Outcome prediction in severe head injury: analyses of clinical prognostic factors

Single Versus Repetitive Traumatic Brain Injury: Current Knowledge on the Chronic Outcomes, Neuropathology and the Role of TDP-43 Proteinopathy

Traumatic brain injury (TBI) is one of the most important causes of death and disability in adults and thus an important public health problem. Following TBI, secondary pathophysiological processes develop over time and condition the development of different neurodegenerative entities. Previous studies suggest that neurobehavioral changes occurring after a single TBI are the basis for the development of Alzheimer's disease, while repetitive TBI is considered to be a contributing factor for chronic traumatic encephalopathy development. However, pathophysiological processes that determine the evolvement of a particular chronic entity are still unclear. Human post-mortem studies have found combinations of amyloid, tau, Lewi bodies, and TAR DNA-binding protein 43 (TDP-43) pathologies after both single and repetitive TBI. This review focuses on the pathological changes of TDP-43 after single and repetitive brain traumas. Numerous studies have shown that TDP-43 proteinopathy noticeably occurs after repetitive head trauma. A relatively small number of available preclinical research on single brain injury are not in complete agreement with the results from the human samples, which makes it difficult to draw specific conclusions. Also, as TBI is considered a heterogeneous type of injury, different experimental trauma models and injury intensities may cause differences in the cascade of secondary injury, which should be considered in future studies. Experimental and post-mortem studies of TDP-43 pathobiology should be carried out, preferably in the same laboratories, to determine its involvement in the development of neurodegenerative conditions after one and repetitive TBI, especially in the context of the development of new therapeutic options.

Prognostic Value of Swirl Sign in Acute Epidural Hemorrhage

Objective  The purpose of this study is to analyze and evaluate the incidence, prognostic value, and impact of swirl sign on the outcome of patients who underwent surgical treatment for epidural hematoma. Materials and Methods  A retrospective analytical study on 307 acute epidural hematoma (AEDH) patients with and without swirl sign was conducted at our hospital between 2015 and 2019. All the patients in this study were treated initially as per the protocols of advanced trauma life support and surgically treated by craniotomy and evacuation of epidural hematoma. Patients with other concomitant intracerebral injuries such as subdural hematoma and contusion and those who were managed conservatively were excluded from the study. Various factors such as age, sex, mechanism of injury, Glasgow Coma Scale (GCS) score at admission, time from injury to surgery, preoperative mydriasis, location of bleed, midline shift, location of fracture, volume of hematoma, duration of stay in the hospital, and GCS score at discharge were taken into consideration and compared in between patients with and without swirl sign. Outcomes were assessed at the end of 6 months using the Glasgow Outcome Scale. Results  Of the 307 patients who were operated for epidural hemorrhage, 92 had swirl sign (29.96%) and the rest had no swirl sign. Univariate analysis revealed a significant correlation between the presence of swirl sign and age, preoperative mydriasis, and time from injury to surgery. The patients with the swirl sign had an unfavorable outcome at the end of 6 months which was statistically significant. Conclusion  It can be concluded that those patients with swirl sign in AEDH had an unfavorable outcome compared to those without swirl sign. Therefore, aggressive treatment and early surgery play an important role in the outcomes of the patients.

Outcomes and Predictors of Outcome with Cisternostomy in the Management of Traumatic Brain Injury—A Prospective Observational Study at Tertiary Centre

Background Traumatic brain injury (TBI) is a major cause of morbidity and mortality in young individuals. Goal of management in TBI patients is mainly focused on the secondary injury. Since the cisterns and the brain communicate, it would be possible to decrease the pressure in both these compartments by opening the cisterns to the atmospheric pressure.

Objective To study the outcomes and predictors of outcome with cisternostomy in the management of TBI.

Methods A single tertiary care center's prospective observational study of outcomes with cisternostomy with intraoperative intracranial pressure (ICP) monitoring. Patients were evaluated clinically and radiologically with Marshall CT score. They were categorized into mild, moderate, and severe head injury groups based on Glasgow coma scale (GCS) score. Outcomes were evaluated with Glasgow outcome scale (GOS) score.

Results A total of 25 patients with TBI were enrolled in this study. They underwent cisternostomy with intraoperative ICP monitoring. They were categorized into 4 groups based on the age. In our study, mortality rate was 32%. As much as 48% had good recovery at 3 months follow-up with GOS 4 and 5. Mean ICP after cisternostomy was 6.36 ± 1.91 mm Hg. In our study, there was decrease in ICP after cisternostomy.

Conclusion Age, time interval from trauma to surgery, and ICP showed prognostic importance on outcomes. Cisternostomy can efficiently decrease the ICP in the TBI patients and reduce postoperative complications.

Analysis of the risk factors for intraoperative acute diffuse brain swelling in patients with isolated traumatic acute subdural haematomas

Background

The purpose of this retrospective study was to investigate the risk factors for intraoperative acute diffuse brain swelling in patients with isolated traumatic acute subdural haematomas (ASDH).

Methods

A total of 256 patients who underwent decompressive craniectomy for isolated traumatic ASDH between April 2013 and December 2020 were included. We evaluated the risk factors for intraoperative acute diffuse brain swelling using a multivariate logistic regression analysis.

Results

The incidence of intraoperative acute diffuse brain swelling in patients with isolated traumatic ASDH was 21.88% (56/256). Dilated pupils (OR = 24.78), subarachnoid haemorrhage (OR = 2.41), and the time from injury to surgery (OR = 0.32) were independent risk factors for intraoperative acute diffuse brain swelling, while no independent associations were observed between these risk factors and sex, age, the mechanism of injury, the Glasgow Coma Scale score, site of haematoma, thickness of haematoma, midline shift and the status of the basal cistern, although the mechanism of injury, the Glasgow Coma Scale score and the status of the basal cistern were correlated with the incidence of intraoperative acute diffuse brain swelling in the univariate analyses.

Conclusions

This study identified the risk factors for intraoperative acute diffuse brain swelling in patients with isolated traumatic ASDH. An increased risk of intraoperative acute diffuse brain swelling occurs in patients with bilaterally dilated pupils, subarachnoid haemorrhage and a shorter time from injury to surgery. These findings should help neurosurgeons obtain information before surgery about intraoperative acute diffuse brain swelling in patients with isolated traumatic ASDH.

