Nerve injury in severe trauma with upper extremity involvement: evaluation of 49,382 patients from the TraumaRegister DGU® between 2002 and 2015

Abstract Background Peripheral nerve injury (PNI) as an adjunct lesion in patients with upper extremity trauma has not been investigated in a Central European setting so far, despite of its devastating long-term consequences. This study evaluates a large multinational trauma registry for prevalence, mechanisms, injury severity and outcome characteristics of upper limb nerve lesions. Methods After formal approval the TraumaRegister DGU® (TR-DGU) was searched for severely injured cases with upper extremity involvement between 2002 and 2015. Patients were separated into two cohorts with regard to presence of an accompanying nerve injury. For all cases demographic data, trauma mechanism, concomitant lesions, severity of injury and outcome characteristics were obtained and group comparisons performed. Results About 3,3% of all trauma patients with upper limb affection (n = 49,382) revealed additional nerve injuries. PNI cases were more likely of male gender (78,6% vs.73,2%) and tended to be significantly younger than their counterparts without nerve lesions (mean age 40,6 y vs. 47,2 y). Motorcycle accidents were the most frequently encountered single cause of injury in PNI patients (32,5%), whereas control cases primarily sustained their trauma from high or low falls (32,2%). Typical lesions recognized in PNI patients were fractures of the humerus (37,2%) or ulna (20,3%), vascular lacerations (arterial 10,9%; venous 2,4%) and extensive soft tissue damage (21,3%). Despite of similar average trauma severity in both groups patients with nerve affection had a longer primary hospital stay (30,6 d vs. 24,2 d) and required more subsequent inpatient rehabilitation (36,0% vs. 29,2%). Conclusion PNI complicating upper extremity trauma might be more commonly encountered in Central Europe than suggested by previous foreign studies. PNI typically affect males of young age who show significantly increased length of hospitalization and subsequent need for inpatient rehabilitation. Hence these lesions induce extraordinary high financial expenses besides their impact on health related quality of life for the individual patient. Further research is necessary to develop specific prevention strategies for this kind of trauma

The burden of headache following aneurysmal subarachnoid hemorrhage: a prospective single-center cross-sectional analysis

Background!#!Aneurysmal subarachnoid hemorrhage (SAH) as a serious type of stroke is frequently accompanied by a so-called initial thunderclap headache. However, the occurrence of burdensome long-term headache following SAH has never been studied in detail so far. The aim of this study was to determine the prevalence and characteristics of long-term burdensome headache in good-grade SAH patients as well as its relation to health-related quality of life (HR-QOL).!##!Methods!#!All SAH cases treated between January 2014 and December 2016 with preserved consciousness at hospital discharge were prospectively interviewed regarding burdensome headache in 2018. Study participants were subsequently scrutinized by means of a standardized postal survey comprising validated pain and HR-QOL questionnaires. A retrospective chart review provided data on the initial treatment.!##!Results!#!A total of 93 out of 145 eligible SAH patients participated in the study (62 females). A total of 41% (38/93) of subjects indicated burdensome headache at follow-up (mean 32.6 ± 9.3 months). Comparison between patients with (HA+) and without long-term headache (HA-) revealed significantly younger mean age (47.9 ± 11.8 vs. 55.6 ± 10.3 years; p < .01) as well as more favorable neurological conditions (WFNS I/II: 95% vs. 75%; p = .03) in HA+ cases. The mean average headache of the HA+ group was 3.7 ± 2.3 (10-point numeric rating scale), and the mean maximum headache intensity was 5.7 ± 2.9. Pain and HR-QOL scores demonstrated profound alterations in HA+ compared to HA- patients.!##!Conclusions!#!Our results suggest that a considerable proportion of SAH patients suffers from burdensome headache even years after the hemorrhage. Moreover, long-term headache is associated with reduced HR-QOL in these cases

Summary of adverse events.

