Severe Head-injured Patients Research Articles

Neuropeptide Y-like immunoreactivity in lumbar cerebrospinal fluid of patients after severe head trauma.

We studied head-injured patients assessed after admission to the hospital according to the Glasgow coma scale (3-8 points). All of them underwent surgical procedure after neuroradiological examination. Due to therapeutic problems, some of these patients had lumbar puncture on the fourth day following surgery. The control group consisted of patients with lumbosacral discopathy in whom lumbar puncture was performed during radiculography. The level of neuropeptide Y (NPY) was examined in 5 ml of cerebrospinal fluid (CSF). The concentration of NPY in CSF was assayed radioimmunologically. Taking into account our results and the clinical course of disease we suggest that high concentration of NPY in lumbar fluid in severe head-injured patients may contribute to poor clinical outcome.

Neurobehavioral outcome of closed head injury: Implications for clinical trials

ABSTRACT This review encompasses the neurobehavioral sequelae of moderate to severe closed head injury (CHI). Following a discussion of posttraumatic amnesia and its measurement, the paper discusses assessment of the global outcome of CHI using the Glasgow Outcome Scale. Domains of residual neurobehavioral sequelae that are reviewed include attention/information processing speed, memory, language, intellectual ability, executive functions, and motor speed. The contribution of behavioral disturbance and psychosocial maladjustment to overall outcome is reviewed, as is the impact on the family. Finally, the neurobehavioral outcome measures for clinical trials involving moderate to severe head-injured patients are presented. Caveats for completing clinical trials that involve assessment of neurobehavioral functioning are provided. Key words: closed head injury; Glasgow Outcome Scale; posttraumatic amnesia; neurobehavioral sequelae

Relationship between arterial carbon dioxide and end-tidal carbon dioxide in mechanically ventilated adults with severe head trauma

To examine the agreement and association of a noninvasive method of measuring CO2 (using end-tidal PCO2) with PaCO2 in mechanically ventilated adults with severe head trauma. A prospective, quasi-experimental, repeated-measures study was used to compare end-tidal PCO2 and PaCO2 at two time points: before and after a standardized endotracheal suctioning procedure. Controlled intervention of endotracheal suctioning. The study was conducted at two intensive care units designated as Level 1 trauma centers. A consecutive sample of 35 severe head-injured patients with a Glasgow Coma Scale score of < or = 8. End-tidal PCO2 and PaC02 values were simultaneously obtained and compared. End-tidal PCO2 was measured, using a sidestream sensor placed in line of the ventilator circuit's deadspace. Arterial gases were drawn from an indwelling arterial catheter. No relationship was found between arterial and end-tidal measures (range r2 = .09 to r2 = .11). Using the Bland-Altman technique, agreement decreased as the amount of positive end-expiratory pressure increased. When a subset of patients (mechanically ventilated, with positive end-expiratory pressures of < 5 cm H2O, paralyzed, and sedated) were examined (n = 12), the correlation between the CO2 measures improved (r2 = .77). This study indicated that end-tidal PCO2 monitoring correlated well with PaCO2 in patients without respiratory complications or without spontaneous breathing, resulting in rebreathing of gases. However, its clinical validity is questionable in patients who have the greatest need for end-tidal PCO2 monitoring (i.e., patients who have respiratory distress or who are breathing spontaneously and overriding the ventilator.

Post-traumatic apallic syndrome following head injury. Part 1: Clinical characteristics

Epidemiological studies made within the western countries indicate an incidence of 200-300 traumatic head injuries per 100 000 residents each year. Severe head injuries account for 5-25% of all head injuries; 10-14% of all severe head-injured patients develop into a vegetative state, in which a sleep-wake rhythm is apparent, but however in which there is no evidence of awakeness or reactivity to the environment. The most commonly used labels, in the German and international literature, for these patients are 'vegetative state', 'apallic syndrome' and 'coma vigile'. This clinical characterization is not sufficient. It is necessary to employ additional criteria to distinguish subsets of vegetative patients e.g. computerized tomography, magnetic resonance imaging, single photon emission tomography, electroencephalography, brainstem reflexes, evoked potentials, assessment scales, age, premorbid brain disorders. Diagnostic and prognostic parameters must form the basis for various decisions relating to patients' care and intervention.

Neurobehavioral outcome of closed head injury: implications for clinical trials.

