Baseline Glasgow Coma Scale Score Research Articles

The frequency of imaging markers adjusted for time since symptom onset in intracerebral hemorrhage: A novel predictor for hematoma expansion.

Hematoma expansion (HE) is common in patients with intracerebral hemorrhage (ICH) and associated with a worse outcome. Imaging makers and shorter time from symptom onset are both associated with HE, but prognostic scores based on these parameters individually have not been satisfactory. We hypothesized that a score including both imaging markers of expansion, and time of onset, would improve prediction. Patients with supratentorial ICH within 6 h after onset were consecutively recruited from six centers between January 2018 and August 2022. Three markers were used: hypodensities, the blend sign, and the island sign. We first defined frequency of imaging markers (FIM) as the relationship between the number of imaging markers and onset-to-CT time (OCT). The time-adjusted FIM was defined as the ratio of the number of imaging markers to the onset-to-initial imaging time. Multivariate analysis was performed to determine the relationship between FIM and HE. Receiver operating curve analysis was used to identify potential threshold values of FIM that optimally predict HE. In addition, the sensitivity, specificity, positive and negative predictive values (PPVs and NPVs), and the area under the curve (AUC) of the optimal cut-off in predicting HE were calculated. In total, 1488 patients were eligible for inclusion, of whom 418 had incident HE. Multivariate analysis showed that age, male sex, baseline Glasgow Coma Scale score, presence of intraventricular hemorrhage, and FIM were independent predictors of HE (odds ratio (OR) = 0.98, 95% confidence interval (CI) = 0.97-0.99; OR = 1.73, 95% CI = 1.28-2.35; OR = 0.87, 95% CI = 0.83-0.92; OR = 0.42, 95% CI = 0.28-0.62; OR = 7.82, 95% CI = 5.86-10.42, respectively). The optimal cut-off point for FIM in predicting HE was 0.63, with sensitivity, specificity, PPV, NPV, and AUC values of 0.69, 0.89, 0.71, 0.88, and 0.83, respectively. The FIM adjusted for time since symptom onset is a significant predictor of HE. Its use may allow improved prediction of those patients with ICH who develop HE, and the score may be clinically applicable in the management of patients with ICH.

Natural History, Pathophysiology, and Recent Management Modalities of Intraventricular Hemorrhage.

Intraventricular hemorrhage (IVH) is a clinical challenge observed among 40-45% of intracerebral hemorrhage (ICH) cases. IVH can be classified according to the source of the hemorrhage into primary and secondary IVH. Primary intraventricular hemorrhage (PIVH), unlike secondary IVH, involves only the ventricles with no hemorrhagic parenchymal source. Several risk factors of PIVH were reported which include hypertension, smoking, age, and excessive alcohol consumption. IVH is associated with high mortality and morbidity and several prognostic factors were identified such as IVH volume, number of ventricles with blood, involvement of fourth ventricle, baseline Glasgow Coma Scale score, and hydrocephalus. Prompt management of patients with IVH is required to stabilize the clinical status of patients upon admission. Nevertheless, further advanced management is crucial to reduce the morbidity and mortality associated with intraventricular bleeding. Recent treatments showed promising outcomes in the management of IVH patients such as intraventricular anti-inflammatory drugs, lumbar drainage, and endoscopic evacuation of IVH, however, their safety and efficacy are still in question. This literature review presents the epidemiology, physiopathology, risk factors, and outcomes of IVH in adults with an emphasis on recent treatment options.

Influencing factors of futile recanalization after endovascular therapy in acute ischemic stroke patients with large vessel occlusions

