Coma Scale Score Research Articles

Abstract P392: Early Brain Injury and Soluble ST2 After Non-Traumatic Subarachnoid Hemorrhage

Intro: Early Brain Injury (EBI) after non-traumatic subarachnoid hemorrhage (SAH) is a significant mediator of neurological injury, but the injury pathways and markers are not well understood. We hypothesized that the inflammatory mediator soluble ST2 (sST2) is associated with markers of EBI. Methods: We studied two independent cohorts, including 190 SAH patients in a discovery cohort and 50 patients in a replication cohort. Clinical markers of EBI included early loss of consciousness, Glasgow Coma Scale (GCS) score at 24 hours, and neurological deterioration within the first 72 hours (defined as a decrease in GCS ≥ 2 points). Radiographic markers included bicaudate index, clinically significant hydrocephalus requiring external ventricular drainage (EVD), and global cerebral edema. Serial plasma sST2 level was measured at early (3.5 ± 1.2 days post-hemorrhage), intermediate (7.8 ± 1.3 days post-hemorrhage), and late (13 ± 2.3 days post-hemorrhage) time points in the discovery cohort and daily during post-hemorrhage days 1-9 in the replication cohort. In the discovery cohort, the relationship between EBI markers and poor functional outcome (90-day modified Rankin Scale; mRS ≥ 3) was assessed using multivariable logistic regression. The association between sST2 level and EBI markers was evaluated using repeated measures analysis. In the replication cohort, associations were examined using an analysis of response profiles. Results: Clinical and radiographic markers of EBI, except for global edema, were each associated with functional outcome in univariate analysis. Of these EBI markers, independent predictors of poor outcome included 24-hour GCS (OR=5.76, 95% CI 2.31-14.4, p<0.001) and clinically significant hydrocephalus (OR=8.74, 95% CI 2.44-31.3, p=0.001). Elevated sST2 was associated with all markers of EBI except for global edema, and independently predicted poor outcome in a multivariate model that included EBI markers. These findings were further replicated in an independent cohort. Conc: Of the potential clinical and radiographic contributors to EBI, poor 24-hour GCS and clinically significant hydrocephalus remain independent predictors of poor outcome. Furthermore, soluble sST2 level is associated with EBI and poor outcome.

Abstract P428: The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults

Introduction: The intracerebral hemorrhage (ICH) score is a widely used scoring system for predicting mortality in patients with ICH. This score has been validated for use in adults of all ages with ICH, but not specifically for use in populations of young adults (age 18-45). We aimed to determine the validity of the ICH score when applied to young adults with ICH. Methods: This was a retrospective analysis of all patients aged 18-45 with spontaneous ICH consecutively admitted to our institution from 2009-2019. We calculated the ICH score for each patient, recording the individual subcomponents, and analyzed the scores for prediction of mortality at 30 days. We also analyzed the individual subcomponents of the score for effect on mortality. Results: We identified 156 patients (mean age 35 +/- 7.8; 67 were female, 103 were white) to include in our study. The 30-day mortality rate was 15% (n=24); these patients had a mean age of 34.9 +/- 7.8, compared to survivors who had mean age 35.4 +/- 7.8 (p=0.797). ICH scores were predictive of mortality (p=0.036 for trend); however, the actual mortality rates in our population were substantially lower than those predicted by the ICH score. Specifically, patients in our population with scores of 1, 2, or 3 had 30-day mortality rates of 0%, 3%, and 41%, compared to the current ICH score mortality predictions of 13%, 26%, and 72%, respectively. Scores of 4 and 5 in our population were more closely aligned to current ICH predictions (85% and 100% compared to 97% and 100%, respectively). Of the ICH score subcomponents, ICH volume >30mL (p=0.007) and Glasgow Coma Scale (GCS) scores of 3 or 4 (p=0.014) were the strongest predictors of mortality at 30 days. Conclusion: The ICH score is predictive of mortality for adults of all ages, but the specific mortality rates associated with this scoring system vary considerably when applied to young adults (age 18-45). This over-estimation should be taken into consideration when applying the predictions of the ICH score to young adults with ICH; additionally, special attention should be given to ICH volume >30mL and very low GCS scores, as these were the strongest predictors of early mortality.

