Poor Glasgow Coma Scale Score Research Articles

Cerebrospinal fluid indices as predictors of treatment response in autoimmune encephalitis.

Cerebrospinal fluid (CSF) indices reflecting intrathecal antibody production and blood-brain barrier impairment are not routinely assessed in patients with autoimmune encephalitis (AE). We aimed to study CSF indices and their association with the prognosis of AE. This retrospective cohort study conducted at Amrita Institute of Medical Sciences (AIMS), Kochi, India, included 60 patients aged more than 18 years with definite/probable/possible AE admitted to the Department of Neurology from August 2016 to November 2021. We introduced a classification of treatment response based on modified Rankin Scale change over time and treatment modalities. In our cohort of 60 patients (six [10%] seropositive cases), a good rapid treatment response was associated with CSF white blood cell count of more than 4 cells/mm3 (OR, 4.57; 95% CI 1.31-15.96; P=.02) and positive immunoglobulin G (IgG) Local Synthesis (OR, 7.27; 95% CI 1.56-33.86; P=.01). Albumin Index had association with a poor Glasgow Coma Scale score at the nadir of the disease (OR, 1.17; 95% CI 1.01-1.34; P=.04). Similar results were yielded in the seronegative cohort. IgG Local Synthesis appeared to be a strong predictor for good rapid treatment response in both univariate and multivariate (adjusted OR, 28.71; 95% CI 2.12-389.22; P= .01) analysis. Time to immunotherapy was reversely correlated with good response overall (in the cohort with outliers removed [N=49]: unadjusted OR 0.97, 95% CI 0.95-0.99; P= .01; adjusted OR 0.97; 95% CI 0.95-0.99; P= .008). CSF indices reflecting intrathecal antibody production and blood-brain barrier impairment appear to be promising predictors of disease severity and therapeutic response in patients with autoimmune encephalitis.

Early post-stroke cognitive impairment and in-hospital predicting factors among stroke survivors in Ethiopia.

In low-and middle-income countries, post-stroke cognitive impairment (PSCI) is the least investigated stroke complication that clinically is given little attention. Finding patients who are at high risk of having cognitive problems after a stroke could allow targeted follow-up and help with prognosis discussions, which would then contribute to improved treatment outcomes. The main aim of this study was to determine the incidence and predictors of PSCI among stroke survivors in Northwest Ethiopia. The study was a multicenter prospective cohort study. The study participants were 403 stroke survivors who were alive on follow-up after 3 months of stroke onset at the neurology department of three hospitals in Northwest Ethiopia. To investigate the link between the outcome and the explanatory variables, analyses of bivariable and logistic multivariable regression were performed. A value of p of 0.05 or less was regarded as statistically significant, and data were presented as odds ratios and 95% confidence intervals. The mean age of the participants was 61.3 years (SD = 0.7), 56% were females, the mean time from symptom onset to hospital arrival was 46 h (SD = 3.32), and the mean National Institute of Health Stroke Scale (NIHSS) score at admission was 14.79 (SD = 0.25). PSCI was observed in 122 patients (30.3%) after 90 days of stroke onset, that is, 83 (20.6%) of female and 39 (9.7%) of male stroke survivors. The result of multivariable logistic regression analysis revealed PSCI was independently associated with age (adjusted OR = 1.04, 95% CI = 1.061-1.981), women (AOR = 1.390, 95% CI = 1.221-2.690), admission modified Rankin scale (mRS) (AOR = 1.629, 95% CI = 1.381-2.037), moderate Glasgow coma scale (GCS) score (AOR = 1.149, 95% CI = 1.402-3.281), and poor GCS score (AOR = 1.632, 95% CI = 1.610-4.361) and stage one (AOR = 1.428, 95% CI = 1.198-2.922) and stage two hypertension (AOR = 1.255, 95% CI = 1.107-2.609). Nearly one-third of stroke survivors developed PSCI. Moreover, further research is needed with a larger sample size, showing a time trend and longer follow-up duration.

Operative versus non-operative management of rib fractures in flail chest after cardiopulmonary resuscitation manoeuvres.

