A 2-year study (Japan Neurotrauma Data Bank: JNTDB) for 1,091 cases of traumatic brain injuries was conducted from 2009 to 2011. Twenty two emergency medical centers took part in the study and it was called Project 2009. Patients with severe head injury were eligible for entry with a Glasgow Coma Scale score of 8 or less at admission. Patients who underwent craniotomy were also included. Data entry form with 208 items were created originally from multi-factorial view points. The results show that patient's age and mechanism of injury are the most important factors in the outcome. Also, we can see a strong influence of the changes in our country, so-called rapid aging population, compared with the result of Project 1998, or that of 2004 , conducted before.
This study documents the epidemiology of severe head injury over the course of 13 years in Japan based on the three projects conducted by Japan Neurotrauma Data Bank Committee: those were Projects of 1998 (1998 – 2000), 2004 (2004 – 2006) and 2009 (2009 – 2011). The registered cases (GCS ≤ 8, including CPAOA, age ≥ 6) in each Projects were 832, 798 and 753 respectively, and were analyzed from the view points of cause of head injury, lesion type and outcome according to age. The results showed 1) the average age of each Project increased by 8.7 years (3.8 and 4.9 respectively) over the study period of 13 years, 2) the peak occurrence of severe head injury shifted from the group aged 15 – 29 to 60 – 84, 3) motor vehcle accidents decreased in the age group of 15 – 29, wehreas severe head injury due to fall tended to increase among the high aged group of patients, 4) acute subural hematoma increased in the high aged, 5) the mortality rate generally increased with age. In conclusion, these epidemiological data will provide useful information to guide further management to prevent severe head injury in the near future.
There are 3 large studies, Project 1998 (P1998), Project 2004 (P2004) and Project 2009 (P2009), in the Japan Neurotrauma Data Bank (JNTDB). The aim of this report is to clarify the recent status of severe head injury (Glasgow Coma Scale (GCS) score 8 or less on admission) caused by road traffic accident.
The number of severely head-injured patients (age: 6 years or more) injured by road traffic accident were 538 in P1998, 429 in P2004, 325 in P2009. Those were divided into 4 groups according to the modality of accident: 4 wheel vehicle (4WV), motorcycle (MC), bicycle (BC) and pedestrian (P). Analyzed here were age, incidence of alcohol intake, means of patient transportation, GCS, Injury Severity Score (ISS), CT findings (Traumatic Coma Data Bank) and outcome (Glasgow Outcome Scale) at discharge.
Results: In the P2009; 1) The patients were older (median age: 52 years). 2) The incidence of alcohol intake was generally elevated. It was decreased in 4WV and MC groups, but elevated in BC and P groups. 3) The transportation by helicopter was increased in rate. 4) Safety device: The rate is increased as for the seat belt and the air bag, but unchanged in the helmet. 5) The mean ISS was highest among 3 groups. The rate of ISS 70 – 75 was considerably increased. 6) The proportion of diffuse injury type 3 and evacuated mass was decreased in P2004 and this phenomenon continued in P2009. In addition, the rate of diffuse injury type 2 was increased, especially in 4WV and BC groups. 7) The outcome at discharge was worse, especially in P group.
These results might present the recent trend of severe head injury caused by road traffic accident in the JNTDB. But more precise analyses are necessary to understand the data.
Background and purpose: In this study, both usefulness and limitations of trephination were investigated by analyzing data from Japan Neurotrauma Data Bank (JNTDB) Project 2009.
Materials and Methods: Total 90 cases, treated with trephinations initially for traumatic head injuries, were involved in this study (M : F = 65 : 25, Age 66±22 y.o.). In these cases, following parameters were summarized from JNTDB Project 2009 database; age, gender, cause of trauma, Glasgow Coma Scale (GCS) scores on admission, worst preoperative GCS scores, presence of midriasis, preoperative CT findings (intracranial hematoma thickness, midline shift, and appearance of ambient cistern), Glasgow Outcome Scale (GOS) scores on discharge. Correlation between preoperative clinical parameters and GOS scores were also examined.
