Good Glasgow Coma Scale Research Articles

Practice and associated factors of Glasgow Coma Scale assessment among nurses working in adult intensive care units of federally administered hospitals in Addis Ababa, Ethiopia

Background & Aim: The Glasgow Coma Scale is a helpful instrument for measuring patients’ level of consciousness with neurosurgical disorders. Literature showed a majority of nurses don’t believe the Glasgow Coma Scale assessment is their area of practice. This study aimed to examine the Glasgow Coma Scale assessment practice and associated factors among nurses working in adult intensive care units of federally administered hospitals
 Methods & Materials: : Institutional-based cross-sectional study was conducted on conventionally selected 126 nurses working in adult intensive care units. Six clinical scenarios were used to assess practice, and those who correctly answered at least four scenario questions out of 6 practical scenario questions for the Glasgow Coma Scale assessment were considered good practice. Data was collected using a self-administered questionnaire. The Chi-square test was applied to examine the variables affecting Glasgow Coma Scale practice. Furthermore, the proportions of categorical variables’ replies were contrasted among the various groups.
 Result: With a response rate of 96.03%, 121 nurses participated in the study. (53.7%) was males. In this study, the overall good Glasgow Coma Scale assessment practice of intensive care units nurses was 47.1%. Lack of training (77.7%), job overload (73.6%), and insufficient knowledge and skills (61.2 %) are barriers for nurses to assess Glasgow Coma Scale.
 Conclusion: In this, only nearly half of the participants displayed good practice on the Glasgow Coma Scale. Sex and educational status were both found to be significant factors in nurses’ Glasgow Coma Scale assessment practice.

Decompressive craniectomy for malignant middle cerebral artery territory infarct: an institutional experience

Background: Decompressive craniectomy is the surgical procedure to reduce intracranial pressure, refractory to medical measures. We have described our experience associated with the clinical profile, radiological profile, postoperative status and long term outcome in patients with malignant middle cerebral artery (MCA) territory infarct.Methods: Data were collected from patients who underwent hemispheric decompressive craniectomy for malignant MCA territory infarct in our hospital from May 2014 to June 2019. Clinical, radiological, surgical profile and long term outcome were studied.Results: There were a total of 51 patients aged between 28 years to 76 years. Hypertension (70%) was the most common comorbidity associated. All the patients had at least one focal neurological deficit at the time of presentation. Mean time from the first symptoms to surgery was 2.4 days (about 58 hours). 7 patients died within one month of the surgery. Two third improved objectively within 1 month of surgery. Out of 44 patients, who survived beyond one month, none of the patients were functionally independent after one year of surgery (modified Rankin scale (mRS) of 0 or 1). The patients had a mean mRS of 3.8 at one year.Conclusions: Over several decades decompressive craniectomy has been found to be the most effective measure to reduce mortality and morbidity associated with malignant MCA territory infarct. Early surgery (<48 hours) in patients with good Glasgow Coma scale score reduces the mortality. Larger multicentric trials are required to look at the long term effect on morbidity and mortality.