Early death prediction in children with traumatic brain injury using computed tomography scoring systems

PURPOSE

Marshall and Rotterdam are the most commonly used CT scoring systems to predict the outcome following traumatic brain injury (TBI). Although several studies have compared the performance of the two scoring systems in adult patients, none of these studies has evaluated the performance of the two scoring systems in pediatric patients. This study aimed to determine the predictive value of the Marshall and Rotterdam scoring systems in pediatric patients with TBI.

METHODS

This retrospective study included 105 children with admission GCS < 12, with a mean age of 6.2 (±3.5) years. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both the Marshall and Rotterdam scores were calculated. We examined whether each score was related to the early death of pediatric patients.

RESULTS

The pediatric patients with higher Marshall and Rotterdam scores had a higher mortality rate. There was a good correlation between the Marshall and Rotterdam scoring systems (Spearman's rho = 0.618, significant at the 0.05 level). Both systems demonstrated a high degree of discrimination when predicting early mortality. The Marshall scoring system had reasonable discrimination (AUC 0.782), and the Rotterdam scoring system had good discrimination (AUC 0.729). Comparing the two CT scoring systems, the Marshall scoring system provided a better positive predictive value (90%) for early mortality than the Rotterdam scoring system (78%).

CONCLUSIONS

Both the Marshall and Rotterdam scoring systems have good predictability for assessing mortality in pediatric patients with TBI. The performance of the Marshall scoring system was equal to or slightly better than that of the Rotterdam scoring system.

Outcome Prediction in Patients of Traumatic Brain Injury Based on Midline Shift on CT Scan of Brain

Background Clinicians treating patients with head injury often take decisions based on their assessment of prognosis. Assessment of prognosis could help communication with a patient and the family. One of the most widely used clinical tools for such prediction is the Glasgow coma scale (GCS); however, the tool has a limitation with regard to its use in patients who are under sedation, are intubated, or under the influence of alcohol or psychoactive drugs. CT scan findings such as status of basal cistern, midline shift, associated traumatic subarachnoid hemorrhage (SAH), and intraventricular hemorrhage are useful indicators in predicting outcome and also considered as valid options for prognostication of the patients with traumatic brain injury (TBI), especially in emergency setting.

Materials and Methods 108 patients of head injury were assessed at admission with clinical examination, history, and CT scan of brain. CT findings were classified according to type of lesion and midline shift correlated to GCS score at admission. All the subjects in this study were managed with an identical treatment protocol. Outcome of these patients were assessed on GCS score at discharge.

Results Among patients with severe GCS, 51% had midline shift. The degree of midline shift in CT head was a statistically significant determinant of outcome (p = 0.023). Seventeen out of 48 patients (35.4%) with midline shift had poor outcome as compared with 8 out of 60 patients (13.3%) with no midline shift.

Conclusion In patients with TBI, the degree of midline shift on CT scan was significantly related to the severity of head injury and resulted in poor clinical outcome.

Isolated traumatic acute subdural haematoma: outcome in relation to age, Glasgow Coma Scale, and haematoma thickness

Background

Traumatic acute subdural haematoma occurs in about 10–20% of patients with severe head injuries. This study aims to investigate the relation between outcome and the age, Glasgow Coma Scale on admission as well as haematoma thickness upon admission CAT scan.

This is a prospective observational clinical trial study of 39 patients with isolated traumatic acute subdural haematomas treated with conservative or surgical procedures during a one-year study period.

Results

There was a statistically significant relation between Glasgow Outcome Score and both age of the patients and Glasgow Coma Scale upon admission. However, there was a non-statistically significant relationship between Glasgow Outcome Score and haematoma thickness upon admission CAT scan.

Conclusions

Age of the patients with traumatic acute subdural haematoma as well as Glasgow Coma Scale upon admission are essential predictors of the outcome.

Clinical trial registration details: Name of the registry: Traumatic Acute Subdural Haematoma: Management and Outcome. Trial registration number: NCT03971240. Date of registration: June 3, 2019. URL of trial registry record: https://clinicaltrials.gov/ct2/show/record/NCT03971240?term=Mohamed+Ahmed+Alghriany&draw=2&rank=1.

Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review

This systematic review provides a comprehensive, up-to-date summary of traumatic brain injury (TBI) epidemiology in Europe, describing incidence, mortality, age, and sex distribution, plus severity, mechanism of injury, and time trends. PubMed, CINAHL, EMBASE, and Web of Science were searched in January 2015 for observational, descriptive, English language studies reporting incidence, mortality, or case fatality of TBI in Europe. There were no limitations according to date, age, or TBI severity. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. Data were presented narratively. Sixty-six studies were included in the review. Country-level data were provided in 22 studies, regional population or treatment center catchment area data were reported by 44 studies. Crude incidence rates varied widely. For all ages and TBI severities, crude incidence rates ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Crude mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies), and 3.3 to 24.4 per 100,000 population per year (regional-level studies.) The most common mechanisms of injury were traffic accidents and falls. Over time, the contribution of traffic accidents to total TBI events may be reducing. Case ascertainment and definitions of TBI are variable. Improved standardization would enable more accurate comparisons.

Quantitative analysis of brain herniation from non-contrast CT images using deep learning

BACKGROUND

Brain herniation is one of the fatal outcomes of increased intracranial pressure (ICP). It is caused due to the presence of hematoma or tumor mass in the brain. Ideal midline (iML) divides the healthy brain into two (right and left) nearly equal hemispheres. In the presence of hematoma, the midline tends to shift from its original position to the contralateral side of the mass and thus develops a deformed midline (dML).

NEW METHOD

In this study, a convolutional neural network (CNN) was used to predict the deformed left and right hemispheres. The proposed algorithm was validated with non-contrast computed tomography (NCCT) of (n = 45) subjects with two types of brain hemorrhages - epidural hemorrhage (EDH): (n = 5) and intra-parenchymal hemorrhage (IPH): (n = 40)).

RESULTS

The method demonstrated excellent potential in automatically predicting MLS with the average errors of 1.29 mm by location, 66.4 mm² by 2D area, and 253.73 mm³ by 3D volume. Estimated MLS could be well correlated with other clinical markers including hematoma volume - R² = 0.86 (EDH); 0.48 (IPH) and a Radiologist-defined severity score (RSS) - R² = 0.62 (EDH); 0.57 (IPH). RSS was found to be even better correlated (R² = 0.98 (EDH); 0.70 (IPH)), hence better predictable by a joint correlation between hematoma volume, midline pixel- or voxel-shift, and minimum distance of (ideal or deformed) midline from the hematoma (boundary or centroid).

