The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Glasgow coma scale score

Quantitative Electroencephalography Analysis for Improved Assessment of Consciousness Levels in Deep Coma Patients Using a Proposed Stimulus Stage

"Coma" is defined as an inability to obey commands, to speak, or to open the eyes. So, a coma is a state of unarousable unconsciousness. In a clinical setting, the ability to respond to a command is often used to infer consciousness. Evaluation of the patient's level of consciousness (LeOC) is important for neurological evaluation. The Glasgow Coma Scale (GCS) is the most widely used and popular scoring system for neurological evaluation and is used to assess a patient's level of consciousness. The aim of this study is the evaluation of GCSs with an objective approach based on numerical results. So, EEG signals were recorded from 39 patients in a coma state with a new procedure proposed by us in a deep coma state (GCS: between 3 and 8). The EEG signals were divided into four sub-bands as alpha, beta, delta, and theta, and their power spectral density was calculated. As a result of power spectral analysis, 10 different features were extracted from EEG signals in the time and frequency domains. The features were statistically analyzed to differentiate the different LeOC and to relate with the GCS. Additionally, some machine learning algorithms have been used to measure the performance of the features for distinguishing patients with different GCSs in a deep coma. This study demonstrated that GCS 3 and GCS 8 patients were classified from other levels of consciousness in terms of decreased theta activity. To the best of our knowledge, this is the first study to classify patients in a deep coma (GCS between 3 and 8) with 96.44% classification performance.

Those who speak survive: the value of the verbal component of GCS in trauma

Aim

To evaluate the value of the individual components of GCS in predicting the survival of trauma patients in the Emergency Department.

Methods

Trauma patients who were admitted for more than 24 h or died after arrival at Al-Ain Hospital from January 2014 to December 2017 were studied. Children < 16 years, elderly > 80 years, patients with facial injuries, those intubated in the ER, and those with missing primary outcomes were excluded. Demography, vital signs, Glasgow Coma Scale (GCS), GCS components, Injury Severity Score (ISS), head AIS, and death were compared between those who died and those who survived. Factors with a p value of < 0.1 were entered into a backward likelihood logistic regression model to define factors that predict death.

Results

A total of 2548 patients were studied, out of whom 11 (0.4%) died. The verbal component of GCS (p < 0.001) and the ISS (p = 0.047) were the only significant predictors for death in the logistic regression model. The AUC (95% CI) of the GCS-VR was 0.763 (0.58–0.95), p = 0.003. The best point of GCS-VR that predicted survival was 5, having a sensitivity of 97%, a specificity of 54.5%, positive predictive value of 99. 8%, negative predictive value of 7.3%, and likelihood ratio of 2.13.

Conclusion

In general trauma patients, acute trauma care professionals can use GCS-VR to predict survival when clinical condition permits instead of the total GCS score or ISS.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

Purpose

Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients.

Methods

A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern.

Results

In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11–0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, − 2.96 days; 95% CI − 5.70 to − 0.23; p = 0.034).

Conclusion

In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

The effects of Taurine supplementation on inflammatory markers and clinical outcomes in patients with traumatic brain injury: a double-blind randomized controlled trial

Background

Traumatic brain injury is a public health concern and is the main cause of death among various types of trauma. The inflammatory conditions due to TBI are associated with unfavorable clinical outcomes. Taurine has been reported to have immune-modulatory effects. Thus, the aim of this study was to survey the effect of taurine supplementation in TBI patients.

Methods

In this study, 32 patients with TBI were randomized into two groups. The treatment group received 30 mg/kg/day of taurine in addition to the Standard Entera Meal and the control group received Standard Entera Meal for 14 days. Prior to and following the intervention, the patients were investigated in terms of serum levels of IL-6, IL-10, hs-CRP and TNF-α as well as APACHEII, SOFA and NUTRIC scores, Glasgow coma scale and weight. In addition, the length of Intensive Care Unit stay, days of dependence on ventilator and 30-day mortality were studied. SPSS software (version 13.0) was used for data analysis.

Results

Taurine significantly decreased the serum levels of IL-6 (p = 0.04) and marginally APACHEII score (p = 0.05). In addition, weight loss was significantly lower in taurine group (p = 0.03). Furthermore, taurine significantly increased the GCS (p = 0.03). The groups were not different significantly in terms of levels of IL-10, hs-CRP, and TNF-α, SOFA and NUTRIC scores, 30-day mortality, length of ICU stay and days of dependence on ventilator.

Conclusion

According to the results of the present study, taurine supplementation can reduce the IL-6 levels as one of the important inflammatory markers in these patients; and enhances the clinical outcomes too.

Trial registration

IRCT, IRCT20180514039657N1. Registered 22 June 2018.

Employment status after traumatic brain injury and the effect of concomitant injuries on return to work

PURPOSE

This study aims to describe the employment status and pattern among survivors of traumatic brain injury after motor vehicle accidents, and to explore the effects of demographic, injury variables and concomitant injuries on the employment status .

