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Epidemiological studies project a significant rise in cases of chronic subdural haematoma over the next 20 years. Patients with this condition are frequently older and medically complex, with baseline characteristics that may increase peri-operative risk. The intra-operative period is only a small portion of a patient's total hospital stay, with a majority of patients in the United Kingdom transferred between institutions for their surgical and rehabilitative care. Definitive management remains surgical, but peri-operative challenges exist which resonate with other surgical cohorts where multidisciplinary working has become the gold standard. These include shared decision-making, medical optimisation, the management of peri-operative anticoagulation and the identification of key points of equipoise for examination in the future trials. In this narrative review, we use a stereotyped patient journey to provide context to the recent literature, highlighting where multidisciplinary expertise may be required to optimise patient care and maximise the benefits of surgical management. We discuss the triage, pre-operative optimisation, intra-operative management and immediate postoperative care of patients undergoing surgery for a chronic subdural haematoma. We also discuss where adjunctive medical management may be indicated. In so doing, we present the current and emerging evidence base for the role of an integrated peri-operative medicine team in the care of patients with a chronic subdural haematoma. [ABSTRACT FROM AUTHOR]

Background: Communication impairments are common and pervasive for people a long time following acquired brain injury (ABI). These impairments have a significant impact on a person's quality of life (QOL) post‐injury. Project‐based treatment is a treatment approach that could have an impact on communication skills and QOL for people with ABI a long‐term post‐injury. This treatment is embedded in a context of meaningful activities chosen by people with ABI, whereby, as a group, they work collaboratively to achieve a tangible end product. Aims: To evaluate the feasibility and initial efficacy of project‐based treatment on improving the communication skills and QOL for people with ABI. Methods & Procedures: An exploratory controlled trial with alternate allocation of groups, and follow‐up at 6–8 weeks, was completed. Twenty‐one people with chronic ABI were recruited in groups of two to three from community settings, allocated to either a TREATMENT (n = 11) or WAITLIST group (n = 10). Participants attended a 20‐h group‐based treatment over 6 weeks where they worked towards achieving a project that helped others. To determine feasibility, four criteria were used: demand, implementation, practicality and acceptability. A range of communication and QOL outcomes was used to determine a fifth feasibility criterion, initial efficacy. Some of these criteria were additionally used to evaluate the feasibility of the outcomes. Outcomes & Results: All participants received the treatment as allocated with high attendance and no dropouts. The treatment was feasible to deliver as intended and was highly acceptable to participants. Medium and large effect sizes were found from pre‐ to post‐treatment, and from pre‐treatment to follow‐up for measures of conversation, perceived communicative ability and QOL. Conclusions & Implications: Project‐based treatment is feasible with indications of initial efficacy for both communication skills and QOL. The treatment provides a promising new approach for improving communication skills and QOL in people with chronic acquired brain injuries in the community setting. [ABSTRACT FROM AUTHOR]

Primary objective: Family members (FM) are affected by the impact of an Acquired Brain Injury (ABI) upon their relatives and play an important role in rehabilitation and long-term support. This study explores how families are affected and integrates their views on the formal/informal support received as a consequence of ABI. Research design: A qualitative research design was employed to capture the lived experience of FM of people with ABI. Method: Semi-structured interviews were conducted with 16 FM of people with severe ABI. Participants were chosen from respondents to a UK national online survey of affected individuals. Interview data were analysed using inductive thematic analysis. Results: Family members' experiences are complex, enduring and are affected by the context in which the ABI occurs as well as by formal/informal support. The grief experienced by FM is ambiguous, develops over time and FM perceive little option but to remain involved. Experience of formal and informal support is noted to vary significantly in availability and quality, poor support exacerbates difficulties and isolates family members. Conclusion: Greater understanding of the lived experience of FM is needed to support more effective responses to both them and the individual with ABI, integrating services and families to improve quality-of-life. [ABSTRACT FROM AUTHOR]

