Glasgow Coma Scale Score Research Articles

Assessment of GCS and FOUR Score as Prognostic Indicators for Hospital Stay and Morbidity in Traumatic Brain Injury Patients: An Observational Study

ABSTRACT Aim: The objective of the present research was to evaluate variations in hospital stay as well as morbidity based on the Glasgow Coma Scale (GCS) and Full Outline of Un-Responsive (FOUR) scores for patients who had traumatic brain injury (TBI). Materials and Methods: A total of 107 patients with TBI patients who attended the emergency department of MES Medical College, Perinthalmanna, were enrolled into the study. FOUR and GCS scoring systems were used to assess the patients within 24 hours of the presentation to the emergency department. Both FOUR and GCS scoring systems were assessed at the same time. The outcome was measured in terms of length of hospital stay and morbidity, which was assessed using modified Rankin score. Chi-square test was used to calculate sensitivity, specificity, positive predictive value, and negative predictive value. The area under the curve (AUC) was calculated using receiver operating characteristic curve analysis. A P value <0.05 was considered significant. Results: We found a strong positive correlation between GCS and FOUR score with a Spearman coefficient of 0.9. Comparison of AUC between GCS score and FOUR score showed a statistically significant difference (P = 0.0044), predicting that FOUR score was a better predictor of hospital stay (>15 days) than GCS score. Comparison of AUC between GCS score and FOUR score showed a significant statistical difference (P = 0.0002), showing that FOUR score was a better predictor of morbidity than GCS. Conclusion: FOUR score was a better predictor of hospital stay and morbidity as compared to GCS score.

Abstract 151: GFAP Measurements for Rapid Prehospital Identification of Intracranial Hemorrhage in Patients With Acute Coma

Background: Prehospital triage and treatment of patients with acute coma is challenging for rescue services, as the underlying pathogenetic conditions are highly heterogenous and difficult to assess. Glial fibrillary acidic protein (GFAP) has been recently identified as a biomarker of intracerebral hemorrhage. The aim of this study was to test the diagnostic value of a GFAP point-of-care(poc) device to rapidly differentiate intracranial hemorrhage from other causes of acute coma (including seizures, metabolic disorders, cardiovascular disorders, and intoxication) in the prehospital phase. Methods: Patients who were admitted to the emergency department due to acute coma (Glasgow Coma Scale scores between 3-8) were enrolled prospectively. Blood samples were collected already in the prehospital phase. Plasma GFAP measurements were performed on the i-STAT Alinity® (Abbott) device (duration of analysis 15 min). The primary endpoint was the final diagnosis at hospital discharge. Results: 95 patients were enrolled (mean age 64±20 years, 43% female). GFAP concentrations were strongly elevated in patients with a primary cerebral cause of coma compared to primary non-cerebral causes (p<0.001). The GFAP concentrations (mean±SD in pg/mL) according to final diagnosis were as follows: intracerebral hemorrhage 4840±4500 (n=15), subarachnoid hemorrhage 4858±4662 (n=11), subdural or epidural hematoma 3462±4005 (n=4), ischemic stroke 992±2857 (n=12), seizure 45±21 (n=11), cardiovascular or metabolic disorder 258±888 (n=29), intoxication 30±2 (n=6), psychogenic stupor 29±0 (n=2); n=5 patients had missing diagnoses. GFAP values over 1000 pg/ml indicated a primary cerebral cause of coma with 100% certainty (hereof, 86% had intracranial hemorrhage). Conclusion: Increased GFAP plasma values in patients with acute coma identify a primary cerebral cause of coma (mostly intracranial hemorrhage) with very high diagnostic accuracy. Patients with primary non-cerebral causes of coma showed overall low GFAP concentrations. Prehospital GFAP measurements on a poc platform may allow rapid stratification according to the underlying cause of coma by rescue services. This could have major impact on triage and management of these critically ill patients.