This review encompasses the neurobehavioral sequelae of moderate to severe closed head injury (CHI). Following a discussion of posttraumatic amnesia and its measurement, the paper discusses assessment of the global outcome of CHI using the Glasgow Outcome Scale. Domains of residual neurobehavioral sequelae that are reviewed include attention/information processing speed, memory, language, intellectual ability, executive functions, and motor speed. The contribution of behavioral disturbance and psychosocial maladjustment to overall outcome is reviewed, as is the impact on the family. Finally, the neurobehavioral outcome measures for clinical trials involving moderate to severe head-injured patients are presented. Caveats for completing clinical trials that involve assessment of neurobehavioral functioning are provided.

Early, routine paralysis for intracranial pressure control in severe head injury: is it necessary?

To investigate the efficacy of early, routine use of neuromuscular blocking agents for intracranial pressure management in patients with severe head injury. Retrospective review of data from the Traumatic Coma Data Bank. The Traumatic Coma Data Bank was a collaborative project of the National Institute of Neurological Disorders and Stroke that involved four Level I trauma centers. The Traumatic Coma Data Bank prospectively collected data on 1,030 severe head-injured patients (Glasgow Coma Score of < or = 8) between 1984 and 1987. Four Level I trauma centers coordinated by the National Institute of Neurological Disorders and Stroke. A total of 514 Traumatic Coma Data Bank patients who met study inclusion criteria were divided into two groups: group 1 consisted of 239 patients who were pharmacologically paralyzed starting within the first intensive care unit (ICU) shift or < or = 6 hrs into the second shift and lasting for at least 12 hrs. Group 2 contained the remaining 275 patients who did not fulfill these criteria. We analyzed the acute care course of these patients from the time of injury through admission, resuscitation, and ICU stay, as well as their rehabilitation follow-up results for < or = 1 yr. These two groups did not differ significantly regarding admission intracranial computed tomography diagnosis, admission Glasgow motor score, percentage of monitored time that intracranial pressure was > or = 20 mm Hg, or frequency of initial intracranial pressure > or = 20 mm Hg. In group 2, more patients were aged > 40 yrs (24% vs. 15% in group 1) or had admission hypotension (33% in group 2 vs. 25% in group 1). Multivariate regression analysis showed that ICU stay was significantly longer in group 1 (mean 7.76 days) than group 2 (mean 4.84 days; p < .001). The occurrence of pneumonia was significantly higher in group 1 (29% vs. 15%, p < .001). There was a tendency toward a higher occurrence of sepsis in group 1, but this difference did not reach statistical significance (11% vs. 7%, p = .08). The final Glasgow Outcome Scale scores for the two groups were not significantly different in those survivors with good and moderate outcomes. Although there were more deaths in group 2 (39% vs. 24%, p < .001), there were more vegetative or severely disabled survivors in group 1 (8% vs. 4% and 21% vs. 13%, respectively). Our findings suggest that early, routine, long-term use of neuromuscular blocking agents in patients with severe head injuries to manage intracranial pressure does not improve overall outcome and may actually be detrimental because of the prolongation of their ICU stay and the increased frequency of extracranial complications associated with pharmacologic paralysis. We suggest that routine early management of the head-injured patient in the ICU should be accomplished using sedation alone and that neuromuscular blockade should be generally reserved for patients with intracranial hypertension who require escalation of treatment intensity.

Médicalisation préhospitalière héliportée et agressions cérébrales secondaires d'origine systémique chez les traumatisés craniocérébraux graves

Advanced supportive therapy at the site of the accident, associated with direct transfer to a trauma centre increases survival and reduces morbidity rates. Patients with severe head injury, especially those with multiple injuries, often arrive in the emergency department with potentially causes of serious secondary systemic insults to the already injured brain, such as acute anemia (Hematocrit ≤ 30 %), hypotension (systolic arterial pressure (Pa sys) ≤ 95 mmHg, 12,7 kPa), hypercapnia (Pa CO 2 ≥ 45 mmHg, 6 kPa) and/or hypoxemia (Pao 2 ≤ 65 mmHg, 8,7 kPa). The incidence of such insults and their impact on mortality were studied in a group of 51 consecutive adults suffering from non penetrating severe head injury (Glasgow score ≤ 8, mean age 31 ± 17 yrs) rescued by a medicalised helicopter. Each patient received medical care on the site of the accident by an anaesthesiologist of a university hospital (UH) complying with an advanced trauma life support protocol including intubation, hyperventilation with F IO 2 = 1, restoration of an adequate Pa sys and direct transportation to the UH. Mean delay from call to arrival of the rescue team on the site was 15 ± 5 min. Mean scene time was 32 ± 10 min in cases not requiring extrication. Nineteen patients (Group I) were admitted without secondary systemic insults to the brain, 13 with isolated head injury, and 6 with multiple injuries, with a low Glasgow Outcome Score (GOS 1–3) of 42 % at 3 months. In 32 patients (Group II), despite advanced supportive measures at the scene of the accident and during transportation, one or more secondary systemic insults to the brain were detected upon arrival at the emergency room, one with isolated head injury, 31 with multiple injuries, with a bad GOS of 72 % at 3 months. We conclude that : 1) advanced trauma life support prevents from secondary systemic insults in the great majority of isolated severe head injured patients, 2) secondary systemic insults to the already injured brain are frequent in patients with multiple injuries and are difficult to avoid despite rapid aeromedical trauma care, 3) secondary systemic insults to the brain have a catastrophic impact on the outcome of severely head injured patients.