Objective: To analyze the influencing factors of futile recanalization after endovascular therapy (EVT) in acute ischemic stroke patients with large vessel occlusions (AIS-LVO). Methods: AIS-LVO patients who underwent EVT with successful recanalization between January 2019 and December 2021 in Neurovascular Center of Changhai Hospital of Naval Medical University were retrospectively selected. Modified Rankin scale (mRS) score 3 months after EVT was used as the prognostic evaluation index, and patients with mRS scores≤2 were classified as the meaningful recanalization group and mRS scores 3-6 as the futile recanalization group. The risk factors, National Institutes of Health stroke scale (NIHSS) score, Glasgow coma scale (GCS) score, Alberta Stroke Program Early CT (ASPECT) score, core infarct volume, etc. in both groups were analyzed, and the influencing factors of futile recanalization after EVT were analyzed by multivariate logistic regression. Continuous variables that do not conform to the normal distribution are represented by [M(Q1,Q3)]. Results: A total of 368 patients meeting the inclusion criteria were collected, including 228 males and 140 females, and aged 68 (61, 77) years. There are 196 patients and 172 patients in the meaningful recanalization and futile recanalization groups, respectively, with the rate of futile recanalization 3 months after EVT of 46.74% (172/368). Comparing the general information and risk factors between the two groups found that the age of patients in the futile recanalization group [71 (65, 79) years] was higher than that in the meaningful recanalization group [65 (59, 72) years]. The baseline NIHSS score [18 (14, 22)] and the rate of not achieving modified Thrombolysis in Cerebral Ischemia grade 3 (mTICI 3) reperfusion (36.1%) were higher in the futile recanalization group than those in the meaningful recanalization group [12 (7, 17) and 19.9%]. The baseline GCS score [11 (9, 13)] was lower in the futile recanalization group than that in the meaningful recanalization group [14 (11, 15)]. The core infarct volume in the futile recanalization group [28 (7, 65) ml] was larger than that in the meaningful recanalization group [6 (0, 17) ml]. The ASPECT score [7 (5, 9)] was lower in the futile recanalization group than that in the meaningful recanalization group [9 (7, 10)]. In addition, the proportion of hypertension, atrial fibrillation, general anesthesia, and symptomatic intracranial hemorrhage was higher in the futile recanalization group (all P<0.05). The time from symptom onset to puncture and from symptom onset to reperfusion was longer in the futile recanalization group (both P<0.05). There were statistically significant differences in trial of Org 10172 in acute stroke treatment (TOAST) classification and the site of occluded blood vessels between the two groups (both P<0.05). Multivariate logistic regression indicated that age ≥80 years(OR=1.935,95%CI: 1.168-3.205), baseline NIHSS score (OR=1.999,95%CI: 1.202-3.325), GCS score (OR=2.299,95%CI: 1.386-3.814), previous stroke history (OR=1.977,95%CI: 1.085-3.604), general anesthesia (OR=1.981,95%CI: 1.143-3.435), not achieving grade 3 recanalization (OR=2.846, 95%CI: 1.575-5.143), ASPECT score<6 (OR=2.616, 95%CI: 1.168-5.857), and core infarct volume>70 ml (OR=2.712, 95%CI: 1.130-6.505) were risk factors for futile recanalization. Conclusion: Age≥80 years, previous stroke history, baseline NIHSS score≥20, GCS score≤8, general anesthesia, ASPECT score<6, core infarct volume>70 ml, and failure to achieve Grade 3 recanalization are independent influencing factors for futile recanalization after endovascular therapy in AIS-LVO patients.

Description of the Quality of Life of Patients With Subarachnoid Hemorrhage at King Abdulaziz University Hospital in Jeddah.

Objective Stroke is a serious medical condition that causes long-term morbidity and disability. There are two types of stroke, i.e., ischemic and hemorrhagic stroke. Subarachnoid hemorrhage (SAH) accounts for 5% of all stroke cases worldwide. Stroke survivors may experience cognitive dysfunction in many forms. Evidence regarding the quality of life (QoL) of patients post-SAH in the Middle East is limited. Therefore, this study aims to describe the quality of life in patients with SAH at the King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, from April 2021 to October 2021. Methods We included patients who were diagnosed with SAH ≤ 10 years prior at our hospital and were admitted within 72 hours of the ictus. Patients were included using non-probability convenience sampling without randomization. We collected the Glasgow Coma Scale (GCS), World Federation of Neurosurgeons (WFNS), and Modified Glasgow Outcome Scale (MGOS) scores. Results We included 48 patients (mean age: 49.78 ± 19.44 years, male proportion: 62.5%). More than 50% of the participants had comorbidities. The mean baseline GCS, WFNS, and MGOS scores at admission were 12.62 ± 3.56, 2.19 ± 1.54, and 3.58 ± 1.67, respectively. Women had significantly higher MGOS scores than men (p ≤ 0.05). Death was significantly associated with low MGOS scores (p ≤ 0.05). Age showed a non-significant negative correlation with the MGOS score (r = - 0.17, p-value = 0.24). Finally, the MGOS score was significantly correlated with the baseline GCS and WFNS scores at admission (r = 0.68 and r = - 0.67, respectively). Conclusion Our findings demonstrated that a low MGOS score, which indicates more comorbidities, greatly affects the quality of life of patients with SAH. Moreover, the baseline GCS score was the best prognostic predictor for patients with SAH.

Development and validation of a random forest model to predict functional outcome in patients with intracerebral hemorrhage.