Results: GCS scores on admission were 3 – 8 in 70 (78%), 9 – 12 in 8 (9%), and 13 – 15 in 12 (13%) out of 90 cases. Worst preoperative GCS scores were 3 – 8 in 75 (83%), 9 – 12 in 8 (9%), and 13 – 15 in 7 (5%) out of 90 cases. Midriasis were presented bilaterally in 40 (44%), ipsilaterally in 17 (19%), and not in 33 (37%) out of 90 cases. GOS scores were GR in 4 (4%), MD in 12 (13%), SD in 9 (10%), VS in 10 (11%), and D in 55 (61%) out of 90 cases. Among clinical parameters, preoperative worst GCS scores, pupil reaction, appearance of ambient cistern on CT were strongly correlated with GOS. Although mortality could not be expected by any single parameter, a combination of GCS score 3 and bilateral midriasis, or disappearance of ambient cistern on CT could correctly expect mortality.
Conclusion: Emergency trephination is simple and useful technique to achieve quick reduction of intracranial pressure in cases with severe traumatic head injury, however, it may not be indicated in preoperative GCS 3 cases with bilateral midriasis or with disappearance of ambient cistern on CT.
There are three large-scale researches in the Japan Neurotrauma Data Bank (JNTDB); Project 1998, 2004, and 2009. We analyzed the recent trends of the treatment and the outcome of the severe head injury in the JNTDB.
The ratio of the aged gradually increased in the JNTDB, which might reflect the population aging in this country.
The treatment for the severe head injury tends to be simplified, remarkable in the institutions participated in all researches. Some results were inconsistent with the recommendation of the guidelines, which might be influenced by the medicosocial factors.
The mortality rate increased and the ratio of the favorable outcome decreased in Project 2009, compared with those in Project 2004. Relatively bad outcome of the aged might depressed the overall outcome.
While the treatment for the severe head injury has been simplified, the outcome of the young or the population treated intensively improved. It might suggest the “simplification” of the treatment in a good sense. We should investigate the inconsistency between the guidelines and the actual treatments.
Temperature management for severe traumatic brain injury (TBI) has been carried out in many institutions, although there is no evidence for the usefulness of hypothermia in the treatment of severe TBI. We investigated recent situation of temperature management and assessed effectiveness of temperature management of severe TBI from the data of the Project 2009 (P2009) in the Japan Neurotrauma Data Bank. We also compared the data of P2009 with that of the Project 2004 (P2004). A total 1091 patients were registered in P2009. Of these patients, those with a Glasgow Coma Scale (GCS) score of 9 or more, a GCS score of 3 with bilateral nonreactive pupils, and only epidural hematoma in CT scan were excluded. Then, a total of 550 patients were analyzed in this study. Patients were divided into the two groups: temperature management (TM) group and non-temperature management (nTM) group. The TM group was further divided into the two groups: hypothermia (HT) group and intensive normothermia (IN) group. The rate of temperature management was similar between P2004 and P2009 in the same population, and about 30% of the patients were treated with intensive normothermia and about 10% of patients were treated with hypothermia. Patient's average age was significantly younger in the HT (44±24 y.o.) and the IN (54±23 y.o.) groups compared with the nTM (64±21 y.o.) group (p<0.001). In the TM group, the rate of surgically evacuated hematomas was significantly higher (59.0%) than that in the nTM group (38.6%) (p<0.001). The rate of favorable neurological outcome (GR/MD) on discharge in the TM group was 28.0%, which was significantly better compared with that in the nTM group (18.3%) (p<0.01). In the subgroup analyses, the HT group showed more favorable outcome than the nTM group in patients who underwent surgical removal for intracranial hematomas (29.3% vs 12.5%, p<0.05). Also, the IN group showed more favorable outcome than the nTM group in patients without surgical intervention (37.7% vs 22.0%, p<0.05). In conclusion, temperature management for severe TBI may increase the rate of favorable neurological outcome in selected patients.
The importance of temperature management has been advocated for critically ill intensive care patients suffering from a variety of conditions. Aggressive normothermia therapy (ANT) has recently been employed in severe head trauma management, but there are few reports on the administration of sedatives and analgesics as a part of intensive care management in the acute phase.
Purpose: To assess the particulars of intensive care management in patients with severe head injury registered in the Japan Neurotrauma Databank Project 2009 (JNTDB P2009), we retrospectively examined the use of muscle relaxants (i.e., neuromuscular blocking drugs [NMBDs]), sedative drugs, and analgesics.
