Lower Glasgow Coma Scale Score Research Articles

Impact of the Coronavirus Disease Pandemic on Patients with Head Injuries in South Korea.

ObjectiveThe coronavirus disease 2019 (COVID-19) pandemic is affecting the characteristics of patients with head injuries. This study aimed to evaluate the effect of the COVID-19 pandemic on patients with head injuries at a regional emergency medical center in South Korea. MethodsFrom April 2019 to November 2020, 350 patients with head injuries were admitted to our hospital. The study period was divided into the pre-COVID-19 (n=169) and COVID-19 (n=181) eras (10 months each). Patients with severe head injuries requiring surgery (n=74) were categorized into those who underwent surgery (n=41) and those who refused surgery (n=33). ResultsHead injuries in pediatric patients (<3 years) were more frequent in the COVID-19 era than in the pre-COVID-19 era (8.8% vs. 3.6%, p=0.048). More patients refused surgery in the COVID-19 era than in the pre-COVID-19 era (57.9% vs. 30.6%, p=0.021). Refusal of surgery was associated with old age (67.7±14.5 vs. 52.4±19.1, p<0.001), marital status (married, 84.8% vs. 61.0%, p=0.037), unemployment (42.4% vs. 68.3%, p=0.034), COVID-19 era (66.7% vs. 39.0%, p=0.021), and lower Glasgow coma scale scores (6.12±3.08 vs. 10.6±3.80, p<0.001). Multivariable logistic regression analysis revealed that refusal of surgery was independently associated with old age (adjusted odds ratio [OR], 1.084; 95% confidence interval [CI], 1.030–1.140; p=0.002), COVID-19 era (adjusted OR, 6.869; 95% CI, 1.624–29.054; p=0.009), and lower Glasgow coma scale scores (adjusted OR, 0.694; 95% CI, 0.568–0.848; p<0.001). ConclusionWe observed an increased prevalence of head injuries in pediatric patients (<3 years) during the COVID-19 pandemic. Additionally, among patients with severe head injuries requiring surgery, more patients refused to undergo surgery during the COVID-19 pandemic.

Clinical Profile of Stroke Patients Presenting to the Emergency Department of a Major Stroke Centre in Oman.

ObjectivesStroke is a significant public health problem and one of the most important preventable non-communicable diseases. Preventive stroke programmes with a better focus on increasing awareness among those who are currently at risk are yet to be properly established in Oman. This study was conducted to describe the characteristics of stroke patients presenting to a tertiary care hospital in Oman.MethodsThis cross-sectional hospital-based study included 193 stroke cases which were prospectively recruited from the Emergency Department of Khoula Hospital, Muscat, Oman. Data were collected from November 2017 to April 2018.ResultsThe total number of patients was 193 with 82.9% of strokes being ischaemic strokes. Of this, 58% were male. The mean age of stroke patients was 61.05 years. Risk factors included hypertension (72.5%) and diabetes mellitus (54.4%). Dyslipidaemia, atrial fibrillation and ischaemic heart diseases were not particularly prevalent in the studied population and 24.4% of ischaemic strokes had large artery atherosclerosis while 21.9% had small vessel occlusion. Significantly more patients had lower Glasgow Coma Scale scores, required intensive care unit admission and experienced in-hospital deaths due to haemorrhagic stroke compared to ischaemic stroke.ConclusionThis study provides essential data regarding stroke characteristics specific to Oman’s population. Most of the information obtained appears to be in-line with what has been described internationally and, hence, preventive strategies similar to those indicated in extant literature can be implemented. This information can be utilised by health administrators in planning resource allocation. Further research is needed to explore rehabilitation aspects and long-term outcomes.

