Improvement In Level Of Consciousness Research Articles

TO STUDY THE ROLE AND EFFICACY OF NEUROHYPERBARIC OXYGEN THERAPY IN PATIENTS WITH HEAD INJURY IN A TERTIARY CARE HOSPITAL.

Traumatic brain injury (TBI) is a major health problem worldwide, resulting in signicant morbidity, mortality and the survivors are often left with cognitive and behavioural disabilities. Various treatment options in TBI are focussed on altering the secondary brain injury. Hyperbaric oxygen therapy (HBOT) is one such adjunctive treatments for TBI, which addresses the TBI induced ischemia and hypoxia. The present study was conducted to assess the role and efcacy of HBOT in patients with head injury mainly in terms of improvement of consciousness and cognitive functions. The study also assessed the level of disability and the level of recovery in patients with traumatic brain injury, immediately post therapy. A total of 120 patients with mild and moderate TBI were included in the present study, 60 patients each in the study or HBOT group and the control group. Depending upon the clinical and radiological ndings of the patients, the HBOT/study group received medical management and HBOT, whereas the control group received only medical management. The improvement in level of consciousness was assessed by Glasgow coma scale (GCS) score, Full outline of Unresponsiveness (FOUR) score. The level of cognitive improvement is assessed by the Ranchos Los Amigos scale and Montreal Cognitive assessment score. The level of disability was assessed by Disability Rating Scale (DRS) and the level of recovery was assessed by Glasgow Outcome Scale (GOS) and Glasgow Outcome Scale Extended (GOS-E) The HBOT group showed signicant improvement in the level of consciousness when compared to the control group. In terms of cognitive improvement, mixed results were obtained. However, there was no signicant difference in the level of disability and recovery post therapy in both the groups.

EFFECT OF PROGESTRONE IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY

ABSTRACT Background: Traumatic brain injury is a major public health concern, resulting in substantial mortality and long-term disability. So, it was important to search for novel therapeutic modalities that play an important role in reducing cerebral edema and had neuro- protective effect. A number of studies showed the feasibility, safety, and effectiveness of early parenteral administration of progesterone in acute severe traumatic brain injury patients compared with standard care. Objective: The study aimed to assess the effect of the progesterone on the neurologic outcome in non-operable patients with acute severe traumatic brain injury. Patients and Methods: This study was conducted on 50 patients presented with severe traumatic brain injury with GCS less than or equal to 8 after resuscitation and stabilization including both sexes. They were categorized into two groups according to applying the progesterone protocol. Patients were subjected to informed consent from next of kin, history taking, clinical neurological examination, routine laboratory and radiological investigations as needed and progesterone administration to patients in group 2which was given intramuscularly in dose of 1 mg/kg every12h for 7 consecutive days. Results: Early parenteral administration of progesterone was associated with significant decrease in the mortality rate at day 28, significant improvement in Glasgow outcome scale of the patients by the end of day 28, significant improvement in level of consciousness of the patients (GCS), SOFA score, and CT brain Marshall scoring. Conclusion: Progesterone administration in acute severe traumatic brain injury patients was associated with significant decrease in 28th day mortality, period of ICU stay, and mechanical ventilation days. Also, it was feasible and safe without noted complications.

