umu.sePublications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Severe traumatic brain injury: clinical course and prognostic factors
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Traumatic brain injury (TBI) constitutes a major health problem and is a leading cause of long-term disability and death. Patients with severe traumatic brain injury, S-TBI, comprise a heterogeneous group with varying complexity and prognosis. The primary aim of this thesis was to increase knowledge about clinical course and outcome with regard to prognostic factors. Papers I, II and III were based on data from a prospective multicentre observational study from six neurotrauma centers (NCs) in Sweden and Iceland of patients (n=103-114), 18-65 years with S-TBI requiring neurosurgical intensive care or collaborative care with a neurosurgeon (the “PROBRAIN” study).  Paper IV and V were performed on a regional subset (n=37).

In Paper I, patients with posttraumatic disorders of consciousness (DOC) were assessed as regards relationship between conscious state at 3 weeks and outcomes at 1 year. The number of patients who emerged from minimally conscious state (EMCS) 1 year after injury according to status at 3 weeks were: coma (0/6), unresponsive wakeful syndrome (UWS) (9/17), minimally conscious state (MCS) (13/13), anaesthetized (9/11). Outcome at 1 year was good (Glasgow Outcome Scale Extended (GOSE>4) in half of the patients in MCS (or anaesthetized) at 3 weeks, but not for any of the patients in coma or UWS.  

 In Paper II, the relationships between clinical care descriptors and outcome at 1 year were assessed. A longer length of stay in intensive care, and longer time between discharge from intensive care and admission to inpatient rehabilitation, were both associated with a worse outcome on the GOSE. The number of intervening care units between intensive care and rehabilitation, was not significantly associated with outcome at 1 year.

 In Paper III, the clinical course of cognitive and emotional impairments as reflected in the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS) were assessed from 3 weeks to 1 year together with associations with outcomes GOSE and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R) at 1 year. Cognition improved over time and appeared to be stable from 3 months to 1 year.

 In Paper IV, clinical parameters, the clinical pathways from injury to 3 months after discharge from the NC in relation to outcomes 3 months post-injury. Ratings on the RLAS-R improved significantly over time. Eight patients had both “superior cognitive functioning” on the RLAS-R and “favourable outcome” on the GOSE. Acute transfers to the one regional NC was direct and swift, transfers for postacute rehabilitation scattered patients to many hospitals/hospital departments, not seldom by several transitional stages.

 In Paper V, an initial computerized tomography of the brain (CTi) and a further posttraumatic brain CT after 24 hours (CT24) were evaluated according to protocols for standardized assessment, the Marshall and Rotterdam classifications. The CT scores only correlated with clinical outcome measures (GOSE and RLAS-R) at 3 months, but failed to yield prognostic information regarding outcome at 1 year. A prognostic model was also implemented, based on acute data (CRASH model). This model predicted unfavourable outcomes for 81% of patients with bad outcome and for 85% of patients with favourable outcome according to GOSE at 1 year. When assessing outcomes per se, both GOSE and RLAS-R improved significantly from 3 months to 1 year.

 The papers in this study point both to the generally favourable outcomes that result from active and aggressive management of S-TBI, while also underscore our current lack of reliable instruments for outcome prediction. In the absence of an ability to select patients based on prognostication, the overall favourable prognosis lends support for providing active rehabilitation to all patients with S-TBI. The results of these studies should be considered in conjunction with the prognosis of long-term outcomes and the planning of rehabilitation and care pathways. The results demonstrate the importance of a combination of active, acute neurotrauma care and intensive specialized neurorehabilitation with follow-up for these severely injured patients.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 109 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1792
Keyword [en]
Severe traumatic brain injury, outcome, rehabilitation, prognosis
National Category
Other Medical Sciences not elsewhere specified
Research subject
Rehabilitation Medicine
Identifiers
URN: urn:nbn:se:umu:diva-119826ISBN: 978-91-7601-416-5 (print)OAI: oai:DiVA.org:umu-119826DiVA: diva2:924611
Public defence
2016-05-27, E04, Umeå universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-05-04 Created: 2016-04-28 Last updated: 2016-06-01Bibliographically approved
List of papers
1. Disorders of consciousness after severe traumatic brain injury: a Swedish-Icelandic study of incidence, outcomes and implications for optimizing care pathways
Open this publication in new window or tab >>Disorders of consciousness after severe traumatic brain injury: a Swedish-Icelandic study of incidence, outcomes and implications for optimizing care pathways
Show others...
2013 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 45, no 8, 741-748 p.Article in journal (Refereed) Published
Abstract [en]

Background: Very severe traumatic brain injury may cause disorders of consciousness in the form of coma, unresponsive wakefulness syndrome (also known as vegetative state) or minimally conscious state. Previous studies of outcome for these patients largely pre-date the 2002 definition of minimally conscious state.

Objectives: To establish the numbers of patients with disorder of consciousness at 3 weeks, 3 months and 1 year after severe traumatic brain injury, and to relate conscious state 3 weeks after injury to outcomes at 1 year.

