Mean Glasgow Coma Scale Score Research Articles

Tracheostomy tube changes by speech-language pathologists: a service review of an expanded scope of practice

Background/Aims Patients in acute care who have received a tracheotomy require efficient management to adequately progress through the acute care setting. This progression is predicated on efficient tracheostomy weaning through tracheostomy downsizing, capping and decannulation. The objective of this retrospective study was to review the outcomes of tracheostomy tube changes by speech-language pathologists. Methods A retrospective cohort analysis was performed of adult patients who received a tracheostomy tube change during their acute care hospitalisation by speech-language pathologists during a 6-month span in 2022. A total of 38 consecutive referrals undergoing an initial tracheostomy tube change had their electronic medical records reviewed. Success was defined as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement with no adverse events. Complications were recorded at the time of the tracheostomy tube change. Results Speech-language pathologists performed 38 (100%) initial tracheostomy tube changes successfully at the bedside without complications. The primary referral services were trauma and neurology. The primary diagnoses were polytrauma with a traumatic brain injury and multiple trauma without a traumatic brain injury or spinal cord injury. The mean Glasgow Coma Scale score and number of intubations were 12.4 and 1.4 respectively. A total of 34 (89%) tracheostomy tube changes resulted in the downsizing of the tracheostomy tube, while the remainder of tracheostomy tube changes (n=4; 11%) maintained the same size but were cuffless. All the tracheostomy tube changes were completed without complications, and all patients were noted as stable after 24 hours. Conclusions The procedural success corroborates the data reported by an earlier study in the literature and further validates the efficacy of a competent and experienced speech-language pathologists' ability to perform low-risk tracheostomy tube changes in the acute setting. This study demonstrates real world data from a single large trauma centre of tracheostomy tube changes performed by speech-language pathologists. Such data better defines the emerging role expansion of speech-language pathologists in the acute care setting. Implications for practice This study has the potential to expand the discussion around speech-language pathologists changing tracheostomy tubes in the acute care setting for a low-risk cohort. The authors have outlined the requisite training that may serve as a resource for speech-language pathologists to develop procedural competency.

EFFACEMENT OF BASAL CISTERNS AS A SINGLE PROGNOSTIC FACTOR IN TRAUMATIC BRAIN INJURY

Effacement of basal cisterns, a condition characterized by the compression or obliteration of the cerebrospinal fluid (CSF)-filled spaces around the brainstem, is an essential radiological finding in the context of traumatic brain injury (TBI). Objectives: The study's primary purpose is to find the effacement of basal cisterns as a single prognostic factor in traumatic brain injury (TBI). Methods: This prospective observational study was conducted at the Pakistan Institute of Medical Sciences, Islamabad, from 2023 to 2023. Data were collected from 250 patients suffering from TBI. For each patient, comprehensive demographic information, including age and gender, was recorded. Additional data included the mechanism of injury, the Glasgow Coma Scale (GCS) score at admission, and the presence of basal cistern effacement as observed on the initial CT scan. Radiological findings, such as midline shift and hematomas, were also documented. Results: The mean age of the patients was 35.6±5.65 years. There were 160 (64%) male and 90 (36%) female patients. Motor vehicle accidents were the most present form of injury 104 (41.6%). The mean GCS score at admission was 7.5 ± 2.1 in the basal cistern group and 12.3 ± 2.8 in the no basal cistern group. The study results revealed a significant association between basal cistern effacement and midline shift, with 61.5% of patients with effacement showing midline shift compared to only 14.8% without effacement (p < 0.01). Conclusion: Basal cistern effacement on initial CT scans is a significant prognostic indicator in traumatic brain injury. Its presence is associated with more severe injury, higher necessity for surgical intervention, and poorer long-term outcomes.

In Search of the Truth: Choice of Ground Truth for Predictive Modeling of Trauma Team Activation in Pediatric Trauma.

Assigning trauma team activation (TTA) levels for trauma patients is a classification task that machine learning models can help optimize. However, performance is dependent on the "ground-truth" labels used for training. Our purpose was to investigate 2 ground truths, the Cribari matrix and the Need for Trauma Intervention (NFTI), for labeling training data. Data were retrospectively collected from the institutional trauma registry and electronic medical record, including all pediatric patients (age <18 years) who triggered a TTA (January 2014 to December 2021). Three ground truths were used to label training data: (1) Cribari (Injury Severity Score >15 = full activation), (2) NFTI (positive for any of 6 criteria = full activation), and (3) the union of Cribari+NFTI (either positive = full activation). Of 1,366 patients triaged by trained staff, 143 (10.47%) were considered undertriaged using Cribari, 210 (15.37%) using NFTI, and 273 (19.99%) using Cribari+NFTI. NFTI and Cribari+NFTI were more sensitive to undertriage in patients with penetrating mechanisms of injury (p = 0.006), specifically stab wounds (p = 0.014), compared with Cribari, but Cribari indicated overtriage in more patients who required prehospital airway management (p < 0.001), CPR (p = 0.017), and who had mean lower Glasgow Coma Scale scores on presentation (p < 0.001). The mortality rate was higher in the Cribari overtriage group (7.14%, n = 9) compared with NFTI and Cribari+NFTI (0.00%, n = 0, p = 0.005). To prioritize patient safety, Cribari+NFTI appears best for training a machine learning algorithm to predict the TTA level.