METHOD

A retrospective analyses of 370 medical reports written for patients who sustained traumatic brain injury from motor vehicle accidents was conducted. To establish the employment pattern, the pre-injury employment history was compared to the latest employment status documented. Types and severity of concomitant injuries were rated according to Abbreviated Injury Scale criteria. All significant variables were further analyzed using logistic regression to explore predictors of employment.

RESULTS

Up to 87% of the patients sustained concomitant injuries, with more than two-thirds (72%) scoring ≤ 2 on the Abbreviated Injury Scale. One hundred and eighty-two patients (49.2%) successfully returned to work. Among those who returned to work, 34% returned to former employment with pre-injury job description. Severity of traumatic brain injury, length of acute hospital stay, ambulation status and cognitive status were found to be significant predictive factors for employment status post traumatic brain injury. Presence of concomitant extremity injuries was found to influence the employment pattern among traumatic brain injury survivors.

CONCLUSION

The return to work rate was somewhat low and was not influenced by presence of concomitant injuries. .

Long-term employment outcomes following moderate to severe traumatic brain injury: a systematic review and meta-analysis

Background: Returning to employment following moderate to severe traumatic brain injury (msTBI) is critical for a survivor's well-being, yet currently there are no systematic reviews that comprehensively describe employment outcomes following msTBI. The objective of this study was to systematically synthesize literature on employment outcomes following msTBI.Methods: Original studies published through April 2018 on MEDLINE/PubMed, PsychINFO, and CINAHL were eligible if the objective was to investigate employment outcomes following msTBI; outcome was measured ≥1 year; participants were ≥15; and size was ≥60. Post-injury employment prevalence and return to pre-injury level of work were summarized through meta-analysis.Results: Of 38 eligible studies, post-injury employment prevalence was most often reported (n = 35), followed by job stability (n = 6), and return to pre-injury level of work (n = 4). Overall post-injury employment prevalence was 42.2%; whereas the return-to-previous-work prevalence was 33.0%. Post-injury employment prevalence appeared to increase over time, from 34.9% at 1 year to 42.1% up to 5 years and 49.9% beyond 5 years.Conclusion: Nearly half of individuals with msTBI were employed post-injury, yet only a third returned to pre-injury level of work. Future researchers are recommended to standardize employment outcome measures to enable better comparison of outcomes across studies.

Prospective Study of the Effectiveness of Paroxetine on the Onset of Posttraumatic Stress Disorder, Depression, and Health and Functional Outcomes After Trauma

OBJECTIVES

To determine whether the administration of medication for posttraumatic stress disorder (PTSD) to injured trauma survivors prevents or mitigates PTSD.

DESIGN

Double-blinded, placebo-controlled.

SETTING

Level I trauma center.

PATIENTS

One hundred twenty patients admitted for traumatic orthopaedic injury.

INTERVENTION

Either paroxetine or placebo starting 2 weeks postinjury.

MAIN OUTCOME MEASUREMENTS

PTSD symptoms were measured with the PTSD Checklist for DSM-IV. The Quick Inventory of Depressive Symptomatology (QIDS) assessed the presence and severity of DSM-IV-TR major depressive symptoms. The SF-36 measured postinjury quality of life and social functioning. The Short Musculoskeletal Functional Assessment rated postinjury musculoskeletal function.

RESULTS

The paroxetine group did not differ from the placebo group in proportions with PTSD as assessed at the 6- or 12-month follow-up or in proportions with major depression symptoms since the injury as assessed at the 3-month follow-up. The groups also did not differ at the 8-week follow-up in the amount of change from baseline in QIDS scores. The paroxetine group had a marginally greater increase from baseline in SF-36 functioning score at the 12-month follow-up as compared with the placebo group and a marginally greater reduction from baseline in Short Musculoskeletal Functional Assessment musculoskeletal functioning at the 12-month follow-up as compared with the placebo group.

CONCLUSIONS

These results suggest the potential for psychotropic medication to prevent or reduce posttraumatic stress symptoms and to improve the function and health of trauma patients. Further research is needed to confirm paroxetine's use for this purpose.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Early Brain Edema is a Predictor of In-Hospital Mortality in Traumatic Brain Injury

BACKGROUND

Identifying patients who may progress to a poor clinical outcome will encourage earlier appropriate therapeutic interventions. Brain edema may contribute to secondary injury in traumatic brain injury (TBI) and thus, may be a useful prognostic indicator.

OBJECTIVE

We determined whether the presence of brain edema on the initial computed tomography (CT) scan of TBI patients would predict poor in-hospital outcome.

METHODS

We performed a retrospective review of all trauma patients with nonpenetrating head trauma at a Level I Trauma Center. International Classification of Diseases, Ninth Revision codes indicated the presence of brain edema and we evaluated the validity of this pragmatic assessment quantitatively in a random subset of patients. In-hospital mortality was the primary outcome variable. Univariate analysis and logistic regression identified predictors of mortality in all TBI patients and those with mild TBI.

