Presenting Glasgow Coma Scale Score Research Articles

Early Tracheostomy versus Late Tracheostomy in Patients with Moderate-to-Severe Traumatic Brain Injury.

Objective The aim of this article was to study the impact of early versus late tracheostomy on clinical outcomes of moderate-to-severe traumatic brain injury (TBI). Materials and Methods A retrospective cross-sectional study was conducted in the Neurosurgery Department, Mayo Hospital, Lahore, in which a sample size of 50 cases was calculated over a period of 6 months from January 1, 2022, to June 30, 2022. The included cases were patients who suffered from moderate-to-severe TBI, isolated TBI, needed elective ventilation, required intensive care unit (ICU) admission during their hospital stay, and were between the ages of 18 and 65 years. All the rest were excluded. A structured proforma was used by the physician to collect data after the informed consent of the patient. The results were computed and analyzed statistically using Statistical Package for Social Sciences , version 26. Results The median age of patients was 40 (interquartile [IQ] range 34) years and were predominantly male (72%). The most common mode of injury was road traffic accidents (58%). The median Glasgow Coma Scale (GCS) score at arrival was 8 (IQ range 6) and the most common pupillary light reflex at presentation was bilaterally equally responsive to light (68%). Neurologic deficits were mostly absent or cannot be assessed on presentation (86%) and in 38% of the cases multiple findings were noted on computed tomography (CT) scan while among single findings seen on CT scan, subdural hematoma was the most common (22%). Multiple regression analysis was done through two separate models using age, gender, mode of injury, presenting GCS score, number of CT-scan findings, number of days after endotracheal intubation after which tracheostomy was done, and the timing of tracheostomy (early vs. late) as predictors, and a significant relationship was noted between the timing of tracheostomy (early vs. late) and GCS at discharge ( p = 0.001) as well as extended Glasgow Outcome Score (GOS) at discharge ( p = 0.013). Conclusion This study suggests that moderate-to-severe TBIs are most common in middle-aged males and mostly involve road traffic accidents. In most cases, multiple CT-scan findings are seen as compared with a single predominant finding. In such patients, early tracheostomy is superior to late tracheostomy as it results in significantly better GCS and GOS scores at discharge as well as a decreased duration of mechanical ventilation and ICU stay.

336 Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries

INTRODUCTION: Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night. METHODS: Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, inhospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk. RESULTS: Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger (P = .004), predominantly male (P = .003), and less frail (P = .003) but had similar presenting Glasgow Coma Scale scores (P = .85), neurointensive care unit stay time (P = .15), neurosurgical interventions (P = .27), and in-hospital mortality (P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]). CONCLUSIONS: Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.

Factors influencing withdrawal of life-supporting treatment in cervical spinal cord injury: a large multicenter observational cohort study

BackgroundTraumatic spinal cord injury (SCI) leads to profound neurologic sequelae, and the provision of life-supporting treatment serves great importance among this patient population. The decision for withdrawal of life-supporting treatment (WLST) in complete traumatic SCI is complex with the lack of guidelines and limited understanding of practice patterns. We aimed to evaluate the individual and contextual factors associated with the decision for WLST and assess between-center differences in practice patterns across North American trauma centers for patients with complete cervical SCI.MethodsThis retrospective multicenter observational cohort study utilized data derived from the American College of Surgeons Trauma Quality Improvement Program database between 2017 and 2020. The study included adult patients (> 16 years) with complete cervical SCI. We constructed a multilevel mixed effect logistic regression model to adjust for patient, injury and hospital factors influencing WLST. Factors associated with WLST were estimated through odds ratios with 95% confidence intervals. Hospital variability was characterized using the median odds ratio. Unexplained residual variability was assessed through the proportional change in variation between models.ResultsWe identified 5070 patients with complete cervical SCI treated across 477 hospitals, of which 960 (18.9%) had WLST. Patient-level factors associated with significantly increased likelihood of WLST were advanced age, male sex, white race, prior dementia, low presenting Glasgow Coma Scale score, having a pre-hospital cardiac arrest, SCI level of C3 or above, and concurrent severe injury to the head or thorax. Patient-level factors associated with significantly decreased likelihood of WLST included being racially Black or Asian. There was significant variability across hospitals in the likelihood for WLST while accounting for case-mix, hospital size, and teaching status (MOR 1.51 95% CI 1.22–1.75).ConclusionsA notable proportion of patients with complete cervical SCI undergo WLST during their in-hospital admission. We have highlighted several factors associated with this decision and identified considerable variability between hospitals. Further work to standardize WLST guidelines may improve equity of care provided to this patient population.