Results: Of 1091 severe head trauma patients registered in the JNTDB P2009 from July 2009 to June 2011, 81 cases were excluded due to incomplete data collection, leaving 1010 cases that met the inclusion criteria in this study. Sedative drugs and analgesics tended to be avoided in higher Injury Severity Score and older cases. Drug intervention was employed in diffuse brain injury and evacuated mass lesion in younger cases. The percentage of NMBD use was significantly higher in younger cases. Thirty-four percent of patients received therapeutic temperature management, 24% of which underwent ANT (deep temperature, 35 – 37˚C) and 10% of which underwent mild hypothermia therapy (deep temperature, 33 – 35˚C). The remaining 66% of patients received no temperature intervention (None group). Seventy-eight percent of the None group, 40% of the ANT group, and 7% of the HT group received no drug intervention. In terms of the sedative drugs, Propofol was used in 61% of the None group and 52% of the ANT group; Midazolam was used in 49% of the HT group. Since targeted temperature management is now commonly included in intensive care treatment, the development of pathophysiology-appropriate sedation protocols is essential.
Objective: This study evaluated the clinical characteristics and effects of brain temperature control in severe traumatic brain injury patients based on traumatic pathophysiology.
Methods: A total of 1091 patients were registered in Japan Neurotrauma Data Bank Project 2009. Of these patients, those with a Glasgow Coma Scale (GCS) score of 9 or more, and a GCS of 3 and bilateral dilated pupils, as well as cardiopulmonary arrest on arrival, were excluded. This left a total of 401 patients. These patients were classified into three groups: no control of brain temperature (F group: 225 patients, 56.1%), intensive normothermia (N group: 129 patients, 32.2%), and hypothermia (H group: 47 patients, 11.7%). We examined the patients' age, GCS, pupillary abnormality, Injury Severity Score (ISS), intracranial pressure (ICP) monitoring, rate of favorable outcome, and mortality according to CT classification (TCDB classification) on admission.
Results: In diffuse injury III, the implementation rate of brain temperature control was high (F group: 13.8%, N group: 62.1%, H group: 24.1%). Patients were significantly older in the F group (average age: 61.5 y.o.) compared with the N group (53.6 y.o.) and H group (46.9 y.o.). There were no significant differences in GCS, papillary abnormality, and ISS between all groups. The rate of ICP monitoring performance was significantly decreased in 85.1% of patients in the H group, 42.6% in the N group, and 14.7% in the F group. The rate of favorable outcome was significantly high in the H group (52.4%) compared with the N group (26.9%) and the F group (20.7%) with evacuated mass lesion.
Conclusion: The cases that underwent brain temperature control also recieved ICP monitoring. Hypothermia therapy was effective for patients with evacuated mass lesion.
In some patients with severe head injury, a mild condition on arrival may be deteriorated in the acute phase, leading to a severe status. No previous analysis conducted by the Japan Neurotrauma Data Bank (JNTDB) involved patients in whom the condition deteriorated in the acute phase. In this study, we examined the course and characteristics of patients in whom the condition deteriorated in the acute phase after trauma by analyzing the JNTDB 2009 data.
The subjects consisted of 322 patients with initial GCS of 9 or higher. In 232 patients (72.0%), deterioration was noted within 72 hours after trauma. Among 232 patients with deterioration, cases of favorable outcome (GR, MD) on discharge were 176, and cases unfavorable outcome were 146. The rate of favorable outcome in deteriorated group was 45.6%, which was significantly worse compared with that in operated group.
The mean interval from the initial computed tomography (CT) until the worst CT of deteriorated group was 5.9 hours. The mean interval from the worst CT until the initial operation of deteriorated group was 2.7 hours. The mean interval from the initial CT until initial operation of deteriorated group was 5.6 hours. A significant difference was present in the mean interval from the initial CT of moderate head injury between favorable group and unfavorable group.
We compared factors between patients with and without deterioration. There were significant differences in patient factors, such as the mechanism of injury, body temperature on arrival, early hyperventilation, CT findings with subarachnoid hemorrhage, and Talk and Deteriorate (T&D), and treatment factors, such as ICP monitoring, hyperventilation therapy, and body-temperature management. In patients with deterioration, the proportions of the following patients were higher than in those without deterioration: 1) patients with traffic, especially pedestrian, 2) those with a body temperature of 35 degrees or lower on arrival, 3) T&D patients, 4) those with early hyperventilation (PaCO2 < 35 mmHg) , 5) those with traumatic subdural hematoma on CT.
