Initial Glasgow Coma Scale Score Research Articles

Clinical, radiological, and laboratory factors associated with mortality and functional outcomes in pediatric patients presenting with intracranial gunshot wounds.

Firearm injuries are now the leading cause of death in children and young adults younger than 25 years of age in the US. Current management of these injuries is extrapolated from adult blunt and penetrating traumatic brain injury guidelines. The objectives of this study were to investigate and analyze the clinical, radiological, and laboratory factors associated with mortality and functional outcomes in pediatric patients presenting with intracranial gunshot wounds (GSWs). Medical records were screened for all patients younger than 21 years of age with an intracranial GSW who presented to the University Medical Center in New Orleans, Louisiana, from 2012 to 2022. Demographics and radiological, clinical, and laboratory data were extracted, and chi-square and Fisher's exact tests were used to evaluate individual association with mortality and functional outcome. Odds ratios were calculated from the cross tabulations for categorical variables and univariate binary logistic regression models for continuous variables. Multivariate binary logistic regression was used to adjust for effects of covariates and isolate the contributions of predictor variables for mortality and functional outcome. Ninety-six patients (82 male, 14 female) had a median age of 18 (interquartile range [IQR] 15-20) years. The 30-day inpatient, 60-day, and 6-month mortality rates among these patients were 53.1%, 0%, and 2.4%, respectively. Those who died were more likely to have an initial Glasgow Coma Scale score ≤ 8 (p < 0.001), bilateral fixed pupils (p < 0.001), transventricular trajectory (p < 0.001), deep nuclear/third ventricle involvement (p = 0.004), bihemispheric trajectory (p = 0.025), injury to ≥ 3 lobes (p = 0.015), parietal lobe involvement (p = 0.023), base deficit < -5 mEq/L (p = 0.013), international normalized ratio (INR) > 1.5 (p = 0.007), and a St. Louis Scale (SLS) score ≥ 5 (p < 0.001). The survivors with favorable functional outcome were more likely to have lower median SLS scores (p = 0.016) and injury to < 3 lobes (p < 0.001). In a multivariate analysis, bilaterally fixed nonreactive pupils were positively associated with mortality and negatively associated with favorable functional outcome, whereas the Injury Severity Score (ISS) and injury to ≥ 3 lobes were negatively associated with favorable functional outcome only. This is one of the largest series of pediatric intracranial GSWs to date. The authors identified certain clinical (bilateral fixed pupils, SLS score ≥ 5, ISS > 16), laboratory (INR > 1.5, base deficit < -5 mEq/L), and radiological (transventricular trajectory, deep nuclear/third ventricle involvement, parietal lobe involvement) factors that were associated with death and poor functional outcome in this pediatric cohort.

Teamwork matters: The association between nontechnical skills and cardiac arrest in trauma patients presenting with hypotension

BackgroundThe impact of trauma team dynamics on outcomes in injured patients is not completely understood. We sought to evaluate the association between trauma team function, as measured by a modified Trauma Non-Technical Skills assessment, and cardiac arrest in hypotensive trauma patients. We hypothesized that better team function is associated with a decreased probability of developing cardiac arrest. MethodsTrauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centers. Hypotension at emergency department presentation was defined as an initial systolic blood pressure <90 mm Hg or an initial systolic blood pressure ≥90 mm Hg followed by a systolic blood pressure <90 mm Hg within the first 5 minutes. Team dynamics were scored using a modified Trauma Non-Technical Skills assessment composed of 5 domains with combined scores ranging from 5 (best) to 15 (worst). Scores were compared between cardiac arrest/noncardiac arrest cases in the trauma bay. Logistic regression was used to evaluate the independent association between the Trauma Non-Technical Skills assessment and cardiac arrest. ResultsA total of 430 patients were included (median age 43 years [interquartile range: 29–61]; 71.8% male; 36% penetrating mechanism; median Injury Severity Score 20 [10–33]; 11% experienced cardiac arrest in trauma bay). The median total Trauma Non-Technical Skills assessment score was 7 (6–9), higher in patients who experienced cardiac arrest in the trauma bay (9 [6–10] vs 7 [6–9]; P = .016). This association persisted after controlling for age, sex, mechanism, injury severity, initial systolic blood pressure, and initial Glasgow Coma Scale score (adjusted odds ratio: 1.28; 95% confidence interval:1.11–1.48; P < .001), indicating a ∼3% higher predicted probability of cardiac arrest per Trauma Non-Technical Skills point. ConclusionBetter team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. This suggests that trauma team training may improve outcomes in peri-arrest patients.

