Abstract
Traumatic brain injury (TBI) poses a huge public health and societal problem worldwide. Uncertainty exists on how care system and treatment approaches for TBI worked in China may differ from those in Europe. Better knowledge on this is important to facilitate interpretation of findings reported by Chinese researchers and to inform opportunities for collaborative studies. We aimed to investigate concordance and variations in TBI care between Chinese and European neurotrauma centers. Investigators from 52 centers in China and 68 in Europe involved in the Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study were invited to complete provider profiling (PP) questionnaires, which covered the main aspects of care system and treatment approaches of TBI care. Participating Chinese and European centers were mainly publicly funded and academic. More centers in China indicated available dedicated neuro-intensive care than those in Europe (98% vs. 60%), and treatment decisions in the ICU were mainly determined by neurosurgeons (58%) in China while in Europe, (neuro)intensivists often took the lead (61%). The ambulance dispatching system was automatic in half of Chinese centers (49%), whereas selective dispatching was more common in European centers (74%). For treatment of refractory intracranial hypertension, a decompressive craniectomy was more frequently regarded as general policy in China compared with in Europe (89% vs. 45%). We observed both concordance and substantial variations with regard to the various aspects of TBI care between Chinese and European centers. These findings are fundamental to guide future research and offer opportunities for collaborative comparative effectiveness research to identify best practices.
Introduction
Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide, with a global annual incidence of more than 50 million cases. 1 With a population of 1.4 billion, the number of patients with TBI in China exceeds that of most other countries, causing an enormous burden to society and families, and meanwhile offering a vast potential for research. 2
Outcome after TBI has substantially improved in China over the past two decades. The population-based mortality of TBI in China (12.99/100,000 people) is now very similar to that in Europe (11.7/100,000 people). 3,4 However, uncertainty exists on how care system and treatment approaches for TBI worked in Chinese centers compare to European countries. Mapping potential variations and concordance is essential for appropriate interpretation of results originating from China. Also, it would be a necessary step when conducting collaborative clinical research on TBI between China and Europe. Potential variations constitute opportunities rather than challenges in enabling comparative effectiveness research (CER), which uses between-center differences to compare the effectiveness of specific practices.
The Collaborative European Neuro Trauma Effectiveness Research in TBI study (CENTER-TBI:
Methods
Study sample
The CENTER-TBI study was conducted in 68 centers from Europe and Israel and in 52 neurotrauma centers from 21 provinces in China. Participants in the study were approached to complete a provider profiling (PP) questionnaire about the care system and treatment approaches of TBI care. In this study, we aim to analyze the questionnaire results of Chinese centers and compare these to results previously obtained in Europe.
Provider profiling of CENTER-TBI for China
The PP questionnaires were developed through a comprehensive process including a literature study and expert opinion meetings, and have been previously applied in the European centers participating in the CENTER-TBI study. 16 Clinical experts from Europe and China selected questions covering most relevant aspects of TBI care in China and Europe from PP questionnaires (Supplementary Appendix S1). Topics included general hospital characteristics, medical ethics, pre-hospital trauma care, emergency department (ED), in-patient admission, intensive care unit (ICU), neurosurgical care, and rehabilitation.
The questionnaires (illustrations included) were translated into Chinese by two bilingual editors with a neurosurgical background to avoid the language barrier affecting the quality and reliability. The translated questionnaires were pilot-tested by several doctors proficient in Chinese and English and subsequently refined according to feedback provided.
In the provider profiling, we explicitly required respondents to fill in the “general policy” for their institution, which was defined as standard treatment or policy estimated to be used in more than 75% of patients, recognizing that there might be exceptions. Most questions used categorical answers.
Questionnaire distribution
Local investigators supervising the study in a specific center were extensively informed in person and by email about the aim of the study. We emphasized the confidentiality of their responses. Instructions were provided on how to respond to the questions, aiming to achieve unequivocal responses. Questionnaires were completed using WeChat relevant application (Shenzhen Tencent computer system Co. Ltd.). Any questions from local investigators could be answered by email, WeChat, or telephone by the corresponding author. The local investigator in each center was responsible for the completion process in their center and was encouraged to involve other staff members with specific expertise when appropriate.
Statistical analysis
We calculated frequencies and percentages for categorical variables, medians, and interquartile ranges (IQRs) for continuous variables. Centers in which the investigator did not respond to every question remained in our study in order to keep groups for descriptive statistics as large as possible. For the question about ambulance dispatching, respondents could fill in more answer categories. Therefore, the responses exceed 68 (100%). Since percentages were rounded to whole numbers, some results added up to 99% or 101%. Respondents could indicate how frequently certain management strategies were used (always 100–90%, frequently 90–70%, sometimes 70–30%, rarely 30–10%, never 10–0%). The sum of “always” and “frequently” were interpreted as representing the general policy of a center, in line with previous reports.
6
Where appropriate, we used Mann-Whitney U test (continuous) or chi-squared test (categorical) to determine significance of differences. Analyses were performed using R statistical software version 3.6.0 (The R Foundation for Statistical Computing, Vienna, Austria.
Results
In total, 45 out of 52 centers in China and 68 centers in Europe completed almost all questions of the PP and approved use of their data for research purposes. The PP questionnaire in China was completed mainly by neurosurgeons, trauma surgeons, and/or ED physicians.
Structural characteristics
We found concordance and variations regarding structural characteristics between 45 centers in China and 68 centers in Europe. Participating centers were both predominately academic, in an urban location, and funded by public resources. Among the participating centers, the median number of beds in Chinese hospitals (median of 1966 [IQR: 1200-2500]) was generally higher than that in European hospitals (median of 1000 [IQR: 755-1390]), while the number of beds in ICU were quantitatively comparable (median of 40 [IQR: 24-60] in China and 31 [IQR: 22-44] in Europe). In this study, the proportions of hospitals with dedicated neuro-intensive care available (n = 44; 98% vs. n = 40; 60%) and separate 24/7 emergency operating rooms (n = 43; 96% vs. n = 49; 73%) in China were larger than that in Europe. Compared with China (n = 14; 31%), European centers were equipped with more helicopter platforms (n = 54; 81%). Treatment decisions regarding medical management in TBI patients in the ICU were mainly determined by neurosurgeons in Chinese centers (n = 26; 58%), compared with neuro-intensivists in European centers (n = 41; 61%). However, no significant difference was found in the use of guidelines for ICU management (Table 1).
