Glasgow Outcome Scale-Extended Score Research Articles

Prognostic significance of serum annexin A7 in severe traumatic brain injury: A prospective longitudinal cohort study

BackgroundAnnexin A7 (ANXA7) may have the potential to exacerbate brain injury. Our purpose was to investigate the role of serum ANXA7 as a biomarker of severity and prognosis after severe traumatic brain injury (sTBI). MethodsIn this prospective cohort study, we consecutively enrolled 102 sTBI patients and 102 controls and measured their serum ANXA7 concentrations. Post-trauma 180-day poor prognosis was considered as extended Glasgow outcome scale score 1–4. ResultsSignificantly increased serum ANXA7 concentrations of sTBI patients, as compared to controls (median, 74.1 vs 8.0 ng/ml; P < 0.001), had independent correlation with Rotterdam computed tomography score (t = 3.251, P = 0.002) and Glasgow coma scale score (t = -2.253, P = 0.027), as well as serum ANXA7 concentrations > 74.1 ng/ml were independently predictive of 180-day overall survival (hazard ratio, 3.356; 95 % confidence interval (CI), 1.233–9.138; P = 0.018), and poor prognosis (OR: 3.558; 95 % CI, 1.264–10.015; P = 0.016). Serum ANXA7 concentrations were of significant efficiency for discriminating risks of mortality (area under receiver operating curve (AUC), 0.808; 95 % CI; 0.718–0.879) and poor prognosis (AUC, 0.772; 95 % CI; 0.678–0.849). Moreover, its AUC was in range of Glasgow coma scale score and Rotterdam computed tomography score (all P > 0.05) ConclusionsIncreased serum ANXA7 concentrations, in close relation to severity, were independently associated with prognosis, indicating that serum ANXA7 may represent a clinically valuable biomarker of sTBI.

Hyperbaric oxygen therapy promotes consciousness, cognitive function, and prognosis recovery in patients following traumatic brain injury through various pathways.

ObjectiveThe aim of this study was to investigate the clinical curative effect of hyperbaric oxygen (HBO) treatment and its mechanism in improving dysfunction following traumatic brain injury (TBI).MethodsPatients were enrolled into control and HBO groups. Glasgow coma scale (GCS) and coma recovery scale-revised (CRS-R) scores were used to measure consciousness; the Rancho Los Amigos scale-revised (RLAS-R) score was used to assess cognitive impairment; the Stockholm computed tomography (CT) score, quantitative electroencephalography (QEEG), and biomarkers, including neuron-specific enolase (NSE), S100 calcium-binding protein beta (S100β), glial fibrillary acidic protein (GFAP), brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), and vascular endothelial growth factor (VEGF), were used to assess TBI severity. The patients were followed up 6 months after discharge and assessed with the Glasgow outcome scale-extended (GOSE), functional independence measure (FIM), and the disability rating scale (DRS).ResultsThe CRS-R scores were higher in the HBO group than the control group at 10 days after treatment. The RLAS-R scores were higher in the HBO group than the control group at 10 and 20 days after treatment. The Stockholm CT scores were significantly lower in the HBO group than the control group at 10 days after treatment. HBO depressed the (δ + θ)/(α + β) ratio (DTABR) of EEG, with lower δ band relative power and higher α band relative power than those in the control group. At 20 days after treatment, the expression of NSE, S100β, and GFAP in the HBO group was lower than that in controls, whereas the expression of BDNF, NGF, and VEGF in the HBO group was higher than that in controls. Six months after discharge, the HBO group had lower DRS scores and higher FIM and GOSE scores than the control group significantly.ConclusionsHBO may be an effective treatment for patients with TBI to improve consciousness, cognitive function and prognosis through decreasing TBI-induced hematoma volumes, promoting the recovery of EEG rhythm, and modulating the expression of serum NSE, S100β, GFAP, BDNF, NGF, and VEGF.