Emergency mortality of non-trauma patients was predicted by qSOFA score.

This study was aimed to evaluate the performance of quick sequential organ failure assessment (qSOFA) in predicting the emergency department (ED) mortality of non-trauma patients and to expand the application scope of qSOFA score. A single, retrospective review of non-trauma patients was conducted in ED between November 1, 2016 and November 1, 2019. The qSOFA score was obtained from vital signs and Glasgow Coma Scale (GCS) score. The outcome was ED mortality. Multivariable logistic regression analysis was performed to explore the association between the qSOFA score and ED mortality. The area under the receiver operating characteristic (AUROC) curve, the best cutoff value, sensitivity and specificity were performed to ascertain the predictive value of the qSOFA score. 228(1.96%) of the 11621 patients were died. The qSOFA score was statistically higher in the non-survival group (P<0.001). The qSOFA score 0 subgroup was used as reference baseline, after adjusting for gender and age, adjusted OR of 1, 2 and 3 subgroups were 4.77 (95%CI 3.40 to 6.70), 18.17 (95%CI 12.49 to 26.44) and 23.63 (95%CI 9.54 to 58.52). All these three subgroups show significantly higher ED mortality compared to qSOFA 0 subgroup (P<0.001). AUROC of qSOFA score was 0.76 (95% CI 0.73 to 0.79). The best cutoff value was 0, sensitivity was 77.63% (95%CI 71.7% to 82.9%), and specificity was 67.2% (95%CI 66.3% to 68.1%). The qSOFA score was associated with ED mortality in non-trauma patients and showed good prognostic performance. It can be used as a general tool to evaluate non-trauma patients in ED. This is just a retrospective cohort study, a prospective or a randomized study will be required.

Klebsiella brain abscess in an immunocompetent patient: a case report

BackgroundKlebsiella pneumoniae brain abscesses are a rare entity and typically present in immunocompromised patients. We present a case of an overall healthy patient who developed a Klebsiella pneumoniae brain abscess in the absence of liver pathology.Case presentationA 46-year-old Vietnamese man with past medical history significant for hypertension presented to the hospital with acute on chronic worsening of altered mental status, personality changes, and gait dysfunction. Initial vitals revealed temperature of 37.1 °C, heart rate 87 beats/minute, blood pressure 150/87 mmHg, respiratory rate 18/minute, and oxygen saturation 99% on room air. Physical exam was notable for altered mental status, Glasgow Coma Scale (GCS) score of 14, and right lower facial droop. Cardiopulmonary exam was within normal limits. Head computed tomography (CT) showed a left frontotemporal mass, with subsequent brain magnetic resonance imaging (MRI) revealing a ring-enhancing lesion concerning for a brain abscess. The abscess was urgently drained; however, there was intraoperative spillage into the ventricles. Intraoperative cultures grew Klebsiella pneumoniae, and the patient was maintained on appropriate antibiotics. He developed worsening mental status, septic shock, and cerebral edema requiring decompressive left hemicraniectomy. Computed tomography of the abdomen and pelvis revealed no hepatic lesions. The patient did not improve, and the family elected for comfort measures.ConclusionHigh mortality is associated with Klebsiella pneumoniae (as opposed to Klebsiella oxytoca) brain abscesses, especially in the setting of intraventricular spread. This case illustrates the need for early detection, and an aggressive medical and surgical treatment approach is required for a potential favorable outcome.

In spontaneous intracerebral hematoma patients, prediction of the hematoma expansion risk and mortality risk using radiological and clinical markers and a newly developed scale