Objectives: With the rapid expansion of the elderly population, there has been an increase of the number of elderly traumatic brain injury (TBI) patients in Japan. Despite the recent progresses in the treatment and monitoring for TBI patients, the prognosis of geriatric TBI remains unfavorable. In this study, transition of aggressive treatment and patient outcome in geriatric TBI patients were analyzed with the data from Japan Neurotrauma Data Bank Project 1998, 2004, and 2009. The functional prognostic factors in geriatric TBI were also examined.
Methods: Of 3,194 cases registered in the JNTDB Project 1998 (P1998), 2004 (P2004), and 2009 (P2009), 1,165 geriatric TBI cases (≥65 years old) were enrolled in this study. The clinical features, aggressive treatment defined as surgical procedure and/or intensive temperature treatment and/or ICP monitoring, and outcomes based on Glasgow Outcome Scale on discharge were compared among P1998, P2004, and P2009. Moreover, to clarify the functional prognostic factors in geriatric TBI patients, logistic regression analysis was performed.
Results: The percentage of geriatric TBI population was significantly increased throughout three projects (P1998; 30.5%, P2004; 34.6%, P2009; 43.9%, p<0.0001). Aggressive treatments including surgical management and intentional temperature management were performed in 71.4% of geriatric patients in P2009 and this percentage was significantly increased from P1998 and P2004. With these efforts for geriatric TBI care, mortality ratio was significantly decreased (P1998; 62.7%, P2009; 51.1%, p=0.0003). On the other hand, the percentage of severe disability patient was significantly increased. The percentage of dependent survivors were also increased (P1998; 63.2%, P2009; 68.4%). Patient Age ≥75, Injury Severity Score ≥21, GCS ≤8, existence of traumatic subarachnoidal hemorrhage (SAH), and existence of intraventricular hemorrhage (IVH) were clarified as the functional prognostic factors. IVH was the strongest functional prognostic factor in geriatric TBI patients (OR 5.762, 95%CI 1.317 – 25.216).
Conclusion: Our result revealed that the aggressive treatments provided less mortality in geriatric TBI patients. On the other hand, the effort of aggressive treatments did not result in better functional outcome in this population. For the prompt decision making, patient age, initial GCS, and anatomical severity including SAH and IVH should be helpful as the functional prognostic factors.
Purpose: Head injury is a major cause of death among children. To clarify ways of decreasing preventable deaths, data from Japan Neurotrauma Data Bank (JNTDB) Project 2009 were analyzed and compared with data from Project 2004.
Subjects and Methods: Project 2009 covered patients with severe head injury and a Glasgow Coma Scale (GCS) score ≤ 8, patients with talk and deteriorate, and patients who underwent surgery for traumatic intracranial lesions in 2007 – 2009. In total, 68 patients ≤ 15 years of age were included. We analyzed age, cause of injury, duration of transfer, time of patient transfer, GCS score, papillary abnormality, body temperature, serum glucose, Injury Severity Score (ISS), skull fracture, computed tomography (CT) findings (as classified by Traumatic Coma Data Bank criteria), main lesion of focal brain injury on CT, traumatic subarachnoid hemorrhage (SAH) on CT, treatment, and outcome at discharge.
Results: Factors associated with poor outcome of pediatric severe head injury were GCS at admission ≤ 8, Serum glucose level at admission < 200 mg/dl and patient with acute subdural hematoma on CT.
Conclusion: We analyzed 68 patients with pediatric severe head injury. To understand the characteristics of pediatric severe head injury in Japan, further studies are needed.
Purpose: Bicycling has recently emerged as a social issue due to its frequencies of traffic accidents. However, even a longstanding problem of wearing no helmet or riding under influence of alcohol for leisure remains unsolved.
Material and Methods: To correlate sex, age, circumstance of injury, admission GCS, alcohol, helmet wear, neurosurgical operation, diagnosis of brain injury, and discharge GOS, we have extracted 119 from 1,091 bicycle accidents registered head trauma data bank project 2009.
