Glasgow Coma Scale Sum Score Research Articles

Clinical Predictors of Survival and Functional Outcome of Stroke Patients Admitted to Critical Care.

To determine the predictive value of commonly used clinical variables upon ICU admission for long-term all-cause mortality and functional outcome of adult stroke patients admitted to the ICU. Retrospective observational cohort study. General and neurosurgical ICUs of the University College London Hospitals in North Central London. All adult ICU patients with a clinical diagnosis of acute stroke admitted between February 2010 and May 2012. None. Demographic and clinical data concerning the first 24 hours after ICU admission were obtained. Patients were followed until February 2016 to assess long-term survival. Functional outcome was determined using the modified Rankin Scale. We evaluated 131 critically ill stroke patients, with a median (interquartile range) age of 70 years (55-78 yr). One-year mortality rate was 52.7%. Surviving patients were followed up over a median (interquartile range) period of 4.3 years (4.0-4.8 yr). The multivariable model that best predicted long-term all-cause mortality indicated that mortality of critically ill stroke patients was predicted by high Acute Physiology and Chronic Health Evaluation II score, impaired consciousness (Glasgow Coma Scale score ≤ 8) as reason for ICU admission, low Glasgow Coma Scale sum score after 24 hours, and absence of brainstem reflexes. Long-term independent functional status occurred in 30.9% of surviving patients and was predicted by low Acute Physiology and Chronic Health Evaluation II score, high Glasgow Coma Scale sum score at ICU admission, and absence of mass effect on CT scan. Mortality in critically ill stroke patients is high and occurs most often shortly after the event. Less than one in three surviving patients is able to function independently after 1 year. This study has identified several clinical variables that predict long-term all-cause mortality and functional outcome among critically ill stroke patients and found that mainly acute physiologic disturbance and absolute values of neurologic clinical assessment are predictive.

Outcome of endovascular treatment for acute basilar artery occlusion in the modern era: a single institution experience.

The beneficial effect of endovascular treatment (EVT) for patients with acute basilar artery occlusion (ABAO) remains uncertain. The purpose of the present study was to evaluate clinical outcome of EVT for patients with ABAO and analyze prognostic factors of good outcome. From our prospectively established database, we reviewed all patients with ABAO receiving EVT during January 2014 to December 2016. Baseline characteristics and outcomes were evaluated. Favorable functional outcome was defined as modified Rankin Scale score of 0 to 3 assessed at 3-month follow-up. The association between clinical and procedural characteristics and functional outcome was assessed. Of the 68 patients included, 50 patients (73.5%) received mechanical thrombectomy with stent retriever device. Successful reperfusion (thrombolysis in cerebral infarction grades 2b-3) was achieved in 61 patients (89.7%). Overall favorable functional outcome was reached by 31 patients (45.6%). In univariate analysis, Glasgow Coma Scale sum score, baseline National Institutes of Health stroke scale score (NIHSS), and baseline glycemia level were identified predicting good clinical outcome. Multivariate analysis showed that lower NIHSS was the only independent risk factor of favorable functional outcome (OR 0.832; 95% CI, 0.715-0.968; p = 0.018). No difference of favorable outcomes was observed between the subgroups of time to EVT < 6h and ≽6h. Data in the present study suggests that EVT for ABAO patients should be reasonable within 24h of symptom onset. The most important factor determining clinical outcome is initial stroke severity.