RESULTS

Over 7200 patients were included in the study, including 6225 with mild TBI. Measurements of gray and white matter CT density verified radiological assessments of brain edema. Patients with documented brain edema had a mortality rate over 10 times that of the entire study population. With logistic regression accounting for Injury Severity Score, Glasgow Coma Scale score, other CT findings, and clinical variables, brain edema predicted an eightfold greater mortality rate in all patients (odds ratio 8.0, 95% confidence interval 4.6-14.0) and fivefold greater mortality rate for mild TBI patients (odds ratio 4.9, 95% confidence interval 2.0-11.7).

CONCLUSIONS

Brain edema is an independent prognostic variable across all categories of TBI severity. By alerting emergency physicians to patients with poor predicted clinical outcomes, this finding will drive better resource allocation, earlier intervention, and reduced patient mortality.

Considerations in Fluids and Electrolytes After Traumatic Brain Injury

Appropriate fluid management of patients with traumatic brain injury (TBI) presents a challenge for many clinicians. Many of these patients may receive osmotic diuretics for the treatment of increased intracranial pressure or develop sodium disturbances, which act to alter fluid balance. However, establishment of fluid balance is extremely important for improving patient outcomes after neurologic injury. The use of hyperosmolar fluids, such as hypertonic saline, has gained significant interest because they are devoid of dehydrating properties and may have other beneficial properties for patients with TBI. Electrolyte derangements are also common after neurologic injury, with many having neurologic manifestations. In addition, the role of electrolyte abnormalities in the secondary neurologic injury cascade is being delineated and may offer a potential future therapeutic intervention.

Comparison of Glasgow Coma Scale, Full Outline of Unresponsiveness and Acute Physiology and Chronic Health Evaluation in Prediction of Mortality Rate Among Patients With Traumatic Brain Injury Admitted to Intensive Care Unit

Background

Traumatic brain injury (TBI) is a common cause of mortality and disability worldwide. Choosing an appropriate diagnostic tool is critical in early stage for appropriate decision about primary diagnosis, medical care and prognosis.

Objectives

This study aimed to compare the Glasgow coma scale (GCS), full outline of unresponsiveness (FOUR) and acute physiology and chronic health evaluation (APACHE II) with respect to prediction of the mortality rate of patients with TBI admitted to intensive care unit.

Patients and Methods

This diagnostic study was conducted on 80 patients with TBI in educational hospitals. The scores of APACHE II, GCS and FOUR were recorded during the first 24 hours of admission of patients. In this study, early mortality means the patient death before 14 days and delayed mortality means the patient death 15 days after admitting to hospital. The collected data were analyzed using descriptive and inductive statistics.

Results

The results showed that the mean age of the patients was 33.80 ± 12.60. From a total of 80 patients with TBI, 16 (20%) were females and 64 (80%) males. The mortality rate was 15 (18.7%). The results showed no significant difference among three tools. In prediction of early mortality, the areas under the curve (AUCs) were 0.92 (CI = 0.95. 0.81 - 0.97), 0.90 (CI = 0.95. 0.74 - 0.94), and 0.96 (CI = 0.95. 0.87 - 0.9) for FOUR, APACHE II and GCS, respectively. In delayed mortality, the AUCs were 0.89 (CI = 0.95. 0.81-0.94), 0.94 (CI = 0.95. 0.74 - 0.97) and 0.90 (CI = 0.95. 0.87 - 0.95) for FOUR, APACHE II and GCS, respectively.

Conclusions

Considering that GCS is easy to use and the FOUR can diagnose a locking syndrome along same values of subscales. These two subscales are superior to APACHI II in prediction of early mortality. Conversation APACHE II is more punctual in the prediction of delayed mortality.

Which score should be used in intubated patients' Glasgow coma scale or full outline of unresponsiveness?

Background and Aims:

Today Glasgow coma scale (GCS) is the most well-known and common score for evaluation of the level of consciousness and outcome predict after traumatic brain injuries in the world. Regarding to some advantages of the full outline of unresponsiveness (FOUR) score over GCS in intubated patients, we’re going to compare the precision of these two scores in predicting the outcome predict in intubated patients.

Methods:

This research was a diagnostic-based study, which was conducted prospectively on 80 patients with Traumatic brain injury who were intubated and admitted to Intensive Care Unit (ICU) of Educational Hospitals of Mazandaran University of Medical Science during February 2013 to August 2013. The scores of FOUR and GCS were measured by the researcher in the first 24 h of admission in ICU. The information's recorded in the check list including the mortality rate of early and late inside of the hospital interred to excel. The findings were analyzed using SPSS software, through descriptive statistics and regression logistic.

Results:

The results showed of 80 patients 21 patients (20%) were female and 59 patients (80%) were male. The age average of the samples was 33.80 ± 12.60 ranging from 16 to 60 years old. 21 patients (26.2%) died during treatment. Of 21 patients, 15 patients died during first 14 days (18.7%) and 6 patients died after 14 years (7.5%). The area under curve (AUC) of FOUR score in early mortality was 0.90 (C₁ = 0.95, 0.88–0.90). The amount AUC for GCS was 0.80 (C₁ = 0.95, 0.78–0.84), which in delayed mortality it was ordered as 0.86 (C₁ = 0.95, 0.84–0.90) and 0.89 (C₁ = 0.95, 0.78–0.88).

