Factors Associated With Poor One\u2010Month Glasgow Outcome Scale Scores After Traumatic Brain Injury With Intracranial Hemorrhage in Adult Patients Presenting to the Emergency Department

Objective: For traumatic brain injury (TBI), therapeutic hypothermia (TH) has not shown efficacy in multicenter randomized controlled trials (RCTs). From the latest RCT (NABISH II and BHYPO), we hypothesized that preoperatively early-induced TH may be beneficial specifically in acute subdural hematoma (ASDH) patients who need evacuation. The aim of this project was thus 1) to test the efficacy of TH in an experimental rat model and 2) to translate these results to a multicenter RCT. Methods and Results-Experimental Study: Under anesthesia ASDH was induced, and the rats were placed into: 1) normothermia (37C) and 2) early-induced TH (33C, 30 minutes prior to decompressive craniotomy and ASDH removal). Results: The number of degenerating cells, extracellular biomarkers (UCH-L1 and GFAP), and injury volume were significantly smaller in the early hypothermia group than for normothermia. Conclusion and Future Implication for Multicenter RCT: Our experimental results suggested that preoperatively early-induced TH could mediate the reduction of neural damage in ASDH. Therefore, we are initiating a multicenter RCT both in JAPAN and US. This trial will employ several novel features as below: 1) The trial will enroll only ASDH patients who need emergency surgery 2) The trial will determine whether preoperatively induced hypothermia alters biomarkers and improves outcome, using a new intravascular cooling device, Quattro , for extra-rapid cooling. The study is conducted with the generous support of the Vivian L. Smith Foundation for Neurologic Research and in kind support from ZOLL Circulation.

ObjectiveTraumatic brain injury (TBI) in children under age 24 months has characteristic features because the brain at this age is rapidly growing and sutures are opened. Moreover, children this age are completely dependent on their parents. We analyzed the demographic data and risk factors for outcomes in TBI patients in this age group to elucidate their clinical characteristics.MethodsWe retrospectively reviewed the medical records and radiological films of children under 24 months who were admitted to Kyungpook National University Hospital from January 2004 to December 2013 for TBI. Specifically, we analyzed age, cause of injury, initial Glasgow coma scale (GCS) score, radiological diagnosis, seizure, hydrocephalus, subdural hygroma, and Glasgow outcome scale (GOS) score, and we divided outcomes into good (GOS 4–5) or poor (GOS 1–3). We identified the risk factors for post-traumatic seizure (PTS) and outcomes using univariate and multivariate analyses.ResultsThe total number of patients was 60, 39 males and 21 females. Most common age group was between 0 to 5 months, and the median age was 6 months. Falls were the most common cause of injury (n=29, 48.3%); among them, 15 were falls from household furniture such as beds and chairs. Ten patients (16.7%) developed PTS, nine in one week; thirty-seven patients (61.7%) had skull fractures. Forty-eight patients had initial GCS scores of 13–15, 8 had scores of 12–8, and 4 had scored 3–7. The diagnoses were as follows: 26 acute subdural hematomas, 8 acute epidural hematomas, 7 focal contusional hemorrhages, 13 subdural hygromas, and 4 traumatic intracerebral hematomas larger than 2 cm in diameter. Among them, two patients underwent craniotomy for hematoma removal. Four patients were victims of child abuse, and all of them had PTS. Fifty-five patients improved to good-to-moderate disability. Child abuse, acute subdural hematoma, and subdural hygroma were risk factors for PTS in univariate analyses. Multivariate analysis found that the salient risk factor for a poor outcome was initial GCS on admission.ConclusionThe most common cause of traumatic head injury in individuals aged less than 24 months was falls, especially from household furniture. Child abuse, moderate to severe TBI, acute subdural hematoma, and subdural hygroma were risk factors for PTS. Most of the patients recovered with good outcomes, and the risk factor for a poor outcome was initial mental status.

Chapter 16. Glucose and nutrition

Factors Affecting Outcome in Treatment of Chronic Subdural Hematoma in ICU Patients: Impact of Anticoagulation