CONCLUSION

All these predictors were computed automatically, which highlighted the excellent clinical potential of the proposed automated method in midline shift (MLS) estimation and severity prediction in hematoma decision support systems.

Thirty-day clinical outcome of traumatic brain injury patients with acute extradural and subdural hematoma: a cohort study at Mulago National Referral Hospital, Uganda

Background

Increasing traumatic brain injury (TBI) has paralleled the need for decompression surgery for acute subdural (ASDH) and acute extradural haematoma (AEDH). Knowledge of key determinants of clinical outcomes of such patients is mandatory to guide treatment protocols.

Objective

To determine the 30-day clinical outcomes and predictor variables for patients with extra-axial hematomas at Mulago National Referral Hospital in Uganda.

Methods

Prospective observational cohort study of 109 patients with computed tomography (CT) confirmed extra-axial hematomas. Ethical clearance was obtained from the School of Medicine Research and Ethics Committee of College of Health Sciences, Makerere University (REC REF. 2018-185). Admitted patients were followed-up and reassessed for Glasgow Outcome Scale (GOS) and final disposition. Multivariate regression analysis was performed using Stata 14.0 (StataCorp. 2015) at 95% confidence interval, regarding p < 0.05 as statistically significant.

Results

The overall proportion of favorable outcome was 71.7% (n = 71), with 42.3% (n = 11) and 81.7% (n = 58) for ASDH and AEDH, respectively (p = 0.111). Factors associated with a favorable outcome were admission systolic BP > 90 mmHg [IRR = 0.88 (0.26–0.94) 95%CI, p = 0.032), oxygen saturation > 90% [IRR = 0.5 (0.26–0.94) 95%CI, p = 0.030] and diagnosis AEDH [IRR = 0.53 (0.30–0.92) 95%CI, p = 0.025). Moderate TBI [IRR = 4.57 (1.15–18.06) 95%CI, p = 0.03] and severe TBI [IRR = 6.79 (2.32–19.86) 95%CI, p < 0.001] were significantly associated with unfavorable outcomes.

Conclusion

The study revealed that post resuscitation GCS, systolic BP, oxygen circulation, and diagnosis of AEDH at admission are the most important determinants of outcome for patients with extra-axial intracranial hematomas. These findings are valuable for the triaging teams in resource-constrained settings.

Comparison between traumatic brain injury with and without concomitant injuries: an analysis based on a national trauma registry 2008-2016

Objective: To compare demographic, injury and hospitalization characteristics and mortality between Isolated and Non-Isolated traumatic brain injury.Methods: A retrospective study based on the Israeli National Trauma Registry of patients hospitalized for traumatic brain injury (TBI) between 2008 and 2016. Isolated TBI was defined as no other anatomic region was having concomitant injury with AIS ≥2. X² test and multivariate logistic regression analysis were used for data analysis.Results: Of the 23566-study population, 40.4% were admitted for isolated TBI. Isolated TBI was significantly more frequent in elderly aged ≥65 years, female, Jews, and injuries sustained at home or in residential institution. The Non-isolated TBI was greater in road traffic injuries, particularly among pedestrians and motor cyclists, and in violence injuries. The Non-isolated TBI group had greater injury severity and hospital resource utilization. In-hospital mortality was higher in the patients with Non-isolated TBI [OR: 1.56(95% CI: 1.33-1.83)], particularly in patients with GCS 13-15; elderly aged 65+ years; and patients with concomitant injuries to abdomen, spine or external body regions.Conclusion: In a patient with TBI, concomitant injuries with AIS ≥2 matter, and awareness of the identified factors has relevance for guiding injury prevention efforts and indeed for potentially improving care and outcome.

Identification of clinical characteristics and factors predicting favorable treatment outcomes in elderly patients with traumatic brain injury

Age is an important prognostic factor for patients with traumatic brain injury (TBI), and worse treatment outcomes have been reported in elderly patients. Therefore, proper treatment is needed for the increasing number of elderly patients with TBI. We aimed to analyze predictive factors of favorable treatment outcomes (FTO) in elderly patients. Clinical and radiological data from 493 patients with TBI who visited a single institute were retrospectively collected from January 2014 to December 2015. We compared the characteristics of the elderly group (individuals above 65 years) and younger group (16-65 years). We analyzed the characteristics and outcomes in both groups and the factors related to the Glasgow outcome scale-extended score at 6 months after injury in 170 elderly patients. The treatment outcomes were dichotomized into favorable and unfavorable groups. In the elderly group, the proportion of female patients and the incidence of subdural hemorrhage (SDH) were higher than in the younger group. Among the 170 elderly patients, 62 had pure SDH, and 21 of the 62 with pure SDH had undergone surgical treatment. Compared with other types of intracranial hemorrhage, FTO was as high as 85.5%, and mortality was as low as 11.3% in patients with pure SDH. High initial Glasgow coma scale score, low injury severity score, and normal pupillary reflex were significantly related to FTO in multivariate analysis. Therefore, active therapeutic strategies, including surgery should be considered for elderly patients with pure SDH without intra-parenchymal injury.

Nonsurviving Patients with Severe Traumatic Brain Injury Have Maintained High Serum sCD40L Levels

BACKGROUND

Soluble cluster of differentiation 40 ligand (sCD40L) is a member of the tumor necrosis factor family with proinflamatory and procoagulant effects. A previous study found higher serum sCD40L levels at day 1 of traumatic brain injury (TBI) in nonsurviving than surviving patients. Thus the objective of this study was to compare serum sCD40L levels during the first week of a severe TBI between surviving and nonsurviving patients and to determine whether it could be used as a mortality predictor biomarker.

METHODS

In this multicenter study severe TBI patients (with Glasgow Coma Scale score <9) with an Injury Severity Score in noncranial item <9 were included. Serum sCD40L concentrations at days 1, 4, and 8 of TBI were determined. We performed receiver operating characteristic analyses to determine the capacity of 30-day TBI mortality prediction by serum sCD40L levels at days 1, 4, and 8 of TBI.