NIH STROKE SCALE CHANGES FOLLOWING CAROTID ARTERY STENTING

Background: Traditionally, carotid endarterectomy (CEA) has been the primary method of treating high-grade asymptomatic and symptomatic carotid artery stenosis. A carotid endarterectomy involves exposure of the carotid artery and removal of plaque, most typically from the carotid bulb and the proximal internal carotid artery, via a neck incision. However, in vascular surgery, as in many other surgical specialties, minimally invasive techniques have evolved over the years. These techniques offer the advantages of smaller incisions, reduced postoperative pain, reduced potential for postoperative wound complications, and a shorter length of stay in the hospital. Objective: To assess the outcome of carotid stenting for carotid stenosis by assessing the changes in NIH stroke scale before and after carotid artery stenting. Patients and Methods: This clinical trial study was conducted on 15 patients who underwent 15 carotid artery stenting (CAS). The study was carried at Al-Azhar University Hospitals and Mabart Masr Elkadema hospital in the period between July 2019 and July 2020. All patients with carotid stenosis with high-grade asymptomatic (more than 70%) or symptomatic carotid artery stenosis treated with carotid artery stenting were included in this study, All patients with carotid stenosis treated with carotid artery end arterectomy, patients with unfavorable aortic arch anatomy including heavily calcified aortic arch or a type 3 aortic arch, and Patients with a common carotid artery length of less than 5 cm from the clavicle were excluded from our study. Cases were subjected to National Institute of Health Stroke Scale (NIHSS) before and after carotid artery stenting. Results: Most of the current study participants were males (66.7%) with a mean age of 58.9±8.9 years, 80% were symptomatic and 20% were asymptomatic. Most of patients in our study had hypertension (HTN) (80%), (53.3%) had diabetes mellitus (DM) and ischemic heart disease (IHD) and (46.7%) were smokers as males were higher than females. Also, 73.3% had dyslipidemia, 20% of patients were asymptomatic and 80% were symptomatic. Motor weakness was common especially on the left side (47.7%) of patients and right side (20%). Also, dysarthria was presented among 20% of patients, while transient ischemic attack (TIA) was presented among 13.3% of patients. Syncopal attack and deterioration of consciousness were among 6.7% of patients. In our study the degree of stenosis by diagnostic Cathter angiography (DCA) ranged from 60% to 90% with a mean of 72.67%±9.2. Right side was more affected (60%) than left side (40%). As regard National Institute of Health Stroke Scale (NIHSS) constructs, our patients had statistically significant improvement in level of consciousness, level of consciousness (loc) questions, loc commands, sensation and extinction/inattention occurred after 3 months. Also, our patients showed statistical significant improvement in best gaze, motor drift, best language and dysarthria after 3 months. Motor power of left arm and left leg showed statistically insignificant mild deterioration immediately after stenting. Visual field, facial palsy and limb ataxia constructs showed insignificant differences among our study patients as no improvement occurred. Conclusion: CAS showed a high technical success rate and a good short term clinical outcome. CAS is a safe and efficacious procedure especially with the availability of proper materials and experienced staff.

Anti GAD Negative Autoimmune Limbic Encephalitis in Diabetic Ketoacidosis: A Case Report

Abstract A 4-year-old boy presented to the emergency room with severe abdominal pain, tachypnea and vomiting followed by progressive obtundation. He was found to have hyperglycemia, ketonuria and metabolic acidosis. A diagnosis of Diabetic ketoacidosis was hence made and the boy was managed as such, with improvement in his laboratory parameters as well as in his level of consciousness. On day 6 after admission, the boy developed a recurrence of altered consciousness and repeated seizures. On examination the boy had spastic quadriparesis lateralizing to the right side. MRI of the brain showed multiple inflammatory lesions involving both temporal lobes. CSF analysis was unremarkable and CSF Herpes Simplex virus PCR was negative. Based on the inflammatory nature of lesions on MRI, with negative PCR for HSV and otherwise unremarkable CSF, together with progressive worsening of level of consciousness and spasticity, the possibility of autoimmune encephalitis was raised and the boy received 2 grams per kilogram of intravenous immunoglobulin with mild improvement in level of consciousness. The boy then received intravenous pulsed methylprednisolone, with a clear improvement in both his motor and mental capabilities. Three months post hospital discharge, the child was back to normal. This case highlights the importance of considering autoimmune encephalitis in the differential diagnosis of altered level of consciousness in a child with type 1 diabetes, especially in the presence of suggestive MRI findings and a lack of an alternative explanation.

Improved response after intrathecal administration of baclofen in a patient with impaired consciousness – A case study

Disorders of consciousness present some of the most difficult diagnostic and therapeutic challenges in brain rehabilitation. Within the spectrum of these disorders, diagnosis remains clinical and depends on the response to various stimuli in the environment rather than objective physiological markers. In recent years, various cases have been reported in the medical literature in which patients with such diagnoses reacted to various stimuli indirectly. Spasticity is a common sequela of brain injury and may significantly impair a patient's ability to respond to stimuli in their environment. A case study of a patient in a state of minimal reactivity demonstrating significantly improved responses to their environment following intrathecal injection of Baclofen. A 59-year-old man who was admitted for rehabilitation following subarachnoid hemorrhage secondary to anterior coronary artery aneurysm (ACA) requiring subsequent periventricular shunt placement. At admission, the patient presented in a vegetative state. During hospitalization, there was a temporary improvement in level of consciousness until the appearance of infection along the VPS drain necessitating removal of the shunt. Upon completion of treatment, the patient returned to our department with inconsistent, minimal reactivity on exam. Due to severe spasticity in all four limbs unresponsive to oral treatment and local injection, a one-time intrathecal injection of Baclofen was administered. Directly following treatment, the patient demonstrated decreased tone and immediate improvement in responsiveness and ultimately the production of a number of intelligible words and phrases. In evaluating patients suffering from disorders of consciousness, it is important to recognize that limited responsiveness results not only from the impairment of information reception, processing, and response initiation, but also from tonal disturbances that may be causing difficulty in performing such movements. This case study supports previous literature demonstrating improved communication following cellophane pump implantation following severe head injury.

Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: Optimal Timing and Literature Review

To compare the results of early or delayed decompressive craniotomy for patients with malignant middle cerebral artery infarction. A prospective randomized study was carried out of a series of 46 consecutive patients with malignant middle cerebral artery territory infarction. Patients were divided randomly into 2 groups: group I, 27 patients who were followed until obvious deterioration of level of consciousness; group II, 19 patients who were operated on prophylactically in 6 hours of presentation even with no clear deterioration of level of consciousness or radiologic findings. Patients were assessed clinically using the Glasgow Coma Scale, motor power by the United Kingdom Medical Research Council, and functionally by the National Institutes of Health Stroke Scale and modified Rankin Scale. Radiologically, patients had primary magnetic resonance imaging on admission, followed by computed tomography scan. Infarction behavior including volume of infarct area, midline shift, and secondary hemorrhage were calculated. At final follow-up, both groups showed good improvement in level of consciousness, motor power, and functional outcome; however, statistically significant neurologic improvement was shown in group II. Functional outcome also showed statistically significant improvement (P < 0.05) in this ultraearly decompression group (group II). There was a significant difference in mortality in both groups; more than half (52%) of group I died as a result of delay in surgery or its other consequences. Another significant difference was in the progression of infarction volume, which was observed more in group I (statistically insignificant). Despite the possible complications from surgery, early decompressive craniotomy (within 6 hours of ictus without waiting for neurologic deterioration) has a significant impact on prognosis. Delay in transferring the patient, diagnosing the condition, or taking the decision of surgery significantly affects mortality and overall outcome.

Myxedema Coma in a Patient with Subclinical Hypothyroidism

Myxedema coma is the extreme manifestation of hypothyroidism, typically seen in patients with severe biochemical hypothyroidism. Its occurrence in association with subclinical hypothyroidism is extremely unusual. We describe a patient with subclinical hypothyroidism who developed clinical manifestations of myxedema coma. A 47-year-old woman presented to our endocrine clinic with complaints of fatigue and biochemical findings of subclinical hypothyroidism. She was started on treatment with thyroxine (T4) but remained unwell and was later admitted to hospital with hormone profile showing persisting subclinical hypothyroidism (elevated thyrotropin and normal free T4 [FT4] and free triiodothyronine [FT3]): FT4 10.7 pmol/L (reference range 10.3-24.5), FT3 2.7 pmol/L (reference range 2.67-7.03), and thyrotropin 6.09 mU/L (reference range 0.4-4.0). She subsequently developed hypothermia (temperature 33.2°C), circulatory collapse, and coma. Biochemical profile showed hyponatremia, elevated creatinine phosphokinase, metabolic acidosis, and renal failure. An echocardiogram revealed a moderate-sized pericardial effusion. We diagnosed myxedema coma and started treatment with intravenous T3. She responded dramatically with improvement in level of consciousness and normalization of metabolic parameters. We found no explanation other than hypothyroidism to account for the presentation. Adrenocorticotrophic hormone (ACTH) stimulation tests excluded adrenal insufficiency, and serum gonadotrophins were within the normal reference range. FT4 estimation by equilibrium dialysis excluded analytical interference, and molecular analysis for the thyroid hormone receptor β gene associated with thyroid hormone resistance was negative. To the best of our knowledge this is the first report of myxedema coma in a patient with subclinical hypothyroidism. The reason for normal thyroid hormone levels is unclear but may reflect deviation from a higher pre-morbid set-point. The case highlights the importance of careful clinical evaluation in patients with disparate clinical and laboratory findings.