Outcomes of patients with traumatic brain injury after stress ulcer prophylaxis: a retrospective multicenter study

BackgroundStress ulcers in patients with traumatic brain injury (TBI) and spinal cord injury (SCI) present significant morbidity and mortality risks. Despite the low reported stress ulcer rates, stress ulcer prophylaxis...

Abstract WP209: Functional Outcomes After Craniotomy or Endoscopic Procedure for Hematoma Evacuation in Patients of Intracerebral Hemorrhage Associated With Oral Anticoagulants

Background and Purpose: The role of surgical evacuation using craniotomy or endoscopic procedure in patients with intracerebral hemorrhage (ICH) associated with oral anticoagulants is not well described. We investigated the 6-month functional outcomes of patients with ICH associated with oral anticoagulants after hematoma evacuation using either craniotomy or endoscopic procedures. Methods: We analyzed data of consecutive ICH patients who underwent hematoma evacuation using either craniotomy or endoscopic procedures. We compared the outcomes between patients with ICH associated with oral anticoagulants to those with spontaneous ICH. We also compared the results between patients treated with craniotomy and those treated with endoscopic procedures. We performed multivariate analyses to assess the effect of ICH associated with oral anticoagulants on modified Rankin Scale (mRS) at 6 months, which was analyzed both as dichotomous and ordinal endpoints after adjusting for age, gender, initial GCS score, initial hematoma volume, and presence or absence of intraventricular hemorrhage. Results: Of the 148 ICH patients undergoing hematoma evacuation, 25 (17%) had ICH associated with oral anticoagulants. There were no statistically significant differences between the two groups in terms of age, gender, admission Glasgow Coma scale (GCS) score, admission National Institutes of Health Stroke Scale (NIHSS) score, peri and post-operative hematoma volume, presence of cardiovascular disease, hypertension, or dyslipidemia. There was no difference in the proportion of patients with mRS 0-2 at 6 months among patients with and without ICH related to oral anticoagulants (4/25 (16%) versus 27/123 (22%), p-value = 0.5). In the ordinal analysis, there was no significant association between ICH associated with oral anticoagulants and mRS grades (OR 1.62 (0.25, 9.65), p-value 0.598. Conclusion: Prior anticoagulation use is not associated with poor functional outcome (mRS 3-6) in patients with intracerebral hemorrhage, procedure use for hematoma evacuation (craniotomy or endoscopic) does not predict good functional outcome at 6 months.

Clinical characteristics and outcomes of traumatic brain injury in patients admitted to surgical ward of Jimma Medical Center, Southwest Ethiopia: a prospective observational follow-up study

ObjectiveTo assess the Clinical Characteristics and Outcomes of Traumatic Brain Injury in Patients Admitted to the Surgical Ward of Jimma Medical Center, Southwest Ethiopia from January to July 2022.Design and...

Retrospective evaluation of shock index and mortality in dogs with head trauma (2015-2020): 86 cases.

To assess the relationship between shock index (SI) and mortality in dogs with head trauma (HT). A secondary objective was to compare SI with the animal trauma triage (ATT) score and Modified Glasgow Coma Scale (MCGS) score in HT cases. A tertiary aim was to assess if SI is predictive of survival to discharge or improvement in presenting neurologic signs. Retrospective study from January 2015 to December 2020. Tertiary referral level II veterinary trauma center. Eighty-six dogs with evidence of HT presenting through emergency for various traumas compared to 60 healthy control dogs. SI was calculated using the quotient of heart rate over systolic blood pressure measured on presentation. SI was significantly higher in HT patients than healthy controls (P=0.0019). SI was not significantly different between traumatic brain injury dogs that died or were euthanized and HT dogs that lived until the time of discharge (P=0.98). SI was not significantly different between HT dogs that were neurologically normal at the time of discharge and HT dogs that were static or improved but not normal neurologically at the time of discharge (P=0.84). In HT dogs, SI did not correlate with ATT score (P=0.16) or MGCS score (P=0.75). There was no significant difference in SI and length of hospitalization until death or discharge (P=0.78). SI was significantly higher in HT patients compared to control patients. Interestingly, SI was not correlated with ATT score or MGCS score. The use of SI in HT patients warrants further investigation to assess the efficacy in predicting mortality.

Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center

IntroductionPediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic...

Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery.

The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS). Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months. With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

Abstract TP167: Hemorrhage Severity Associates With Hospital Acquired Delirium During Intracerebral Hemorrhage

Introduction: Delirium associates with poor outcome after intracerebral hemorrhage (ICH), yet its incidence and contributing factors are poorly characterized. We show delirium proportions among older ICH patients and identify factors that associate with hospital-acquired delirium (HAD). Methods: Data from older adult (≥70 years) patients with primary nontraumatic ICH were retrieved from electronic medical records. Delirium was assessed once every 12 hours or per shift using the modified Arousal, Attention, Abbreviated Mental Test-4, Acute change test. Delirium on admission (DOA) was defined as a positive screen within 48 hours of admission and HAD was defined as a positive screen among non-DOA patients. Population differences between HAD and non-HAD patients were assessed using Wilcoxon Rank Sum and Pearson’s Chi Squared tests. Factors associated with HAD were identified via multivariable logistic regression modelling. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported. Results: The cohort included 647 patients (median age: 79, interquartile range: [74-85]; 55.0% female) with an ethno-racial distribution of 57.6% White, 16.4% Black, 15.9% Hispanic, 8.5% Asian, and 1.6% Other. The median hemorrhage volume was 8.0 [1.6-24.7] cm 3 . DOA was present in 327 (50.5%) patients. Among patients without DOA (n=320), 90 (28.1%) developed HAD. In univariate analyses, patients with HAD (vs non-HAD) were significantly older and had lower admission Glasgow Coma Scale scores, larger hemorrhages volumes, more frequent intraventricular hemorrhage (IVH), and longer lengths of stay. In multivariable modelling, HAD was independently associated with older age (1.05 [1.01-1.10]), top-quartile hemorrhage volume (2.89 [1.08-7.75]), length of stay (1.14 [1.08-1.19]), and IVH (2.03 [1.08-1.19]) (Figure 1). Discussion: Older patients and those with more severe hemorrhage characteristics show greater odds of developing in-hospital delirium.

Differences in clinical outcomes and resource utilization in pediatric traumatic brain injury between countries of different sociodemographic indices.

The burden of traumatic brain injury (TBI) is disproportionately high in low- and middle-income countries (LMICs). This study aimed to compare clinical outcomes and healthcare utilization for children with moderate to severe TBIs between LMICs and non-LMICs in Asia and Latin America. The authors performed an observational multicenter study from January 2014 to February 2023 among children with moderate to severe TBIs admitted to participating pediatric intensive care units (PICUs) in the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) and Red Colaborativa Pediátrica de Latinoamérica (LARed Network). They classified sites according to their 2019 sociodemographic index (SDI). Low, low-middle, and middle SDI sites were considered LMICs, while high-middle and high SDI sites were considered non-LMICs. The authors documented patient demographics and TBI management. Accounting for death, they recorded 14-day PICU-free and 28-day hospital-free days, with fewer free days indicating poorer outcome. The authors compared children who died and those who had poor functional outcomes (defined as Pediatric Cerebral Performance Category [PCPC] level of moderate disability, severe disability, or vegetative state or coma) between LMICs and non-LMICs and performed a multivariable logistic regression analysis for predicting poor functional outcomes. In total, 771 children with TBIs were analyzed. Mortality was comparable between LMICs and non-LMICs (9.6% vs 12.9%, p = 0.146). Children with TBIs from LMICs were more likely to have a poor PCPC outcome (31.0% vs 21.3%, p = 0.004) and had fewer ICU-free days (median [IQR] 6 [0-10] days vs 8 [0-11] days, p = 0.004) and hospital-free days (median [IQR] 9 [0-18] days vs 13 [0-20] days, p = 0.007). Poor functional outcomes were associated with LMIC status (adjusted OR [aOR] 1.53, 95% CI 1.04-2.26), a lower Glasgow Coma Scale score (aOR 0.83, 95% CI 0.78-0.88), and the presence of multiple trauma (aOR 1.49, 95% CI 1.01-2.19). Children with TBIs in LMICs required greater resource utilization in the form of early intubation and mechanical ventilation (81.6% vs 73.2%, p = 0.006), use of hyperosmolar therapy (77.7% vs 63.6%, p < 0.001), and use of antiepileptic drugs (73.9% vs 53.1%, p < 0.001). Within Asia and Latin America, children with TBIs in LMICs were more likely to have poor functional outcomes and required greater resource utilization. Further research should focus on investigating causal factors and developing targeted interventions to mitigate these disparities.

