Evaluation of the Glasgow Coma Scale-Pupils score for predicting inpatient mortality among patients with traumatic subdural hematoma at United States trauma centers

OBJECTIVE

The Glasgow Coma Scale-Pupils (GCS-P) score has been suggested to better predict patient outcomes compared with GCS alone, while avoiding the need for more complex clinical models. This study aimed to compare the prognostic ability of GCS-P versus GCS in a national cohort of traumatic subdural hematoma (SDH) patients.

METHODS

Patient data were obtained from the National Trauma Data Bank (2017-2019). Inclusion criteria were traumatic SDH diagnosis with available data on presenting GCS score, pupillary reactivity, and discharge disposition. Patients with severe polytrauma or nonsurvivable head injury at presentation were excluded. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of GCS-P versus GCS scores for inpatient mortality prediction were evaluated across the entire cohort, as well as in subgroups based on age and traumatic brain injury (TBI) type (blunt vs penetrating). Calibration curves were plotted based on predicted probabilities and actual outcomes.

RESULTS

A total of 196,747 traumatic SDH patients met the study inclusion criteria. Sensitivity (0.707 vs 0.702), specificity (0.821 vs 0.823), and AUC (0.825 vs 0.814, p < 0.001) of GCS-P versus GCS scores for prediction of inpatient mortality were similar. Calibration curve analysis revealed that GCS scores slightly underestimated inpatient mortality risk, whereas GCS-P scores did not. In patients > 65 years of age with blunt TBI (51.9%, n = 102,148), both GCS-P and GCS scores underestimated inpatient mortality risk. In patients with penetrating TBI (2.4%, n = 4,710), the AUC of the GCS-P score was significantly higher (0.902 vs 0.851, p < 0.001). In this subgroup, both GCS-P and GCS scores underestimated inpatient mortality risk among patients with lower rates of observed mortality and overestimated risk among patients with higher rates of observed mortality. This effect was more pronounced in the GCS-P calibration curve.

CONCLUSIONS

The GCS-P score provides better short-term prognostication compared with the GCS score alone among traumatic SDH patients with penetrating TBI. The GCS-P score overestimates inpatient mortality risk among penetrating TBI patients with higher rates of observed mortality. For penetrating TBI patients, which comprised 2.4% of our SDH cohort, a low GCS-P score should not justify clinical nihilism or forgoing aggressive treatment.

Impact of Antithrombotic Medications and Reversal Strategies on the Surgical Management and Outcomes of Traumatic Acute Subdural Hematoma

OBJECTIVE

Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications. We sought to compare outcomes between patients with aSDH taking antithrombotic medications at admission who received antithrombotic reversal with patients with aSDH not taking antithrombotics.

METHODS

Retrospective review identified patients with traumatic aSDH requiring surgical evacuation. The cohort was divided based on antithrombotic use and whether pharmacologic reversal agents or platelet transfusions were administered. A 3-way comparison of outcomes was performed between patients taking anticoagulants who received pharmacologic reversal, patients taking antiplatelets who received platelet transfusion, and patients not taking antithrombotics. Multivariable regressions, adjusted for injury severity, further investigated associations with outcomes.

RESULTS

Of 138 patients who met inclusion criteria, 13.0% (n = 18) reported taking anticoagulants, 16.7% (n = 23) reported taking antiplatelets, and 3.6% (n = 5) reported taking both. Patients taking antiplatelets who received platelet transfusion had longer intraoperative times (P = 0.040) and higher rates of palliative care consultations (P = 0.046) compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics. Across groups, no significant differences were found in frequency of in-hospital intracranial hemorrhage and venous thromboembolism, length of hospital stay, rate of inpatient mortality, or follow-up health status. In multivariable analysis, intraoperative time remained longest for the antiplatelets with platelet transfusion group. Other outcomes were not associated with patient group.

CONCLUSIONS

Among surgical patients with traumatic aSDH, those taking antiplatelet medications who receive platelet transfusions experience longer intraoperative procedure times and higher rates of palliative care consultation. Comparable outcomes were observed between patients receiving antithrombotic reversal and patients not taking antithrombotics.

Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes

BACKGROUND AND OBJECTIVES

Acute subdural hematoma (aSDH) after traumatic brain injury frequently requires emergent craniotomy (CO) or decompressive craniectomy (DC). We sought to determine the variables associated with either surgical approach and to compare outcomes between matched patients.

METHODS

A multi-center retrospective review was used to identify traumatic aSDH patients who underwent CO or DC. Patient variables independently associated with surgical approach were used for coarsened exact matching.Multivariate logistic regression and multivariate Cox proportional-hazards regression wereconducted on matched patients to determine independent predictors of mortality.