Structural Characteristics of the Participating Centers (China versus Europe)
Separate 24/7 emergency operating rooms = operating rooms that are exclusively used for emergency surgery, and never used for planned or elective surgery.
IQR, interquartile range; TBI, traumatic brain injury; ICU, intensive care unit; BTF, Brain Trauma Foundation.
Ethics and consent
Approaches towards ethical and consent aspects varied on all reported items. Chinese centers (n = 39; 87%) in the CENTER-TBI study had a higher proportion of medical ethics departments than that in European centers (n = 38; 56%). More than half of European centers (n = 50; 74%) in the study reported that emergency research involving mentally incapacitated patients without prior patient or proxy consent was ethically feasible, while fewer centers in China (n = 14; 31%) indicated that. With regard to decisions on surgery for acute subdural hematoma patients or on referral of patients to rehabilitation facilities, compared with centers in China, higher proportions of centers in Europe indicated that age had a substantial influence on these decisions (Table 2).
Consent and Ethics of the Participating Centers (China versus Europe)
SDH, subdural hematoma.
Pre-hospital care and ED organization of the participating centers
In-hospital multidisciplinary teams alerted for severe trauma victims was the general policy for the majority of the participating centers in both China and Europe. Apart from that, we found variation regarding all reported items. Significantly, helicopter use was not a general policy in Chinese centers (n = 0; 0%), whereas this was a general policy in nearly half of European centers (n = 31; 46%). Also, with regard of the system used for ambulance dispatching, including the basic type of response to the scene of trauma and the policy at the scene, all varied significantly between centers in China and Europe: Automatic dispatching of ambulances, basic life support and the scoop and run policy were reported to be priorities in Chinese centers, whereas selective dispatching, advanced life support, and stay and play strategy were dominant in European centers. Besides, severe TBI patients were transferred to the participating center directly in more than half of European centers (n = 46; 71%); however, only 13 centers (29%) in China indicated that. Severe TBI patients were transferred to the majority of Chinese centers indirectly in this study. Lastly, with regard to applying guidelines to determine which mild TBI (mTBI) patients should have an initial head CT, centers in China (n = 25; 56%) had a lower utilization rate than European centers (n = 52; 80%; Table 3).
Pre-Hospital Trauma Care and Emergency Department (ED) of the Participating Centers (China versus Europe)
In-hospital treatment
Reported in-hospital treatment indicated significant differences in participating centers between Europe and China. However, we found no significant differences in the general policy concerning the management of extremity (limb) fractures in TBI patients, and the general policy for management of intraparenchymal mass lesions (contusions). Routine repetitive CT scanning was more often reported to be used in TBI patients in the ICU in Chinese centers (n = 45; 100%) compared with European centers (n = 44; 67%). Decompressive craniectomy in severe TBI patients with refractory intracranial hypertension was a general policy in more Chinese centers (n = 40; 89%) than in European centers (n = 29; 45%). Thresholds for treating elevated intracranial pressure (ICP) were slightly higher in China (> 25 mm Hg in 11 centers; 24%) compared with Europe (n = 6; 9%). ICP was measured mostly by both parenchymal monitors without optional ventricular drainage and ventricular catheters in both China and Europe. However, in some European centers (n = 21; 32%), parenchymal monitors were the only way ICP was measured. Coma stimulation was used more often in comatose TBI patients in Chinese centers (n = 36; 80%) than in European centers (n = 34; 51%; Table 4).
In-Hospital Treatment of the Participating Centers (China versus Europe)
CT, computed tomography; TBI, traumatic brain injury; ICU, intensive care unit; ICP, intracranial pressure.
Discussion
We found both substantial variations and varying degrees of concordance regarding the various aspects of TBI care between Chinese and European centers participating in the CENTER-TBI study. To our knowledge, this is the first study that compares care system and treatment approaches in TBI between Chinese and European TBI centers. Although the participating neurotrauma centers indicated agreement in some basic structural features (e.g., publicly funded and academic), there was substantial variation in structures and processes of TBI care, such as emergency medical service system and treatment policies.
We found substantial variations in pre-hospital trauma care and the ED care between Chinese and European centers. The variation already has been reported between European centers. 9,13 In consideration of superior characteristics such as high speed, reliable mobility, and less vulnerability to traffic conditions, many developed countries have established a well-organized, command-efficient helicopter emergency medical service (HEMS). Nearly half of the European centers in CENTER-TBI study had a general policy to transport a TBI patient to the hospital by helicopter. 9,17 However, helicopter use was not a general policy for any Chinese center in this study, even though around one-third of Chinese centers reported to have a helicopter platform. China's HEMS has actually only recently been launched. Lack in using HEMS may partly reflect the differences in socioeconomic situations between China and Europe. More awareness of the importance of helicopter management and additional capital investments may stimulate the development of HEMS in Chinese centers. Moreover, more research is essential to further enhance the development of HEMS in China. 18
The ambulance dispatching system, life support crew, and policy at the scene varied between Chinese and European centers, and also differs among Chinese centers, which may result in more indirect transfers of severe TBI patients in China. 19 Diversified modes in pre-hospital trauma care exist across the vast territory of China due to regional differences in geographical and socioeconomic situation. For example, instead of implementing rescue aid itself, the emergency command center in Guangzhou appoints emergency units from different hospitals for rescue tasks. In contrast, the emergency center in Shanghai and its substations take charge of pre-hospital rescue and then transfer patients to cooperative hospitals for further care. Strong evidence for the effectiveness of different formats of pre-hospital trauma care is lacking, but different practices in pre-hospital trauma care may influence the outcome of TBI patients. Therefore, more research on this topic is needed to inform improvement of TBI care in China and Europe.
