Long-term survival of children and adolescents after traumatic brain injury

doi:10.1016/S0003-9993(98)90177-0

Archives of Physical Medicine and Rehabilitation

Volume 79, Issue 9, September 1998, Pages 1095-1100

https://doi.org/10.1016/S0003-9993(98)90177-0 Get rights and content

Abstract

Objective: To obtain information on long-term mortality risk and life expectancy after traumatic brain injury (TBI), to improve planning and for counseling patients and their families. In contrast to the literature for spinal cord injury and other disabilities, there have been few such reports for TBI.

Design: Records were reviewed on 946 persons aged 5 to 21 years who had sustained TBI. All were patients who subsequently received disability services in California, 1987 to 1995.

Results: The chief predictors of mortality were basic functional skills such as mobility and self-feeding. After the initial high-risk period, mortality risk for TBI was much lower than for similarly functioning persons with cerebral palsy (a comparison group), although after 10 years the two sets of mortality rates had largely converged. For high-functioning persons, life expectancies were only 3 to 5 years shorter than for the general population. By contrast, the remaining life expectancy for those without mobility 6 months after injury was only 15 years.

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Cited by (62)

Eyeball pressure stimulation induces subtle sympathetic activation in patients with a history of moderate or severe traumatic brain injury
2018, Clinical Neurophysiology
Citation Excerpt :
At least 5.3 million US citizens suffer from cognitive, behavioral and emotional disabilities due to a history of TBI (Ghajar, 2000; Fleminger and Ponsford, 2005; Maas et al., 2008; Masel and DeWitt, 2010). Moreover, there is evidence of increased long-term mortality rates and significantly reduced long-term survival among TBI survivors (Walker et al., 1971; Lewin et al., 1979; Rish et al., 1983; Conroy and Kraus, 1988; Kilaru et al., 1996; Strauss et al., 1998; Baguley et al., 2000; Shavelle et al., 2001; Brown et al., 2004; Pentland et al., 2005; McMillan and Teasdale, 2007; Baguley et al., 2008a,b; McMillan et al., 2011; Baguley et al., 2012; McMillan et al., 2014). So far, mechanisms of increased long-term fatalities are unclear.
After traumatic brain injury (TBI), there may be persistent central-autonomic-network (CAN) dysfunction causing cardiovascular-autonomic dysregulation. Eyeball-pressure-stimulation (EPS) normally induces cardiovagal activation. In patients with a history of moderate or severe TBI (post-moderate-severe-TBI), we determined whether EPS unveils cardiovascular-autonomic dysregulation.
In 51 post-moderate-severe-TBI patients (32.7 ± 10.5 years old, 43.1 ± 33.4 months post-injury), and 30 controls (29.1 ± 9.8 years), we recorded respiration, RR-intervals (RRI), systolic and diastolic blood-pressure (BPsys, BPdia), before and during EPS (120 sec; 30 mmHg), using an ocular-pressure-device (Okulopressor®). We calculated spectral-powers of mainly sympathetic low (LF: 0.04–0.15 Hz) and parasympathetic high (HF: 0.15–0.5 Hz) frequency RRI-fluctuations, sympathetically mediated LF-powers of BPsys, and calculated normalized (nu) LF- and HF-powers of RRI. We compared parameters between groups before and during EPS by repeated-measurement-analysis-of-variance with post-hoc analysis (significance: p < 0.05).
At rest, sympathetically mediated LF-BPsys-powers were significantly lower in the patients than the controls. During EPS, only controls significantly increased RRIs and parasympathetically mediated HFnu-RRI-powers, but decreased LF-RRI-powers, LFnu-RRI-powers, and LF-BPsys-powers; in contrast, the patients slightly though significantly increased BPsys upon EPS, without changing any other parameter.
In post-moderate-severe-TBI patients, autonomic BP-modulation was already compromised at rest. During EPS, our patients failed to activate cardiovagal modulation but slightly increased BPsys, indicating persistent CAN dysregulation.
Our findings unveil persistence of subtle cardiovascular-autonomic dysregulation even years after TBI.
Long-term survival after traumatic brain injury part I: External validity of prognostic models
2015, Archives of Physical Medicine and Rehabilitation
To develop prognostic models for long-term survival in adults with traumatic brain injury (TBI) and to assess their external validity in 2 independent populations.
Survival analysis.
Post-discharge from rehabilitation units and long-term follow-up at regional centers.