Time to Care: Analysis of Time Differences and Outcomes in the Management of Pediatric Traumatic Brain Injury for a High-Income and Lower-Middle-Income Country

Pediatric cranial trauma is the leading cause of acquired death and disability in children worldwide. However, trauma resources vary widely among countries. We sought to compare management and timely access to care between a level 1 U.S. pediatric trauma center and a tertiary referral hospital in a lower-middle-income country to assess whether system and resource differences influence care and outcomes. We compared data from 214 pediatric head trauma admissions to Philippine General Hospital (Manila) with 136 children from the TRACK-TBI pediatrics study cohort at Massachusetts General Hospital (MGH). Admitted MGH patients were compared with the Philippine cohort regarding demographics; mechanism of injury; times to neurosurgical consult, imaging, and surgery; in-hospital mortality; and length of hospitalization. Age (9 years), gender distribution (67% male), and presenting Glasgow Coma Scale scores were similar (P= 0.10) between sites. More children had intracranial injury in the Philippine cohort (73% vs. 60%; n= 319) and more underwent neurosurgery (27% vs. 4%). Times to consult, imaging, and surgery were longer in the Philippines (12.3 vs. 6.5, 12.0 vs. 2.8, and 45.4 vs. 5.6 hours, respectively). In-hospital mortality across all admissions was similar between cohorts (3% vs. 0%; P= 0.09), but significantly higher in the most severe Philippines cases (31% vs. 0%, P=0.04). Length of stay was longer (5 vs. 2 days; P < 0.001) in the Philippine cohort. High-income country status correlated with faster care, shorter hospitalizations, and better outcomes among severe cases. Prompt care through sophisticated trauma system implementation may improve pediatric health in resource-limited settings.

Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries.

Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night. To compare care patterns and outcomes between homeless and nonhomeless individuals with acute neurotraumatic injuries. Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, in-hospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk. Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger ( P = .004), predominantly male ( P = .003), and less frail ( P = .003) but had similar presenting Glasgow Coma Scale scores ( P = .85), neurointensive care unit stay time ( P = .15), neurosurgical interventions ( P = .27), and in-hospital mortality ( P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]). Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.

662: PROPHYLAXIS FOR THE PREVENTION OF EARLY POSTTRAUMATIC SEIZURES IN TRAUMATIC BRAIN INJURY

Introduction: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children under 18 years of age. Early posttraumatic seizures (EPTS), seizures occurring within 7 days of initial neurologic injury, are a known complication following TBI. The goal of this study is to discern how efficacious prophylaxis with Levetiracetam or Fosphenytoin is in preventing EPTS in moderate to severe TBI in pediatric patients. Methods: A retrospective observational study at a Level 1 Pediatric Trauma Center was conducted with patients 0-5 years with moderate to severe TBI admitted to the PICU from January 1, 2015 – January 1, 2021. Moderate to severe TBI was defined as Glasgow Coma Scale (GCS) < 13. Patients were identified using ICD-9 and ICD-10 codes. Excluded were patients >5 years old, who presented to the ED with seizures, who received anti-epileptic drug (AED) after a seizure, with non-accidental trauma as the cause of TBI, who did not receive 7 days of AED prophylaxis or died within 7 days of hospital stay. The following points were collected and compared: initial GCS, AED dosage, time to 1st AED dose, occurrence of EPTS, and number of days into hospital stay EPTS occurred. Results: Of 244 patients identified with moderate/severe TBI, 50 patients met inclusion criteria. Subdural hematoma was the most common primary diagnosis (48%). 44 patients (88%) received Levetiracetam. 6 patients (12%) received Fosphenytoin. 5 patients (10%) had EPTS, 95% CI [1.8%, 18.2%]. These 5 patients had received Levetiracetam. The 6 patients that received Fosphenytoin did not have EPTS. Seizures were confirmed with electroencephalography and on average occurred 2.6 days into hospital course. Mean data points of the patients who experienced EPTS: Levetiracetam dose 32.6 mg/kg/day, presenting GCS score 7, and time to administration of 1st AED dose 243 minutes. Mean data points of the patients who did not experience EPTS: Levetiracetam dose 29.3 mg/kg/day, presenting GCS score 9, and time to administration of 1st AED dose 366 minutes. Conclusions: Patients who received Levetiracetam prophylaxis had a higher incidence of EPTS compared to patients who received Fosphenytoin prophylaxis. These patients also had a lower presenting GCS, potentially playing a role in the neuropathophysiology of EPTS.