Predictive Factors for Regression versus Progression of Nonevacuated Posttraumatic Acute Extradural Hematoma.

Study Design This study was a retrospective study conducted from October 2020 to October 2022 on 106 posttraumatic patients with acute extradural hematomas (EDHs) who were initially planned for conservative treatment. 74 patients had spontaneous EDH regression (EDHR), while 32 patients developed EDH progression (EDHP) and were shifted for surgery. The two groups were statistically compared regarding the different demographic, clinical, and radiographic factors to identify the significant predictors for regression versus progression of acute posttraumatic EDH. Objectives Conventionally, urgent evacuation is the accepted management for EDH. However, several recent reports have described successful conservative management in selected patients. There are no adequate clues to verify patients who will have spontaneous EDHR from those at risk for EDHP and delayed surgery. The main objective of this study was to identify the significant predictors for possible regression versus progression of acute posttraumatic EDH initially planned for nonsurgical treatment. Materials and Methods A retrospective study conducted over 2 years, included 106 head trauma patients with acute EDH, who were admitted to our department and were initially planned for conservative treatment. Various demographic, clinical, and radiographic factors were analyzed to verify the significant predictors for spontaneous EDHR (EDHR group) versus EDHP and subsequent surgical evacuation (EDHP group). Results The mean age was 20.37 ± 12.712 years and the mean Glasgow Coma Scale score (GCS) was 12.83 ± 2.113. Total 69.8% of patients showed spontaneous EDHR, while 30.2% developed EDHP and were shifted for surgical evacuation. Statistical comparison showed that higher GCS ( p = 0.002), frontal location ( p = 0.022), and concomitant fissure fracture ( p = 0.014) were the significant predictors for EDHR, while younger age ( p = 0.006), persistent nausea/vomiting ( p = 0.046), early computed tomography (CT) after trauma ( p = 0.021), temporal location ( p < 0.001), and coagulopathy ( p = 0.001) were significantly associated with EDHP. Conclusion Patients with traumatic EDH fitting the criteria of initial nonsurgical treatment necessitates 48 hours of close observation and serial CT scans at 6, 12, 24, and 48 hours to confirm the regression or early detect the EDHP. Patients with high GCS, frontal hematomas, and associated fissure fracture are at low risk for EDHP. Increased alertness is mandatory for young age and patients with persistent nausea/vomiting, early CT scan, temporal hematomas, or coagulopathy.

Outcome of Awake Craniotomy at a Tertiary Care Hospital

Objective: To evaluate the outcomes of awake craniotomy, in terms of complications and linguistic consequences at a tertiary care Hospital. Methodology: A prospective cohort study was done at department of Neurosurgery of PIMS Islamabad, from June 2023 to March 2023. Patients aged 18 years or above, both genders, diagnoses with brain tumors (both low and high-grade gliomas) and patients who already scheduled for Awake Craniotomy as per indications and Hospital protocols were included. Following surgery, all patients were moved to the intensive care unit for overnight assessment. During surgery, the operative time was recorded. Post-surgery, patients were monitored for neurological deficits, seizures, brain swelling, hospital stay and linguistic outcomes in terms of good, average and poor. All the relevant information was entered and analyzed via SPSS version 26. Results: Overall average age of the patients was 47.17+5.11 years, and their mean BMI was 29.12+2.96 kg/m2. Males were 16(40.0%) and females were 24 (60.0%). None of the patients found with neurological deficits or seizures, while brain swelling was observed in 23 patients (57.5%). Linguistic outcomes were uniformly positive, with all 40 patients (100%) reporting good outcomes. Mean operative time was 5.06 ± 0.80 hours, the mean Glasgow Coma Scale (GCS) score was 13.35 ± 1.20, and the average hospital stay was 6.32+1.84 days. Furthermore the brain swelling was statistically significant according to gender and operative time (p-&gt;0.05), while it was significantly high among patients with Grade II (Oligodendrogliomas) and with grade IV as pert he WHO grading (p-0.024). Conclusion: The awake craniotomy observed to be a reliable and easily tolerated method for brain tumor removal. Individuals who underwent this treatment reported no substantial neurological abnormalities or seizures, and almost all of the cases showed good linguistic outcomes.

