Lower Admission Glasgow Coma Scale Research Articles

The Trends of Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Systemic Immunoinflammatory Index in Patients with Intracerebral Hemorrhage and Clinical Value in Predicting Pneumonia 30 Days After Surgery

BackgroundInflammatory response is closely associated with secondary brain injury and pneumonia in intracerebral hemorrhage (ICH). In this study, we aimed to investigate the value of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immunoinflammatory index (SII) in the development of pneumonia in ICH patients 30 days after surgery. MethodsWe retrospectively collected clinical data on patients with ICH who underwent surgical treatment at our institution from January 2016 to December 2022, mainly including NLR, PLR and SII at different time points. Receiver operating characteristic (ROC) curves were used to compare the value of different inflammatory indicators in predicting the development of postoperative pneumonia 30 days after surgery in ICH patients, and multivariate logistic regression analyses were used to identify independent risk factors for pneumonia 30 days after surgery. ResultsAmong 112 patients with intracerebral hemorrhage undergoing surgical treatment, 31 (27.7%) developed pneumonia postoperatively. The results of the univariate analysis demonstrated that patients in the pneumonia group experienced significantly higher blood glucose, NLR3, PLR3, and SII3 than those in the non- pneumonia group, and significantly lower admission Glasgow Coma Scale (GCS) scores than those in the Non- pneumonia group (all P<0.05). NLR, PLR, and SII showed an increasing and then decreasing in the disease process of intracerebral hemorrhage, and peaked at 48 hours postoperatively. Multivariable logistic regression analysis revealed that SII3 was an independent risk factor for postoperative pneumonia 30 days after surgery in ICH patients (OR=1.001, 95%CI: 1.000-1.002, P=0.008). The area under the curve (AUC) of the developed nomogram model was 0.895 (95%CI = 0.823 - 0.967), with a sensitivity and specificity of 0.903 and 0.815, respectively, providing good predictive power. ConclusionsIn the course of intracerebral hemorrhage, NLR, PLR, and SII increased and then decreased, and peaked at 48 hours postoperatively. The SII3 was the best predictor of the occurrence of pneumonia postoperatively in ICH patients.

Study of the association between anemia and prognosis of moderate-to-severe traumatic brain injury

Objective: To investigate the impact of admission anemia on the prognosis of patients with moderate- to-severe traumatic brain injury (TBI). Methods: The clinical data of patients with moderate-to-severe TBI treated in the Department of Intensive Care Unit in our hospital from January 2020 to September 2022 were retrospectively analyzed. The patients were divided into admission non-anemia group (Hb ≥ 100 g/L) and admission anemia group (Hb&lt;100 g/L) based on hemoglobin (Hb) levels. The Glasgow Coma Scale (GCS) score, first blood analysis, arterial blood gas, blood pressure, injury mechanism, pupillary reflex at admission and others were compared, multivariate logistic was used to analyse independent risk factors for patient death. Results: One hundred and nine patients were included in the study, of which 17 died in the hospital and 52 had anemia at admission. Compared with patients in the admission non-anemia group, patients in the admission anemia group were younger, had lower admission GCS and trauma score (PTS) scores, higher mortality rates, and longer hospital stay (all P&lt;0.05).Univariate analysis showed that moderate-to-severe TBI patients with admission anemia, admission hyperglycemia, GCS&lt;8, PTS&lt;8, abnormal pupillary reflex, and other organ injuries had higher mortality rates (all P&lt;0.05) .Multivariate logistic regression analysis showed that admission anemia (OR=9.383, 95% CI=1.086~81.094, P=0.042), admission pupillary reflex abnormalities (OR=23.121,95% CI=3.680~145.270,P=0.001), and admission hyperglycemia (OR=15.181, 95% CI=2.019~114.160, P=0.008) are independent risk factors for death of Moderate-to-severe TBI patients. Conclusions: Admission anemia is an independent risk factor for death of moderate-to-severe TBI patients, and it can prolong the length of hospital stay for such patients.