Poor outcome in frail elderly patient after severe TBI

ABSTRACT Objective To investigate the influence of frailty in elderly with severe TBI on mortality and functional outcome. Method 126 patients with TBI aged 60 years or older and with a presenting Glasgow Coma Scale score of 8 or lower were retrospectively included. To investigate frailty, we used the CSHA Clinical Frailty Scale. The primary outcome measures were mortality, and the secondary outcome measures were Glasgow Outcome Scale Extended (GOSE) at discharge and GOSE at 6 months after trauma. Results High frailty was a significant predictor for mortality (OR 2.38, p 0.047), if adjusted for the injury severity scale. High frailty was also a significant predictor for poor functional outcome after 6 months (OR 4.35, p 0.03). After 6 months, the GOSE of the low frailty group was significantly higher than in the high frailty group (p 0.019). Also, the improvement of the GOSE was significant in the low frailty group (p 0.007), while in the high frailty group there was no significant improvement of the GOSE (p 0.546) after 6 months. Conclusion Frailty has a significant impact on outcome in elderly with severe TBI. There is a higher mortality in the frail elderly and there is less recovery after TBI.

Cisternostomy versus Decompressive Craniectomy for the Management of Traumatic Brain Injury: A Randomized Controlled Trial

The goal of treatment of traumatic brain injury (TBI) is to avoid secondary brain injury. Decompressive craniectomy has been shown to reduce intracranial pressure (ICP), but it actually provides an outlet for brain tissue to expand without reducing edema. Basal cisternostomy is an emerging microsurgical technique to manage cerebral edema in TBI. Cerebrospinal fluid is released from basal cisterns, which reduces cerebral edema. We compared outcomes of cisternostomy with decompressive craniectomy in a randomized controlled trial and studied the effectiveness of cisternostomy in decreasing cerebral edema. All enrolled patients were randomly assigned to 2 groups and assessed clinically and radiologically. TBIs were categorized as mild, moderate, and severe injuries, and Marshall computed tomography-based score was assessed. Intraoperative ICP was measured in both groups. Outcomes were assessed based on postoperative intensive care unit stay, days on ventilator support, and Glasgow Outcome Scale score. There were 50 patients randomly assigned to 2 groups (25 patients in each group). Mortality rate was 32% (8 deaths) in the cisternostomy group and 44% (11 deaths) in the decompressive craniectomy group. Patients in the cisternostomy group had decreased mean days of ventilator support and intensive care unit stay. Cisternostomy resulted in significant decreases in ICP after craniotomy. Age, time from trauma to surgery, and Marshall score showed prognostic importance on outcomes. Cisternostomy was effective in reducing ICP in patients with TBI. Good Glasgow Outcome Scale scores and low rates of complications were found in the postoperative period after cisternostomy. Age, presenting Glasgow Coma Scale score, Marshall score, other major injuries, and time from trauma to surgery had a significant prognostic impact on outcome in management of TBI.

Association of Posttraumatic Epilepsy With 1-Year Outcomes After Traumatic Brain Injury