Conclusion:

The research results indicated that FOUR score is more exact and more practical in intubated patients regarding lack of verbal response factor in early mortality prediction in GCS. Hence, it is recommended for health professionals to use the FOUR score to predict the early outcome of intubated patients with traumatic brain injuries.

Quality-of-life after brain injury in childhood: time, not severity, is the significant factor

OBJECTIVE

Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI.

METHODS

The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL.

RESULTS

The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS.

CONCLUSIONS

QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.

Persistent hypoglycemia as an early, atypical presentation of hepatocellular carcinoma: A case report and systematic review of the literature

The current study presents a case of persistent hypoglycemia as the initial manifestation of advanced hepatocellular carcinoma (HCC), as well as a systematic review of the management of hypoglycemia associated with HCC. A 42-year-old female presented with loss of consciousness and a blood glucose level of 30 mg/dl (normal range, 80–140 mg/dl). Abdominal ultrasound and computed tomography were performed to investigate tenderness in the right upper quadrant, and the results revealed a hepatic mass of 15 cm in diameter, with metastasis. A diagnosis of insulinoma was ruled out by examining the insulin level. Prednisolone treatment was ineffective for relieving the persistent hypoglycemia, however, a single dose of palliative radiotherapy reduced the hypoglycemic episodes to once monthly. Due to the advanced disease, the patient refused further treatment, with the exception of a palliative therapy with glucose fluid. The patient succumbed to pneumonia with sepsis. A systematic review of the literature indicated that steroids were the most commonly used drug for hypoglycemia associated with HCC, however, in the majority of cases no effect was noted as observed in this study. Cytoreduction by surgery or systemic chemotherapy has been the most effective treatment. Although rare, hypoglycemia may be the initial symptom of HCC. Cytoreduction is the most effective method of treating hypoglycemia associated with HCC.

A comparison of the diagnostic power of the Full Outline of Unresponsiveness scale and the Glasgow coma scale in the discharge outcome prediction of patients with traumatic brain injury admitted to the intensive care unit

Background and Aim:

This study aimed to determine whether the Full Outline of Unresponsiveness (FOUR) score is an accurate predictorof discharge outcome in traumatic brain injury (TBI) patients and to compare its performanceto Glasgow coma scale (GCS).

Materials and Methods:

Thisis diagnostic study conducted prospectively on 53 TBI patients admitted to ICU of education hospitals of Medical Science University of Mazandaran during February 2013 to June 2013. Data collection was done with a checklist including biographic, clinical information and outcome. The FOUR score and GCS were determined by the researcher in the first 24 hours. Outcomes considered as in-hospital mortality and poor neurologic outcome (Glasgow Outcome Scale (GOS) 1-3) in discharge time from the hospital.

Results:

In terms of predictive power for in-hospital mortality, the area under the receiver operating characteristic (ROC) curve was 0/92 (95% CI. 0/81-0/97) for FOUR score and 0/96 (95% CI. 0/87-0/99) for GCS. In terms of predictive power of poor neurologic outcome, the area under the ROC curve was 0/95 (95% CI. 0/86-0/99) for FOUR score and 0/90 (95% CI.0/79-0/96) for GCS as evidenced by GOS 1-3. The cut-off of 6 showed sensitivity and specificity of total four score predicting poor outcome at 0/86 and 0/87 while the cut-off of 4 showed the value of in hospital mortality at 0/90 and 0/90. The total GCS score showed sensitivity and specificity 0/100 and 0/61 at cut-off 7 in predicting poor outcome while in predicting mortality at cut-off of 4 this range was 0/100 and 0/92.

Conclusion:

The FOUR score is an accurate predictor of discharge outcome in TBI patients. Thus, researchers recommend for therapeutic Schematizationto use in neurosurgical patients at admission day.

Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality?

Mortality is higher in patients with traumatic brain injury (TBI) resuscitated with albumin compared with saline, but the mechanism for increased mortality is unknown. In patients from the Saline vs. Albumin Fluid Evaluation (SAFE) study with TBI who underwent intracranial pressure (ICP) monitoring, interventional data were collected from randomization to day 14 to determine changes in ICP (primary outcome) and in therapies used to treat increased ICP. Pattern mixture modelling, designed to address informative dropouts, was used to compare temporal changes between the albumin and saline groups, and 321 patients were identified, of whom 164 (51.1%) received albumin and 157 (48.9%) received saline. There was a significant linear increase in mean ICP and significantly more deaths in the albumin group compared with saline when ICP monitoring was discontinued during the first week (1.30±0.33 vs. -0.37±0.36, p=0.0006; and 34.4% vs. 17.4%; p=0.006 respectively), but not when monitoring ceased during the second week (-0.08±0.44 vs. -0.23±0.38, p=0.79; and 18.6% vs. 12.1%; p=0.36 respectively). There were statistically significant differences in the mean total daily doses of morphine (-0.42±0.07 vs. -0.66±0.0, p=0.0009), propofol (-0.45±0.11 vs. -0.76±0.11; p=0.034) and norepinephrine (-0.50±0.07 vs. -0.74±0.07) and in temperature (0.03±0.03 vs. 0.16±0.03; p=0.0014) between the albumin and saline groups when ICP monitoring ceased during the first week. The use of albumin for resuscitation in patients with severe TBI is associated with increased ICP during the first week. This is the most likely mechanism of increased mortality in these patients.