Predictors of Outcome in Warfarin-Related Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) associated with warfarin sodium therapy is becoming more common as the use of this medication increases in the aging population. To delineate factors associated with early mortality, determine variables responsible for poor functional outcome, and evaluate possible reasons for expansion of hemorrhage and associated parenchymal edema. Retrospective study of clinical and radiologic information for 88 patients with warfarin-associated ICH. A single hospital. Patients Eighty-eight consecutive patients with warfarin-associated ICH. Patients were included if the international normalized ratio (INR) at presentation with ICH was 1.5 or greater. Computed tomographic scans were reviewed for volumetric analysis of hematoma and perihematomal edema volume. Outcome variables included 7-day mortality, hematoma enlargement, and functional outcome based on the modified Rankin Scale score. Seven-day mortality (39.8%) was associated with a lower Glasgow Coma Scale sum score and larger ICH volume at presentation. Univariate analysis revealed that a lower Glasgow Coma Score sum score, larger initial ICH volume, higher initial and 48-hour maximum glucose concentrations, and higher percentage of ICH expansion were significantly associated with poor functional outcome at hospital discharge. At multivariate analysis, only Glasgow Coma Score and ICH volume remained significantly associated with functional outcome measured at hospital discharge and at the last follow-up visit. Conversely, INR at presentation, time to INR correction, initial blood pressure, and enlargement of edema were not associated with functional outcome either at hospital discharge or at the last follow-up. Neither serum glucose concentration at admission nor highest level during the first 48 hours had any correlation with ICH or parenchymal edema enlargement. In addition, neither initial INR nor time to INR correction correlated with expansion of ICH or parenchymal edema. Lower level of consciousness at presentation and larger initial ICH volume predict poor prognosis in patients with warfarin-associated ICH. In our study population, INR at presentation was not associated with functional outcome.

Cause Is the Main Predictor of Outcome in Patients with Pontine Hemorrhage

Background: Pontine hemorrhages frequently lead to death or severe disability. Predictors of early mortality have been previously described but little is known about the factors influencing long-term disability. Objective: Determine clinical predictors of long-term outcome in a large hospital series of patients with acute pontine hemorrhage. Methods: Review of all patients with acute pontine hemorrhage admitted to a single tertiary center from 1990 to 2002 who underwent a diagnostic workup including brain magnetic resonance imaging (MRI). Long-term outcome was rated using the modified Rankin Scale (mRS) score at the time of the last follow-up. Odds ratios (ORs) for predictive factors were calculated using univariate and multivariable logistic regression analysis. Level of significance was established at p < 0.01. Results: We identified 44 consecutive patients with acute pontine hemorrhage. Twenty-four patients had primary hemorrhages (no cause other than hypertension). Arteriovenous or cavernous malformations were documented by brain MRI in 20 patients. Patients with primary hemorrhages had worse Glasgow Coma Scale sum scores (p = 0.01) and more unfavorable CT patterns (p = 0.005) at presentation. Eighteen percent of the patients died in the hospital. Mean follow-up among survivors was 20 months (range 3–144 months). Twenty-two percent of the patients remained severely disabled (mRS greater than 2) at 3 months and at the time of the last follow-up. All deaths occurred in patients with primary pontine hemorrhage. Poor outcome (death or severe disability) was more frequent in patients with primary hemorrhages when compared with patients harboring cavernous malformations (62 versus 5%; p < 0.01). Primary hemorrhage was the only independent predictor of poor outcome in multivariable regression analysis (OR 12; p = 0.029). Conclusions: Cause is a main predictor of clinical and radiological severity at presentation and outcome in patients with pontine hemorrhage. The first episode of hemorrhage in patients with brainstem cavernous malformations is usually benign. Pontine hemorrhage associated with prior hypertension is much more devastating.

Comparison of the Three Strategies of Verbal Scoring of the Glasgow Coma Scale in Patients with Stroke

Presence of aphasia in patients with stroke poses a problem in the use of the full form (eye-motor-verbal) Glasgow Coma Scale (GCS). Stroke investigators and clinicians have used three different strategies to deal with the untestable verbal subscale, i.e. eliminating the verbal subscale; pseudoscoring with ‘one’, and median value substitution; but the predictive accuracy of the strategies has not been compared. To compare the predictive accuracy of the three strategies for acute mortality in stroke, we prospectively applied the GCS to 275 consecutive patients with acute stroke and recorded their survival status before discharge from hospital. 95 (33.8%) patients died. 32 (12%) patients had untestable verbal score. Receiver-Operator-Characteristic curves for predicting mortality were constructed with the GCS sum score and with the multivariate logistic models, and areas under the curves were measured to compare the predictive accuracy. They were all found to be similar (0.87–0.88 sq unit). Specifically, the GCS with eye and motor subscale had 87% accuracy compared to 88% for the model with eye, motor and verbal scale. We conclude that the short-form (eye-motor) GCS is as good a predictor of early mortality (within 2 weeks) as the full form (eye-motor-verbal) GCS in patients with stroke.

Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery.

A prospective study was performed to analyze whether the Glasgow Coma Scale (GCS) was useful in predicting the outcome after early surgical intervention for aneurysmal subarachnoid hemorrhage (SAH). In a consecutive series of 765 patients who underwent surgery for aneurysms within 7 days after SAH, the level of consciousness was assessed by the GCS just before surgery and the outcome was graded by the Glasgow Outcome Scale 6 months after surgery. The patient distribution in accordance with the GCS sum scores in descending order from 15 to 3 was as follows: 334, 140, 58, 27, 20, 26, 27, 19, 26, 17, 20, 27, and 24 patients, respectively. In general, the higher the preoperative GCS score was, the better the surgical outcome was. The overall surgical result was significantly correlated with the preoperative GCS score (rs = 0.615, P < 0.001). With respect to the levels that distinguish the outcome along the GCS axis, a significant difference in the outcome was observed only between the GCS scores of 15 and 14 (P < 0.001, Wilcoxon test). The GCS proved useful in the preoperative evaluation of patients with SAH, in terms of outcome prediction. It is suggested that the SAH scale proposed by the World Federation of Neurosurgical Societies be reexamined, because differences in outcomes were not clear between the GCS scores of 13 and 12 or between those of 7 and 6, in which Grades III and IV and Grades IV and V are differentiated in the scale, respectively.

A comparative study of the Reaction Level Scale (RLS 85) with Glasgow Coma Scale (GCS) and Edinburgh-2 Coma Scale (modified) (E2CS(M))

In this work a new coma scale for the assessment of responsiveness in acute brain disorders, constructed near the year 1985 by Scandinavian investigators, the Reaction Level Scale (RLS85), is compared with two other coma scales namely: (i) the Glasgow Coma Scale: (GCS); (ii) the Edinburgh-2 Coma Scale, after modification: (E2CS(M)). The study proceeded in the form of a statistical analysis of assessments made on 46 patients according to RLS85 and GCS (i.e., when comparison was with GCS) and on 28 patients according to RLS85 and E2CS(M). In all 74 cases two physicians participating as "observers" carried out the assessments. They were both contacting the patient--not together but--successively within a time interval of less than 20'. Hence the data appeared as "pairwise" observations for any of the three scales above. The results of the analysis, arising from a rather strict statistical reasoning, can be summarized as follows: (1) The rank correlation coefficient r(s) between: (i) RLS85 and GCS sum score, (ii) RLS85 and E2CS(M), was found to be at a satisfactory level meaning that all three scales indicate almost the same "ranking order of severity". (2) Reliability was compared by taking into account as to what extent the two observers agreed on RLS85 and--simultaneously--disagreed on the other scale. The "sign" test was applied and as a result RLS85 proved to be more reliable than; (i) GCS (EMY profile), (ii) GCS sum score, and (iii) E2CS(M), in all the above mentioned at a high level of significance. (3) Apart from the test above, some values of the index kappa (kappa) of interobserver agreement were calculated. Those corresponding to RLS85 are considerably higher. In particular the overall value based on 74 pairwise assessments amounted to kappa = 0.733 associated with a standard error sigma(kappa) = 0.061. This was a satisfactory result regarding the features of RLS85. (4) As far as coverage is concerned, again--by the "sign" test--the predominance of RLS85 versus GCS (EMY profile) was accepted.