Outcome Predictors of Glasgow Coma Scale Score in Patients with Severe Traumatic Brain Injury

Abstract: Background: - The “Glasgow Coma Scale” is routinely used to assess responsiveness and guide early care for individuals with head injury or severe brain impairment. Severely impaired patients may need MRI, hospitalization for observation, or discharge, which is determined based on Glasgow Coma Scale assessments. Purpose: - The study's objective is to evaluate that Glasgow coma scale scores are outcome Methods: - A retrospective study was conducted on 30 patients who visited the outpatient department of Teerthanker Mahaveer Hospital &amp; Research Center, Moradabad. Only TBI patients with a GCS score of 5-8 were included. Patient demographics, physical exams, doctor assessments, medicinal interventions, and health status evaluations were recorded. The study analyzed the correlation between each variable and the GCS score to determine their relationship.

Surgical Management of a Thalamic Arteriovenous Malformation in a Young Male in a Low Resource Setting: An Illustrative Case Report

Introduction: The natural history of patients with arteriovenous malformations (AVMs) suggests that 10-17% die due to hemorrhage and 40-50% experience serious physical deterioration of their working capacity in their 20-40-year period after presentation and treatment. Deep basal ganglia and thalamus lesions account for 3-12% of all AVMs and some literature suggests that these lesions have a more hostile clinical course. Case Presentation: 16-year-old male, a student with no known chronic illnesses came to our hospital as a referral from Lubaga hospital. He presented with fifteen days’ history of sudden onset of severe headache with no known relieving or exacerbating factors. This was associated with episodes of vomiting, altered mentation, right sided weakness, however there was no history of convulsions, blurring of vision or trauma. This was the first time for this kind of presentation. On admission: He was lethargic, moderately dehydrated, not pale nor jaundiced. BP was 109/52mmHg, HR of 60bpm, SPO2=96% on room air. Glasgow Coma Scale score of 14/15, V=4, PEAL, soft neck, normal muscle bulky with a power of 2/5 on the left side and 4/5 on the right side. Successful surgical resection of the AVM was done at Mbarara regional referral Hospital-Uganda. Currently the patient is back in the community and has returned to school. Conclusion: Children who present with intracranial hemorrhage from a previously undiagnosed AVM have a 12% chance of sudden death. Clinical triggers of hemorrhage are unpredictable, and all fatal cases were in locations with high risk of potential herniation. These data support a proactive, aggressive approach toward definitive treatment of AVMs in children and adults. Patients with diagnosed AVM can once again get a chance to survive like other children in the community in LMICs like Uganda by undergoing open surgery, although advanced opportunities are still limited.

An Exploratory Analysis of Preclinical and Clinical Factors Associated With Sleep Disturbance Assessed via the Neuro-QoL After Hemorrhagic Stroke.