RESULTS

Seventy-six patients underwent CO and sixty-two underwent DC for aSDH evacuation. DC patients were21.4 years younger (P < 0.001), more likely to be male (80.6 % vs 60.5 %,P = 0.011), and present with GCS ≤ 8 (64.5 % vs 36.8 %,P = 0.001). Age (P < 0.001), epidural hematoma (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and intraventricular hemorrhage (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003).

CONCLUSION

aSDH patients who receive surgical evacuation via DC as opposed to CO are younger, more likely to be male, and have worse clinical exam. After controlling for patient differences via coarsened exact matching, DC is independently associated with mortality.

Dataset on flow diversion procedures performed with the Pipeline Embolization Device, Pipeline Flex, and Surpass Streamline for intracranial aneurysms

Flow diversion is an evolving endovascular modality for treating intracranial aneurysms. Although rare, serious adverse events following flow diversion may include ischemic stroke, intracranial hemorrhage, or delayed rupture of the treated aneurysm. This dataset describes 141 flow diversion procedures performed with the Pipeline Embolization Device, Pipeline Flex, or Surpass Streamline on 126 subjects with intracranial aneurysms [1]. The retrospective data were collected from electronic medical records at two large tertiary centers. Baseline patient data included age, sex, and medical comorbidities. The dataset also describes aneurysm characteristics including laterality, anatomic location, morphology, dome height, and neck width. In addition, digital subtraction images showing the internal carotid artery tortuosity were included for aneurysms in the anterior cerebral circulation [2]. Procedural data include case duration, radiation exposure, number of flow diverters deployed, and complications encountered during deployment. In addition, data related to the duration of hospitalization and postoperative adverse events are included. Finally, time to follow up and rates of total aneurysm obliteration at first and second postoperative visits are included. This data is propensity score matching are included. This data is presented as a starting point for future prospective comparisons in the safety and efficacy of flow diverters as more devices become approved and commercially available.

Pipeline Embolization Device and Pipeline Flex Versus Surpass Streamline Flow Diversion in Intracranial Aneurysms: A Retrospective Propensity Score-Matched Study

OBJECTIVE

To compare safety and efficacy profiles in aneurysms treated with Pipeline Embolization Device or Pipeline Flex versus Surpass Streamline flow diverters (FDs).

METHODS

Patients who underwent flow diversion for aneurysm treatment at 2 centers were included. Covariates comprised patient demographics, comorbidities, and aneurysm characteristics. Metrics included number of devices, adjuvant device use, case duration, and radiation exposure. Outcomes included periprocedural complications and radiographic results at follow-up. Propensity score-matched pairs were generated using demographic and aneurysm characteristics to verify the outcomes in equally sized groups.

RESULTS

The majority of 141 flow diversion procedures performed on 126 patients were in the anterior circulation (96%) and unruptured (93%). Operators experienced more complications placing Surpass FDs compared with Pipelines (18.2% vs. 3.1%, P = 0.005) but used fewer Surpass devices per case (1 device in all Surpass cases and range for Pipeline cases 1-7; P < 0.001). Ballooning was more frequent for Surpass (29.5% vs. 2.1%, P < 0.001). There were no differences in mortality (2.1% vs. 0, P = 1.00), intracranial hemorrhage (3.1% vs. 0, P = 0.551), or stroke (4.2% vs. 6.8%, P = 0.680). Rates of aneurysm obliteration at follow-up were similar. Propensity-matched pairs had no differences in FD deployment complications or perioperative events, yet the significant differences remained for adjuvant balloon use and number of FDs deployed.

CONCLUSIONS

While the devices demonstrated similar safety and efficacy profiles, deployment of the Surpass Streamline was more technically challenging than Pipeline Embolization Device or Pipeline Flex. Prospective cohort studies are needed to corroborate these findings.

Associating cryptogenic ischemic stroke in the young with cardiovascular risk factor phenotypes