RESULTS

We found that nonsurviving (n = 34) patients in comparison with surviving (n = 90) patients had higher sCD40L levels on days 1 (P < 0.001), 4 (P = 0.004), and 8 (P < 0.001) of TBI. We also found that the areas under curve of serum sCD40L concentrations at days 1, 4, and 8 of TBI to 30-day mortality prediction were 82% (P < 0.001), 72% (P = 0.01) and 83% (P < 0.001), respectively.

CONCLUSIONS

The existence of higher serum sCD40L levels in nonsurviving than surviving patients during the first week of TBI and fact that serum sCD40L levels during the first week of TBI can be used as a mortality predictor biomarker are the new findings of our study.

Prognostic Predictors of Early Outcomes and Discharge Status of Patients Undergoing Decompressive Craniectomy After Severe Traumatic Brain Injury

OBJECTIVE

Although several prognostic factors for traumatic brain injury (TBI) have been evaluated, a useful predictive scoring model for the outcomes has not been developed for patients with severe TBI who undergo decompressive craniectomy (DC). The aim of the present study was to determine independent predictors and develop a multivariate logistic regression equation to predict the early outcome and discharge status for patients with severe TBI who have undergone DC.

METHODS

A total of 13 different variables were evaluated. The data from all 278 patients with severe TBI who had undergone DC in the present study were retrospectively evaluated from July 2011 to June 2017. Using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw receiver operating characteristic curves to predict the early outcomes and discharge status after TBI.

RESULTS

We found that younger age (P = 0.012), no significant medical history (P = 0.044), diameter of both pupils <4 mm (P = 0.032), higher admission Glasgow coma scale score (P = 0.004), no tracheotomy (P < 0.001), and DC for severe TBI were associated with a favorable early outcome and discharge status. Using receiver operating characteristic curves to predict the probability of a favorable outcome, the sensitivity was 80.0% and the specificity was 79.5%.

CONCLUSIONS

Our preliminary findings have shown that 5 variables can be used as independent predictors in assessing the early outcome and discharge status for patients with severe TBI after DC.

The profile of blunt traumatic supratentorial cranial bleed types

The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ± 6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.

The profile of blunt traumatic infratentorial cranial bleed types

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Neurotrauma

Traumatic brain injury remains a major cause of morbidity and mortality throughout the world, affecting young and old alike. Pathologic data have been developed through observations of human autopsies and developing animal models to investigate mechanisms, although animal models do not represent the polypathology of human brain injury and there are likely to be significant differences in the anatomic basis of injury and cellular responses between species. Traumatic brain injury can be defined pathologically as either focal or diffuse, and can be considered to be either primary, directly related to the force associated with the neurotrauma, or secondary, developing as a downstream consequence of the neurotrauma. While neuropathology has traditionally focused on severe head injury, there is increasing recognition of the long-term consequences of traumatic brain injury, particularly repetitive mild traumatic brain injury, and a possible long-term association with chronic traumatic encephalopathy.

Management of severe traumatic brain injury (first 24hours)

The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade^® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.

Radiologic Factors Predicting Deterioration of Mental Status in Patients with Acute Traumatic Subdural Hematoma

OBJECTIVE

To evaluate whether subdural hematoma (SDH) volume and other radiologic factors predict deterioration of mental status in patients with acute traumatic SDH.

METHODS

SDH volumes were measured with a semiautomated tool. The area under the receiver operating characteristic curve was used to determine optimal cutoff values for mental deterioration, including the variables midline shift, SDH volume, hematoma thickness, and Sylvian fissure ratio. Multivariate logistic regression was used to calculate the odds ratio for mental deterioration based on several predictive factors.

RESULTS

We enrolled 103 consecutive patients admitted to our hospital with acute traumatic SDH over an 8-year period. We observed an increase in SDH volume of approximately 7.2 mL as SDH thickness increased by 1 mm. A steeper slope for midline shift was observed in patients with SDH volumes of approximately 75 mL in the younger age group compared with patients in the older age group. When comparing cutoff values used to predict poor mental status at time of admission between the 2 age groups, we observed smaller midline shifts in the older patients.

CONCLUSIONS

Among younger patients, an overall tendency for more rapid midline shift progression was observed in patients with relatively low SDH volumes compared with older patients. Older patients seem to tolerate larger hematoma volumes owing to brain atrophy compared with younger patients. When there is a midline shift, older patients seem to be more vulnerable to mental deterioration than younger patients.

Volumetric analysis of day of injury computed tomography is associated with rehabilitation outcomes after traumatic brain injury

BACKGROUND

Day-of-injury (DOI) brain lesion volumes in traumatic brain injury (TBI) patients are rarely used to predict long-term outcomes in the acute setting. The purpose of this study was to investigate the relationship between acute brain injury lesion volume and rehabilitation outcomes in patients with TBI at a level one trauma center.

METHODS

Patients with TBI who were admitted to our rehabilitation unit after the acute care trauma service from February 2009-July 2011 were eligible for the study. Demographic data and outcome variables including cognitive and motor Functional Independence Measure (FIM) scores, length of stay (LOS) in the rehabilitation unit, and ability to return to home were obtained. The DOI quantitative injury lesion volumes and degree of midline shift were obtained from DOI brain computed tomography scans. A multiple stepwise regression model including 13 independent variables was created. This model was used to predict postrehabilitation outcomes, including FIM scores and ability to return to home. A p value less than 0.05 was considered significant.

RESULTS

Ninety-six patients were enrolled in the study. Mean age was 43 ± 21 years, admission Glasgow Coma Score was 8.4 ± 4.8, Injury Severity Score was 24.7 ± 9.9, and head Abbreviated Injury Scale score was 3.73 ± 0.97. Acute hospital LOS was 12.3 ± 8.9 days, and rehabilitation LOS was 15.9 ± 9.3 days. Day-of-injury TBI lesion volumes were inversely associated with cognitive FIM scores at rehabilitation admission (p = 0.004) and discharge (p = 0.004) and inversely associated with ability to be discharged to home after rehabilitation (p = 0.006).

CONCLUSION

In a cohort of patients with moderate to severe TBI requiring a rehabilitation unit stay after the acute care hospital stay, DOI brain injury lesion volumes are associated with worse cognitive FIM scores at the time of rehabilitation admission and discharge. Smaller-injury volumes were associated with eventual discharge to home. Volumetric neuroimaging in the acute injury phase may improve surgeons' ultimate outcome predictions in TBI patients.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level V.