Long-term outcomes of major trauma patients with concussion

IntroductionConcussion may be sustained in the setting of injuries to multiple body regions and persistent effects of concussion may impact recovery. This project aimed to evaluate the association between concussion and 6-month and 12-month functional outcomes in survivors after major trauma. MethodsThis was a registry-based cohort study that included adult patients with major trauma who presented to hospital between 01 Jan 2008 and 31 Dec 2017 and survived to hospital discharge. We excluded patients presenting with a Glasgow Coma Scale score <13 and those diagnosed with other intracranial injuries. Additionally, from the non-concussed group, patients with fractured skull and/or face were excluded, with the assumption that such patients may have had undiagnosed concussion. A good recovery was considered for Glasgow Outcome Scale-Extended (GOS-E) scores of 7 or 8. In addition, we assessed for patient reported anxiety and/or depression measured using the 3-level EuroQol 5 dimensions questionnaire. A modified mixed effects Poisson models with random intercepts for participant was used to assess the association between concussion and outcome. ResultsThere were 28,161 eligible patients and 12,822 met inclusion criteria. Concussion was diagnosed in 1860 patients (14.5%; 95%CI: 13.9–15.1). There was no association between concussion and good recovery at 12 months (aRR 1.05 (95%CI: 0.99–1.11). There was no association between concussion and anxiety and/or depression at 12 months (aRR 1.03; 95%CI: 0.99–1.07). ConclusionsConcussion was sustained among 14.5% of included patients in the setting of major trauma but not associated with longer-term adverse outcomes using GOS-E. Concussed patients did not report differential rates of anxiety and/or depression.

Long-term outcomes after aneurysmal subarachnoid hemorrhage: A prospective observational cohort study.

The survival rates for patients affected by aneurysmal subarachnoid hemorrhage (aSAH) have increased in recent years; however, many patients continue to develop cognitive dysfunctions that affect their quality of life. The commonly used outcome measures often fail to identify these cognitive dysfunctions. This study aimed to evaluate the long-term outcomes at 1 and 3 years after aSAH to assess changes over time and relate outcomes to patient characteristics and events during the acute phase. This prospective observational study included patients that experienced aSAH. Patients were assessed according to the extended Glasgow Outcome Scale, Life Satisfaction Questionnaire, Mayo-Portland Adaptability inventory-4, and Mental Fatigue scale. Patients were assessed after 1 year (n=62) and 3 years (n=54). At 3 years, the extended Glasgow Outcome Scale score improved in 15% and worsened in 12% of the patients. Mental fatigue was observed in 57% of the patients at 1 year. Patients <60 years of age at the time of aSAH had more self-assessed problems, including pain/headache (p < .01), than patients >60 years of age. Patients with delayed cerebral ischemia during the acute phase reported more dissatisfaction at 3 years, whereas no significant result was seen at 1 year. Cognitive dysfunction, especially mental fatigue, is common in patients with aSAH, which affects quality of life and recovery. Patient outcome is a dynamic process developing throughout years after aSAH, involving both improvement and deterioration. This study indicates the importance of longer follow-up periods with broad outcome assessments.

Diffusion Tensor Imaging Reveals Elevated Diffusivity of White Matter Microstructure that Is Independently Associated with Long-Term Outcome after Mild Traumatic Brain Injury: A TRACK-TBI Study.

Diffusion tensor imaging (DTI) literature on single-center studies contains conflicting results regarding acute effects of mild traumatic brain injury (mTBI) on white matter (WM) microstructure and the prognostic significance. This larger-scale multi-center DTI study aimed to determine how acute mTBI affects WM microstructure over time and how early WM changes affect long-term outcome. From Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI), a cohort study at 11 United States level 1 trauma centers, a total of 391 patients with acute mTBI ages 17 to 60 years were included and studied at two weeks and six months post-injury. Demographically matched friends or family of the participants were the control group (n = 148). Axial diffusivity (AD), fractional anisotropy (FA), mean diffusivity (MD), and radial diffusivity (RD) were the measures of WM microstructure. The primary outcome was the Glasgow Outcome Scale Extended (GOSE) score of injury-related functional limitations across broad life domains at six months post-injury. The AD, MD, and RD were higher and FA was lower in mTBI versus friend control (FC) at both two weeks and six months post-injury throughout most major WM tracts of the cerebral hemispheres. In the mTBI group, AD and, to a lesser extent, MD decreased in WM from two weeks to six months post-injury. At two weeks post-injury, global WM AD and MD were both independently associated with six-month incomplete recovery (GOSE <8 vs = 8) even after accounting for demographic, clinical, and other imaging factors. DTI provides reliable imaging biomarkers of dynamic WM microstructural changes after mTBI that have utility for patient selection and treatment response in clinical trials. Continued technological advances in the sensitivity, specificity, and precision of diffusion magnetic resonance imaging hold promise for routine clinical application in mTBI.