Palliative Care in Primary and Metastatic Brain Tumors

Introduction: Early palliative care interventions and structured advance care planning can improve symptom control and quality of life in patients with a brain tumor. In this study, we aimed to investigate symptoms, hospital discharge conditions, and the length of stay of patients with primary and metastatic brain tumors in our palliative care center (PCC). Material and Method: Ninety-one patients; who had been followed-up in the PCC with the diagnosis of a primary or metastatic brain tumor were included in this retrospective study. Demographic characteristics, Glasgow Coma Scale (GCS) scores, Karnofsky Performance Scale (KPS) scores, hospital discharge status, and symptoms of the patients included in the study were compared. Results: The mean age of the patients was 60.67 years; 59.3% were male, and the mean length of hospital stay was 29.26 days. The rates of PEG, tracheostomy, seizures, and paresis symptoms were significantly higher in patients with a primary brain tumor (p&amp;lt;0.05). The rates of death in the hospital were significantly higher in patients with metastatic tumors and low GCS scores (p=0.032 and p=0.00, respectively). Conclusion: We observed differences in clinical findings and prognoses between primary and metastatic brain tumor patients during the follow-up in PCC. Further to advances in treatment methods, we believe that identifying the need for palliative care and appropriate symptom management will improve the quality of life in brain tumor patients with poor prognosis.

A prospective observational study of electrocardiographic and echocardiographic changes in traumatic brain injury – effect of surgical decompression

Background Traumatic brain injury (TBI) causes significant changes in myocardial function, which is represented by ECG and echocardiographic changes. We intended to study the effect of surgical decompression on these changes. Materials and methods We recruited adult TBI patients undergoing surgery within 48 h of injury. Preoperatively, the patient’s demographic and clinical details were recorded. ECG and TTE were performed before surgery and 24 h later (first postoperative day [POD1]). ECG was analyzed for heart rate, PR, QRS, and QTc intervals, morphologic end-repolarization abnormalities (MERA), and ST-segment and T wave changes. TTE data included left ventricular ejection fraction (LVEF) and regional wall motion abnormalities (RWMA). Glasgow coma scale (GCS) at discharge was recorded. ECG and TTE changes before and after surgery were compared, and its association with discharge GCS was analyzed. Preoperative predictors of LV dysfunction were analyzed. Results Of the 110 patients recruited, common ECG changes were prolonged QTc interval (42%) and MERA (47%). TTE showed poor LVEF (<50%) in 10% and RWMA in 10.8% of patients. Following surgery, both ECG and TTE changes improved. Preoperative LVEF <50% and/or RWMA were associated with a lower GCS score at discharge. Preoperative poor GCS motor score and prolonged QTc interval were independent predictors of LV dysfunction. Conclusions Poor LV function was associated with poor admission GCS and prolonged QTc interval. Patients with reduced LV function had lower GCS at discharge.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing.

in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality. a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing. data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05). age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

Mortality of hospital walk-in trauma patients: a multicenter retrospective cohort study.

AimTo investigate the characteristics of patients who visited the emergency department by themselves after experiencing trauma and subsequently died, and to identify the prognostic factors of mortality in such patients.MethodsAdult patients with trauma visiting the emergency department by themselves between 2004 and 2019 in Japan were identified using a nationwide trauma registry (the Japan Trauma Data Bank). The characteristics of patients who died were compared with those who survived, and multivariable logistic regression analysis was used to determine the independent association of each preselected variable with in‐hospital mortality (end‐point).ResultsOf the 9753 patients eligible for analysis, 4369 (44.8%) were men, and the median age was 75 years. Of these patients, 130 (1.3%) died in the hospital. The following factors had a significant association with in‐hospital mortality: age, male sex, Charlson Comorbidity Index (CCI) 3–4 and ≥5 with CCI = 0 as a reference, circumstances of injury (free fall and fall at ground level), Glasgow Coma Scale score, Shock Index ≥ 0.9, severe injuries of the head, abdomen and lower extremities, and Injury Severity Score ≥ 15.ConclusionsSeveral risk factors, including older age, male sex, higher CCI, circumstances of injury (free fall and fall at ground level), lower Glasgow Coma Scale score, higher Shock Index, and severe injuries of the head, abdomen, and lower extremities, were identified as being associated with the death of trauma patients visiting the emergency department by themselves. Early identification of patients with these risk factors and appropriate treatment may reduce mortality posttrauma.