Two cohorts of long-term survivors of TBI (N=12,481): the Traumatic Brain Injury Model Systems (TBIMS) cohort comprised 7365 persons who were admitted to a TBIMS facility and were assessed at ≥1 years postinjury, and the California Department of Developmental Services (CDDS) cohort comprised 5116 persons who sustained a TBI and received long-term services from the CDDS.
Not applicable.
Survival/mortality.
Older age, male sex, and severity of disability in walking and feeding were significant predictors of increased long-term mortality rates (all P<.05, both databases). The CDDS model predicted 623 deaths for persons in the TBIMS cohort, with an observed-to-expected ratio of .94 (95% confidence interval [CI], 0.87–1.02). The TBIMS model predicted a total of 525 deaths for persons in the CDDS cohort, with an observed-to-expected ratio of 1.08 (95% CI, 0.99–1.17). Regression calibration statistics were satisfactory, and both models ranked survival times well from shortest to longest (TBIMS: C index, .78; 95% CI, .76–.80; CDDS: C index, .80; 95% CI, .78–.82).
Long-term survival prognosis in TBI is related to age, sex, and severity of disability. When compared on the basis of these factors, the survival estimates derived from the TBIMS and CDDS cohorts are found to be similar. The close agreement between model predictions and actual mortality rates confirm the external validity of the prognostic models presented herein.
Long-term survival after traumatic brain injury part II: Life expectancy
2015, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
For example, in persons who do not walk or self-feed, one might consider more basic motor skills including the ability to sit or stand independently, the degree of functional hand use, continence, and communication skills. As shown in previous research,11 dependence on a feeding tube is one of the most important markers of disability and therefore has a significant effect on life expectancy in this group. At the other end of the disability spectrum, we found (in supplementary analysis; data not shown) that among persons who were fully ambulatory, those who were able to live independently and engage in competitive employment lived longer (on average) than those who were not.
To compute the life expectancy of persons with traumatic brain injury (TBI) based on validated prognostic models from 2 cohorts, to compare mortality and life expectancy of persons with TBI with those of the U.S. general population, and to investigate trends toward improved survival over the last 2 decades.
Survival analysis.
Postdischarge from rehabilitation units and long-term follow-up at regional centers.
Two cohorts of long-term survivors of TBI (N=12,481): the Traumatic Brain Injury Model Systems (TBIMS) cohort comprised 7365 persons who were admitted to a TBIMS facility with moderate to severe TBI and were assessed at ≥1 years postinjury, and the California Department of Developmental Services (CDDS) cohort comprised 5116 persons who sustained a TBI and received long-term services from the CDDS.
Not applicable.
Life expectancy.
The estimates of age-, sex-, and disability-specific life expectancy of persons with TBI derived from the CDDS and TBIMS were similar. The estimates of age- and sex-specific life expectancy were lower than those of the U.S. general population. Mortality rates of persons with TBI were higher than those of the U.S. general population. Mortality rates did not improve and the standardized mortality ratio increased over the study period from 1988 to 2010.
Life expectancy of persons with TBI is lower than that of the general population and depends on age, sex, and severity of disability. When compared, the survival outcomes in the TBIMS and CDDS cohorts are remarkably similar. Because there have been no marked trends in the last 20 years, the life expectancies presented in this article may remain valid in the future.
Long-term disability and survival in traumatic brain injury: Results from the national institute on disability and rehabilitation research model systems
2013, Archives of Physical Medicine and Rehabilitation
To document long-term survival in 1-year survivors of traumatic brain injury (TBI); to compare the use of the Disability Rating Scale (DRS) and FIM as factors in the estimation of survival probabilities; and to investigate the effect of time since injury and secular trends in mortality.
Cohort study of 1-year survivors of TBI followed up to 20 years postinjury. Statistical methods include standardized mortality ratio, Kaplan-Meier survival curve, proportional hazards regression, and person-year logistic regression.