Cognitive-motor dissociation and time to functional recovery in patients with acute brain injury in the USA: a prospective observational cohort study

Recovery trajectories of clinically unresponsive patients with acute brain injury are largely uncertain. Brain activation in the absence of a behavioural response to spoken motor commands can be detected by EEG, also known as cognitive-motor dissociation. We aimed to explore the role of cognitive-motor dissociation in predicting time to recovery in patients with acute brain injury. In this observational cohort study, we prospectively studied two independent cohorts of clinically unresponsive patients (aged ≥18 years) with acute brain injury. Machine learning was applied to EEG recordings to diagnose cognitive-motor dissociation by detecting brain activation in response to verbal commands. Survival statistics and shift analyses were applied to the data to identify an association between cognitive-motor dissociation and time to and magnitude of recovery. The prediction accuracy of the model that was built using the derivation cohort was assessed using the validation cohort. Functional outcomes of all patients were assessed with the Glasgow Outcome Scale-Extended (GOS-E) at hospital discharge and at 3, 6, and 12 months after injury. Patients who underwent withdrawal of life-sustaining therapies were censored, and death was treated as a competing risk. Between July 1, 2014, and Sept 30, 2021, we screened 598 patients with acute brain injury and included 193 (32%) patients, of whom 100 were in the derivation cohort and 93 were in the validation cohort. At 12 months, 28 (15%) of 193 unresponsive patients had a GOS-E score of 4 or above. Cognitive-motor dissociation was seen in 27 (14%) patients and was an independent predictor of shorter time to good recovery (hazard ratio 5·6 [95% CI 2·5-12·5]), as was underlying traumatic brain injury or subdural haematoma (4·4 [1·4-14·0]), a Glasgow Coma Scale score on admission of greater than or equal to 8 (2·2 [1·0-4·7]), and younger age (1·0 [1·0-1·1]). Among patients discharged home or to a rehabilitation setting, those diagnosed with cognitive-motor dissociation consistently had higher scores on GOS-E indicating better functional recovery compared with those without cognitive-motor dissociation, which was seen as early as 3 months after the injury (odds ratio 4·5 [95% CI 2·0-33·6]). Recovery trajectories of clinically unresponsive patients diagnosed with cognitive-motor dissociation early after brain injury are distinctly different from those without cognitive-motor dissociation. A diagnosis of cognitive-motor dissociation could inform the counselling of families of clinically unresponsive patients, and it could help clinicians to identify patients who will benefit from rehabilitation. US National Institutes of Health.

Revisiting the Timeline of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: Toward a Temporal Risk Profile

BackgroundDelayed cerebral ischemia (DCI) is one of the main determinants of clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). The classical description of risk for DCI over time is currently based on the outdated concept of angiographic vasospasm. The goal of this study was to assess the temporal risk profile of DCI, defined by extended clinical and radiological criteria, as well as the impact the time point of DCI onset has on clinical outcome.MethodsAll patients with aneurysmal SAH referred to a single tertiary care center between 2010 and 2018 were considered for inclusion. This study was designed as a retrospective cohort analysis and data were extracted from existing patient files. In conscious patients, DCI was diagnosed clinically, and in unconscious patients, diagnosis was based on perfusion computed tomography imaging and multimodal neuromonitoring. Extended Glasgow Outcome Scale scores were assessed after 12 months and compared between patients with early (< day 7) and late (≥ day 7) DCI onset.ResultsThe median delay from day of the hemorrhage (day 0) until detection of the first DCI event was 7.0 days, with an interquartile range of 5 days. The probability of DCI development over time demonstrated a bimodal distribution with a peak risk on day 5 (0.084; confidence interval 0.05.5–0.122) and a second peak on day 9 (0.077; confidence interval 0.045–0.120). A total of 27 patients (15.6%) suffered dominant hemispheric or severe bilateral DCI-related infarctions, resulting in the withdrawal of technical life support. Of those, the majority (20 patients, 22.2%) presented with early DCI onset (vs. late onset: 7 patients, 8.4%; p = 0.013).ConclusionsThe risk profile of DCI over time mirrors the description of angiographic vasospasm; however, it comes with an added timely delay of 1 to 2 days. Early occurrence of DCI (before day 7) is associated with a higher infarct load and DCI-related mortality. Although the exact causal relationship remains to be determined, the time point of DCI onset may serve as an independent prognostic criterion in decision-making.