Traumatic intracranial hematomas: prognostic value of contrast extravasation

BACKGROUND AND PURPOSE

Contrast extravasation within spontaneous intracranial hemorrhage is a well-described predictor of hematoma growth, poor clinical outcome, and mortality. The purpose of this study was to assess the prognostic value of contrast extravasation in acute traumatic intracranial hematomas.

MATERIALS AND METHODS

In our institution, CTA (including PCCT) is the primary screening technique for cervical vascular injuries. Sixty consecutive patients with at least 1 acute intracranial hematoma (ICH, subdural hematoma, and/or epidural hematoma) meeting predefined size criteria, with CTA/PCCT performed within 24 hours of admission and follow-up CT within 72 hours of admission, were retrospectively evaluated for CE by 2 observers. The predictive value of CE for a composite outcome (hematoma expansion, need for hematoma evacuation, in-hospital mortality) was evaluated on a per-patient basis. Interobserver agreement for CE and the association between baseline variables and outcome were also examined. Different patterns of extravasation were evaluated on a per-lesion basis, with outcomes including hematoma expansion and evacuation.

RESULTS

CE was present in 30 (50%) patients with almost perfect interobserver agreement (κ=0.87; 95% CI, 0.74-0.99). The per-patient multivariate analysis showed independent association of midline shift (P=.020), Glasgow Coma Scale score≤8 (P=.024), and CE (P=.017), with poor outcome and demonstrated a trend toward poor outcome prediction for age 65 years or older (P=.050). In the per-lesion analysis, only extravasation identified on CTA (active and contained extravasation) was associated with hematoma expansion and evacuation.

CONCLUSIONS

Contrast extravasation within intracranial hematomas predicts poor in-hospital outcome in the setting of acute traumatic intracranial injuries.

Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality

In the setting of acute brainstem herniation in traumatic brain injury (TBI), the use of hyperventilation to reduce intracranial pressure may be life-saving. However, undue use of hyperventilation is thought to increase the incidence of secondary brain injury through direct reduction of cerebral blood flow. This is a retrospective review determining the effect of prehospital hyperventilation on in-hospital mortality following severe TBI. All trauma patients admitted directly to a single level 1 trauma center from January 2000 to January 2007 with an initial Glasgow Coma Scale (GCS) score <or=8 were included in the study (n = 77). Patients without documented or with late (>20 min) arterial blood gas at presentation (n = 12) were excluded from the study. The remaining population (n = 65) was sorted into three groups based on the initial partial pressure of carbon dioxide: hypocarbic (Pco(2) < 35 mm Hg), normocarbic (Pco(2) 35-45 mm Hg), and hypercarbic (Pco(2) > 45 mm Hg). Outcome was based on mortality during hospital admission. Survival was found to be related to admission Pco(2) in head trauma patients requiring intubation (p = 0.045). Patients with normocarbia on presenting arterial blood gas testing had in-hospital mortality of 15%, significantly improved over patients presenting with hypocarbia (in-hospital mortality 77%) or hypercarbia (in-hospital mortality 61%). Although there are many reports of the negative impact of prophylactic hyperventilation following severe TBI, this modality is frequently utilized in the prehospital setting. Our results suggest that abnormal Pco(2) on presentation after severe head trauma is correlated with increased in-hospital mortality. We advocate normoventilation in the prehospital setting.

Comparative evaluation of corpus callosum DTI metrics in acute mild and moderate traumatic brain injury: its correlation with neuropsychometric tests

PRIMARY OBJECTIVE

To look for differences in vulnerability of corpus callosum (CC) in patients of mild and moderate traumatic brain injury (TBI) in the acute stage using quantitative diffusion tensor imaging (DTI) and to correlate these with neuropsychometric tests (NPT) done at 6 months post-injury. RESEARCH DESIGN, METHODS AND PROCEDURES: Conventional MRI, DTI and NPT were performed on 83 patients (moderate TBI, n = 57; mild TBI, n = 26) within 5-14 days after TBI. Thirty-three age- and sex-matched healthy controls were also included for comparison.

RESULTS

Significantly decreased fractional anisotropy (FA) in genu and splenium; significantly increased radial diffusivity (RD) values in genu, midbody and splenium with significant increase in mean diffusivity (MD) and a decrease in axial diffusivity (AD) only in genu, respectively, in patients with moderate TBI compared to healthy controls were observed. However, in moderate TBI, significantly decreased FA was found only in genu compared to mild TBI. Moderate TBI showed poor NPT scores compared to mild TBI, but this did not reach statistical significance.