To develop and validate a machine learning (ML)-based model to predict functional outcome in Chinese patients with intracerebral hemorrhage (ICH). This retrospective cohort study enrolled patients with ICH between November 2017 and November 2020. The follow-up period ended in February 2021. The study population was divided into training and testing sets with a ratio of 7:3. All variables were included in the least absolute shrinkage and selection operator (LASSO) regression for feature selection. The selected variables were incorporated into the random forest algorithm to construct the prediction model. The predictive performance of the model was evaluated via the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and calibration curve. A total of 412 ICH patients were included, with 288 in the training set, and 124 in the testing set. Twelve attributes were selected: neurological deterioration, Glasgow Coma Scale (GCS) score at 24 h, baseline GCS score, time from onset to the emergency room, blood glucose, diastolic blood pressure (DBP) change in 24 h, hematoma volume change in 24 h, systemic immune-inflammatory index (SII), systolic blood pressure (SBP) change in 24 h, serum creatinine, serum sodium, and age. In the testing set, the accuracy, AUC, sensitivity, specificity, PPV, and NPV of the model were 0.895, 0.964, 0.872, 0.906, 0.810, and 0.939, respectively. The calibration curves showed a good calibration capability of the model. This developed random forest model performed well in predicting 3-month poor functional outcome for Chinese ICH patients.

Factors associated with an unfavourable outcome in elderly intensive care traumatic brain injury patients. a retrospective multicentre study

BackgroundChanges in the epidemiology of traumatic brain injury (TBI) in older patients have received attention, but limited data are available on the outcome of these patients after admission to intensive care units (ICUs). The aim of this study was to evaluate the outcomes of patients over 65 years of age who were admitted to an ICU for TBI.MethodsThis was a multicentre, retrospective, observational study conducted from January 2013 to February 2019 in the surgical ICUs of 5 level 1 trauma centres in France. Patients aged ≥ 65 years who were hospitalized in the ICU for TBI with or without extracranial injuries were included. The main objective was to determine the risk factors for unfavourable neurological outcome at 3 months defined as an Extended Glasgow Outcome Scale (GOSE) score < 5.ResultsAmong the 349 intensive care patients analysed, the GOSE score at 3 months was ≤ 4 and ≥ 5 in 233 (67%) and 116 (33%) patients, respectively. The mortality rate at 3 months was 157/233 (67%), and only 7 patients (2%) fully recovered or had minor symptoms. Withdrawal or withholding of life-sustaining therapies in the ICU was identified in 140 patients (40.1%). Multivariate analysis showed that age (OR 1.09, CI 95% 1.04–1.14), male sex (OR 2.94, CI95% 1.70–5.11), baseline Glasgow Coma Scale score (OR 1.20, CI95% 1.13–1.29), injury severity score (ISS; OR 1.04, CI95% 1.02–1.06) and use of osmotherapy (OR 2.42, CI95% 1.26–4.65) were associated with unfavourable outcomes (AUC = 0.79, CI 95% [0.74–0.84]). According to multivariate analysis, the variables providing the best sensitivity and specificity were age ≥ 77 years, Glasgow Coma Scale score ≤ 9 and ISS ≥ 25 (AUC = 0.79, CI 95% [0.74–0.84]).ConclusionsAmong intensive care patients aged ≥ 65 years suffering from TBI, age (≥ 77 years), male sex, baseline Glasgow coma scale score (≤ 9), ISS (≥ 25) and use of osmotherapy were predictors of unfavourable neurological outcome.Trial registrationClinicalTrials.gov Identifier: NCT04651803. Registered 03/12/2020. Retrospectively registered.

Association of Hyponatremia on Mortality in Cryptococcal Meningitis: A Prospective Cohort.

BackgroundSodium abnormalities are frequent in central nervous system infections and may be caused by cerebral salt wasting, syndrome of inappropriate antidiuretic hormone secretion, or medication adverse events. In cryptococcal meningitis (CM), the prevalence of baseline hyponatremia and whether hyponatremia adversely impacts survival is unknown.MethodsWe conducted a secondary analysis of data from 2 randomized trials of human immunodeficiency virus–infected adult Ugandans with CM. We grouped serum sodium into 3 categories: <125, 125–129, and 130–145 mmol/L. We assessed whether baseline sodium abnormalities were associated with clinical characteristics and survival.ResultsOf 816 participants with CM, 741 (91%) had a baseline sodium measurement available: 121 (16%) had grade 3–4 hyponatremia (<125 mmol/L), 194 (26%) had grade 2 hyponatremia (125–129 mmol/L), and 426 (57%) had a baseline sodium of 130–145 mmol/L. Hyponatremia (<125 mmol/L) was associated with higher initial cerebrospinal fluid (CSF) quantitative culture burden (P < .001), higher initial CSF opening pressure (P < .01), lower baseline Glasgow Coma Scale score (P < .01), and a higher percentage of baseline seizures (P = .03). Serum sodium <125 mmol/L was associated with increased 2-week mortality in unadjusted and adjusted survival analyses (adjusted hazard ratio, 1.87 [95% confidence interval, 1.26–2.79]; P < .01) compared to those with sodium 130–145 mmol/L.ConclusionsHyponatremia is common in CM and is associated with excess mortality. A standardized management approach to correctly diagnose and correct hyponatremia in CM needs to be developed and tested.