Substantial variations also were found in medical ethical topics between Chinese and European centers. In our study, a department of medical ethics was deemed to be an academic department of ethics and philosophy of medicine, and not an office for institutional reviews of research documents. The lower proportion of ethic department in Europe was caused by part of European centers did not establish such a specific department for medical ethics. However, they have the ethicists and faculty members who stand for research and education in medical ethics or collaborate with clinicians on topics in different research areas in biomedical ethics. In other words, the process of ethical review is commonly centralized in Europe.
The variation regarding the use of CT scan is in line with previous research. 20,21 Compared with most Western countries, CT scan is more accessible and much cheaper in China. Although CT scan is a very important diagnostic method to evaluate patients with intracranial injuries, excessive use has been questioned due to potential adverse effects of radiation risk, unnecessary resource occupation, and economic costs. Especially when considering low risk of intracranial damage, CT scan is not always necessary in patients with mild TBI (mTBI). 22 Various prediction rules and guidelines (e.g., the Canadian CT head rule [CCHR] and New Orleans Criteria) have been developed to estimate the risk of intracranial abnormalities in mTBI. 23,24 Besides, these worldwide popular criteria also show high sensitivity and specificity to prevent missing timely neurosurgical intervention and to avoid the overuse of CT in different countries by various studies. 24 –28 Although national or local guidelines for cranial CT among patients with mTBI are still absent in China, a study to evaluate the effectiveness of clinical decision rules for CT scanning in Chinese patients with mTBI has indicated high sensitivity and specificity, which indicates applicability of these rules to Chinese patients. 21 However, our study demonstrated that only 55.6% of centers in China applied guidelines to triage initial head CT for mTBI patients, and their utilization rate was significantly lower than that in European centers. This might partly be attributed to relatively lower awareness of these criteria among Chinese doctors. 20,27 In 2013, a survey study in 247 emergency physicians from different Chinese hospitals reported that awareness and utilization rate of CCHR were 41.7% and 24.7%, respectively. 20 In addition, fear of insufficient medical practice and low awareness of radiation risk were the two principal barriers to use the CCHR in the triage of CT scanning for patients with mTBI. Further study is necessary to explore whether the variation in CT scan policies is associated with outcome in TBI patients.
Similarities in guidelines adherence and implementation for ICU management were found, which might suggest the importance of guidelines in reducing variation in clinical practice. However, substantial differences were found in guidelines adherence and implementation among neurotrauma centers in Europe in previous studies, which indicated that the goal of guidelines to minimize variation has not always been achieved. 6,12,15 Guidelines resulting from weak evidence underpin the recommendations for the treatment of patients with TBI. The threshold for medical management of elevated intracranial hypertension (ICP), for instance, as recommended in the guidelines for severe TBI is not based on high-level evidence. 29 Moreover, we found that decompressive craniectomy (DC) in refractory ICP was performed in Chinese centers more often than that in European centers. This procedure is recommended (level II A evidence) in the Brain Trauma Foundation guidelines. 29 DC for refractory ICP may be considered an intuitive choice for neurosurgeons but may not be for neuro-intensivists, which may explain its higher utilization in China compared with Europe. In China, neurosurgeons mainly make treatment decisions regarding the management of TBI patients in the ICU, whereas neuro-intensivists make the decision in the majority of European centers.
This study has limitations that should be taken into account when interpreting the results. First, although we requested the general policy rather than individual preferences, we cannot exclude that the results reflect personal treatment preferences. Second, respondents might have (even subconsciously) presented a more favorable picture of their centers. Third, this PP questionnaire did not cover all the subtleties that underpin clinical practice. Importantly, because the majority of centers in our study were academic centers interested in TBI research, the data may not be representative for all TBI centers within China and Europe. Thus, findings should be interpreted with caution. It also should be pointed out that our results reflect practices reported by respondents, rather than actual documentation of clinical practice.
Although we only reported on general structures and processes of TBI care, it is evident that the between-continent variation is substantial and provides an opportunity for collaborative comparative effectiveness research for identifying best practices. Based on the fact that the CENTER-TBI study has collected individual patient data, especially considering a vast potential for research causing by large number of patients with TBI in China, future research could focus on the source and effect of these variations. For example, we can study the influence of medical management decisions in ICU on severe TBI patients by comparing patients' outcome in centers whose decisions are mainly determined by neurosurgeon and in centers where neuro-intensivists are in charge. Further studies, involving multidisciplinary and national/international groups, are expected to advance care system and treatment approaches on TBI patients.
Conclusion
Both similarities and significant differences regarding the various aspects of TBI care were observed when comparing the neurotrauma centers in CENTER-TBI between China and Europe. The findings provide a new perspective to better understand TBI care in China and Europe. This study may guide possible future comparative effectiveness research for better medical practices, advanced guidelines, and ultimately for improving outcome of TBI patients.
Footnotes
Acknowledgments
The authors thank all clinical and research staff at the CENTER-TBI sites for completing the provider profiling questionnaires. Data used in preparation of this manuscript were obtained in the context of CENTER-TBI.