Sleep disturbance after hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) can impact rehabilitation, recovery, and quality of life. We sought to explore preclinical and clinical factors associated with sleep disturbance after hemorrhagic stroke assessed via the Quality of Life in Neurological Disorders (Neuro-QoL) short form sleep disturbance inventory. We telephonically completed the Neuro-QoL short form sleep disturbance inventory 3-months and 12-months after hemorrhagic stroke for patients >18-years-old hospitalized between January 2015 and February 2021. We examined the relationship between sleep disturbance (T-score >50) and social and neuropsychiatric history, systemic and neurological illness severity, medical complications, and temporality. The inventory was completed for 70 patients at 3-months and 39 patients at 12-months; 18 (26%) had sleep disturbance at 3-months and 11 (28%) had sleep disturbance at 12-months. There was moderate agreement (κ = .414) between sleep disturbance at 3-months and 12-months. Sleep disturbance at 3-months was related to unemployment/retirement prior to admission (P = .043), lower Glasgow Coma Scale score on admission (P = .021), higher NIHSS score on admission (P = .041) and infection while hospitalized (P = .036). On multivariate analysis, sleep disturbance at 3-months was related to unemployment/retirement prior to admission (OR 3.58 (95% CI 1.03-12.37), P = .044). Sleep disturbance at 12-months was related to premorbid mRS score (P = .046). This exploratory analysis did not demonstrate a sustained relationship between any preclinical or clinical factors and sleep disturbance after hemorrhagic stroke. Larger studies that include comparison to patients with ischemic stroke and healthy individuals and utilize additional techniques to evaluate sleep disturbance are needed.

A retrospective analysis of 20,178 adult neurological infection admissions to United Kingdom critical care units from 2001 to 2020

BackgroundNeurological infection is an important cause of critical illness, yet little is known on the epidemiology of neurological infections requiring critical care.MethodsWe analysed data on all adults with proven or probable neurological infection admitted to UK (NHS) critical care units between 2001 and 2020 reported to the Intensive Care National Audit and Research Centre. Diagnoses, physiological variables, organ support and clinical outcomes were analysed over the whole period, and for consecutive 5-year intervals within it. Predictors of in-hospital mortality were identified using a backward stepwise regression model.ResultsWe identified 20,178 critical care admissions for neurological infection. Encephalitis was the most frequent presentation to critical care, comprising 6725 (33.3%) of 20,178 cases. Meningitis– bacterial, viral or unspecified cases - accounted for 10,056 (49.8%) of cases. In-hospital mortality was high, at 3945/19,765 (20.0%) overall. Over the four consecutive 5-year periods, there were trends towards higher Glasgow Coma Scale scores on admission, longer critical care admissions (from median 4 [IQR 2–8] to 5 days [IQR 2–10]), and reduced in-hospital mortality (from 24.9 to 18.1%). We identified 12 independent predictors of in-hospital death which when used together showed good discrimination between patients who die and those who survive (AUC = 0.79).ConclusionsAdmissions with neurological infection to UK critical care services are increasing and the mortality, although improving, remains high. To further improve outcomes from severe neurological infection, novel approaches to the evaluation of risk stratification, monitoring and management strategies are required.

Longitudinal Associations Between Persistent Post-Concussion Symptoms and Blood Biomarkers of Inflammation and CNS-Injury After Mild Traumatic Brain Injury.