ABSTRACT Objective: In patients with spontaneous intracerebral hematoma (ICH), early-stage hematoma expansion has been associated with poor prognosis in literature. This study aimed to develop predictive parameter(s) as well as a new scale to define hematoma expansion and short-term prognosis in patients with ICH. Methods: In 46 patients with ICH, Glasgow Coma Scale (GCS) scores, non-contrast CT (NCCT) markers (hematoma volume on admission and follow-up, hypodensity, intraventricular hemorrhage, blend and island sign, BAT score), and modified Rankin Scale scores were evaluated for predicting the hematoma expansion risk and mortality risk. Furthermore, a newly developed scale called the ‘HEMRICH scale’ was constituted using the GCS score, hematoma volumes, and some NCCT markers. Results: Roc-Curve and Logistic Regression test results revealed that GCS score, initial hematoma volume value, hypodensity, intraventricular haemorrhage, BAT score, and HEMRICH scale score could be the best markers in predicting hematoma expansion risk whereas GCS score, intraventricular haemorrhage, BAT score, hematoma expansion, and HEMRICH scale score could be the best markers in predicting mortality risk (p = 0.01). Moreover, Factor analysis and Reliability test results showed that HEMRICH scale score could predict both hematoma expansion and mortality risks validly (Kaiser-Meyer-Olkin test value = 0.729) and reliably (Cronbach’s alpha = 0.564). Conclusion: It was concluded that the GCS score, intraventricular haemorrhage, and BAT score could predict both hematoma expansion risk and mortality risk in the early stage in patients with ICH. Furthermore, it was suggested that the newly produced HEMRICH scale could be a valid and reliable scale for predicting both hematoma expansion and mortality risk.

Study to assess the effectiveness of structured teaching programme on knowledge regarding four score (full outline of unresponsiveness) coma scale among Staff nurses working in intensive care units in selected Hospitals

Study to assess the effectiveness of structured teaching programme on knowledge regarding four score (full outline of unresponsiveness) coma scale among Staff nurses working in intensive care units in selected Hospitals

Brain Injury in Critical Illness and a Note on the Virus

Brain Injury in Critical Illness and a Note on the Virus

Abstract 317: Outcome Predictors in Substance - Related Cardiac Arrests

Introduction: The incidence of substance-related cardiac arrests (SRCA) has increased due to the opioid epidemic. Previous studies have shown that SRCA present differently than non-SRCA. Weinvestigated differences in the clinical courses between the two groups for patients who were initially comatose post-resuscitation. Methods: Data from out-of-hospital arrest patients seen between 2007-2019 were retrospectively analyzed. Arrests were classified as SRCA if the patient had a positive toxicology screen, witnesses testified to substance use, or drug paraphernalia was present at the scene. Arrest types were categorized as shockable or non-shockable. Cerebral edema classifications were based on MRI or CT radiology reports. Poor outcomes were defined as Cerebral Performance Category (CPC) &gt; 3 at discharge. Differences in demographics, presentation and outcomes were compared (Fisher’s Exact Test or Exact Wilcoxon-Mann-Whitney). Multivariable backward stepwise logistic regression was performed. Results: SRCA patients (N=90) were younger (p&lt;.001), more likely to be non-shockable (p&lt;.001) and have worse Glasgow Coma Scale (GCS) scores (p=.041) and higher Incidence (p&lt;.001) and earlier development of cerebral edema (p=.04) than non-SRCA patients (N=339) (see Table). Adjusting for age and sex, SRCA was a significant predictor of GCS (p=0.02), shockable rhythm (p&lt;.001), edema (p=.004) and poor outcomes (p=.016). SRCA (p&lt;.001) remained an independent predictor of shockable rhythm in multivariable regression including sex (p&lt;.001) and GCS (p=.006). Multivariable analyses showed younger age (p=.001) and non-shockable rhythm (p=.002) to be predictors of edema development. Older age (p=.002) and edema (p&lt;.001) remained significant predictors of poor outcomes. Discussion: SRCA patients are more likely to have non-shockable arrests which in turn leads to cerebral edema development and potentially worse outcomes.

Violence \u2013related injuries in a rapidly developing Middle Eastern country: a retrospective study from a level 1 trauma center