Identification of Concussion Subtypes Based on Intrinsic Brain Activity

The identification of brain activity-based concussion subtypes at time of injury has the potential to advance the understanding of concussion pathophysiology and to optimize treatment planning and outcomes. To investigate the presence of intrinsic brain activity-based concussion subtypes, defined as distinct resting state quantitative electroencephalography (qEEG) profiles, at the time of injury. In this retrospective, multicenter (9 US universities and high schools and 4 US clinical sites) cohort study, participants aged 13 to 70 years with mild head injuries were included in longitudinal cohort studies from 2017 to 2022. Patients had a clinical diagnosis of concussion and were restrained from activity by site guidelines for more than 5 days, with an initial Glasgow Coma Scale score of 14 to 15. Participants were excluded for known neurological disease or history of traumatic brain injury within the last year. Patients were assessed with 2 minutes of artifact-free EEG acquired from frontal and frontotemporal regions within 120 hours of head injury. Data analysis was performed from July 2021 to June 2023. Quantitative features characterizing the EEG signal were extracted from a 1- to 2-minute artifact-free EEG data for each participant, within 120 hours of injury. Symptom inventories and days to return to activity were also acquired. From the 771 participants (mean [SD] age, 20.16 [5.75] years; 432 male [56.03%]), 600 were randomly selected for cluster analysis according to 471 qEEG features. Participants and features were simultaneously grouped into 5 disjoint subtypes by a bootstrapped coclustering algorithm with an overall agreement of 98.87% over 100 restarts. Subtypes were characterized by distinctive profiles of qEEG measure sets, including power, connectivity, and complexity, and were validated in the independent test set. Subtype membership showed a statistically significant association with time to return to activity. In this cohort study, distinct subtypes based on resting state qEEG activity were identified within the concussed population at the time of injury. The existence of such physiological subtypes supports different underlying pathophysiology and could aid in personalized prognosis and optimization of care path.

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.

Correlation between Time to Hyperbaric Oxygen Therapy and Delayed Neurological Sequelae in Acute Carbon Monoxide Poisoning Patients.

Carbon monoxide (CO) is one of the most common causes of intoxication. Delayed neurologic sequelae (DNS) have a major impact on prognosis of CO poisoning patients. Hyperbaric oxygen therapy (HBOT) is widely used to treat DNS. However, there is no consensus regarding the optimal timing of HBOT. This prospective study enrolled patients who visited the hospital from November 2019 to October 2022. The cutoff value for the latency to HBOT after CO exposure was determined, and the area under the receiver operating characteristic curve (AUC) was estimated. In total, 167 patients were divided into non-DNS and DNS groups. The initial Glasgow Coma Scale (GCS) score, CO exposure time, latency to HBOT after CO exposure, median length of hospital stay (p < 0.001) and creatine kinase (p = 0.016) showed significant differences. A GCS score ≤ 9 had an odds ratio (OR) of 5.059 (95% confidence interval [CI]: 1.602-15.976, p = 0.006), and latency to HBOT after CO exposure ≥ 200 min had an OR of 18.971 (95% CI: 4.310-83.508, p < 0.001). The AUC was 0.8235 (95% CI: 0.7504-0.8966). A GCS score ≤ 9 and latency to HBOT ≥ 200 min may be significant risk factors for DNS.

Predictors of extubation failure and prolonged mechanical ventilation among patients with intracerebral hemorrhage after surgery

BackgroundSpontaneous intracerebral hemorrhage (ICH) is a condition associated with high mortality and morbidity. Survivors may require prolonged intubation with mechanical ventilation (MV). The aim of this study was to analyze the predictors of extubation failure and prolonged MV in patients who undergo surgical evacuation.MethodsThis retrospective study was conducted on adult patients with ICH who underwent MV for at least 48 h and survived > 14 days after surgery. The demographics, clinical characteristics, laboratory tests, and Glasgow Coma Scale score were analyzed.ResultsA total of 134 patients with ICH were included in the study. The average age of the patients was 60.34 ± 15.59 years, and 79.9% (n = 107) were extubated after satisfying the weaning parameters. Extubation failure occurred in 11.2% (n = 12) and prolonged MV in 48.5% (n = 65) patients. Multivariable regression analysis revealed that a white blood cell count > 10,000/mm3 at the time of extubation was an independent predictor of reintubation. Meanwhile, age and initial Glasgow Coma Scale scores were predictors of prolonged MV.ConclusionsThis study provided the first comprehensive characterization and analysis of the predictors of extubation failure and prolonged MV in patients with ICH after surgery. Knowledge of potential predictors is essential to improve the strategies for early initiation of adequate treatment and prognosis assessment in the early stages of the disease.