Evaluation of Brain Death Due to Methanol Intoxication

Objective: Intoxication may mimic brain death and cause brain death. In the literature, brain death due to methanol intoxication is limited to case reports. In this report, patients with methanol intoxication who had findings of imminent brain death were evaluated. Materials and Methods: The study population consisted of patients with methanol intoxication treated in the adult intensive care unit (ICU) between October 2014 and October 2020. The records in the hospital automation system of patients with methanol intoxication were evaluated retrospectively. According to the outcomes, the patients were divided into two groups: survivors and patients who had imminent brain death. Results: Eighteen patients with methanol intoxication were investigated. The brainstem reflexes disappeared in seven patients who were in a coma. The imminent brain death rate of patients with methanol intoxication was 39%. Patients who had imminent brain death had lower Glasgow Coma Scale scores during ICU admission and a higher ratio of pathologic neuroimaging findings due to methanol intoxication (P &lt; 0.05). According to the clinical criteria and ancillary tests, four patients were declared brain dead. The brain death rate of patients with methanol intoxication was 22%. One of four patients with brain death was an organ donor. The liver was transplanted from our donor. Conclusion: Treatment should be initiated immediately in cases of methanol intoxication. Patients who do not respond well to treatment should be followed closely in terms of brain death. Based on published data and our personal experience, organ donations can be performed after appropriate investigations in brain death cases due to methanol intoxication.

Hyperglycemia as a positive predictor of mortality in major trauma

Background:Hyperglycemia in the acute phase after trauma is a stress response and a metabolic reflection in humans with injury, which could adversely affect outcome in trauma patients. In this study, we attempted to identify if hyperglycemia a reliable predictor for mortality in major trauma patients.Objectives:In order to identify if hyperglycemia a reliable predictor for mortality in major trauma, we designed and proformed a prospective observational study in a tertiary hospital.Method:We performed a prospective observational study to review the records of 601 patients with major trauma (injury severity scores &gt;15) who visited our hospital's emergency department from August 2012 to July 2015. Logistic regression was performed to assess the effect of hyperglycemia on mortality.Result:Major trauma patients in the hyperglycemia group had low systolic/diastolic blood pressure at triage, low initial Glasgow Coma Scale score, high incidence of hypotension episodes, coagulopathy, acidosis, and anemia. Hyperglycemia was significantly correlated with mortality in major trauma patients in this study (odds ratio: 1.97, 95% confidence interval: 1.04–3.74).Conclusion:In major trauma patients with injury severity scores &gt;15, hyperglycemia has a positive correlation with mortality, which could be a predictor of mortality in clinical practice.

Intraoperative blood flow monitor for aneurysm clipping

Background: Both indocyanine green videoangiography (ICG-VA) and flowmetry were considered beneficial in preventing parent artery compromise during aneurysm surgery. However, the appropriate strategy that should be used remains controversial. The objective of the study is to assess the outcomes of aneurysm clipping through flowmetry or ICG-VA monitoring.Materials and Methods: This retrospective cohort study included 75 patients who underwent aneurysm clipping with vascular patency monitoring. In total, 42 patients underwent flowmetry monitoring and 33 ICG-VA monitoring. Preoperative disease severity and functional outcomes were assessed using the World Federation of Neurosurgical Societies (WFNS) grading system and the modified Rankin scale, respectively.Results: As compared with ICG-VA, flowmetry group had nonsignificant higher incidence of clip modification (31.7% vs. 18.2%, P = 0.29) and residual neck (22% vs. 10%, P = 0.218). Besides Fisher grade, flowmetry monitoring (Crude odds ratio [OR] = 0124, P = 0.015), young age, and anterior communicating artery location were the independent risk factors for vasospasm based on multivariate analysis. The incidence of parent artery compromise did not differ between both groups. Old age, poor preoperative WFNS grade, low Glasgow coma scale (GCS) score, left-side location, and long hospital stay were associated with poor functional outcomes in the univariate analysis. However, only the GCS score was considered a prognostic factor in the multivariate analysis (Adjusted OR = 0.03, P = 0.034).Conclusion: Both monitoring methods have similar functional outcomes. Although not influencing outcome, the flowmetry group has a higher incidence of angiographic vasospasm than the ICG-VA group. The vessel preparation for flowmetry monitoring is more complicated than that for ICG-VA; thus, we recommend ICG-VA for routine monitoring. Flowmetry may be applicable in distal aneurysms when hemodynamic insufficiency in a parent artery is suspected.

Surgical Outcomes in Patients with Simultaneous Traumatic Brain and Torso Injuries in a Single Regional Trauma Center over a 5-Year Period

Purpose The purpose of the study is to analyze the results of surgical treatment of patients with brain and torso injury for 5 years in a single regional trauma center. Methods We analyzed multiple trauma patients who underwent brain surgery and torso surgery for chest or abdominal injury simultaneously or sequentially among all 14,175 trauma patients who visited Dankook University Hospital Regional Trauma Center from January 2015 to December 2019. Results A total of 25 patients underwent brain surgery and chest or abdominal surgery, with an average age of 55.4 years, 17 men and eight women. As a result of surgical treatment, there were 14 patients who underwent the surgery on the same day (resuscitative surgery), of which five patients underwent surgery simultaneously, four patients underwent brain surgery first, and one patient underwent chest surgery first, four patients underwent abdominal surgery first. Among the 25 treated patients, the 10 patients died, which the cause of death was five severe brain injuries and four hemorrhagic shocks. Conclusions In multiple damaged patients require both torso surgery and head surgery, poor prognosis was associated with low initial Glasgow Coma Scale and high Injury Severity Score. On the other hand, patients had good prognosis when blood pressure was maintained and operation for traumatic brain injury was performed first. At the same time, patients who had operation on head and torso simultaneously had extremely low survival rates. This may be associated with secondary brain injury due to low perfusion pressure or continuous hypotension and the traumatic coagulopathy caused by massive bleeding.

Factors Associated with the Development of Coagulopathy after Open Traumatic Brain Injury.

Background: The incidence of coagulopathy after open traumatic brain injury (TBI) is high. Coagulopathy can aggravate intracranial hemorrhage and further increase morbidity and mortality. The purpose of this study was to determine the clinical characteristics of coagulopathy after open TBI and its relationship with the prognosis. Methods: This study retrospectively evaluated patients with isolated open TBI from December 2018 to December 2020. Coagulopathy was defined as international normalized ratio (INR) > 1.2, activated thromboplastin time (APTT) > 35 s, or platelet count <100,000/μL. We compared the relationship between the clinical, radiological, and laboratory parameters of patients with and without coagulopathy, and the outcome at discharge. Logistic regression analysis was used to evaluate the risk factors associated with coagulopathy. We then compared the effects of treatment with and without TXA in open TBI patients with coagulopathy. Results: A total of 132 patients were included in the study; 46 patients developed coagulopathy. Patients with coagulopathy had significantly lower platelet levels (170.5 × 109/L vs. 216.5 × 109/L, p < 0.001), and significantly higher INR (1.14 vs. 1.02, p < 0.001) and APTT (30.5 s vs. 24.5 s, p < 0.001) compared to those with no coagulopathy. A Low Glasgow Coma Scale (GCS) score, high neutrophil/lymphocyte ratio (NLR), low platelet/lymphocyte ratio (PLR), and hyperglycemia at admission were significantly associated with the occurrence of coagulopathy. Conclusions: Coagulopathy often occurs after open TBI. Patients with a low GCS score, high NLR, low PLR, and hyperglycemia at admission are at greater risk of coagulopathy, and therefore of poor prognosis. The efficacy of TXA in open TBI patients with coagulopathy is unclear. In addition, these findings demonstrate that PLR may be a novel indicator for predicting coagulopathy.

