Outcome In Severe Head Injury Research Articles

Risk factor assessment and outcome analysis in elderly (≥60 years) patients of severe head injury

Background: Incidence of head injuries is rising all over the world. Only few studies have been performed regarding severe head injury in elderly people. We aimed to study the epidemiology, mode of injury, management, co-morbidity, associated injuries which affects the outcomes. Severe head injury is unconsciousness >6 hours and GCS 3-8. In India 6.63% of the total population above 60 years is considered elderly. Falls are the major contributor to TBI in elderly but in India RTA is still the main contributor. Outcomes of TBI, both in terms of mortality and function, are significantly worse in the elderly.Methods: Objective of this study was to find the risk factors affecting the outcome in severe head injury. This was a prospective study and carried on 56 patient in Department of surgery of M. L. N. Medical College, Prayagraj from September 2018 to September 2019.Results: Male were most commonly affected but the gender had no significant prognostic effect on outcome. RTA were the most common cause of head injury. GCS at admission was directly related to outcome. Bilateral non-reactive pupils had poor outcome. Type of hematoma and midline shift had also affected the outcome. Operated cases had better outcome than non-operated cases. Any associated injury with TBI had worsened the outcome in patient. Any co-morbid condition associated with brain injury had slower recovery and worsen the outcome. Overall mortality in this series was 64.28% and unfavourable outcome was 76.79%.Conclusions: Severe head injury in elderly people had worst outcome.

Early Survival of Comatose Patients after Severe Traumatic Brain Injury with the Dual Cannabinoid CB1/CB2 Receptor Agonist KN38-7271: A Randomized, Double-Blind, Placebo-Controlled Phase II Trial

BACKGROUND AND STUDY OBJECT: Despite many drug trials, no substance has yet been identified that improves the outcome of severe head injury. The dual cannabinoid CB1/CB2 receptor agonist KN38-7271 mediates potent neuroprotection in animal models. We describe here the first randomized, double-blind, prospective, placebo-controlled clinical phase IIa proof-of-concept trial to investigate the safety, pharmacokinetics, and potential efficacy of a cannabinoid receptor agonist in humans. Out of the 439, 97 comatose patients at 14 European neurosurgical centers met the inclusion criteria. KN38-7271 was administered within 4.5 hours of the injury, and the patients received 1000, 500 μg, or placebo. The primary analysis was pharmacokinetic; efficacy was measured by survival and by neurological improvement or deterioration 7 and 14 days and 1, 3, and 6 months after the injury. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were analyzed from start of treatment to end of day 7. Survival rates within 1 month of the injury were significantly better in the treatment groups than in the placebo group (high-dose, Kaplan-Meier difference on day 30 + 0.12 with p = 0.043; low-dose, difference +0.15 with p = 0.011) but this effect was not seen after 6 months. Critical ICP and CPP were less extreme and less frequent in the treatment group. There were no severe and no serious adverse effects that could be attributed to KN38-7271. KN38-7271 appeared beneficial in the acute early phase of the comatose patient after a head injury. Its use was safe and well tolerated by patients. These results may provide the basis for further phase II/III trials in larger study populations.

Factors predicting outcome in patients with severe head injury: Multivariate analysis

BackgroundOutcome prediction after severe head injury is of great clinical importance especially for countries like India for better targeting of limited healthcare resources. This study was undertaken to evaluate various factors as predictors of outcome in severe head injury. Patients and MethodsThis study is based on prospective analysis of 110 patients admitted over a period of one and half year with severe head injury. Patients with associated severe chest, abdominal or orthopedic trauma were excluded. Clinical outcome was evaluated at the time of discharge and after six months, according to Glasgow outcome score. ResultsRoad traffic accident was commonest (83.64%) mode of severe head injury. Only 5.71% of patients were following traffic rules. Increasing age of patients, hypoxia, low GCS and abnormal pupillary reflex were found to be significant predictors of adverse clinical outcome. Early operative intervention, when indicated as per CT findings, was significantly associated with favorable outcome. Greater degree of midline shift and effacement of Basal cisterns were associated with adverse outcome. ConclusionPredicting outcome is an assimilative and integrative process of various pre-injury, injury and post-injury variables. Strict enforcement of traffic rules can help us to save precious life. Hypoxia should be avoided on absolute basis. CT scan should be done on urgent basis to look for operable mass lesions.

Can glasgow score at discharge represent final outcome in severe head injury?