Clinical features and predictors of delayed neurological syndrome in carbon monoxide poisoning: the AMICO study.

To identify predictors for developing delayed neurological syndrome (DNS) after an initial episode of carbon monoxide (CO) poisoning in the interest of detecting patients most likely to develop DNS so that they can be followed. Retrospective review of cases of CO poisoning treated in the past 10 years in the emergency departments of 4 hospitals in the AMICO study (Spanish acronym for the multicenter analysis of CO poisoning). We analyzed demographic characteristics of the patients and the clinical characteristics of the initial episode. The records of the cohort of patients with available follow-up information were reviewed to find cases of DNS. Data were analyzed by multivariant analysis to determine the relationship to characteristics of the initial exposure to CO. A total of 240 cases were identified. The median (interquartile range) age of the patients was 36.2 years (17.6-49.6 years); 108 patients (45.0%) were men, and the poisoning was accidental in 223 cases (92.9%). The median carboxyhemoglobin concentration on presentation was 12.7% (6.2%-18.7%). Follow-up details were available for 44 patients (18.3%). Eleven of those patients (25%) developed DNS. A low initial Glasgow Coma Scale score predicted the development of DNS with an odds ratio (OR) of 0.61 (95% CI, 0.41-0.92) and an area under the receiver operating characteristic curve of 0.876 (95% CI, 0.761-0.990) (P .001). The initial Glasgow Coma Scale score seems to be a clinical predictor of DNS after CO poisoning. We consider it important to establish follow-up protocols for patients with CO poisoning treated in hospital EDs.

Outcomes and physiologic responses associated with ketamine administration after traumatic brain injury in the United States and Canada: a retrospective analysis

Purpose: Ketamine has historically been contraindicated in traumatic brain injury (TBI) due to concern for raising intracranial pressure. However, it is increasingly being used in TBI due to the favorable respiratory and hemodynamic properties. To date, no studies have evaluated whether ketamine administered in subjects with TBI is associated with patient survival or disability. Methods: We performed a retrospective analysis of data from the multicenter Prehospital Tranexamic Acid Use for Traumatic Brain Injury trial, comparing ketamine-exposed and ketamine-unexposed TBI subjects to determine whether an association exists between ketamine administration and mortality, as well as secondary outcome measures.Results: We analyzed 841 eligible subjects from the original study, of which 131 (15.5%) received ketamine. Ketamine-exposed subjects were younger (37.3±16.9 years vs. 42.0±18.6 years, P=0.037), had a worse initial Glasgow Coma Scale score (7±3 vs. 8±4, P=0.003), and were more likely to be intubated than ketamine-unexposed subjects (88.5% vs. 44.2%, P&lt;0.001). Overall, there was no difference in mortality (12.2% vs. 15.5%, P=0.391) or disability measures between groups. Ketamine-exposed subjects had significantly fewer instances of elevated intracranial pressure (ICP) compared to ketamine-unexposed subjects (56.3% vs. 82.3%, P=0.048). In the very rare outcomes of cardiac events and seizure activity, seizure activity was statistically more likely in ketamine-exposed subjects (3.1% vs. 1.0%, P=0.010). In the intracranial hemorrhage subgroup, cardiac events were more likely in ketamine-exposed subjects (2.3% vs. 0.2%, P=0.025). Ketamine exposure was associated with a smaller increase in TBI protein biomarker concentrations.Conclusions: Ketamine administration was not associated with worse survival or disability despite being administered to more severely injured subjects. Ketamine exposure was associated with reduced elevations of ICP, more instances of seizure activity, and lower concentrations of TBI protein biomarkers.