CENTER-TBI Investigators and Participants
Cecilia Åkerlund, Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden; Krisztina Amrein, János Szentágothai Research Centre, University of Pécs, Pécs, Hungary; Nada Andelic, Division of Surgery and Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway; Lasse Andreassen, Department of Neurosurgery, University Hospital Northern Norway, Tromso, Norway; Audny Anke, Department of Physical Medicine and Rehabilitation, University Hospital Northern Norway, Tromso, Norway; Anna Antoni, Trauma Surgery, Medical University Vienna, Vienna, Austria; Gérard Audibert, Department of Anesthesiology & Intensive Care, University Hospital Nancy, Nancy, France; Philippe Azouvi, Raymond Poincare hospital, Assistance Publique – Hopitaux de Paris, Paris, France; Maria Luisa Azzolini, Department of Anesthesiology & Intensive Care, S Raffaele University Hospital, Milan, Italy; Ronald Bartels, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands; Pál Barzó, Department of Neurosurgery, University of Szeged, Szeged, Hungary; Romuald Beauvais, International Projects Management, ARTTIC, Munchen, Germany; Ronny Beer, Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria; Bo-Michael Bellander, Department of Neurosurgery & Anesthesia & intensive care medicine, Karolinska University Hospital, Stockholm, Sweden; Antonio Belli, NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK; Habib Benali, Anesthesie-Réanimation, Assistance Publique – Hopitaux de Paris, Paris, France; Maurizio Berardino 17 , Department of Anesthesia & ICU, AOU Città della Salute e della Scienza di Torino - Orthopedic and Trauma Center, Torino, Italy; Luigi Beretta, Department of Anesthesiology & Intensive Care, S Raffaele University Hospital, Milan, Italy; Morten Blaabjerg, Department of Neurology, Odense University Hospital, Odense, Denmark; Peter Bragge, BehaviourWorks Australia, Monash Sustainability Institute, Monash University, Victoria, Australia; Alexandra Brazinova, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; Vibeke Brinck, Quesgen Systems Inc., Burlingame, California, USA; Joanne Brooker, Australian & New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Camilla Brorsson, Department of Surgery and Perioperative Science, Umeå University, Umeå, Sweden; Andras Buki, Department of Neurosurgery, Medical School, University of Pécs, Hungary and Neurotrauma Research Group, János Szentágothai Research Centre, University of Pécs, Hungary; Monika Bullinger, Department of Medical Psychology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany; Manuel Cabeleira, Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Alessio Caccioppola, Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Emiliana Calappi, Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Maria Rosa Calvi, Department of Anesthesiology & Intensive Care, S Raffaele University Hospital, Milan, Italy; Peter Cameron, ANZIC Research Centre, Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia; Guillermo Carbayo Lozano, Department of Neurosurgery, Hospital of Cruces, Bilbao, Spain; Marco Carbonara, Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Simona Cavallo, Department of Anesthesia & ICU, AOU Città della Salute e della Scienza di Torino - Orthopedic and Trauma Center, Torino, Italy; Giorgio Chevallard, NeuroIntensive Care, Niguarda Hospital, Milan, Italy;
Arturo Chieregato, NeuroIntensive Care, Niguarda Hospital, Milan, Italy; Giuseppe Citerio, School of Medicine and Surgery, Università Milano Bicocca, Milano, Italy; NeuroIntensive Care, ASST di Monza, Monza, Italy; Iris Ceyisakar, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Hans Clusmann, Department of Neurosurgery, Medical Faculty RWTH Aachen University, Aachen, Germany; Mark Coburn, Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany; Jonathan Coles, Department of Anesthesia & Neurointensive Care, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK; Jamie D. Cooper, School of Public Health & PM, Monash University and The Alfred Hospital, Melbourne, Victoria, Australia; Marta Correia, Radiology/MRI department, MRC Cognition and Brain Sciences Unit, Cambridge, UK; Amra Čović , Institute of Medical Psychology and Medical Sociology, Universitätsmedizin Göttingen, Göttingen, Germany; Nicola Curry, Oxford University Hospitals NHS Trust, Oxford, UK; Endre Czeiter, Department of Neurosurgery, Medical School, University of Pécs, Hungary and Neurotrauma Research Group, János Szentágothai Research Centre, University of Pécs, Hungary; Marek Czosnyka, Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Claire Dahyot-Fizelier, Intensive Care Unit, CHU Poitiers, Potiers, France; Paul Dark, University of Manchester NIHR Biomedical Research Centre, Critical Care Directorate, Salford Royal Hospital NHS Foundation Trust, Salford, UK; Helen Dawes, Movement Science Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK; Véronique De Keyser, Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium; Vincent Degos, Anesthesie-Réanimation, Assistance Publique – Hopitaux de Paris, Paris, France; Francesco Della Corte, Department of Anesthesia & Intensive Care, Maggiore Della Carità Hospital, Novara, Italy; Hugo den Boogert, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands; Bart Depreitere, Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium; Đula Đilvesi, Department of Neurosurgery, Clinical centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; Abhishek Dixit, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Emma Donoghue, Australian & New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Jens Dreier, Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Guy-Loup Dulière, Intensive Care Unit, CHR Citadelle, Liège, Belgium; Ari Ercole, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Patrick Esser, Movement Science Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK; Erzsébet Ezer, Department of Anaesthesiology and Intensive Therapy, University of Pécs, Pécs, Hungary; Martin Fabricius, Departments of Neurology, Clinical Neurophysiology and Neuroanesthesiology, Region Hovedstaden Rigshospitalet, Copenhagen, Denmark; Valery L. Feigin, National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand; Kelly Foks, Department of Neurology, Erasmus MC, Rotterdam, the Netherlands; Shirin Frisvold, Department of Anesthesiology and Intensive care, University Hospital Northern Norway, Tromso, Norway; Alex Furmanov, Department of Neurosurgery, Hadassah-hebrew University Medical center, Jerusalem, Israel; Pablo Gagliardo, Fundación Instituto Valenciano de Neurorrehabilitación (FIVAN), Valencia, Spain; Galanaud, Anesthesie-Réanimation, Assistance Publique – Hopitaux de Paris, Paris, France ; Dashiell Gantner, ANZIC Research Centre, Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia; Guoyi