Primary objective: This qualitative study aimed to gain a better understanding of how medical and social services in the UK currently support patients with Traumatic Brain Injury (TBI) in the community. Furthermore, we explored patients’ wishes and expectations of a newly established TBI clinic.Methods and procedures: We conducted semi-structured interviews with 10 patients with mild-to-severe TBI. The interview schedule was designed to cover contacts with health services, information provided, post-discharge support, current social circumstances, expectations from the newly established brain injury service and participants’ desires for any new service. Transcripts were analysed using a thematic analysis.Main results: Participants highlighted the importance of the human component of their care and of fostering trusting relationships. This validates patients’ experience and helps them to regain confidence. Follow-up and education are important for patients and relatives through all stages of care, regardless of the severity of the injury. Patients strive for meaningful lives and need to be supported to engage in activities. They need hands-on support, particularly with the UK’s bureaucratic welfare system.Conclusions: There is much room for improvement in the TBI community care in the UK. Our findings support the development of a holistic service that can address the multifactorial problems which the patients with TBI and their families face. [ABSTRACT FROM PUBLISHER]

Context: Measurement and improvement of informal caregiver burden are central aims of policy and intervention. Burden itself is a complex construct, and total burden can differ by patient diagnosis, although how diagnosis affects different aspects of caregiver subjective burden is unclear.Objectives: To compare the subjective burden of caregivers across three diagnostic groups using the 22-item Zarit Burden Inventory.Methods: We performed a secondary analysis of pooled cross-sectional data from four U.K. studies of informal caregivers of patients with advanced cancer (n = 105), dementia (n = 131), and acquired brain injury (ABI) (n = 215). Zarit Burden Inventory totals, subscales (personal and role strain), and individual mean scores were compared between diagnostic groups using the general linear model, adjusting for caregiver characteristics.Results: Caregiver age (mean years [SD]: cancer 66.1 [12.0]; dementia 61.9 [13.4]; and ABI 53.8 [10.9]) differed significantly across diagnostic groups (P < 0.001); 81.9%, 36.6%, and 59.1% of caregivers were spouse/partners, respectively (P < 0.001). Total burden was highest in ABI caregivers and lowest in cancer (mean total score [SD]: cancer 23.3 [13.4]; dementia 27.9 [16.4]; and ABI 39.1 [17.3]) (P < 0.001). Subscale scores showed similar patterns (mean personal and role subscale scores [SD]: cancer 11.8 [6.9], 5.8 [4.8]; dementia 14.4 [8.8], 7.3 [5.7]; and ABI 18.7 [9.1], 11.8 [6.0]) (P < 0.001 for both subscales). Most (17 of 22) individual item scores differed by diagnosis group (P < 0.05), except concepts of duty, responsibility, and perception of financial situation.Conclusion: Our data show that total, subscale, and most individual elements of caregiver subjective burden differ between cancer, dementia, and ABI caregivers. This should be considered when designing future intervention strategies to reduce caregiver burden in these groups. [ABSTRACT FROM AUTHOR]

INTRODUCTION: This article explores Life Care Planning and the models of the provision of rehabilitation, case management and care for people with brain-injury in the context of the health and social care systems in the UK. BACKGROUND: Life Care Planning for individuals with brain injury is not generally a term recognised or understood in the UK. The authors have worked in the field of rehabilitation, case management and care with this client group for many years and integrated their knowledge of the systems associated with Life Care Planning in the UK. PURPOSE: The article explains the process of assessment and Life Care Planning for individuals with brain injury in the UK. Case management, rehabilitation and care are described, highlighting the positive and negative influences that can affect the provision of these services. Research evidence is given of potential factors that can predict needs for brain-injured clients and their families in a Life Care Plan. CONCLUSION: In the UK, Life Care Planning is only undertaken by Care Experts in a one-off assessment for the litigation process for individuals claiming compensation; and, by those acting as Case Managers with a specialism in brain injury, who review or provide clinical work with clients on a long-term basis. [ABSTRACT FROM AUTHOR]