A population-based study on epidemiology of intensive care unit treated traumatic brain injury in Iceland

BACKGROUND

Traumatic brain injury is a worldwide health issue and a significant cause of preventable deaths and disabilities. We aimed to describe population-based data on intensive care treated traumatic brain injury in Iceland over 15 years period.

METHODS

Retrospective review of all intensive care unit admissions due to traumatic brain injury at The National University Hospital of Iceland 1999-2013. Data were collected on demographics, mechanism of injury, alcohol consumption, glasgow come scale upon admission, Injury Severity Scoring, acute physiology and chronic health evaluation II score, length of stay, interventions and mortality (defined as glasgow outcome score one). All computerized tomography scans were reviewed for Marshall score classification.

RESULTS

Intensive care unit admissions due to traumatic brain injury were 583. The incidence decreased significantly from 14/100.000/year to 12/100.000/year. Males were 72% and the mean age was 41 year. Majority of patients (42%) had severe traumatic brain injury. The most common mechanism of injury was a fall from low heights (36.3%). The mortality was 18.2%. Increasing age, injury severity score, Marshall score and acute physiology and chronic health evaluation II score are all independent risk factors for death. Glasgow coma scale was not an independent prognostic factor for outcome.

CONCLUSIONS

Incidence decreased with a shift in injury mechanism from road traffic accidents to falls and an increased rate of traumatic brain injury in older patients following a fall from standing or low heights. Mortality was higher in older patients falling from low heights than in younger patients suffering multiple injuries in road traffic accidents. Age, injury severity score, acute physiology and chronic health evaluation II score and Marshall score are good prognostic factors for outcome. Traumatic brain injury continues to be a considerable problem and the increase in severe traumatic brain injury in the middle age and older age groups after a seemingly innocent accident needs a special attention.

Prognostic model for patients with traumatic brain injuries and abnormal computed tomography scans

Traumatic brain injury (TBI) is an important cause of death and disability worldwide. The prognosis evaluation is a challenge when many variables are involved. The authors aimed to develop prognostic model for assessment of survival chances after TBI based on admission characteristics, including extracranial injuries, which would allow application of the model before in-hospital therapeutic interventions. A cohort study evaluated 1275 patients with TBI and abnormal CT scans upon admission to the emergency unit of Hospital das Clinicas of University of Sao Paulo and analyzed the final outcome on mortality. A logistic regression analysis was undertaken to determine the adjusted weigh of each independent variable in the outcome. Four variables were found to be significant in the model: age (years), Glasgow Coma Scale (3-15), Marshall Scale (MS, stratified into 2,3 or 4,5,6; according to the best group positive predictive value) and anysochoria (yes/no). The following formula is in a logistic model (USP index to head injury) estimates the probability of death of patients according to characteristics that influence on mortality. We consider that our mathematical probability model (USP Index) may be applied to clinical prognosis in patients with abnormal CT scans after severe traumatic brain injury.

Outcome after operative intervention for traumatic brain injuries in the elderly

INTRODUCTION

The management of traumatic brain injuries in the elderly (age ≥ 65 years) is a constant dilemma. The aim of this study is to investigate for factors that may predict outcome of operative treatment in this group of patients.

MATERIALS AND METHODS

A retrospective analysis was conducted on 68 elderly patients who had been operated in a designated center from 2006 to 2010. Patients' age, Glasgow Coma score (GCS), pupillary responses, imaging findings, medical conditions, and the use of anticoagulant/antiplatelet agents on patient outcomes were studied.

RESULTS

The overall mortality rate was 55.9%. Older age, abnormal pupillary response, low GCS, the presence of midline shift and cistern obliteration on computerized tomography were associated with poor survival. Patient aged 75-84 with normal bilateral pupillary response still had an overall survival rate of 52.6% and good outcomes (Glasgow outcome score: 4 or 5) in 36.8% of patients. Abnormal pupillary response in at least one eye and preoperative GCS ≤ 12 were associated with very poor prognosis.

CONCLUSIONS

More advanced age was found to be associated with progressively worse outcome. A subgroup patients aged below 85 would survive and could achieve good clinical outcome. The prognosis of those aged over 85 with moderate or severe head injuries was extremely poor.

Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010–2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13–15), and median head Abbreviated Injury Scale score was 3 (2–4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay ( P = 0.02) and longer intensive care unit length of stay ( P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.

Oxidation-Reduction Potential as a Biomarker for Severity and Acute Outcome in Traumatic Brain Injury

There are few reliable markers for assessing traumatic brain injury (TBI). Elevated levels of oxidative stress have been observed in TBI patients. We hypothesized that oxidation-reduction potential (ORP) could be a potent biomarker in TBI. Two types of ORP were measured in patient plasma samples: the static state of oxidative stress (sORP) and capacity for induced oxidative stress (icORP). Differences in ORP values as a function of time after injury, severity, and hospital discharge were compared using ANOVAs with significance at p ≤ 0.05. Logit regression analyses were used to predict acute outcome comparing ORP, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), and Glasgow Coma Scale (GCS). Antioxidant capacity (icORP) on day 4 was prognostic for acute outcomes (p < 0.05). An odds ratio of 4.08 was associated with poor acute outcome when icORP > 7.25 μC. IcORP was a better predictor than ISS, AIS, or GCS scores. sORP increased in those with the highest ISS values (p < 0.05). Based on these findings ORP is useful biomarker for severity and acute outcome in TBI patients. Changes in ORP values on day 4 after injury were the most prognostic, suggesting that patients' response to brain injury over time is a factor that determines outcome.

Role of computed tomography scores and findings to predict early death in patients with traumatic brain injury: A reappraisal in a major tertiary care hospital in Nepal

Background:

Glasgow Coma Scale has been a long sought model to classify patients with head injury. However, the major limitation of the score is its assessment in the patients who are either sedated or under the influence of drugs or intubated for airway protection. The rational approach for prognostication of such patients is the utility of scoring system based on the morphological criteria based on radiological imaging. Among the current armamentarium, a scoring system based on computed tomography (CT) imaging holds the greatest promise in conquering our conquest for the same.

Methods:

We included a total of 634 consecutive neurosurgical trauma patients in this series, who presented with mild-to-severe traumatic brain injury (TBI) from January 2013 to April 2014 at a tertiary care center in rural Nepal. All pertinent medical records (including all available imaging studies) were reviewed by the neurosurgical consultant and the radiologist on call. Patients’ worst CT image scores and their outcome at 30 days were assessed and recorded. We then assessed their independent performance in predicting the mortality and also tried to seek the individual variables that had significant interplay for determining the same.

