Rafael Wabl, Craig A. Williamson, Aditya S. Pandey and Venkatakrishna Rajajee
Data on long-term functional recovery (LFR) following severe brain injury are essential for counseling of surrogates and for appropriate timing of outcome assessment in clinical trials. Delayed functional recovery (DFR) beyond 3–6 months is well documented following severe traumatic brain injury (sTBI), but there are limited data on DFR following severe cerebrovascular brain injury. The objective of this study was to assess LFR and DFR in patients with sTBI and severe stroke dependent on tracheostomy and tube feeding at the time of discharge from the intensive care unit (ICU).
The authors identified patients entered into their tracheostomy database 2008–2013 with sTBI and severe stroke, encompassing SAH, intracerebral hemorrhage (ICH), and acute ischemic stroke (AIS). Eligibility criteria included disease-specific indicators of severity, Glasgow Coma Scale score < 9 at time of tracheostomy, and need for tracheostomy and tube feeding at ICU discharge. Assessment was at 1–3 months, 6–12 months, 12–24 months, and 24–36 months after initial injury for presence of tracheostomy, ability to walk, and ability to perform basic activities of daily living (B-ADLs). Long-term functional recovery (LFR) was defined as recovery of the ability to walk or perform B-ADLs by the 24- to 36-month follow-up. Delayed functional recovery (DFR) was defined as progression in functional milestones between any 2 time points beyond the 1- to 3-month follow-up.
A total of 129 patients met the eligibility criteria. Functional outcomes were available for 129 (100%), 97 (75%), 83 (64%), and 80 (62%) patients, respectively, from assessments at 1–3, 6–12, 12–24 and 24–36 months; 33 (26%) died by 24–36 months. Fifty-nine (46%) regained the ability to walk and 48 (37%) performed B-ADLs at some point during their recovery. Among survivors who had not achieved the respective milestone at 1–3 months, 29/58 (50%) were able to walk and 28/74 (38%) performed B-ADLs at 6–12 months. Among survivors who had not achieved the respective milestone at 6–12 months, 5/16 (31%) were able to walk and 13/30 (43%) performed B-ADLs at 12–24 months. There was no significant difference in rates of LFR or DFR between patients with sTBI and those with severe stroke.
Among patients with severe brain injury requiring tracheostomy and tube feeding at ICU discharge, 46% regained the ability to walk and 37% performed B-ADLs 2–3 years after injury. DFR beyond 1–3 and 6–12 months was seen in over 30% of survivors, with no significant difference between sTBI and severe stroke.
Joseph R. Linzey, Craig Williamson, Venkatakrishna Rajajee, Kyle Sheehan, B. Gregory Thompson and Aditya S. Pandey
Recent observational data suggest that ultra-early treatment of ruptured aneurysms prevents rebleeding, thus improving clinical outcomes. However, advances in critical care management of patients with ruptured aneurysms may reduce the rate of rebleeding in comparison with earlier trials, such as the International Cooperative Study on the Timing of Aneurysm Surgery. The objective of the present study was to determine if an ultra-early aneurysm repair protocol will or will not significantly reduce the number of incidents of rebleeding following aneurysmal subarachnoid hemorrhage (SAH).
A retrospective analysis of data from a prospectively collected cohort of patients with SAH was performed. Rebleeding was diagnosed as new or expanded hemorrhage on CT, which was determined by independent review conducted by multiple physicians. Preventability of rebleeding by ultra-early aneurysm clipping or coiling was also independently reviewed. Standard statistics were used to determine statistically significant differences between the demographic characteristics of those with rebleeding compared with those without.
Of 317 patients with aneurysmal SAH, 24 (7.6%, 95% CI 4.7–10.5) experienced rebleeding at any time point following initial aneurysm rupture. Only 1/24 (4.2%, 95% CI −3.8 to 12.2) incidents of rebleeding could have been prevented by a 24-hour ultra-early aneurysm repair protocol. The other 23 incidents could not have been prevented for the following reasons: rebleeding prior to admission to the authors’ institution (14/23, 60.9%); initial diagnostic angiography negative for aneurysm (4/23, 17.4%); postoperative rebleeding (2/23, 8.7%); patient unable to undergo operation due to medical instability (2/23, 8.7%); intraoperative rebleeding (1/23, 4.3%).
At a single tertiary academic center, the overall rebleeding rate was 7.6% (95% CI 4.7–10.5) for those presenting with ruptured aneurysms. Implementation of a 24-hour ultra-early aneurysm repair protocol would only result in, at most, a 0.3% (95% CI −0.3 to 0.9) reduction in the incidence of rebleeding.
Lynze R. Franko, Kyle M. Sheehan, Christopher D. Roark, Jacob R. Joseph, James F. Burke, Venkatakrishna Rajajee and Craig A. Williamson
Subdural hematoma (SDH) is a common disease that is increasingly being managed nonoperatively. The all-cause readmission rate for SDH has not previously been described. This study seeks to describe the incidence of unexpected 30-day readmission in a cohort of patients admitted to an academic neurosurgical center. Additionally, the relationship between operative management, clinical outcome, and unexpected readmission is explored.
This is an observational study of 200 consecutive adult patients with SDH admitted to the neurosurgical ICU of an academic medical center. Demographic information, clinical characteristics, and treatment strategies were compared between readmitted and nonreadmitted patients. Multivariable logistic regression, weighted by the inverse probability of receiving surgery using propensity scores, was used to evaluate the association between operative management and unexpected readmission.
Of 200 total patients, 18 (9%) died during hospitalization and were not included in the analysis. Overall, 48 patients (26%) were unexpectedly readmitted within 30 days. Sixteen patients (33.3%) underwent SDH evacuation during their readmission. Factors significantly associated with unexpected readmission were nonoperative management (72.9% vs 54.5%, p = 0.03) and female sex (50.0% vs 32.1%, p = 0.03). In logistic regression analysis weighted by the inverse probability of treatment and including likely confounders, surgical management was not associated with likelihood of a good outcome at hospital discharge, but was associated with significantly reduced odds of unexpected readmission (OR 0.19, 95% CI 0.08–0.49).
Over 25% of SDH patients admitted to an academic neurosurgical ICU were unexpectedly readmitted within 30 days. Nonoperative management does not affect outcome at hospital discharge but is significantly associated with readmission, even when accounting for the probability of treatment by propensity score weighted logistic regression. Additional research is needed to validate these results and to further characterize the impact of nonoperative management on long-term costs and clinical outcomes.
René Post, Jantien Hoogmoed, Dagmar Verbaan and W. Peter Vandertop