Posttraumatic epilepsy (PTE) is a recognized sequela of traumatic brain injury (TBI), but the long-term outcomes associated with PTE independent of injury severity are not precisely known. To determine the incidence, risk factors, and association with functional outcomes and self-reported somatic, cognitive, and psychological concerns of self-reported PTE in a large, prospectively collected TBI cohort. This multicenter, prospective cohort study was conducted as part of the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study and identified patients presenting with TBI to 1 of 18 participating level 1 US trauma centers from February 2014 to July 2018. Patients with TBI, extracranial orthopedic injuries (orthopedic controls), and individuals without reported injuries (eg, friends and family of participants; hereafter friend controls) were prospectively followed for 12 months. Data were analyzed from January 2020 to April 2021. Demographic, imaging, and clinical information was collected according to TBI Common Data Elements. Incidence of self-reported PTE was assessed using the National Institute of Neurological Disorders and Stroke Epilepsy Screening Questionnaire (NINDS-ESQ). Primary outcomes included Glasgow Outcome Scale Extended, Rivermead Cognitive Metric (RCM; derived from the Rivermead Post Concussion Symptoms Questionnaire), and the Brief Symptom Inventory-18 (BSI). Of 3296 participants identified as part of the study, 3044 met inclusion criteria, and 1885 participants (mean [SD] age, 41.3 [17.1] years; 1241 [65.8%] men and 644 [34.2%] women) had follow-up information at 12 months, including 1493 patients with TBI; 182 orthopedic controls, 210 uninjured friend controls; 41 patients with TBI (2.8%) and no controls had positive screening results for PTE. Compared with a negative screening result for PTE, having a positive screening result for PTE was associated with presenting Glasgow Coma Scale score (8.1 [4.8] vs.13.5 [3.3]; P < .001) as well as with anomalous acute head imaging findings (risk ratio, 6.42 [95% CI, 2.71-15.22]). After controlling for age, initial Glasgow Coma Scale score, and imaging findings, compared with patients with TBI and without PTE, patients with TBI and with positive PTE screening results had significantly lower Glasgow Outcome Scale Extended scores (mean [SD], 6.1 [1.7] vs 4.7 [1.5]; P < .001), higher BSI scores (mean [SD], 50.2 [10.7] vs 58.6 [10.8]; P = .02), and higher RCM scores (mean [SD], 3.1 [2.6] vs 5.3 [1.9]; P = .002) at 12 months. In this cohort study, the incidence of self-reported PTE after TBI was found to be 2.8% and was independently associated with unfavorable outcomes. These findings highlight the need for effective antiepileptogenic therapies after TBI.

Factors Affecting Neurosurgeons' Decisions to Forgo Life-Sustaining Treatments After Traumatic Brain Injury

Traumatic brain injury (TBI) is a multifaceted condition that causes mortality and disability worldwide. Limited data are available on the factors associated with the decision for the withdrawal of life-sustaining treatment (WLST) for patients with TBI. In the present study, we aimed to determine the risk factors and attitudes affecting neurosurgeons when deciding on WLST for patients with TBI using a multicenter survey. An online questionnaire was applied worldwide and shared using social media platforms and electronic mail to ∼5000 neurosurgeons. The social media group "Neurosurgery Cocktail" was used to post a link to the questionnaire. In addition, randomly chosen neurosurgery clinics around the world were sent the survey via electronic mail. Of the participants, 17.22% had decided on WLST after TBI for >26 patients. Neurosurgeons with more WLST decisions were older, had had more clinical experience and intensive care unit (ICU) training, and were better prepared to involve the family members of TBI patients in their decision-making compared with those with fewer WLST decisions. The respondents stated that the patient's family, ICU consultants, and themselves played the most influential role in the WLST decisions, with the hospital administration, social workers, spiritual caregivers, and nurses having lesser roles. The current and presenting Glasgow coma scale scores, pupillary response, advanced patient age, candidates for a vegetative state, and impaired neurological function were significant factors associated with the WLST decision. To the best of our knowledge, the present study is the first to evaluate neurosurgeons concerning their opinions and behaviors regarding WLST decisions after TBI. Increased patient age, Glasgow coma scale score, pupillary response, the presence of comorbidities, candidacy for a vegetative state, and impaired neurological function were the main factors contributing to the decision for WLST. We also found that the family, ICU consultants, and the attending neurosurgeon had the most effective roles in the decisions regarding WLST.

A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits.