BackgroundViolence is a global public health concern leading to injuries, long-term physical, sexual or mental health problems and even mortality. The burden of violence-related injuries on hospital systems remains understudied in the Arabian Gulf region. The present study aimed to describe the epidemiology of hospitalized violence-related injuries in a rapidly developing Middle Eastern country.MethodsA retrospective analysis from a level 1 trauma center, in the state of Qatar, was conducted. Data were retrieved from the Qatar national trauma registry for all patients who were admitted with violence-related injuries between June 2010 and June 2017. Analyzed data were used to compare hospitalized interpersonal and self-inflicted violence groups.ResultsThe hospitalization rate of violence-related injuries was 4.6 per 100,000 population per year; it was significantly higher in males (5.5/100,000 males/year vs. 1.8/100,000 females/year) and younger persons, particularly in the 25–34 years old population (41%). South Asians constituted 55% of the affected study population. Interpersonal violence (76.7%) was the most common mechanism of injury. Significant differences between interpersonal and self-inflicted violence groups were evident, especially for the type of trauma (i.e. blunt or penetrating), injured body regions, alcohol use, injury severity, need for intubation and psychiatric referral (p < 0.05). Overall, in-hospital mortality was 6.4%; with a significantly higher rate in females (16% vs.5%, p = 0.001). Outcomes, including length of hospital stay and mortality, were comparable between the two study groups. Multivariate analysis showed that male gender and alcohol use were predictors for interpersonal violence whereas high Injury Severity Score (ISS) and low Glasgow Coma Scale (GCS) were predictors of hospital mortality.ConclusionsThe rate of hospitalization for violence-related injuries in Qatar is low; however, its burden on the trauma system is of concern. Although it comprised only 9.6% of the study population, females are more likely to get hospitalized following self-inflicted injuries when compared to interpersonal violence. The disproportionate burden of violence among South Asian and young populations warrants an evidence-based public health approach to appropriately address the risk factors and set prevention programs.

The relationship between consciousness and the ascending reticular activating system in patients with traumatic brain injury

BackgroundWe investigated the relationship between consciousness and the ascending reticular activating system (ARAS) by using diffusion tensor tractography (DTT) in patients with traumatic brain injury (TBI).MethodsTwenty-six patients with TBI and 13 healthy control subjects were recruited for this study. Glasgow Coma Scale (GCS) scores were used for evaluation of subject consciousness state at the chronic stage of TBI (at DTT scanning), According to the GCS score, the patient group was divided into two subgroups: A (14 patients;impaired consciousness: GCS score < 15, and B (12 patients;intact consciousness;GCS score = 15). Fractional anisotropy (FA) and tract volume (TV) values were assessed in the lower dorsal and upper ARAS.ResultsThe FA values of the lower dorsal ARAS and the upper ARAS in patient subgroup A were significantly lower than those in patient subgroup B and the control group(p < 0.05). However, the FA and TV values for the lower dorsal ARAS and the upper ARAS were not significantly different between patient subgroup B and the control group(p > 0.05). The FA value of the lower dorsal ARAS(r = 0.473,p < 0.05) and the TV of upper ARAS(r = 0.484,p < 0.05) had moderate positive correlations with the GCS score. The FA value of the upper ARAS had a strong positive correlation with the GCS score of the patient group(r = 0.780,p < 0.05).ConclusionsWe detected a close relationship between consciousness at the chronic stage of TBI and injuries of the lower dorsal and upper ARAS (especially, the upper ARAS) in patients who showed impaired consciousness at the onset of TBI. We believe that our results can be useful during the development of therapeutic strategies for patients with impaired consciousness following TBI.Trial registrationYUMC 2019–06–032-003. Retrospectively registered 06 Jun 2020.

Clinical outcomes of different treatments and risk factors in patients with otogenic brain abscess, a real-world evidence-based retrospective study

Background Otogenic Brain Abscess (OBA) is a life-threatening complication secondary to otitis media, but its appropriate management remains controversial. Objectives To understand the demographic characteristics, management, and variables that affect the outcomes of patients with OBA based on our experiences over 11 years. Material and methods Clinical data were collected for 41 patients. Prognostic factors associated with mortality were assessed, and clinical outcomes compared among groups receiving different treatments. Results Among the 41 patients, 19.6% did not undergo surgery, 39.0% were treated with two-stage surgery (otological surgery and neurosurgery) and 41.4% were treated with single-stage surgery (otological surgery or neurosurgery). Overall mortality rate was 32.5%, and mortality was significantly higher in patients with invasion of the petrous apex (odds ratio [OR]: 7.81, 95% confidence interval [95% CI]: 1.26–48.36), and lower in those with appropriate surgical management (single otological surgery, OR: 0.07, 95% CI: 0–0.97; single neurosurgery, OR: 0.13, 95% CI: 0.02–1.0; two-stage surgery, OR: 0.08, 95% CI: 0.01–0.64) or a higher Glasgow Coma Scale (GCS) score at admission (OR: 0.64, 95% CI: 0.44–0.93). Conclusions and significance Data on invasiveness and pre-surgery GCS greatly aid in predicting the prognosis of OBA patients. Early evaluation will facilitate decision-making by physicians treating OBA patients.