Retrospective Review of the Clinical Outcomes of Surgically Managed Patients with Intracranial Abscesses: A Single-Center Review

This study analyzed patient, radiologic, and clinical factors associated with operative brain abscesses and patients' functional outcomes. A retrospective analysis was conducted of neurosurgical cases of brain abscesses from 2009 to 2019 at a Canadian center. Functional outcome was recorded as Modified Rankin Scale score and Extended Glasgow Outcome Scale score. Multivariate analysis was conducted to identify relevant prognostic factors. We identified 139 patients managed surgically for brain abscesses. Resection alone was performed in 64% of patients, whereas 26.6% underwent aspiration alone. Most were adults (93.2%) and male (68.3%). Immunocompromise risk factors included diabetes (24.5%), cancer (23.7%), and immunosuppressive therapy (11.5%). Likely sources were postoperative (17.3%), systemic spread (16.5%), and poor dentition (12.9%). Microorganisms cultured from abscess samples were mixed growth (28%), Streptococcus anginosus (24.5%), and Staphylococcus aureus (7.9%). Disposition was home (42.4%) or repatriation to a home hospital (50.4%). By Extended Glasgow Outcome Scale, 25.2% had an unfavorable outcome including a mortality of 11.5%. Factors on multivariate analysis associated with poor outcome included diabetes (odds ratio, 2.8; 95% confidence interval [CI], 1.2-5.0) and ventricular rupture (odds ratio, 5.0; 95% CI, 1.7-13.5; hazard ratio, 12; 95% CI, 3.9-37.0). Supratentorial superficial eloquently located abscess was also associated with poor outcome (hazard ratio, 5.5; 95% CI, 1.8-16.7). Outcomes were similar with surgical excision and aspiration. Ventricular rupture and diabetes are significant risk factors for poor outcomes in intraparenchymal brain abscesses. No clear difference in outcomes was found between surgical excision or aspiration in our retrospective cohort.

The leap to ordinal: Detailed functional prognosis after traumatic brain injury with a flexible modelling approach.

When a patient is admitted to the intensive care unit (ICU) after a traumatic brain injury (TBI), an early prognosis is essential for baseline risk adjustment and shared decision making. TBI outcomes are commonly categorised by the Glasgow Outcome Scale-Extended (GOSE) into eight, ordered levels of functional recovery at 6 months after injury. Existing ICU prognostic models predict binary outcomes at a certain threshold of GOSE (e.g., prediction of survival [GOSE > 1]). We aimed to develop ordinal prediction models that concurrently predict probabilities of each GOSE score. From a prospective cohort (n = 1,550, 65 centres) in the ICU stratum of the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) patient dataset, we extracted all clinical information within 24 hours of ICU admission (1,151 predictors) and 6-month GOSE scores. We analysed the effect of two design elements on ordinal model performance: (1) the baseline predictor set, ranging from a concise set of ten validated predictors to a token-embedded representation of all possible predictors, and (2) the modelling strategy, from ordinal logistic regression to multinomial deep learning. With repeated k-fold cross-validation, we found that expanding the baseline predictor set significantly improved ordinal prediction performance while increasing analytical complexity did not. Half of these gains could be achieved with the addition of eight high-impact predictors to the concise set. At best, ordinal models achieved 0.76 (95% CI: 0.74-0.77) ordinal discrimination ability (ordinal c-index) and 57% (95% CI: 54%- 60%) explanation of ordinal variation in 6-month GOSE (Somers' Dxy). Model performance and the effect of expanding the predictor set decreased at higher GOSE thresholds, indicating the difficulty of predicting better functional outcomes shortly after ICU admission. Our results motivate the search for informative predictors that improve confidence in prognosis of higher GOSE and the development of ordinal dynamic prediction models.

Utility of Serum Growth Arrest-Specific Protein 6 as a Biomarker of Severity and Prognosis After Severe Traumatic Brain Injury: A Prospective Observational Study.

