Call for debate on global brain injury outcome gaps

The quality of the treatment of traumatic brain injuries differs significantly depending on where you are around the globe.

Neurosurgery experts from Cambridge University have led the largest ever study examining the surgical management of traumatic brain injuries with the results highlighting significant global inequalities in causes and treatment.

The Global Neurotrauma Outcomes Study was designed to create new data to assist in decision making and improving outcome for patients with traumatic brain injury globally. It focuses on types of cases, the way they are managed, and the death rates, and was compiled using data submitted by 159 hospitals in 57 countries to a central database, which they then analysed.

Professor Peter Hutchinson, professor of Neurosurgery and director of the NIHR Global Neurotrauma Research Group, said: “This is the largest study in the world looking at the surgical management of head injuries and will be of practical value to clinicians and others planning strategies for the future.”

The researchers’ seperated countries into four tiers (very high, high, medium, low) according to their Human Development Index (HDI), which takes account of factors like life expectancy, education, and income.

The prospective study determined that patients in the low HDI tier were often young and suffered skull fractures due to assault but were classified as ‘mild’ traumatic brain injury (TBI).

In the medium and high HDI tiers, patients were also young, but most had moderate to severe TBI caused by a road traffic collision and extradural haematoma – a bleed on the outside of the dura mater, the membrane covering of the brain.

In the very high tier, patients tended to be older and presented with a moderate or severe TBI associated with a fall and acute subdural haematoma – a bleed on the inner surface of the dura mater.

“Quality of care was generally less favourable in lower HDI settings, including delays to surgery and a lack of postoperative monitoring equipment and intensive care,” said the research. “The very high HDI tier had the highest proportion of operations in which the most senior surgeon present in the operating theatre was a fully qualified neurosurgeon and the medium HDI tier had the lowest proportion.”

The study also found significant between-hospital variations in the outcome of patients.

Angelos Kolias, consultant neurosurgeon and NIHR Global Neurotrauma Research Group associate director, said: “The results show that overall mortality is low, reflecting the life-saving nature of surgery for traumatic brain injuries. Many of these patients would have died without an operation. However, we also need to address deficits in pre-hospital management and long-term rehabilitation.”

David Clark, a trainee neurosurgeon and University of Cambridge research fellow, said: “A particularly important finding is that outcome is influenced more by hospital characteristics than country of origin, which raises the possibility that changing the systems and processes of care in individual hospitals might be able to improve mortality. The paper sows the seeds for discussion and change.”

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