Predicting Community Discharge for Occupational Therapy Recipients in the Neurological Critical Care Unit.

Occupational therapy in the neurological critical care unit (NCCU) may enable safe community discharge by restoring functional ability. However, the influence of patient characteristics and NCCU occupational therapy on discharge disposition is largely unknown. To examine how patient factors and receipt of occupational therapy predict discharge disposition for NCCU patients. Retrospective cross-sectional cohort study of electronic health records data from adults admitted to the NCCU between May 2013 and September 30, 2015. NCCU in a large urban academic hospital. Adults age 18 yr or older (N = 1,134) admitted to the NCCU. Outcomes and Measures: Using logistic regression with discharge disposition as the dependent variable, we entered sex, age, length of stay (LOS), baseline Glasgow Coma Scale score, Elixhauser Comorbidity Index, and receipt of occupational therapy services as predictor variables. Of NCCU patients, 39% received occupational therapy. Younger age, shorter LOS, lower comorbidity burden, and not receiving occupational therapy services increased the likelihood of discharge to the community. Men who received occupational therapy were less likely to be discharged to the community than men who did not receive occupational therapy. As age increased, differences in the probability of community discharge decreased between recipients and nonrecipients of occupational therapy services. Our results suggest that patients receiving occupational therapy services in the NCCU may have a lower likelihood of community discharge. However, these findings may result from therapist's consideration of the safest discharge location to ensure the greatest balance between independence and support. What This Article Adds: This study's findings suggest that receipt of occupational therapy in the NCCU is associated with higher likelihood for noncommunity discharge (i.e., to inpatient rehabilitation, skilled nursing, or long-term care). However, activity limitations and comorbidity burden may be greater for recipients of occupational therapy, and these NCCU patients are presumably less prepared for community discharge.

Clinical Characteristics and Outcomes of Children with Acute Catastrophic Brain Injury: A 13-Year Retrospective Cohort Study.

The purpose of this study was to describe and analyze clinical characteristics and outcomes in children with acute catastrophic brain injury (CBI). This was a single-center, 13-year (2008-2020) retrospective cohort study of children in the pediatric and cardiac intensive care units with CBI, defined as (1) acute neurologic injury based on clinical and/or imaging findings, (2) the need for life-sustaining intensive care unit therapies, and (3) death or survival with a Glasgow Coma Scale score < 13 at discharge. Patients were excluded if they were discharged directly to home < 14days from admission or had a chronic neurologic condition with a baseline Glasgow Coma Scale score < 13. The association between the primary outcome of death and clinical variables was analyzed by using Kaplan-Meier estimates and multivariable Cox proportional hazard models. Outcomes assessed after discharge were technology dependence, neurologic deficits, and Functional Status Score. Improved functional status was defined as a change in total Functional Status Score [Formula: see text] 2. Of 106 patients (58% boys, median age 3.9years) with CBI, 86 (81%) died. Withdrawal of life-sustaining therapies was the most common cause of death (60 of 86, 70%). In our multivariable analysis, each unit increase in admission pediatric sequential organ failure assessment score was associated with 10% greater hazard of death (hazard ratio 1.10, 95% confidence interval 1.04-1.17, p < .01). After controlling for admission pediatric sequential organ failure assessment scores, compared with those of patients with traumatic brain injury, all other etiologies of CBI were associated with a greater hazard of death (p = .02; hazard ratio 3.76-10). The median survival time for the cohort was 22days (95% confidence interval 14-37days). Of 23 survivors to hospital discharge, 20 were still alive after a median of 2years (interquartile range 1-3years), 6 of 20 (30%) did not have any technology dependence, 12 of 20 (60%) regained normal levels of alertness and responsiveness, and 15 of 20 (75%) had improved functional status. Most children with acute CBI died within 1month of hospitalization. Having traumatic brain injury as the etiology of CBI was associated with greater survival, whereas increased organ dysfunction score on admission was associated with a higher hazard of mortality. Of the survivors, some recovered consciousness and functional status and did not require permanent technology dependence. Larger prospective studies are needed to improve prediction of CBI among critically ill children, understand factors guiding clinician and family decisions on the continuation or withdrawal of life-sustaining treatments, and characterize the natural history and long-term outcomes among CBI survivors.

New Prediction Models of Functional Outcome in Acute Intracerebral Hemorrhage: The dICH Score and uICH Score.

