Emergency medical care of trauma victims has undergone major changes in the last 10 years. The aim of this study was to assess how the improved care influences early physiological abnormalities, intracranial pathology, and outcomes after traumatic brain injury (TBI). Two cohorts of severe TBI patients were compared. The first cohort was treated from 1998 to 2001 and the second from 2004 to 2006. Between groups, the mean age increased from 49±24 years to 53±23 years. The incidences of initial hypoxia and hypotension, which adversely affected outcomes, were decreased. Intracranial mass lesion was more frequent in the second cohort, probably because of the increasing age. The mortality rate was improved, although the proportion of patients with severe disability or vegetative state in survivors was increased. The sustained efforts to reduce early respiratory and circulatory abnormalities during prehospital care probably contributed to this improved mortality rate, but they do not appear to have led to improvements in functional outcomes.
The usefulness of brain hypothermia in patients with severe traumatic brain injury (TBI) was denied as a whole with Prospective Randomized Controlled Trials (PRCT) in the United States. In this study, recent situation of brain hypothermia as a treatment strategy of severe TBI was analyzed from the data of the Project 2004 (P2004) in the Japan Neurotrauma Data Bank (JNTDB). Also, the incidence and the outcome of brain hypothermia in P2004 were compared with those in the Project 1998 (P1998) to clarify whether there are any changes after the disappointing PRCT results.
A total of 1101 cases were registered in P2004. We analyzed all patients enrolled in this study including extradural evacuated mass lesion. The incidences of brain hypothermia and intensive normothermia in P2004 were 9.7% and 26.8%, respectively. Patient's average age was younger in the hypothermia group (40.5±22.2 y.o.) compared with the intensive normothermia (47.8±23.3 y.o.) and the non-controlled (52.8±24.6 y.o.) groups. Brain hypothermia was intended to induce in patients with low GCS and with papillary abnormality. However, critically ill patients were treated with intensive normothermia or conservatively. The rate of good outcome (GR/MD) on discharge in hypothermia patients was 21.5%, which was significantly worse compared with that in intensive normothermia (33.9%) and non-controlled (34.6%) patients, maybe due to low initial GCS. When comparison was made with P1998 in a subgroup age above 6 y.o. excluding extradural mass lesion and cardiopulmonary arrest on arrival, there was no significant improvement of outcome on discharge and reduction of mortality rate with hypothermia in P2004. Patients treated with intensive normothermia showed most favorable outcome and lowest mortality rate in P2004. Further studies are necessary to validate the usefulness of intensive normothermia in patients with severe TBI.
We investigated the relationship between abnormalities of physiological parameters and clinical outcome in patients with severe head injury. The results were then compared with those of the previous project (Project 1998) reported by Tokutomi and Shigemori. The data for 1101 patients enrolled in the Japan Neurotrauma Data Bank were studied. Of these patients, those with a Glasgow Coma Scale (GCS) score of 9 or more, cardiopulmonary arrest, under 9 years of age, and for whom physiological data were incomplete were excluded. This left a total of 556 patients. Hypoxia and hypoxia at admission were seen in 5% and 10% of the patients, respectively, thus accounting for a lower proportion of patients relative to those reported in Project 1998. Hyperglycemia was associated with a poorer outcome, similar to the results obtained in Project 1998. Hypothermia and hyperthermia on admission were not associated with outcome. The influence of multiple trauma (abbreviated injury score ≥ 3) on the examined parameters was almost the same as that observed in Project 1998. Intracranial pressure (ICP) was monitored in only 31% of the patients, the proportion being lower than that (35%) in Project 1998. To improve patient outcome, the lessons learned from both projects should be applied practically.
We analyzed the outcome of the patients who received severe head injury from the Project 2004 in the Japan Neurotrauma Data Bank. Among 1,101 cases registered, 805 cases with Glasgow Coma Scale (GCS) score 8 or less on admission were classified 3 groups including survival-good (SG) group (88 cases in good recovery and 114 cases in moderate disability), survival-poor (SP) group (157 cases in severe disability and 86 cases in vegetative state), and dead (D) group (360 cases in dead) and compared with each group.
These results showed the characteristics including age (< 40 years old), GCS (≧6), serum glucose (< 165 mg/dl), and Injury Severity Score (ISS) (< 24) were related with good outcome. Although the factors of age (≧60 years old), GCS (< 4), serum glucose (≧210 mg/dl), and ISS (≧31) were related with critical condition.
We suggest that it is difficult to get good outcome in severe head injured patients, even if the patients were treated in the intensive care units.