BackgroundGlobally, severe traumatic brain injury (TBI) has been the principal cause of mortality among individuals aged 45 and below. The incidence of road traffic accidents in Malaysia is one of the highest in the world with thousands of victims sustaining severe disabilities. The aim of this study is to determine the association between leucocytosis and extended Glasgow Outcome Scale (GOSE) scores as well the relationship of other factors and the outcomes of severe TBI.MethodsThis was a retrospective observational study. A total of 44 consecutive patients who were admitted to Sarawak General Hospital from January 1, 2018, to September 30, 2018, with severe TBI were included. Data were collected from discharge summaries and hospital medical records. Chi-square and t test were used. SPSS was employed.ResultsOf a total of 44 patients with severe TBI, 18 patients (41%) died during the same admission. The mean age of patients was 37.1 years with 93.2% of affected patients being male. 56.9% of patients presented with a Glasgow Coma Scale (GCS) of 6 and less. A large percentage (86.3%) were discharged with a GOSE of less than 7. Older age and low admission GCS (6 and less) were significantly associated with poor GOSE scores on discharge and after 6 months (p < 0.05) on multivariate analysis. Leucocytosis on admission was also associated with poor outcomes where patients with higher total white counts on presentation attaining lower GOSE scores (p < 0.05).ConclusionWe concluded that leucocytosis was significantly associated with poor outcomes in severe TBI patients in addition to other factors such as advanced age and poor GCS on arrival.

Dynamic change in cortisol levels associated with severity, progression, and survival of patients with traumatic brain injury

Background: The present study aims to describe the severity of injury [Glasgow Coma Scale (GCS)] and outcome of patients [Glasgow Outcome Scale (GOS)] who presented to our hospital with TBI and factors which affect the clinical outcome.Subjects and Methods:All patients, aged equal to or more than 18 years, presenting to the Emergency Department of our hospital due to head trauma during the study period were examined and assessed using GCS at the time of admission, and GOS at the time of discharge.Results:The most common mode of injury was road traffic accident (48%). At the time of admission, 47% had GCS of 13 to 15, 37% had GCS of 9 to 12 and 16% had GCS of 3 to 8. At the time of discharge, we found that 18 patients had GOS of 1, no patient had GOS of 2, 14 patients had GOS Of 3, 28 had GOS of 4 and 29 had GOS of 5. We found that age of the patients was significantly associated with the GOS severity (p value &lt;0.05). Furthermore, GCS at admission was found to be significantly associated with GOS at discharge (p value &lt;0.01). Midline shift on CT head, effaced basal cistern, and presence of subarachnoid haemorrhage were also found to be significantly associated with poor GOS at discharge.Conclusion: The results of our study may be used for stratification of patients, and developing prognostic models to improve the clinical outcome of head injury.

Neurobehavioral symptoms are not uncommon after a traumatic brain injury. However, psychiatric syndromes per se have rarely been studied in patients with such an injury. The purpose of this study was to evaluate the type and extent of psychiatric syndromes in patients with traumatic brain injury. One hundred ninety-six hospitalized adults were studied 1 year after a traumatic brain injury with the use of a two-stage psychiatric diagnostic procedure. Psychiatric diagnoses were made according to ICD-10 criteria on the basis of data from the Schedules for Clinical Assessment in Neuropsychiatry interview. Of 164 patients interviewed, 30 (18.3%) had an ICD-10 diagnosis of a psychiatric illness. Among the 120 patients who were 18-64 years old, 21.7% had a psychiatric illness, compared with 16.4% in a study of the general population. A depressive illness was present in 13.9% of the traumatic brain injury patients, compared with 2.1% of the general population, and panic disorder was present in 9.0%, compared with 0.8% of the general population. In comparison with the general population, a higher proportion of adult patients had developed psychiatric illnesses 1 year after a traumatic brain injury; the rates of depressive episode and panic disorder were significantly higher in the study group. A history of psychiatric illness, an unfavorable global outcome according to the Glasgow Outcome Scale, a lower score on the Mini-Mental State examination, and fewer years of formal education seemed to be important risk factors in the development of a psychiatric illness. Compensation claims, however, were not associated with the rate of psychiatric illness.

Posterior pituitary function remains poorly investigated after traumatic brain injury (TBI). We report the results of a study designed to prospectively define the natural history of post-traumatic diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) using standard reliable methodology. 50 consecutive patients with severe or moderate TBI (initial Glasgow Coma Scale (GCS) score 3/15-13/15) were prospectively studied on three occasions: at the acute phase and at 6 months and at 12 months following TBI. In the acute phase, DI was diagnosed either by the presence of hypernatraemia in association with hypotonic polyuria or by the water-deprivation test (WDT) and, at 6 and 12 months by the WDT in all patients. Normative data on response to the WDT were obtained from healthy matched volunteers. Functional outcome was assessed using the Glasgow Outcome Scale (GOS). 13 patients (26%) had DI in the acute post-TBI phase, of whom nine patients recovered by 6 months and one additional patient recovered by 12 months. Of the remaining three patients with permanent DI, two had partial vasopressin deficiency. Acute-phase peak plasma osmolality correlated negatively with the initial GCS scores (r = -0.39, P = 0.005) and with the GOS scores (r = -0.45, P = 0.001). Seven patients had SIADH in the acute phase of TBI but none did at 6 or 12 months. No new cases of DI or SIADH were noted after the acute phase. This prospective study shows that posterior pituitary dysfunction is common following TBI. Most cases recover completely but there is an appreciable frequency of long-term DI which can be subtle and should be recognized and managed appropriately.

Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a "normal" outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.

Objective To compare the clinical efficacy of multi-target lateral puncture combined with intracranial pressure monitoring in treatment of basal ganglia hypertensive cerebral hemorrhage. Methods Sixty-six patients of basal ganglia hypertensive cerebral hemorrhage, with bleeding volume over 40 ml were divided into experimental group (36 cases) and control group (30 cases) by random digits table method. Patients in experimental group underwent multi-target puncture combined with routine intracerebroventricular treatment of intracranial pressure monitoring,and patients in control group underwent frontotemporal craniotomy and small hematoma decompressive craniotomy. The operation time, length of stay, hematoma evacuation rate, catheter drainage time, total amount of mannitol, Glasgow Coma Scale (GCS) scores 3 days after treatment, complication rate and 3-month Glasgow Outcome Scale (GOS) scores were recorded and compared between two groups. Results The operation time, length of stay, hematoma evacuation rate 1 day after treatment, and total amount of mannitol in experimental group were significantly lower than those in control group: (67.5 ± 8.0) min vs. (109.3 ± 9.6) min, (18.6 ± 4.2) min vs. (23.3 ± 5.9) min, (59.7 ± 9.2)% vs. (80.4 ± 11.6)%, (668.6 ± 83.5) g vs. (1 430.4 ± 107.1) g,P 0.05). The GOS scores in experimental group: 5 points (9 cases), 4 points (10 cases), 3 points (8 cases), 2 points(5 cases), and 1 point(4 cases). The GOS scores in control group: 5 points (4 cases), 4 points (4 cases), 3 points (7 cases), 2 points (9 cases), and 1 point (6 cases). Long curative effect in experimental group was better than that in control group (Z =2.318,P =0.020). The incidence of intracranial air in experimental group was significantly higher than that in control group: 27.8%(10/36) vs. 3.3%(1/30),P 0.05). Conclusions Multi-target lateral puncture combined with intracranial pressure monitoring in treatment of basal ganglia hypertensive cerebral hemorrhage has more advantages, including less trauma, wide surgical indications, short operation time and hospital stay, less postoperative mannitol, and decreased mortality rate. For older, patients with organ dysfunction, and patients who can not tolerate craniotomy, it is an effective treatment, and worthy of promotion. Key words: Punctures; Intracranial pressure; Intracranial hemorrhage, hypertensive

α-Synuclein is one of the most abundant proteins in presynaptic terminals. Normal expression of α-synuclein is essential for neuronal survival and it prevents the initiation of apoptosis in neurons through covalent cross-linking of cytochrome c released from mitochondria. Exocytosis of α-synuclein occurs with neuronal mitochondrial dysfunction, making its detection in cerebrospinal fluid (CSF) of children after severe traumatic brain injury (TBI) a potentially important marker of injury. Experimental therapeutic hypothermia (TH) improves mitochondrial function and attenuates cell death, and therefore may also affect CSF α-synuclein concentrations. We assessed α-synuclein levels in CSF of 47 infants and children with severe TBI using a commercial ELISA for detection of monomeric protein. 23 patients were randomized to TH based on published protocols where cooling (32–33°C) was initiated within 6–24 h, maintained for 48 h, and then followed by slow rewarming. CSF samples were obtained continuously via an intraventricular catheter for 6 days after TBI. Control CSF (n = 9) was sampled from children receiving lumbar puncture for CSF analysis of infection that was proven negative. Associations of initial Glasgow Coma Scale (GCS) score, age, gender, treatment, mechanism of injury and Glasgow Outcome Scale (GOS) score with CSF α-synuclein were compared by multivariate regression analysis. CSF α-synuclein levels were elevated in TBI patients compared to controls (p = 0.0093), with a temporal profile showing an early, approximately 5-fold increase on days 1–3 followed by a delayed, >10-fold increase on days 4–6 versus control. α-Synuclein levels were higher in patients treated with normothermia versus hypothermia (p = 0.0033), in patients aged <4 years versus ≧4 years (p < 0.0001), in females versus males (p = 0.0007), in nonaccidental TBI versus accidental TBI victims (p = 0.0003), and in patients with global versus focal injury on computed tomography of the brain (p = 0.046). Comparisons of CSF α-synuclein levels with initial GCS and GOS scores were not statistically significant. Further studies are needed to evaluate the conformational status of α-synuclein in CSF, and whether TH affects α-synuclein aggregation.

C-tau biomarker of neuronal damage in severe brain injured patients: association with elevated intracranial pressure and clinical outcome

Objective To explore the appropriate target ranges of blood glucose in intensive insulin therapy (IIT) for acute hyperglycemia following traumatic brain injury (TBI). Methods A randomized, open-label and controlled clinical trial was performed on 208 patients, admitted to our hospitals from Junuary 2014 to Sepember 2016. They were divided into IIT group (n=156), who were subdivided into slight (10.1-13.0 mmol/L), moderate (7.1-10.0 mmol/L), and strict (4.4-7.0 mmol/L) control blood glucose groups (n=52), and non-IIT group (n=52). Survival analysis 6 months after treatment was performed by Kaplan-Meier method. Modified Rankin scale (mRS) scores and Barthel index (BI), Glasgow Outcome scale (GOS) scores, concentrations of lactic acid in cerebrospinal fluid (CSF) and glycosylated hemoglobin, Glasgow coma scale (GCS) scores, Acute Physiology and Chronic Health Evaluation (APACHE II) scores, Length of staying in intensive care unit (ICU) and incidence of adverse events were compared between the patients from different groups at different treatment times. Results Blood glucose level within 7 d of admission in patients of IIT group was in target ranges. The survival rate of patients from slight and moderate control blood glucose groups was significantly higher than that in the non-IIT group and strict control blood glucose group 6 months after treatment (χ2=4.237, P=0.040; χ2=5.621, P=0.018). As compared with those in the non-IIT group and strict control blood glucose group, the mRS scores 3 months after treatment were significantly decreased, and GOS scores and BI one, 3 and 6 months after treatment were significantly increased in patients from slight and moderate control blood glucose groups (P<0.05). As compared with that in the non-IIT group, and slight and moderate control blood glucose groups, the glycosylated hemoglobin level 7 d after treatment was significantly decreased in strict control blood glucose group (P<0.05). As compared with those in the non-IIT group and strict control blood glucose group, the concentration of lactic acid in CSF 7 d after treatment, APACHE II scores 7 and 14 d after treatment, length of staying in ICU and incidence of adverse events were significantly decreased in patients from slight and moderate control blood glucose groups (P<0.05). The mean value of blood glucose in slight and moderate control blood glucose groups was (8.40±0.39) mmol/L. Conclusion Proper IIT improves the outcomes of TBI patients and (8.40±0.39) mmol/L are established as the target ranges in IIT for TBI. Key words: Traumatic brain injury; Hyperglycemia; Intensive insulin therapy; Outcome

Decompressive craniectomy (DC) is often performed in conjunction with evacuation of intracranial hemorrhage (ICH) to control intracranial pressure (ICP) in patients with a traumatic brain injury (TBI). The efficacy of DC in lowering ICP is well established; however, its effect on clinical outcomes remains controversial. The aim of our study is to assess outcomes in TBI patients undergoing DC versus craniotomy only (CO) for the evacuation of ICH. We performed a 5-year retrospective analysis of TBI patients with ICH who underwent craniotomy or craniectomy for traumatic ICH. Patients were divided into two groups, those who underwent CO and those who underwent DC. Propensity scoring matched patients in a 1:2 ratio for demographics, admission Glasgow Coma Scale (GCS) score, severity of injury, type and size of ICH, and anticoagulant use. Outcome measures included mortality, adverse discharge disposition (skilled nursing facility), discharge GCS and Glasgow Outcome Scale scores, and complications. We reviewed 1,831 patients with TBI, of which 155 underwent craniotomy and/or craniectomy. After propensity score matching, we included 99 of those patients in our study (DC, 33; CO, 66). Matched groups were similar in age (p = 0.68), admission GCS score (p = 0.50), Injury Severity Score (p = 0.70), head Abbreviated Injury Scale score (p = 0.32), and intracranial bleeding characteristics. Overall, 26.3% (n = 26) of the patients died and 62.6% (n = 62) were discharged to Rehab/skilled nursing facility. There was no difference in the mortality rate (27.3% vs. 25.0%; p = 0.99), adverse discharge disposition (45% vs. 33%; p = 0.66), GCS score (p = 0.53), and Glasgow Outcome Scale (p = 0.80) at discharge between the DC and the CO groups. However, patients in DC group had higher complication rates and ventilator days. This study showed no significant difference in clinical outcomes for patients undergoing evacuation of ICH regardless of the procedure performed. DC did not appear to be superior to craniotomy alone for the treatment of acute ICH. Therapeutic, level III.