Abstract TP167: Hemorrhage Severity Associates With Hospital Acquired Delirium During Intracerebral Hemorrhage

Introduction: Delirium associates with poor outcome after intracerebral hemorrhage (ICH), yet its incidence and contributing factors are poorly characterized. We show delirium proportions among older ICH patients and identify factors that associate with hospital-acquired delirium (HAD). Methods: Data from older adult (≥70 years) patients with primary nontraumatic ICH were retrieved from electronic medical records. Delirium was assessed once every 12 hours or per shift using the modified Arousal, Attention, Abbreviated Mental Test-4, Acute change test. Delirium on admission (DOA) was defined as a positive screen within 48 hours of admission and HAD was defined as a positive screen among non-DOA patients. Population differences between HAD and non-HAD patients were assessed using Wilcoxon Rank Sum and Pearson’s Chi Squared tests. Factors associated with HAD were identified via multivariable logistic regression modelling. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported. Results: The cohort included 647 patients (median age: 79, interquartile range: [74-85]; 55.0% female) with an ethno-racial distribution of 57.6% White, 16.4% Black, 15.9% Hispanic, 8.5% Asian, and 1.6% Other. The median hemorrhage volume was 8.0 [1.6-24.7] cm 3 . DOA was present in 327 (50.5%) patients. Among patients without DOA (n=320), 90 (28.1%) developed HAD. In univariate analyses, patients with HAD (vs non-HAD) were significantly older and had lower admission Glasgow Coma Scale scores, larger hemorrhages volumes, more frequent intraventricular hemorrhage (IVH), and longer lengths of stay. In multivariable modelling, HAD was independently associated with older age (1.05 [1.01-1.10]), top-quartile hemorrhage volume (2.89 [1.08-7.75]), length of stay (1.14 [1.08-1.19]), and IVH (2.03 [1.08-1.19]) (Figure 1). Discussion: Older patients and those with more severe hemorrhage characteristics show greater odds of developing in-hospital delirium.

Venovenous extracorporeal membrane oxygenation in patients with traumatic brain injuries and severe respiratory failure: A single-center retrospective analysis.

Venovenous extracorporeal membrane oxygenation (VV ECMO) can support trauma patients with severe respiratory failure. Use in traumatic brain injury (TBI) may raise concerns of worsening complications from intracranial bleeding. However, VV ECMO can rapidly correct hypoxemia and hypercarbia, possibly preventing secondary brain injury. We hypothesize that adult trauma patients with TBI on VV ECMO have comparable survival with trauma patients without TBI. A single-center, retrospective cohort study involving review of electronic medical records of trauma admissions between July 1, 2014, and August 30, 2022, with discharge diagnosis of TBI who were placed on VV ECMO during their hospital course was performed. Seventy-five trauma patients were treated with VV ECMO; 36 (48%) had TBI. Of those with TBI, 19 (53%) had a hemorrhagic component. Survival was similar between patients with and without a TBI (72% vs. 64%, p = 0.45). Traumatic brain injury survivors had a higher admission Glasgow Coma Scale (7 vs. 3, p < 0.001) than nonsurvivors. Evaluation of prognostic scoring systems on initial head computed tomography demonstrated that TBI VV ECMO survivors were more likely to have a Rotterdam score of 2 (62% vs. 20%, p = 0.03) and no survivors had a Marshall score of ≥4. Twenty-nine patients (81%) had a repeat head computed tomography on VV ECMO with one incidence of expanding hematoma and one new focus of bleeding. Neither patient with a new/worsening bleed received anticoagulation. Survivors demonstrated favorable neurologic outcomes at discharge and outpatient follow-up, based on their mean Rancho Los Amigos Scale (6.5; SD, 1.2), median Cerebral Performance Category (2; interquartile range, 1-2), and median Glasgow Outcome Scale-Extended (7.5; interquartile range, 7-8). In this series, the majority of TBI patients survived and had good neurologic outcomes despite a low admission Glasgow Coma Scale. Venovenous extracorporeal membrane oxygenation may minimize secondary brain injury and may be considered in select patients with TBI. Prognostic and Epidemiological; Level IV.

Machine learning algorithms for predicting outcomes of traumatic brain injury: A systematic review and meta-analysis.