<p>Summary of adverse events.</p

Towards unambiguous reporting of complications related to deep brain stimulation surgery: A retrospective single-center analysis and systematic review of the literature

<div><p>Background and objective</p><p>To determine rates of adverse events (AEs) related to deep brain stimulation (DBS) surgery or implanted devices from a large series from a single institution. Sound comparisons with the literature require the definition of unambiguous categories, since there is no consensus on the reporting of such AEs.</p><p>Patients and methods</p><p>123 consecutive patients (median age 63 yrs; female 45.5%) treated with DBS in the subthalamic nucleus (78 patients), ventrolateral thalamus (24), internal pallidum (20), and centre médian-parafascicular nucleus (1) were analyzed retrospectively. Both mean and median follow-up time was 4.7 years (578 patient-years). AEs were assessed according to three unambiguous categories: (i) hemorrhages including other intracranial complications because these might lead to neurological deficits or death, (ii) infections and similar AEs necessitating the explantation of hardware components as this results in the interruption of DBS therapy, and (iii) lead revisions for various reasons since this involves an additional intracranial procedure. For a systematic review of the literature AE rates were calculated based on primary data presented in 103 publications. Heterogeneity between studies was assessed with the I² statistic and analyzed further by a random effects meta-regression. Publication bias was analyzed with funnel plots.</p><p>Results</p><p>Surgery- or hardware-related AEs (23) affected 18 of 123 patients (14.6%) and resolved without permanent sequelae in all instances. In 2 patients (1.6%), small hemorrhages in the striatum were associated with transient neurological deficits. In 4 patients (3.3%; 0.7% per patient-year) impulse generators were removed due to infection. In 2 patients electrodes were revised (1.6%; 0.3% per patient-year). There was no lead migration or surgical revision because of lead misplacement. Age was not statistically significant different (p>0.05) between patients affected by AEs or not. AE rates did not decline over time and similar incidences were found among all patients (423) implanted with DBS systems at our institution until December 2016. A systematic literature review revealed that exact AE rates could not be determined from many studies, which could not be attributed to study designs. Average rates for intracranial complications were 3.8% among studies (per-study analysis) and 3.4% for pooled analysis of patients from different studies (per-patient analysis). Annual hardware removal rates were 3.6 and 2.4% for per-study and per-patient analysis, respectively, and lead revision rates were 4.1 and 2.6%, respectively. There was significant heterogeneity between studies (I² ranged between 77% and 91% for the three categories; p< 0.0001). For hardware removal heterogeneity (I² = 87.4%) was reduced by taking study size (p< 0.0001) and publication year (p< 0.01) into account, although a significant degree of heterogeneity remained (I² = 80.0%; p< 0.0001). Based on comparisons with health care-related databases there appears to be publication bias with lower rates for hardware-related AEs in published patient cohorts.</p><p>Conclusions</p><p>The proposed categories are suited for an unequivocal assessment of AEs even in a retrospective manner and useful for benchmarking. AE rates in the present cohorts from our institution compare favorable with the literature.</p></div

Sum of AEs defined by same severity, reversibility, and attribution to DBS therapy.

<p>Green, reversible; orange, non reversible; grey, unknown. The actual number of AEs is presented. The dotted area indicates AEs that were <i>severe</i> or worse and at least <i>possibly</i> related to DBS therapy and, thus, regarded the most critical. N.B. The number of affected patients may be less than the number indicated because individual patients may have suffered from more than one AE of respective groups (e.g. impairment of gait and speech rated as <i>mild</i>, <i>probably</i> related and <i>non-reversible</i>).</p

Reporting of adverse events in prospective multicentric DBS studies for movement disorders.

<p>Reporting of adverse events in prospective multicentric DBS studies for movement disorders.</p

DBS-related neurological and psychiatric adverse events.

<p>DBS-related neurological and psychiatric adverse events.</p

(Supplement) DBS-related and -unrelated neurological and psychiatric adverse events.

<p>(Supplement) DBS-related and -unrelated neurological and psychiatric adverse events.</p