Design: Multi-centre, prospective, observational study of severe traumatic brain injury.

Inclusion criteria: Lowest (non-sedated) Glasgow Coma Scale 3-8 during the first 24 h; requirement for neurosurgical intensive care; age 18-65 years; alive 3 weeks after injury. Diagnosis of coma, unresponsive wakefulness syndrome, minimally conscious state or emerged from minimally conscious state was based on clinical and Coma Recovery Scale Revised assessments 3 weeks, 3 months and 1 year after injury. One-year outcome was measured with Glasgow Outcome Scale Extended (GOSE).

Results: A total of 103 patients was included in the study. Of these, 81% were followed up to 1 year (76% alive, 5% dead). Three weeks after injury 36 were in coma, unresponsive wakefulness syndrome or minimally conscious state and 11 were anaesthetized. Numbers of patients who had emerged from minimally conscious state 1 year after injury, according to status at 3 weeks were: coma (0/6), unresponsive wakefulness syndrome (9/17), minimally conscious state (13/13), anaesthetized (9/11). Outcome at 1 year was good (GOSE>4) for half of patients in minimally conscious state or anaesthetized at 3 weeks, but for none of the patients in coma or unresponsive wakefulness syndrome. These differences in outcome were not revealed by prognostic predictions based on acute data.

Conclusion: Patients in minimally conscious state or anaesthetized 3 weeks after injury have a better prognosis than patients in coma or unresponsive wakefulness syndrome, which could not be explained by acute prognostic models.

Place, publisher, year, edition, pages
Foundation Rehabilitation Information, 2013
Keyword
traumatic brain injury, prognosis, vegetative state, minimally conscious state, outcome, care pathways
National Category
Health Sciences
Identifiers
urn:nbn:se:umu:diva-83647 (URN)10.2340/16501977-1167 (DOI)000326357500008 ()
Available from: 2013-12-03 Created: 2013-12-03 Last updated: 2017-12-06Bibliographically approved
2. Associations Between Care Pathways and Outcome 1 Year After Severe Traumatic Brain Injury
Open this publication in new window or tab >>Associations Between Care Pathways and Outcome 1 Year After Severe Traumatic Brain Injury
Show others...
2015 (English)In: The journal of head trauma rehabilitation, ISSN 0885-9701, E-ISSN 1550-509X, Vol. 30, no 3, E41-E51 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To assess associations between real-world care pathways for working-age patients in the first year after severe traumatic brain injury and outcomes at 1 year. Setting and Design: Prospective, observational study with recruitment from 6 neurosurgical centers in Sweden and Iceland. Follow-up to 1 year, independently of care pathways, by rehabilitation physicians and paramedical professionals. Participants: Patients with severe traumatic brain injury, lowest (nonsedated) Glasgow Coma Scale score 3 to 8 during the first 24 hours and requiring neurosurgical intensive care, age 18 to 65 years, and alive 3 weeks after injury. Main Measures: Length of stay in intensive care, time between intensive care discharge and rehabilitation admission, outcome at 1 year (Glasgow Outcome Scale Extended score), acute markers of injury severity, preexisting medical conditions, and post-acute complications. Logistic regression analyses were performed. Results: A multivariate model found variables significantly associated with outcome (odds ratio for good outcome [confidence interval], P value) to be as follows: length of stay in intensive care (0.92 [0.87-0.98], 0.014), time between intensive care discharge and admission to inpatient rehabilitation (0.97 [0.94-0.99], 0.017), and post-acute complications (0.058 [0.006-0.60], 0.017). Conclusions: Delays in rehabilitation admission were negatively associated with outcome. Measures to ensure timely rehabilitation admission may improve outcome. Further research is needed to evaluate possible causation.

Keyword
health facility planning, outcome, rehabilitation, severe traumatic brain injury
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-104378 (URN)10.1097/HTR.0000000000000050 (DOI)000354298100005 ()24901323 (PubMedID)
Available from: 2015-07-01 Created: 2015-06-10 Last updated: 2017-04-25
3. Cognitive Impairment after Severe Traumatic Brain Injury, Clinical Course and Impact on Outcome: A Swedish-Icelandic Study
Open this publication in new window or tab >>Cognitive Impairment after Severe Traumatic Brain Injury, Clinical Course and Impact on Outcome: A Swedish-Icelandic Study
Show others...
2015 (English)In: Behavioural Neurology, ISSN 0953-4180, E-ISSN 1875-8584, 680308Article in journal (Refereed) Published
Abstract [en]

Objective. To assess the clinical course of cognitive and emotional impairments in patients with severe TBI (sTBI) from 3 weeks to 1 year after trauma and to study associations with outcomes at 1 year. Methods. Prospective, multicenter, observational study of sTBI in Sweden and Iceland. Patients aged 18-65 years with acute Glasgow Coma Scale 3-8 were assessed with the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS). Outcome measures were Glasgow Outcome Scale Extended (GOSE) and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R). Results. Cognition was assessed with the BNIS assessed for 42 patients out of 100 at 3 weeks, 75 patients at 3 months, and 78 patients at 1 year. Cognition improved over time, especially from 3 weeks to 3 months. The BNIS subscales "orientation" and "visuospatial and visual problem solving" were associated with the GOSE and RLAS-R at 1 year. Conclusion. Cognition seemed to improve over time after sTBI and appeared to be rather stable from 3 months to 1 year. Since cognitive function was associated with outcomes, these results indicate that early screening of cognitive function could be of importance for rehabilitation planning in a clinical setting.