Investigating the Diagnostic Significance of Neutrophil Percentage to Albumin Ratio (NPAR) in Patients with Infectious Meningitis

Background: Meningitis, characterized by inflammation of the meninges, typically presents with fever, headache, and neck rigidity. Despite the availability of numerous diagnostic techniques, determining the etiology of infectious meningitis remains challenging, often leading to diagnostic delays and increased mortality. The neutrophil percentage-to-albumin ratio (NPAR) is a novel biomarker for systemic infection and inflammation. Objective: To assess the neutrophil-to-albumin ratio in cases of infectious meningitis. Methods: Following REC approval (05/01/REC-206-2020), this cross-sectional study included 78 patients with clinical findings consistent with meningitis. Data on age, gender, fever, headache, neck rigidity, and Glasgow Coma Scale (GCS) were collected. NPAR was calculated by dividing the neutrophil percentage by serum albumin levels. Statistical analysis was performed using SPSS 22.0 for T-test (two-tailed) and Pearson Correlation. Results were presented as mean±SD (95% CI) with a significance level of p&lt;0.05. Results: The mean age of patients was 27 years. The mean GCS score was 11±1.59, serum albumin levels were 3.44±0.5 mg/dl, neutrophil percentage was 75.6±7.2%, and the neutrophil-to-albumin ratio (NPAR) was 0.22±0.03. Common symptoms such as fever, neck rigidity, and headache were present in all cases, while seizures were observed in 36 cases. Conclusion: The study indicated a significant correlation between elevated NPAR levels and cases of infectious meningitis, suggesting NPAR as a potential diagnostic marker.

Safety and Efficacy of Levetiracetam for Prevention of Epileptic Seizures in Acute Phase of Intracerebral Bleeding

Background: Epilepsy, characterized by recurrent, unprovoked seizures due to anomalous brain activity, is a significant complication for patients with intracerebral hemorrhage (ICH). The onset of epileptic convulsions during the acute phase of ICH can worsen the patient's prognosis and survival chances, making it crucial to identify a safe and effective method to prevent these seizures. Levetiracetam, a pyrrolidone derivative, is noted for its unique mechanism of action, exceptional tolerability, and advantageous pharmacokinetics, making it efficacious against various types of seizures. Objective: This study aims to evaluate the safety and efficacy of levetiracetam in preventing epileptic seizures during the acute phase of ICH and to determine its impact on neurological outcomes in this patient population. Methods: A cross-sectional investigation was conducted between October 2022 and June 2023 at Pak Emirates Military Hospital in Rawalpindi, Pakistan, involving 85 patients with spontaneous ICH confirmed by CT or MRI within 24 hours of symptom onset. Inclusion criteria included adult patients aged 18 or older, with various forms of ICH, excluding isolated subarachnoid hemorrhage, penetrating wound injury, depressed skull fracture, or early posttraumatic seizure. Patients with a Glasgow Coma Scale (GCS) score of less than 6, serum creatinine level &gt;1.7 mg/dL, history of psychosis, unprovoked seizures, cerebrovascular accidents, traumatic brain injuries, or encephalitis within the previous three years were excluded. Patients were administered an initial loading dose of levetiracetam (1,000 to 1,500 mg), followed by a maintenance dose (500 to 1,500 mg every 12 hours) based on renal function. Continuous electroencephalography (cEEG) monitoring was used to detect seizures for at least the first 72 hours of hospital admission. The primary outcome was the incidence of epileptic seizures during hospitalization, while the secondary outcome was the patient's neurological status at discharge, assessed using the Modified Rankin Scale (mRS). Data were analyzed using descriptive statistics and the Chi-square test, with a p-value of ≤0.05 considered statistically significant. Analyses were conducted using SPSS version 25. Results: The mean age of the patients was 47.89 years (SD=7.46), with 62.35% male and 37.65% female. The mean GCS score at admission was 10.52 (SD=2.13), and the mean volume of ICH was 17.5 ml (SD=3.4). At baseline, 2.35% of patients had GCS scores of 3-5, which improved to 0% after treatment. The percentage of patients with GCS scores of 13-15 increased from 65.88% to 83.52% (p=0.3730). Seizures within the first 7 days occurred in 10.58% of patients, and the overall seizure incidence during hospitalization was 20%. At discharge, 9.41% of patients had an mRS score of 0, and the percentage of patients with an mRS score of 2 increased significantly from 18.18% to 37.64% (p=0.4086*). The percentage of patients with severe disability (mRS score of 5) significantly decreased from 22.72% to 5.68% (p=0.0094*). Conclusion: Levetiracetam is effective in improving neurological outcomes and reducing the incidence of seizures in patients with acute intracerebral hemorrhage, with a manageable safety profile. These findings suggest that levetiracetam can be a valuable addition to therapeutic strategies for managing ICH-related seizures, potentially enhancing patient care and improving health outcomes.

Patient Factors Associated With Prolonged Length of Stay After Traumatic Brain Injury.