Controlling nutritional status score and prognostic nutrition index predict the outcome after severe traumatic brain injury

ABSTRACT Objectives Immune-nutritional status is correlated with a clinical outcome in critical illness. Recently, controlling nutritional status (CONUT) score and prognostic nutrition index (PNI) has been reported to predict prognosis following cancer and other diseases. The aim of this study was to explore the relationship between the CONUT score and PNI and 6-month outcome in patients with severe traumatic brain injury (STBI). Methods We retrospectively analyzed the clinical data of 78 patients with STBI, including the CONUT score and PNI. Patients were divided into high CONUT group and low CONUT group. Patients were also divided into high PNI and low PNI group respectively. The 6-month outcome was evaluated by the modified Rankin scale (mRS). The unfavorable outcome was defined as mRS score ≥3. Results The unfavorable outcome group had lower Glasgow coma scale (GCS) scores, serum albumin, total cholesterol, PNI, and higher CONUT scores (P < 0.05). Both CONUT scores and PNI were strongly correlated with mRS (r = 0.429, P < 0.05; r = −0.590, P < 0.05, respectively). After adjustment for confounding factors, the odds ratios of CONUT scores and PNI for predicting unfavorable outcome were 10.478 (95% CI: 2.793–39.301) and −0.039 (95% CI: 0.008–0.204), respectively. The area under the curve (AUC) of CONUT scores for predicting unfavorable outcome was 0.777 (95% CI: 0.674–0.880, P < 0.01), which was similar to PNI (0.764, 95% CI: 0.657–0.87, P < 0.01). Conclusion Both CONUT scores and PNI might be novel independent predictors of the poor outcome in STBI.

The epidemiology and prehospital care of motorcycle crashes in a sub-Saharan African urban center

Objective Road traffic crashes (RTCs) are common among motorcyclists in Kigali, Rwanda. The Service d’Aide Medicale Urgente (SAMU), a prehospital ambulance service, responds to many of these crashes. We aimed to describe motorcycle-related RTCs managed by SAMU. Methods SAMU clinical data including demographic information, injury characteristics, and management details were analyzed descriptively for all motorcycle crashes occurring between December 2012 and July 2016. Results Every patient included in this study was injured. These patients all called the ambulance for their injuries after a motorcycle crash. There were 2,912 motorcycle-related RTCs over the study period, representing 26% of all patients managed by SAMU. The incidence of motorcycle crashes in Kigali was 258 crashes per 100,000 people over the 3.5-year study period. The average age was 30 years and 80% were males. The most common injuries were to the lower extremities (n = 958, 33%), head (n = 878, 30%), or upper extremities (n = 453, 16%). Injuries often resulted in fractures of extremities (n = 740, 25%) and external hemorrhage anywhere in the body (unspecified region; n = 660, 23%), yet few were severe based on the Kampala Trauma Score (n = 23, 2%) and Glasgow Coma Scale (n = 42, 1.5%). The most common interventions were provision of diclofenac (n = 1,526, 52.5%), peripheral intravenous (IV) access (n = 1,217, 42%), and administration of IV fluids (n = 1,048, 36%). Conclusion Motorcycle-related RTCs represent a large burden of disease for patients treated by SAMU in Kigali, Rwanda. Young men are most at risk of injury, which imposes a financial strain on society. Though injuries occurred frequently, critical trauma cases from motorcycle crashes were uncommon. This may be a result of several initiatives in Rwanda to improve road safety.

Comparison of Long-Term Outcomes of Endoscopic and Minimally Invasive Catheter Evacuation for the Treatment of Spontaneous Cerebellar Hemorrhage

Recently, minimally invasive techniques, including endoscopic evacuation and minimally invasive catheter (MIC) evacuation, have been used for the treatment of patients with spontaneous cerebellar hemorrhage (SCH). However, credible evidence is still needed to validate the effects of these techniques. To explore the long-term outcomes of both surgical techniques in the treatment of SCH. Fifty-two patients with SCH who received endoscopic evacuation or MIC evacuation were retrospectively reviewed. Six-month mortality and the modified Rankin Scale (mRS) score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of the different surgical techniques on patient outcomes. In the present study, the mortality rate for the entire cohort was 34.6%. Univariate analysis showed that the surgical technique and preoperative Glasgow Coma Scale (GCS) score affected 6-month mortality. However, no variables were found to be correlated with 6-month mRS scores. Further multivariate analysis demonstrated that 6-month mortality in the endoscopic evacuation group was significantly lower than that in the MIC evacuation group (OR = 4.346, 95% CI 1.056 to 17.886). The 6-month mortality rate in the preoperative GCS 9–14 group was significantly lower than that in the GCS 3–8 group (OR = 7.328, 95% CI 1.723 to 31.170). Compared with MIC evacuation, endoscopic evacuation significantly decreased 6-month mortality in SCH patients. These preliminary results warrant further large, prospective, randomized studies.

Association of blood glucose with 30-day mortality in patients with intracerebral hemorrhage undergoing neurosurgical treatment

Objective Published studies have shown hyperglycemia is associated with poor outcome in patients with intracerebral hemorrhage (ICH). However, the association between blood glucose and outcome in surgical ICH patients is unknown. In the present study, we sought to evaluate the predictive value of admission and postoperative glucose for 30-day outcome in patients with ICH undergoing neurosurgical treatment. Methods We retrospectively studied acute ICH patients who underwent neurosurgical treatment at a tertiary care hospital between January 2013 and December 2018. Patient demographics, clinical and radiological data were recorded. Serum glucose was measured at admission and after surgery. Receiver operating characteristic curves were used to evaluate the predictive power of important predictors. Multivariable logistic regression analyses were performed to identify independent factors of 30-day mortality. Results The present analysis included 344 patients (66.3% male, mean age 59.1 years). Elevated admission glucose (odds ratio [OR] 1.11; 95% confidence interval [CI] 1.03–1.20; p = .007) and postoperative glucose (OR 1.18, 95% CI 1.06–1.31; p = .003) were independently associated with increased 30-day mortality. There was no significant difference in predictive ability between admission glucose (area under curve [AUC] 0.668, 95% CI 0.608–0.719) and postoperative glucose (AUC 0.631, 95% CI 0.573–0.687) for 30-day death (p = .467). Multivariate logistic regression analysis also identified that admission Glasgow Coma Scale (GCS) score (p < .001), initial hematoma volume (p = .001), and the presence of intraventricular hemorrhage (IVH, p = .002) were independently predicted 30-day mortality. Conclusions For patients with ICH who received neurosurgical treatment, admission GCS score, initial hematoma volume, presence of IVH, admission and postoperative glucose level are independently associated with 30-day mortality. Admission and postoperative glucose may apply as predictors and targets for surgical ICH patients.

The impact of time from injury to surgery in functional recovery of traumatic acute subdural hematoma

BackgroundThe time from injury to surgery (TIS) is critical in the functional recovery of individuals with traumatic acute subdural hematoma (TASDH). However, only few studies have confirmed such notion.MethodsThe data of TASDH patients who were surgically treated in Chia-Yi Christian Hospital between January 2008 and December 2015 were collected. The significance of variables, including age, sex, traumatic mechanism, coma scale, midline shift on brain computed tomography (CT) scan, and TIS, in functional recovery was assessed using the student’s t-test, Mann-Whitney U test, chi-square test, univariate and multivariate models, and receiver operating characteristic (ROC) curve.ResultsA total of 37 patients achieved functional recovery (outcome scale score of 4 or 5) and 33 patients had poor recovery (outcome scale score of 1–3) after at least 1 year of follow-up. No significant difference was observed in terms of age, sex, coma scale score, traumatic mechanism, or midline shift on brain CT scan between the functional and poor recovery groups. TIS was found to be significantly shorter in the functional recovery group than in the poor recovery group (145.5 ± 27.0 vs. 181.9 ± 54.5 min, P-value = 0.002). TIS was a significant factor for functional outcomes in the univariate and multivariate regression models. The analysis of TIS with the ROC curve between these two groups showed that the threshold time for functional recovery in comatose patients and those with TASDH who were surgically treated was 2 h and 57.5 min.ConclusionsTIS is an important factor l for the functional recovery of comatose TASDH patients who underwent surgery.

HEMORRHAGIC PROGRESSION OF CONTUSION IN PATIENTS WITH MILD TRAUMATIC BRAIN INJURY ON THE ROUTINE REPEAT HEAD COMPUTED TOMOGRAPHY

Computed tomography (CT) scan is a standard for the diagnosis of intracranial pathology after traumatic brain injury (TBI). Hemorrhagic progression of contusion (HPC) is frequently seen on repeat CT, but its clinical and radiological significance in case of mild TBI is not well define. The aim of the study: to evaluate the result of routine repeat head CT in patients with mild TBI and brain contusions. Materials and methods: retrospective analysis of management of patients with mild TBI (Glasgow Coma Scale (GCS) score – 13 to 15) and cerebral contusion. All patients were treated at the Kyiv City Clinical Emergency Hospital between 2016 and 2017. Results: within 202 patients with mild TBI, 87 (43.1 %) met the inclusion criteria and were selected for detailed analysis. There were 69 (79.3 %) men and 18 (20.7 %) women. The mean age of the patients was 43.8±12.7 years (17–82 years). The average time between trauma and CT was 3.3 hours. The average volume of contusion on the initial CT was 1.9±0.6 cm3 (0.2–9.6 cm3). The average time of routine CT was 6.8 hours (range 4–24 hours) after the initial scans. HPC was found in 24 (30.7 %) of 87 cases. The average volume of brain contusion on the repeat CT was 2.3±0.5 cm3 (0.2-17.1 cm3). In 3 (3.4 %) patients the size of the hematoma increased. Clinical deterioration occurred in 10 (11.5 %) patients. Six (6.9 %) patients were operated after a CT scan due to HPC with midline shift in 4 cases and increasing of subdural hematoma – 2 cases. Four of these patients had clinical deterioration, and 2 patients were neurological stable. Patients with HPC at admission had lower points of GCS, fractures of the skull (both p &lt;0.001), subdural blood collection (p=0.002), a higher average duration of treatment 8.1±4.2 vs 14.3±5.2 days (p=0.0001), and mortality rate 0 vs. 3 (12.5 %) (p=0.02). Conclusions: Routine repeat CT in patients with mild TBI with brain contusions is aimed to find a patients with s high risk for clinical deterioration. One third of patients with mild TBI and brain contusion experienced HPC. Patients with HPC often have unfavorable clinical course with higher average duration of treatment, delay surgical treatment and mortality rate.

Serum netrin-1 levels at presentation and delayed neurological sequelae in unintentional carbon monoxide poisoning

Objectives: The early identification of patients with a high risk of developing delayed neurological sequelae (DNS) can improve the quality of care in carbon monoxide (CO) poisoning cases. The aim of this study is to investigate whether the serum netrin-1 levels measured at presentation to the emergency department (ED) predicted the development of DNS after acute CO intoxication.Methods: This prospective observational study was conducted between 1 August 2018 and 31 July 2019 in a single tertiary hospital. The patients with acute CO intoxication and serum netrin-1 levels measured at the time of ED presentation were included in the study. All patients were followed up for six weeks regarding the development of DNS. The patients were divided into two groups, including those who developed DNS (DNS group) and those who did not (non-DNS group).Results: A total of 183 patients were included in the study, and 54 (29.5%) developed DNS. The median serum netrin-1 level at ED presentation was significantly lower in the DNS group (391.5 pg/mL [263.0–550.5]) than in the non-DNS group (626.0 pg/mL [505.9–755.6]) (p < .001). Multivariate analysis revealed that a low serum netrin-1 level (adjusted odds ratio [AOR]: 8.02, 95% CI: 2.45–26.20), low Glasgow coma scale (GCS) score at ED presentation (AOR: 0.81, 95% CI: 0.68–0.97), long CO exposure time (AOR: 1.96, 95% CI: 1.49–2.56), and the presence of acute brain lesions (AOR: 8.24, 95% CI: 2.37–28.58) on diffusion-weighted imaging were independent predictors of DNS. Serum netrin-1 levels less than 432 pg/mL predicted the development of DNS with a sensitivity of 68.5% (95% CI: 54.4%-80.5%) and a specificity of 86.0% (95% CI: 78.8%-91.5%).Conclusions: Low serum netrin-1 levels were significantly associated with the development of DNS. Therefore, serum netrin-1 at ED presentation can help identify patients at risk of developing DNS following discharge.

