Hydrocephalus following severe traumatic brain injury: Incidence and relation to short-term recovery

1
Hydrocephalus following severe traumatic brain
injury Incidence and relation to short-term
recovery

• Maiken Tibæk MD
• Mia Linneman Med. Stud. Lars Peter Kammersgaard
  MD DMSci
• Department of Neurorehabilitation TBI Unit,
  Copenhagen University Hospital, Glostrup.

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Background

• Hydrocephalus (HC) reported in 12-50 of cases
  with severe TBI
• HC may influence long-term outcome

3
Setting

• 22 bed subacute neurorehabilitation hospital
  facility
• Dedicated interdisciplinary rehabilitation
• Well-defined catchment area in eastern Denmark
  (2.4 million)

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Selection criteria

• Glasgow Coma Score 3-9
• GCS 10-12 with severe focal neurological
  deficits, i.e., hemiparesis, aphasia or severe
  agitation
• Severe cognitive disturbance and paresis or
  agitation

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Materials and methods

• 303 consecutive patients
• Oct 2000 to December 2008
• Clinical data collected prospectively
• HC retrospectively (case notes)
• PTA assessed by Galveston Orientation and Amnesia
  Test (GOAT)

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Hydrocephalus

• Diagnosed with CT scans
• All patients had ventricular shunts installed
• HC between time of injury and disharge considered

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Statistics

• Comparison with vs. without HC by univariate
  statistics
• Adjusted relative influence of HC for duration of
  PTA by multiple linear regression

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Clinical Characteristics for TBI patients with
vs. without hydrocephalus
hydrocephalus - hydrocephalus p-value
Number of patients 38 (12.5) 265 (87.5)
Age, years, median 52 (17 to 82) 40 (16 to 87) 0.06
Sex, male 31 (82) 193 (73) 0.32
SAH 26 (87) 135 (58) 0.002
Sedation, days, median 6 (0 to 32) 5 (0 to 24) 0.23
Acute phase, days, median 22 (6 to 82) 16 (1 to 151) lt0.0001
GCS, median 9 (3 to 14) 12 (4 to 15) lt0.0001
PTA, median 140 (27 to 365) 42 (5 to 365) lt0.0001
LOHS, weeks, median 29 (6 to 42) 14 (2 to 72) lt0.0001
Died during hospital stay 4 (11) 7 (3) 0.04
on admission for rehabilitation
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Results I

• Overall 13 developed HC
• Patients with HC - more frequently SAH
• - longer acute treatment
• - lower GCS at rehabilitation
• - longer PTA
• - longer LOHS

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Multiple linear regression, backward method
(final model)
Independent variable B 95 CI p-value
Age, per 1 year increase 0.6 -0.1 to 1.1 0.07
Sex, male 25 4 to 46 0.02
Hydrocephalus 63 25 to 100 0.001
Subarachnoid hemorrhage NS 0.13
Sedation, per day NS 0.87
Acute phase, per day 1.4 0.7 to 2.1 lt0.0001
GCS, per 1 point decrease 13 9.8 to 16.5 lt0.0001

• Dependent variable Length of PTA in days, n
  192
• Glasgow Coma Score on admission for
  rehabilitation

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Results II

• Hydrocephalus prolonged length of PTA by 63 days
  independent of age, sex, SAH, duration of
  sedation, acute stay, and GCS on admission for
  rehabilitation

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Conclusions

• HC was found to be a complication in 13 of
  severe TBI
• HC appears to prolong PTA by a mean of 63 days
  irrespective of demographics and clinical
  characteristics
• As a complication, HC is not an innocent
  bystander
• Instead, HC delays recovery from TBI

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Acknowledgements

• Thanks to
• All members of the teams for contribution of data
• Patients and relatives
• Dr. Lars Westergaard for his input on the
  diagnosis of hydrocephalus