The executive functions among patients with an initial Glasgow coma scale score of 15

Executive functions (EF) were the critical neuropsychological functions linked to long-term adaptation. Given the heterogeneous prognosis trajectories of mild traumatic brain jury (mTBI), the mildest TBI may not always be benign in the chronic stage. The present study explored the long-term EF in patients with chronic complicated mTBI and a Glasgow Coma Scale (GCS) score of 15. Fifty patients with complicated mTBI and GCS scores of 15 and 35 control participants were recruited in this study. Medical records were retrospectively analyzed, and neuropsychological assessments and subjective measures examined the neuropsychological functions. Compared with healthy controls, complicated mTBI patients with a GCS score of 15 performed significantly worse on most EF assessments, including longer reaction time (RT) and poor cognitive flexibility and abstract reasoning performances. Patients also reported more EF problems and lower quality of life (QoL) than healthy controls. Females and those with subdural hematoma (SDH) had significantly longer reaction times (RT) on executive attention tests. This study found that complicated mTBI with a GCS score of 15 had incomplete recovery of EF, even in the chronic stage. We suggest that early neuropsychological assessment and rehabilitation should be arranged for such patients.

Is neutrophil-to-lymphocyte ratio a prognostic marker for traumatic brain injury in the pediatric population?

The neutrophil-to-lymphocyte ratio (NLR) is used for the prognosis of diseases characterized by inflammatory processes. This study aims to discuss the long-term outcomes and NLR in pediatric traumatic brain injury cases. This study investigated traumatic brain injury patients younger than 18 years. Patients were grouped into 5 groups according to their Glasgow outcome scores (GOS). Initial admission Glasgow coma scale (GCS) values, neurological examinations, pupil conditions, cardiopulmonary resuscitation (CPR) administration, and seizure occurrence were recorded. Neutrophil counts and lymphocyte counts, derived from complete blood count (CBC) values taken during the patient's first 8 hours of admission, were used to calculate the NLR value. A total of 150 patients, 54 (36%) females and 96 (64%) males, were assessed in the study. The most frequent accident type was falling from a height [84 patients (56%)]. The GCS, CPR, pupillary reflex, anisocoria, surgical procedure, and neutrophil counts were significantly different between the GOS scores. There was no statistically significant difference between the GOS and the NLR (p=0.400). There was a significant difference in NLR value according to CPR, seizures, and brain injury type (p<0.05). NLR values are not correlated with 1-year outcome scores in pediatric traumatic brain injury patients, unlike proven parameters such as initial GCS scores and neurological status.

Critical Emergency Department Interventions and Clinical Deterioration in Children With Nonsevere Traumatic Intracranial Hemorrhage.

Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification. We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models. Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS (P = 0.001) and nonaccidental trauma (P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH. Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics.

A-093 Clinical Performance of Biomarkers for Traumatic Brain Injury

Abstract Background An estimated 5 million people are evaluated in emergency departments (ED) for Traumatic Brain Injury (TBI) in the United States each year. The vast majority (80%) of patients evaluated for TBI in the ED will receive head CT scans, however less than 10% of those will have any findings of acute traumatic abnormalities. This highlights the need for objective, rapid, accurate tools to help clinicians evaluate and triage TBI patients and reduce unnecessary radiation exposure. The Alinity i TBI test is a panel of in vitro diagnostic chemiluminescent microparticle immunoassays used to measure glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) in human plasma and serum. TBI performance was evaluated in a multi-center study by performing reproducibility and a pivotal study. Methods A pivotal study using prospectively collected archived (frozen) plasma specimens was conducted to establish the clinical performance of the TBI test on the Alinity i system. The testing of the archived specimens was performed at three clinical sites in the United States. The specimens tested were originally collected in a prospective, multi-center clinical study and were from individuals 18 years of age or older who presented to a health care facility or emergency department with suspected traumatic brain injury. These subjects had an initial Glasgow Coma Scale (GCS) score of 13–15 and had a computed tomography (CT) scan of the head performed per the clinical site’s standard of care. Reproducibility was assessed using multiple panel/control members for 5 days based on guidance from Clinical and Laboratory Standards Institute EP05-A3. Testing was conducted using 3 lots of GFAP and UCH-L1 reagents, and 1 Alinity i system at each of 3 testing sites. Results Of the 1899 mild TBI subjects, 120 had positive head CT scan results; 116 of the 120 specimens had a positive TBI interpretation (Sensitivity 96.7%;95%CI:91.7%,98.7%). Of the 1779 subjects with negative CT scan results, 713 had a negative TBI interpretation (Specificity 40.1%;95%CI:37.8%,42.4%). The negative predictive value (NPV) of the test was 99.4% (713/717, 95%CI:98.6%,99.8%). Within-Laboratory imprecision (includes repeatability, between-run, and between-day variance components) results ranged from 2.2% to 3.5% CV for GFAP and 1.8 to 3.2 %CV for UCH-L1. The Overall Reproducibility (includes repeatability, between-run, between-day, between-lot, between-site, and site-lot interaction variance components) results ranged from 2.5% to 4.7% CV for GFAP and 2.6 to 6.6 %CV for UCH-L1. Conclusion The Alinity i TBI clinical performance results demonstrated that the TBI test is characterized by high sensitivity and high NPV, which supports the clinical utility to assist in determining the need for a CT scan of the head in subjects presenting with suspected mild TBI. The GFAP and UCH-L1 assays demonstrated acceptable reproducibility across a wide dynamic range. These assays can report results within 18 min and be conveniently loaded into the Electronic Health Records to aid clinicians in their triage (or imaging) decisions. Funding The study was funded by Abbott Laboratories and in collaboration with the US Army Medical Materiel Development Activity, US Army Medical Research and Development Command CRADA 20-1266-CRA.