Objectives: The original intracerebral hemorrhage (oICH) score is the severity score most commonly used in clinical intracerebral hemorrhage (ICH) research but may be influenced by hematoma expansion or intraventricular hemorrhage (IVH) growth in acute ICH. Here, we aimed to develop new clinical scores to improve the prediction of functional outcomes in patients with ICH.Methods: Patients admitted to the First Affiliated Hospital of Chongqing Medical University with primary ICH were prospectively enrolled in this study. Hematoma volume was measured using a semiautomated, computer-assisted technique. The dynamic ICH (dICH) score was developed by incorporating hematoma expansion and IVH growth into the oICH score. The ultra-early ICH (uICH) score was developed by adding the independent non-contrast CT markers to the oICH score. Receiver operating characteristic curve analysis was used to compare performance among the oICH score, dICH score, and uICH score.Results: There were 310 patients in this study which included 72 patients (23.2%) with hematoma expansion and 58 patients (18.7%) with IVH growth. Of 31 patients with two or more non-contrast computed tomography markers, 61.3% died, and 96.8% had poor outcomes at 90 days. After adjustment for potential confounding variables, we found that age, baseline Glasgow Coma Scale score, presence of IVH on initial CT, baseline ICH volume, infratentorial hemorrhage, hematoma expansion, IVH growth, blend sign, black hole sign, and island sign could independently predict poor outcomes in multivariate analysis. In comparison with the oICH score, the dICH score and uICH score exhibited better performance in the prediction of poor functional outcomes.Conclusions: The dICH score and uICH score were useful clinical assessment tools that could be used for risk stratification concerning functional outcomes and provide guidance in clinical decision-making in acute ICH.

Predictors of favorable outcomes for vertebrobasilar artery occlusion after endovascular therapy within 24 hours of symptom onset

ObjectiveThe aim of the present study was to describe our results of endovascular therapy (EVT) for vertebrobasilar artery occlusion (VBAO) within 24 h of symptom onset, and to evaluate prognostic factors associated with favorable outcomes. MethodsThe present study enrolled patients who underwent EVT for acute ischemic stroke (AIS) caused by VBAO. Inclusion criteria for EVT to treat VBAO were as follows: (1) computed tomography angiography (CTA) or magnetic resonance angiography (MRA) confirmed acute VBAO; (2) baseline National Institutes of Health Stroke Scale (NIHSS) score ≥2; (3) premorbid modified Rankin scale (mRS) score ≤2; (4) onset or last known time to puncture within 24 h; and (5) posterior-circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS) ≥6. Favorable outcomes were defined as mRS scores of 0–3 at three months following EVT. The associations among baseline parameters, procedural parameters, and favorable outcomes were assessed. ResultsA total of 67 patients were recruited in this study, of which 40 patients (59.7 %) had favorable outcomes. Of the 50 patients with a late-window (6–24 h), 29 patients (58 %) had favorable outcomes. Univariate analysis revealed significant associations of the following parameters with favorable outcomes in the enrolled patients: age, sex, smoking status, baseline NIHSS score, baseline Glasgow coma scale (GCS) score, Pons-midbrain index (PMI), and intracranial atherosclerosis (ICAS). Multivariate logistic regression indicated that only age (OR 0.914, 95 % CI: 0.849 to 0.984; p = 0.017), baseline GCS score (OR 1.234, 95 % CI: 1.061–1.435; p = 0.006), and PMI (OR 0.448, 95 % CI: 0.252 to 0.798; p = 0.006) were independently associated with favorable outcomes at three months following EVT. After adjustments for confounding factors in patients with a late-window, only age (OR 0.879, 95 % CI: 0.799 to 0.967; p = 0.008) was associated with favorable outcomes. ConclusionsYounger age, lower PMI, and higher GCS scores in patients with VBAO-induced AIS were associated with more favorable outcomes. In late-window (6–24 h) patients, younger age associated to favorable outcomes, and lower NIHSS scores and lower PMI each also had a tendency to associated with favorable outcomes.

Ethnic differences in characteristics and outcome of acute ischemic stroke in China: A single center experience