An Option for Good Outcome of Intracerebral Hematoma

Abstract Background: Intracerebral hematoma affects about 2.5 per 10,000 people each year. The incidence is more in males and older people. The mortality rate is about 44% in the first month. 20% of cases has a good outcome. Symptoms can include headache, one-sided weakness, vomiting, seizures, decreased level of consciousness, and neck stiffness. Often symptoms get worse over time. In many cases bleeding occurs in the brain tissue and the ventricles at the same time. Many procedures and techniques have been introduced for the management of intracerebral hematoma and debate always exist about the management of sizable intracerebral hematomas especially if the conscious level isn't markedly affected. Aim of Study: To evaluate the role of early evacuation of sizable intracerebral hematomas even if the conscious level isn't markedly deteriorated. Method: This is a retrospective study of 30 cases of intracerebral hematoma operated in Kasr El-Aini Hospitals and Bani Suef University Hospitals by evacuation assisted by microscope with a Glasgow Coma Scale more than 10 in most cases with a sizable intracerebral haemorrhage more than 30cc in the volume. Results: This study results was 22 (73%) male patients and 8 (27%) was female patients. The age group was 4 patients (13%) under 30 years, 22 patients (73%) were from 30-45 years and 4 patients (13%) were more than 45 years old. The Glasgow Coma Scale (GCS) on admission was 14-15 in 4 patients (13%) patients, from 10-13 was 14 patients (46%), and from 9 and less was 12 patients (41%). 20 patients (67%) case was diabetics, 23 patients (46%) cases was hypertensive, 2 patients (7%) had chronic renal failure on regular dialysis, 1 patient (3%) case was pregnant. The GCS post-operative was 14-15 in 20 patients (70%), 10-13 in 5 patients (16%), and from 9 and less in 5 (24%) cases. The operation done was evacuation in all cases, decompressive craniectomy in 8 patients (26%), ventriculosubgaleal shunt done (VSG) in 3 patients (10%). The side of the hematoma was left sided in 7 patients (24%), right in 23 patients (76%). Good out come in 25 cases (83%), recollection in 3 (10%) cases, residual hematoma in 2 (6%) of the cases, re evacuation done in 1 patient (3%). Mortality were 4 patients.Conclusion: Sizable intracerebral hematoma (volume more than 30cc) in good Glasgow coma scale mostly obeying orders, spontaneous eye opening, and aphasic or not, to obtain a good outcome is to evacuate the hematoma not to wait for conservative management.

Identifying Modifiable Predictors of Patient Outcomes After Intracerebral Hemorrhage with Machine Learning.

Demonstrating a benefit of acute treatment to patients with intracerebral hemorrhage (ICH) requires identifying which patients have a potentially modifiable outcome, where treatment could favorably shift a patient's expected outcome. A decision rule for which patients have a modifiable outcome could improve the targeting of treatments. We sought to determine which patients with ICH have a modifiable outcome. Patients with ICH were prospectively identified at two institutions. Data on hematoma volumes, medication histories, and other variables of interest were collected. ICH outcomes were evaluated using the modified Rankin Scale (mRS), assessed at 14 days and 3 months after ICH, with "good outcome" defined as 0-3 (independence or better) and "poor outcome" defined as 4-6 (dependence or worse). Supervised machine learning models identified the best predictors of good versus poor outcomes at Institution 1. Models were validated using repeated fivefold cross-validation as well as testing on the entirely independent sample at Institution 2. Model fit was assessed with area under the ROC curve (AUC). Model performance at Institution 1 was strong for both 14-day (AUC of 0.79 [0.77, 0.81] for decision tree, 0.85 [0.84, 0.87] for random forest) and 3 month (AUC of 0.75 [0.73, 0.77] for decision tree, 0.82 [0.80, 0.84] for random forest) outcomes. Independent predictors of functional outcome selected by the algorithms as important included hematoma volume at hospital admission, hematoma expansion, intraventricular hemorrhage, overall ICH Score, and Glasgow Coma Scale. Hematoma expansion was the only potentially modifiable independent predictor of outcome and was compatible with "good" or "poor" outcome in a subset of patients with low hematoma volumes, good Glasgow Coma scale and premorbid modified Rankin Scale scores. Models trained on harmonized data also predicted patient outcomes well at Institution 2 using decision tree (AUC 0.69 [0.63, 0.75]) and random forests (AUC 0.78 [0.72, 0.84]). Patient outcomes are predictable to a high level in patients with ICH, and hematoma expansion is the sole-modifiable predictor of these outcomes across two outcome types and modeling approaches. According to decision tree analyses predicting outcome at 3 months, patients with a high Glasgow Coma Scale score, less than 44.5mL hematoma volume at admission, and relatively low premorbid modified Rankin Score in particular have a modifiable outcome and appear to be candidates for future interventions to improve outcomes after ICH.