Background:Patients with head injury continue to improve over time and a minimum follow-up of six months is considered necessary to evaluate outcome. However, this may be difficult to assess due to lack of follow-up. It is also well known that operated patients who return for cranioplasty usually have the best outcome.Aims and Objectives:To assess the outcome following severe head injury using cranioplasty as a surrogate marker for good outcome.Materials and Methods:This was a retrospective study carried out from January 2009 to December 2010. All patients with severe head injury who underwent decompressive craniectomy (DC) in the study period were included. Patients who came back for cranioplasty in the same period were also included. Case records, imaging and follow up visit data from all patients were reviewed. Glasgow Coma Score (GCS) on admission and Glasgow Outcome Score (GOS) at discharge were assessed.Observations and Results:Of the 273 patients, 84.25% (n=230) were males and 15.75% (n= 43) were females. The mean age was 34.3 years (range 2-81 years, SD 16.817). The mean GCS on admission was 5.615 (range 3-8, SD 1.438). The in-hospital mortality was 54% (n=149). Good outcome (GOS of 4 or 5) at discharge was attained in 22% (n=60) patients. Sixty five patients returned for cranioplasty (with a GOS of 4 or 5) during the study period. There was no statistical difference in the number of patients discharged with good outcome and those coming back for cranioplasty in the study period (P>0.5). Patients who came back for cranioplasty were younger in age (mean age 28.815 years SD 13.396) with better admission GCS prior to DC (mean GCS 6.32 SD1.39).Conclusions:In operated severe head injury patients significant number of patients (24% in our study) have excellent outcome. However, insignificant number of patients had further improvement to GOS 4 or 5 (good outcome) from the time of initial discharge. This suggests that due to lack of intensive rehabilitative facilities, GOS at discharge may be representative of final outcome in the vast majority of cases of severe head injury in developing countries like India

An expected association between low haemoglobin and poor outcome in severe head injury and an insufficiently detailed multivariate analysis

I read with interest the paper by Sekhon and colleagues, ‘Association of hemoglobin concentration in critically ill patients with severe traumatic brain injury’ (July edition of Critical Care) [1]. Whilst the conclusion (‘mean 7-day haemoglobin concentration <90 g/L associated with increased hospital mortality in patients with severe traumatic brain injury’) is striking, it is plausible, if not likely, that both the haemoglobin defi cit and the observed mortality are dependent upon the severity of the initial injury, and therefore an association between these two might be expected. Given the lack of transfusion trigger and a target haemo globin concentration post-transfusion in this study, and a generous group upper limit of 90 g/L, would those patients with the lowest initial haemoglobin concen tration not be likely to stay below that threshold despite transfusion? Are not the most severe injuries also likely to be associated with a 7-day mean haemoglobin of less than 90 g/L? Injury severity was reportedly accounted for in the multivariate analysis, although the details of the model used were not given. What weighting was given to each variable, such as Glasgow Coma Scale, or CT appearance, and on what basis? Of note is the lack of information regarding other injuries, not just in the multivariate analysis but indeed the entire paper. Were only isolated head injuries considered or were polytrauma patients included in this study? To accept that more than an association exists between two variables - as implied - we must be satisfi ed of the validity of the multivariate analysis.

Severe head injury in the elderly: risk factor assessment and outcome analysis in a series of 100 consecutive patients at a Level 1 trauma centre

Incidence of head injuries is rising all over the world. Very few studies have been performed regarding severe head injury in the elderly. We aimed to study the epidemiology, mode of injury, clinical profile,management, complications and outcome in severe head injury occurring in the elderly (age e"60years). One hundred consecutive patients of severe head injury(GCSd" 8) admitted at a Level 1 trauma centre from 2006 through 2008 were retrospectively analysed. The cases were reviewed in the light of epidemiology, clinico-radiological findings, associated injuries, comorbidities, surgical intervention, post-operative complications and long-term outcome. Mean age was 63.5 years± 4.64(60-85 years, 74%male). Road traffic accident was the most common mode of injury(72%). Median GCS at admission was 5(range-3-8). CT scan revealed acute subdural hematoma in 53 (53%) patients, cerebral contusion in 53, SAH in 20, extradura hematoma in 10 and diffuse axonal injury in 11 patients. Associated comorbidities included DM in 17%, CAD in 10%, hypertension in 9%, alcoholic liver disease in 8%. Associated spinal injury was observed in 10%, abdominal solid organ injury in 5, pneumothorax in 6 patients. Eighty two patients underwent operative intervention. Remaining 18 patients were managed conservatively. Forty patients(40%) developed ventilator —associated pneumonia (VAP), meningitis(16%), septicemia(20%), coagulopathy(11%) and multi-organ dysfunction syndrome (MODS)(20%). Overall mortality was 70%. Follow up was available for 24 out of the 30 survivors (80%). Median GOS score for those patients who survived was 4(3–5) at 6m follow-up period was positively correlated with pre-admission GCS score (Correlation coefficient +0.78). Mean time interval from injury to intervention, associated comorbidities, associated spinal, orthopaedic and abdominal injury; traumatic SAH on CT head all were more common in patients with ultimate unfavourable outcome as compared to patients who survived and this difference was statistically significant (p value<0.05). Severe head injury in elderly carries a high mortality owing to associated comorbidities. Pre-admission GCS score bears a positive correlation to GOS score at 6 months followup. VAP with resultant septicemia is the foremost post-operative cause of death in severe head injury in the elderly. In this regard, there is a need for an integrated multi-modality multidepartmental dedicated teamwork.

Cranioplasty as a surrogate marker for excellent outcome in severe head injury

Outcome in severe head injury is difficult to assess due to lack of follow up. Operated patients who return for cranioplasty usually have the best outcome. The aim of this study was to assess outcome following severe head injury using cranioplasty as a surrogate marker. This was a retrospective study carried out from November 2008 to March 2010. All patients with severe head injury who underwent decompressive craniectomy (DC) or cranioplasty in the study period were included. Case records, imaging and follow up visit data from all patients were reviewed. Glasgow Coma Score on admission and Glasgow Outcome Score at discharge were assessed.Of the 273 patients, 84.25% (n=230) were male and 15.75% (n=43) were female. The mean age was 34.3 years (range 2–81 years SD 16.817). The mean GCS on admission was 5.615 (range 3–8, SD 1.438). The in-hospital mortality was 54% (n=149). GOS of 4 or 5 at discharge was attained in 22% (n=60) patients. Sixty five patients returned for cranioplasty during follow up. The M:F ratio (6.2:1) matched with the study cohort. However, the difference in mean age (28.815 years SD 13.396) and mean GCS on first admission of 6.323 (SD 1.393) were statistical significant. Therefore, at the very minimum, 65 patients (24%) of the study cohort had excellent outcome. In operated severe head injury patients significant number of patients (24% in our study) have excellent outcome. Also, cranioplasty can serve as a useful marker to assess outcome of operated severe head injury patients in an institution.

Clinical outcome of severe head injury in different protocol-driven therapies

In the past 5 years cerebral perfusion pressure (CPP) management has become mainstream in the treatment of severe head injuries. The American Association of Neurological Surgeons guidelines (2000) suggest that CPP should be maintained at least 70 mmHg; however, there is still debate about optimal CPP level. The purpose of this study is to evaluate the effectiveness of three widely used therapies: intracranial pressure (ICP)-targeted therapy, CPP-targeted therapy with CPP > 70 mmHg, and modified CPP-targeted therapy with CPP > 60 mmHg. The clinical procedures, complications, and patient outcomes are compared. Data including patient age, sex, initial Glasgow Coma Score (GCS), ICP, CPP, fluid status, amount of mannitol and vasopressor used, daily intake and output, complications, and clinical results were collected from 213 patients with severe head injuries over a 12-year period. Patients were categorized into three groups (ICP, CPP, modified CPP [mCPP]) according to treatment protocol used. Retrospective data collection was by chart review. The mortality rate was 28.6%, 14.3%, and 13.5% in groups ICP, CPP, and mCPP, respectively. Highest intake/output ratio, amount of vasopressor used, and pulmonary complication rates were seen in group CPP patients. Group mCPP patients showed the best clinical outcome and lowest complication rate. Though CPP-targeted therapy is the most recommended therapeutic protocol, our data showed that the outcome is as good in the mCPP-targeted group with CPP > 60 mmHg as in the CPP-targeted group, but complications are fewer in the mCPP group.