Automated Pupillometry Value Differences Serve as a Prognostic Indicator Even When They are Within Normal Range

Introduction. The pupillary light reflex (PLR) is an integral aspect of the neurologic exam. With the enhancement of automated infrared pupillometry (AIP), the Neurological Pupil index (NPi) is being increasingly used when performing a neurological examination. NPi difference (the absolute difference between paired NPi readings from the left and right eye) is a relatively unexplored variable in AIP assessment.Aim. This study evaluates the association between Glasgow Coma Scale (GCS) scores and NPi differences between the left and right eyes, when the NPi is normal, in patients enrolled in a multi-center prospective database.Material and Methods. Restricting observations to only include NPi values ≥ 3 (normal), there were 2,572 qualifying patients with 3,519 pupillometer readings linked to GCS values. Linear regression and ANOVA models were developed to investigate the relationship between GCS and NPi difference.Results. Subject mean age was 55.88 (16.95) years and 54.5% were female. Mean NPi difference was 0.36 and mean GCS was 12.06. Regression analysis indicated a slight negative association between NPi difference and GCS (r2 = 0.0696, P &lt; .0001). When observations were dichotomized as either NPi difference ≥ 0.7 (large) or &lt; 0.7 (small), there was a statistically significant difference in the mean GCS (10.76 [3.90]) for large NPi difference vs. small NPi difference (13.15 [2.68]; P &lt; .0001).Conclusions. Even among patients with normal PLR, a large NPi difference is associated with lower GCS scores. Trending and evaluating the NPi difference may become an important aspect of patient assessment. (JNNN 2021;10(4):168–174)

Determinants of Outcomes in Older Adult Patients Admitted to The Intensive Care Unit from The Emergency Department

There is no consensus among clinicians on the criteria for admission of older adult patients to the intensive care unit (ICU). In this study, we aimed to determine the impact of risk factors assessed during admission to the emergency department (ED) in older adult patients admitted to the ICU from the ED on ICU mortality. Patients aged 65 years or older, who were admitted to the ICU between January 1, 2019, and December 31, 2019, were retrospectively evaluated. Patients were divided into two groups according to their age: 65–74 years old and 75 years and older. Clinical and demographic data were evaluated and patients were analyzed according to the age groups. The association of risk factors on ICU mortality was determined using logistic regression analysis. Of the 839 patients included in the study, 66.3% were in the 65–74 age group and 33.7% were in the ≥75 age group. A proportion of 24.7% of the patients (n=207) died. The risk factors associated with ICU mortality were low mean arterial pressure (OR=0.98, 95% CI:0.97-0.99), low Glasgow Coma Scale score (OR=0.73, 95% CI:0.66-0.80), intubation requirement (OR=12.58, 95% CI:6.02–26.30), underlying cancer diagnosis (OR = 7.23, 95% CI: 2.60-20.16), and long stay in the ED (OR=1.65, 95% CI:1.46–1.87).Age alone was not associated with ICU mortality (p=0.122). Admission to the ICU from the ED should consider the risk factors associated with ICU mortality.

Predictive factors for high-flow nasal cannula failure in acute hypoxemic respiratory failure in an intensive care unit.

Background and Objective:High-flow nasal cannula (HFNC), a relatively new technique in acute hypoxemic respiratory failure (AHRF), is gaining popularity in intensive care units (ICUs). Our study aims to identify the predictive factors for failure of HFNC.Materials and Methods:This is a 5-year retrospective cohort study in patients with AHRF using HFNC in an ICU of a regional hospital in Hong Kong. The primary outcome is to identify the predictive factors for failure of HFNC which is defined as escalation of treatment to noninvasive ventilation, mechanical ventilation, extracorporeal membrane oxygenation, or death.Results:Of the 124 ICU patients with AHRF, 69 (55.65%) failed in the use of HFNC. The patients failing HFNC had higher Acute physiology and Chronic Health Evaluation IV scores, lower Glasgow Coma Scale scores, lower platelet counts and serum sodium levels upon ICU admission, and higher pH on day of HFNC commencement. They had higher respiratory rates before HFNC and higher heart rates before and 1 h after HFNC. The respiratory rate-oxygenation (ROX) index which is defined as a ratio of SpO2/FiO2 to respiratory rate was significantly lower in the failure group 1 h and 12 h after HFNC. By multivariate binary logistic regression, failure of HFNC is associated with lower ROX index at 12 h after HFNC.Conclusion:ROX index at 12 h serves as a valuable tool to monitor the responsiveness to HFNC treatment. Close monitoring is required to identify patient failing using HFNC.