ObjectiveGrowth arrest-specific protein 6 (Gas6) may harbor protective effects in acute brain injury. This study was designed to determine the relation of serum Gas6 levels to severity and prognosis after traumatic brain injury (TBI).MethodsIn this prospective cohort study of 114 controls and 114 patients with severe TBI, multivariate analysis was used to assess relationships between serum Gas6 levels, Glasgow coma scale (GCS) score, Rotterdam computed tomography (CT) score, postinjury 180-day mortality, overall survival and poor prognosis (Extended Glasgow outcome scale score 1–4).ResultsSignificantly increased serum Gas6 levels of patients (median, 10.3 ng/mL versus 32.5 ng/mL; P < 0.001), as compared with controls, were independently correlated with Rotterdam CT score (t = 3.629, P < 0.001) and GCS score (t=−3.393, P = 0.001), and independently predicted 180-day mortality (odds ratio, 1.078; 95% confidence interval (CI), 1.007–1.154), overall survival (hazard ratio, 1.074; 95% CI, 1.012–1.139) and poor prognosis (odds ratio, 1.129; 95% CI, 1.059–1.205). Areas under receiver operating characteristic curve (AUCs) of serum Gas6 levels for discriminating risks of 180-day mortality and poor prognosis were 0.785 (95% CI, 0.699–0.857) and 0.793 (95% CI, 0.707–0.863), respectively; and serum Gas6 levels above 30.9 ng/mL and 28.3 ng/mL predicted 180-day mortality and poor prognosis with maximum Youden indices of 0.451 and 0.468, respectively. The predictive ability of serum Gas6 levels for mortality was similar to those of GCS score (AUC, 0.833; 95% CI, 0.751–0.896; P = 0.286) and Rotterdam CT score (AUC, 0.823; 95% CI, 0.740–0.888; P = 0.432). The discriminatory capability of serum Gas6 levels for the risk of poor prognosis was in the range of GCS score (AUC, 0.846; 95% CI, 0.766–0.906; P = 0.178) and Rotterdam CT score (AUC, 0.831; 95% CI, 0.750–0.895; P = 0.368).ConclusionSerum Gas6 may appear as a promising biochemical parameter for aiding in the assessment of trauma severity and prediction of prognosis among patients with severe TBI.

Patients With Better Outcome Have Higher ERP Response to Emotional Auditory Stimuli.

Accuracy of outcome prognosis is one of the most important tasks of coma arousal therapy. Reactions toward sensory stimuli are the most significant predictor of conscience and cognitive functions restoration after a brain injury. A paradigm that includes ERP registration has the advantage of detailed stimuli processing visualization. The authors aimed to investigate perception and distinguishing of emotionally significant sounds (crying and laughter) in coma patients with different consciousness restoration prognosis. EEG was recorded in 24 comatose patients with different outcomes (scored with Glasgow Outcome Scale-Extended) and 32 healthy volunteers. The authors presented sounds of crying and laughter. ERPs for sound stimulation were calculated. An analysis of the correlation of ERP components and Glasgow Outcome Scale-Extended score was performed. P200 (r = 0.6, P = 0.0014) and N200 amplitudes (r = -0.56, P = 0.0037) for emotional sounds correlated with the Glasgow Outcome Scale-Extended score. The significant differences of P300 and N400 amplitudes corresponded to differences of response between sounds of crying and laughter in subjects of the control group. Unlike the control group, comatose participants with good outcome produced similar electrical activity toward pleasant and unpleasant emotional stimuli. Comatose patients with good outcome produced more prominent ERP for emotional sounds. Even the good outcome participants were unable to distinguish emotional sounds of different moods, which indicate the preservation of solely robust mechanisms of sound processing. N200 and P200 amplitudes for emotional stimuli correlated significantly with outcome prognosis in coma patients.

Incomplete recovery in patients with minor head injury directly discharged home from the emergency department: a prospective cohort follow-up study

ObjectivesTo determine the frequency of post-traumatic complaints and recovery rate of non-hospitalised patients with minor head injury (MHI) and their relationship with demographic and injury characteristics. We also evaluated the...

Minimally Invasive Neurosurgery for Spontaneous Intracerebral Hemorrhage-10 Years of Working Progress at National Taiwan University Hospital.