Results: These 119 cases consisted of 78 males and 41 females, ranging from 6 to 91 years. The helmet use rate was as low as 7/119 (6%) while alcohol use was confirmed in 19/119 (16%). Neurosurgical operation was performed in 79/119 (66%) to treat the following brain lesions: acute epidural hematoma in 24/79 (30%), acute subdural hematoma in 31/79 (39.2%), brain contusion in 6/79 (7.6%), acute subdural hematoma plus brain contusion in 6/79 (7.6%), acute epidural hematoma plus acute subdural hematoma in 2/79 (2.5%), brain swelling in 6/79 (7.6%), depressed fracture in 1/79 (1.2%), and others in 3/79 (3.8%). Outcomes were rated as GR in 26/119 (22%), MD in 21/119 (18%), SD in 18/119 (15%), VS in 10/119 (8%) and D in 44/119 (37%). The deceased included 32/119 (27%) that wore no helmet and 21/119 (18%) that had taken alcohol. GR was rated most frequently in the young whereas the aged were ranked as SD, VS or D in most cases. Meanwhile, 15-year-old or younger cases were 15/119 (12%) and nobody wore a helmet. Neurosurgical operation was performed on 11/15 (73%). Outcomes were better overall as follows: GR in 9/15 (60%), MD in 1/15 (6.6%), SD in 2/15 (13.4%), VS in 0/15 (0%), and D in 3/15 (20%).
Conclusion: Bicycle-related injury is caused by a combination of various factors. If we intend to look for factors to prevent a head trauma in bicycle accidents, it is very important to gather more detailed data on pre-accident situations.
Project 2009 of Japan Neurotrauma Data Bank was conducted from July 2009 to June 2011. We summarized the recent trends of severe head injury view from the outcome, and analyzed the factors of death and unfavorable outcome from the patients in Project 2009. Among 1,091 cases registered, 766 cases with Glasgow Coma Scale (GCS) score 8 or less on admission were classified 3 groups, including survival-good (SG) group (148 cases in good recovery and moderate disability), survival-poor (SP) group (223 cases in severe disability and vegetative state), and dead (D) group (395 cases). The factors of death were analyzed in all 766 cases, and factors of unfavorable outcome were analyzed in 371 cases of survival group (SG + SP). The factors were made from the same viewpoints as Project 2004, including age, sex, the causes of accident, GCS of admission, pupil abnormality, systolic blood pressure, heart rate, respiratory rate, body temperature, pH, PaO2, PaCO2, glucose, cranial CT findings (diffuse injury or mass lesion, pneumocephalus, foreign body, subaracnoid hemorrhage, intraventricular hemorrhage), Injury Severity Score (ISS), Abbrebiated Injury Score (AIS), and treatment methods (hyperventilation, hypo and normothermia, intracranial pressure monitoring). These factors were included in the multiple logistic regression analysis.
The age (over 60 y/o), M score of GCS (less than 2), anisocoria, heart rate (less than 60 /min), PaCO2 (less than 37 torr), glucose (over 200 mg/dl), pneumocephalus, ISS (over 26), AIS of head and neck (over 5), and non indication of intracranial pressure monitoring were the factors of death statistically significantly. And the age (over 40 y/o), anisocoria, PaCO2 (less than 37 torr), glucose (over 200 mg/dl), intraventricular hemorrhage, and ISS (over 25) were the factors of unfavorable outcome statistically siginificantly in the severe head trauma patients in Project 2009.
Prognosis of severe head injured patients presenting with Glasgow Coma Scale (GCS) score of 3 is still poor. We analyzed present status of patients with GCS score of 3 between the Project 2004 and the Project 2009 in the Japan Neurotrauma Data Bank. Among 1,092 cases registered, 767 cases with GCS score of 8 or less on admission. Of those, 265 cases with GCS Score of 3 were entered in the Project 2009 and compared with Project 2009.
These results showed that there were no differences of both project except respiratory rate, initial CT findings including pneumocephalus, skull base fracture, and cardiopulmonary arrest. And these characteristics are not affected with the Glasgow Outcome Scale in discharge.
We suggest that it is important to treat brain and systemic problems aggressively in severe head injured patients with GCS score of 3 according to the characteristics associated with favorable outcome in Project 2004.