Gao, Department of Neurosurgery, Shanghai Renji hospital, Shanghai Jiaotong University/school of medicine, Shanghai, China; Pradeep George, Karolinska Institutet, INCF International Neuroinformatics Coordinating Facility, Stockholm, Sweden; Alexandre Ghuysen, Emergency Department, CHU, Liège, Belgium; Lelde Giga, Neurosurgery clinic, Pauls Stradins Clinical University Hospital, Riga, Latvia; Ben Glocker, Department of Computing, Imperial College London, London, UK; Jagoš Golubovic, Department of Neurosurgery, Clinical centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; Pedro A. Gomez, Department of Neurosurgery, Hospital Universitario 12 de Octubre, Madrid, Spain; Johannes Gratz, Department of Anesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Austria; Benjamin Gravesteijn, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Francesca Grossi, Department of Anesthesia & Intensive Care, Maggiore Della Carità Hospital, Novara, Italy; Russell L. Gruen, College of Health and Medicine, Australian National University, Canberra, Australia; Deepak Gupta, Department of Neurosurgery, Neurosciences Centre & JPN Apex trauma centre, All India Institute of Medical Sciences, New Delhi-110029, India; Juanita A. Haagsma, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Iain Haitsma, Department of Neurosurgery, Erasmus MC, Rotterdam, the Netherlands; Raimund Helbok, Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria; Eirik Helseth, Department of Neurosurgery, Oslo University Hospital, Oslo, Norway; Lindsay Horton, Division of Psychology, University of Stirling, Stirling, UK; Jilske Huijben, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Peter J. Hutchinson, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK; Bram Jacobs, Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands; Stefan Jankowski, Neurointensive Care , Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Mike Jarrett 21 , Quesgen Systems Inc., Burlingame, California, USA; Ji-yao Jiang58, Department of Neurosurgery, Shanghai Renji hospital, Shanghai Jiaotong University/school of medicine, Shanghai, China; Faye Johnson73, Salford Royal Hospital NHS Foundation Trust Acute Research Delivery Team, Salford, UK; Kelly Jones, National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand; Mladen Karan, Department of Neurosurgery, Clinical centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; Angelos G. Kolias, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK; Erwin Kompanje, Department of Intensive Care and Department of Ethics and Philosophy of Medicine, Erasmus Medical Center, Rotterdam, The Netherlands; Daniel Kondziella, Departments of Neurology, Clinical Neurophysiology and Neuroanesthesiology, Region Hovedstaden Rigshospitalet, Copenhagen, Denmark; Evgenios Koraropoulos, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Lars-Owe Koskinen, Department of Clinical Neuroscience, Neurosurgery, Umeå University, Umeå, Sweden; Noémi Kovács, Hungarian Brain Research Program - Grant No. KTIA_13_NAP-A-II/8, University of Pécs, Pécs, Hungary; Ana Kowark, Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany; Alfonso Lagares, Department of Neurosurgery, Hospital Universitario 12 de Octubre, Madrid, Spain; Linda Lanyon, Karolinska Institutet, INCF International Neuroinformatics Coordinating Facility, Stockholm, Sweden; Steven Laureys, Cyclotron Research Center , University of Liège, Liège, Belgium; Fiona Lecky, Centre for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Emergency Department, Salford Royal Hospital, Salford, UK; Didier Ledoux, Cyclotron Research Center , University of Liège, Liège, Belgium; Rolf Lefering, Institute of Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany; Valerie Legrand, VP Global Project Management CNS, ICON, Paris, France; Aurelie Lejeune, Department of Anesthesiology-Intensive Care, Lille University Hospital, Lille, France; Leon Levi, Department of Neurosurgery, Rambam Medical Center, Haifa, Israel; Roger Lightfoot, Department of Anesthesiology & Intensive Care, University Hospitals Southhampton NHS Trust, Southhampton, UK; Hester Lingsma, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Andrew I.R. Maas, Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium; Ana M. Castaño-León, Department of Neurosurgery, Hospital Universitario 12 de Octubre, Madrid, Spain; Marc Maegele, Cologne-Merheim Medical Center (CMMC), Department of Traumatology, Orthopedic Surgery and Sportmedicine, Witten/Herdecke University, Cologne, Germany; Marek Majdan, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; Alex Manara, Intensive Care Unit, Southmead Hospital, Bristol, Bristol, UK; Geoffrey Manley, Department of Neurological Surgery, University of California, San Francisco, California, USA; Costanza Martino, Department of Anesthesia & Intensive Care,M. Bufalini Hospital, Cesena, Italy; Hugues Maréchal, Intensive Care Unit, CHR Citadelle, Liège, Belgium; Julia Mattern, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany; Catherine McMahon, Department of Neurosurgery, The Walton centre NHS Foundation Trust, Liverpool, UK; Béla Melegh, Department of Medical Genetics, University of Pécs, Pécs, Hungary; David Menon, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Tomas Menovsky, Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium; Ana Mikolic, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Benoit Misset, Cyclotron Research Center , University of Liège, Liège, Belgium; Visakh Muraleedharan, Karolinska Institutet, INCF International Neuroinformatics Coordinating Facility, Stockholm, Sweden; Lynnette Murray, ANZIC Research Centre, Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia; Ancuta Negru, Department of Neurosurgery, Emergency County Hospital Timisoara , Timisoara, Romania; David Nelson, Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden; Virginia Newcombe, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Daan Nieboer, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; József Nyirádi, János Szentágothai Research Centre, University of Pécs, Pécs, Hungary; Otesile Olubukola, Centre for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Matej Oresic, School of Medical Sciences, Örebro University, Örebro, Sweden; Fabrizio Ortolano, Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Aarno Palotie, Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland; Analytic and Translational Genetics Unit, Department of Medicine; Psychiatric & Neurodevelopmental Genetics Unit, Department of Psychiatry; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Program in Medical and Population Genetics; The Stanley Center for Psychiatric Research, The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Paul M. Parizel, Department of