Acute Ischemic Stroke (AIS) in the young is increasing in prevalence and the largest subtype within this cohort is cryptogenic. To curb this trend, new ways of defining cryptogenic stroke and associated risk factors are needed. We aimed to gain insights into the presence or absence of cardiovascular risk factors in cases of cryptogenic stroke. We conducted a retrospective cohort study of patients aged 18-49 who presented to an urban tertiary care center with AIS. We manually collected predefined demographic, clinical, laboratory and radiological variables. Clinical risk phenotypes were determined using these variables through multivariate analysis of patients with the small and large vessel disease subtypes (vascular phenotype) and cardioembolic subtype (cardiac phenotype). The resultant phenotype models were applied to cases deemed cryptogenic. Within the 449 patients who met criteria, patients with small and large vessel disease (vascular phenotype) had higher rates of hypertension, intracranial atherosclerosis, and diabetes mellitus, and higher admission glucose, HbA1c, admission blood pressure, and cholesterol compared to the patients with cardioembolic AIS. The cardioembolic subgroup (cardiac phenotype) had significantly higher rates of congestive heart failure (CHF), rheumatic heart disease, atrial fibrillation, clotting disorders, left ventricular hypertrophy, larger left atrial sizes, lower ejection fractions, and higher B-type natriuretic peptide and troponin levels. Adjusted multivariate analysis produced six variables independently associated with the vascular phenotype (age, male sex, hemoglobin A1c, ejection fraction (EF), low-density lipoprotein (LDL) cholesterol, and family history of AIS) and five independently associated with the cardiac phenotype (age, female sex, decreased EF, CHF, and absence of intracranial atherosclerosis). Applying these models to cryptogenic stroke cases yielded that 51.5% fit the vascular phenotype and 3.1% fit the cardiac phenotype. In our cohort, half of young patients with cryptogenic stroke fit the risk factor phenotype of small and large vessel strokes.

Abstract TP183: Characteristics of Stroke in the Young in a Diverse Urban County

Introduction: The incidence of acute ischemic stroke (AIS) among the young in the United States has increased by as much as 35% over the past 15 years. To curb this trend, more information is needed on the subtypes and risk factors for AIS in the young. We sought to characterize AIS subtypes in patients aged 19 to 49 in a racially and ethnically diverse urban county.

Hypothesis: We hypothesized that race/ethnic minorities would have a younger median age of AIS and more small vessel disease given known disparities in cardiovascular health.

Methods: We performed a retrospective cohort study of AIS patients aged 19-49 discharged from two Bronx-based academic teaching hospitals from 2013 to 2018. Strokes were subtyped using TOAST criteria. ANOVA and Mann-Whitney U-tests were used to determine age differences and chi-squared analysis was used to determine differences in subtype.

Results: In the 451 patients that met inclusion criteria, mean age was 41.1 (median = 44) and 48.2% were women. We found no differences in subtype by race or ethnicity. In addition, though the median age of AIS was similar by race, it was significantly lower in Hispanic patients compared to non-Hispanic patients (median Hispanic = 42; median non-Hispanic = 45; p = 0.024; table 1). Finally, the median ages of patients with cardioembolic (CE), cryptogenic and other subtypes were significantly lower than the median ages of patients with lacunar and large artery atherosclerosis (LAA) subtypes (median CE = 41yrs; median cryptogenic = 43 yrs; median other = 40 yrs; median lacunar = 47 yrs; median LAA = 47 yrs; figure 1).

Conclusions: The proportion of AIS subtypes in a diverse urban cohort aged 19-49 did not vary by race or ethnicity. Patients with CE and cryptogenic stroke types were significantly younger than those with lacunar and LAA subtypes. More exploration of subtype-specific risk factors is needed to understand drivers of stroke in the young.

Error bars indicate median and 95% CI. ** p <0.01; *** p <0.001; **** p <0.0001

Kinesin-6 KIF20B is required for efficient cytokinetic furrowing and timely abscission in human cells

KIF20B is in the Kinesin-6 family that includes KIF23/MKLP1 and KIF20A/MKLP2. Previously we showed that mouse Kif20b regulates cerebral cortex growth and neural stem cell midbodies. Now we show KIF20B has a cell-autonomous role in regulating cytokinetic furrowing and abscission. KIF20B may coordinate late midbody maturation before abscission.

Cytokinesis requires the cooperation of many cytoskeletal and membrane regulators. Most of the major players required for cytokinesis are known, but the temporal regulation and adaptations for different cell types are less understood. KIF20B (previously called MPHOSPH1 or MPP1) is a member of the Kinesin-6 family, which also includes the better-known members KIF23/MKLP1 and KIF20A/MKLP2. Previously, we showed that mouse Kif20b is involved in cerebral cortex growth and midbody organization of neural stem cells. Here, using siRNA-mediated knockdown of KIF20B in a human cell line and fixed and live imaging, we show that KIF20B has a cell-autonomous role in cytokinesis. KIF20B depletion affects the speed of both furrow ingression and abscission. It localizes to microtubules of the central spindle and midbody throughout cytokinesis, at sites distinct from the other Kinesin-6 family members. KIF20B is not required for midbody assembly, but may accelerate or coordinate midbody maturation. In particular, KIF20B appears to regulate late steps of maturation including anillin dispersal, ESCRT-III recruitment, and the formation of microtubule constriction sites.