Clinical analysis of 34 diffuse axonal injured (DAI) patients below GCS 8.

A consecutive series of 34 severe head-injured patients (DAI) were studied prospectively. Patients were categorized according to a new, simple classification system comprised of four lesion types according to the compression or obliteration of the ventricles or cisterns. Five patients belonged to type II and 19 patients to type IV. Each type was further subdivided into two GCS score ranges (5 to 8 and below 5). The distribution of the posttraumatic infarction was mainly in the frontal and temporal lobes (60% of all cases). Our data demonstrated that the ICP was significantly lower at a 30 degrees head elevation than at 0 degree (18.6 +/- 7.21 mmHg vs 23.0 +/- 10.60 mmHg. t = 4.22 P < 0.001), but head position did not statistically affect CPP (69.4 +/- 19.86 mmHg vs 68.2 +/- 19.87 mmHg. t = -0.54, P < 0.59). The effect of intensive therapy on ICP, CPP and AVDO2 was studied in all cases, employing steroids and diuretics in a modified intensive care scale. In cases where barbiturates were employed, there were statistically significant changes in ICP and AVDO2 (P < 0.001), but CPP was not affected (P < 0.59). Surviving patients were analyzed by using the GOS and the neurological grading score (NGS, Nihon University) of the persistent vegetative state. Our data suggests that head elevation of 30 degrees and barbiturate therapy are more effective on ICP and AVDO2, and NGS more exact than GOS in vegetative patients.

Monitoring of severe head-injured patients with transcranial Doppler (TCD) ultrasonography.

Intracranial haemodynamics were studied in 36 patients with severe head injury and experimental animals with acute intracranial hypertension by the use of TCD ultrasound. The mean flow velocity (FV) in the basal cerebral arteries commonly decreased on the side of the haematoma depending on intracranial pressure (ICP) elevation and cerebral perfusion pressure (CPP) reduction in focal brain injury. The FV decreased bilaterally and there was no difference between the right and left sides in diffuse brain injury without a clear relationship between the FV and CPP. The FV of the middle cerebral artery and blood flow in the internal carotid artery exhibited flow patterns which changed correlatively depending on CPP reduction in experimental animals. Monitoring with TCD ultrasound is valuable in evaluating compression ischaemia in focal brain injury. But many complicated factors are considerable in diffuse brain injury.

Evolution of energy expenditure and nitrogen excretion in severe head-injured patients

The aim of the study was to estimate the influence of therapeutic changes on the level of energy expenditure (EE) and N excretion in a homogeneous group of patients usually considered hypermetabolic. EE and N excretion of head-injured patients were measured simultaneously at phases 1 and 2 (patients treated 4 +/- 3 and 18 +/- 8 days after injury, respectively). Acute care hospital. Eight severe head-injured patients, mean weight 63.1 +/- 6.1 (SD) kg, mean age 21 +/- 3.8 (SD) yr. At phase 1, all patients were sedated with fentanyl (6.7 +/- 1.9 micrograms/kg.hr) plus flunitrazepam (9.1 +/- 4.8 micrograms/kg.hr) and were mechanically ventilated. All patients received continuous total parenteral nutrition. The nonprotein caloric intake averaged 1092 +/- 200 kcal/day, including 77% glucose and 23% fat (Intralipid 20%). The total N intake averaged 7 +/- 5 g/day, consisting of crystalline amino acids. At phase 2, no patient received any sedative and all were breathing spontaneously via tracheostomy. All patients received parenteral and/or enteral nutrition. The nonprotein caloric intake averaged 1929 +/- 200 kcal/day consisting of 65% carbohydrates and 35% fat. The total N intake averaged 13 +/- 2 g/day. The EE was significantly higher at phase 2 than at phase 1 (2121 vs. 1737 kcal), but the interindividual variability was low at both phases. N excretion was high at the two periods of the study and not correlated to the level of EE. The RQ was 0.75 at both periods, indicating predominant fat oxidation. We could not demonstrate any parallelism in the evolution of EE and protein catabolism in head-injured patients. The therapeutics (mechanical ventilation, sedation, and nutrition) have a major effect on EE but little on N excretion.

