Globally, significant differences have been noted in casemix, management, and mortality of patients who undergo emergency neurosurgery for traumatic brain injury (TBI), according to a prospective, observational study published in The Lancet Neurology.
Although neurosurgical interventions are a key aspect of care for patients with TBI, scant epidemiologic data are available on the topic. This prompted the researchers to conduct a study (Global Neurotrauma Outcomes Study, ClinicalTrials.gov identifier: NCT04212754) to describe differences in casemix, management, and mortality among patients undergoing emergency neurosurgery for TBI across various levels of human development.
The researchers used a convenience sample of hospitals that were identified by open invitation, via international and regional societies and meetings, individual contacts, and social media. All individuals who underwent emergency neurosurgery for TBI in the 30-day study period for each hospital were eligible for study inclusion, except for patients who received insertion of an intracranial pressure monitor only, who underwent ventriculostomy placement only, or who underwent a procedure for drainage of a chronic subdural hematoma.
The primary study outcome measure was mortality at 14 days postoperatively (or last point of observation if the participant was discharged prior to this time point). Secondary outcome measures included length of hospital stay, length of stay in the intensive care unit, infection at the surgical site, return to the operating room, Glasgow Coma Scale score at discharge vs admission, and discharge destination.
Countries were stratified according to their Human Development Index (HDI), which is a composite of life expectancy, education, and income measures, into the following groups: very high HDI tier, high HDI tier, medium HDI tier, and low HDI tier.
A total of 1635 records from 159 hospitals in 57 countries, which were obtained between November 1, 2018, and January 31, 2020, were included. Overall, 20% of the records were from countries in the very high HDI tier, 33% from countries in the high HDI tier, 38% from countries in the medium HDI tier, and 9% from countries in the low HDI tier. The median participant age was 35 years (range, 24 to 51 years). The oldest patients were in the very high HDI tier, whereas the youngest patients were in the low HDI tier.
The most common procedures among the participants included the following: elevation of a depressed skull fracture in 45% of those in the low HDI tier; evacuation of a supratentorial extradural hematoma among 31% of those in the medium HDI tier and 32% of those in the high HDI tier; and evacuation of a supratentorial acute subdural hematoma in 47% of those in the very high HDI tier. The median time from sustaining an injury to undergoing surgery was 13 hours (range, 6 to 32 hours).
Mortality was reported among 18% (299 of 1635) of the participants. Following adjustment for casemix, the likelihood of mortality was greater among those in the medium HDI tier (odds ratio [OR], 2.84; 95% CI, 1.55 to 5.20) and the high TDI tier (OR, 2.26; 95% CI, 1.23 to 4.15), but not among those in the low HDI tier (OR, 1.66; 95% CI, 0.61 to 4.46), relative to the very high HDI tier. Significant between-hospital variation in mortality was observed (median OR, 2.04; 95% CI, 1.17 to 2.49).
Quality of care among the patients was generally less favorable in lower human development settings, which included temporal delays in surgery, as well as a lack of access to postsurgical intracranial pressure monitoring and the receipt of intensive care.
A major limitation of the current study is the fact that participation by hospitals was on a voluntary basis, thus the possibility of selection bias exists. In addition, functional outcomes were not evaluated in the present analysis.
“Longitudinal studies are being planned to assess long-term outcomes and design contextually appropriate interventions to reduce preventable deaths in this patient population globally,” the researchers concluded.
Disclosure: One of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of the author’s disclosures.
Clark D, Joannides A, Adeleye AO, et al; Global Neurotrauma Outcomes Study collaborative. Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study. Lancet Neurol. Published online March 16, 2022. doi:10.1016/S1474-4422(22)00037-0