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  • Two Year Mortality and Functional Outcomes of Combat Related Penetrating Brain Injuries, Point of Injury Through Rehabilitation

    Final Number:

    Michael B. Larkin PharmD; R. Michael Meyer; Nicholas S. Szuflita MPH; John J. Delaney MD; Randy S. Bell MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2016 Annual Meeting

    Introduction: Outcomes of penetrating brain injuries (PBI) have historically been very poor. In the civilian trauma center setting, mortality has been noted to be greater than 90%. Outcomes of combat-related PBI have been observed to be better, however past studies have not begun analysis at the point of injury and thus don't provide complete insight into the prognosis of this population.

    Methods: Retrospective chart review of US active-duty PBI managed at Kandahar Airfield, January 2010-March 2013.

    Results: Eighty patients were included. All were male, mean age of 25, and mean Glasgow Coma Score at admission of 8.5. The predominant injury mechanism was blast (72.5%), the remainder suffered gunshots to the head. The most frequent lesions were intraparenchymal hemorrhage (80%), retained fragments (45%) subarachnoid hemorrhage (40%), subdural hematoma (30%), and transtentorial or tonsillar herniation (18.8%). Epidural hematoma, intraventricular hemorrhage, and major cerebrovascular injury (ICA, proximal ACA/MCA/PCA, vein of Galen, or a dural venous sinus) were less common, occurring in less than 10%. The mean GOS at two years was 3.96. Herniation or a cerebrovascular injury correlated with lower two year GOS (1.47, 3.14), as did lower GCS at admission. Comorbid herniation and cerebrovascular injury was 100% mortal. Subdural and epidural hematoma was correlated with higher two year GOS (4.26, 3.8). Thirteen patients expired during resuscitation or had grossly unsalvageable neurological injuries; excluding these, GOS at two years was 4.54.

    Conclusions: Contrary to historic understanding of PBI, the prognosis of combat-related PBI is good provided that the patient survives to reach neurosurgical care without frankly non-survivable injury. Even when these are included, GOS at two years still approaches functional independence. Low GCS, herniation, and major cerebrovascular injury appear to confer a worse prognosis; extra-axial lesions that are readily amenable to surgery appear to confer an improved prognosis.

    Patient Care: Provide an insight into the probable clinical course of a given combat induced PBI patient to assist in management decision making, and to combat any historically based nihilism that may persist in today's neurosurgical and trauma surgery communities with regards to PBI patients given the excellent (functionally independent) outcomes in this particular cohort.

    Learning Objectives: 1. Discuss the outcomes of penetrating brain injury in the military population, and how it differs from civilian casualties. 2. Discuss the clinical presentations that are associated with worse and better outcomes in combat induced PBI. 3. Discuss the reasons that PBI outcomes appear to differ between the civilian and the military populations.

    References: 1. Armonda RA, Bell RS, Vo AH, Ling G, DeGraba TJ, Crandall B, Ecklund J, Campbell WW. Wartime traumatic cerebral vasospasm: recent review of combat casualties. Neurosurgery. 59(6):1215-25. 2006. 2. Bell RS, Mossop CM, Dirks MS, Stephens FL, Mulligan L, Ecker R, Neal CJ, Kumar A, Tigno T, Armonda RA. Early decompressive craniectomy for severe penetrating and closed head injury during wartime. Neurosurg Focus. 28(5):E1. 2010. 3. Bell RS, Vo AH, Neal CJ, Tigno J, Roberts R, Mossop C, Dunne JR, Armonda RA. Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma. 66(4 Suppl):S104-11. 2009. 4. Bell RS, Vo AN, Roberts R, Wanebo J, Armonda RA. Wartime Traumatic Aneurysms: Acute Presentation, Diagnosis, and Multimodal Treatment of 64 Craniocervical Arterial Injuries. Neurosurgery. 66(1):66-79. 2010. 5. Brain Trauma Foundation, ed. Bullock MR and Povlishock JT. Guidelines for the Management of Severe Traumatic Brain Injury, 3rd Ed. Journal of Neurotrauma. 24: Supplement I (S32-35). 2007. 6. Denson K, Morgan D, Cunningham R, Nigliazzo A, Brackett D, Lane M, Smith B, Albrecht R. Incidence of Venous Thromboembolism in Patients with Traumatic Brain Injury. The American Journal of Surgery. 193: 380-384. 2007. 7. Ecker RD, Mulligan LP, Dirks M, Bell RS, Severson MA, Howard RS, Armonda RA. Outcomes of 33 patients from the wars in Iraq and Afghanistan undergoing bilateral or bicompartmental craniectomy. J Neurosurg. 115(1):124-9. 2011. 8. Ekeh AP, Dominguez KM, Markert RJ, McCarthy MC. Incidence and Risk Factors for Deep Venous Thrombosis After Moderate and Severe Brain Injury. The Journal of Trauma. 68(4): 912-915. 2010. 9. Farooqui A, Hiser B, Barnes SL, Litofsky NS. Safety and Efficacy of Early Thromboembolism Chemoprophylaxis After Intracranial Hemorrhage from Traumatic Brain Injury. Journal of Neurosurgery. 119:1576-1582. 2013. 10. Ingalls N, Zonies D, Bailey JA, Martin KD, Iddins BO, Carlton PK, Hanseman D, Branson R, Dorlac W, Johannigman J. A Review of the First 10 Years of Critical Care Aeromedical Transport During Operation Iraqi Freedom and Operation Enduring Freedom, The Importance of Evacuation Timing. JAMA Surgery. 149(8):807-13, 2014. 11. Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism After Trauma. Annals of Surgery. 240(3): 490-498. 2004. 12. Phelan HA, Wolf SE, Norwood SH, Aldy K, Brakenridge SC, Eastman AL, Madden CJ, Nakonezny PA, Yang L, Chason DP, Arbique GM, Berne J, Minei JP. A randomized, double-blinded, placebo-controlled pilot trial of anticoagulation in low-risk traumatic brain injury: The Delayed Versus Early Enoxaparin Prophylaxis I (DEEP I) study. Journal of Trauma and Acute Care Surgery. 73(6): 1434-1441. 2012. 13. Reiff DA, Haricharan RN, et. al. Traumatic Brain Injury Is Associated With the Development of Deep Vein Thrombosis Independent of Pharmacological Prophylaxis. The Journal of Trauma, 66(5): 1436-1440. 2009. 14. Scudday T, Brasel K, Webb T, Codner P, Somberg L, Weigelt J, Herrmann D, Peppard W. Safety and Efficacy of Prophylactic Anticoagulation in Patients with Traumatic Brain Injury. Journal of the American College of Surgeons. 213(1): 148-153. 2011. 15. Shen X, Dutcher SK, Palmer J, Liu X, Kiptanui Z, Khokhar B, Al-Jawadi MH, Zhu Y, Zuckerman IH. A Systematic Review of the Benefits and Risks of Anticoagulation Following Traumatic Brain Injury. The Journal of Head Trauma Rehabilitation. 00: 1-9. 2014. 16. Stephens FL, Mossop CM, Bell RS, Tigno T Jr, Rosner MK, Kumar A, Moores LE, Armonda RA. Cranioplasty complications following wartime decompressive craniectomy. Neurosurgery Focus. 28(5):E3. 2010. 17. Weisbrod AB, Rodriguez C, Bell RS, Neal CJ, Armonda RA, Dorlac W, Schreiber M, Dunne JR. Long-Term Outcomes of Combat Casualties Sustaining Penetrating Traumatic Brain Injury. J Trauma Acute Care Surg. 73(6): 1525-1530. 2012.

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