Large experiences with the treatment of pediatric arteriovenous malformations (AVMs) remain relatively rare, with limited data on presentation, treatment, and long-term functional outcomes. Because of the expected long lifespan of children, caregivers are especially interested in outcome measures that assess quality of life. The authors' intention was to describe the long-term functional outcomes of pediatric patients who undergo AVM surgery and to identify predictors of sustained neurological deficits. The authors analyzed a 21-year retrospective cohort of pediatric patients with intracranial AVMs treated with microsurgery at two institutions. The primary outcome was a persistent neurological deficit at last follow-up. Secondary outcome measures included modified Rankin Scale (mRS) score and independent living. Overall, 97 patients (mean age 11.1 ± 4.5 years; 56% female) were treated surgically for intracranial AVMs (mean follow-up 77.5 months). Sixty-four patients (66%) presented with hemorrhage, and 45 patients (46%) had neurological deficits at presentation. Radiologically, 39% of lesions were Spetzler-Martin grade II. Thirty-seven patients (38%) with persistent neurological deficits at last follow-up were compared with those without deficits; there were no differences in patient age, presenting Glasgow Coma Scale score, AVM size, surgical blood loss, or duration of follow-up. Multivariate analysis demonstrated that a focal neurological deficit on presentation, AVM size > 3 cm, and lesions in eloquent cortex were independent predictors of persistent neurological deficits at long-term follow-up. Overall, 92% of the children had an mRS score ≤ 2 on long-term follow-up. Pediatric patients with AVMs treated with microsurgical resection have good functional and radiological outcomes. There is a high rate (38%) of persistent neurological deficits, which were independently predicted by preoperative deficits, AVMs > 3 cm, and lesions located in eloquent cortex. This information can be useful in counseling families on the likelihood of long-term neurological deficits after cerebral AVM surgery.

Management of Isolated Skull Fractures in Pediatric Patients: A Systematic Review.

Isolated skull fractures (ISFs) in children are one of the most common emergency department injuries. Recent studies suggest these children may be safely discharged following ED evaluation with little risk of delayed neurological compromise. The aim of this study was to propose an evidence-based protocol for the management of ISF in children in an effort to reduce medically unnecessary hospital admissions. Using PubMed and The Cochrane Library databases, a literature search using the search terms (pediatric OR child) AND skull fracture AND (isolated OR linear) was performed. Three hundred forty-three abstracts were identified and screened based on the inclusion criteria: (1) linear, nondepressed ISF; (2) no evidence of intracranial injury; (3) age 18 years or younger; and (4) data on patient outcomes and management. Data including age, Glasgow Coma Scale score on arrival, repeat imaging, admission rates, need for neurosurgical intervention, and patient outcome were collected. Two authors reviewed each study for data extraction and quality assessment. Fourteen articles met the eligibility criteria. Data including admission rates, outcomes, and necessity of neurosurgical intervention were analyzed. Admission rates ranged from 56.8% to 100%; however, only 8 of more than 5000 patients developed new imaging findings after admission, all of which were nonsurgical. Only 1 patient required neurosurgical intervention for a finding evident upon initial evaluation. Pediatric ISF patients with a presenting Glasgow Coma Scale score of 15 who are neurologically intact and tolerating feeds without concern for nonaccidental trauma or an unstable social environment can safely be discharged following ED evaluation to a responsible caregiver.

Ability of Serum Glial Fibrillary Acidic Protein, Ubiquitin C-Terminal Hydrolase-L1, and S100B To Differentiate Normal and Abnormal Head Computed Tomography Findings in Patients with Suspected Mild or Moderate Traumatic Brain Injury.

Head computed tomography (CT) imaging is still a commonly obtained diagnostic test for patients with minor head injury despite availability of clinical decision rules to guide imaging use and recommendations to reduce radiation exposure resulting from unnecessary imaging. This prospective multicenter observational study of 251 patients with suspected mild to moderate traumatic brain injury (TBI) evaluated three serum biomarkers' (glial fibrillary acidic protein [GFAP], ubiquitin C-terminal hydrolase-L1 [UCH-L1] and S100B measured within 6 h of injury) ability to differentiate CT negative and CT positive findings. Of the 251 patients, 60.2% were male and 225 (89.6%) had a presenting Glasgow Coma Scale score of 15. A positive head CT (intracranial injury) was found in 36 (14.3%). UCH-L1 was 100% sensitive and 39% specific at a cutoff value >40 pg/mL. To retain 100% sensitivity, GFAP was 0% specific (cutoff value 0 pg/mL) and S100B had a specificity of only 2% (cutoff value 30 pg/mL). All three biomarkers had similar values for areas under the receiver operator characteristic curve: 0.79 (95% confidence interval; 0.70–0.88) for GFAP, 0.80 (0.71–0.89) for UCH-L1, and 0.75 (0.65–0.85) for S100B. Neither GFAP nor UCH-L1 curve values differed significantly from S100B (p = 0.21 and p = 0.77, respectively). In our patient cohort, UCH-L1 outperformed GFAP and S100B when the goal was to reduce CT use without sacrificing sensitivity. UCH-L1 values <40 pg/mL could potentially have aided in eliminating 83 of the 215 negative CT scans. These results require replication in other studies before the test is used in actual clinical practice.