CONCLUSIONS

It is concluded that DTI abnormalities in the regions of CC were more in patients with moderate TBI compared to mild TBI and this was associated with relatively poor neuropsychological outcome 6 months post-injury.

The natural history of brain contusion: an analysis of radiological and clinical progression

Object

Although brain contusions are a common neurosurgical condition, surprisingly little has been written about their natural history. The purpose of this study was to identify factors that predict radiological and clinically significant progression of this pattern of traumatic brain injury in patients who did not initially require surgery. On the basis of their results and the available literature, the authors suggest a management algorithm.

Methods

The authors performed a retrospective review of clinical and radiological records of consecutive patients with brain contusions who initially underwent conservative treatment. Significant radiological progression was defined as a 30% increase in contusion size on CT scans. Statistical analysis was performed to identify clinical and radiological predictors of CT contusion progression, the significance of progression, and predictors of clinical outcome.

Results

Of 98 patients identified with brain contusions who initially received conservative treatment, 44 (45%) had significant progression on CT, and 19 (19%) required surgical intervention. The initial size of the contusion and the presence of subdural hematoma were the only statistically significant predictors of CT progression in the multivariate analysis (p = 0.0212 and 0.05, respectively). Four patients required delayed contusion evacuation (3 had radiological progression on follow-up scans). Good Glasgow Coma Scale (GCS) scores on presentation and younger age were predictors of eventual discharge from the hospital (OR 1.471, CI 1.233–1.755, p < 0.001 and OR 0.949, CI 0.912–0.988, p = 0.011, respectively). No patients with an initial GCS score of 15 or an initial contusion size < 14 ml required delayed evacuation.

Conclusions

Contusion progression is a common phenomenon that is seen more commonly in larger contusions. Patients with large contusions and low initial GCS scores are at risk for delayed deterioration. A proposed management algorithm for patients with contusions initially treated conservatively may help practitioners identify the best course of treatment.

The significance of altered temperature after traumatic brain injury: an analysis of investigations in experimental and human studies: part 2

Raised body temperature is a common occurrence after severe traumatic brain injury (TBI). It is widely accepted that experimental evidence points to a harmful effect of raised temperature both during and after TBI. Consequently, the policy of many neurocritical care units is to implement therapies for body temperature control. This article reviews the evidence that links spontaneous temperature changes with worsened outcome after experimentally-induced and human brain trauma. The current evidence-base and rationale for treatment of raised temperature after TBI is presented with discussion positing areas for further work to explore the notion that raised temperature may not be deleterious in all neurosurgical patients.

[Diagnostic imaging of traumatic brain injury]

Traumatic brain injury (TBI)--either in isolation or within the context of multiple trauma--is a major cause of disability and death in young adults. The prognosis depends not only on the extent and localization of traumatic lesions, but also on the promptness of surgical intervention if indicated. The following article presents diagnostic imaging strategies in the acute and sub-acute phases of head injury, discussing their relevance with regard to various clinical situations. In addition to standard CT and MRI techniques, the use of other methods such as perfusion measurements, magnetic resonance spectroscopy or diffusion tensor imaging is briefly discussed. By means of these relatively new techniques it is possible to visualize not only structural changes but also gain information relating to functional and metabolic aspects of traumatic brain injury.

Saline or albumin for fluid resuscitation in patients with traumatic brain injury

BACKGROUND

The Saline versus Albumin Fluid Evaluation study suggested that patients with traumatic brain injury resuscitated with albumin had a higher mortality rate than those resuscitated with saline. We conducted a post hoc follow-up study of patients with traumatic brain injury who were enrolled in the study.

METHODS

For patients with traumatic brain injury (i.e., a history of trauma, evidence of head trauma on a computed tomographic [CT] scan, and a score of < or =13 on the Glasgow Coma Scale [GCS]), we recorded baseline characteristics from case-report forms, clinical records, and CT scans and determined vital status and functional neurologic outcomes 24 months after randomization.

RESULTS

We followed 460 patients, of whom 231 (50.2%) received albumin and 229 (49.8%) received saline. The subgroup of patients with GCS scores of 3 to 8 were classified as having severe brain injury (160 [69.3%] in the albumin group and 158 [69.0%] in the saline group). Demographic characteristics and indexes of severity of brain injury were similar at baseline. At 24 months, 71 of 214 patients in the albumin group (33.2%) had died, as compared with 42 of 206 in the saline group (20.4%) (relative risk, 1.63; 95% confidence interval [CI], 1.17 to 2.26; P=0.003). Among patients with severe brain injury, 61 of 146 patients in the albumin group (41.8%) died, as compared with 32 of 144 in the saline group (22.2%) (relative risk, 1.88; 95% CI, 1.31 to 2.70; P<0.001); among patients with GCS scores of 9 to 12, death occurred in 8 of 50 patients in the albumin group (16.0%) and 8 of 37 in the saline group (21.6%) (relative risk, 0.74; 95% CI, 0.31 to 1.79; P=0.50).

CONCLUSIONS

In this post hoc study of critically ill patients with traumatic brain injury, fluid resuscitation with albumin was associated with higher mortality rates than was resuscitation with saline. (Current Controlled Trials number, ISRCTN76588266 [controlled-trials.com].).