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. The use of machine learning (ML) has emerged as a key advancement in TBI management. This study aimed to identify ML models with demonstrated effectiveness in predicting TBI outcomes. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. In total, 15 articles were identified using the search strategy. Patient demographics, clinical status, ML outcome variables, and predictive characteristics were extracted. A small meta-analysis of mortality prediction was performed, and a meta-analysis of diagnostic accuracy was conducted for ML algorithms used across multiple studies. ML algorithms including support vector machine (SVM), artificial neural networks (ANN), random forest, and Naïve Bayes were compared to logistic regression (LR). Thirteen studies found significant improvement in prognostic capability using ML versus LR. The accuracy of the above algorithms was consistently over 80% when predicting mortality and unfavorable outcome measured by Glasgow Outcome Scale. Receiver operating characteristic curves analyzing the sensitivity of ANN, SVM, decision tree, and LR demonstrated consistent findings across studies. Lower admission Glasgow Coma Scale (GCS), older age, elevated serum acid, and abnormal glucose were associated with increased adverse outcomes and had the most significant impact on ML algorithms. ML algorithms were stronger than traditional regression models in predicting adverse outcomes. Admission GCS, age, and serum metabolites all have strong predictive power when used with ML and should be considered important components of TBI risk stratification.

Care pathways and factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe traumatic brain injury: a population-based study from the Norwegian trauma registry

BackgroundSystems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals.MethodsA population-based cohort study from the national Norwegian Trauma Registry (2015–2020) of adult patients (≥ 16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head ≥ 3, AIS Body < 3 and maximum 1 AIS Body = 2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability.ResultsThe study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P < 0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P < 0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤ 13: 55% vs. 27, P < 0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients < 77 years, and increasing NISSs until the effect was inverted at higher scores. Decreased transfer probability was significantly associated with increasing age and comorbidity, and distance between the acute care trauma hospital and the nearest neurotrauma center, except for extreme NISSs.ConclusionsAcute care trauma hospitals managed a substantial burden of isolated moderate-to-severe TBI patients primarily and definitively, highlighting the importance of high-quality neurotrauma care in non-neurosurgical hospitals. The transfer probability declined with increasing age and comorbidity, suggesting that older patients were carefully selected for transfer to specialized care.

Neurosurgical Consequences of e-Scooter Use: Strategies to Prevent Neurological Injury.

Rideshare electric scooter accidents have led to increasing emergency department (ED) visits and neurosurgical consultations. This study categorizes e-scooter-related injuries requiring neurosurgical consultation at a single level 1 trauma center. Patients who required neurosurgical consultation from June 2019 to June 2021 with a positive finding on computed tomography imaging were selected for review of patient and injury characteristics, resulting in a sample size of 50 cases. Average patient age was 36.9 (15-69) years, and 70% were male. Seventy-four percent of patients were under the influence of alcohol and 12% illicit drugs. None (0%) were helmeted. Seventy-eight percent of accidents occurred between 6:00 pm and 6:00 am. Twenty-two percent of patients required surgical intervention by craniotomy/craniectomy, and 4% required intracranial pressure monitor placement. Average intracranial hemorrhage volume was 17.8 cc (trace to 125). Volume of hemorrhage was associated with the need for an intensive care unit (ICU) stay (odds ratio [OR] = 1.01; p = 0.04), need for surgical intervention (OR = 1.007; p = 0.0001), and mortality (1.816; p < 0.001) and trended toward, but did not reach significance for, overall poor outcome (OR = 1.63; p = 0.06). Sixty-two percent of this patient pool required ICU admission. Average length of ICU stay was 3.5 days (0-35), and average length of hospital stay was 8.3 days (0-82). Mortality in this series was 8%. Lower admission Glasgow Coma Scale (OR = 0.974; p < 0.001) and increased volume of hemorrhage (OR = 1.816; p < 0.001) were associated with increased risk of mortality in the linear regression analysis. Electric scooters have become prevalent in most urban centers, and accidents are a potential source of severe intracranial injury requiring extended ICU and hospital stays, surgical intervention, and sometimes resulting in long-term morbidity and/or mortality. Injuries often occur in the evening hours and are often associated with alcohol/drug use and lack of helmet use. Policy changes to help mitigate the risk of these injuries are recommended.