Glasgow Coma Scale on admission as predictor of neurological sequelae at discharge and acute respiratory failure in patients with heatstroke.

Transient neuronal dysfunction may occur in most brain regions with heatstroke (HS). This study aimed to explore the prognostic significance of initial Glasgow Coma Scale (GCS) scores in HS. Retrospective data regarding HS were obtained from six hospitals. The primary outcome was neurological sequelae at discharge. Secondary outcomes included acute respiratory failure (ARF) and intensive care unit (ICU) admission. Logistic regression models and random forest imputation were used to assess the independent association between GCS score and outcomes. Interaction and stratified analyses of body temperature (BT) at 0.5hours were also conducted. Receiver operating characteristic curves and decision curve analysis were used to estimate prognostic values. Of 206 patients, 44 (21.36%) had neurological sequelae at discharge. The mean ± standard deviation initial GCS score was 8.17 ± 4.05. After adjustment for confounders, GCS, as a continuous variable, was significantly related to neurological sequelae at discharge [odds ratio (OR): 0.65; 95% confidence interval (CI): 0.50-0.85; P = 0.002], ARF (OR: 0.76; 95% CI: 0.66-0.87; P = 0.001), and ICU admission (OR: 0.68; 95% CI: 0.53-0.87; P = 0.003). These relationships were consistent in the random forest imputation cohort. The OR between GCS and neurological sequelae at discharge was much lower (P = 0.048) in participants with BT at 0.5hours ≤39°C than in those with BT at 0.5hours >39°C. The GCS and National Early Warning Score (NEWS) had similar prognostic ability for all outcomes, whereas the net benefits were greater with the GCS compared with the NEWS. Initial GCS score was an independent prognostic factor for neurological sequelae at discharge in HS. Rapid cooling played a positive role in this relationship. Key messages What is already known on this topic Brain damage caused by heatstroke (HS) can be transient or result in irreversible injury. Early recognition of those at risk of death or developing neurological complications is very important for improving the outcomes of HS. What this study adds Initial Glasgow Coma Scale (GCS) score was an independent prognostic factor for neurological sequelae at discharge, acute respiratory failure, and intensive care unit (ICU) admission in HS. Rapid cooling played a positive role in this relationship. How this study might affect research, practice, or policy The GCS upon emergency department admission can be a useful predictor of prognosis in patients with HS.

Characteristics, Outcomes, and Its Associated Factors Among Patients Hospitalized With Mild Traumatic Brain Injuries.

The aim of the study is to investigate the characteristics and hospital outcomes of patients with mild traumatic brain injuries. A total of 1940 patients with mild traumatic brain injuries from seven community hospitals between 2017 and 2019 were identified using International Classification of Disease codes and an documented initial Glasgow Coma Scale score of 13-15. A stepwise logistic regression was used to identify demographics and clinical characteristics associated with in-hospital mortality and home discharge. The median age was 69 yrs old with 66.6% associated with falls at admission. Subdural hemorrhage was the most common brain lesion and more common in the group with falls. Increased age, male sex, epidural hemorrhage, presence of hemiplegia, paraplegia, renal disease, cancer, hospital-acquired sepsis, anemia, and use of direct vasodilator were associated with increased odds of in-hospital mortality. Increased age, medical coverage by Medicare, cerebral edema, lower initial Glasgow Coma Scale, length of stay, comorbidity of acute myocardiac infarction, and use of thiamine and opioids were associated with decreased likelihood of discharge to home. Recognizing characteristics of hospitalized patients with mild traumatic brain injuries and their association with increased in-hospital mortality and nonhome discharge can be useful for improving care of this vulnerable population.