The purpose of this study is to evaluate the clinical characteristics of the pediatric patients in the Japan Neurotrauma Data Bank: Project 2004. Project 2004 consisted of severe head injury patients with a Glasgow Coma Scale (GCS) score of 8 or less on admission or during course and patients who were operated for traumatic intracranial lesion between 2004 – 2006. The subjects were 101 pediatric patients aged 15 years old or less (mean: 7.8 y/o). We retrospectively examined the patients' age, GCS, cause of injury, duration and time of patient transfer, pupillary abnormality, body temperature, serum glucose level, Injury Severity Score (ISS) excluding cranio-cervical score, skull fracture, CT classification of the Traumatic Coma Data Bank (TCDB), main lesion of focal brain injury on CT, and traumatic subarachnoid hemorrhage (SAH) on CT. The mortality rate in children is lower than in adults: 18.8% vs. 39.7%. The factors that correlated to the poor outcome in pediatric patients are lower GCS score on admission, pupillary abnormality, hyperglycemia (more than 200 mg/ dl), complications of severe other organ injury, diffuse injury III according to classification of CT, acute subdural hematoma and SAH. Pathophysiologically pediatric patients are not miniatures of adult patients. The data of Project 2004 is extremely significant and indicates the profile of one general view of pediatric patients with severe head injury in Japan. However, further collection of data and careful analysis are necessary for standardizing pediatric head trauma care.
This study was conducted to clarify the recent trends of severe head injury in the Japan Neurotrauma Data Bank (JNTDB) with special reference to traffic accident.
In the JNTDB, the number of severely head-injured patients (Glasgow Coma Scale (GCS) score of 8 or less) were 832 in Project 1998 and 797 in Project 2004. Those were divided into 2 groups: traffic accident (TA) group, and non-TA (nTA) group. In addition, the former group was classified into 4 groups: 4 wheel vehicle (4WV) group, motorcycle (MC) group, bicycle (BC) group, and pedestrian (P) group. Analyzed here were cause of injury, age distribution, incidence of alcohol intake, means of transportation, clinical severity (GCS and injury severity score), initial CT findings (Traumatic Coma Data Bank), and outcome at discharge (Glasgow Outcome Scale).
Results: In the Project 2004; 1) Traffic accident was less common as the cause of injury. 2) The proportion of younger patients was lower in the TA group, especially in the 4WV and MC groups. 3) Incidence of alcohol intake was lower in the TA group, particularly in the MC groups. 4) Patient transfer by helicopter was more common in both the TA and nTA groups. 5) The proportion of GCS of 3 to 5 was lower in the TA group, especially in the MC group. 6) In the initial CT findings, type 3 of diffuse injury and evacuated mass were less frequent in both groups, and in the 4WV, BC, and P groups. 7) Outcome at discharge: Mortality rate was lower in both groups, and in the 4WV, MC and P groups, but the percentage of good outcomes was unchanged.
These results indicated the recent trends of severely head-injured patients who were injured by traffic accident. But there were some problems, such as study protocol and meaningless results, so that further verification is indispensable in the JNTDB study.
In order to elucidate the regional characteristics of severe head injury in Japan, data from Japan Neurotrauma Data Bank (JNTDB) and Miyagi Neurotrauma Data Bank (Miyagi) were retrospectively analyzed. There were 1491 head injured patients with GCS ≦8 (722 cases in 1998 – 2000 and 769 cases in 2004 – 2006) from 10 and 19 hospitals in JNTDB, whereas Miyagi had 1115 head injured patients with GCS ≦8 admitted to the 17 neurosurgical departments in Miyagi prefecture between July 1995 and December 2006. The comparative analysis of these two projects was made from the viewpoints of age distribution, cause of head injury, pathology, outcome, and sequential changes. The results showed 1) the age distribution of all cases, GCS on admission and the age distribution of two major causes (motor vehicle accident and fall) did not show statistical difference between the two studies, 2) the age distribution of 4-wheel, bicycle and pedestrian accidents did not show statistical difference, but the occurrence of automobile accidents was more in Miyagi, and motor cycle accidents was more in younger generation of JNTDB, 3) the varied definition of pathology among the projects has made it difficult to obtain reliable results, 4) the outcome at discharge and age was almost identical between the two projects; the poor outcome clearly increased with age in both projects, 5) the analysis of chronological change showed motor vehicle accidents statistically decreased in number between 1998 – 2000 and 2004 – 2006 in both JNTDB and Miyagi, and it decreased statistically in younger generation of JNTDB. In conclusion, the comparison of JNTDB and Miyagi showed only small regional differences in severe head injury.
Objective: The number of institutions participating in the Japan Neurotrauma Data Bank was 10 in 1998, but it increased to 19 in 2004. The data of the institutions participating in 1998 and in 2004 were compared.
Methods: The 637 cases in 1998 (1998 group) and the 464 cases in 2004 (2004 group) were reviewed.
