future to analyze downstream financial opportunity costs arising from TBI, in addition to the direct costs. TBI may have a disproportionate negative financial impact on people living in countries with lower incomes, and data are needed from a variety of environments to help clarify the mechanisms by which care is provided and ultimately target public health initiatives to reduce injury rates, decrease complication rates, and improve outcomes. For example, in a truly integrated trauma and public health system, injury data should be collected and utilized to prioritize prevention efforts for the jurisdiction in question.3 The majority of severe TBI patients were motorcyclists in the study by You et al.5 The identification of motorized cycling as a major mechanism of injury can be used to advocate for effective expenditure of resources on preventive measures such as educational programs, safety initiatives, and even government actions aimed at reduction of motorcycle crashes in this region of Malaysia or indeed nationwide. Having these data should inform efforts to improve the EDITORIAL The challenges of estimating the cost of traumatic brain injury worldwide

Neurosurgical Coverage for Emergency and Trauma Call

Traditionally, neurosurgeons have responded to calls to treat new patients or address emergent, acute neurosurgical pathology in the hospitals they staff as part of their duty to the medical profession and community. Due to increasing financial pressures placed upon neurosurgical practice from hospitals and regulatory mandates, remuneration for neurosurgeon availability to serve on trauma call has become more frequent and is increasingly seen as essential. In this study, we present the first peer-review published survey of neurosurgical emergency and trauma call coverage patterns, scope, schedules, compensation, liability exposure, and call cessation. We surveyed all practicing neurosurgeon members of the American Association of Neurological Surgeons and Congress of Neurological Surgeons with a 24% response rate. The vast majority of respondents (86%), through their practice, provide 24/7/365 trauma coverage at their primary hospital site. About a third (29%) of respondents have been sued by a patient seen in the emergency department. Twenty percent of respondents anticipate retiring within the next 2 yr. Understanding trauma call coverage, remuneration, and the barriers to taking call provide needed transparency to neurosurgeons who are providing emergency, life-saving services for patients across the country. An understanding of supply and demand forces governing call coverage also assists the field in necessary workforce planning and innovation in providing access to needed, timely acute neurosurgical care.