Background For traumatic brain injury (TBI) survivors, recovery can lead to significant time spent in the inpatient/rehabilitation settings. Hospital length of stay (LOS) after TBI is a crucial metric of resource utilization and treatment costs. Risk factors for prolonged LOS (PLOS) after TBI require further characterization. Methodology We conducted a retrospective analysis of patients with diagnosed TBI at an urban trauma center. PLOS was defined as the 95th percentile of the LOS of the cohort. Patients with and without PLOS were compared using clinical/injury factors. Analyses included descriptive statistics, non-parametric analyses, and multivariable logistic regression for PLOS status. Results The threshold for PLOS was >24 days. In the cohort of 1,343 patients, 77 had PLOS. PLOS was significantly associated with longer mean intensive care unit (ICU) stays (16.4 vs. 1.5 days), higher mean injury severity scores (18.6 vs. 13.8), lower mean Glasgow coma scale scores (11.3 vs. 13.7) and greater mean complication burden (0.7 vs. 0.1). PLOS patients were more likely to have moderate/severe TBI, Medicaid insurance, and were less likely to be discharged home.In the regression model, PLOS was associated with ICU stay, inpatient disposition, ventilator use, unplanned intubation, and inpatient alcohol withdrawal. Conclusions TBI patients with PLOS were more likely to have severe injuries, in-hospital complications, and Medicaid insurance. PLOS was predicted by ICU stay, intubation, alcohol withdrawal, and disposition to inpatient/post-acute care facilities. Efforts to reduce in-hospital complications and expedite discharge may reduce LOS and accompanying costs.Further validation of these results is needed from larger multicenter studies.

438 Lesion Combination on Susceptibility-Weighted MRI Predicts Functional Recovery After Diffuse Axonal Injury

INTRODUCTION: Early prediction of long-term functional outcome after diffuse axonal injury (DAI) remains controversial. METHODS: In a retrospective observational study, axonal injuries on MRI were correlated with long-term functional outcome. The predictive value of poor functional outcome (GOSE &lt; 5) was determined by ROC analysis for clinical factors and location of combinations of DAI lesions in the connectome. RESULTS: Over a 10-year period, 451 patients underwent MRI within 30 days of severe blunt TBI of which 322 (71.4%) survived to = 6-month clinical follow-up. The mean age was 38.4 and 242 (75%) patients were male. Mechanisms of injury were motor vehicle crash (53%) and falls (26%). Mean Glasgow coma scale (GCS) score was 4.7. At 6-24 months, quality MRI and functional outcome data were available for 213 and 104 patients, respectively. The best single-area predictors of early and late long-term functional outcome were the ventral midbrain (AUC6mo 0.65 (95% CI 0.56-0.74), p = 0.010) and dorsal pons (AUC24mo 0.68 (95% CI 0.51-0.86) p = 0.001). The best multiple-lesion predictors of poor long-term functional outcome (GOSE &lt; 5) were dorsal pons and splenium of corpus callosum (AUC24mo 0.92 (95% CI 0.84-0.99), p &lt; 0.0001) and the dorsal and ventral pons (AUC24mo 0.91 (95% CI 0.79-1.00), p &lt; 0.0001). The strength of these combinations’ predictive value was not improved by considering three or more areas. The 6-area cluster of internal capsule, corpus callosum genu, body, and splenium; and dorsal and ventral midbrain lesions was a good predictor of outcome at 24 months (AUC24mo 0.82 (95% CI 0.66-0.98), p &lt; 0.0001). CONCLUSIONS: In patients with severe TBI, the strongest predictors of poor long-term functional outcome were combined lesions in the splenium and dorsal pons and the dorsal and ventral pons.

Comparison of Full Outline of UnResponsiveness Score and Glasgow Coma Scale in Predicting the Outcome of Children aged 3 to12 Years with Altered Level of Consciousness Admitted to the Paediatric Intensive Care Unit

Introduction: The commonly used Glasgow Coma Scale (GCS) score for assessing consciousness has several shortcomings, especially in intubated patients. Recently, the Full Outline UnResponsive Score (FOUR) has been validated as an alternative to the GCS due to its additional benefits in evaluating brainstem reflexes and respiratory patterns. The use of the FOUR score can overcome the shortcomings of the GCS and aid in prognosticating patients with altered sensorium. Aim: To compare the FOUR score with GCS score to find a better scoring system for predicting outcomes among children aged 3-12 years with non-traumatic causes of Altered Level Of Consciousness (ALOC) in the hospital. Materials and Methods: A prospective cohort study was conducted on a total of 100 children with ALOC in the Paediatric Intensive Care Unit (PICU) of Gandhi Medical College and Hospital, Telangana, from December 2020 to November 2021. FOUR and GCS assessments were performed simultaneously within two hours of admission. For statistical analysis, continuous variables are expressed as mean±standard deviations. The predictive values of the GCS score and FOUR score were established using the Receiver Operating Characteristic (ROC) curve, by calculating the Area Under the Curve (AUC) with a 95% Confidence Interval (CI). Results: The mean age of the study population was 7.3±5.2 years, and the mean duration of hospital stay was 7.5±6.74 days. In-hospital mortality was 34%, and the survival rate was 66%. The mean FOUR score for in-hospital mortality and survival was 8.47±3.01 and 12.24±1.46, respectively (p-value &lt;0.001). The mean GCS scores were 11.35±1.64 in survivors and 7.45 ±2.63 in non-survivors (p-value &lt;0.001). A FOUR score of &lt;10 was associated with higher mortality than a FOUR score of &gt;10 (p&lt;00.05). The Area Under Curve (AUC) for the FOUR score was 0.862 with a 95% CI (0.774 to 0.95) in the ROC curve (p-value &lt;0.001), and for the GCS score, the AUC was 0.822 with a 95% CI (0.723 to 0.92) and p-value &lt;0.001. The FOUR Score has a higher AUC than the GCS in the ROC curve, indicating that the FOUR Score has better discrimination than the GCS in outcome assessment. Conclusion: FOUR score and GCS score were comparable for predicting outcomes in children with ALOC. However, the FOUR score showed better discrimination than the GCS; hence, the FOUR score can be used as an alternative tool to the GCS for prognosis.

Comparison of Secondary Ischaemia Incidence, Intracranial Pressure, and Cerebrovascular Reactivity Dynamics During Intrahospital Transportation of Severe TBI Patients.

A total of 153 severe TBI patients and 182 IT were included. The mean Glasgow Coma Scale (GCS) score was 6.7±2.1. ICP and arterial pressure were invasively monitored, and an improved pressure reactivity index (iPRx) was calculated from the measured parameters. Statistical analysis was done using Student's t-criterion and Wilcoxon criterion where appropriate. Perfusion computed tomography (PCT) revealed a neuroimaging PTCI pattern in all 153 severe TBI patients (100%). In 58 patients (37.9%), ischaemia extended to both hemispheres; in 95 patients (62.1%), it affected only one hemisphere. The mean ICP during IT was significantly higher (26.1±13.5 mm Hg, p<0.001) than before the IT (19.9±5.3 mm Hg). All patients had increased ICP, especially during vertical movement in an elevator (maximum 75.2 mm Hg). PTCI was detected in all severe TBI patients in coma. The IT of comatose severe TBI patients leads to a significant increase in ICP and iPRx.

Retrospective Observational Study of Patients With Subdural Hematoma Treated With Idarucizumab.

Use of anticoagulants is increasing with the aging of societies. The safe first-line drug is likely to be a direct oral anticoagulant (DOAC), but outcomes of treatment of traumatic brain injury (TBI) with anticoagulants are uncertain. Therefore, we examined the clinical effect of idarucizumab as reversal therapy in elderly patients with TBI who were treated with dabigatran. A retrospective multi-center observational study was performed in patients ≥65 years of age who developed acute traumatic subdural hematoma during treatment with dabigatran and underwent reversal therapy with idarucizumab. The items examined included patient background, neurological and imaging findings at arrival, course after admission, complications, and outcomes. A total of 23 patients were enrolled in the study. The patients had a mean age of 78.9 years. Cause of TBI was fall in 60.9% of the subjects. Mean Glasgow Coma Scale score at arrival was 8.7; anisocoria was present in 31.8% of cases. Exacerbation of consciousness was found in 30.4%, but only in 13.3% of subjects treated with idarucizumab before consciousness and imaging findings worsened. Dabigatran was discontinued in 81.8% of cases after hematoma development, with a mean withdrawal period of 12.1 days. The favorable outcome rate was 21.7%, and mortality was 39.1%. In multi-variate analysis, timing of idarucizumab administration was associated with a favorable outcome. There were ischemic complications in 3 cases (13.1%), and all three events occurred ≥7 days after administration of idarucizumab. These findings suggest that in cases that develop hematoma during treatment with dabigatran, it is important to administer idarucizumab early and restart dabigatran after conditions stabilize.

Discontinuation of Levetiracetam and Valproic Acid Due to Adverse Effects in Early Post-traumatic Seizure Prophylaxis.