Predictors of revision surgery after bedside subdural drain placement for chronic subdural hematomas

Background and objectiveFor chronic subdural hematoma (cSDH), bedside subdural drains (SDD) provide a useful alternative to more invasive neurosurgical techniques, including evacuation through multiple burr holes or formal craniotomy. However, no scale currently exists adequately predicting SDD candidacy or treatment response. The present study sought to characterize predictors of revision surgery after initial treatment with bedside SDD for cSDH. MethodsWe conducted a retrospective case control study of cSDH patients treated with bedside SDD at a level one trauma center between 2018 and 2022. Binomial regression was used to compare SDD patients and generate odds ratios associated with revision surgery, which were compared using a binary random effects model. ResultsNinety six cSDH patients were included, of whom 13 (13.5%) required a revision surgery after initial treatment failure with bedside SDD. Patients requiring revision surgery demonstrated an increased male predominance (84.6% vs. 69.9% of SDD patients not requiring revision surgery), tended to be younger (67.8 vs. 70.5 years) with a greater body mass index (28.7 vs. 25.6 kg/m2), and have a lower Glasgow Coma Scale (GCS) score on presentation of 12.5 (versus 14). Patients with an initial GCS score less than 13 (OR 11.0 95% CI 2.8 – 43.3), midline shift greater than 10 mm on CT (OR 6.5 95% CI 1.7 – 25.7), or duration of SDD placement longer than 3 days (OR 10.5 95% CI 2.6 – 41.9) demonstrated a greater likelihood of needing a revision surgery after initial treatment with bedside SDD. ConclusionAmong patients treated with SDD, we identified 3 independent factors predicting the need for revision surgery: GCS score, midline shift, and duration of drain placement. Craniotomy may be favored over bedside SDD in patients presenting with a GCS score less than 13 or midline shift greater than 10 mm and for SDD patients demonstrating inadequate clinical response after 3 days.

The Role of Cisternostomy in the Management of Severe Traumatic Brain Injury: A Triple-Center Study

Background: Traumatic brain injury (TBI) is a critical public health problem worldwide, constituting a major cause of mortality and morbidity for people of all ages, but especially in the younger population. Decompressive craniectomy (DC) and cisternostomy are surgical procedures commonly used in the management of severe TBI, but their effectiveness in improving outcomes remains controversial. Methods: We conducted a prospective longitudinal study on patients who underwent surgical treatment for severe TBI between 2021 and 2022. The extended Glasgow outcome scale (GOS-E) was used to assess clinical outcome at 2 weeks, 3 months, and 6 months after surgery. Results: The study included 30 patients (21 men and 9 women) who met the inclusion criteria. Among them, 24 patients (80%) underwent DC combined with cisternostomy, while 6 patients (20%) underwent cisternostomy alone. The initial Glasgow Coma Scale (GCS) score at admission ranged from 4 to 8 points, with an average score of 5.9. The overall mortality and overall morbidity was 13.3% and 20%, respectively. The mortality rate was 12.5% and 16.7% in the DC + cisternostomy group and in the cisternostomy alone group, respectively. No statistically significant difference was seen between the two groups in terms of mortality, morbidity and favorable outcome at 2 weeks, 3 months and 6 months. Conclusions: Our preliminary multi-center study shows a good clinical outcome in patients who underwent DC + cisternostomy or cisternostomy alone in both early and long-term follow-up. Larger multi-center randomized trials are needed to establish the effectiveness of cisternostomy in the management of TBI.

Effect of ionized calcium level on short-term prognosis in severe multiple trauma patients: a clinical study

BackgroundHypocalcemia has been reported as an independent predictor of trauma mortality. We investigated the relationship between temporal variations in blood ionized calcium concentration (iCa) and prognosis in severe trauma patients...