Clinical outcome of severe head injury using three different ICP and CPP protocol-driven therapies

In the past 5 years, cerebral perfusion pressure (CPP) management has become the standard in the treatment of severe head injuries. Guidelines published in 2000 suggest that CPP should be at least 70 mmHg; however, there is still debate about the optimal CPP. The purpose of the present study was to evaluate the effectiveness of these three widely used therapies: (i) intracranial pressure (ICP) targeted; (ii) CPP-targeted with CPP >70 mmHg; and (iii) modified CPP-targeted (mCPP) therapy with CPP >60 mmHg. The clinical procedures, complications and outcomes of patients in the different groups were compared. Data, including patient age, sex, initial Glasgow Coma Scale, ICP, CPP, fluid status, amount of mannitol and vasopressor used, daily fluid intake and output, complications and clinical results, were collected from 213 patients with severe head injuries over a 12-year period. Patients were categorized into three groups (ICP, CPP, mCPP) according to the treatment protocol used. Retrospective data collection was performed by chart review. The mortality rate was 28.6%, 14.3% and 13.5% in the ICP, CPP, and mCPP groups, respectively. Highest intake/output ratio, amount of vasopressor used and pulmonary complications were seen in the CPP patients. The mCPP patients showed the best clinical outcome and lowest complication rate. Although CPP-targeted therapy is the most recommended therapeutic protocol, our data show that patients treated with modified CPP-target therapy with CPP >60 mmHg have better clinical outcomes and fewer complications.

SEVERE HEAD INJURY

Objective: To assess the outcome of severe head injury in patients with GCS 8 or below. Design:Retrospective study. Setting: Department of Neurosurgery, Allied Hospital, Punjab Medical College, Faisalabad.Period: Two years Aug 2002 to July 2004. Material and Methods: Two hundred patients admitted in the departmentof Neurosurgery, Allied Hospital, with Glasgow Coma scale 8 or below irrespective of mode of injury and age wereselected with a follow up of up to twelve months. The patients were assessed on arrival in the emergency room on thebasis of GCS. The patients were managed accordingly. Results: 71% patients were managed conservatively and 29%patients under went surgical intervention. Overall mortality was 40%. Outcome was good in 15% where as 11% patientsremained vegetative. Conclusion: Severe head injury has a mortality of 40%, especially in very young and very oldpatients.

Status Quo of Severe Head Injury Management

Hun-Joo Kim, M.D. Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea Traumatic brain injury (TBI) is a major health problem even in developed countries not to speak of under-developed countries despite declines in TBI over the past 20 years. However, there is no definite therapy until now even though these cause a great burden to the head-injured victims as well as to the society to which they belong. The main aim of this review is to provide a short update on the most recent advances in our knowledge of non-pharmacological strategies and new pharmacological avenues, which are still being developed to improve the outcome of severe head injury.

Prognosis of severe head injury: an experience in Thailand

This study of 300 patients with severe head injury evaluated the clinical predictors determined after admission and associated with significant increase of poor outcome. The overall poor outcome was 58%. Logistic regression showed that age, status of basal cisterns on initial CT, Glasgow Coma Scale score (GCS) at 24 h after injury and electrolyte derangement occurring during admission strongly correlated with the outcome. A probability diagram of the outcome determined at 24 h after injury from the combination of the significant predictive factors provides a basis for determining the interventions to the appropriate target population. Intracranial pressure monitors with sophisticated devices may not be suitable for a developing country. Allocation of resources toward development of adequate intensive care beds and well-trained staff combined with serial CT imaging may be an alternative approach for the improvement of the outcome of severe head injury.

Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury

Object Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate. Methods The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-D-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.4% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP ≥ 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg. Conclusions Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.

Factors influencing the outcome of severe head injury at Kenyatta National Hospital.

To study the factors influencing the outcome of severe head injury. A retrospective study. Kenyatta National Hospital, Nairobi, Kenya. Six hundred and seventy seven patients with severe head injuries who were seen at Kenyatta National Hospital between January 1992 and December 1996. Six hundred and seventy seven patients with severe head injuries were treated at Kenyatta National Hospital, between January 1992 and December 1996. Three hundred and eighty one patients died while undergoing treatment, 56.2% overall mortality. Age specific mortality was 35.7% in patients below 13 years, 44% in age group 14-25 years, 56% in age group 26-45 years. The admission Glasgow coma scale (GCS) was recorded in 637 patients. Patients with admission GCS of 3-4 had a mortality of 88%, those with GCS 5-6 had a mortality of 60% and those with admission GCS 7-8 had a mortality of 52%. Ninety per cent of the patients who had bilaterally dilated pupils not reacting to light on admission died and 66% of the patients with bilaterally constricted pupils at the time of admission died. Only 20% of patients with severe head injury who had normal pupillary reaction to light at the time of admission died. Eighty five per cent of the patients with systolic BP of less than 90 mmHg on admission died while 60% of those with systolic BP greater than 120 mmHg died. In this study, factors associated with poor outcome in severe head injury patients at Kenyatta National Hospital were age, admission GCS, admission blood pressure (systolic), presence of other associated injuries and pupillary reaction to light.