BackgroundThis study aimed to explore ethnic differences of acute ischemic stroke (AIS) in patients' characteristics, management and outcome in Chinese population in an institutional retrospective study. MethodsData of consecutive patients with AIS treated at our center from January 2018 to December 2019 were retrospectively reviewed. Ethnic differences in demographics, risk factors, treatment, and outcomes were evaluated. ResultsA total of 400 patients were included in the present analysis. Compared with Han patients, patients in ethnic group showed shorter interval between symptom onset and admission, lower baseline Glasgow coma scale (GCS) score, lower prevalence of diabetes, higher prevalence of medical history of anticoagulation or antiplatelet treatment, lower rates of partial anterior circulation infarct (PACI), lacunar infarct (LACI) and posterior circulation infarct (POCI). They were less likely to receive antiplatelet therapy and more likely to present higher risks of pulmonary infection. Furthermore, multivariable analysis revealed that the ethnic group was associated with unfavorable outcomes in AIS patients at discharge. In subgroup analysis after adjustment, only pulmonary infection remained an independent predictor of poor outcomes at discharge in ethnic group, while in Han group, baseline GCS score, total anterior circulation infarct (TACI), LACI and pulmonary infection were determined to be independent predictors of poor outcomes at discharge. ConclusionsPatients from ethnic minority groups presented distinctive characteristics in their baseline measurements, background cerebrovascular risk factors, treatment after admission, risk of in-hospital complications compared with Han patients. The ethnic difference of the AIS appeared to affect the neurological outcome.

Association between Serum Lipid and Hematoma Expansion after Spontaneous Intracerebral Hemorrhage in Chinese Patients

Objectives: Although several studies have shown that interventions to lower blood lipid concentration may reduce the risk of coronary arterial disease and ischemic stroke, the correlation between serum lipid levels and hemorrhagic stroke remains controversial. To clarify any possible association between serum lipid and hematoma expansion, we examined various serum lipid indices in patients with and without early hematoma expansion.Methods: Data of 572 intracerebral hemorrhage (ICH) patients from the cerebral small vessel disease cohort of Peking Union Medical College Hospital were retrospectively analyzed. Patients who finished the baseline brain computed tomography (CT) examination within 6 h post-ictus and the follow-up CT within 48 h after initial CT were included in the study. Hematoma expansion was delimited as an enlargement of hemorrhage volume over 33% or 12.5 mL between baseline and subsequent CT. Both uni- and multivariate logistic regression analyses were conducted to explore the association between early hematoma growth and various serum lipid indices, including triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, ratios of LDL-C/HDL-C and LDL-C/TC, as well as other demographic and clinical features. Results: Out of 157 patients included in the analysis, hematoma growth occurred in 45 (28.7%). Only higher baseline systolic blood pressure was found to be correlated with an increased risk of hematoma growth based on both univariate (odds ratio [OR] 1.014, 95% confidence interval [CI]: 1.002-1.026, P = .024) and multivariate logistic regression analyses (OR 1.022, 95%CI: 1.008-1.037, P = .003). No associations were detected between the various serum lipid indices examined and other clinical features with a likelihood of early hematoma growth between groups or within various subgroups defined by different characteristics including age, gender, baseline Glasgow Coma Scale score, systolic blood pressure, intraventricular extension, and hematoma location. Conclusions: No association between various indices of serum lipid and hematoma growth was identified among patients and subgroups with spontaneous ICH in the Chinese population; these findings may help to guide lipid management after ICH. However, further multi-centered, larger scale studies are expected to verify our results.

Model-Based Meta-analysis of Rifampicin Exposure and Mortality in Indonesian Tuberculous Meningitis Trials.

BackgroundIntensified antimicrobial treatment with higher rifampicin doses may improve outcome of tuberculous meningitis, but the desirable exposure and necessary dose are unknown. Our objective was to characterize the relationship between rifampicin exposures and mortality in order to identify optimal dosing for tuberculous meningitis.MethodsAn individual patient meta-analysis was performed on data from 3 Indonesian randomized controlled phase 2 trials comparing oral rifampicin 450 mg (~10 mg/kg) to intensified regimens including 750–1350 mg orally, or a 600-mg intravenous infusion. Pharmacokinetic data from plasma and cerebrospinal fluid (CSF) were analyzed with nonlinear mixed-effects modeling. Six-month survival was described with parametric time-to-event models.ResultsPharmacokinetic analyses included 133 individuals (1150 concentration measurements, 170 from CSF). The final model featured 2 disposition compartments, saturable clearance, and autoinduction. Rifampicin CSF concentrations were described by a partition coefficient (5.5%; 95% confidence interval [CI], 4.5%–6.4%) and half-life for distribution plasma to CSF (2.1 hours; 95% CI, 1.3–2.9 hours). Higher CSF protein concentration increased the partition coefficient. Survival of 148 individuals (58 died, 15 dropouts) was well described by an exponentially declining hazard, with lower age, higher baseline Glasgow Coma Scale score, and higher individual rifampicin plasma exposure reducing the hazard. Simulations predicted an increase in 6-month survival from approximately 50% to approximately 70% upon increasing the oral rifampicin dose from 10 to 30 mg/kg, and predicted that even higher doses would further improve survival.ConclusionsHigher rifampicin exposure substantially decreased the risk of death, and the maximal effect was not reached within the studied range. We suggest a rifampicin dose of at least 30 mg/kg to be investigated in phase 3 clinical trials.