Analysis of Prognostic Factors in Patients with Hemorrhagic Moyamoya Disease

Background: Hemorrhagic Moyamoya disease (MMD) is a common subtype of MMD in adult patients, especially in East Asian countries. To our knowledge, current studies regarding factors affecting the prognosis in patients with hemorrhagic MMD is lacking. This study aimed to determine the potential prognostic factors for hemorrhagic MMD.Methods: This retrospective study reviewed patients with hemorrhagic MMD diagnosed at our hospital between June 2011 and June 2021. Patient outcome was measured at discharge using the extended Glasgow outcome scale (GOSE). Prognostic factors were assessed by multivariate logistic regression analysis.Results: Patients discharged with worst outcomes (GOSE 1 and 2) had significantly lower initial Glasgow coma scale (GCS) scores (5.9 ± 3.1 vs. 10.3 ± 3.7; P = 0.002) and were associated with more severe intraventricular hemorrhage (IVH) (P = 0.007), and IVH-related hydrocephalus requiring extraventricular drain (EVD) insertion was more common (n = 12 vs. n = 7; P = 0.001). The multivariate analysis showed that IVH-related hydrocephalus requiring EVD placement (OR 8.256, 95% CI 0.996–68.450; P = 0.016) and low initial GCS scores (OR 0.644; 95% CI 0.465–0.892; P = 0.008) were independent risk factors for unfavorable outcomes (GOSE 1–4) in patients with hemorrhagic MMD.Conclusion: This study analyzed several potential prognostic factors for patients with hemorrhagic MMD. Low initial GCS scores and IVH-related hydrocephalus requiring EVD insertion were related to unfavorable outcomes.

Investigating the relationship between high-dose norepinephrine administration and the incidence of delayed cerebral infarction in patients with aneurysmal subarachnoid hemorrhage: A single-center retrospective evaluation.

One of the longest-standing treatments to prevent delayed cerebral infarction (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) remains raising the blood pressure to a certain level of mean arterial pressure. This may require high doses of norepinephrine, which has been associated with severe end organ damage. With this study, we aimed to investigate the effects of norepinephrine on the incidence of DCI in a clinical setting. We conducted a retrospective evaluation of patients with aSAH admitted to our institution between November 2018 and March 2021. Potential risk factors for DCI were analyzed and significant predictors were assessed by means of a logistic regression analysis to account for potential confounders. In this study, 104 patients were included. Hereof, 39 (38%) showed radiologic signs of DCI between day three and 14 post-intervention. These patients had more frequent vasospasms (n = 37 vs. 30, p = 0.022), a higher Hunt & Hess score (3 ± 2 vs. 2 ± 1, p = 0.004), a lower initial Glasgow Coma Scale score (9 ± 5 vs. 12 ± 4, p = 0.003) and received a higher median norepinephrine dose (20,356μg vs. 6,508μg, p < 0.001). A logistic regression analysis revealed that only high-dose norepinephrine administration (OR 2.84, CI 1.56-7.8) and vasospasm (OR 3.07, CI 1.2-7.84) appeared to be significant independent risk factors for DCI. Our results indicate a significant association between higher dose norepinephrine administration and the occurrence of DCI. Future research including greater sample sizes and a prospective setting will be necessary to further investigate the relationship.

Incidence of Chronic Subdural Hematoma after Mild Head Trauma in Elderly Patients with or without Pre-traumatic Conditioning of Anti-thrombotic Drugs.

Anti-thrombotic drugs may increase the risk for chronic subdural hematoma (CSDH). However, whether to continue or discontinue/counteract these drugs has not been investigated in patients with mild head trauma. CSDH incidence after mild head trauma, as well as the risk for CSDH in patients with anti-thrombotic drugs, were investigated in this study. The study included 765 consecutive elderly (>65 y.o.) patients with mild head trauma and an initial Glasgow Coma Scale (GCS) score of 14 or 15. All patients received initial CT within 24 hours after trauma and were re-examined 30 days after trauma to detect CSDH formation, repeating for every 30 days to examine symptomatic CSDH progression. Patients were divided into two groups, with anti-thrombotic drugs (n = 195) or without them (n = 263), to investigate the influence of pre-traumatic conditioning with anti-thrombotic drugs on CSDH. The whole sample was 458 out of 765 cases. The incidence of CSDH formation was 91 out of 458 cases (19.9%) after mild head trauma, with no significant difference between with and without anti-thrombotic drugs. CSDH progressed as symptomatic in 21 out of 458 cases (4.6%), with no significant difference between with and without anti-thrombotic drugs. Pre-traumatic conditioning with anti-thrombotic drugs and its continuation after trauma did not affect the incidence of formation or symptomatic progression of CSDH. This finding suggests that discontinuing and/or counteracting anti-thrombotic drugs may be unnecessary in patients with mild head trauma.