One confused patient, many confused physicians: a case of delayed post-hypoxic leucoencephalopathy

A 28-year-old gentleman was referred to our medical department from the psychiatry department, with problems of confusion, disorientation and inappropriate behaviour. He was apyrexic and physical examination was unremarkable. He denied hallucinations, delusions or mood disturbance and had no insight of his current problems. Mini-Mental State Examination (MMSE)1 score was 6/30. Two years previously he started to use cocaine and heroin episodically. He consumed more than 40 units of alcohol each week. Five weeks prior to his transfer, he had been admitted to another local hospital after an episode of heavy alcohol and drug consumption. His girlfriend had been unable to wake him up for a number of hours, and on arrival he was treated with naloxone, with a rapid improvement in level of consciousness. Routine investigations were normal. A urinary toxicology screen was suggestive of recent ingestion of benzodiazepines, opiates and …

Gefäßverletzungen in der täglichen Praxis

It was the objective of this retrospective study to analyse the causes of injury, surgical approaches, outcome, and complications in patients with vascular trauma and to report our experience with vein homografts for arterial reconstruction in the upper and lower limbs and cervicothoracic region in patients operated on over a period between 1981-2001. In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 20 cases. In 4 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were aggravated by concomitant bone fractures, and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%), crural (22.6%), and ulnar and radial (13.2%) arteries. 16 patients with penetrating cervicothoracic arterial injuries were registered during this period. 8 patients underwent emergency exploration and 8 patients angiography prior urgent exploration. Saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene and Dacron grafts were used in eight cases, end to end anastomosis in 12 cases, venous bypasses in 5 cases, venous patches in 7 cases. 17 patients underwent arterial repair and 9 venous repair. Vein homografts as an arterial substitute were implanted in 8 patients. Five secondary amputations were performed and five patients died. The limb salvage rate was 95% and the primary patency rate of vein homografts was 75% (excluded primary amputations). The penetrating cervicothoracic injuries were all repaired with improvement in level of consciousness and neurological deficit when present. Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues. In the absence of suitable autologous vein grafts, homografts appear to be an interesting alternative for arterial repair. In penetrating cervicothoracic vascular injuries immediate operative repair offers the best chance of recovery.

An Analysis of 32 Surgically Managed Penetrating Carotid Artery Injuries

A review of the surgical management of penetrating carotid artery injuries in the Trauma Unit at Groote Schuur Hospital, Cape Town, is presented.Materials and Methods: a retrospective analysis of all surgically treated penetrating carotid artery injuries over a 3-year period was performed. The policy is to repair all injuries to the common and internal carotid arteries. Ligation is reserved for patients with prolonged coma; ischaemic infarcts or cerebral oedema on computerised axial tomography of the brain; technically inaccessible high internal carotid artery injuries, and those with occluded arteries with no distal patency detected during surgery or with angiography.Results: thirty-two patients with penetrating carotid artery injuries were reviewed. Eleven patients underwent emergency exploration. Twenty-one patients had angiography prior to exploration. Injuries in the emergency group were all repaired, with improvement in level of consciousness; also, two patients had preoperative neurological deficits that improved. Three of the 21 patients in the urgent group underwent ligation of the common carotid artery: one comatose patient with a hemiparesis died following ligation; the other two had improvement in their level of consciousness, one of whom showed improvement of his hemiparesis. The remaining injuries to the common and internal carotid arteries were repaired with improvement in level of consciousness and neurological deficit when present.Conclusion: operative repair offers the best chance of recovery.

Experience with multiple intracranial haematomas in New South Wales.

A retrospective survey of head injuries in NSW in 1977 and 1978 was conducted by the Trauma Subcommittee of the Neurosurgical Society of Australasia. This paper describes the findings for 129 patients who had more than one significant intracranial haematoma. Overall, the case fatality rate for these patients was 85%. The presence of low or fluctuating blood pressure was associated with a significantly higher mortality than in the rest of the group. Bilateral reacting pupils or an improvement in level of consciousness following decompressive surgery carried a more favourable prognosis. There was 100% fatality if surgery was not carried out or if the bleeding was not found at operation. A subset of patients who died was selected on the basis of a calculated prognostic variable, and compared with a similar subset of survivors. A higher proportion of patients who died had a delay in the provision of definitive treatment and failure to correct shock. This comparison was made on two criteria. Using the first accepted optimal treatment in 1984, nearly all cases were treated suboptimally, as might be expected. Using the second, acceptable treatment in 1977-78, it was calculated that between nine and 12 patients died with MIH in NSW in the 2 years of the survey, whose deaths might have been prevented.

The significance of post-traumatic status epilepticus in childhood.

Five cases of early post-traumatic status epilepticus in childhood are reported. In all cases the trauma was apparently of a minor nature and the seizures appeared within two hours after injury. In none of the cases was a significant intracranial clot detected, nor was lasting cerebral damage evident. This is in contrast with adults, where status epilepticus after head injury is thought to be an ominous sign. Rapid improvement in level of consciousness after prompt treatment is certainly the most important criterion in assessing the role of the seizures. In the same period of time, post-traumatic status epilepticus was not seen in children with more severe head injury.