Levetiracetam (LEV) and valproic acid (VPA) are two anti-epileptic drugs (AEDs) routinely used for post-traumatic seizure (PTS) prophylaxis at our institution. In our practice, VPA is used for its beneficial effects on behavioral agitation and headaches, but it is also associated with abnormal liver function tests (LFTs). Both medications may be associated with thrombocytopenia. There is less literature comparing the adverse effect profiles and discontinuation rates of LEV and VPA in the context of PTS prophylaxis. We conducted a quality improvement (QI) analysis to determine the safety of LEV and VPA for traumatic brain injury (TBI) patients at our institution. In particular, our QI analysis involved calculating the rates of discontinuation or change of drug regimen due to the adverse effects. Our QI analysis focused on patients treated for TBI at our institution during a six-year period. We recorded the AED usedand if the AED was discontinued or switched due to thrombocytopenia, behavioral agitation, headaches, or elevated LFTs (including elevated aspartate aminotransferase or alanine aminotransferase values). We also recorded the incidence of early PTS, defined as seizures within seven days of the TBI. Our QI analysis included patients with a mean age of approximately 49 years with nearly 75% males. The mean Glasgow Coma Scale (GCS) score was 12.88, with 73.11% of patients having a mild GCS. The three leading injury mechanisms were fall, assault, and motor vehicle collision. The three leading types of TBI were traumatic subarachnoid hemorrhage, subdural hematoma, and cerebral contusion. Among patients with no prior history of seizures, we found an early PTS incidence of 7.28%. For patients administered LEV and VPA, 0.11% (1/898) and 3.85% (4/104)had the medication discontinued or changed because of thrombocytopenia (p < 0.001), respectively. For patients on LEV, 4.01% (36/898) and 1.78% (16/898) had the medication discontinued or changed because of behavioral agitation and headaches, respectively. For patients on VPA, 2.88% (3/104) had the medication discontinued or changed because of hepatotoxicity. In total, 5.90% versus 6.73% (p > 0.5) of patients on LEV and VPA, respectively, had their medication regimens changed due to the adverse effects. The incidence of early PTS in our patients is within the range of what has been reported in the literature. The rate of discontinuation of LEV and VPA on account of adverse events is low in the context of PTS prophylaxis. Both medications had similar overall rates of discontinuation. VPA was discontinued more frequently than LEV due to thrombocytopenia, but discontinuation was not common in either case. LEV is associated with behavioral agitation and headaches, which makes VPA a desirable alternative for patients suffering from these symptoms.

Safe and time-saving treatment method for acute cerebellar infarction: Navigation-guided burr-hole aspiration - 6-years single center experience.

While patients with medically intractable acute cerebellar infarction typically undergo suboccipital craniectomy and removal of the infarcted tissue, this procedure is associated with long operating times and postoperative complications. This study aimed to investigate the effectiveness of minimally invasive navigationguided burr hole aspiration surgery for the treatment of acute cerebellar infarction. Between January 2015 and December 2021, 14 patients with acute cerebellar infarction, who underwent navigation-guided burr hole aspiration surgery, were enrolled in this study. The preoperative mean Glasgow Coma Scale (GCS) score was 12.7, and the postoperative mean GCS score was 14.3. The mean infarction volume was 34.3 cc at admission and 23.5 cc immediately following surgery. Seven days after surgery, the mean infarction volume was 15.6 cc. There were no surgery-related complications during the 6-month follow-up period and no evidence of clinical deterioration. The mean operation time from skin incision to catheter insertion was 28 min, with approximately an additional 13 min for extra-ventricular drainage. The mean Glasgow Outcome Scale score after 6 months was 4.8. Navigation-guided burr hole aspiration surgery is less time-consuming and invasive than conventional craniectomy, and is a safe and effective treatment option for acute cerebellar infarction in selected cases, with no surgery-related complication.

Correlation of Bleeding Volume and Cognitive Function Impairment in Hemorrhage Traumatic Brain Injury

Background/aim: Traumatic Brain Injury (TBI) is a neurological emergency. When a traumatic brain injury occurs, there will be short-term and long-term effects that will affect the brain. This study was aimed to determine the correlation of bleeding volume and cognitive function impairment in hemorrhagic traumatic brain injury. Method: This study uses data collection methods in the form of interviews with samples which will later be presented in the form of analytical observational study. Consecutive data collection on TBI patients in poly and unit room medical neurosurgery at Sanglah Hospital from August – Oktober 2021. The questionnaire used to cognitive function impairment with Montreal Cognitive Assessment version Indonesia (MoCA-INA). Data analysis using SPSS Version 23 for windows. Results: A total of 42 subjects were divided into normal and decreased cognitive function The patients’ mean age was average 29 (17-49) years old, Man 62%, cases epidural hemorrhagic 50 %, subdural 38% and intracerebral 12%, and their mean Glasgow Coma Scale score at admission was 11.5 ± 1.7 and significant with OR = 0.1 (95% CI = (0.02-0.4; p = 0.003) were. Lesions were predominantly localized to the frontal (14 lesions) and temporal (10 lesions) lobes. Lobe lesion volume did not correlate with cognitive function. The volume bleeding average 10.43 (1-40) significant with p= 0.016 (OR 5.2 (95% CI (1.3-19.7). Conclusion: Bleeding volume in hemorrhagic TBI increased five times in volume &gt; 10 mL and GCS 9-13 first times came emergency room significant increased 0.1 times decreased function cognitive. Keywords: sleep quality, non-vegetarian, diet, serotonin, vegetarian

The clinical and biomarker approach to predict sepsis mortality in pediatric patients