Background. The increasing utilisation of decompressive craniectomy for traumatic brain injury and stroke has led to an increase in the number of cranioplasties undertaken. Cranioplasty is also undertaken following excision of tumours originating from or invading the skull vault, removal of bone flaps due to post-operative infection, and decompressive craniectomy for the management of rarer causes of brain oedema and/or refractory intracranial hypertension. The existing literature which mainly consists of single-centre, retrospective studies, shows a significant variation in practice patterns and a wide range of morbidity. There also exists a need to measure the outcome as perceived by the patients themselves with patient reported outcome measures (PROMs; functional outcome, quality of life, satisfaction with cosmesis). In the UK, the concept of long-term surveillance of neurosurgical implants is well established with the UK shunt registry. Based on this background, we propose to establish the UK Cranial Reconstruction Registry (UKCRR). Aim. The overarching aim of the UKCRR is to collect high-quality data about cranioplasties undertaken across the UK and Ireland in order to improve outcomes for patients. Methods. Any patient undergoing reconstruction of the skull vault with autologous bone, titanium, or synthetic material in participating units will be eligible for inclusion. Data will be submitted directly by participating units to the Outcome Registry Intervention and Operation Network secure platform. A Steering Committee will be responsible for overseeing the strategic direction and running of the UKCRR. Outcome measures. These will include re-operation due to a cranioplasty-related issue, surgical site infection, re-admission due to a cranioplasty-related issue, unplanned post-operative escalation of care, adverse events, length of stay in admitting unit, destination at discharge from admitting unit, mortality at discharge from admitting unit, neurological status and PROMs during routine follow-up. Conclusion. The UKCRR will be an important pillar in the ongoing efforts to optimise the outcomes of patients undergoing cranioplasty. [ABSTRACT FROM AUTHOR]

AbstractCurrently available prognostic models in Traumatic Brain Injury (TBI) are derived from historical data sets or from heterogeneous data sets, depending upon the trauma care delivered. The objective of our study was to develop models to predict survival in a recent cohort of TBI patients within a relatively homogeneous trauma care system. Records of patients with brain injury were extracted from the Trauma Audit and Research Network (TARN) database. The relationship of the variables (i.e., age, Glasgow Coma Score [GCS], pupillary reactivity, Injury Severity Score [ISS], Computed Tomography [CT] classifications, classification of various intracranial pathologies, systolic and mean blood pressure, oxygen saturation, and the presence of extracranial injury) to survival at discharge were determined. Stepwise logistical regression analysis was performed to determine the best prognostic model. Two models were derived from data of 802 patients (models A and B). Age, GCS, pupillary reactivity, hypoxia, and brainstem injury are significant predictors in both. However, model A contains ISS in contrast to model B, which contains the presence of brain swelling and major extracranial injury instead. Both models have good predictive performance (model A: area under the Receiver Operating Characteristic [ROC] curve [AUC]=0.92 [95% CI, 0.90–0.95], Nagelkerke R2, 0.62; model B: AUC=0.93 [95% CI: 0.91–0.95], Nagelkerke R2: 0.63). Hence, two accurate and reliable prognostic models were developed from a recent cohort of the TBI population. [ABSTRACT FROM AUTHOR]