Intracerebral hemorrhage (ICH) is a life-threatening disease with a global health burden. Traditional craniotomy has neither improved functional outcomes nor reduced mortality. Minimally invasive neurosurgery (MIN) holds promise for reducing mortality and improving functional outcomes. To evaluate the feasibility of MIN for ICH, a retrospective analysis of patients with ICH undergoing endoscopic-assisted evacuation was performed. From 2012 to 2018, a total of 391 patients who underwent ICH evacuation and 76 patients who received early (<8 h) MIN were included. The rebleeding, mortality, and morbidity rates were 3.9, 7.9, and 3.9%, respectively, 1 month after surgery. At 6 months, the median [interquartile range (IQR)] Glasgow Coma Scale score was 12 (4.75) [preoperative: 10 (4)], the median (IQR) Extended Glasgow Outcome Scale score was 3 (1), and the median (IQR) Modified Rankin Scale score was 4 (1). The results suggested that early (<8 h) endoscope-assisted ICH evacuation is safe and effective for selected patients with ICH. The rebleeding, morbidity, and mortality rates of MIN in this study are lower than those of traditional craniotomy reported in previous studies. However, the management of intraoperative bleeding and hard clots is critical for performing endoscopic evacuation. With this retrospective analysis of MIN cases, we hope to promote the specialization of ICH surgery in the field of MIN.

A population-based study of global outcome after moderate to severe traumatic brain injury in children and adolescents.

The primary aim of this study was to evaluate the global outcome longitudinally over 5 years in children and adolescents surviving moderate to severe traumatic brain injury (msTBI) to investigate changes in outcome over time. The secondary aim was to explore how age at the time of injury affected outcome. All children and adolescents (aged 0-17 years; subdivided into children aged 0-10 years and adolescents aged 11-17 years) with moderate (Glasgow Coma Scale [GCS] score 9-13) or severe (GCS score ≤ 8) TBI who were admitted to a level I trauma center in Norway over a 10-year period (2004-2014) were prospectively included. In addition, young adults (aged 18-24 years) with msTBI were included for comparison. Outcome was assessed with the Glasgow Outcome Scale-Extended (GOS-E) at 6 months, 12 months, and 5 years after injury. The effect of time since injury and age at injury on the probability of good outcome was estimated by the method of generalized estimating equations. A total of 30 children, 39 adolescents, and 97 young adults were included, among which 24 children, 38 adolescents, and 76 young adults survived and were planned for follow-up. In-hospital mortality from TBI was 7% for children, 3% for adolescents, and 18% for young adults. In surviving patients at the 5-year follow-up, good recovery (GOS-E score 7 or 8) was observed in 87% of children and all adolescents with moderate TBI, as well as in 44% of children and 59% of adolescents with severe TBI. No patient remained in a persistent vegetative state. For all patients, the odds for good recovery increased from 6 to 12 months (OR 1.79, 95% CI 1.15-2.80; p = 0.010), although not from 12 months to 5 years (OR 0.98, 95% CI 0.62-1.55; p = 0.940). Children/adolescents (aged 0-17 years) had higher odds for good recovery than young adults (OR 2.86, 95% CI 1.26-6.48; p = 0.012). In this population-based study of pediatric msTBI, surprisingly high rates of good recovery over 5 years were found, including good recovery for a large majority of children and all adolescents with moderate TBI. Less than half of the children and more than half of the adolescents with severe TBI had good outcomes. The odds for good recovery increased from 6 to 12 months and were higher in children/adolescents (aged 0-17 years) than in young adults.

Mobile telephone follow-up assessment of postdischarge death and disability due to trauma in Cameroon: a prospective cohort study

ObjectivesIn Cameroon, long-term outcomes after discharge from trauma are largely unknown, limiting our ability to identify opportunities to reduce the burden of injury. In this study, we evaluated injury-related death...

Tranexamic acid is not inferior to placebo with respect to adverse events in suspected traumatic brain injury patients not in shock with a normal head computed tomography scan: A retrospective study of a randomized trial.