The aim of our study was to investigate the biological underpinnings of persistent post-concussion symptoms (PPCS) at 3 months following mild traumatic brain injury (mTBI). Patients (n = 192, age 16-60 years) with mTBI, defined as Glasgow Coma Scale (GCS) score between 13 and 15, loss of consciousness (LOC) <30 min, and post-traumatic amnesia (PTA) <24 h were included. Blood samples were collected at admission (within 72 h), 2 weeks, and 3 months. Concentrations of blood biomarkers associated with central nervous system (CNS) damage (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], and tau) and inflammation (interferon gamma [IFNγ], interleukin [IL]-8, eotaxin, macrophage inflammatory protein-1-beta [MIP]-1β, monocyte chemoattractant protein [MCP]-1, interferon-gamma-inducible protein [IP]-10, IL-17A, IL-9, tumor necrosis factor [TNF], basic fibroblast growth factor [FGF]-basic platelet-derived growth factor [PDGF], and IL-1 receptor antagonist [IL-1ra]) were obtained. Demographic and injury-related factors investigated were age, sex, GCS score, LOC, PTA duration, traumatic intracranial finding on magnetic resonance imaging (MRI; within 72 h), and extracranial injuries. Delta values, that is, time-point differences in biomarker concentrations between 2 weeks minus admission and 3 months minus admission, were also calculated. PPCS was assessed with the British Columbia Post-Concussion Symptom Inventory (BC-PSI). In single variable analyses, longer PTA duration and a higher proportion of intracranial findings on MRI were found in the PPCS group, but no single biomarker differentiated those with PPCS from those without. In multi-variable models, female sex, longer PTA duration, MRI findings, and lower GCS scores were associated with increased risk of PPCS. Inflammation markers, but not GFAP, NFL, or tau, were associated with PPCS. At admission, higher concentrations of IL-8 and IL-9 and lower concentrations of TNF, IL-17a, and MCP-1 were associated with greater likelihood of PPCS; at 2 weeks, higher IL-8 and lower IFNγ were associated with PPCS; at 3 months, higher PDGF was associated with PPCS. Higher delta values of PDGF, IL-17A, and FGF-basic at 2 weeks compared with admission, MCP-1 at 3 months compared with admission, and TNF at 2 weeks and 3 months compared with admission were associated with greater likelihood of PPCS. Higher IL-9 delta values at both time-point comparisons were negatively associated with PPCS. Discriminability of individual CNS-injury and inflammation biomarkers for PPCS was around chance level, whereas the optimal combination of biomarkers yielded areas under the curve (AUCs) between 0.62 and 0.73. We demonstrate a role of biological factors on PPCS, including both positive and negative effects of inflammation biomarkers that differed based on sampling time-point after mTBI. PPCS was associated more with acute inflammatory processes, rather than ongoing inflammation or CNS-injury biomarkers. However, the modest discriminative ability of the models suggests other factors are more important in the development of PPCS.

Two-Stage Anatomic Myocutaneous Flap Dissection in Cranioplasty: Technical Nuances and Single-Surgeon Experience.

Temporalis muscle management remains one of the most challenging aspects of cranioplasty, which accounts for considerable rates of dissection-related complications. Since 2019, the senior author has developed and consistently used a methodical, two-stage anatomic dissection technique to separate the scalp and temporalis muscle from the underlying brain. This technique is believed to facilitate dissection and minimize the risk of brain injury, while optimizing cosmetic outcomes. All patients who underwent cranioplasty between January 2019 and February 2023 were identified from a prospectively maintained database. Charts were retrospectively reviewed. Demographic, clinical, and procedural data were extracted and analyzed. Twenty-nine patients, 20 men and 9 women with a median age of 37 years (range 17-72), were identified. Indications for craniectomy were traumatic brain injury in 18 (62.1%), hemorrhagic stroke in five (17.2%), ischemic stroke in four (13.8%), and aneurysmal subarachnoid hemorrhage in two (6.9%). Median precranioplasty modified Rankin Scale and Glasgow Coma Scale scores were 5 (range in series: 0-5) and 14 (range in series: 3-15), respectively. The median time to cranioplasty was 131 days (32-1717). Cranioplasty was technically successful in all patients, with a median operative time of 106 minutes (62-182). There were no intraoperative complications. Postoperative complications occurred in three patients (10.3%): hemorrhagic brain contusion (n = 1), meningitis (n = 1), and seizure (n = 1). Of those, one patient (3.4%) died 2 weeks after surgery from suspected pulmonary embolism. After a median follow-up of 4 months (1-44), all 28 survivors have either remained clinically stable or exhibited neurological improvement. Cosmetic results were good or excellent in 27 (96.4%) and fair in one (3.6%). Two-stage anatomic dissection of the scalp and temporalis muscle during cranioplasty can maximize surgical efficiency and result in excellent outcomes. Cranioplasty should be considered a low-risk, low-complexity neurosurgical procedure. Safe and efficient management of the temporalis muscle is key.