Prediction of recovery from a post-traumatic coma state by diffusion-weighted imaging (DWI) in patients with diffuse axonal injury

INTRODUCTION

To determine whether diffusion-weighted magnetic resonance (MR) imaging findings combined with initial clinical factors indicate the depth of shearing lesions in the brain structure and therefore relate to coma duration in diffuse axonal injury (DAI).

METHODS

A total of 74 adult patients (48 male and 26 female) with DAI were examined with conventional MR imaging and diffusion-weighted MR imaging between 2 hours and 20 days after injury. Apparent diffusion coefficient (ADC) maps were obtained and the mean ADC values of each region of interest (ROI) were measured using MRI console software. The involvement of the brainstem, deep gray matter, and corpus callosum was determined for each sequence separately as well as for the combination of all sequences. The correlations between MR imaging findings indicating the presence of apparent brain injury combined with initial clinical factors were determined.

RESULTS

Clinical characteristics, such as initial score on the Glasgow coma scale (GCS), age and number of all lesions, and ADC scores were predictive of the duration of coma.

CONCLUSION

It was possible to predict post-traumatic coma duration in DAI from cerebral MR imaging findings combined with clinical prognostic factors in the acute to subacute stage after head injury. Age, ADC scores, GCS score and number of lesions were highly significant in predicting coma duration. The technique presented here might provide a tool for in vivo detection of DAI to allow the prediction of the coma duration during the early stages in patients with traumatic brain injury.

Approach to the comatose patient

BACKGROUND

Coma is a medical emergency and may constitute a diagnostic and therapeutic challenge for the intensivist.

OBJECTIVE

To review currently available data on the etiology, diagnosis, and outcome of coma. To propose an evidence-based approach for the clinical management of the comatose patient.

DATA SOURCE

Search of Medline and Cochrane databases; manual review of bibliographies from selected articles and monographs.

DATA SYNTHESIS AND CONCLUSIONS

Coma and other states of impaired consciousness are signs of extensive dysfunction or injury involving the brainstem, diencephalon, or cerebral cortex and are associated with a substantial risk of death and disability. Management of impaired consciousness includes prompt stabilization of vital physiologic functions to prevent secondary neurologic injury, etiological diagnosis, and the institution of brain-directed therapeutic or preventive measures. Neurologic prognosis is determined by the underlying etiology and may be predicted by the combination of clinical signs and electrophysiological tests.

Coma duration prediction in diffuse axonal injury: analyses of apparent diffusion coefficient and clinical prognostic factors

The purpose of this paper is to evaluate the hypothesis that the Apparent Diffusion Coefficient (ADC) values combined with initial clinical factors indicates the depth of shearing lesions in the brain structure and therefore relates to coma duration of diffuse axonal injury (DAI). Seventy-four adult patients (48 male and 26 female patients) with diffuse axonal injury were examined with convention MR imaging and diffusion weighted MR imaging between 2 hours and 20 days after injury. Apparent diffusion coefficient (ADC) maps were obtained and the mean ADC values of each Region of Interest (ROI) were measured using MRI console software. The lesions involvement of brainstem, deep gray matter, and corpus callosum were determined for each sequence separately as well as for the combination of all sequences. The correlations between magnetic resonance (MR) imaging findings of presence of apparent brain injury combined with initial clinical factors were investigated. Clinical characteristics, such as initial score on the Glasgow Coma Scale (GCS), age, and the number of all lesions, ADC scores of the patient in MR findings were predictive of the duration of coma. Post-traumatic coma duration of DAI could be predicted by cerebral MRI findings in the acute to subacute stage after head injury combined with clinical prognostic factors. Age, ADC scores, GCS, number of lesions are highly significant in predicting coma duration. The technique presented herein might provide a tool for in vivo detection of DAI for the coma duration at the early stages in patients with traumatic brain injury.

Interrater reliability of Glasgow Coma Scale scores in the emergency department

STUDY OBJECTIVE

Emergency physicians often use the Glasgow Coma Scale (GCS) to help guide decisions in patient care, yet the reliability of the GCS has never been tested in a typical broad sample of emergency department (ED) patients. We determined the interrater reliability of the GCS between emergency physicians when adult patients with altered levels of consciousness are assessed.

METHODS

In this prospective observational study at a university Level I trauma center, we enrolled a convenience sample of ED patients older than 17 years who presented with an altered level of consciousness. Two residency-trained attending emergency physicians independently assessed and recorded the GCS score and its components (eye, verbal, and motor) in blinded fashion within a 5-minute period. Data were analyzed for interrater reliability by using standard ordinal calculations. We also created scatter plots and Bland-Altman plots for each GCS component and for the GCS score.