A 2-g bolus of tranexamic acid (TXA) has been shown to reduce 28-day mortality in a randomized controlled trial. This study investigates whether out-of-hospital TXA use is associated with adverse events or unfavorable outcomes in suspected traumatic brain injury (TBI) when intracranial hemorrhage (ICH) is absent on initial computed tomography. This study used data from a 2015 to 2017, multicenter, randomized trial studying the effect of the following TXA doses on moderate to severe TBI: 2-g bolus, 1-g bolus plus 1-g infusion over 8 hours, and a placebo bolus with placebo infusion. Of the 966 participants enrolled, 395 with an initial computed tomography negative for ICH were included in this analysis. Fifteen adverse events (28-day incidence) were studied: myocardial infarction, deep vein thrombosis, seizure, pulmonary embolism, acute respiratory distress syndrome, cardiac failure, liver failure, renal failure, cerebrovascular accident, cardiac arrest, cerebral vasospasm, "any thromboembolism," hypernatremia, acute kidney injury, and infection. Other unfavorable outcomes analyzed include mortality at 28 days and 6 months, Glasgow Outcome Scale-Extended score of ≤4 at discharge and 6 months, intensive care unit-free days, ventilator-free days, hospital-free days, and combined unfavorable outcomes. In both study drug groups, the incidence of dichotomous outcomes and quantity of ordinal outcomes were compared with placebo. No statistically significant increase in adverse events or unfavorable outcomes was found between either TXA dosing regimen and placebo. Demographics and injury scores were not statistically different other than two methods of injury, which were overrepresented in the 1-g TXA bolus plus 1-g TXA infusion. Administration of either a 2-g TXA bolus or a 1-g TXA bolus plus 1-g TXA 8-hour infusion in suspected TBIs without ICH is not associated with increased adverse events or unfavorable outcomes. Because the out-of-hospital 2-g bolus is associated with a mortality benefit, it should be administered in suspected TBI. Therapeutic/Care Management; Level II.

Improving the Precision of the Glasgow Outcome Scale-Extended Using Item Response Theory: A TRACK-TBI Study.

The Glasgow Outcome Scale-Extended (GOSE) is a functional outcome measure intended to place individuals with traumatic brain injury (TBI) into one of eight broad levels of injury-related disability. This simplicity is not always optimal, particularly when more granular assessment of individuals' injury recovery is desired. The GOSE, however, is customarily assessed using a multi-question interview that contains richer information than is reflected in the GOSE score. Using data from the multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study (N = 1544), we used item response theory (IRT) to evaluate whether rescoring the GOSE using IRT, which posits that a continuous latent variable (disability) underlies responses, can yield a more precise index of injury-related functional limitations. We fit IRT models to GOSE interview responses collected at three months post-injury. Each participant's level of functional limitation was estimated from the model (GOSE-IRT) and comparisons were made between IRT-based and standard (GOSE-Ordinal) scores. The IRT scoring resulted in 141 possible scores (vs. 7 GOSE-Ordinal scores in this sample of individuals with GOSE scores ranging between 2 and 8). Moreover, GOSE-IRT scores were significantly more strongly associated with measures of TBI-related symptoms, psychological symptoms, and quality of life. Our findings demonstrate that rescoring the GOSE interview using IRT yields more granular, meaningful measurement of injury-related functional limitations, while adding no additional respondent or examiner burden. This technique may have utility for many applications, such as clinical trials aiming to detect small treatment effects, and small-scale studies that need to maximize statistical efficiency.

Posttraumatic Amnesia: A Systematic Review and Meta-Analysis. Proposal for a New Severity Classification

Posttraumatic amnesia (PTA) duration is used to predict outcome after traumatic brain injury (TBI): however, no meta-analysis exists. A systematic review was performed following PRISMA reporting guidelines. The databases Scopus-1966, PubMed/MEDLINE, CINAHL, PsycINFO, and Embase were searched for relevant texts. Random effects meta-analysis derived pooled estimates of the odds ratio of outcomes of interest and sensitivity and specificity of PTA at different cutoffs, and subsequently a summary receiver operating curve was derived. PTA prediction of Glasgow Outcome Scale (GOS) and Glasgow Outcome Scale-Extended (GOSE) scores was assessed both qualitatively and quantitatively by pooled odds ratio regarding both a good outcome (GO: GOS-5 or GOSE-7/GOSE-8) and a severe disability outcome (SDO: GOS-3 or a GOSE-3/GOSE-4). Summary receiver operating curve analysis was performed in the prediction of composite of a moderate disability outcome (MDO: GOS-4 or GOSE-5/GOSE-6) and SDO. Twenty-four studies were included in qualitative synthesis, and 9 (12,386 patients; males, 64%-84%) in meta-analysis. The odds of a GO and SDO were significantly different between PTA >56 days and PTA <7 days (P= 0.04 and P= 0.03). PTA <7 days (mild TBI) excluded MDO/SDO and SDO alone with 87% and 90% sensitivity. PTA of 43-86 days (severe TBI) predicted MDO/SDO or SDO with 90%-96% and 80%-90% specificity. However, PTA of 7-42 days (moderate TBI) predicted MDO/SDO or SDO with only 38%-89% and 30%-80% specificity. PTA duration was reliable in predicting outcome when <7 days, and especially when >42 days but was often unreliable between 7 and 42 days duration.