Results: There were no significant differences in the distributions of age, gender, and admission Glasgow Coma Scale between the two groups. The most common type of injury was a traffic accident, over 50% in both groups. The most commonly injured was the passenger, while the least commonly injured was the driver. In non-traffic accident cases, the most common injury was a fall in both groups. There were no significant differences in the distributions of the admission injury severity score and the discharge Glasgow Outcome Scale between the two groups. On head CT, more patients had a mass lesion (ML) than diffuse injury. The proportion with ML was higher in the 2004 group than in the 1998 group. Among patients with MLs, there were more evacuated mass lesions (EMLs) than non evacuated mass lesions in both groups. However, the proportion of EMLs and the proportion of skull base fractures were significantly higher in the 2004 group than in the 1998 group.
Conclusion: There were no significant differences in the patients’ background characteristics between the 1998 group and the 2004 group. But, the proportions of patients with mass lesions, evacuated mass lesions, and skull base fractures were higher in the 2004 group than in the 1998 group.
In comparison with the other developed countries, bicycle is widely used for transportation in all ages in Japan. In 2006, the number of death caused by bicycle related injury in Japan was worst among the member of Organisation for Economic Co-operation and Development (OECD). The aim of this study is to clarify the features of bicycle related severe head injury in Japan. One thousand and one hundred one cases had been registered in the Japan Neurotrauma Data Bank from 2004 to 2005. We enrolled 580 cases (52.7%) of head injury by traffic accident. These cases were divided to Bicycle related head injury group (BR group) and the others (non-BR group). The number of BR group was 149 cases (25.7%). Only 2 infants (0.7%) had put on helmet in BR group. The female ratio and the mean age of BR group were higher than that of non-BR group. The proportion over 65 years of age in BR group was higher (33.6%) than that of non-BR group (22.7%). The average of Glasgow Coma Scale (GCS) score in BR group is higher in comparison to non-BR group. The number of cases with lucid interval was higher as compared to non-BR group. Though the rate of the case with focal brain injury was high and the average of Injury Severity Score (ISS) was low in BR group, there was no statistical significance in the mortality rate among the two groups. This discrepancy was caused by elderly patients of BR group. And then there is a big number of elderly patients with bicycle related injury in Japan. This might have been caused by the rapid increase in aging society and decrease in birth rate. The results of our study provide the important information for taking preventive countermeasures against bicycle related head injury such as safety education, helmet and other campaigns not only for youngsters but also for elderly cyclist in Japan.
In the last decade, we have experienced substantial changes of medicosocial systems, e.g. introductions of the treatment guideline, the diagnosis related groups ⁄ prospective payment system by diagnosis procedure combination (DPC), or the compulsory system for postgraduate clinical training, which may influence medical affairs and hospital managements. In the present study, changes in managements of severe head injury were evaluated using the data from Japan Neurotrauma Databank Project 1998 (1998–2001: n=1002) and Project 2004 (2004–2006: n=1101). The results indicated that the executing rates of brain hypothermia and intracranial pressure (ICP) monitoring decreased. The cases with evacuated acute subdural hematoma showed the largest reduction in executing rates of ICP monitoring. In Project 2004, induced normothermia has been introduced as a novel management for brain protection, replacing hypothermia. These findings suggest that management of severe head injury have been simplified and uniformed in the last decade.
With the rapid expansion of the elderly population, there has been an increase in the number of elderly traumatic brain injury (TBI) patients in Japan. Despite the recent progress in the treatment and monitoring of TBI patients, the prognosis of geriatric TBI remains unfavorable.
In this study, differences in treatment and outcome between young and elderly TBI patients were compared in the Japan Neurotrauma Data Bank Project 2004 (JNTDB P2004).
Methods: Of 1101 cases registered in the JNTDB P2004, cases of cardiopulmonary arrest on arrival and pediatric patients (< 16 y.o) were excluded, and 952 cases were enrolled in this study. These cases were divided into two groups, the non-elderly group (Group N: 16 – 64 y.o) and the elderly group (Group E: over 65 y.o).
The clinical features, treatment and outcomes of the two groups were compared. To clarify the reasons for aggressive treatment of geriatric TBI cases, logistic regression analysis was performed in Group E.
Results: Initial Glasgow Coma Scale (GCS), worst GCS (< 48 hours after injury), pulse rate, and initial body temperature did not differ significantly between the two groups. Injury Severity Score (ISS) and respiratory rate on admission were significantly lower in Group E. On the other hand, systemic blood pressure and the pH of the arterial blood gas on admission were significantly higher in Group E.
Based on the Glasgow Outcome Scale at discharge, the ratio of good outcome (good recovery and moderate disability) was significantly lower in Group E.
With the analysis of Group E, age, initial GCS and worst GCS were correlated with the decision for aggressive treatment. In particular, initial GCS was most correlated with the determination for aggressive treatment.