Current Issues in the Management of Severe Head Injury

Learning Objectives: After reading this article, the participant should be able to: 1. Discuss the principles of assessment and resuscitation of head-injured patients in the prehospital setting and in the emergency center. 2. Describe indications for and principles of surgery in head-injured patients. 3. Review intracranial monitoring strategies and basic management principles as they relate to the concept of secondary injury. 4. Outline a rational approach to the treatment of refractory intracranial hypertension. 5. Describe the outcome of severe head injury.

Intracranial hypertension and cerebral perfusion pressure: Influence on neurological deterioration and outcome in severe head injury.

Intracranial hypertension and cerebral perfusion pressure: Influence on neurological deterioration and outcome in severe head injury.

Evaluating the outcome of severe head injury with transcranial Doppler ultrasonography

The authors conducted a study to determine the value of transcranial Doppler (TCD) ultrasonography in evaluating the outcome of severely head injured patients and to correlate the TCD values with those obtained from intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring. The authors conducted a prospective study of 125 patients with severe head injury (Glascow Coma Scale scores of less than 9) who underwent TCD ultrasonography according to the standard technique of insonating the middle cerebral artery (MCA) and measuring the mean blood flow velocity and pulsatility index within the first 24 hours of admission. The ICP and CPP values, as well as other clinical, analytical, and neuroimaging data, were also recorded. After 6 months, outcome was evaluated using the Glasgow Outcome Scale. Moderate disability and complete recovery were considered "good" outcome; death, vegetative state, and severe disability were considered "poor." In 67 patients (54%) good outcome was demonstrated whereas in 58 (46%) it was poor. The mean blood flow velocity of the MCA in patients with good outcome was 44 cm/second; in those with poor outcomes it was 36 cm/second (p < 0.003). The mean PI in cases of good outcome was 1 whereas in poor outcome was 1.56 (p < 0.0001). The correlations of ICP and CPP to PI were statistically significant (r2 = 0.6; p < 0.0001). When performed in the first 24 hours of severe head injury, TCD ultrasonography is valid in predicting the patient's outcome at 6 months and correlates significantly with ICP and CPP values.

Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury

Object Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate. Methods The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-D-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.5% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP &gt;/= 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg. Conclusions Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.

Enhanced enteral nutrition in head injury

Background: Early enhanced enteral nutrition (EN) improves clinical outcome in severe head injury. However, poor gastric emptying and certain aspects of intensive care may inhibit delivery of optimum nutrition. Aim: To determine the important causes of interruption to EN and whether attempting early adequate EN could enhance nutritional intake in severe head injury. Methods: Eighty-two patients were randomized to receive either standard EN or early adequate EN. Data was collected on nutritional intake, causes of interruption to EN, nitrogen balance, volume of gastric residuals and incidence of pneumonia. Results: The median percentage of energy and nitrogen delivered was greater in intervention patients compared to controls over the first week post-injury ( P < 0.02). During the first 96 h post-injury, patients received EN during 57% of the potential feeding time. Intervention patients received a higher fluid volume ( P < 0.02) but did not have a higher incidence of pneumonia. Conclusion: Taking into account the importance of initiating and maintaining adequate EN, prioritizing procedures in intensive therapy units could further improve nutritional intake in severe head injury.

Enhanced enteral nutrition in head injury: effect on the efficacy of nutritional delivery, nitrogen balance, gastric residuals and risk of pneumonia

Background: Early enhanced enteral nutrition (EN) improves clinical outcome in severe head injury. However, poor gastric emptying and certain aspects of intensive care may inhibit delivery of optimum nutrition. Aim: To determine the important causes of interruption to EN and whether attempting early adequate EN could enhance nutritional intake in severe head injury. Methods: Eighty‐two patients were randomized to receive either standard EN or early adequate EN. Data was collected on nutritional intake, causes of interruption to EN, nitrogen balance, volume of gastric residuals and incidence of pneumonia. Results: The median percentage of energy and nitrogen delivered was greater in intervention patients compared to controls over the first week post‐injury ( P &lt; 0.02). During the first 96 h post‐injury, patients received EN during 57% of the potential feeding time. Intervention patients received a higher fluid volume ( P &lt; 0.02) but did not have a higher incidence of pneumonia. Conclusion: Taking into account the importance of initiating and maintaining adequate EN, prioritizing procedures in intensive therapy units could further improve nutritional intake in severe head injury.