OBJECTIVESBlunt chest trauma after mechanical resuscitation manoeuvres appears to have a significant impact on the often complicated course. Due to a lack of data in the literature, the purpose of this study was to investigate the feasibility and immediate outcome of chest wall stabilization for flail chest in this vulnerable patient population.METHODSWe retrospectively reviewed the medical records of patients after cardiopulmonary resuscitation between January 2014 and December 2018 who were diagnosed with flail chest. We attempted to compare patients after surgery with those after conservative treatment.RESULTSOf a total of 56 patients with blunt chest trauma after mechanical resuscitation and after coronary angiography, 25 were diagnosed with flail chest. After the exclusion of 2 patients because of an initial decision to palliate, 13 patients after surgical stabilization could be compared with 10 patients after conservative therapy. Although there was no significant difference in the total duration of ventilatory support, there was a significant advantage when the time after stabilization to extubation was compared with the duration of ventilation in the conservative group. The presence of pulmonary contusion, poor Glasgow Coma Scale score or the development of pneumonia negatively affected the outcome, but additional sternal fracture did not.CONCLUSIONSSurgical stabilization for chest wall instability is well tolerated even by this vulnerable patient population. Our results should be used for further randomized controlled approaches. It is necessary to evaluate the situation with all parameters in an interdisciplinary manner and to decide on a possible surgical therapy at an early stage if possible.

Management and Outcome of Acute Subdural Hematoma in Gabriel Touré Hospital

Background: Traumatic Brain Injury (TBI) is a major health problem worldwide. It is the main cause of trauma mortality. Acute subdural hematoma (ASDH) has a reputation for being the most serious of all posttraumatic head injuries. Its frequency is estimated to be 1% to 5% of all head injuries and 22% of severe head injuries. The aim of this study was to assess the epidemiological, clinical and prognosis aspects of ASDH in our department. Material and Methods: This prospective study, from January to December 2019, included 57 patients admitted to the Gabriel Touré Teaching Hospital for ASDH. Patients underwent detailed clinical and radiological evaluation and ASDH was diagnosed by non-contrast computed tomography (CT) scan. Functional outcome was evaluated 6 months after injury by Glasgow Outcome Scale. Results: During the study period, 662 patients were admitted for TBI including 57 (8.61%) cases of ASDH. The mean age was 34 years with extremes of 2 and 77 years. There was a male predominance with 52 (91.2%). The main cause of trauma was motor vehicle accidents in 38 (66.6%) patients. According to the Glasgow coma scale (GCS), 33 (57.9%) patients were classified mild (Table 2). The thickness of the hematoma was more than 1 cm in 13 (22.8%) patients and less than 1 cm in 44 (77%) patients. Surgical treatment was performed in 13 (22.8%) patients. The outcome was favorable in 30 (52.6%) patients and the mortality rate was 33.3%. Conclusion: ASDH remains a difficult challenge because of the high mortality. The mortality rate remains high particularly in patient with poor GCS score at admission.

Role of Brain Natriuretic Peptide in the Prediction of Early Postoperative Seizures Following Surgery for Traumatic Acute Subdural Hematoma: A Prospective Study.

IntroductionBrain natriuretic peptide (BNP) is a reliable biomarker in the acute phase of traumatic brain injury. However, the relationship between BNP and traumatic acute subdural hematoma (aSDH) has not yet been addressed. This study aimed to analyze BNP levels on admission in surgically treated patients and assess their relationship with early postoperative seizures (EPS) and functional outcomes.MethodsPatients with unilateral traumatic aSDH who were surgically treated in our department between July 2017 and May 2020 were included in the study. BNP was preoperatively measured. Patients’ neurologic condition, radiographic variables on initial cranial computed tomography, sodium serum levels on admission, and occurrence of EPS were prospectively assessed. Functional outcome was assessed using the modified Rankin Scale (mRS) at discharge and follow-up (at 2–3 months). A poor outcome was defined by a mRS score > 3.ResultsEPS occurred in 20 (19.6%) of 102 surgically treated patients in the final cohort on the median day 3. A significant association between EPS and a poor Glasgow Coma Scale score at the 7th postoperative day was found, which in turn independently predicted a poor functional outcome at discharge and follow-up. Nonetheless, EPS were not associated with poor functional outcomes. The multivariate analysis revealed BNP > 95.4 pg/ml (aOR = 5.7, p = 0.003), sodium < 137.5 mmol/l (aOR = 4.6, p = 0.009), and left-sided aSDH (aOR = 4.4, p = 0.020) as independent predictors of EPS.ConclusionIn the early postoperative phase of traumatic aSDH, EPS were associated with worse neurologic conditions, which in turn independently predicted poor outcomes at discharge and follow-up. Although several EPS risk factors have already been elucidated, this study presents BNP as a novel reliable predictor of EPS. Further larger studies are needed to determine whether a more precise estimate of EPS risk using BNP levels can be reached.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40120-021-00269-w.