Background Sepsis is a leading cause of pediatric morbidity and mortality. The prevalence of sepsis mortality in Indonesia varies between 22.5 to 52%.&#x0D; Objective To identify the clinical criteria for predicting sepsis mortality and evaluate the performance of the PELOD-2 score.&#x0D; Methods This retrospective cohort study included pediatric patients admitted to the emergency department or pediatric intensive care unit (PICU) of Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from January 2015 to May 2020. Demographic characteristics (age and sex), clinical manifestations [nutritional status, presence of shock, need for intubation, source of infection, inotrope use, mean arterial pressure, pulse rate, respiratory rate, and Glasgow Coma Scale (GCS) score], laboratory [leukocyte, platelet, neutrophil, and lymphocyte counts, neutrophil-to-lymphocyte count ratio (NLCR), procalcitonin, C-reactive protein (CRP), and lactate profile], PELOD-2 score, and mortality data were recorded as outcomes.&#x0D; Results We analyzed data from 241 sepsis subjects. The overall mortality rate was 65%. Shock [OR 3.2 (95%CI 1.80 to -5.55, P&lt;0.001)], GCS &lt;9 [OR 2.4 (95%CI 1.30 to 4.23, P=0.005)], inotrope use [OR 3.1 (95%CI 1.74 to 5.5, P&lt;0.001)], CRP &gt;33.5 mg/L [OR 2.5 (95%CI 1.14 to 5.35, P=0.02)], and lactate level &gt;2.85 [OR 2.1 (95%CI 1.02 to 4.56, P=0.04)] were considered significant predictors of mortality. A PELOD-2 cut-off score of &gt;8 had optimal sensitivity (81.2%) and specificity (72.9%) to predict mortality, with an OR of 11.6 (95%CI 5.72 to 23.5, P&lt;0.001).&#x0D; Conclusion Shock, GCS score, inotrope use, CRP, and lactate level can serve as clinical biomarkers to predict mortality in pediatric sepsis. A PELOD-2 score of &gt;8 can predict mortality with reasonably good sensitivity and specificity.

Abstract Number ‐ 111: Endovascular embolization of traumatic vessel injury using n‐butyl cyanoacrylate: A case series

Introduction There is limited evidence on the use of N‐butyl cyanoacrylate (n‐BCA) liquid embolic in endovascular embolization of traumatic face and neck vessel injuries. We sought to investigate the safety and effectiveness of n‐BCA in treating traumatic vessel injuries. Methods In a prospectively maintained database, we retrospectively analyzed consecutive patients who presented with a vessel injury caused by either a penetrating or blunt injury in a large academic Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years with any vessel injury in the face and neck circulation. The primary endpoint was effectiveness of n‐BCA by immediate control of the active bleeding post‐embolization. Results A total of 10 patients required neuro‐endovascular embolization of traumatic vessel injury via n‐BCA. The mean age of patients was 41.10 (95%CI 28.41, 53.79), with a male predominance (n = 8, 80.0%). The mean Glasgow Coma Scale score on presentation was 10 (95% CI 6.20, 14.40). One patient had concomitant brain injury having subdural and subarachnoid hemorrhages. The mean score for Biffl classification was 5.00. Eight patients suffered penetrating gunshot wound injuries, and two patients suffered blunt injuries. Injured vessels included facial artery (n = 4, 40.0%), buccal branch artery (n = 2, 20.0%), internal maxillary artery (n = 2, 20.0%), cervical segment of the internal carotid artery (n = 1, 10.0%), and the V2 segment of the vertebral artery (n = 1, 10.0%). All patients were successfully treated with 2:1 n‐BCA to ethiodol with immediate extravasation control. Balloon guide catheter was used in 3 patients (30.0%). There was no recurrence of bleeding via vessel imaging or need for retreatment. One patient died in‐hospital (10.0%). Most patients were discharged home (n = 5, 50.0%), one discharged home with day rehab (n = 1, 10.0%), and one to an acute rehab facility (n = 1, 10.0%). One patient developed a right posterior cerebral artery territory infarct with hemorrhagic transformation post‐embolization. Conclusions To the best of our knowledge, this is the first study demonstrating the safety and effectiveness of n‐BCA liquid embolic in traumatic vessel injuries, especially penetrating gunshot wound injuries. Further research is needed to investigate the safety and efficacy in this population.

Correlation between Glasgow Coma Scale with central venous pressure and near-infrared spectroscopy in patients with acquired brain injury in the intensive care unit of Adam Malik Hospital Medan