Results:

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute TBI with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift, and status of the peri-mesencephalic cisterns.

Conclusion:

We demonstrated in this cohort that though the Marshall score has the high predictive power to determine the mortality, better discrimination could be sought through the application of the Rotterdam score that encompasses various individual CT parameters. We thereby recommend the use of such comprehensive prognostic model so as to augment our predictive power for properly dichotomizing the prognosis of the patients with TBI. In the future, it will therefore be important to develop prognostic models that are applicable for the majority of patients in the world they live in, and not just a privileged few who can use resources not necessarily representative of their societal environment.

A comparative study between Marshall and Rotterdam CT scores in predicting early deaths in patients with traumatic brain injury in a major tertiary care hospital in Nepal

PURPOSE

CT plays a crucial role in the early assessment of patients with traumatic brain injury (TBI). Marshall and Rotterdam are the mostly used scoring systems, in which CT findings are grouped differently. We sought to determine the values of the scoring system and initial CT findings in predicting the death at hospital discharge (early death) in patients with TBI.

METHODS

There were consecutive 634 traumatic neurosurgical patients with mild-to-severe TBI admitted to the emergency department of College of Medical Sciences. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score is related to early death; compared the two scoring systems' performance in predicting early death, and identified the CT findings that are independent predictors for early death.

RESULTS

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute traumatic brain injury with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift and status of the peri-mesencephalic cisterns.

CONCLUSIONS

Marshall CT classification has strong predictive power, but greater discrimination can be obtained if the individual CT parameters underlying the CT classification are included in a prognostic model as in Rotterdam score. Consequently, for prognostic purposes, we recommend the use of individual characteristics rather than the CT classification. Performance of CT models for predicting outcome in TBI can be significantly improved by including more details of variables and by adding other variables to the models.

Bilateral Traumatic Intracranial Hematomas and its Outcome: a Retrospective Study

The objective of this study was to evaluate the age distribution, mode of injury, type of hematomas, and their surgical outcome in patients with bilateral traumatic head injuries. The present study included 669 cases of traumatic head injury who presented at the neurosurgery emergency out of which 94 cases had bilateral head injuries from the period of August 2009 to April 2014. The data from the hospital computerized database were retrospectively analysed. Cases of bilateral traumatic head injury included 94 patients out of which 88.29 % (n = 83) were males and 11.70 % (n = 11) were females. Commonest mode of injury was road traffic accident in 56.38 % (n = 53) followed by fall from height in 29.78 % (n = 28). In our study, 25.53 % patients had epidural hematoma (EDH) with intracerebral hematoma (ICH) or contusion (n = 24), followed by EDH with subarachnoid hemorrhage (SAH) in 18.08 % (n = 17). At the time of discharge, all those patients managed conservatively had good Glasgow outcome scale (GOS) while with surgical intervention 58 % patients had good GOS, 19 % had moderate disability, and 9 % remained with severe disability. In cases of bilateral hematomas, EDH is most common and should be managed in neurosurgical emergency. Other combinations of bilateral intracranial hematomas should be managed according to the surgical indication and serial CT imaging.

Serum substance P levels are associated with severity and mortality in patients with severe traumatic brain injury

INTRODUCTION

Substance P (SP) is a member of the tachykinin family of neuropeptides, which are widely distributed throughout the central nervous system (CNS) and actively involved in inflammatory processes. SP is released early following acute injury to the CNS, promoting a neurogenic inflammatory response characterized by an increase in the permeability of the blood-brain barrier and the development of vasogenic edema. High levels of SP could lead to an exacerbated inflammatory response that could be fatal for patients with traumatic brain injury (TBI). Thus, the main goal of the present study was to determine whether serum SP levels are associated with injury severity and mortality in patients with severe TBI.

METHODS

This multicenter, observational, prospective study was carried out in six Spanish intensive care units and included patients with Glasgow Coma Scale (GCS) scores ≤ 8. Patients with an Injury Severity Score ≥ 10 in non-cranial aspects were excluded. Blood samples were collected on day 1 of TBI to measure serum SP levels. The endpoint was 30-day mortality.

RESULTS

We found higher serum SP levels (P = 0.002) in non-surviving patients (n = 27) than in surviving patients (n = 73). The area under the curve for serum SP levels with regard to predicting 30-day mortality was 0.70 (95% confidence interval (CI), 0.60 to 0.79; P < 0.001). Survival analysis showed that patients with serum SP levels >299 pg/ml had higher 30-day mortality than patients with lower levels (hazard ratio = 3.7; 95% CI, 1.75 to 7.94; P < 0.001). Multiple binomial logistic regression analysis showed that serum SP levels >299 pg/ml were associated with 30-day mortality when we controlled for APACHE II score and Marshall computed tomography lesion classification (odds ratio (OR) = 5.97; 95% CI, 1.432 to 24.851; P = 0.01) and for GCS score and age (OR = 5.71; 95% CI, 1.461 to 22.280; P = 0.01). We found a negative association between serum SP levels and GCS score (Spearman's ρ = -0.22; P = 0.03).

CONCLUSIONS

We report, for the first time to our knowledge, that serum SP levels were associated with injury severity and mortality in patients with severe TBI. These results open the possibility that SP antagonists may be useful in the treatment of patients with severe TBI.

Prognostic Value of Evoked Responses and Event-Related Brain Potentials in

The behaviourally unresponsive patient, unable to exhibit the presence of cognition, constitutes a conundrum for health care specialists. Prognostic uncertainty impedes accurate management decisions and the application of ethical principles. An early, reliable prognosis is highly desirable. In this review investigations studying comatose patients with coma of different etiologies were selected. It is concluded that objective prognostication is enhanced by the use of electrophysiological tests. Persistent abnormalities of brainstem auditory evoked potentials and short-latency somatosensory evoked potentials reliably indicate the likelihood of irreversible neurological deficit or death. Meanwhile, the presence of “cognitive” event-related brain potentials (e.g., P300 and mismatch negativity) reflects the functional integrity of higher level information processing and, therefore, the likelihood of capacity for cognition. An approach that combines clinical and electrophysiological values provides optimal prediction of outcome and level of disability.

