Table 1 Clinical studies investigating the effect of extracranial injury (ECI) on traumatic brain injury (TBI)
From: The effect of concomitant peripheral injury on traumatic brain injury pathobiology and outcome
Studies reporting effects of ECI on TBI | |||
Author | Subjects | Major Relevant Findings | Limitations |
Kumar et al., 2015 | 114 TBI patients TBI: GCS ≤ 8, AIS ≥ 3 and evidence of damage by CT PT: TBI + AIS ≥ 3 at least one ECI | - Weekly average patient serum IL-6 and IL-10 higher in PT compared to isolated TBI group - No difference in GOS scores between TBI and PT patients | –TBI group older than PT (Mean age 39 v 30) –PT group higher incidence of skull fractures –Low numbers |
Leitgeb et al., 2013 | 767 TBI patients TBI: AIS 2–5 (Mean 4) MT: TBI + AIS > 2 at least one ECI | –Mortality higher in mild TBI (AIS = 2) patients with ECI, however overall mortality comparable between groups –Favourable outcome (GOS 4/5) reported in more MT patients | –TBI group older than MT (Mean age 61 v 46) –Orthopaedic interventions common (25% MT had ECI surgery) but not accounted for |
Lingsma et al., 2013 | 508 TBI patients TBI: GCS 9–13 (moderate), 3–8 (severe) MT: TBI + ECI (Median ISS = 4) | –Unfavourable outcome (GOS = 2/3) and mortality higher for patients with moderate TBI and ECI than for isolated moderate TBI | –Missing patients in follow up –Variability in ECI severity |
Leong et al., 2013 | 100 TBI patients TBI: mild (GCS 13–15), moderate (9–12), severe (3–8) MT: TBI + AIS ≥ 3 at least one ECI | –Fewer mild TBI patients with ECI made ‘good recovery’ (GOS = 5) compared with those with isolated mTBI | –Low numbers |
Van Leeuwen et al., 2012 | 39,274 TBI patients (IMPACT, CRASH, TARN databases) TBI: GCS 13–15 (mild), 9–12 (moderate), 3–8 (severe) MT: TBI + AIS ≥ 3 (or requiring hospital admission) at least one ECI | –IMPACT/CRASH pooled adjusted OR: Effect of ECI on mortality = 2.14 in mild-, 1.46 moderate-, 1.18 severe-TBI. –TARN adjusted OR higher in MT patients (2.81 mild-, 2.18 moderate-, 2.14 severe-TBI). | –Missing values in databases –Variability in ECI severity –No functional outcomes |
Lefering et al., 2008 | 21,356 trauma patients Various combinations of TBI and/or ECI to extremity or torso (AIS 0–6) | –Non-significant increase in mortality in MT versus TBI only overall, but significant difference at all TBI severities when ECI AIS ≥ 4 | –No GCS used –No functional outcomes |
Hensler et al., 2002 | 125 trauma patients TBI: GCS ≤ 8 or AIS ≥ 3 PT with TBI: TBI + AIS ≥ 3 for one ECI PT without TBI: AIS ≥ 3 for two ECI | –Serum levels of IL-6, IL-10, 55- and 75-kDa soluble tumor necrosis factor receptors, polymorphonuclear neutrophil elastase all lower in patients with TBI only compared with PT (with and without TBI) | –Low numbers –TBI group older than PT (Mean age 42 v 36) –Only pathological changes reported |
Siegel et al., 1991 | 1709 TBI patients TBI: GCS 13–14 (mild), 9–12 (moderate), 7–8 (moderately severe), 4–6 (severe), 3 (near fatal) MT: TBI + ECI separated by location (no defined AIS) | –Overall mortality rate (all GCS) almost tripled in blunt TBI patients with pelvis or femur fracture (similar results for lung-, liver-, bowel-, major vessel- injury). –Increase in mortality most substantial in mild to moderate TBI. | –Variability in ECI severity –No functional outcomes |
Gennarelli et al., 1989 | 16,524 TBI patients TBI: AIS 2–6 MT: TBI + AIS 1–6 at least one ECI | –Synergistic effect on mortality when moderate head injuries (AIS 3–4) combined with severe ECI (AIS 4–6). –No additive effect on mortality when ECI AIS ≤ 3 | –No GCS used |
Studies reporting no/inconclusive effects of ECI on TBI | |||
Author | Subjects | Major Relevant Findings | Limitations |
Stulemeijer et al., 2006 | 299 TBI patients TBI: GCS 13–15 MT: TBI + AIS ≥ 2 for one ECI | –Mild TBI patients with ECI had worsened GOS-E scores, however no differences in post-concussion symptoms at 6 months –Acute symptoms (headache, dizziness, nausea) lower in MT group | –TBI slightly more severe in MT patients –Symptoms masked by frequent use of analgesic in MT patients? |
Sarrafzadech et al., 2001 | 119 trauma patients TBI: GCS 3–7, Mean total ISS = 25 MT: TBI + AIS other 1–6, Mean total ISS = 39.5 ECI only: AIS other 1–6, Mean ISS = 29 | –No difference in physiological variables between patients with isolated TBI or MT with TBI between days 1–12 post-injury –No differences in GOS score at 6 and 12 months between TBI and MT patients, higher GOS scores in extracranial injury only patients. | –TBI group older than MT (Mean age 36 v 28) –Low numbers –Wide range of injury severities and locations |
Baltas et al., 1998 | 386 TBI patients TBI: GCS 3–8 MT: TBI + ECI (no defined AIS) | –No difference in mortality in MT versus TBI only groups. | –No defined AIS for extracranial injury –No functional outcomes |