Keyword
Brain Injuries, Cognitive Science, Population, Treatment Outcome
National Category
Clinical Medicine
Identifiers
urn:nbn:se:umu:diva-114043 (URN)10.1155/2015/680308 (DOI)000366850100001 ()
Available from: 2016-01-11 Created: 2016-01-11 Last updated: 2017-04-25
4. Severe traumatic brain injuries in Northern Sweden: a prospective 2-year study
Open this publication in new window or tab >>Severe traumatic brain injuries in Northern Sweden: a prospective 2-year study
2013 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 45, no 8, 792-800 p.Article in journal (Refereed) Published
Abstract [en]

To assess: (i) the clinical characteristics and injury descriptors of patients with severe traumatic brain injury in Northern Sweden admitted to the single Neurotrauma Center (NC) serving this region; (ii) the care pathway of patients from injury to 3 months after discharge from the NC; and (iii) the outcomes at 3 months post-injury. Population-based prospective 2-year cohort study.Patients age 17–65 years with acute severe traumatic brain injury, lowest non-sedated Glasgow Coma Scale (GCS) score of 3–8 within 24 h post-trauma. Patients were treated according to an intracranial pressure-oriented protocol based on the Lund concept at the NC. They were assessed at 3 weeks after injury with Rancho Los Amigos Cognitive Scale Revised (RLAS-R), Levels of Cognitive functioning, and at 3 months with RLAS-R and Glasgow Outcome Scale Extended (GOSE).A total of 37 patients were included. Hospital deaths within 3 months post-injury occurred in 5 patients. After 3 months the RLAS-R scores were significantly improved (< 0.001). Eight patients had both “superior cognitive functioning” on the RLAS-R and “favourable outcome” on the GOSE. Thirty-four patients (92%) were directly admitted to the NC. By contrast, after discharge patients were transferred back to one of several county hospitals or to one of several local hospitals, and some had multiple transfers between different hospitals and departments. Overall outcomes were surprisingly good in this group of severely injured patients. The routines for transferring patients with severe traumatic brain injury from a geographically large, sparsely populated region to a regional NC to receive well-monitored neurosurgical care seem to work very well. The post-acute clinical pathways are less clearly reflecting an optimized medical and rehabilitative strategy.

Place, publisher, year, edition, pages
Stiftelsen Rehabiliteringsinformation, 2013
Keyword
traumatic brain injury, outcome, demographics, critical pathways
National Category
Health Sciences
Research subject
Rehabilitation Medicine
Identifiers
urn:nbn:se:umu:diva-83022 (URN)10.2340/16501977-1200 (DOI)000326357500015 ()24002316 (PubMedID)
Available from: 2013-11-15 Created: 2013-11-15 Last updated: 2017-04-26Bibliographically approved
5. Computed tomography and clinical outcome in patients with severe traumatic brain injury
Open this publication in new window or tab >>Computed tomography and clinical outcome in patients with severe traumatic brain injury
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-119822 (URN)
Available from: 2016-04-28 Created: 2016-04-28 Last updated: 2016-05-02Bibliographically approved

Open Access in DiVA

fulltext(906 kB)231 downloads
File information
File name FULLTEXT01.pdfFile size 906 kBChecksum SHA-512
582d98c3f2276b524c41117f8d9a45cbf2859d3eb03fbdadc82e2e86247ba186aec050f913dd721385629a6605d486ce6b2b2757f8b04650ffa64ae680819330
Type fulltextMimetype application/pdf
spikblad(26 kB)27 downloads
File information
File name SPIKBLAD01.pdfFile size 26 kBChecksum SHA-512
ef84200b8d38870f90120efc7a7bf3d17ecc751536f98ddcb0a22be2f1d7a67c8758394e997ed92a2a2723439c6168e66dea3622fbb7f04cc3d835d85e40978b
Type spikbladMimetype application/pdf
Omslagsbild(99 kB)12 downloads
File information
File name FULLTEXT02.jpgFile size 99 kBChecksum SHA-512
1bf29dde784a703be6d4c3e1eacf7a76999cf17d0e7013b31eb197d156fdf919aa8bf5b3a805ff7f5a0631cb72f8e866694defd4ca7df75092dd15ce92943e15
Type fulltextMimetype image/jpeg

Search in DiVA

By author/editor
Stenberg, Maud
By organisation
Rehabilitation Medicine
Other Medical Sciences not elsewhere specified

Search outside of DiVA

GoogleGoogle Scholar
Total: 243 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 998 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf