Admission GCS Research Articles

Time to Mobility Is Associated With Pulmonary Complications in Patients With Spine Fractures.

Treatment of spine fractures may require periods of prolonged immobilization which prevents effective pulmonary toileting. We hypothesized that patients with longer time to mobilization, as measured by time to first physical therapy (PT) session, would have higher pulmonary complications. We performed a retrospective review of all trauma patients with cervical and thoracolumbar spinal fractures admitted to a level 1 trauma center over a 12-month period. Demographic data collection included age, gender, BMI, pulmonary comorbidities, concomitant rib fractures, admission GCS, Injury Severity Score (ISS), GCS at 24h, treatment with cervical or thoracolumbar immobilization, and time to first PT evaluation. The primary outcome was the presence of any one of the following complications: unplanned intubation, pneumonia, or mortality at 30days. Multivariable logistic regression analysis was used to assess significant predictors of pulmonary complication. In total, 491 patients were identified. In terms of overall pulmonary complications, 10% developed pneumonia, 13% had unplanned intubation, and 6% died within 30days. In total, 19% developed one or more complication. Overall, 25% of patients were seen by PT <48h, 33% between 48 and 96h, 19% at 96h to 1week, and 7% > 1week. Multivariable logistic regression analysis showed that time to PT session (OR 1.010, 95% CI 1.005-1.016) and ISS (OR 1.063, 95% CI 1.026-1.102) were independently associated with pulmonary complication. Time to mobility is independently associated with pulmonary complications in patients with spine fractures.

273 A Direct Domparative Analysis of Pediatric Traumatic Brain Injury Presentation and Outcomes in the United States and Uganda

INTRODUCTION: Pediatric traumatic brain injury (pTBI) is the leading cause of death and disability among children globally. However, few studies have explored pTBI in low- and middle-income countries (LMICs) compared to high-income countries (HICs). METHODS: Patient records were extracted from the Duke University Hospital subset of the National Trauma Data Bank (NTDB, n = 866) and a dataset at the Mbarara Regional Referral Hospital in Uganda (MRRH, n = 571). Descriptive statistics were performed to compare across settings. Logistic regression was used to quantify the odds of mortality in each setting given ICU utilization, admission GCS, and other factors. RESULTS: In-hospital mortality was higher in the LMIC versus the HIC (9.4% vs 2.9%, p &lt; 0.001), while ICU utilization was lower in the LMIC (9.0% vs 33.4%, p &lt; 0.001). Rates of surgical management did not differ significantly (15.8% vs 17.0%). More patients presented with moderate (27.8% vs 4.3%) and severe TBI (16.5% vs 11.8%) in the LMIC (p &lt; 0.001). No deaths were reported among patients presenting with moderate or mild TBI in the HIC setting, whereas LMIC pTBI patients died in every TBI severity category. Over 50% of LMIC ICU patients died, versus 8.1% of HIC ICU patients. In a multivariate regression model of mortality, ICU placement was associated with mortality (OR: 6.7, 95% CI: 2.1-20.9), an association not seen in the HIC setting. CONCLUSIONS: Pediatric TBI mortality is greater in the LMIC vs the HIC setting. The LMIC setting also had a high prevalence of moderate/severe TBI and low ICU availability and effectiveness. Future work should involve the implementation and evaluation of interventions to assess these gaps in the LMIC setting.

Abstract TP168: Association of Factors With Disorders of Consciousness in Hemorrhagic Stroke Patients

Objective: Disorders of consciousness (DoC) are known to correlate with worse functional outcome after hemorrhagic stroke. Here we evaluate factors associated low Glasgow Coma Scale [GCS] score at time of admission in patients with hemorrhagic stroke. Methods: We performed a prospective cohort study of patients enrolled in the Neurological Emergencies Outcomes Study between January 2014 and June 2023 of patients with primary intracranial hemorrhage (intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH)). The primary outcome was coma (GCS ≤ 8) at time of admission. Univariable analysis with chi-squared test and Mann Whitney U test followed by adjusted logistic regression were used to assess the relationship between admission factors and DoC. We then confirmed the association with admission GCS and discharge modified Rankin score (mRS). Results: We included 314 patients admitted with intracranial hemorrhage, 51 (16%) of whom had GCS ≤ 8 at time of admission, 51% female and median [interquartile (IQR)] age of 63 [51-73]. The median [IQR] ICH volume was 9.3 ml [2.5-27.2] for ICH patients and the median [IQR] modified Fisher score was 3 [3-4] for SAH patients. Female gender, Asian race, hematoma size, hydrocephalus, peak temperature, lowest hemoglobin, and peak glucose in the first 24 hours were all associated with DoC (p&lt;0.05 for all). Controlling for age, disease process (ICH vs SAH), and all factors with p &lt; 0.05, we found female gender (OR 4.7, 95% CI 1.7-13.4), highest temperature (OR 3.8, 95% CI 1.9-7.3), lowest hemoglobin (OR 0.8, 95% CI 0.6-0.99), and highest glucose OR 1.01, 95% CI 1.00-1.02) remained significantly associated with coma at time of admission. Premorbid dependency as measured by Barthel Index was not a predictor of coma. However, coma at time of admission was associated with a worse discharge mRS (median discharge mRS [IQR] for patients with coma 5 [4-6] vs without 3 [2-4], p &lt; 0.001). Conclusions: We found that female gender, low hemoglobin, high body temperature, and elevated glucose at time of admission were all associated with coma. Low admission GSC (≤ 8) was associated with higher mRS at time of discharge. These modifiable risk factors are an important therapeutic target for improving outcomes for patients with DoC.

A nomogram for the prediction of short-term mortality in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a post-hoc analysis.

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype with high morbidity and mortality. Although several studies have developed a prediction model in aSAH to predict individual outcomes, few have addressed short-term mortality in patients requiring mechanical ventilation. The study aimed to construct a user-friendly nomogram to provide a simple, precise, and personalized prediction of 30-day mortality in patients with aSAH requiring mechanical ventilation. We conducted a post-hoc analysis based on a retrospective study in a French university hospital intensive care unit (ICU). All patients with aSAH requiring mechanical ventilation from January 2010 to December 2015 were included. Demographic and clinical variables were collected to develop a nomogram for predicting 30-day mortality. The least absolute shrinkage and selection operator (LASSO) regression method was performed to identify predictors, and multivariate logistic regression was used to establish a nomogram. The discriminative ability, calibration, and clinical practicability of the nomogram to predict short-term mortality were tested using the area under the curve (AUC), calibration plot, and decision curve analysis (DCA). Admission GCS, SAPS II, rebleeding, early brain injury (EBI), and external ventricular drain (EVD) were significantly associated with 30-day mortality in patients with aSAH requiring mechanical ventilation. Model A incorporated four clinical factors available in the early stages of the aSAH: GCS, SAPS II, rebleeding, and EBI. Then, the prediction model B with the five predictors was developed and presented in a nomogram. The predictive nomogram yielded an AUC of 0.795 [95% CI, 0.731-0.858], and in the internal validation with bootstrapping, the AUC was 0.780. The predictive model was well-calibrated, and decision curve analysis further confirmed the clinical usefulness of the nomogram. We have developed two models and constructed a nomogram that included five clinical characteristics to predict 30-day mortality in patients with aSAH requiring mechanical ventilation, which may aid clinical decision-making.

Clinical and Radiological Prognostication of Diffuse Axonal Injury

Introduction: We studied the efficacy of the admission neurological status (Glasgow Coma Score - GCS) and the radiological findings (Marshall, Rotterdam and MRI scoring systems) in prognostication of Diffuse Axonal Injury (DAI) using the Glasgow Outcome Score (GOS) to quantify the clinical outcome. Material and Methods: This is a prospective observational study of 158 consecutive Diffuse Axonal Injury (DAI) patients conducted at Madras Medical College. GCS at admission was taken as the clinical data. Marshall’s, Rotterdam and MRI scores were taken as radiological data. The patients’ GOS at 1 month was taken as clinical outcome. Statistical Analysis: Statistical analyses were then made to correlate the clinical and radiological data with the one-month outcome of the patients. Statistical analysis was done using the SPSS software – version 16 using statistical tests like Pearson’s coefficient and ANOVA. A p value of less than 0.05 was considered statistically significant. Results: The admission GCS and MRI grade of DAI showed a statistically significant correlation with the clinical outcome, but the Marshall and Rotterdam scores did not. Conclusion: Proper neurological evaluation of the patient with GCS score on admission and MRI brain when feasible, with both having a statistically significant correlation with clinical outcome, provide reliable prediction models for prognosticating outcome in DAI patients.

Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article.

Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.

Admission serum creatinine in non-hemodialysis-dependent patients with spontaneous supratentorial intracerebral hemorrhage: Is it a prognosticator?

IntroductionSpontaneous intracerebral hemorrhage (ICH) carries a high mortality rate, with end-stage renal disease (ESRD) and hemodialysis being risk factors for early mortality. However, the role of admission serum creatinine in ICH prognosis remains unclear. This study aimed to analyze the correlation between admission serum creatinine levels and short-term ICH prognosis in non-hemodialysis-dependent patients. MethodsThis retrospective study analyzed 296 adult patients admitted with spontaneous supratentorial ICH. Demographic, clinical, and radiographic data were collected, including admission serum creatinine levels. The primary outcomes were mortality and unfavorable outcomes, defined as Modified Rankin Scale scores of 4–6. Univariate or multivariate analysis was performed to examine the association between admission serum creatinine levels and ICH prognosis, with and without the inclusion of maintenance hemodialysis patients. ResultsAmong all patients, elevated admission serum creatinine levels were significantly associated with increased mortality (OR = 1.39, 95% CI: 1.21–1.59, P < 0.01). However, this association disappeared when excluding patients undergoing maintenance hemodialysis (OR = 0.95, 95% CI: 0.53–1.69, P = 0.86). No significant association was found between admission serum creatinine levels and unfavorable outcomes. Other well-established prognostic factors, such as age and admission GCS, demonstrated significant associations with both mortality and unfavorable outcomes in multivariate analysis. ConclusionAdmission serum creatinine appears to have limited prognostic value in non-hemodialysis-dependent patients with spontaneous supratentorial ICH. Our findings suggest that the relationship between renal function and ICH prognosis is complex and may be influenced by factors such as comorbidities and maintenance hemodialysis.

Diffuse Axonal Injury Pattern Predicts Timing of In-Hospital Neurologic Recovery: A Retrospective Case Series

Diffuse axonal injury (DAI) is a devastating traumatic neurological injury with variable prognosis. Although outcomes such as mortality have been described, the time course of neurological progression is poorly understood. We investigated the association between DAI neuroanatomical injury pattern and neurological recovery timing. A retrospective review of our institution's trauma registry identified patients diagnosed with DAI from 2017-2021. Neuroradiologist review of head CT was used to score DAI severity. In-hospital neurological exams were reviewed, and GCS was calculated for all patients throughout the hospital stay. Categorical variables were analyzed using Fisher's exact test and continuous variables were analyzed using Kruskal-Wallis test. Nineteen DAI patients (Grade 1=8; Grade 2=1; Grade 3=10) were included (mean age 31 years, 79% male). Mean Rotterdam CT score, Injury Severity Scale, and admission GCS were comparable across DAI grades. Mean time in days to follow commands was shorter for those with Grade 1 DAI (9.3) compared to Grade 2 (17 days) or Grade 3 (19 days) DAI (p=0.02). Throughout hospitalization, patients with Grade 1 DAI had higher motor (p=0.006), eye (p=0.001), and total GCS (p=0.011) score compared to those with Grade 2 or 3 DAI. At the time of discharge, total GCS and the frequency of command following was similar across DAI grades. Patients with Grade 1 DAI demonstrated the fastest short-term neurological recovery, although final discharge neurological examination was comparable across DAI grades. DAI classification can provide useful short-term prognostic information regarding in-hospital neurological improvement.

Clinical Features of Herpes Simplex Encephalitis and Risk Factors for Post-Encephalitic Epilepsy in Children

ObjectiveHerpes simplex encephalitis (HSE) is a common form of sporadic encephalitis and is prone to neurological sequelae such as epilepsy in young children, which can have a significant impact on young children at the time of neurological development. This study aimed to analyze the clinical features of HSE in children and to explore its risk factors for post-encephalitic epilepsy (PE).MethodsThe case data of children who met the HSE diagnostic criteria between January 2013 and June 2021 at the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed.Results The incidence of PE in children with HSE was 42.2% (19/45cases). The initial symptoms were fever with headache or convulsions. In the acute phase, there were 13 cases (28.9%) with psychiatric behavior disorders, 16 cases (35.6%) with neurological deficit symptoms, and 24 cases (53.3%) with altered consciousness. Univariate analysis of fever duration, fever peak, psychiatric behavior disorders, neurological deficit symptoms, acute phase seizures and seizure frequency, ICU length of stay, admission GCS, and cranial imaging in children with HSE indicated statistically significant mixed involvement (all P < 0.05), and multivariate logistic regression analysis suggested that repetitive seizures (more than 5 seizures) (OR = 1.551;95% CI 1.229–1.958, P < 0.001) in the acute phase was an independent risk factor for the occurrence of PE.Conclusion The main symptoms in children with HSE in the acute phase include seizures, altered consciousness, neurological deficit symptoms, and psychiatric behavioral abnormalities. Children with HSE has a high incidence of PE, especially if they have repetitive seizures (more than 5 seizures) in the acute phase.

Neighborhood Disadvantage and Outcomes Following Intracerebral Hemorrhage (S29.002)

<h3>Objective:</h3> We aimed to determine if neighborhood disadvantage is associated with poor outcomes following intracerebral hemorrhage (ICH). <h3>Background:</h3> Neighborhood disadvantage uniquely captures numerous social and environmental exposures. There is mounting evidence linking social determinants to various health outcomes. <h3>Design/Methods:</h3> We conducted a nested study within an ongoing longitudinal study that prospectively follows patients with brain injury within Connecticut’s largest healthcare system. The nested study included ICH survivors and evaluated neighborhood deprivation using the Area Deprivation Index (ADI), a publicly available metric that ranks neighborhoods’ disadvantage based on numerous factors. Patients were given an ADI tertile designation: low, intermediate, and high deprivation. Initial ICH severity was defined with admission GCS. Outcome was evaluated through the discharge and 6-month post-ICH Modified Rankin Scale (mRS), dichotomized as 0–3 (good outcome) and 4–6 (poor outcome). We used chi-square tests and multivariable logistic regression for unadjusted and adjusted association analyses, respectively. <h3>Results:</h3> Out of 687 enrolled ICH patients, 518 (mean age 67, 47.5% female, 19% Black, 8% Hispanic) had 9-digit zip-code and outcomes data. Neighborhood disadvantage was not associated with admission GCS (adjusted p=0.59) or discharge mRS (adjusted p=0.95). However, at 6-months post-discharge, the risk of poor outcome was 28%, 44%, and 47% for patients in neighborhoods with low, intermediate, and high disadvantage (unadjusted p=0.02). Multivariable analyses adjusting for potential confounders confirmed these results: compared to low-disadvantage neighborhoods, those living in neighborhoods with intermediate and high disadvantage had 52% (OR 1.52, 95%CI 0.76–3.08) and 89% (OR 1.89, 95%CI 0.91–3.94) higher risk of poor outcomes (test-for-trend p=0.01). <h3>Conclusions:</h3> Among ICH patients enrolled in a prospective study of acute brain injury, higher neighborhood disadvantage was associated with a higher risk of poor outcomes 6-months post-ICH but not with admission or discharge clinical status. These results suggest that the numerous factors captured by the ADI influence these subjects’ complex post-discharge evolution. <b>Disclosure:</b> Ms. Kim has nothing to disclose. Ms. Kitlen has nothing to disclose. Mr. Torres-Lopez has nothing to disclose. Dr. Rivier has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Pyxis Partners. Dr. Renedo has nothing to disclose. Ms. Schlechter has nothing to disclose. Ms. Kleinberg has nothing to disclose. Ms. Pish has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Twill Therapeutics. Mr. Kampp has nothing to disclose. Sara Jasak has nothing to disclose. Dr. Sansing has nothing to disclose. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll. Dr. Sheth has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NControl. Dr. Sheth has received stock or an ownership interest from Astrocyte. Dr. Sheth has received stock or an ownership interest from Alva. The institution of Dr. Sheth has received research support from Biogen. The institution of Dr. Sheth has received research support from Novartis. The institution of Dr. Sheth has received research support from Bard. The institution of Dr. Sheth has received research support from Hyperfine. Dr. Sheth has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Falcone has received research support from NIH. The institution of Dr. Falcone has received research support from AHA.

Secondary Neurologic Deterioration After Moderate Traumatic Brain Injury: Development of a Multivariable Prediction Model and Proposition of a Simple Triage Score.

Identifying patients at risk of secondary neurologic deterioration (SND) after moderate traumatic brain injury (moTBI) is a challenge, as such patients will need specific care. No simple scoring system has been evaluated to date. This study aimed to determine clinical and radiological factors associated with SND after moTBI and to propose a triage score. All adults admitted in our academic trauma center between January 2016 and January 2019 for moTBI (Glasgow Coma Scale [GCS] score, 9-13) were eligible. SND during the first week was defined either by a decrease in GCS score of >2 points from the admission GCS in the absence of pharmacologic sedation or by a deterioration in neurologic status associated with an intervention, such as mechanical ventilation, sedation, osmotherapy, transfer to the intensive care unit (ICU), or neurosurgical intervention (for intracranial mass lesions or depressed skull fracture). Clinical, biological, and radiological independent predictors of SND were identified by logistic regression (LR). An internal validation was performed using a bootstrap technique. A weighted score was defined based on beta (β) coefficients of the LR. A total of 142 patients were included. Forty-six patients (32%) showed SND, and 14-day mortality rate was 18.4%. Independent variables associated with SND were age above 60 years (odds ratio [OR], 3.45 [95% confidence interval {CI}, 1.45-8.48]; P = .005), brain frontal contusion (OR, 3.22 [95% CI, 1.31-8.49]; P = .01), prehospital or admission arterial hypotension (OR, 4.86 [95% CI, 2.03-12.60]; P = .006), and a Marshall computed tomography (CT) score of 6 (OR, 3.25 [95% CI, 1.31-8.20]; P = .01). The SND score was defined with a range from 0 to 10. The score included the following variables: age >60 years (3 points), prehospital or admission arterial hypotension (3 points), frontal contusion (2 points), and Marshall CT score of 6 (2 points). The score was able to detect patients at risk of SND, with an area under the receiver operating characteristic curve (AUC) of 0.73 (95% CI, 0.65-0.82). A score of 3 had a sensitivity of 85%, a specificity of 50%, a VPN of 87%, and a VPP of 44 % to predict SND. In this study, we demonstrate that moTBI patients have a significant risk of SND. A simple weighted score at hospital admission could be able to detect patients at risk of SND. The use of the score may enable optimization of care resources for these patients.

Clinical frailty scale as a predictor of outcome in elderly patients affected by moderate or severe traumatic brain injury.

Older age is a well-known risk factor for unfavorable outcome in traumatic brain injury (TBI). However, many older people with TBI respond well to aggressive treatments, suggesting that chronological age and TBI severity alone may be inadequate prognostic markers. Frailty is an age-related homeostatic imbalance of loss of physiologic and cognitive reserve resulting in both limitation in autonomy of activities of daily living and vulnerability to adverse events. We hypothesized that frailty would be associated with 6-month adverse functional outcome in older people affected by moderate or severe TBI. This was a single-center prospective observational study. We enrolled consecutive patients aged ≥65 years after TBI with Glasgow Coma Scale ≤13 and admitted to our Neurosurgical Intensive Care Unit. Frailty was evaluated by Clinical Frailty Scale (CFS). Relationships between TBI severity, frailty and extended Glasgow Outcome Scale (GOSE) at 6-month were evaluated. Sixty patients were studied, 65% were males, their age was 76 years (IQR 70-80) and their admission GCS was 8 (IQR 6-11) with a GCS motor score of 5 (IQR 4-5). Twenty eight were vulnerable-frail (defined as CFS ≥ 4). Vulnerable-frail patients showed greater 6-month mortality and unfavorable outcome compared to non-frail [87% vs. 30% OR and 95% CI: 15.7 (3.9-55.2), p < 0.0001 and 92% vs. 51% OR and 95% CI: 9.9 (2.1-46.3), p = 0.002]. In univariate analysis patients with unfavorable outcome were more frequently male and vulnerable-frail, had a higher prevalence of pre-existing neurodegenerative disease, abnormal pupil, lower GCS and had worst CT scan characteristics. At multivariate analysis, only CFS ≥ 4 and traumatic subarachnoid hemorrhage remained associated to 6-month outcome. Frailty was associated with 6 month-outcome, suggesting that the pre-injury functional status could represent an additional indicator to stratify patient's severity and to predict outcome.

766 Use of Ventriculostomy for Severe Traumatic Brain Injury Significantly Reduces Mortality Compared to Intraparenchymal Monitor Use

INTRODUCTION: There is a lack of data on whether intracranial pressure (ICP)-guided therapy with an intraparenchymal fiberoptic monitor (IPM) or an external ventricular drain (EVD) leads to superior outcomes. Given the lack of consensus on whether an EVD or an IPM monitor should be preferentially used if both are feasible options, there is a pressing need to determine which modality leads to more effective ICP-guided therapy while also minimizing the procedure-related complications. METHODS: Retrospective analysis of severe TBI that required IPM or EVD placement for ICP-guided therapy from 1/1/2010-12/31/2020. The data was obtained from the Pennsylvania Trauma Systems Foundation (PTSF) registry. RESULTS: A total of 2,305 patients met the inclusion criteria with 1,048 (45.5%) IPM and 1,257 (54.5%) EVD placed. A craniectomy was performed in 47.0% of the patients in the IPM cohort and 66.0% of the EVD cohort (p &lt; 0.001). Multivariable logistic regression analysis showed that older age (OR 1.03, p &lt; 0.001), decreasing GCS score (OR 1.16, p &lt; 0.001), requiring craniectomy (OR 1.22, p = 0.049), and an IPM (OR 1.40, p = 0.001) were significant predictors of mortality. Among those treated medically only, inpatient mortality occurred in 171 (30.8%) of those with an IPM and in 100 (23.4%) of those with an EVD (p = 0.010); the EVD conferred significant mortality benefit (30% decrease, p = 0.005) when controlling for age and admission GCS. CONCLUSIONS: The lack of consensus on whether IPM monitor or EVD is more effective leads to ambiguity in the treatment of patients with severe TBI. Our study demonstrates a significant improvement in mortality was associated with the use of EVD in comparison to IPM. This mortality benefit was seen in patients who underwent decompressive hemicraniectomy as well as those who did not.

Abstract Number ‐ 213: Single Center Experience of Intrathecal Nicardipine Use in The Treatment of Vasospasm‐ Lessons Learned

Introduction Symptomatic cerebral vasospasm and delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage leads to significant morbidity and mortality. Intrathecal (IT) nicardipine has been shown to improve outcome and reduce DCIin retrospective cohort studies1. Ecological validity of such reported conclusions may be a real‐world test of the efficacy of the proposed treatment.We sought to study our limited experience with this treatment modality in our cohort, in order to potentially inform our practice in treating vasospasm. Methods Retrospective case series of all patients who received IT nicardipine for the treatment of cerebral vasospasm from 2016 to 2021 at our University Hospital. Demographics, risk factors, clinical course and outcomes were analyzed. Results In addition to standard of care treatments and interventions, 12 patients received intrathecal nicardipine during the study period. IT nicardipine was given at doses of 2 mg every 8 hrs. Linear regression was conducted and found that IT nicardipine was associated with a reduction of the mean cerebral blood flow velocity of 16% on average. Among 12 patients, 5 patients had in‐hospital mortality; 4 out of these 5 patients developed in‐hospital DCI. Age (p 0.017), history of hypertension(HTN) (p 0.0007) were significant predictors for in‐hospital mortality. 6 patients developed DCI: mFisher scale (p 0.03), admission GCS (p 0.000998), vasopressor requirement to maintain target pressure (p 0.04) were significant predictors for developing DCI. Only 1 patient was diagnosed with bacterial ventriculitis (positive CSF culture). 80% (n = 5) patients had a favorable functional outcome (mRS≤2) at 90 days. Conclusions Our experience does not conform to the reported outcomes in a much larger patient cohort1. Nonetheless, the choice of this treatment on a case‐by‐case basis somewhat has led to rendering it as a salvage treatment at our center. In our cohort we found significant mortality rate, with age and HTN as predictive factors for in‐hospital mortality, and mFisher scale, admission GCS and vasopressor usage as predictors for DCI development. These results can be difficult to interpret, especially that the use of IT nicardipine was in only few selected patients with initial comorbidities potentially confounding the high mortality and morbidity in our cohort. Intrathecal nicardipine treatment without a well‐vetted protocol with clear inclusion and exclusion criteria can potentially misinform the practice style and lead to early abandonment of this promising therapy as part of our armamentarium. Thus, it is important to develop a standardized protocol with participation of all stakeholders of neurosurgery, neurocritical care, vascular neurology, pharmacy, and patient/family input before deploying in clinical practice on institutional level. Such protocols allow for a pilot study and more contextual prospective assessment of outcomes.

EPIDEMIOLOGY, TREATMENT STRATEGY &amp; OUTCOME IN PATIENTS WITH TRAUMATIC BASIFRONTAL CONTUSION- A RETROSPECTIVE STUDY IN A TERTIARY CARE HOSPITAL IN SOUTH INDIA

Background: Frontal contusions especially basifrontal region is quite common brain injury following road trafc accidents. The management of these basifrontal contusions depends upon various factors and appropriate management is important as these patients can deteriorate anytime during the hospital stay. The aim of this study is to analyze the epidemiology of basifrontal contus Objective: ions in head injury and assess the outcome following conservative vs. surgical treatment and to identify risk factors involving poor outcome in patients with traumatic basifrontal contusions. This study is a retrospective study from January 2022 to December 2022 conduc Material &amp; methods: ted in institute of neurosurgery , madras medical college. Total 310 patients with CT ndings of basifrontal contusion admitted between jan 2022- dec 2022 were studied. Results: Initial surgical decompression was done in 50 patients of which 10 patients having contusion volume &gt;50cm3 and 40 patients having contusion volume &gt; 35cm3&lt; 50cm3 . 10 patients were seen having increase in contusion volume &amp; were undergone delayed surgical intervention after 48 hours. Of 310 patients treated , 74 patients died of which 38 deaths were in post operative period and 10 death in patients who were managed conservatively , 26 deaths in those patients whose admission GCS was 3. Seven patients died due to rapid deterioration within 24 hours of admission having GCS 9 to 13 with contusion volume 20cm3 – 35cm3. Three patients died after 7 days with GCS 13-15 who were conservatively managed with contusion volume &lt; 20 cm3. Both sudden &amp; delayed deterioration complicated the clinical course of this disease with both increased mortality &amp; morbidity in bilateral lesions. Basifrontal contusion remains a Conclusion: challenge for the treating neurosurgeon when compared to contusions of other areas of brain as the basifrontal region is a silent area of brain and it is difcult to interrupt the quantum of injury and to elicit the features of increased intracranial pressure. Early surgical intervention might be appropriate in patients with contusion volume &gt;35cm3 with GCS &lt;9. Close observation with hourly GCS monitoring is essential in patients who are managed conservatively.

Implications of stimulus-induced, rhythmic, periodic, or ictal discharges (SIRPIDs) in hospitalized patients.

Stimulus-induced electroencephalographic (EEG) patterns are commonly seen in acutely ill patients undergoing continuous EEG monitoring. Despite ongoing investigations, the pathophysiology, therapeutic and prognostic significance of stimulus-induced rhythmic, periodic or ictal discharges (SIRPIDs) and how it applies to specific pathologies remain unclear. We aimed to investigate the clinical implications of SIRPIDs in hospitalized patients. This is a retrospective single-center study of hospitalized patients from May 2016 to August 2017. We included patients above the age of 18 years who underwent >16 h of EEG monitoring during a single admission. We excluded patients with cardiac arrest and anoxic brain injury. Demographic data were obtained as well as admission GCS, and discharge modified Rankin Score (mRS). EEGs were reviewed for background activity in addition to epileptiform, periodic, and rhythmic patterns. The presence or absence of SIRPIDs was recorded. Our outcome was discharge mRS defined as good outcome, mRS 0-4, and poor outcome mRS, 5-6. A total of 351 patients were included in the final analysis. The median age was 63 years and 175 (50%) were women. SIRPIDs were identified in 82 patients (23.4%). Patients with SIRPIDs had a median initial GCS of 12 (IQR, 6-15) and a length of stay of 12 days (IQR, 6-15). They were more likely to have absent posterior dominant rhythm, decreased reactivity, and more likely to have spontaneous periodic and rhythmic patterns and higher frequency of burst suppression. After adjusting for baseline clinical variables, underlying disease type and severity, and EEG background features, the presence of SIRPIDs was also associated with poor outcomes classified as MRS 5 or 6 (OR 4.75 [2.74-8.24] p ≤ 0.0001). In our cohort of hospitalized patients excluding anoxic brain injury, SIRPIDs were identified in 23.4% and were seen most commonly in patients with primary systemic illness. We found SIRPIDs were independently associated with poor neurologic outcomes. Several studies are indicated to validate these findings and determine the risks vs. benefits of anti-seizure treatment.

Insulin resistance is associated with an unfavorable outcome among non-diabetic patients with isolated moderate-to-severe traumatic brain injury - A propensity score-matched study.

BackgroundHyperglycemia is an independent risk factor for the poor prognosis in patients with traumatic brain injury (TBI), and stress-induced impaired insulin function is the major factor of hyperglycemia in non-diabetic patients with TBI. Several types of research suggested that insulin resistance (IR) is related to the poor prognosis of neurocritical ill patients; here we focused on the role of IR in non-diabetic patients after TBI.MethodsWe performed a prospective observational study with the approval of the Ethics Committee of our institute. IR was accessed via the update Homeostasis Model Assessment (HOMA2) of IR, a computer-calculated index by glucose and insulin level. HOMA2 ≥ 1.4 was considered as the threshold of IR according to the previous studies. The glycemic variability (GV) indices were calculated by fingertip blood glucose concentration at an interval of 2 h within 24 h to explore the relationship between IR and GV. The outcome was the 6-month neurological outcome evaluated with the Glasgow outcome scale.ResultsA total of 85 patients with isolated moderate-to-severe TBI (admission GCS ≤ 12) were finally included in our study, 34 (40%) were diagnosed with IR with HOMA2 ≥ 1.4. After propensity score matching (PSM), 22 patients in IR group were matched to 34 patients in non-IR group. Patients with IR suffered increased systemic glycemic variation after isolated moderate-to-severe TBI. IR was a significant factor for the poor prognosis after TBI (OR = 3.25, 95% CI 1.03–10.31, p = 0.041).ConclusionsThe IR estimated by HOMA2 was associated with greater GV and an unfavorable outcome after isolated moderate-to-severe TBI. Ameliorating impaired insulin sensitivity may be a potential therapeutic strategy for the management of TBI patients.

Abstract WMP82: Diffusion Tensor Imaging Is Independently Associated With Mobility After Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) patients may appear disabled despite intact cortical spinal tracts (CST). ICH lesions may also vary in volume and location relative to the CST with differential impacts on motor outcome. In this study, we evaluated whether diffusion tensor imaging (DTI) integrity of CST fiber tracking associates with mobility three months post ICH. Methods: The Recovery and Outcomes from StrokE (ROSE) Study is a prospective, multi-center study of ICH serially assessed with motor, cognitive, and functional outcomes and MRI/DTI. Outcome data were collected by hospital chart review and interview/exam. Acute MRI images were analyzed by a central neuroimaging core for ICH location, size, intraventricular hemorrhage, and fractional anisotropy (FA) derived from DTI of the CST. Mobility was assessed at 3-month follow-up using the Barthel Mobility Index. We computed single variable logistic regression analyses (outcome = Barthel mobility at 3 months). We also computed a stepwise logistic model, with and without age, sex, and race, including variables that met P&lt;0.1 to best fit. Results: There were 76 ICH patients with DTI FA data available for analysis; 61 with complete data for the multivariate model. Poor mobility after ICH (N = 21; 27.6%) was associated with ICH volume, presence of IVH, Glasgow coma score, ipsilesional CST FA, ipsilesional CP FA and CP FA asymmetry index (Table 1). The multivariate model that adjusted for age, sex, and race identified ipsilesional CP FA, admission GCS and presence of IVH as associated with poor mobility at 3 months; notably, log ICH volume was not associated after controlling for CST injury (Table 1). Conclusions: The presence of IVH and the GCS score at baseline were associated with poor mobility. In addition, the CP FA asymmetry index was independently associated with poor mobility even after accounting for log ICH volume, suggesting that DTI is informative of outcome beyond classic ICH outcome predictors.

Abstract TP132: Associations Of N-acetyl-aspartyl-glutamate With Intracerebral Hemorrhage Characteristics And Functional Outcomes: A Pilot Study

Introduction: N-acetyl-aspartyl-glutamate (NAAG) is a peptide-based neurotransmitter that has been extensively studied in many neurological diseases. N-acetylaspartate (NAA) and NAAG are markers of neuronal integrity. Decreased NAA on MR-spectroscopy is associated with neuronal damage in ischemic and hemorrhagic stroke. We investigated serial plasma concentrations of NAA and NAAG in patients with ICH to examine correlations with ICH severity. Methods: Plasma from 38 consecutive patients with ICH was collected up to 8 days post-ictus. Days 1 and 2 were defined as time point 1 (T1), days 3 and 4 as T2, etc. Five patients underwent surgery and were analyzed separately. NAA and NAAG concentrations were assessed using mass spectrometry. ICH, intraventricular hemorrhage (IVH) and perihematomal edema (PHE) volumes were analyzed from CT scans using computerized volumetrics. Modified Rankin Scale (mRS) was collected at 90 days. Spearman rank correlations (r s ) were used to describe associations between changes in metabolite values and continuous measures. Results: Mean age was 63 ± 13 years, 58% male, and median [IQR] initial ICH and IVH volumes were 16 [7-35] and 0 [0-5.2] mL respectively. Mean NAA/NAAG levels at T1 were 114k ± 112k and 18k ± 30k ion counts respectively. Mean levels of NAA were stable and NAAG decreased over time. T1 levels of NAAG were higher in males than females (25k vs. 6k ion counts; p=0.02), negatively correlated with admission GCS (r s = -0.5), and positively correlated with IVH volume (r s = 0.7). T1 levels of NAA/NAAG did not correlate with ICH or PHE volume or admission NIHSS. Increases (percent change) in NAAG from T1 to T3 correlated with higher 90-day mRS (r s = 0.5), and correlated negatively with IVH volume (r s = -0.6 for both T1-T3 and T1-T2). Percent change in NAAG from T1 to T4 correlated positively with both ICH and PHE volume (r s = 0.98 and 0.9). These correlations were not significant for percent change in NAA. In patients who had hematoma evacuation, median level of NAAG 1-2 days post-op was lower than pre-surgery (18k vs. 16k; p &gt; 0.05). Conclusions: Admission NAAG levels were associated with IVH volume, lower GCS, and male sex. Elevation of plasma NAAG following ICH correlated with worse 90-day outcomes and with higher ICH and PHE volumes.

Abstract 101: Predicting Hematoma Expansion Using An Artificial Neural Network: An Exploratory Analysis Of The Atach 2 Trial

Introduction: Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. Current clinical scoring models, radiological markers, and labs have limited ability to predict HE. This study aimed to create a more robust classification model to predict HE in patients with ICH using a deep learning algorithm, an artificial neural network (ANN). Methods: Data from the ATACH 2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient factors associated with HE and clinical expertise. HE was defined as increase in either &gt;33% or 6mL in hematoma volume in the first 24 hours. A multi-layer feedforward ANN was trained using the back-propagation method to minimize the loss function with 5-fold cross validation. 80% of patients were used for training and 20% for testing. The ANN was compared to a logistic regression model (GLM). Given the imbalance in patients with HE, AUPRC (area under the precision-recall curve), recall and precision were calculated for the respective models. Results: Of the 963 patients in the study (mean age 62±13.0, 38.5% female), 31% had hematoma expansion. The median [interquartile range (IQR)] initial hematoma volume was 10.5mm 3 [5.16 - 20.25], median admission SBP [IQR] was 200 [184-217], median platelet count [IQR] was 213 [178-256], median INR [IQR] was 1.0 [0.9-1.0], and median admission GCS [IQR] was 15 [13-15]. The GLM model had AUPRC of 0.38 with recall of 0.60 and precision of 0.38 in the testing cohort. The ANN training model demonstrated AUPRC of 0.92 with recall of 0.72 with precision of 0.39 during testing. Initial ICH volume, platelets, INR, and GCS had the highest feature importance. Conclusion: We developed an ANN to predict HE in ICH patients performing with improved sensitivity and similar positive predictive value when compared to GLM. We support that ANN can capture complex associations between variables not attainable in classic regression models. This model may help identify patients at risk for HE who warrant careful monitoring and aggressive treatment upfront including those suitable for clinical trials for treatments.