Incidence, Prevalence, and Outcomes of Pediatric Trauma in Rural Appalachia (West Virginia) From 2017 to 2019.

BackgroundAppalachian rural pediatric trauma has its unique incidence, presentation, and distribution due to the mechanisms of injury, geographic location, access to care, and social issues. PurposeTo review, analyze, and understand pediatric trauma in West Virginia during the period 2017-2019.Materials and methodsAfter institutional review board approval, the statewide trauma database was queried and analyzed in a retrospective cohort study for all pediatric trauma ages zero to 18 from 2017-2019 in the Appalachian regions one through four in West Virginia.The following were analyzed: gender, injury mechanism, Glasgow Coma Scale Score (GCS) at admission, injury severity score (ISS), toxicology screen results, hospital length of stay, duration of ventilatory support, number of procedures performed during admission, presence of non-accidental trauma, cardiac arrest, patient discharge disposition, and mortality.ResultsOne-thousand eighty-two (1182) patients between the ages of zero to 18 were admitted to the trauma center. An average of 37% was female and 63% male. In the 11-18 age group, 24% were female and 76% were male. Most injuries were due to blunt force (89%), followed by penetrating injuries (7.2%) and burns (1.4%). The majority had minor or moderate injuries with 95% receiving a Glasgow Coma Scale (GCS) >13 and 72% listed as minor on the injury severity score (ISS). Children in ages 0-2 years had the highest proportion of poor (0-8) GCS scores, high ISS (>14) scores, most hospital admission days, most days on a ventilator, highest mortality, most pre-hospital cardiac arrests, child abuse, burns, and placement with child protective services. An average of 31% of children tested, and 17% in the age group of 0-2 had a positive toxicology screen. There were 3670 procedures done in total and the most common procedure performed was an ultrasound of the abdomen. Procedures were performed in 90% of the patients.Conclusions and relevanceBased on our study, the zero to two-year-old pediatric trauma patients are most vulnerable to poor outcomes and may need targeted preventative interventions. Toxicology screens may need to be more widely implemented in pediatric trauma in the Appalachian region.Rural trauma in Appalachia has endemic issues related to substance abuse, poverty, and a lower degree of social support as compared to urban areas. Although the distribution of injury may follow a national distribution, mechanism, management, and outcomes can vary.

A case report of acute Marchiafava-Bignami disease: a rare clinical entity in chronic alcoholism

Marchiafava‑Bignami disease (MBD) is a rare neurological disease often associated with a chronic consumption of alcohol and malnutrition, which is characterized by a demyelination and necrosis of the corpus callosum. We present a case of a 21-year-old male with chronic alcoholism who presented with an acute altered sensorium and seizure, which were initially treated as meningoencephalitis. His persistent poor Glasgow coma scale score and ideomotor recovery with encephalitic changes on his electroencephalogram prompted urgent magnetic resonance imaging (MRI) of his brain, which revealed extensive symmetrical hyperintensities in the corpus callosum. The diagnosis of MBD was made because of the typical MRI findings and after the exclusion of other possible diagnosis. The patient was promptly treated with a parenteral thiamine and showed a good recovery at 3 months follow-up. This case highlights the importance of diagnosing and recognizing MBD in a patient with chronic alcoholism as prompt treatment could prevent irreversible damage, which could carry high morbidity.