Minimal Invasive Surgery for Chronic Subdural Hematoma

Objective: To assess significant improvement in terms of the Glasgow Coma Scale in patients subjected to minimally invasive surgery for a chronic subdural hematoma.&#x0D; Materials and Methods: A total of 80 patients with chronic subdural hematoma (CSDH) were enrolled in a sequential fashion using a retrospective study design. The patients were treated with minimally invasive surgery (MIS) and assessed at the end of the 2nd postoperative day (POD) for any significant improvement in the Glasgow coma scale (GCS).&#x0D; Results: There were 76.25% male and 23.75% female patients. A maximum number of patients (42.5%) were found with a GCS ranging from 9/15 – 11/15 (Class B) followed by Class A having GCS 12-13 (36.25%) and then Class C with GCS 5 – 8 (21.25% patients). In 86.2% and 13.7&amp; of the patients, positive and negative outcomes were recorded. Maximum favorable surgical outcome was observed in 51-60 years of age group. In the majority of male patients, a favorable surgical outcome was reported. Similarly, a favorable surgical outcome was observed in Class B (GCS 9-11). There existed an insignificant difference between favorable surgical outcome vs. age groups, gender, and GCS class at baseline.&#x0D; Conclusion: This study found that CSDH using the MIS approach is linked to a high frequency of positive outcomes in terms of GCS improvement. A lower admission GCS score and older age are linked to a lower frequency of favorable outcomes and a higher likelihood of bad outcomes.

Clinical Deterioration and Neurocritical Care Utilization in Pediatric Patients With Glasgow Coma Scale Score of 9-13 After Traumatic Brain Injury: Associations With Patient and Injury Characteristics.

To define the clinical characteristics of hospitalized children with moderate traumatic brain injury and identify factors associated with deterioration to severe traumatic brain injury. Retrospective cohort study. Tertiary Children's Hospital with Level 1 Trauma Center designation. Inpatient children less than 18 years old with an International Classification of Diseases code for traumatic brain injury and an admission Glasgow Coma Scale score of 9-13. We queried the National Trauma Data Bank for our institutional data and identified 177 patients with moderate traumatic brain injury from 2010 to 2017. These patients were then linked to the electronic health record to obtain baseline and injury characteristics, laboratory data, serial Glasgow Coma Scale scores, CT findings, and neurocritical care interventions. Clinical deterioration was defined as greater than or equal to 2 recorded values of Glasgow Coma Scale scores less than or equal to 8 during the first 48 hours of hospitalization. Thirty-seven patients experienced deterioration. Children who deteriorated were more likely to require intubation (73% vs 26%), have generalized edema, subdural hematoma, or contusion on CT scan (30% vs 8%, 57% vs 37%, 35% vs 16%, respectively), receive hypertonic saline (38% vs 7%), undergo intracranial pressure monitoring (24% vs 0%), were more likely to be transferred to inpatient rehabilitation following hospital discharge (32% vs 5%), and incur greater costs of care ($25,568 vs $10,724) (all p < 0.01). There was no mortality in this cohort. Multivariable regression demonstrated that a higher Injury Severity Score, a higher initial international normalized ratio, and a lower admission Glasgow Coma Scale score were associated with deterioration to severe traumatic brain injury in the first 48 hours (p < 0.05 for all). A substantial subset of children (21%) presenting with moderate traumatic brain injury at a Level 1 pediatric trauma center experienced deterioration in the first 48 hours, requiring additional resource utilization associated with increased cost of care. Deterioration was independently associated with an increased international normalized ratio higher Injury Severity Score, and a lower admission Glasgow Coma Scale score.

Coagulopathy and its effect on treatment and mortality in patients with traumatic intracranial hemorrhage

BackgroundThe role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality.MethodsAn observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count < 100 E9/L), international normalized ratio > 1.2, or thromboplastin time < 60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality.ResultsOf our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p < 0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy.ConclusionsCoagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.

A Comparison of Prehospital Nonphysician and Hospital Physician Placed Tube Thoracostomy.

