Elsevier

World Neurosurgery

Volume 111, March 2018, Pages e82-e90
World Neurosurgery

Original Article
The Outcome of Severe Traumatic Brain Injury in Latin America

https://doi.org/10.1016/j.wneu.2017.11.171Get rights and content

Background

Traumatic brain injury (TBI) disproportionately affects lower- and middle-income countries (LMIC). The factors influencing outcomes in LMIC have not been examined as rigorously as in higher-income countries.

Methods

This study was conducted to examine clinical and demographic factors influencing TBI outcomes in Latin American LMIC. Data were prospectively collected during a randomized trial of intracranial pressure monitoring in severe TBI and a companion observational study. Participants were aged ≥13 years and admitted to study hospitals with Glasgow Coma Scale score ≤8. The primary outcome was Glasgow Outcome Scale, Extended (GOS-E) score at 6 months. Predictors were analyzed using a multivariable proportional odds model created by forward stepwise selection.

Results

A total of 550 patients were identified. Six-month outcomes were available for 88%, of whom 37% had died and 44% had achieved a GOS-E score of 5–8. In multivariable proportional odds modeling, higher Glasgow Coma Scale motor score (odds ratio [OR], 1.41 per point; 95% confidence interval [CI], 1.23–1.61) and epidural hematoma (OR, 1.83; 95% CI, 1.17–2.86) were significant predictors of higher GOS-E score, whereas advanced age (OR, 0.65 per 10 years; 95% CI, 0.57–0.73) and cisternal effacement (P < 0.001) were associated with lower GOS-E score. Study site (P < 0.001) and race (P = 0.004) significantly predicted outcome, outweighing clinical variables such as hypotension and pupillary examination.

Conclusions

Mortality from severe TBI is high in Latin American LMIC, although the rate of favorable recovery is similar to that of high-income countries. Demographic factors such as race and study site played an outsized role in predicting outcome; further research is required to understand these associations.

Introduction

Traumatic brain injury (TBI) is a major public health problem worldwide, accounting for substantial morbidity and mortality. As many as 1.5 million people die annually of TBI,1 and it is the leading cause of disability in young people.2 The incidence of TBI varies considerably between nations, but in general, the rate is believed to be higher in lower- and middle-income countries (LMIC).3, 4 This discrepancy is at least in part a result of the lack of regulations aimed at injury prevention5 and the higher frequency of risk factors in these nations; people in LMIC are more likely to be young, to live below the poverty line, and to reside in an area of conflict.4, 6, 7

Although the pathophysiology is likely to be similar in high-income countries (HIC) and LMIC, there are important differences in demographics and injury mechanism that may influence outcome. For example, patients with TBI in LMIC are younger, take longer to arrive at the hospital, and are more likely to have been involved in a motorcycle or pedestrian road traffic accident.1, 4, 8 Once patients reach medical attention, the specific intracranial injuries identified on computed tomography (CT) differ significantly, and there may be substantial differences in the care they receive compared with HIC.8, 9 Mortality seems to be higher in LMIC; secondary analyses of the CRASH (Corticosteroid Randomization After Significant Head Injury) trial showed that patients in LMIC with severe TBI had higher mortality at 2 weeks and at 6 months.8, 10

Although differences between HIC and LMIC are important, there remain substantial social, cultural, and economic dissimilarities within these categories that may influence outcomes from TBI.4 Latin America has a high proportion of LMIC, with approximately one third of the overall population living at or under the poverty line.11 The region also has a high incidence of TBI. Older estimates from the World Health Organization1 place the incidence of TBI as a result of road accidents alone at 163 per 100,000, the highest in the world. With continued economic development and increased road traffic, the rate of TBI is likely to have increased since these estimates were published, and it will probably continue to increase as growth continues.12 A better understanding of TBI in this region is therefore imperative.

The goal of this study is to better understand the long-term outcomes of severe TBI in Latin America and to identify factors associated with recovery. The analysis is based on the data collected during the BEST:TRIP (Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure) study,13 a multicenter randomized controlled trial comparing the effectiveness of 2 treatment protocols for severe closed head injury (one based on intracranial pressure [ICP] monitoring and one based on Imaging and Clinical Examination [ICE]) and an observational study conducted in parallel.

Section snippets

Methods

The details of the study design, including patient enrollment and data collection, have been described previously.13, 14 Patients were enrolled in the randomized trial through 4 hospitals in Bolivia and 2 hospitals in Ecuador. All 6 of these facilities featured intensive care units (ICUs), 24-hour access to CT scanners, and round-the-clock neurosurgical coverage. All patients arriving at the study hospitals were screened for TBI.

Patients were included if they were admitted to the study hospital

Results

A total of 550 patients were enrolled between September 2008 and October 2011 across the 9 study centers. The 6 randomized controlled trial sites screened 528 patients and enrolled 324, and the observational sites identified and enrolled 226 individuals. Overall, 484 (88%) were followed for 6 months or until death. A total of 156 (28%) died during the index hospitalization.

Demographics and clinical data are presented in Table 1. In general, patients were young, with 69% younger than 40 years.

Discussion

Although clinical outcomes after TBI have been the subject of numerous reports, most of these studies have focused on clinical outcomes in high-resource settings such as Europe and North America.17 Although the pathophysiology is likely to be similar, discrepancies in clinical outcomes may exist because of differences in clinical care and sociocultural factors.10

Here, we describe the outcomes of 550 patients with severe TBI from LMIC in Latin America. Overall, this cohort consisted of severely

Acknowledgments

The authors wish to acknowledge the contributions of the Global Neurotrauma Research Group, whose members include Joanie Machamer, MA; Kelley Chaddock, BA; Juanita Celix, MD; Mariana Cherner, PhD; Terence Hendrix, BA; Freddy Sandi, MD; Erick Garcia, MD; Juan Merida, MD; Maria del Carmen Valverde; Elisa Vilca; Rosmery Gross, MD; Maria Luisa Chavez; Vianka Valle, MD; Jesusa Torres; Maria Krutzfaldt, MD; Fernando Justiniano; Katty Trelles, MD; Saul Zavala, MD; Carlos Rocha, MD; Marcos Mello

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    Conflict of interest statement: This study was based on previous work supported by the National Institute of Neurological Disorders and Stroke (ROINS058302), the Fogarty International Center, and Integra Life Sciences. R.H.B. received indirect salary support via an educational grant provided to the University of Washington Department of Neurological Surgery by Codman Neuro. R.M.C. holds an Endowed Neurotrauma Professorship from Integra LifeSciences. These commercial entities had no role in the design, conduct, or reporting of this research. The remaining coauthors report no competing financial interests.

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