Pediatric Gunshot Head Injury: Prevalence of Prognostic Factors in Surgical Patients: An Institutional Experience in Ten Years.

This article aims to evaluate the predictive factors of morbidity and mortality in pediatric patients who suffered gunshot wounds to the head. We reviewed a series of 43 patients who were admitted to a referential neurosurgical hospital between 2010 and 2019. Data from 43 patients who underwent a surgical treatment in our institution were collected, and the following parameters were considered in the analysis: the initial Glasgow Coma Scale (GCS), age, sex, bullet entry site, and bullet trajectory. Computed tomography (CT) scans at admission, complications, midline crossing, and Glasgow score scale at the time of discharge (Glasgow Outcome Scale; GOS) were also factored in. Male sex corresponded to 90.7% of cases (N = 39), and 16–17 years of age was the most common age (60.5%). The frontal region was the most common entry site (41.9%), followed by the parietal wall and occipital entry. Penetrating trajectory was shown in 48.8% of cases, perforation/transfixing in 39.5%, and tangential in 11.6%. CT showed that sinking is the most common alteration (74.4%), followed by cerebral contusion (44.2%). According to the GOS, 23.3% died, 23.3% were classified by an unfavorable outcome (GOS, 2–3), and 53.5% a favorable outcome (GOS, 4 and 5). In our study, there was a significant association between the low GCS scores on admission and low GOS (1–3; p = 0.001) at time of discharge. Patients with wounds that crossed the midline also had a significant association with low GOS (p = 0.014) in our clinical experience. We concluded that low GCS scores at admission and children with a wound that crosses the midline are predictive factors of high mortality and morbidity, in our clinical experience.

December 2021 Stroke Highlights

December 2021 <i>Stroke</i> Highlights

Readmission into intensive care unit in patients with aneurysmal subarachnoid hemorrhage.

ObjectiveAneurysmal subarachnoid hemorrhage (aSAH) is a devastating cerebrovascular event; patients are routinely admitted to the intensive care unit (ICU) for initial management. Because complications may be delayed, unplanned ICU readmissions can occur. Therefore, in this study we evaluate the rate of and factors associated with readmission after aSAH and identify if readmission is associated with poor clinical outcomes.MethodsWe retrospectively reviewed the medical records of all patients receiving surgical or endovascular treatment for aSAH and admitted to the ICU between January 2008 and December 2019. We categorized patients by readmission and analyzed their clinical parameters.ResultsOf the 345 patients who transferred to ward-level care after an initial ICU stay (Group 2), 27 (7.3%) were readmitted to the ICU (Group 1). History of hypertension (HTN), initial Glasgow Coma Scale (GCS) score, modified Fisher grade, and vasospasm therapy during first ICU stay were significantly different between the groups. The most common reason for readmission was delayed cerebral ischemia (DCI; 70.3%; OR 5.545; 95% CI 1.25−24.52; p=0.024). Comorbid HTN (OR 5.311; 95% CI 1.75−16.12; p=0.03) and vasospasm therapy during first ICU stay (OR 7.234; 95% CI 2.41−21.7; p＜0.01) also were associated with readmission. Readmitted patients had longer hospital stay and lower GCS scores at discharge (p＜0.01).ConclusionsDCI was the most common cause of ICU readmission in patients with aSAH. Readmission may indicate clinical deterioration, and patients who are at a high risk for DCI should be monitored to prevent readmission.

Early cognitive impairment is common in pediatric patients following mild traumatic brain injury.