Effect of Daytime Versus Night-time on Outcome in Patients Undergoing Emergent Neurosurgical Procedures.

Timing of neurosurgical procedures is controversial. Challenges identified with night-time surgeries include physician fatigue and sleep deprivation, and fewer staff and resources compared with daytime surgery. These might contribute to medical errors and complications, and, hence, worse patient outcomes. This single center retrospective study of 304 patients who underwent emergent neurosurgical procedures between January 1, 2010 and December 31, 2016 included 2 groups based on the timing of surgery: daytime (7:00 AM to 6:59 PM) and night-time (7:00 PM to 6:59 AM) surgery groups. Patient demographics, diagnosis, surgical characteristics, complications, and neurological outcome were obtained from the medical records. There was no difference in patient demographics, intraoperative complications, and length of surgery between the 2 groups. Although there was no statistically significant difference in neurological outcome between the 2 groups at hospital discharge and 1 month postdischarge, there was a higher proportion of patients in the night-time surgical group with unfavorable neurological outcome (Glasgow Outcome Score 1 to 3) at both these times. There were differences in hospital length of stay, location of postoperative management (postanesthesia care unit or intensive care unit), midline shift, baseline Glasgow Coma Scale score, and acuity of surgery between the 2 groups. Logistic regression analysis showed that age, baseline Glasgow Coma Scale score, surgery acuity status, procedure type, and intraoperative complications influenced neurological outcome. This study found no difference in the rate of unfavorable neurological outcome in patients undergoing emergent neurosurgical procedures during the daytime and night-time. However, our findings cannot exclude the possibility of an association between timing of surgery and outcome given its limitations, including small sample size and omission of potentially confounding variables. Further well-designed prospective trials are warranted to confirm our findings.

Defining the Optimal Midline Shift Threshold to Predict Poor Outcome in Patients with Supratentorial Spontaneous Intracerebral Hemorrhage.

Midline shift (MLS) has been associated with unfavorable outcome in patients with intracerebral hemorrhage (ICH). However, the optimal criteria to define the MLS measurements that indicate future outcome in ICH patients are absent, and the quantitative threshold of MLS that differentiates favorable and poor clinical outcome should be further explored. We enrolled patients with ICH who underwent admission computed tomography (CT) within 6h after onset of symptoms. We assessed MLS at several locations, including the pineal gland, septum pellucidum, and cerebral falx. MLS(max) was defined as the maximum midline shift among these locations. Functional outcomes were assessed with the Modified Rankin Scale (mRS) at 3months. We performed multivariate logistic regression analysis to investigate the MLS locations for predicting poor outcome. ROC curve analysis was used to establish whether MLS values were predictive of 90-day poor outcome. In 199 patients with ICH, 78 (39.2%) patients had poor functional outcome at 3-month follow-up. Pineal gland shift, septum pellucidum shift, cerebral falx shift, and MLS(max) all showed a significant difference between poor outcome and favorable outcome (p<0.001). After adjustment for age, baseline Glasgow Coma Scale score, ICH location, time to initial CT, baseline ICH volume, and intraventricular hemorrhage, the MLS(max) was independently associated with poor outcome (p=0.032). MLS(max)>4mm (our proposed optimal threshold) was more likely to have poorer outcomes than those without (p<0.001). MLS(max) can be a good independent predictor of clinical outcome, and MLS(max)>4mm is an optimal threshold associated with poor outcome in patients with ICH.

Low-Density Lipoprotein and Intracerebral Hematoma Expansion in Daily Alcohol Users

