The Operating Theatre Journal May 2022

Largest ever study on traumatic brain injury highlights
global inequality in causes and treatment
Neurosurgery experts from
Cambridge have led the largest
ever study examining the surgical
management of traumatic brain
injuries, highlighting regional
inequalities in both major causes
and treatment of such injuries.
The Global Neurotrauma
Outcomes Study, funded by the
NIHR, is published in The Lancet
Neurology and provides data to
assist in decision making and
improving outcome for patients
with traumatic brain injury
globally.
The paper focuses on types of
cases, the way they are managed,
and death rates, and was
compiled using data submitted
by 159 hospitals in 57 countries
to a central database, which the
researchers then analysed. The
researchers stratified 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 tended
to suffer 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.
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,
while the medium HDI tier had
the lowest proportion. The study
also found significant variations
between hospitals in the outcome
of patients.
Angelos Kolias, Consultant
Neurosurgeon at Cambridge
University Hospitals NHS
Foundation Trust (CUH) 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.”
The research was funded by the
NIHR using UK government aid to
support global health research.
Alexis Joannides, Consultant
Neurosurgeon at CUH and NIHR
Global Neurotrauma Research
Group informatics lead, added:
“The contribution of several
clinicians and researchers from
several hospitals across the world
has been possible due to the
infrastructure and collaborations
supported by the NIHR.
“The database and data
management process used in
the study have now laid the
foundation for a global registry
of traumatic brain injuries that
we have established to support
ongoing quality improvement and
research in the field of traumatic
brain injury.”
Peter Hutchinson, Professor of
Neurosurgery at the University
of Cambridge 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 collaboration across such
a vast number of hospitals and
countries, together with the
support of the World Federation
of Neurosurgical Societies
and continental neurosurgical
societies, has been phenomenal.”
Reference
Clark, D et al. Casemix, management,
and mortality of patients receiving
emergency neurosurgery for traumatic
brain injury in the Global Neurotrauma
Outcomes Study: a prospective
observational cohort study. The
Lancet Neurology; 17 March 2022; DOI:
10.1016/S1474-4422(22)00037-0
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