RESULTS

One hundred thirty-one patients were screened and enrolled in the study, with 15 excluded because of protocol violations. Of the 116 remaining patients, the agreement percentage for exact total GCS was 32% (tau-b=0.739; Spearman rho=0.864; Spearman rho2=75%). Agreement percentage for GCS components were eye 74% (tau-b=0.715; Spearman rho=0.757; Spearman rho2=57%), verbal 55% (tau-b=0.587; Spearman rho=0.665; Spearman rho2=44%), and motor 72% (tau-b=0.742; Spearman rho=0.808; Spearman rho2=65%). Our Spearman's analyses found that only approximately half (44% to 65%) of the observed variance could be explained by the relationship between the paired component measures. For GCS components, only 55% to 74% of paired measures were identical, and 6% to 17% of them were 2 or more points apart.

CONCLUSION

We found only moderate degrees of interrater agreement for the GCS and its components.

Diffusion-weighted MR imaging in closed head injury: high correlation with initial glasgow coma scale score and score on modified Rankin scale at discharge

PURPOSE

To determine whether diffusion-weighted magnetic resonance (MR) imaging findings and conventional MR imaging findings correlate with initial Glasgow Coma Scale score and score on modified Rankin scale at discharge.

MATERIALS AND METHODS

Twenty-six patients (18 male and eight female patients; mean age, 25.2 years; age range, 4-72 years) with diffuse axonal injury were examined with diffusion-weighted MR imaging and with fluid-attenuated inversion recovery, T2-weighted fast spin-echo, and T2*-weighted gradient-echo sequences. All images were evaluated by two neuroradiologists in consensus. Tissue volume with trauma-related signal-intensity abnormality on images from each sequence, number of lesions for each sequence, number of lesions for all sequences, and number of lesions with reduced apparent diffusion coefficient were correlated with scores on Glasgow Coma Scale and modified Rankin scale. Involvement of brainstem, deep gray matter, and corpus callosum were also correlated with clinical scores. Spearman rank correlation coefficients (r) were calculated.

RESULTS

The strongest correlation was between signal-intensity abnormality volume on diffusion-weighted images and modified Rankin score (r = 0.772, P <.001). The strength of this correlation did not improve when only volume of lesions with decreased apparent diffusion coefficient was considered. For lesion number, the strongest correlation was between lesion number on images acquired with all sequences and modified Rankin score (r = 0.662, P <.001). For lesion location, the strongest correlation was between lesion location in the corpus callosum and modified Rankin score (r = 0.513, P =.007).

CONCLUSION

Volume of lesions on diffusion-weighted MR images provides the strongest correlation with a score of subacute on modified Rankin scale at discharge. Total lesion number also correlates well with modified Rankin score. In future, diffusion-weighted images may be useful in determining treatment strategies for acute head injury.

Outcome of severe traumatic brain injury: comparison of three monitoring approaches

The determination of cerebral perfusion pressure (CPP) is regarded as vital in monitoring patients with severe traumatic brain injury. Besides indicating the status of cerebral blood flow (CBF), it also reveals the status of intracranial pressure (ICP). The abnormal or suboptimal level of CPP is commonly correlated with high values of ICP and therefore with poor patient outcomes. Eighty-two patients were divided into three groups of patients receiving treatment based on CPP and CBF, ICP alone, and conservative methods during two different observation periods. The characteristics of these three groups were compared based on age, sex, time between injury and hospital arrival, Glasgow Coma Scale score, pupillary reaction to light, surgical intervention, and computerized tomography scanning findings according to the Marshall classification system. Only time between injury and arrival (p = 0.001) was statistically significant. There was a statistically significant difference in the proportions of good outcomes between the multimodality group compared with the group of patients that underwent a single intracranial-based monitoring method and the group that received no monitoring (p = 0.003) based on a disability rating scale after a follow up of 12 months. Death was the focus of outcome in this study in which the multimodality approach to monitoring had superior results.

Outcome 3 to 5 years after moderate to severe traumatic brain injury

OBJECTIVE

To investigate neuropsychologic, emotional, and functional status and quality of life (QOL) 3 to 5 years after moderate to severe traumatic brain injury (TBI).

DESIGN

Observational cohort.

SETTING

Level I trauma center.

PARTICIPANTS

Consecutive adult admissions with TBI involving intracranial abnormalities, prospectively followed up for 3 to 5 years, with 80% follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Neuropsychologic functioning (Paced Auditory Serial Addition Test, California Verbal Learning Test), emotional status (Center for Epidemiologic Studies Depression Scale, Brief Symptom Inventory), functional status (Functional Status Examination, Glasgow Outcome Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, employment), and perceived QOL.

RESULTS

Significant functional limitations were observed in all areas. Recovery to preinjury levels ranged from 65% of cases in personal care to approximately 40% in cognitive competency, major activity, and leisure and recreation. Brain injury severity, measured by the modified Abbreviated Injury Scale, related to functional status and neuropsychologic functioning, but not to emotional or QOL measures. Length of impaired consciousness appeared to contribute to outcome more than did anatomic lesions.

CONCLUSIONS

The results provide representative estimates of long-term morbidity in patients with TBI involving intracranial lesions. The magnitude of morbidity was high. Although direct costs of TBI have received the most attention, the long-term consequences and their cost implications are much larger, unfold over time, and are borne by the survivors, their families, and the public subsidy system.