Indication, Timing, and Surgical Treatment of Spontaneous Intracerebral Hemorrhage: Systematic Review and Proposal of a Management Algorithm

To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case. Based on PubMed/MEDLINE, Embase, and the Cochrane Library databases, a systematic review of the literature was performed using as keywords the terms "spontaneous intracerebral hemorrhage," "surgical management," "medical management," "supratentorial," and "infratentorial." Because of the highest level of evidence, only randomized and nonrandomized clinical trials, meta-analyses, and comparative cohort studies reported within the last 12 years were selected. An updated and evidence-based treatment algorithm was reported also. The search initially returned 255 articles. After application of the exclusion criteria, only 19 studies were selected. According to the site and volume of the hematoma, admission Glasgow Coma Scale (GCS) score, and progressive neurologic decline, specific subgroups were identified. Surgery must be considered in patients with an admission GCS score ranging between 5 and 12 and a hematoma volume >30 mL. The best time-window has been reported to be 7-24 hours after ictus. Endoscopic surgery is recommendable for patients with a supratentorial hematoma >60 mL and with a poor GCS score (4-8). Alternative techniques, such as minimally invasive puncture and thrombolysis, may be considered for deeper hematoma. Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.

Prognostic Value of Serum Levels of S100 Calcium-Binding Protein B, Neuron-Specific Enolase, and Interleukin-6 in Pediatric Patients with Traumatic Brain Injury

To analyze serum levels of S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), and interleukin (IL)-6 in pediatric patients with traumatic brain injury (TBI) and to assess their relationship with clinical outcome. To measure biomarkers, peripheral venous blood was collected within 6 hours and 1 week after TBI. Initial Glasgow Coma Scale (GCS) scores and Glasgow Outcome Scale scores 6 months after the trauma were used to evaluate clinical outcome. Median serum levels of S100B (178.12 pg/mL), NSE (16.54 ng/mL), and IL-6 (15.48 pg/mL) at admission decreased significantly 1 week after TBI to 40.86 pg/mL, 5.85 ng/mL, and 8.63 pg/mL. In the group with poor GCS scores, serum S100B and NSE levels both at admission and 1 week after TBI were significantly higher than levels in the group with good GCS scores. Serum S100B and NSE levels 1 week after injury in patients with unfavorable 6-month outcomes were significantly higher than levels 1 week after injury in patients with favorable outcomes. Serum levels of S100B, NSE, and IL-6 decreased 1 week after injury. Serum levels of S100B and NSE at admission were related to initial GCS scores, and these levels 1 week after TBI were related to 6-month Glasgow Outcome Scale scores. Thus, serial measurements of serum S100B and NSE, but not IL-6, may help assess brain damage and clinical outcome of pediatric patients with TBI.

Neurologic Outcome After Decompressive Craniectomy: Predictors of Outcome in Different Pathologic Conditions.

Decompressive craniectomy (DC) has been proposed as a lifesaving treatment in patients with elevated intracranial pressure, but its effectiveness on reaching a favorable neurologic outcome remains unclear. We identified predictors of outcome in a large, single-center cohort of patients undergoing DC for different pathologic conditions. This retrospective study included all patients undergoing DC from 2006 to 2014. The 1-year outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS 4-5) and unfavorable (GOS 1-3) outcome. Predictors of outcome were identified by analyzing patient characteristics. DC was performed in 204 patients for ischemic stroke (n= 57), traumatic brain injury (n= 50), aneurysmal subarachnoid hemorrhage (aSAH) (n= 44), intracerebral hemorrhage (ICH) (n= 29), cerebral venous thrombosis (CVT) (n= 14), or other indications (n= 10). Overall, 69 (34%) patients survived favorably, 39 (19%) survived unfavorably, and 96 (47%) died. Higher age, poor Glasgow Coma Scale score, intubated status before DC, bilateral absence of pupillary light reflexes, DC for aSAH, and additional surgeries after DC (excluding cranioplasty) were significant predictors of unfavorable outcome. When patients were sorted for pathologic conditions and predictors of outcome, favorable outcome rates differed remarkably, ranging from 91% for CVT patients undergoing uncomplicated DC to 0% for aSAH patients undergoing DC for secondary infarction or ICH patients with unilateral or bilateral abnormal pupillary light reflexes upon admission. Long-term neurologic outcome after DC differed remarkably among subpopulations of patients, with favorable outcome rates ranging from 0% to >90%.

Very Low Incidence of Ischaemic Stroke Associated with Thrombus Aspiration in a Large Series of STEMI Patients Treated with Primary PCI

Background: Thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) was recommended to minimise distal embolisation and ischaemia, improve myocardial reperfusion, and reduce thrombus burden prior to PPCI. Subsequent larger randomised trials showed no benefit and suggested an increased risk of stroke with TA, mostly in the first 48 hours. Aim: To describe the rate of ischaemic stroke in STEMI patients treated with TA and PPCI at two large Western Sydney hospitals. Methods: We conducted a retrospective analysis of all STEMI patients treated with TA and PPCI from 2008 to 2015 at Westmead and Blacktown Hospitals. Patients received protocol dose heparin and dual antiplatelet therapy. TA was performed using 6Fr and 7Fr catheters. The guide catheter was selectively engaged prior to removal of the aspiration catheter. Negative suction was maintained during removal, followed by generous aspiration of the guide catheter. The incidence of ischaemic stroke within the first 48 hours was retrieved from patient records. Results: Of 1463 patients (mean age 68 ± 11; 58% male), 2 patients had ischaemic stroke in the first 48 hours post index procedure (incidence rate 0.14%). Both patients were intubated prior to PPCI due to poor Glasgow Coma Scale scores. 1, 6 and 12 month stroke rates will be presented at the meeting. Conclusion: Very low ischaemic stroke rates were seen in this real-world study. TA can be performed safely in STEMI patients undergoing PPCI with a stroke risk equivalent to reported risk in PPCI without TA.

Treatment Practices and Outcomes After Blunt Cerebrovascular Injury in Children

Pediatric blunt cerebrovascular injury (BCVI) lacks accepted treatment algorithms, and postinjury outcomes are ill defined. To compare treatment practices among pediatric trauma centers and to describe outcomes for available treatment modalities. Clinical and radiographic data were collected from a patient cohort with BCVI between 2003 and 2013 at 4 academic pediatric trauma centers. Among 645 pediatric patients evaluated with computed tomography angiography for BCVI, 57 vascular injuries (82% carotid artery, 18% vertebral artery) were diagnosed in 52 patients. Grade I (58%) and II (23%) injuries accounted for most lesions. Severe intracranial or intra-abdominal hemorrhage precluded antithrombotic therapy in 10 patients. Among the remaining patients, primary therapy was an antiplatelet agent in 14 (33%), anticoagulation in 8 (19%), endovascular intervention in 3 (7%), open surgery in 1 (2%), and no treatment in 16 (38%). Among 27 eligible grade I injuries, 16 (59%) were not treated, and the choice to not treat varied significantly among centers (P < .001). There were no complications from medical management. Glasgow Coma Scale (GCS) score <8 and increasing injury grade were predictors of injury progression (P = .001 and .004, respectively). Poor GCS score (P = .02), increasing injury grade (P = .03), and concomitant intracranial injury (P = .02) correlated with increased risk of mortality. Treatment modality did not correlate with progression of vascular injury or mortality. Treatment of BCVI with antiplatelet or anticoagulant therapy is safe and may confer modest benefit. Nonmodifiable factors, including presenting GCS score, vascular injury grade, and additional intracranial injury, remain the most important predictors of poor outcome. ATT, antithrombotic therapyBCVI, blunt cerebrovascular injuryCTA, computed tomography angiographyGCS, Glasgow Coma Scale.

Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction

Purpose: Several studies have investigated the incidence and risk factors of hydrocephalus after decompressive craniectomy (DC) for malignant hemispheric cerebral infarction. However, the results are controversial. Therefore, the following is a retrospective cohort study to determine the incidence and risk factors of hydrocephalus after DC for malignant hemispheric cerebral infarction. Materials and methods: From January 2004 to June 2014, patients at two medical centres in south-west China, who underwent DC for malignant hemispheric cerebral infarction, were included. The patients’ clinical and radiologic findings were retrospectively reviewed. A chi-square test, Mann–Whitney U-test and logistic regression model were used to identify the risk factors. Results: A total of 128 patients were included in the study. The incidence of ventriculomegaly and shunt-dependent hydrocephalus were 42.2% (54/128) and 14.8% (19/128), respectively. Lower preoperative Glasgow Coma Scale (GCS) score and presence of subarachnoid haemorrhage (SAH) were factors significantly associated with the development of post-operative hydrocephalus after DC. Conclusions: Cerebral infarction patients receiving DC have a moderate tendency to suffer from post-operative hydrocephalus. A poor GCS score and the presence of SAH were significantly associated with the development of hydrocephalus after DC.

Inhaled Isoflurane Sedation During Therapeutic Hypothermia After Cardiac Arrest

Therapeutic hypothermia in the ICU requires mechanical ventilation and sedation. Hypothermia reduces the metabolism of commonly used IV sedatives. The use of long-acting sedative agents may confound neurologic assessment. Volatile anesthetics have been reported to provide protection against ischemia-reperfusion injury and have been safely used in the ICU to provide sedation in trials with shorter wake-up times. There are no clinical studies in this setting. We describe a case series and discuss potential benefits. Retrospective study. Ten-bed ICU, university hospital. Twelve patients resuscitated from cardiac arrest with Glasgow Coma Scale score less than or equal to 4. Isoflurane sedation with the AnaConDa during 24 hours therapeutic hypothermia, until rewarming. Data were extracted from the computerized ICU chart/monitors, hospital and prehospital charts, and the national death index. Patients were 49-76 years old. Median return of spontaneous circulation was 14 minutes. Glasgow Coma Scale scores were assessed within 24 hours from reaching normal body temperature and compared with outcomes at 6 months: six patients had poor Glasgow Coma Scale scores (< 8) that remained low and all died before 6-month follow-up, whereas another six patients had high scores (> 8) and survived to 6 months with good Cerebral Performance Category. In the ICU, four of the survivors were directly extubated after rewarming while two were once more sedated due to pneumonia requiring invasive ventilator therapy. All patients required norepinephrine to maintain adequate mean arterial pressure. Isoflurane sedation was changed to midazolam in two nonsurviving patients because of hemodynamic instability, which persisted despite the change. Sedation with volatile anesthetics during therapeutic hypothermia may be a feasible short-acting option with potential postconditioning effects protecting vital organs from ischemia-reperfusion injury. Its measurability and insignificant drug accumulation could facilitate early neurologic assessment. Prospective clinical trials are warranted.

Relationship Between Time from Ambulance Call to Arrival at Emergency Center and Level of Consciousness at Admission in Severe Stroke Patients

Timely access to acute medical treatment can be critical for patients suffering from severe stroke. Little information is available about the impact of prehospital delays on the clinical conditions of stroke patients, but it is possible that prehospital delays lead to neurological deterioration. The aim of this study was to examine the impact of prehospital delays related to emergency medical services on the level of consciousness at admission in patients with severe stroke. This retrospective study assessed 712 consecutive patients diagnosed with cerebrovascular diseases who were admitted to an intensive care unit in Tokyo, Japan, from April 1998 through March 2008. Data, including the time from the call to the ambulance service to the arrival of the ambulance at the patient location (on-scene), and the time from the arrival of the ambulance on-scene to its arrival at the emergency center were obtained. The following demographic and clinical information also were obtained from medical records: sex, age, and Glasgow Coma Scale (GCS) score at admission. The mean time from ambulance call to arrival on-scene was 7 (SD=3) minutes, and the mean time from ambulance call to arrival at the center was 37 (SD=8) minutes. A logistic regression model for predicting GCS scores of 3 and 4 at admission was produced. After adjusting for sex, age, and time from arrival on-scene to arrival at the center, a longer call-to-on-scene time was significantly associated with poor GCS scores (OR = 1.056/min; 95% confidence interval, [CI] = 1.008-1.107). After adjusting for sex and age, a longer call-to-arrival at the center time also was significantly associated with poor GCS scores (OR = 1.020; 95% CI = 1.002-1.038). Prehospital delays were significantly associated with decreased levels of consciousness at admission in patients suffering from a stroke. As level of consciousness is the strongest predictor of outcome, reducing prehospital delays may be necessary to improve the outcomes in patients with severe stroke.