Background: Epidemiological studies suggest that the intracerebral hemorrhage (ICH) rate correlates with alcohol consumption. Alcohol leads to elevated blood pressure (BP) and inhibition of platelet aggregation. These factors could promote excessive bleeding. To our knowledge, in the setting of normal liver function tests, there are no studies that have systematically evaluated the relationship between daily alcohol use and hematoma expansion. The aim of this study is to compare the baseline ICH characteristics, frequency of hematoma expansion, and outcomes in patients with ICH who are daily alcohol users with those who are not daily alcohol users. Methods: A retrospective chart review was performed on consecutive patients who presented from July 2008 to July 2013 to the Tulane University Hospital in New Orleans, La., USA, with a spontaneous ICH. Ninety-nine patients who met these criteria were admitted. Patients who underwent hematoma evacuation were excluded. Hemorrhage volumes were calculated based on the ABC/2 method. Low-density lipoprotein (LDL) was dichotomized into low (<100 mg/dl) and high (≥100 mg/dl) values. Comparisons were made using t tests, χ² and nonparametric equivalents where appropriate. ICH growth in 24 h and LDL were evaluated using linear regression. Results: Of the 226 patients who met inclusion criteria, 20.4% had a history of daily alcohol use. The average age was 61 years (range 19-94), 55.6% of the patients were males, and 67.1% were of African American origin. Daily alcohol use was associated with male gender, lower rate of home antihypertensive, higher presenting BP, and lower platelet counts, but there was no difference in ICH characteristics, ICH growth, or clinical outcome. Daily alcohol use in patients with a low LDL level was associated with supratentorial location and trends for lower baseline Glasgow Coma Scale score, higher ICH score, and follow-up ICH volume, but no significant difference in significant hematoma expansion or clinical outcome except for a trend for higher mortality was found (25 vs. 9.5%, p = 0.1311) compared to patients with high LDL values. Conclusions: Our data suggest that neither chronic daily alcohol use nor a low LDL level in combination with daily alcohol use can be used to predict ICH growth. Daily alcohol use was associated with untreated hypertension and higher BP on presentation. A low LDL level in combination with daily alcohol use may be linked with larger and more severe ICH, but we were unable to demonstrate a relationship with hematoma expansion or poor clinical outcome. The role of LDL in vessel fragility and clot stabilization needs to be further explored before concluding that a low LDL level confers risk of bleeding.

Reduced Brain/Serum Glucose Ratios Predict Cerebral Metabolic Distress and Mortality After Severe Brain Injury

The brain is dependent on glucose to meet its energy demands. We sought to evaluate the potential importance of impaired glucose transport by assessing the relationship between brain/serum glucose ratios, cerebral metabolic distress, and mortality after severe brain injury. We studied 46 consecutive comatose patients with subarachnoid or intracerebral hemorrhage, traumatic brain injury, or cardiac arrest who underwent cerebral microdialysis and intracranial pressure monitoring. Continuous insulin infusion was used to maintain target serum glucose levels of 80-120 mg/dL (4.4-6.7 mmol/L). General linear models of logistic function utilizing generalized estimating equations were used to relate predictors of cerebral metabolic distress (defined as a lactate/pyruvate ratio [LPR] ≥ 40) and mortality. A total of 5,187 neuromonitoring hours over 300 days were analyzed. Mean serum glucose was 133 mg/dL (7.4 mmol/L). The median brain/serum glucose ratio, calculated hourly, was substantially lower (0.12) than the expected normal ratio of 0.40 (brain 2.0 and serum 5.0 mmol/L). In addition to low cerebral perfusion pressure (P = 0.05) and baseline Glasgow Coma Scale score (P < 0.0001), brain/serum glucose ratios below the median of 0.12 were independently associated with an increased risk of metabolic distress (adjusted OR = 1.4 [1.2-1.7], P < 0.001). Low brain/serum glucose ratios were also independently associated with in-hospital mortality (adjusted OR = 6.7 [1.2-38.9], P < 0.03) in addition to Glasgow Coma Scale scores (P = 0.029). Reduced brain/serum glucose ratios, consistent with impaired glucose transport across the blood brain barrier, are associated with cerebral metabolic distress and increased mortality after severe brain injury.

Conjugate Eye Deviation in Acute Intracerebral Hemorrhage

Conjugate eye deviation (CED) occurs frequently in patients with acute stroke. The purpose of this study was to elucidate the factors that correlate with CED as well as the relationship between CED and outcomes in patients with acute intracerebral hemorrhage. A total of 211 patients with acute supratentorial intracerebral hemorrhage were recruited in a multicenter, prospective study. CED was assessed with a National Institutes of Health Stroke Scale "best gaze" subscore of ≥1. Hematoma location and volume were assessed on CT. Forty-five percent of the patients had CED. On multivariable analysis, right-sided lesion (OR, 2.36; 95% CI, 1.18-4.93), hematoma volume (OR, 1.07; 95% CI, 1.04-1.10 per 1 mL), and baseline Glasgow Coma Scale score (OR, 0.66; 95% CI, 0.53-0.80 per 1 point) were independently associated with CED. After adjusting for sex, age, intraventricular extension of the hematoma, baseline Glasgow Coma Scale score, and hematoma volume, the presence of CED both on admission and 72 hours later was an independent predictor of death or dependency at 3 months poststroke (OR, 5.77; 95% CI, 2.27-16.94). The optimal cutoff volume of hematoma related to CED was ≥13.5 mL for patients with putaminal hemorrhage (sensitivity, 76%; specificity, 72%) and ≥7.7 mL for patients with thalamic hemorrhage (sensitivity, 82%; specificity, 83%). The persistence of CED was a significant predictor of death or dependency after acute supratentorial intracerebral hemorrhage even after adjusting for initial severity and hematoma volume. CED can be evoked by a relatively smaller thalamic hematoma than a putaminal hematoma.