Decompressive Craniectomy vs. Craniotomy Only for Traumatic Brain Injury: A Propensity-Matched Study of Long-Term Outcomes in Neuropsychology.

BackgroundBoth decompressive craniectomy (DC) and craniotomy only (CO) are commonly performed to treat patients with traumatic brain injury (TBI) by evacuation of intracranial hemorrhage (ICH) and control intracranial pressure (ICP). The outcomes of these two procedures have been well-studied; however, most research studies have focused on physical functions. The purpose of our study is to assess long-term outcomes in neuropsychology after DC or CO in TBI patients.MethodsInformation was collected from patients with TBI who had undergone DC or CO and were then in the postoperative stable phase (6–24 months after injury). Propensity scoring matched the patients in a 1:1 ratio for demographics, cause of injury, TBI subtype, TBI severity, computed tomography (CT) findings, surgery side, and interval from TBI. We used Wechsler Adult Intelligence Scale-Chinese Revision (WAIS-RC), Wechsler Memory Scale-Chinese Revision (WMS-RC), Physical Self-maintenance Scale (PSMS), Instrumental Activities of Daily Living Scale (IADL), and Glasgow Outcome Scale-Extended (GOSE) to measure the long-term outcomes in TBI patients, especially in neuropsychology.ResultsThere were 120 TBI patients included in our study. After matching, 74 patients were paired into the DC group (n = 37) and the CO group (n = 37). There were no differences in the gender (P = 1.000), age at injury (P = 0.268), marital status (P = 0.744), pre-injury employment (P = 0.711), comorbidities (P = 1.000), education level (P = 0.969), cause of injury (P = 0.357), TBI subtype (P = 0.305), Glasgow Coma Scale (GCS) total score (P = 0.193), unconsciousness (P = 0.485), traumatic subarachnoid hemorrhage (tSAH) (P = 0.102), unresponsive pupil (P = 1.000), midline shift (P = 0.409), cisterns compressed or absent (P = 0.485), surgery side (P = 0.795), and interval from TBI (P = 0.840) between the two groups. The CO group was associated with better cognitive function in WAIS-RC OIQ (P = 0.030) and WAIS-RC FIQ (P = 0.021) and better daily function in IADL (P = 0.028) and ADL total (P = 0.030). The DC group also had a lower GOSE (P = 0.004) score compared to the CO group. No difference was observed in WAIS-VIQ (P = 0.062), WMS-RC MQ (P = 0.162), and PSMS (P = 0.319).ConclusionIn the matched cohort, patients who underwent CO had better long-term outcomes in cognitive and daily function compared with DC. Future randomized control trials are needed for intensive studies on physical and neuropsychological prognosis in TBI patients.

How Do Scores on the Functional Status Examination (FSE) Correspond to Scores on the Glasgow Outcome Scale-Extended (GOSE)?

This study was designed to determine how raw scores correspond between two alternative measures of functional recovery from traumatic brain injury (TBI), the Functional Status Examination (FSE) and the Glasgow Outcome Scale-Extended (GOSE). Using data from 357 persons with moderate-severe TBI who participated in a large clinical trial, we performed item response theory analysis to characterize the relationship between functional ability measured by the FSE and GOSE at 6 months post-injury. Results revealed that raw scores for the FSE and GOSE can be linked, and a table is provided to translate scores from one instrument to the other. For example, a FSE score of 7 (on its 0–21 scale, where higher scores reflect more impairment) is equivalent to a GOSE score of 6 (where GOSE is scaled on an 8-point scale, with higher scores reflecting less impairment). These results allow clinicians or researchers who have a score for a person on one instrument to cross-reference it to a score on the other instrument. Importantly, this enables researchers to combine data sets where some persons only completed the GOSE and some only the FSE. In addition, an investigator could save participant time by eliminating one instrument from a battery of tests, yet still retain a score on that instrument for each participant. More broadly, the findings help anchor scores from these two instruments to the broader continuum of injury-related functional limitations.