The GCS-Pupils (GCS-P) score to assess outcomes after traumatic brain injury: a retrospective study

Introduction The Glasgow Coma Scale (GCS) and pupil response to light are commonly used to assess brain injury severity and predict outcomes. The aim of this study was to investigate whether the GCS combined with pupil response (GCS-P), compared to the GCS alone, could be a better predictor of hospital mortality for patients with traumatic brain injury (TBI). Methods A retrospective cohort study was undertaken at an adult level one trauma centre including patients with isolated TBI of Abbreviated Injury Scale above three. The GCS and pupil response were combined to an arithmetic score (GCS score (range 3–15) minus the number of nonreacting pupils (0, 1, or 2)), or by treating each factor as separate categorical variables. The association of in-hospital mortality with GCS-P as a categorical variable was evaluated using Nagelkerke’s R 2 and compared using areas under the receiver operating characteristic (AUROC) curve. Results There were 392 patients included over the study period of 1 July 2014 and 30 September 2017, with an overall mortality rate of 15.2%. Mortality was highest at GCS-P of 1 (79%), with lowest mortality at a GCS-P 15 (1.6%). Nagelkerke’s R 2 was 0.427 for GCS alone and 0.486 for GCS-P. The AUROC for GCS-P to predict mortality was 0.87 (95%CI: 0.82–0.72), higher than for GCS alone (0.85; 95%CI: 0.80–0.90; p < .001). Discussion GCS-P provided a better predictor of mortality compared to the GCS. As both the GCS and pupillary response are routinely recorded on all patients, combination of these pieces of information into a single score can further simplify assessment of patients with TBI, with some improvement in performance.

Fulminant hemorrhagic course of a thalamic H3 K27-altered diffuse midline glioma in an adult patient: illustrative case.

H3 K27-altered diffuse midline gliomas (DMGs) are rare tumors, which are, regardless of their histological appearance, classified as World Health Organization grade 4 tumors. They are characterized by a diffuse growth pattern, midline anatomical location, and poor prognosis. Although DMGs occur predominantly in childhood, these tumors can also be found in young adults. The authors present a case of a 29-year-old patient who was found unconscious with a Glasgow Coma Scale score of 4, along with abnormal extensor movements and bilateral middilated nonreactive pupils. Computed tomography revealed obstructive hydrocephalus due to an acute hemorrhage in a right thalamic lesion. To drain the hydrocephalus and relieve the ongoing central herniation, emergent placement of a right-sided, and later a left-sided, extraventricular drain was performed. Despite the postoperative resolution of hydrocephalus, the patient died shortly after because of the central brain herniation that had occurred. Brain autopsy revealed a H3 K27-altered DMG in the right thalamus. Although typically described in the pediatric population and located in the pons, H3 K27-altered DMG should also be considered in young adult patients with midline lesions, particularly if they are located in the thalamus or brainstem. In rare cases, H3 K27-altered DMG may present with an acute tumor-related hemorrhage, leading to a fulminant clinical course.

Plasma Exchange in Pediatric Neurology Patients: A Single-Center Experience.