"After-hours" staffing of trauma centres and outcomes among patients presenting with acute traumatic coagulopathy.

To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC). Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011. Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality. There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P=0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10-2.87). The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.

A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15

Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention. We hypothesized that repeat computed tomography in persons with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical progression of neurologic symptoms, does not impact the need for neurosurgical intervention or discharge GCS scores. This prospective cohort study followed all patients presenting to our urban Level I trauma center with intracranial hemorrhage and a GCS score of 13 to 15 from February 2010 to December 2010. Subjects were divided into two groups: those in whom repeat CT scans were performed routinely (ROUTINE) and those in whom they were performed selectively (SELECTIVE) based on changes in clinical examination. CT scanning decisions were made at the discretion of the neurosurgical service attending physician. One hundred forty-five patients met the inclusion criteria (ROUTINE, n = 92; SELECTIVE, n = 53). Group demographics, including age, sex, and presenting GCS score were not significantly different. Of SELECTIVE patients, six (11%) required a repeat head computed tomography for a neurologic change, with one having a radiographic progression of hemorrhage (16%) versus 26 (28%) of 92 in the ROUTINE group showing a radiographic progression. No patient in either group required medical or neurosurgical intervention based on repeat scan. The number of CT scans performed differed between the two groups (three scans in ROUTINE vs. one scan in SELECTIVE, p < 0.001), as did the intensive care unit (2 days vs. 1 day, p < 0.001) and hospital (5 days vs. 2 days, p < 0.001) lengths of stay. Discharge GCS score was similar for both groups (15 vs. 15, p = 0.37). One death occurred in the SELECTIVE group, unrelated to intracranial findings. The negative predictive value of a repeat CT scan leading to neurosurgical intervention with no change in clinical examination was 100% for both groups. A practice of selective repeat head CT scans in patients with traumatic brain injury admitted with a GCS score of 13 to 15 decreases use of the test and is associated with decreased hospital length of stay, without impacting discharge GCS scores. Diagnostic study, level II.

The Subdural Evacuation Port System: Outcomes from a single institution experience and predictors of success