Postdischarge from rehabilitation units.
Population-based sample of persons (N=7228) who were admitted to a TBI Model Systems facility and survived at least 1 year postinjury. These persons contributed 32,505 person-years, with 537 deaths, over the 1989 to 2011 study period.
Not applicable.
Survival.
Survival was poorer than that of the general population (standardized mortality ratio=2.1; 95% confidence interval, 1.9–2.3). Age, sex, and functional disability were significant risk factors for mortality (P<.001). FIM- and DRS-based proportional hazards survival models had comparable predictive performance (C index: .80 vs .80; Akaike information criterion: 11,005 vs 11,015). Time since injury and current calendar year were not significant predictors of long-term survival (both P>.05).
Long-term survival prognosis in TBI depends on age, sex, and disability. FIM and DRS are useful prognostic measures with comparable statistical performance. Age- and disability-specific mortality rates in TBI have not declined over the last 20 years. A survival prognosis calculator is available online (http://www.LifeExpectancy.org/tbims.shtml).
Mortality After Discharge From Acute Care Hospitalization With Traumatic Brain Injury: A Population-Based Study
2010, Archives of Physical Medicine and Rehabilitation
Ventura T, Harrison-Felix C, Carlson N, DiGuiseppi C, Gabella B, Brown A, DeVivo M, Whiteneck G. Mortality after discharge from acute care hospitalization with traumatic brain injury: a population-based study.
To characterize mortality after acute hospitalization with traumatic brain injury (TBI) in a socioeconomically diverse population.
Population-based retrospective cohort study.
Statewide TBI surveillance program.
Colorado residents with TBI discharged alive from acute hospitalization between 1998 and 2003 (N=18,998).
Not applicable.
Vital status at the end of the study period (December 31, 2005) and statewide population mortality rates were used to calculate all-cause and cause-specific standardized mortality ratios (SMRs) and life expectancy compared with population mortality rates. The influence of demographics, injury severity, and comorbid conditions on time until death was investigated using age-stratified Cox proportional hazards modeling.
Patients with TBI carried about 2.5 times the risk of death compared with the general population (SMR=2.47; 95% confidence interval [CI], 2.31–2.65). Life expectancy reduction averaged 6 years. SMRs were largest for deaths caused by mental/behavioral (SMR=3.84; 95% CI, 2.67–5.51) and neurologic conditions (SMR=2.79; 95% CI, 2.07–3.77) and were smaller but significantly higher than 1.0 for an array of other causes. Injury severity and older age increased mortality among young people (age <20y). However, risk factors for mortality among adults age 20 and older involved multiple domains of demographics (eg, metropolitan residence), injury-related measures (eg, falls versus vehicular incidents), and comorbidity (eg, ≥3 comorbid health conditions versus none).
TBI confers an increased risk of mortality in the months and years after hospital discharge. Although life expectancy is reduced across the population, the excess in mortality lessens as time since injury increases. Specific risk factors (eg, high injury severity, poor general health) pose an especially high threat to survival and should prompt an increased vigilance of health status, especially among younger patients.
Predicting outcome after childhood brain injury
2012, CMAJ. Canadian Medical Association Journal

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ArticleLong-term survival of children and adolescents after traumatic brain injury☆

Abstract

Pediatr Neurol

J Pediatr

Chest

Pediatr Neurol

Variability in outcomes after traumatic brain injury: a developmental perspective

Long-term outcome after severe head injury

BMJ

Severe accidental head injury: an assessment of long-term prognosis

Life expectancy of head-injured men with and without epilepsy

Arch Neurol

Survival in transverse myelitis

Paraplegia

Survival in traumatic spinal cord injury

Paraplegia

Survival and cause of death after traumatic spinal cord injury: a long-term epidemiological survey from Denmark

Spinal Cord

Long-term survival of veterans with traumatic spinal cord injury

Arch Neurol

Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago

Paraplegia

Client Development Evaluation Report

Concurrent validity of the client development and evaluation report

Article
Long-term survival of children and adolescents after traumatic brain injury☆