Prehospital chest decompression can be a lifesaving procedure in severe chest trauma. Studies investigating prehospital chest decompression are mostly European where physicians are assigned to prehospital care units. This report is one of the first to compare demographics and outcomes in patients undergoing prehospital chest decompression by trained aeromedical nonphysician personnel to hospital chest decompression by physicians. Prehospital tube thoracostomy (PTT) patients were identified from January 2014 to January 2019 and were matched in a 1:2 ratio based on age, Injury Severity Score (ISS), and chest Abbreviated Injury Score (AIS) to patients who underwent hospital tube thoracostomy (HTT) within 24 hours of admission. Forty-nine PTT patients were matched to 98 HTT patients. PTT patients had lower admission Glasgow Coma Scale (GCS), a higher rate of pre-chest tube needle decompression, and higher level 1 trauma activation. PTT were placed sooner (21.9 vs 157.0 minutes, P < .001). Rates of tube malposition, organ injury, tube dislodgement, empyema, and hospital-acquired pneumonia over the course of hospital admission were not significantly different between the 2 groups. PTT patients had longer intensive care unit length of stay (LOS), but similar hospital LOS, and overall mortality. This report demonstrates that PTT is performed sooner than hospital placed tubes. Complication rates associated with tube thoracostomy and patient outcomes were not statistically different between PTT and HTT groups.

Natural History of Infratentorial Intracerebral Hemorrhages: Two Subgroups with Distinct Presentations and Outcomes

Background/ObjectiveInfratentorial intracerebral hemorrhage (ICH) is associated with worse prognosis than supratentorial ICH; however, infratentorial ICH is often excluded or underrepresented in clinical trials of ICH. We sought to evaluate the natural history of infratentorial ICH stratified by brainstem or cerebellar location using a prospective observational study inclusive of all spontaneous ICH. MethodsUsing a prospective, single center cohort of patients with spontaneous ICH between 2008-2019, we conducted a descriptive analysis of baseline demographics, severity of injury scores, and long-term functional outcomes of infratentorial ICH stratified by cerebellar or brainstem location. ResultsInfratentorial ICH occurred in 82 (13%) of 632 patients in our ICH cohort. Among infratentorial ICH, cerebellar ICH occurred in 45 (55%) and brainstem ICH occurred in 37 (45%). Compared to cerebellar ICH, patients with brainstem ICH had significantly worse severity of injury scores, including lower admission Glasgow Coma Scale (median 14 [7.0 – 15.0] versus 4 [3.0 – 8.0], respectively; P < 0.001) and higher ICH Score (median 2 [1.0 – 3.0] versus 3 [2.75 – 4.0], respectively; P = 0.02). Patients with cerebellar ICH were more likely to be discharged home or to acute rehabilitation (OR 4.8, 95% CI 1.8 – 12.8) but there was no difference in in-hospital mortality (OR 0.4, 95% CI 0.1 – 1.1, P = 0.08) or cause of death (P = 0.5). Modified Rankin Scale scores at 3 months were significantly better in patients with cerebellar ICH compared to brainstem ICH (median 3.5 [1.8 - 6.0] versus median 6 [5.0 - 6.0], P = 0.03). ConclusionsLocation of infratentorial ICH is an important determinant of admission severity and clinical outcome in unselected patients with ICH. Patients with cerebellar ICH have less severe symptoms at presentation and more favorable functional outcomes compared to patients with brainstem ICH.

Initial leucocytosis and other significant indicators of poor outcome in severe traumatic brain injury: an observational study

BackgroundGlobally, severe traumatic brain injury (TBI) has been the principal cause of mortality among individuals aged 45 and below. The incidence of road traffic accidents in Malaysia is one of the highest in the world with thousands of victims sustaining severe disabilities. The aim of this study is to determine the association between leucocytosis and extended Glasgow Outcome Scale (GOSE) scores as well the relationship of other factors and the outcomes of severe TBI.MethodsThis was a retrospective observational study. A total of 44 consecutive patients who were admitted to Sarawak General Hospital from January 1, 2018, to September 30, 2018, with severe TBI were included. Data were collected from discharge summaries and hospital medical records. Chi-square and t test were used. SPSS was employed.ResultsOf a total of 44 patients with severe TBI, 18 patients (41%) died during the same admission. The mean age of patients was 37.1 years with 93.2% of affected patients being male. 56.9% of patients presented with a Glasgow Coma Scale (GCS) of 6 and less. A large percentage (86.3%) were discharged with a GOSE of less than 7. Older age and low admission GCS (6 and less) were significantly associated with poor GOSE scores on discharge and after 6 months (p < 0.05) on multivariate analysis. Leucocytosis on admission was also associated with poor outcomes where patients with higher total white counts on presentation attaining lower GOSE scores (p < 0.05).ConclusionWe concluded that leucocytosis was significantly associated with poor outcomes in severe TBI patients in addition to other factors such as advanced age and poor GCS on arrival.