IntroductionNumerous surgical options for treatment of chronic subdural hematomas (cSDH) exist. Several reports have examined the Subdural Evacuating Port System (SEPS), a variation of the twist drill craniotomy (TDC) technique. Although high success rates have been reported, a significant portion of patients treated with SEPS fail and require additional procedures. This report examines the largest single institution experience with the SEPS and explores patient and imaging characteristics associated with successful procedures. MethodsA retrospective chart review was performed to identify all patients who have undergone SEPS drainage of cSDH. Demographic and radiographic characteristics were evaluated. Demographic data included patient's age, sex, presenting symptoms, pre-procedural GCS score, and use of anticoagulation or antiplatelet agents. The volume of drainage per procedure and radiographic data including laterality, density, and maximal diameter of the collection, presence of septations, midline shift, resolution of the collection 3 weeks post procedure, and measurements to assess atrophy were collected. Total length of stay and time in the intensive care unit was also recorded. Results were classified as a success or failure based on the need for additional procedures including craniotomy or burr hole craniotomy in the operating room. Patients treated with two SEPS procedures during the same hospitalization and no other procedures were included in the success group for statistical analyses. Results171 subdural collections were treated in 159 patients (147 unilateral and 12 bilateral). One hundred thirty three collections (77.8%) were successfully drained. In a comparison of the success and failure groups, there were no statistically significant differences (p<0.05) in the patients’ mean age, sex, presenting Glasgow Coma Scale score, coagulation profile, presenting symptoms (except altered mental status and language disturbance), subdural diameter or laterality, midline shift, presence of atrophy, density of most acute portion, or time in hospital. In the success group, there was a shorter mean stay in the intensive care unit (S: 4.1±4.5 days vs F: 5.4±4.6 days; p=0.03) and a larger output drained (S: 131.1±71.2ml vs F: 99.0±84.2ml; p=0.04). Success was less likely with mixed density collections (S: 38.2% vs F: 64.3%; p=0.02) and with collections containing greater than 2 intrahematomal septations (S: 17.1% vs F: 40.7%; p=0.007). In successful cases, mean volumes for collections prior to SEPS, immediately after SEPS, and on delayed scans (≥30 days since SEPS placement) the respective volumes were 83.1±35.1ml, 41.5±23.2ml, and 37.9±26.5ml. Both post-SEPS volumes were less than the pre-SEPS volume (p<0.0001). 76.0% of patients with delayed scans had complete resolution of cSDH or minimal residual cSDH with no local mass effect on the most recent imaging. The mean period of follow-up imaging was 95.6±196.2 days. Only one patient in our series required an emergent craniotomy following immediate complications from SEPS placement. ConclusionsThe SEPS is an effective, safe, and durable treatment for cSDH. Although we consider the SEPS a first-line treatment for the majority of patients with cSDH, management of cSDH must be tailored to each patient. In mixed density collections with large proportions of acute hemorrhage and in collections with numerous intrahematomal septations, alternative surgical techniques should be considered as first-line therapies.

Decompressive Craniectomy in 14 Children With Severe Head Injury: Clinical Results With Long-Term Follow-Up and Review of the Literature

Decompressive craniectomy (DC) is a controversial therapeutic measure used in patients with intractable intracranial hypertension after severe head injury. This study describes the morbidity and mortality of DC in 14 children with a mean follow-up of 3.2 years. We review published evidence from the past 10 years on the indications for DC in pediatric brain trauma. We also examine timing, surgical technique, and the results of this procedure. We retrospectively reviewed patients who underwent DC from 2002 to 2010. Clinical data were collected at admission, as were data on the indication for craniectomy, timing, and surgical technique. Perioperative intracranial pressure (ICP), complications of craniectomy, and Glasgow Outcome Scale score at 2 years were recorded as outcome variables. Fourteen craniectomies were performed. The median presenting Glasgow Coma Scale score was 6.5 (range, 4-15). Ten patients were presented with anisocoria. In 13 patients, craniectomy initially decreased ICP to <25 mm Hg. Two patients (14%) had a poor prognosis on admission and died. The most frequent complications were hygroma (8 patients) and infections (3 patients). The mean Glasgow Outcome Scale score at the 2-year follow-up visit was 4.4 (range, 4-5). Behavioral and psychiatric abnormalities and poor academic performance were frequent (82%). DC reduces ICP in pediatric patients with traumatic brain injury. The mortality rate is low and long-term prognosis in survivors is good. Complications related to surgery are frequent. Wide craniectomy with duraplasty seems to be the most common technique. Defining the most appropriate indications and timing for DC in pediatric patients should be the objective of future prospective studies.

Clinical outcome of leukemia patients with intracranial hemorrhage

Intracranial hemorrhage (ICH) is a frequent complication found in leukemia patients with thrombocytopenia. At the University of Texas MD Anderson Cancer Center, when a leukemia patient is found to have ICH, a platelet transfusion is generally recommended until 50,000/μl is reached. The authors examine the feasibility and outcome of their intervention strategy in this study. Records were reviewed from 76 consecutive leukemia patients with newly diagnosed ICH at the University of Texas MD Anderson Cancer Center from January 1, 2007, to December 31, 2009. Variables of interest included age, platelet count at presentation, leukemia subtype, history of trauma, Glasgow Coma Scale score at presentation, whether the 50,000/μl goal was reached after transfusion, and whether the patient was a transfusion responder (platelet count increase > 2000/μl/unit transfused). Outcome parameters were mortality rates at 72 hours and 30 days and imaging-documented hemorrhage progression. Thrombocytopenia was prevalent at the time of presentation (68 of 76 patients had platelet levels < 50,000/μl at presentation). Despite an aggressive transfusion protocol, only 24 patients reached the 50,000/μl target after an average of 16 units of transfusion. Death due to ICH occurred in 15 patients within the first 72 hours (mortality rate 19.7%). Death correlated with the presenting Glasgow Coma Scale score (p = 0.0075) but not with other transfusion-related parameters. A significant mortality rate was again observed after 30 days (32.7%). The 30-day mortality rate, however, was largely attributable to non-ICH related causes and correlated with patient age (p = 0.032) and whether the patient was a transfusion responder (p = 0.022). Reaching and maintaining a platelet count > 50,000/μl did not positively correlate with the 30-day mortality rate (p = 0.392 and 0.475, respectively). Platelet transfusion in the setting of ICH in leukemia patients is undoubtedly necessary, but whether the transfusion threshold should be 50,000/μl remains unclear. Factors other than thrombocytopenia likely contribute to the overall poor prognosis.