Long-term outcome prediction after a traumatic brain injury using early somatosensory and acoustic evoked potentials: analysis of the predictive value of the different single components of the potentials

PURPOSE

The prediction of the long-term outcome of comatose patients after severe traumatic brain injury (TBI) using early somatosensory and acoustic evoked potentials is controversial. It was our aim to examine the different single components of the evoked potentials regarding their predictive capacity in comatose patients.

METHODS

We examined the amplitude and latency of the wave N20, the amplitude differences between right and left hemisphere, the central conduction time (CCT), the amplitude ratio N20 left/N20 right, the amplitude and latency of peak V, the inter-peak latency I-V and the amplitude ratio V/I. The long-term clinical outcome of the patients was re-evaluated 3 years after their discharge and correlated with the different components.

RESULTS

Only the central conduction time (CCT) and the latency of the wave N20 indicated a statistical correlation with the later outcome (p = 0.0366). The amplitude ratio of wave V/I of the EAEP did not reveal a significant statistical difference between the various outcome groups.

CONCLUSIONS

In this study, the use of single components of the SSEP and EAEP per se could not predict the long-term clinical outcome after TBI. Combined systems such as the Riffel Score are necessary in order to achieve this goal.

Surgery for bilateral large intracranial traumatic hematomas: evacuation in a single session

Objective

Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia.

Methods

In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated.

Results

The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived.

Conclusion

Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy.

Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury*

OBJECTIVES

Evidence-based traumatic brain injury guidelines support cerebral perfusion pressure thresholds for adults at a class 2 level, but evidence is lacking in younger patients. The purpose of this study is to identify the impact of age-specific cerebral perfusion pressure thresholds on short-term survival among patients with severe traumatic brain injury.

DESIGN

Institutional review board-approved, prospective, observational cohort study.

SETTING

Level I or II trauma centers in New York State.

PATIENTS

Data on all patients with a postresuscitation Glasgow Coma Score less than 9 were added in the Brain Trauma Foundation prospective New York State TBI-trac database.

MEASUREMENTS AND MAIN RESULTS

We calculated the survival rates and relative risks of mortality for patients with severe traumatic brain injury based on predefined age-specific cerebral perfusion pressure thresholds. A higher threshold and a lower threshold were defined for each age group: 60 and 50 mm Hg for 12 years old or older, 50 and 35 mm Hg for 6-11 years, and 40 and 30 mm Hg for 0-5 years. Patients were stratified into age groups of 0-11, 12-17, and 18 years old or older. Three exclusive groups of CPP-L (events below low cerebral perfusion pressure threshold), CPP-B (events between high and low cerebral perfusion pressure thresholds), and CPP-H (events above high cerebral perfusion pressure threshold) were defined. As an internal control, we evaluated the associations between cerebral perfusion pressure events and events of hypotension and elevated intracranial pressure. Survival was significantly higher in 0-11 and 18 years old or older age groups for patients with CPP-H events compared with those with CPP-L events. There was a significant decrease in survival with prolonged exposure to CPP-B events for the 0-11 and 18 years old and older age groups when compared with the patients with CPP-H events (p = 0.0001 and p = 0.042, respectively). There was also a significant decrease in survival with prolonged exposure to CPP-L events in all age groups compared with the patients with CPP-H events (p< 0.0001 for 0- to 11-yr olds, p = 0.0240 for 12- to 17-yr olds, and p < 0.0001 for 18-yr old and older age groups). The 12- to 17-year olds had a significantly higher likelihood of survival compared with adults with prolonged exposure to CPP-L events (< 50 mm Hg). CPP-L events were significantly related to systemic hypotension for the 12- to 17-year-old group (p = 0.004) and the 18-year-old and older group (p < 0.0001). CPP-B events were significantly related to systemic hypotension in the 0- to 11-year-old group (p = 0.014). CPP-B and CPP-L events were significantly related to elevated intracranial pressure in all age groups.

CONCLUSIONS

Our data provide new evidence that cerebral perfusion pressure targets should be age specific. Furthermore, cerebral perfusion pressure goals above 50 or 60 mm Hg in adults, above 50 mm Hg in 6- to 17-year olds, and above 40 mm Hg in 0- to 5-year olds seem to be appropriate targets for treatment-based studies. Systemic hypotension had an inconsistent relationship to events of low cerebral perfusion pressure, whereas elevated intracranial pressure was significantly related to all low cerebral perfusion pressure events across all age groups. This may impart a clinically important difference in care, highlighting the necessity of controlling intracranial pressure at all times, while targeting systolic blood pressure in specific instances.

A multidimensional physical therapy program for individuals with cerebellar ataxia secondary to traumatic brain injury: a case series

The purpose of this case series is to describe changes in impairments and activity limitations in three individuals with severe cerebellar ataxia from traumatic brain injury (TBI) who participated in a long-term, multidimensional physical therapy program. A secondary purpose is to document use of a climbing wall for these persons. Each of the individuals had a TBI, severe ataxia and was admitted to a transitional neuro-rehabilitation day treatment program. The first person, a 22-year-old, was 6 years post injury and had 127 individual physical therapy sessions over 12 months. The second person, a 16-year-old, was 5½ months post injury and had 187 individual therapy sessions over 19 months. The third person, a 20-year-old, was 6 months post injury and had 89 individual therapy sessions over 23 months. An integrative treatment approach was used, and the individuals participated in activities to minimize ataxia and improve mobility. Each of them made gains in coordination, balance, balance confidence, endurance and mobility. The three individuals with cerebellar ataxia participated in a long-term, individualized, multidimensional physical therapy treatment program, and made improvements in all areas of impairment and activity limitations. This study reinforces the need for long-term, multidimensional physical therapy for individuals with ataxia.

Online correlation of spontaneous arterial and intracranial pressure fluctuations in patients with diffuse severe head injury

Determination of relevant clinical monitoring parameters for helping guide the intensive care therapy in patients with severe head injury, is one of the most demanding issues in neurotrauma research. New insights into cerebral autoregulation and metabolism have revealed that a rigid cerebral perfusion pressure (CPP) regimen might not be suitable for all severe head injured patients. We thus developed an online analysis technique to monitor the correlation (AI rho) between the spontaneous fluctuations of the mean arterial blood pressure (MABP) and the intracranial pressure (ICP). In addition, brain tissue oxygen (PtiO2) and metabolic microdialysate measures including glucose and lactate were registered. We found that in patients with good outcome, the AI rho values were significantly lower as compared with patients with poor outcome. Accordingly, microdialysate glucose and lactate were significantly higher in the good outcome group. We conclude that online determination of AI rho offers a valuable additional and technically easily performable tool for guidance of therapy in patients with severe head injury.