The incidence and factors related to early cognitive impairment (ECI) after mild traumatic brain injury (mTBI) in pediatric trauma patients (PTPs) are unknown. Prior data in the adult population demonstrated an ECI incidence of 51% after mTBI and strong correlation with initial Glasgow Coma Scale (GCS) and Brain Injury Guidelines (BIG) category. Therefore, we hypothesized that ECI is common after mTBI in PTPs and associated with initial GCS and BIG category. A single-center, retrospective review of PTPs (age, 8-17 years) from 2015 to 2019 with intracranial hemorrhage and mTBI (GCS score, 13-15) was performed. Primary outcome was ECI, defined as Ranchos Los Amigos score less than 8. Comparisons between ECI and non-ECI groups regarding Injury Severity Score (ISS), demographics, and cognitive and clinical outcomes were evaluated using χ2 statistics and Wilcoxon rank sum tests. Odds of ECI were evaluated using multivariable logistic regression. From 47 PTPs with mTBI, 18 (38.3%) had ECI. Early cognitive impairment patients had a higher ISS than non-ECI patients (19.7 vs. 12.6, p = 0.003). Injuries involving motor vehicles were more often related to ECI than non-auto-involved mechanisms (55% vs. 15%, p = 0.005). Lower GCS score (odds ratio [OR], 6.60; 95% confidence interval [CI], 1.34-32.51, p = 0.02), higher ISS (OR, 1.12; 95% CI, 1.01-1.24; p = 0.030), and auto-involved injuries (OR, 6.06; 95% CI, 1.15-31.94; p = 0.030) were all associated with increased risk of ECI. There was no association between BIG category and risk of ECI (p > 0.05). Nearly 40% of PTPs with mTBI suffer from ECI. Lower initial GCS score, higher ISS, and autoinvolved mechanism of injury were associated with increased risk of ECI. Brain Injury Guidelines category was not associated with ECI in pediatric patients. Prognostic study, Level III.

The influence of first-line endovascular treatment on clinical outcome in patients with acute vertebrobasilar artery occlusion

Objective: To compare the effectiveness of first-line mechanical thrombectomy (MT) with other types of endovascular treatment (EVT) in patients with acute vertebrobasilar artery occlusion (VBAO). Methods: From May 2012 to December 2019, acute VBAO patients diagnosed by angiographic examinations were consecutively enrolled from Nanjing Stroke Registry. Patients were divided into first-line MT group who were treated with stent retriever and direct aspiration, and other types of EVT group who underwent intraarterial thrombolysis, tirofiban infusion, balloon dilation, and stent placement etc. Clinical characteristics at baseline with statistical trends (P<0.1) between different groups were analyzed to calculate propensity scores, which were adjusted in binary Logistic regression for the relationship between first-line treatment and clinical outcome. Results: A total of 107 patients were enrolled in this study including 82 males and 25 females with average age 62 years old (35-82). The overall recanalization rate was 82.2% (88/107). During follow-up, 33.6% (36/107) and 37.1% (39/105) patients achieved good outcome (defined as modified Rankin Scale score 0-3) at 90 days and 1 year, respectively. The MT group received EVT earlier than the other types of EVT group (median year: 2017 vs. 2015, P=0.017), as well as higher proportion of atrial fibrillation history (21.6% vs. 0, P=0.002), higher baseline National Institution of Health Stroke Scale scores (median: 26 vs. 23, P=0.049), lower Glasgow Coma Scale scores (median: 6 vs. 7, P=0.027), and longer estimated occlusion to groin-puncture time (median: 367 min vs. 283 min, P=0.023). There were significant differences in the stroke etiologies between two groups (P=0.002). The MT group had a lower ratio of rescue device treatment (28.4% vs. 54.5%, P=0.009). After propensity scores were adjusted, the recanalization rate of MT group was significantly higher than that in the other group [odds ratio (95% confidence interval [CI]):5.201, 95%CI 1.562-17.317, P=0.007]. No difference was noted regarding other clinical outcomes. Subgroup analysis indicated that recanalization rates in patients without atherosclerosis were different between intervention types [odds ratio (95%CI): 7.859, 95%CI 1.469-42.042, P=0.016], while the recanalization rates was comparable in population with atherosclerosis [odds ratio (95%CI): 3.739, 95%CI 0.613-22.812, P=0.153]. Conclusion: In acute VBAO patients, first-line MT is associated with higher recanalization rate compared with other types of EVT, especially in non-atherosclerosis patients.

Development of a delirium predictive model for adult trauma patients in an emergency and critical care center: a retrospective study

BackgroundDelirium has been shown to prolong the length of intensive care unit stay, hospitalization, and duration of ventilatory control, in addition to increasing the use of sedatives and increasing the...