Fractures of the clivus and traumatic diastasis of the central skull base in the pediatric population

Fractures of the clivus and traumatic diastases of the clival synchondroses are rare in the pediatric population. The incidence, outcome, and biomechanics associated with these fractures have been difficult to ascertain secondary to the lack of literature pertaining to their occurrence. A Boolean search of the electronic medical record database at the Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, was performed to identify patients with fractures of the clivus that were diagnosed using CT of the head. A retrospective review of the chart and radiographic imaging was then performed to assess data regarding patient demographics, mechanism of injury, and skull and brain parenchymal injuries, as well as outcomes. Between May 2002 and November 2007, 16 patients with fractures of the clivus were identified. The mean age of these patients was 9 years (range 1-16 years). Eleven (68.8%) of the 16 patients had an associated traumatic diastasis of the central skull base. Five (31.3%) of the 16 patients died. However, of the 11 patients who survived, all had a good outcome with a Glasgow Outcome Scale score of 4 or 5 at the time of discharge. The incidence of clival fractures among patients with head injuries was 0.33%. Clival fractures occur with a similar incidence in both the pediatric and adult trauma population. Outcome is not correlated directly with the extent of clival fracture, but rather with the presenting Glasgow Coma Scale score and concomitant brain parenchymal injuries. The identification of traumatic diastases in patients with clival fractures suggests that static loading forces are a significant factor in the biomechanics producing these types of fractures.

HYPERTONIC SALINE AND ITS EFFECT ON INTRACRANIAL PRESSURE, CEREBRAL PERFUSION PRESSURE, AND BRAIN TISSUE OXYGEN

Hypertonic saline is emerging as a potentially effective single osmotic agent for control of acute elevations in intracranial pressure (ICP) caused by severe traumatic brain injury. This study examines its effect on ICP, cerebral perfusion pressure (CPP), and brain tissue oxygen tension (PbtO2). Twenty-five consecutive patients with severe traumatic brain injury who were treated with 23.4% NaCl for elevated ICP were evaluated. Bolt catheter probes were placed in the noninjured hemisphere, and hourly ICP, mean arterial pressure, CPP, and PbtO2 values were recorded. Thirty milliliters of 23.4% NaCl was infused over 15 minutes for intracranial hypertension, defined as ICP greater than 20 mm Hg. Twenty-one male patients and 4 female patients aged 16 to 64 years were included. The mean presenting Glasgow Coma Scale score was 5.7. Mean pretreatment values included an ICP level of 25.9 mm Hg and a PbtO2 value of 32 mm Hg. The posttreatment ICP level was decreased by a mean of 8.3 mm Hg (P < 0.0001), and there was an improvement in PbtO2 of 3.1 mm Hg (P < 0.01). ICP of more than 31 mm Hg decreased by 14.2 mm Hg. Pretreatment CPP values of less than 70 mm Hg increased by a mean of 6 mm Hg (P < 0.0001). No complications occurred from this treatment, with the exception of electrolyte and chemistry abnormalities. At 6 months postinjury, the mortality rate was 28%, with 48% of patients achieving a favorable outcome by the dichotomized Glasgow Outcome Scale. Hypertonic saline as a single osmotic agent decreased ICP while improving CPP and PbtO2 in patients with severe traumatic brain injury. Patients with higher baseline ICP and lower CPP levels responded to hypertonic saline more significantly.