Transcalvarial brain herniation volume as a predictor of posttraumatic hydrocephalus after decompressive craniectomy

ObjectivesIn patients undergoing decompressive craniectomy for traumatic brain injury(TBI) there has been reported an incidence of hydrocephalus between 0–45%. There are several radiological and clinical features described in association with development of hydrocephalus. For study the influence of these factors we conducted a retrospective observational single-center cohort study in a tertiary care center with special attention to the transcalvarial herniation(TCH) volume after decompressive craniectomy.Patients and methods: We selected 50 patients that underwent decompressive craniectomy after closed head injury between january 2014 and January 2015. Hydrocephalus was defined as a modified frontal horn index greater than 33%, presence of Gudeman CT scan criteria or insertion of ventriculoperitoneal Shunt. Variables analyzed were: age, post-resuscitation Glasgow coma scale (GCS) score, pupil reactivity, Zunkeller index, presence of hygroma, TCH volume, craniectomy diameter and distance of craniectomy from midline. Logistic regression was used with hydrocephalus as the primary outcome measure. Results17 patients developed hydrocephalus (34%). TCH volume after decompression(p < 0.01), subdural hygroma (p < 0.01), lower admission Glasgow Coma Scale score (p = 0.015), unilateral pupil reactivity(p = 0.042) and higher Zumkeller index(p = 0.044) were significant risk factors for hydrocephalus. Logistic regression analysis showed that factors independently associated with the development of hydrocephalus was the TCH volume (odds ratio 11.08; 95%CI 2.10, 58.4; p = 0.0046), and presence of hygroma (odds ratio 49.59; 95%IC 4.1, 459; p = 0.002). ConclusionsThere was a clear association between severity of TBI, TCH volume and subdural hygroma with the development of hydrocephalus. Clinicians should follow closely patients with those findings in order to avoid late deterioration.

Significance of Cardiac Troponin I Elevation in Traumatic Brain Injury Patients.

BackgroundMyocardial dysfunction is frequently described as an underlying cause of mortality in traumatic brain injury (TBI) known as brain-cardiac link. However the impact on prognosis of a disease remains uncertain.ObjectivesThe current study aimed at investigating the correlation between TBI and cardiac troponin I (cTnI) rise and in-hospital mortality rate among patients with TBI.MethodsIn the current prospective study TBI patients with abbreviated injury scale score (AIS) > 3 and Glasgow coma scale (GCS) score ≤ 8 with cTnI measurement within the first 24 hours of admission were evaluated. Chi-square, Kruskal-Wallis, Mann-Whitney U and Logistic Regression tests were used for data analysis.ResultsA total of 166 eligible patients were studied .The mean age of the cases was 37.64 ± 17.21 years, largely under 65 (93.4%) and male (86.7%).The most common injuries were cerebral contusion (35.1%), while motor vehicle crash (MVC) was the most common cause of injuries (83.73%); 59 % of the patients showed detectable cTnI concentrations within 24 hours of admission; 65.7% of the patients expired; they showed higher levels of cTnI compared to survivors that showed lower levels, 0.148 ± 0.074 vs 0.057 ± 0.055, respectively (P < 0.001). Moreover, a significant association was observed between mortality rate and lower admission GCS 3.49 ± 1.08 vs 6.79 ± 1.66, respectively (P < 0.001).ConclusionsIncreased cTnI levels could be a predictor of mortality among patients with TBI. Its measurement and investigation for therapeutic strategies could lead to better management of these cases.

Abstract WP438: Hematoma Expansion and Outcomes in Vitamin K versus Non-Vitamin K Antagonist Oral Anticoagulation Related Intracerebral Hemorrhages

Background: There is mounting evidence that functional outcome after intracranial hemorrhage (ICH) related to non-vitamin K antagonist oral anticoagulation (NOAC-ICH) is similar if not better as compared to vitamin K antagonist (VKA)-related ICH (VKA-ICH). This has been partially attributed to a smaller initial hematoma volume (HV). However, the association with other hematoma characteristics such as hematoma expansion (HE) are not well understood. Methods: We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to compare HV and HE, and their relation to the 90-day modified Rankin scale (mRS) score. Results: A specific reversal agent was used in 72 (93.5%) VKA-ICH versus two (8%) NOAC-ICH. In unadjusted analyses, VKA-ICH (n=77) and NOAC ICH (n=25) had a similar admission HV (p&gt;0.05) and HE (p&gt;0.05), and NOAC-ICH patients more frequently had lower 90-day mRS scores than VKA-ICH patients (p=0.017). After adjustment, an unfavorable 90-day functional outcome (mRS 4-6) was independently associated with lower admission Glasgow coma scale score (OR 1.63; 95%-CI 1.26-2.10; p&lt;0.001) and greater HV (OR 1.03; 95%-CI 1.00-1.05; p=0.046), but not the oral anticoagulant strategy (OR 2.85; 95%-CI 0.69-11.86; p=0.15). After exclusion of patients without follow-up head CT to allow for adjustment by the HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95%-CI 1.01-13.09; p=0.048). Conclusions: Our observations support the notion that NOAC does not relate to a worse ICH extent and post-ICH functional outcome, information that may aid clinical decision making if confirmed in prospective studies.

Clinical and Radiological Characteristics of Vitamin K Versus Non-Vitamin K Antagonist Oral Anticoagulation-Related Intracerebral Hemorrhage

Recent studies indicated that functional outcome after intracranial hemorrhage (ICH) related to direct oral anticoagulation (DOAC-ICH) is similar, if not better, than vitamin K antagonist (VKA)-related ICH (VKA-ICH) due to a smaller initial hematoma volume (HV). However, the association with hematoma expansion (HE) and location is not well understood. We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to determine HV and HE stratified by hematoma location, and the relation to the 90-day outcome. DOAC-ICH (n = 25) and VKA-ICH (n = 77) had a similar admission HV and HE (unadjusted p > 0.05, each). Targeted reversal strategies were used in 93.5% of VKA-ICH versus 8% of DOAC-ICH. After adjustment, an unfavorable 90-day functional outcome (modified Rankin scale score 4-6) was independently associated with alower admission Glasgow Coma Scale score (OR 1.63; 95% CI 1.26-2.10; p < 0.001) and greater HV (OR 1.03; 95% confidence interval (CI) 1.00-1.05; p = 0.046). After exclusion of patients without follow-up head computed tomography to allow for adjustment by occurrence of HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95% CI 1.01-13.09; p = 0.048). However, there was no significant association of the oral anticoagulant strategy with 90-day outcome in the entire cohort (OR 2.85; 95% CI 0.69-11.86; p = 0.15). DOAC use did not relate to worse HE, HV, and functional outcome after ICH, adding to the notion that DOAC is a safe alternative to VKA even in the absence of access to targeted reversal strategies (which are still not universally available).

Prescription patterns for routine EEG ordering in patients with intracranial hemorrhage admitted to a neurointensive care unit

PurposeTo examine clinical factors, including established electroencephalography (EEG) consensus recommendations, that may influence EEG-prescription in critically-ill intracerebral hemorrhage (ICH) patients in the neurointensive care unit. MethodsRetrospective analysis of 330 ICH patients admitted to a neurointensive care unit at an academic medical center between 01/2013–12/2015. We compared EEG prescription patterns with current EEG consensus recommendations, and employed univariate and multivariable logistic regression modeling to determine clinical variables associated with EEG ordering. ResultsSeventy-eight (41%) of 190 subjects underwent EEG in accordance with EEG-consensus guidelines, demonstrating an overall accuracy (probability that EEG prescription aligned with EEG consensus recommendations) of 64.6% (95%-CI59.1–69.7). Factors independently associated with EEG ordering included fulfillment of EEG consensus recommendations, lower admission Glasgow Coma Scale (GCS), and presence of clinical seizures. The unadjusted and adjusted C-statistics for fulfillment of consensus recommendations was 0.74 (95%-CI 0.69–0.80) and 0.85 (95%-CI 0.81–0.90), respectively. Among 83 subjects undergoing EEG (25.2%), EEG findings informed clinical decision-making in 50 patients (60%). ConclusionsEEG appeared underused in ICH, since <50% of patients who fulfilled guideline criteria underwent EEG. Prescription of EEG was related to factors beyond those included in consensus recommendations. Validation of our findings and their association with outcome is required.