Radiology, University of Antwerp, Edegem, Belgium; Jean-François Payen, Department of Anesthesiology & Intensive Care, University Hospital of Grenoble, Grenoble, France; Natascha Perera, International Projects Management, ARTTIC, Munchen, Germany; Vincent Perlbarg, Anesthesie-Réanimation, Assistance Publique – Hopitaux de Paris, Paris, France; Paolo Persona, Department of Anesthesia & Intensive Care, Azienda Ospedaliera Università di Padova, Padova, Italy; Wilco Peul, Dept. of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands and Dept. of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands; Anna Piippo-Karjalainen, Department of Neurosurgery, Helsinki University Central Hospital; Matti Pirinen, Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland; Horia Ples, Department of Neurosurgery, Emergency County Hospital Timisoara , Timisoara, Romania; Suzanne Polinder, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Inigo Pomposo, Department of Neurosurgery, Hospital of Cruces, Bilbao, Spain; Jussi P. Posti , Division of Clinical Neurosciences, Department of Neurosurgery and Turku Brain Injury Centre, Turku University Hospital and University of Turku, Turku, Finland; Louis Puybasset, Department of Anesthesiology and Critical Care, Pitié -Salpêtrière Teaching Hospital, Assistance Publique, Hôpitaux de Paris and University Pierre et Marie Curie, Paris, France; Andreea Radoi, Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Barcelona, Spain; Arminas Ragauskas, Department of Neurosurgery, Kaunas University of technology and Vilnius University, Vilnius, Lithuania; Rahul Raj, Department of Neurosurgery, Helsinki University Central Hospital; Malinka Rambadagalla, Department of Neurosurgery, Rezekne Hospital, Latvia; Jonathan Rhodes, Department of Anaesthesia, Critical Care & Pain Medicine NHS Lothian & University of Edinburg, Edinburgh, UK; Sylvia Richardson, Director, MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK; Sophie Richter, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Samuli Ripatti, Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland; Saulius Rocka, Department of Neurosurgery, Kaunas University of technology and Vilnius University, Vilnius, Lithuania; Cecilie Roe, Department of Physical Medicine and Rehabilitation, Oslo University Hospital/University of Oslo, Oslo, Norway; Olav Roise, Division of Orthopedics, Oslo University Hospital, Oslo, Norway; Institue of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Jonathan Rosand, Broad Institute, Cambridge MA Harvard Medical School, Boston MA, Massachusetts General Hospital, Boston MA, USA; Jeffrey V. Rosenfeld, National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia; Christina Rosenlund, Department of Neurosurgery, Odense University Hospital, Odense, Denmark; Guy Rosenthal, Department of Neurosurgery, Hadassah-hebrew University Medical center, Jerusalem, Israel; Rolf Rossaint, Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany; Sandra Rossi, Department of Anesthesia & Intensive Care, Azienda Ospedaliera Università di Padova, Padova, Italy; Daniel Rueckert, Department of Computing, Imperial College London, London, UK; Martin Rusnák, International Neurotrauma Research Organisation, Vienna, Austria; Juan Sahuquillo, Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Barcelona, Spain; Oliver Sakowitz, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany; Klinik für Neurochirurgie, Klinikum Ludwigsburg, Ludwigsburg, Germany; Renan Sanchez-Porras, Klinik für Neurochirurgie, Klinikum Ludwigsburg, Ludwigsburg, Germany; Janos Sandor, Division of Biostatistics and Epidemiology, Department of Preventive Medicine, University of Debrecen, Debrecen, Hungary; Nadine Schäfer, Institute of Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany; Silke Schmidt, Department Health and Prevention, University Greifswald, Greifswald, Germany; Herbert Schoechl, Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Salzburg, Austria; Guus Schoonman, Department of Neurology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands; Rico Frederik Schou, Department of Neuroanesthesia and Neurointensive Care, Odense University Hospital, Odense, Denmark; Elisabeth Schwendenwein, Trauma Surgery, Medical University Vienna, Vienna, Austria; Charlie Sewalt, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Toril Skandsen, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Trondheim, Norway; Department of Physical Medicine and Rehabilitation, St.Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Peter Smielewski, Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Abayomi Sorinola, Department of Neurosurgery, University of Pécs, Pécs, Hungary; Emmanuel Stamatakis, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Simon Stanworth, Oxford University Hospitals NHS Trust, Oxford, UK; Robert Stevens, Division of Neuroscience Critical Care, John Hopkins University School of Medicine, Baltimore, USA; William Stewart, Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK; Ewout W. Steyerberg, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Dept. of Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands; Nino Stocchetti, Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy; Nina Sundström, Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden; Anneliese Synnot, Australian & New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia; Riikka Takala, Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland; Viktória Tamás, Department of Neurosurgery, University of Pécs, Pécs, Hungary; Tomas Tamosuitis, Department of Neurosurgery, Kaunas University of Health Sciences, Kaunas, Lithuania; Mark Steven Taylor, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; Braden Te Ao, National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand; Olli Tenovuo, Division of Clinical Neurosciences, Department of Neurosurgery and Turku Brain Injury Centre, Turku University Hospital and University of Turku, Turku, Finland; Alice Theadom, National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand; Matt Thomas, Intensive Care Unit, Southmead Hospital, Bristol, Bristol, UK; Dick Tibboel, Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands; Marjolein Timmers, Department of Intensive Care and Department of Ethics and Philosophy of Medicine, Erasmus Medical Center, Rotterdam, The Netherlands; Christos Tolias, Department of Neurosurgery, Kings college London, London, UK; Tony Trapani, ANZIC Research Centre, Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia; Cristina Maria Tudora, Department of Neurosurgery, Emergency County Hospital Timisoara , Timisoara, Romania; Peter Vajkoczy, Neurologie, Neurochirurgie und Psychiatrie, Charité – Universitätsmedizin Berlin, Berlin, Germany; Shirley Vallance, ANZIC Research