Therapeutic plasma exchange (TPE) is a procedure involving the filtration of a patient's plasma to eliminate pathogenic components or address deficiencies. This technique finds varied indications in the pediatric age group, particularly in neuroinflammatory diseases. The objective of this study is to delve into our local experience with TPE, focusing on indications, outcomes, and complications among children with neurological diseases at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. Conducted at the pediatric department of KAUH in Jeddah from November 2008 to July 2023, this retrospective cohort study examined 15 patients, revealing a notable male predominance with 12 male patients (80%) and three female patients (20%). About two-thirds of patients exhibited an average illness severity, with a Glasgow Coma Scale (GCS) score of 10.7 and anExpanded Disability Status Scale (EDSS) score of 4.8. The median length of hospital stay was 23 days, and in the pediatric intensive care unit (PICU), it was 8.5 days. Presenting symptoms included limb weakness (n = 6), loss of consciousness (n = 3), dysphagia (n = 3), photophobia (n = 1), and ascending paralysis (n = 1). The TPE was performed for Guillain-Barré syndrome (GBS) (n = 7), myasthenia gravis (MG) (n = 3), transverse myelitis (TM) (n = 2), neuromyelitis optica (NMO) (n = 2), and systemic lupus erythematosus (SLE) cerebritis (n = 1). Twelve patients were admitted to the PICU, and mechanical ventilation was required for 10 patients. In magnetic resonance imaging (MRI) findings, abnormalities were observed in 10 cases, while the remaining five either had normal results or did not undergo MRI. Most patients required five sessions of TPE (n = 7). The median age at the initiation of TPE was 13 years. Twelve patients improved with TPE treatment, while three did not. Complications observed during and following TPE included fever (n = 5), electrolyte disturbance (n = 5), hypotension (n = 3), hypocalcemia (n = 2), bradycardia (n = 2), vomiting (n = 1), tachycardia (n = 1), eye rash (n = 1), infection (n = 1), and bleeding originating from the TPE procedure site (n = 1). In conclusion, our study underscores the significance of TPE as a therapeutic modality, emphasizing the imperative for ongoing research to fully exploit its potential across diverse medical contexts for enhancing patient care. Our findings, consistent with prior research, reveal plasma exchange's (PLEX's) wide-ranging applications and complications in neurological disorders.

Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial

Patients with acute brain injury are at high risk of ventilator-associated pneumonia (VAP). The benefit of short-term antibiotic prophylaxis remains debated. We aimed to establish the effect of an early, single dose of the antibiotic ceftriaxone on the incidence of early VAP in patients with severe brain injury who required mechanical ventilation. PROPHY-VAP was a multicentre, randomised, double-blind, placebo-controlled, assessor-masked, superiority trial conducted in nine intensive care units in eight French university hospitals. We randomly assigned comatose (Glasgow Coma Scale score [GCS] ≤12) adult patients (age ≥18 years) who required mechanical ventilation for at least 48 h after acute brain injury to receive intravenous ceftriaxone 2 g or placebo once within the 12 h following tracheal intubation. Participants did not receive selective oropharyngeal and digestive tract decontamination. The primary outcome was the proportion of patients developing early VAP from the 2nd to the 7th day of mechanical ventilation, confirmed by masked assessors. The analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew or did not give consent to continue and those who did not receive the allocated treatment because they met a criterion for non-eligibility. The trial is registered with ClinicalTrials.gov, NCT02265406. From Oct 14, 2015, to May 27, 2020, 345 patients were randomly assigned (1:1) to receive ceftriaxone (n=171) or placebo (n=174); 330 received the allocated intervention and 319 were included in the analysis (162 in the ceftriaxone group and 157 in the placebo group). 166 (52%) participants in the analysis were men and 153 (48%) were women. 15 patients did not receive the allocated intervention after randomisation and 11 withdrew their consent. Adjudication confirmed 93 cases of VAP, including 74 early infections. The incidence of early VAP was lower in the ceftriaxone group than in the placebo group (23 [14%] vs 51 [32%]; hazard ratio 0·60 [95% CI 0·38-0·95], p=0·030), with no microbiological impact and no adverse effects attributable to ceftriaxone. In patients with acute brain injury, a single ceftriaxone dose decreased the risk of early VAP. On the basis of our findings, we recommend that an early, single dose of ceftriaxone be included in all bundles for the prevention of VAP in patients with brain injury who require mechanical ventilation. French Ministry of Social Affairs and Health.