17p12 Influences Hematoma Volume and Outcome in Spontaneous Intracerebral Hemorrhage.

Hematoma volume is an important determinant of clinical outcome in spontaneous intracerebral hemorrhage (ICH). We performed a genome-wide association study (GWAS) of hematoma volume with the aim of identifying novel biological pathways involved in the pathophysiology of primary brain injury in ICH. We conducted a 2-stage (discovery and replication) case-only genome-wide association study in patients with ICH of European ancestry. We utilized the admission head computed tomography to calculate hematoma volume via semiautomated computer-assisted technique. After quality control and imputation, 7 million genetic variants were available for association testing with ICH volume, which was performed separately in lobar and nonlobar ICH cases using linear regression. Signals with P<5×10-8 were pursued in replication and tested for association with admission Glasgow coma scale and 3-month post-ICH dichotomized (0-2 versus 3-6) modified Rankin Scale using ordinal and logistic regression, respectively. The discovery phase included 394 ICH cases (228 lobar and 166 nonlobar) and identified 2 susceptibility loci: a genomic region on 22q13 encompassing PARVB (top single-nucleotide polymorphism rs9614326: β, 1.84; SE, 0.32; P=4.4×10-8) for lobar ICH volume and an intergenic region overlying numerous copy number variants on 17p12 (top single-nucleotide polymorphism rs11655160: β, 0.95; SE, 0.17; P=4.3×10-8) for nonlobar ICH volume. The replication included 240 ICH cases (71 lobar and 169 nonlobar) and corroborated the association for 17p12 (P=0.04; meta-analysis P=2.5×10-9; heterogeneity, P=0.16) but not for 22q13 (P=0.49). In multivariable analysis, rs11655160 was also associated with lower admission Glasgow coma scale (odds ratio, 0.17; P=0.004) and increased risk of poor 3-month modified Rankin Scale (odds ratio, 1.94; P=0.045). We identified 17p12 as a novel susceptibility risk locus for hematoma volume, clinical severity, and functional outcome in nonlobar ICH. Replication in other ethnicities and follow-up translational studies are needed to elucidate the mechanism mediating the observed association.

Stroke in-hospital survival and its predictors: the first results from Tabriz Stroke Registry of Iran.

ObjectiveThe aim of this study was to determine the in-hospital survival of patients referred to the 2 stroke centers in North-West of Iran during a full seasonal year from April 2015.MethodsAll the consecutive patients with stroke admitted to the 2 main stroke centers at Tabriz (Imam Reza University Hospital and Razi University Hospital) were recruited in this study. Stroke patients from both ischemic and hemorrhagic subtypes were selected based on the registry data and International Classification of Diseases, 10th edition. At admission, details of examination including vital signs, neurologic and systemic examination, Modified Rankin Scale, and Glasgow Coma Scale were recorded. Baseline hematological and biochemical parameter assessments as well as computerized tomographic scanning were conducted. Cox regression was used to investigate and detect potential predictors of in-hospital survival.ResultsA total of 1,990 patients with stroke were studied. Males comprised 52.1% (1,036) of the subjects. The mean age of the patients was 65.8 years. Three hundred and fifty-seven (17.9%) patients had hemorrhagic stroke vs 1,633 (82.1%) with ischemic stroke. In-hospital case-fatality proportion was 12.5% (95% CI: 11.1–14). Based on modified Rankin Scale score at admission, 1,377 of 1,990 patients (69.2%) had a poor outcome (modified Rankin Scale score ≥3) at the admission time. The regression analysis showed that at least 7 variables could independently predict hospital survival of patients with stroke including age ≥65 years, higher admission modified Rankin Scale score, lower admission Glasgow Coma Scale score, hemorrhagic stroke nature, diabetes, having valvular heart disease, and having aspiration pneumonia.ConclusionThe case-fatality of stroke in the present study setting is high and needs to be appropriately addressed through prevention or management of some of these factors such as diabetes, pneumonia, and valvular heart diseases.