Progressive epidural hematoma in patients with head trauma: incidence, outcome, and risk factors

Progressive epidural hematoma (PEDH) after head injury is often observed on serial computerized tomography (CT) scans. Recent advances in imaging modalities and treatment might affect its incidence and outcome. In this study, PEDH was observed in 9.2% of 412 head trauma patients in whom two CT scans were obtained within 24 hours of injury, and in a majority of cases, it developed within 3 days after injury. In multivariate logistic regression, patient gender, age, Glasgow Coma Scale (GCS) score at admission, and skull fracture were not associated with PEDH, whereas hypotension (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.17-0.84), time interval of the first CT scanning (OR 0.42, 95% CI 0.19-0.83), coagulopathy (OR 0.36, 95% CI 0.15-0.85), or decompressive craniectomy (DC) (OR 0.46, 95% CI 0.21-0.97) was independently associated with an increased risk of PEDH. The 3-month postinjury outcome was similar in patients with PEDH and patients without PEDH (χ(2) = 0.07, P = 0.86). In conclusion, epidural hematoma has a greater tendency to progress early after injury, often in dramatic and rapid fashion. Recognition of this important treatable cause of secondary brain injury and the associated risk factors may help identify the group at risk and tailor management of patients with TBI.

[Prognostic factors in severe traumatic brain injury]

OBJECTIVE

To describe the factors associated to mortality of patients with severe traumatic brain injury (TBI).

DESIGN

A retrospective observational study was made of patients with severe TBI covering the period between 1 January 2007 and 31 December 2010.

SETTING

Virgen de la Vega Hospital, Salamanca (Spain).

PATIENTS

All patients hospitalized during the consecutive study period.

MAIN VARIABLES OF INTEREST

The dependent variable has been the death rate, while the independent variables were divided into two groups: epidemiological and clinical.

RESULTS

The mean patient age was the 50.84 years; 75.5% were males. The average score on the Glasgow Coma Scale (GCS) was 5.09, and the average Injury Severity Score (ISS) was 30.8. Higher mortality was observed in older patients with a higher ISS score. A total of 68.1% of the patients in which intracranial pressure (ICP) was monitored showed intracranial hypertension (ICH). The mortality rate in patients with severe TBI was 36.8%, and was associated mainly to a lower GCS score, the existence of hyperglycemia, coagulopathy, hypoxemia, the presence of mydriasis and shock. The independent mortality indicators in patients with severe TBI were the existence of mydriasis (OR: 32.75), the GCS score (OR: 2.65) and hyperglycemia (OR: 6.08).

CONCLUSIONS

The existence of mydriasis, the GCS score and hyperglycemia should be taken into account as prognostic factors in TBI patients.

Prognostic predictors of outcome in an operative series in traumatic brain injury patients

BACKGROUND

Although several prognostic factors for traumatic brain injury (TBI) have been evaluated, a useful predictive scoring model for outcome has yet to be developed for TBI patients. The aim of this study was to determine independent predictors and develop a multivariate logistic regression equation to determine prognosis in TBI patients.

METHODS

A total of 13 different variables were evaluated. All 84 patients in this study were retrospectively evaluated between October 2003 and January 2008 and all underwent craniectomy or craniotomy for hematoma removal and were fitted with intracranial pressure (ICP) microsensor monitors. By using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw Receiver-Operating Characteristic curves (ROC) to predict Glasgow Outcome Scale (GOS) 6 months after TBI.

RESULTS

We found that patients over 40 years of age (p < 0.001), unresponsive pre-op pupil reaction (p =0.001), pre-op midline shift (p =0.008), higher injury severity score (ISS; p=0.007), and craniectomy (p < 0.05) were associated with poor outcome in patients with TBI. Using ROC curve to predict the probability of unfavorable outcome, the sensitivity was 97.5% and the specificity was 90.7%.

CONCLUSION

In our preliminary findings, five variables to predict poor outcomes 6 months after TBI were useful. These sensitive variables can be used as a referential guideline in our daily practice to decide whether or not to perform advanced management or avoid decompressive craniectomy.

Pediatric patients with poor neurological status and arteriovenous malformation hemorrhage: an outcome analysis

OBJECT

In general, patients who present with low Glasgow Coma Scale (GCS) scores and/or fixed and dilated pupils are not expected to do well following arteriovenous malformation (AVM) hemorrhage. However, there is a sense among neurosurgeons that pediatric patients may make a better recovery than adults following such an event. There have been few studies focusing on the outcome of pediatric patients with poor neurological status following AVM hemorrhage. The purpose of this study was to characterize functional outcome in pediatric patients with severe disability after AVM hemorrhage.

METHODS

This was a retrospective analysis of clinical presentation and outcome in 15 patients seen at the authors' pediatric hospital presenting with low GCS scores (defined as GCS ≤ 8) following AVM hemorrhage.

RESULTS

Initial GCS scores ranged from 3 to 6, and 11 of 14 patients had fixed pupils on clinical examination (data were not available in 1 patient). Eight of 15 patients suffered primarily a lobar hemorrhage, 3 suffered primarily infratentorial bleeding, 2 suffered primarily hemorrhages of the basal ganglia, and 2 suffered intraventricular hemorrhage. The overall mortality rate was 20% (3 of 15 patients). The clinical outcome of survivors was defined by the Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) scores at follow-up. One year after AVM hemorrhage, 7 (58%) of the 12 surviving patients showed normal or mild disability (PCPC Score 1 or 2), whereas 5 (42%) of 12 patients had moderate or severe disability (PCPC Score 3 or 4). No patients were in a coma or vegetative state, and 11 (92%) of the 12 patients were functioning independently (POPC Score 1, 2, or 3) 1 year after AVM hemorrhage. All patients were functionally independent by last follow-up, with 8 patients (67%) in the normal or mild disability PCPC category, and 4 in the moderate category (PCPC Score 3). All 12 survivors made a meaningful recovery and went on to live independent lives.

CONCLUSIONS

Pediatric patients suffering AVM hemorrhage have a good outcome and are able to function independently, despite a poor neurological state initially.