Our result revealed differences in the pathophysiological features between young and elderly TBI patients. We also found that the initial GCS was the most correlative factor for determination of aggressive treatment in geriatric TBI patients. Further examination of prognostic factors will be needed in elderly TBI patients, and specific guidelines for geriatric head injuries should be established.
The purpose of this study was clarify the clinical features, a change of the therapy and the effect, connection with the outcome of acute subdural hematoma registered on the Japan Neurotrauma Data Bank (JNTDB) presented in 1998 and 2004. Among those, 421 cases in P1998 and 380 cases in P2004 aged more than 6 years who presented with Glasgow Coma Scale (GCS) 8 or less on admission and with ASDH on CT findings were retrospectively analyzed.
As for the age distribution, two peaks were seen in young aged 16 – 20 years and old aged 61 – 65 years. The ratio of the ASDH case in young cases (45 years) decreased compared with P1998. A ratio of traffic accidents decreased, and a ratio of the injury by the fall increased. Surgical treatment was performed to 63.2% (P2004), 65.1% (P1998), and was performed both projects most together by a 46 – 65 year-old case. Hematoma evacuation group increased to 21.1% from 14.5%, and a burr hole opening decreased to 17.1% (P2004) from 22.3% (P1998). The temperature management was performed to 41.2% (P2004), 20.5% (P1998), especially the younger cases (45 years) in P2004, the temperature management was performed to 56.2%.
The overall mortality is 67.7% (P1998), and 54.5% (P2004). The mortality of the temperature management cases was decreased, but the favorable outcome group does not increase. In younger cases (45 years), the favorable outcome group improved to 47.1% (P2004) from 33.3% (P1998) in the hypothermia group, and improved to 45.5% (P2004) from 30.0% (P1998) in the normothemia group. Temperature management after surgical treatment was more common, used to 57.5% (P2004) and 29.2% (P1998). The rate of favorable outcome group tends to increase in the hypothermia and normothermia group with craniotomy, but the mortality was not seen in the difference with the no temperature management group. For the case that used temperature management with a burr hole opening, the effect was not clear.
An outcome tends to be good for the case that used temperature management together with craniotomy and will require the accumulation of the further case in future.
Induction of hypothermia therapy in patients with severe brain injury was shown to improve outcome in clinical study, but the results were not definitive. Therapy of patients with severe head injury is need to combination of many therapies.
In this study, effect of intentional normothermia therapy and surgical therapy was analyzed from the data of the Project 2004 in Japan Neurotrauma data bank, and compared with hypothermia and intentinal normothermia therapy. A total of 1101 cases were registered in Project 2004. We analyzed all patients in Project 2004. Cases of induction of hypothermia and intentional normothermia therapy in Project 2004 was 107 cases and 295 cases. Cases of hypothermia therapy used with surgical treatment were 71 cases, intentional normothermia therapy 189 cases. The rate of good outcome on discharge in hypothermia cases was 26.2%, intentional normothermia cases was 36.9%. Especially hypothermia therapy patients of GCS 5 – 8 case was worse compared with intentional normothermia patients. Rate of good outcome in hypothermia therapy patients with surgical treatment 28.2%, intentional normothermia patients was 31.6%. Patients of treated with intentional normothermia therapy showed good outcome and reduction of mortality rate in Project 2004. Further studies were necessary to show the effective combination therapy of intentional normothermia therapy in patients with severe brain injury.
Objective: The Japan Neurotrauma Data Bank (JNTDB) 2004 newest data that registered from the selected hospitals which are distributed all over the country are analyzed from the viewpoint of operative treatment, and it aims at using for the present understanding and a future medical guideline.
Method: Object were brain injury cases who's GCS on admission were 8 or less on admission or within 48 hours after admission and operated cases. The comparative analysis of treatments (550 operated and 497 not-operated cases ) was made for 1047 cases excluding 52 CPA on admission and two undecided outcome cases from 1101 whole registration data.
Results: In analysis of 550 operated cases, burr hole was performed to 87 cases as the 1st-step operation, and craniotomy for hematoma removal was performed to 392 cases, and there were 37 external decompressions. When 119 operated cases of GCS 3 – 4 of the acute subdural hematoma are compared in terms of the 1st operation, outcome of the craniotomy group was better significantly. About external decompression, 187 cases were analyzed by the age group, and decline in favorable outcome and the upward tendency of mortality rate were accepted by the group aged over 61yr.
Conclusion: It is difficult to decide the indication and operative methods, such as a burr hole operation, craniotomy for hematoma removal, an external decompression, internal decompression, and CSF drainage simultaneously because of many factors. However, the usefulness of the craniotomy was shown as a whole as the 1st operation of an acute subdural hematoma except some cases.