Acute alcohol intoxication as a confounding factor for mild traumatic brain injury.

Acute alcohol intoxication is universally considered a risk factor for traumatic brain injury (TBI), therefore an indication for head CT scan. There is no evidence in the literature for this attitude. Aim of this study is to assess the need for head CT scan in acutely alcohol-intoxicated subjects with mTBI and the role of Glasgow coma scale (GCS) score in this kind of patients. We retrospectively analyzed all 3358 consecutive patients presenting to our department in Switzerland, with TBI as chief complaint between January 2014 and January 2018. Alcohol was a statistically significant factor for presentation with a GCS score lower than 15. As for bleedings in mild TBI patients, the results were somewhat contradictory with GCS 15 patients showing a higher percentage of hemorrhages than GCS 14 patients. By dividing alcohol-intoxicated subjects into groups per blood alcohol concentration, the higher was the alcohol level, the lower the GCS score. We can affirm that GCS score is underestimated in acutely intoxicated head trauma patients. In this kind of patient, alcohol is a confounding factor and mild TBI could be safely managed by watchful waiting.

Abstract TP348: Extraventricular Drain Placement is Associated With Improved Outcome After Intracerebral Hemorrhage With Intraventricular Hemorrhage

Background and Aims: Many patients with intracerebral hemorrhage (ICH) develop intraventricular hemorrhage (IVH). External ventricular drains (EVDs) are commonly placed to treat obstructive hydrocephalus, but there is little data on how much patients benefit. We explored the use of EVD in ICH patients and any association with clinical outcome. Methods: We analyzed patients with primary ICH presenting to one academic medical center between 2000-2019. Patients with ICH secondary to trauma, aneurysm, and stroke were excluded. 3 month telephone interviews were used to assess clinical outcome. Good outcome was defined as 90 day modified Rankin score (mRS) of 0-3. Results: During this period 2,486 patients presented with primary ICH. Overall, patients were 73 (+/- 13) years old; 54% were male, 46% had IVH. Factors associated with IVH presence included ICH volume (29 cm 3 vs 9 cm 3 , p &lt; 0.001), deep location (48% vs 37%, p &lt; 0.001), and lower median Glasgow Coma Scale (GCS) score (9 vs 15, p &lt; 0.001). IVH presence was associated with higher 90 day mortality (57% vs. 19%, p &lt; 0.001) and poor outcome (86% vs 47%, p &lt; 0.001). An EVD was placed in 29% of patients with IVH and 4% of those without. IVH patients with EVD were younger (67 +/- 13 vs 74 +/- 13, p &lt; 0.001), had larger IVH volumes (17 cm 3 vs 8 cm 3 , p &lt; 0.001), and had lower GCS scores (7 vs 10, p &lt; 0.001) compared to other IVH patients. In univariate analysis, EVD placement was associated with poor outcome (88% vs 85%, p &lt; 0.001) but lower 90 day mortality (53% vs 59%, p = 0.048). In multivariate analysis controlling for age, ICH and IVH volumes, and Comfort Measures Only (CMO) status, EVD placement was associated with lower 90 day mortality (OR 0.68, 95% CI 0.47 - 0.98, p = 0.041), and was associated with lower chance of poor outcome (OR 0.43, 95% CI 0.25 - 0.72, p = 0.002). However, when controlling for intubation, these associations were no longer seen with 90-day mortality (OR 1.07, 95% CI 0.72 - 1.60, p = 0.737) or with poor outcome (OR 0.68, 95% CI 0.38 - 1.23, p = 0.202). Conclusion: IVH is relatively common after ICH. In univariate analysis, EVD placement is associated with lower mortality but worse neurologic outcome. However, after controlling for potential confounding factors, EVD is associated with lower mortality and better neurologic outcome.