Decompressive Hemicraniectomy in the Treatment of Malignant Middle Cerebral Artery Infarction

Abstract Background: Malignant middle cerebral artery infarctions affecting about 10% of stroke patients. Formed of huge space-occupying infarctions with extensive edema which lead to herniation, and usually death. Treatment includes medical treatment in addition to decompressive hemicraniectomy associated with duroplasty in many cases. Decompressive craniectomy has a great effect in reduction of mortality rates and improving the functional outcome of the patients. Aim of Study: We reviewed the outcome of decompressive hemicraniectomy in the treatment of Malignant Middle Cer-ebral Artery infarction. Patients and Methods: The study includes 14 patients of malignant middle cerebral artery infarctions operated upon by decompressive surgery (from January 2015 to August 2018). We evaluated the outcome by estimation of the mortality rate after one month, Glasgow Outcome Score (GOS) on leaving the hospital, at 3 months, and 6 months by modified Rankin scale (mRS). Results: Decompressive craniectomy leads to decrease in mortality rate at 30 days and acceptable GOS outcome at discharge. At 3 months and 6 months good functional outcome based on mRS occurred in cases of the infarction volume below than 250ml, midline shift below 10mm, good Glasgow Coma Scale (GCS) score before surgery and rapid surgical intervention (within 24 hours). Conclusion: Decompressive craniectomy gets great func-tional outcome in cases of young cases with acceptable GCS score before surgery, fair radiological pictures, and operated upon in less than 24 hours of onset.

A Cross-Sectional Study: Head Injury in Children of Karachi

A cross-sectional study was conducted to determine the prevalence, causes and outcome of head injury in children at Neurosurgery Department of Jinnah Postgraduate Medical Centre from 1st December, 2013 to 1st February, 2014. A total of 37 patients under the age of 12 years, presented with head injuries to the emergency department, were included in the study. A self-designed questionnaire was filled for these children after getting the oral consent from their parents. The questionnaire comprised a complete detail on the causes of head injury, clinical presentation on reaching the hospital, X-rays and Computed Tomography (CT) scans of the children and their reports. SPSS version 20 was utilized as an analytical tool. The mean age of patients was 6.93 years ± 3.02. Out of these 37 patients, 54.1% were males and 45.9% were females. Road traffic accidents accounted for most of cases (48.6%) with marked peak observed in boys as compared to the girls. Majority had a good Glasgow Coma Scale (GCS) score (43.2%) whereas a depressed fracture was found to be the dominant feature (21.6%) on X-rays. Additionally, 29.7% of children had intracranial hemorrhage while 32.4% also acquired other injuries. In total 29.7% were offered surgical intervention with majority (83.8%) landing in neurosurgical ward. As head injury in childhood is an important issue, keeping in view the lack of research in this field we need to properly highlight the burden of such injuries in childhood so that all the concerned governing authorities should take every possible step in preventing as well as managing this devastating health concern.

Chapter 12 - Surgical management of civilian gunshot wounds to the head

Each year close to 20000 Americans are involved in gunshot wounds to the head (GSWH). Over 90% of the victims of GSWH eventually fail to survive and only a meager 5% of the patients have a chance to continue with a useful life. One of the fundamental jobs of providers is to realize who the best candidate for the best possible management is. Recent evidence indicates that a good Glasgow Coma Scale (GCS) score at the time of admission puts such patients at high priority for management. Lack of abnormal pupillary response to light, trajectory of slug away for central gray, and visibility of basal cisterns upgrade the need for utmost care for such a victim. Surgical management is careful attention to involvement of air sinuses and repair of base dura. Patients with diffuse injury should have intraventricular intracranial pressure (ICP) monitoring and if needed a timely decompressive craniectomy. Since close to 2% of patients with penetrating brain injury may harbor a vascular injury, subjects with injuries close to the Sylvian fissure and those with the fragment crossing two dural compartments should have computed tomography angiography and if needed digital subtraction angiography to rule out traumatic intracranial aneurysms. In case of a positive study, these patients should have endovascular management of their vascular injuries in order to prevent catastrophic intracerebral hematomas and permanent deficit. Although supported by class III data, subjects of GSWH need to be on broad spectrum antibiotics for a period of 3-5 days. If cerebrospinal fluid (CSF) fistulas are observed at any time during the patient's hospital course, they should be taken very seriously and appropriate management is needed to prevent deep intracranial infections.