Centre, Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia; Egils Valeinis, Neurosurgery clinic, Pauls Stradins Clinical University Hospital, Riga, Latvia; Zoltán Vámos, Department of Anaesthesiology and Intensive Therapy, University of Pécs, Pécs, Hungary; Mathieu van der Jagt, Department of Intensive Care Adults, Erasmus MC– University Medical Center Rotterdam, Rotterdam, the Netherlands; Gregory Van der Steen, Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium; Joukje van der Naalt, Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands; Jeroen T.J.M. van Dijck, Dept. of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands and Dept. of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands; Thomas A. van Essen, Dept. of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands and Dept. of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands; Wim Van Hecke, icoMetrix NV, Leuven, Belgium; Caroline van Heugten, Movement Science Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK; Dominique Van Praag, Psychology Department, Antwerp University Hospital, Edegem, Belgium; Thijs Vande Vyvere, icoMetrix NV, Leuven, Belgium; Roel P. J. van Wijk, Dept. of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands and Dept. of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands; Alessia Vargiolu, NeuroIntensive Care, ASST di Monza, Monza, Italy; Emmanuel Vega, Department of Anesthesiology-Intensive Care, Lille University Hospital, Lille, France; Kimberley Velt, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Jan Verheyden, icoMetrix NV, Leuven, Belgium; Paul M. Vespa, Director of Neurocritical Care, University of California, Los Angeles, USA; Anne Vik, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Trondheim, Norway; Department of Neurosurgery, St.Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Rimantas Vilcinis, Department of Neurosurgery, Kaunas University of Health Sciences, Kaunas, Lithuania; Victor Volovici, Department of Neurosurgery, Erasmus MC, Rotterdam, the Netherlands; Nicole von Steinbüchel, Institute of Medical Psychology and Medical Sociology, Universitätsmedizin Göttingen, Göttingen, Germany; Daphne Voormolen, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Petar Vulekovic, Department of Neurosurgery, Clinical centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; Kevin K.W. Wang, Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA; Eveline Wiegers, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, The Netherlands; Guy Williams, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Lindsay Wilson, Division of Psychology, University of Stirling, Stirling, UK; Stefan Winzeck, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Stefan Wolf, Department of Neurosurgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Zhihui Yang, Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA; Peter Ylén, VTT Technical Research Centre, Tampere, Finland; Alexander Younsi, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany; Frederick A. Zeiler, Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Veronika Zelinkova, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia; Agate Ziverte, Neurosurgery clinic, Pauls Stradins Clinical University Hospital, Riga, Latvia; Tommaso Zoerle, Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Yue Ma, Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China; Wei Kang, Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China; Shuanglin Fu, Department of Neurosurgery, First Hospital of Jilin University, Changchun, Jilin, China; Yongxin Luan, Department of Neurosurgery, First Hospital of Jilin University, Changchun, Jilin, China; Huaping Qin, Department of Neurosurgery, First People's Hospital of Changzhou, Changzhou, Jiangsu, China; Zhaosheng Sun, Department of Neurosurgery, Harrison International Peace Hospital, Hengshui, China; Hong Guo, Department of Neurosurgery, Harrison International Peace Hospital, Hengshui, China; Hengli Tian, Department of Neurosurgery, Sixth People's Hospital of Shanghai, Shanghai, China; Shiming Ju, Department of Neurosurgery, Sixth People's Hospital of Shanghai, Shanghai, China; Yimin Xu, Department of Neurosurgery, The First Affiliated Hospital of Shantou University medical college, Shantou, China; Quantang Wei, Department of Neurosurgery, The First Affiliated Hospital of Shantou University medical college, Shantou, China; Sai Zhang, Department of Neurosurgery, Medical Centre of Chinese People's Armed Police, Tianjin, China; Yue Tu, Department of Neurosurgery, Medical Centre of Chinese People's Armed Police, Tianjin, China; Dong Wang, Department of Neurosurgery, Jiangning Hospital, Nanjing, China; Liang Zhang, Department of Neurosurgery, Jiangning Hospital, Nanjing, China; Liansheng Long, Department of Neurosurgery, The 98th Hospital of Chinese People's Liberation Army, Huzhou, China; Chaochao Jiang, Department of Neurosurgery, The 98th Hospital of Chinese People's Liberation Army, Huzhou, China; Xiaofeng Yang, Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Liang Wen, Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Ke Liu, Department of Neurosurgery, Chongqing Emergency Medical Centre, Chongqing, China; Lei Xu, Department of Neurosurgery, Chongqing Emergency Medical Centre, Chongqing, China; Jinfang Liu, Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China; Zhongyi Sun, Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China; Ligang Chen, Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China; Yong Jiang, Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China; Wei Xu, Department of Neurosurgery, Second Affiliated Hospital of Kunming Medical University, Kunming, China; Yongjun Gao, Department of Neurosurgery, Second Affiliated Hospital of Kunming Medical University, Kunming, China; Rongcai Jiang, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Yu Guo, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Liang Gao, Department of Neurosurgery, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, China; Tao Zeng, Department of Neurosurgery, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, China; Lijun Hou, Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China; Liang Zhao, Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China; Xingen Zhu, Department of Neurosurgery, Second Affiliated Hospital of Nanchang University, Nanchang, China; Shigang Lv, Department of Neurosurgery, Second Affiliated Hospital of Nanchang University, Nanchang, China; Zhaohui Mou, Department of Neurosurgery, The First People's Hospital of Taizhou, Taizhou, China; Jian Wu, Department of Neurosurgery, The First People's Hospital of Taizhou, Taizhou, China; Yinghui Xu, Department of Neurosurgery, Dalian Medical University Affiliated NO.1 Hospital, Dalian, China; Bin Dong, Department