Primary objective: Research has shown that traumatic brain injury (TBI) can affect a person's ability to perform previously learned skills. Dysexecutive syndrome and inattention, for example, alongside a number of other cognitive and behavioural impairments such as memory loss and lack of motivation, significantly affect day-to-day functioning following TBI. This study examined the efficacy of video modelling in emerging speech in an adult male with TBI caused by an assault. Research design: In an effort to identify functional relations between this novice intervention and the target behaviour, experimental control was achieved by using within-system research methodology, overcoming difficulties of forming groups for such an highly non-homogeneous population. Methods and procedures: Across a number of conditions, the participant watched a videotape in which another adult modelled a selection of 19 spoken words. When this modelled behaviour was performed in vivo, then generalization across 76 other words in the absence of a videotape took place. Main outcomes and results: It was revealed that video modelling can promote the performance of previously learned behaviours related to speech, but more significantly it can facilitate the generalization of this verbal behaviour across untrained words. Conclusions: Video modelling could well be added within the rehabilitation programmes for this population. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) remains a major public health problem. This review aims to present the principles upon which modern TBI management should be based. The early management phase aims to achieve haemodynamic stability, limit secondary insults (eg hypotension, hypoxia), obtain accurate neurological assessment and appropriately select patients for further investigation. Since 2003, the mainstay of risk stratification in the UK emergency departments has been a system of triage based on clinical assessment, which then dictates the need for a CT scan of the head. For patients with acute subdural or extradural haematomas, time from clinical deterioration to operation should be kept to a minimum, as it can affect their outcome. In addition, it is increasingly recognised that patients with severe and moderate TBI should be managed in neuroscience centres, regardless of the need for neurosurgical intervention. The monitoring and treatment of raised intracranial pressure is paramount for maintaining cerebral blood supply and oxygen delivery in patients with severe TBI. Decompressive craniectomy and therapeutic hypothermia are the subject of ongoing international multi-centre randomised trials. TBI is associated with a number of complications, some of which require specialist referral. Patients with post-concussion syndrome can be helped by supportive management in the context of a multi-disciplinary neurotrauma clinic and by patient support groups. Specialist neurorehabilitation after TBI is important for improving outcome. INSET: Sources and selection criteria. [ABSTRACT FROM AUTHOR]

Objective: To identify factors associated with the use of intracranial pressure (ICP) monitoring and to establish which ICP-targetted therapies are being used in children with severe traumatic brain injury (TBI) in the United Kingdom. To evaluate current practice against recently published guidelines.Design and Setting: Prospective data collection of clinical and demographic information from paediatric and adult intensive care units in the UK and Ireland admitting children (< 16 years) with TBI between February 2001 and August 2003.Results: Detailed clinical information was obtained for 501 children, with information on the use of ICP monitoring available in 445. ICP monitoring was used in only 59% (75/127) of children presenting with an emergency room Glasgow Coma Scale of 8 or below. Large between centre variation was seen in the use of ICP monitoring, independent of severity of injury. There were 86 children who received ICP-targetted therapies without ICP monitoring. Wide between centre variation was found in the use of ICP-targetted therapies and in general aspects of management, such as fluid restriction, the use of muscle relaxants and prophylactic anticonvulsants. Intra-ventricular catheters are rarely placed (6% of cases); therefore cerebrospinal fluid drainage is seldom used as a first-line therapy for raised ICP. Jugular venous bulb oximetry (4%), brain microdialysis (< 1%) and brain tissue oxygen monitoring (< 1%) are rarely used in current practice. Contrary to published guidelines, moderate to severe hyperventilation is being used without monitoring for cerebral ischaemia.Conclusions: There is an urgent need for greater standardisation of practice across UK centres admitting children with severe TBI. [ABSTRACT FROM AUTHOR]

Presents the results of a postal questionnaire survey on the use of thromboprophylactic methods in the management of patients with traumatic brain injury at neurosurgical centers in Great Britain. Advantages of mechanical methods of prophylaxis; Administration of low-molecular weight heparins; Incidence of venous thromboembolism without significant increase of major bleeding.

The author reflects on the 25th anniversary of charity The Children's Trust which offers therapy, care, rehabilitation, and education to children with multiple disabilities in Great Britain. She notes that the combination of services of the charity is unique and that its paediatric residential rehabilitation centre is considered the largest in the country. She observes that it increases awareness and understanding of childhood brain injury.

This section offers health and medicine news briefs including a Dutch trial about the benefits of specialized extra treatment for patients with acute ischaemic stroke, the possible strike by Scottish ambulance staff, and the digital excellence nominations received by the Royal College of Nursing.

A letter to the editor is presented in response to an article on the involvement of neurologists in the management of patients with head injuries in Great Britain that was published in a previous issue.