Cranioplasty Infections—Adding Insult to Injury

ranioplasty infections represent a dreaded complication in patientswho have generally already experienced a serious, C usually traumatic event. Craniectomies are frequently performed in an effort to decrease the intracranial hypertension that accompanies a massive cerebral infarct or a serious head injury. Patients considered candidates for a decompressive craniectomy (DC) after a traumatic brain injury (TBI) are those younger in agewith reactive pupils with a good Glasgow Coma Scale score. In contrast, patients with bilateral fixed and dilated pupils or with brain stem involvement, which can include Duret hemorrhages, are usually excluded fromsurgical consideration.A recentCochraneReviewon theutility ofDCconcluded that therewasnoevidence tosupport the routine use of DC to improve mortality and quality of life in braininjured adults with high intracranial pressure (8). Overall, DC does not improve the outcome in good prognosis adult patients but can convert mortality to severe disability in poor prognosis patients. There are 2 ongoing randomized controlled trials of decompressive craniectomy (RescueICP and DECRA) that will hopefully provide further conclusions on the efficacy of DC in adults. Bilateral hemicraniectomy for TBI carries 67% mortality and provides benefit primarily to very young adults (10). In addition, DC may improve survival and neurological outcomes in pediatric patients with raised intracranial pressure froma TBI forwhomothermedical treatments had failed. The results in the pediatric population are based on 1 randomized controlled trial in 27 children.

The natural history of brain contusion: an analysis of radiological and clinical progression

Although brain contusions are a common neurosurgical condition, surprisingly little has been written about their natural history. The purpose of this study was to identify factors that predict radiological and clinically significant progression of this pattern of traumatic brain injury in patients who did not initially require surgery. On the basis of their results and the available literature, the authors suggest a management algorithm. The authors performed a retrospective review of clinical and radiological records of consecutive patients with brain contusions who initially underwent conservative treatment. Significant radiological progression was defined as a 30% increase in contusion size on CT scans. Statistical analysis was performed to identify clinical and radiological predictors of CT contusion progression, the significance of progression, and predictors of clinical outcome. Of 98 patients identified with brain contusions who initially received conservative treatment, 44 (45%) had significant progression on CT, and 19 (19%) required surgical intervention. The initial size of the contusion and the presence of subdural hematoma were the only statistically significant predictors of CT progression in the multivariate analysis (p = 0.0212 and 0.05, respectively). Four patients required delayed contusion evacuation (3 had radiological progression on follow-up scans). Good Glasgow Coma Scale (GCS) scores on presentation and younger age were predictors of eventual discharge from the hospital (OR 1.471, CI 1.233-1.755, p < 0.001 and OR 0.949, CI 0.912-0.988, p = 0.011, respectively). No patients with an initial GCS score of 15 or an initial contusion size < 14 ml required delayed evacuation. Contusion progression is a common phenomenon that is seen more commonly in larger contusions. Patients with large contusions and low initial GCS scores are at risk for delayed deterioration. A proposed management algorithm for patients with contusions initially treated conservatively may help practitioners identify the best course of treatment.

A Tangential Gunshot Wound to the Head: Case Report and Review of the Literature

Background: Patients with tangential gunshot wounds (TGSWs) commonly present with a good Glasgow Coma Scale score and without a history of loss of consciousness. Typically, the bullet does not breach the skull, however, there is a considerable force directed into the brain, and these patients are best treated as sustaining a moderate-to-severe blunt head injury. These patients require observation and repeat imaging. Physicians should be aware of this entity as these patients can deteriorate in a delayed fashion. Objectives: The authors present a case of a TGSW to the head in a neurologically intact patient. The initial post-injury computed tomography (CT) scan showed a very small subdural hematoma (SDH) with no overlying fracture of the skull. A delayed CT scan performed 4 h after arrival to the Emergency Department and 6 h after injury demonstrated an increase in size of the SDH, new traumatic subarachnoid hemorrhage, and bilateral cerebral contusions. Clinically, the patient showed worsening of her neurological examination. She underwent aggressive non-surgical treatment for increased intracranial pressure with almost complete recovery. Conclusion: Although patients with TGSWs are typically in good condition upon presentation, these injuries are not always trivial, and these patients should have, at minimum, a non-contrast brain CT scan to evaluate underlying damage to the brain and skull. In addition, a delayed CT scan and close observation on a neurosurgical service are indicated.