Abstract Background Acquired brain injury (ABI) is caused by trauma or nontrauma to the brain after birth. Increased intracranial pressure in patients with traumatic or nontraumatic brain injury affects the cerebral perfusion pressure. After traumatic brain injury, there is an increase in air content in the brain and an increase in volume of blood flow to the brain, which can cause increased intracranial pressure, herniation of brain tissue, impaired cerebral perfusion, and brain damage. Most patients with traumatic brain injury die from uncontrolled increases in intracranial pressure. Near-infrared spectroscopy (NIRS) and central venous pressure (CVP) monitoring are also associated with cerebral perfusion. This study aimed to determine the relationship between the Glasgow Coma Scale (GCS) scores and CVP and NIRS values in patients with ABI. Methods This prospective analytical study used a cross-sectional design to compare GCS scores with CVP and NIRS values in patients with traumatic and nontraumatic brain injury in the intensive care unit (ICU) of Haji Adam Malik Hospital Medan. GCS, CVP, and NIRS descriptive data in patients with brain injury were presented in terms of mean and standard deviation if the data were normally distributed, or median (interquartile range) values if the data were not normally distributed. The relationship between GCS scores and CVP and NIRS values was assessed using the Pearson correlation test if the data were normally distributed, or the Spearman test if the data were not normally distributed. Results In this study, the mean GCS score and CVP values were 7.04 ± 2.69 and 5.63 ± 25.82 mmHg, respectively. The right tissue oxygen saturation (StO2) was 55.61% ± 18.72%, and the left StO2 was 57.57% ± 17.48% with normally distributed data. There was no correlation between GCS scores and CVP values (P = 0.829), and no correlation between moderate GCS scores and right and left StO2 (P = 0.343; P = 0.121); however, there was a significantly strong positive correlation between severe GCS scores and right and left StO2 (P = 0.028, r = 0.656; P = 0.005, r = 0.777). Conclusion There was no significant correlation between GCS scores and CVP values, and no correlation between moderate GCS scores and NIRS values; however, there was a significantly strong positive correlation between severe GCS scores and NIRS values in patients with ABI at the ICU of Haji Adam Malik Hospital Medan.

Clinical outcomes and prognostic factors of traumatic basal ganglia hematomas: A 4-year single-center study.

Traumatic basal ganglia hematomas (TBGH) are rare entities. They are situated in the deep cerebral parenchyma and have also been termed as intermediate coup contusions. Available literature is sparse with regards to the characteristics and prognosis of TBGH. We aim to share our experience in the management, outcomes, and prognostic factors of TBGH. A 4-year retrospective study which included all cases of TBGH, except dot contusions (<2 mL) and those with coagulopathies. Admission variables were correlated with Glasgow Outcome Scale score at discharge and 12 months. Thirty-two patients were analyzed. The mean age was 39.2 years. Two-thirds were due to road traffic accidents. Around 60% were severe head injuries. The mean Glasgow coma scale (GCS) score at presentation was 8.5. Twenty patients had moderate-to-severe hemiparesis. The mean hematoma volume was 18.1 mL. Associated traumatic intracranial lesions were seen in 28 cases. Only 7 patients (22%) underwent surgery. The mean follow-up was 17.4 months (range 14-34 months). The mortality rate was 12.5% (n = 4). Among the survivors, only 39% (n = 11) had good outcomes at discharge which showed modest improvement to 54% (n = 15) at 12 months. Our study noted that poor admission GCS scores, poor motor response, presence of significant hemiparesis, and larger hematoma volumes (>20 mL) correlated with poor outcomes at 12 months. The overall outcomes have been mostly unfavorable as observed in majority of studies due to deeper location of these hematomas, high proportion of severe head injuries, and high proportion of residual weakness in survivors.

Prevalence and independent predictors of in-hospital stroke among patients who developed acute alteration of consciousness in the medical intensive care unit: A retrospective case-control study.

In-hospital stroke is a serious event, associated with poor outcomes and high mortality. However, identifying signs of stroke may be more difficult in critically ill patients. This study investigated the prevalence and independent predictors of in-hospital stroke among patients with acute alteration of consciousness in the medical intensive care unit (MICU) who underwent subsequent brain computed tomography (CT). This retrospective study enrolled eligible patients during the period 2007 - 2017. The alterations researched were radiologically confirmed acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH). Of 4 360 patients, 113 underwent brain CT. Among these, 31% had AIS, while 15% had ICH. They had higher diastolic blood pressures and arterial pH than non-stroke patients. ICH patients had higher mean (standard deviation (SD) systolic blood pressures (152 (48) v. 129 (25) mmHg; p=0.01), lower mean (SD) Glasgow Coma Scale scores (4 (3) v. 7 (4); p=0.004), and more pupillary abnormalities (75% v. 9%; p<0.001) than AIS patients. AIS patients were older (65 (18) v. 57 (18) years; p=0.03), had more hypertension (60% v. 39%; p=0.04), and more commonly presented with the Babinski sign (26% v. 9%; p=0.04). Multivariate analysis found that pupillary abnormalities independently predicted ICH (adjusted odds ratio (aOR) 26.9; 95% CI 3.7 - 196.3; p=0.001). The Babinski sign (aOR 5.1; 95% CI 1.1 - 23.5; p=0.04) and alkalaemia (arterial pH >7.4; aOR 3.6; 95% CI 1.0 - 12.3; p=0.05) independently predicted AIS. Forty-six percent of the cohort had ICH or AIS. Both conditions had high mortality. The presence of pupillary abnormalities predicts ICH, whereas the Babinski sign and alkalaemia predict AIS. The present study reports that almost half (46%) of critically ill patients with alterations of consciousness had an acute stroke. Of these, two-thirds had an acute ischaemic stroke (AIS), and one-third had an intracranial haemorrhage (ICH). Multivariate analysis revealed that a pupillary abnormality was a predictor for ICH and the Babinski sign was identified as a predictor of AIS.