of Neurosurgery, Dalian Medical University Affiliated NO.1 Hospital, Dalian, China; Chaohua Yang, Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China; Zhonghua An, Department of Neurosurgery, Zhengzhou Second Hospital, Zhengzhou, China; Xiaoming Wang, Department of Neurosurgery, Zhengzhou Second Hospital, Zhengzhou, China; Xiaojiang Zhu, Department of Neurosurgery, Shanghai General Hospital, Shanghai, China; Lianping Gu, Department of Neurosurgery, Shanghai General Hospital, Shanghai, China; Chiyuan Ma, Department of Neurosurgery, General Hospital of Eastern Theatre Command, Nanjing, China; Haichen Sun, Department of Neurosurgery, General Hospital of Eastern Theatre Command, Nanjing, China; Weiping Li, Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China; Xianjian Huang, Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China; Lihong Li, Department of Neurosurgery, Tangdu Hospital, Xi'an, China; Binghui Qiu, Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Yun Bao, Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Suokai Qian, Department of Neurosurgery, The 94th Hospital of Chinese People's Liberation Army, Nanchang, China; Xiao Bu, Department of Neurosurgery, The 94th Hospital of Chinese People's Liberation Army, Nanchang, China; Yuhai Wang, Department of Neurosurgery, the 904 Hospital of PLA Joint Logistic Support Force, Wuxi, China;
Likun Yang, Department of Neurosurgery, the 904 Hospital of PLA Joint Logistic Support Force, Wuxi, China; Xi'an Fu, Department of Neurosurgery, Suzhou Municipal Hospital, Suzhou, China; Surong Qian, Department of Neurosurgery, Suzhou Municipal Hospital, Suzhou, China; Junpu Zhang, Department of Neurosurgery, The People's Hospital of Dezhou, Dezhou, China; Shengqiang Fan, Department of Neurosurgery, The People's Hospital of Dezhou, Dezhou, China; Yunjie Wang, Department of Neurosurgery, First Affiliated Hospital of China Medical University, Shenyang, China; Yijun Bao, Department of Neurosurgery, First Affiliated Hospital of China Medical University, Shenyang, China; Yangang Wang, Department of Neurosurgery, The People's Hospital of Jiaozuo, Jiaozuo, China; Hongguang Chen, Department of Neurosurgery, Yuhuangding Hospital, Yantai, China; Guangqiang Cui, Department of Neurosurgery, Yuhuangding Hospital, Yantai, China; Changqing Sun, Department of Neurosurgery, The People's Hospital of Baodi District, Tianjin, China; Zhigang Guo, Department of Neurosurgery, The People's Hospital of Baodi District, Tianjin, China; Yansheng Li, Department of Neurosurgery, First People's Hospital of Horqin District, Tongliao, China; Xinjun Wang, Department of Neurosurgery, Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Shaolong Zhou, Department of Neurosurgery, Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Xiwang Wang, Department of Neurosurgery, Handan Central Hospital, Handan, China; Xide Zhu, Department of Neurosurgery, Linyi People's Hospital, Linyi, China; Guodong Zheng, Department of Neurosurgery, Linyi People's Hospital, Linyi, China; Qibing Huang, Neurosurgery Intensive Care Unit & Emergency Neurosurgery, Qilu Hospital, Shandong University, Jinan, China; Yuan Zhang, Neurosurgery Intensive Care Unit & Emergency Neurosurgery, Qilu Hospital, Shandong University, Jinan, China; Hua Feng, Department of Neurosurgery, Southwest Hospital, Chongqing, China; Yi Huang, Department of Neurosurgery, Southwest Hospital, Chongqing, China; Haijun Ren, Department of Neurosurgery, Second Hospital of Lanzhou University, Lanzhou, China; Boru Hou, Department of Neurosurgery, Second Hospital of Lanzhou University, Lanzhou, China; Chizhong Zhou, Department of Neurosurgery, Puren Hospital, Wuhan, China; Jun Chen, Department of Neurosurgery, Puren Hospital, Wuhan, China; Jin Hu, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China; Zhuoying Du, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China; Sheng Wang, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Peng Xiang, Department of Neurosurgery, Changsha Central Hospital, Changsha, China; Yunfeng Huang, Department of Neurosurgery, Changsha Central Hospital, Changsha, China; Yang Qu, Department of Neurosurgery, First Hospital of Harbin, Harbin, China; Hongjiao Yu, Department of Neurosurgery, First Hospital of Harbin, Harbin, China; Rong Wang, Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China; Jian Chen, Department of Neurosurgery, The Affiliated Hospital of Nantong University, Nantong, China; Jianguo Chen, Department of Neurosurgery, The Affiliated Hospital of Nantong University, Nantong, China; Long Xu, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Peng Kang, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Hanmin Chen, Department of Neurosurgery, The 180th Hospital of Chinese People's Liberation Army, Quanzhou, China; Guoxin Wu, Department of Neurosurgery, The 180th Hospital of Chinese People's Liberation Army, Quanzhou, China; Maode Wang, Department of Neurosurgery, The Affiliated Hospital of Xi'an Medical University, Xi'an, China; Ruichun Li, Department of Neurosurgery, The Affiliated Hospital of Xi'an Medical University, Xi'an, China; Hengzhu Zhang, Department of Neurosurgery, Clinical Medical College of Yangzhou University, The Northern Jiangsu People's Hospital, Yangzhou, China; Yuping Li, Department of Neurosurgery, Clinical Medical College of Yangzhou University, The Northern Jiangsu People's Hospital, Yangzhou, China; Xiaoou Sun, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China; Xingping Tan, Department of Neurosurgery, The People's Hospital of Pingxiang, Pingxiang, China.
Authors Contributions
GG and AIRM developed the idea for current paper. JF, EvV, and CY analyzed the data and wrote the first draft of the manuscript. All authors gave feedback on the manuscript. All authors were involved in the development of the questionnaire, critically commented on the manuscript, and approved the final version.
Funding Information
This research was supported by grants from the National Natural Science Foundation of China (grant numbers 81971699 and 81671198), and CENTER-TBI was supported by the European Union 7th Framework program (EC grant 602150). Additional funding was obtained from the Hannelore Kohl Stiftung (Germany), from OneMind (USA) and from Integra LifeSciences Corporation (USA). The funders had no role in the collection, analysis and interpretation of data, nor in the writing of the report or in publication decisions. The authors had full access to study data and the senior authors had final responsibility for the decision to publish.
Author Disclosure Statement
The funders had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Supplementary Material
Supplementary Appendix S1
References
Supplementary Material
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