Hypodensity of extradural hematomas in children: an ominous sign

The aim of this study was to analyze the correlation of hypodensity in extradural hematomas on CT with the clinical profile in pediatric patients. This is the only study available in this age group. This was a prospective study conducted over a period of 3 years in which all children 18 years old or younger with a diagnosis of cranial extradural hematoma were included. The patients were allocated to 2 groups: those with mixed-density clots (17 cases) and those with classically hyperdense clots (52 cases). A comparative analysis between the 2 groups was conducted. Patients with mixed-density clots presented earlier to the hospital, had poor Glasgow Coma Scale scores at admission, exhibited large clot volumes, had a high incidence of active bleeding at surgery, and had increased morbidity and mortality as compared with the patients with hyperdense extradural hematomas. Early recognition and rapid evacuation of the mixed-density clot with restoration of hemostasis may result in a decline in morbidity and death in children with this entity.

TRACHEOSTOMY IN CRITICALLY ILL NEUROSURGICAL PATIENTS

Objective: To determine the value of early tracheostomy in ventilated neurosurgical patients.Methods:Retrospective review of intubated patients in the Neurosurgical Intensive Care Unit who underwent elective open tracheostomies for prolonged ventilation.Results:Thirty patients over a 2‐year period were analyzed. There were 19 males and 11 females, mean age 53.9 ± 18.1 years (range 14–89), and mean Glasgow Coma Scale (GCS) score on admission, 7.1 ± 3.8 (range 3–15). The underlying disease etiology was cerebrovascular disease in 53% of patients, head trauma in 33% and tumor or infection in 13%. Tracheostomy was performed after a mean period of 8.5 ± 3.5 days (range 2–18), with patients requiring ventilation for a mean duration of 13.5 ± 6.3 days (range 3–31). Complications were minimal; 1 wound infection (3.3%) and 4 tube obstructions (13.3%). Patients who underwent elective early tracheostomy (Group I = within 7 days) had poorer GCS on admission (6.3 ± 2.9 vs 7.7 ± 4.3 in Group II, P = 0.271). Tracheostomy was performed after a mean of 5.3 ± 1.7 days in Group I vs 10.6 ± 2.7 days in Group II. Group I patients had faster recovery from nosocomial pneumonia (12.3 ± 6.2 vs 17.9 ± 12.5 days, P = 0.168), shorter duration of ventilation (9.8 ± 5.9 vs 16.0 ± 5.4 days, P = 0.007), and reduced incidence of multibacterial tracheobronchial colonization (42%vs 72%, P = 0.098). The most prevalent organisms were Acinetobacter baumanii (43.3%), Pseudomonas (40%), Methicillin resistant Staphylococcus Aureus (MRSA) (33%), Klebsiella (30%) and Staphylococcus Aureus (26.7%).Conclusion:Early tracheostomy in selected neurosurgical patients with poor GCS scores was associated with reduced incidence of tracheobronchial colonization by multiple pathogens, improvement in chest infections, and rapid weaning from ventilatory support.

Tracheostomy in a neuro-intensive care setting: indications and timing.

A retrospective review was made of 49 survivors who were mechanically ventilated for more than 48 hours in the neurosurgical ICU. Thirty-two patients (Gp I) were successfully extubated, 9 patients (Gp II) underwent tracheostomy after one or more failed extubations, and 8 patients (Gp III) underwent elective tracheostomy. Glasgow Coma Scale (GCS) scores at extubation were 11.3 +/- 2.8 (mean (SD) for Gp I vs 7.8 +/- 2.7 for Gp II (P = n.s.) and at elective tracheostomy (Gp III) was 5.4 +/- 2.3. Incidence of ventilator-associated pneumonia were 35% in Gp I vs 100% of patients in Gp II and III (P < 0.05). Reasons for reintubation in 7 of 9 patients (Gp II) were upper airway obstruction and tenacious tracheal secretions while 14 of 17 patients were weaned off the ventilator within 48 hours of tracheostomy. The length of stay in ICU was 16.8 +/- 7.1 days in Gp II vs 11.7 +/- 2.9 days in Gp III (P < 0.05). In our study, elective tracheostomy for selected patients with poor GCS scores and nosocomial pneumonia has resulted in shortened ICU length of stay and rapid weaning from ventilatory support.