Self-rating versus neuropsychological performance of moderate versus severe head-injured patients

Head-injured patients frequently appear to be inaccurate in judging their cognitive functioning. To examine this clinical impression, self-ratings were compared with neuropsychological test performances. The sample was comprised of 28 patients with severe and 28 with mild-moderate head injuries, and these two groups were further subdivided according to chronicity, i.e. less than or equal to 1 year versus greater than 1 year between the date of injury and the evaluation. The control group of 31 adults was matched according to age and education. Head-injured patients rated themselves lower than normals regardless of severity of injury. Chronicity affected only the self-rating of learning and memory. The severely head-injured were generally less accurate when comparing self-ratings to test performance. However, this was not uniform across cognitive domains. Recommendations for self-assessment in neuropsychology are discussed.

Impairment after severe blunt head injury: the results from a consecutive series of 100 patients.

Three scales, assessing the degree of brain impairment after severe blunt head injury in neurophysical and neuropsychological functions as well as overall organic functioning, are described. A consecutive series of 100 severe blunt head injured patients was followed up 6 years post-trauma and the scales were used to measure the residual impairments and determine the level of recovery for 82 subjects in the series. No subject made a complete neurophysical and neuropsychological recovery, 92% of the series was classified as suffering clinically significant impairments and in half the series the moderate or severe impairments were consistent with a poor level of recovery. The impairments of a large proportion (42%) of the series, however, were classified as mild. Although most subjects demonstrated impairments in both neurophysical and neuropsychological functions, 43% of the series suffered isolated impairments in either the neurophysical or neuropsychological areas. There was strong agreement between the overall organic impairment profile and the subjects' classifications on the Glasgow Outcome Scale.

Effects of labetalol and pindolol on nitrogen balance in severe head injured patients : [formula omitted], L. Zanardi, M. Agostini, G. Davia', A. Boninsegna and G. P. Giron (Institute of Anesthesiology and Intensive Care and Institute of Biochemistry — University of Padova — Italy)

Effects of labetalol and pindolol on nitrogen balance in severe head injured patients : [formula omitted], L. Zanardi, M. Agostini, G. Davia', A. Boninsegna and G. P. Giron (Institute of Anesthesiology and Intensive Care and Institute of Biochemistry — University of Padova — Italy)

On the nature of brain stem disorders in severe head injured patients. II. A study on caloric vestibular reactions and neurotransmitter treatment.

The results of electro-oculographic recordings made after caloric vestibular stimulation (C.O.G.) in severe head injured patients are discussed. It was found that: 1. The C.O.G. correlates with the state of consciousness of the patients. 2. The rate of improvement of the C.O.G. correlates with the rate of the clinical improvement. 3. A prediction of the duration of unconsciousness can be made by repeated C.O.G. scores as well as by repeated scoring of the clinical state. 4. In all patients a paradoxical response is present except in those who have regained clear consciousness and in those persisting in a vegetative state, so the presence of a paradoxical response indicates the possibility of further improvement. It was supposed that in patients with a paradoxical response a functional brain dysfunction was present, which was at least partly caused by disturbed neurotransmitter metabolism. Therapeutic trials with L-DOPA and physostigmine were successful in patients with a paradoxical response, but without any result in those without this phenomenon. The responses to L-DOPA and to physostigmine are related respectively to motor pattern and to verbal or non-verbal communication.

On the nature of brain stem disorders in severe head injured patients.

In head injured patients changes were found in the CSF levels of metabolites of the dopaminergic and the serotonergic neurotransmission (HVA and 5-HIAA). After the fifth day following trauma a significant decrease of the HVA levels in the lumbar CSF after probenecid treatment was found. The intensity of this decrease was found to be related to the severity of the trauma (period of unconsciousness), but not to the state of consciousness. Also the probenecid-induced 5-HIAA levels in conscious patients were decreased after the fifth post-traumatic day. In unconscious patients, the period of unconsciousness, particularly in the period of 5-20 days after trauma. Between 21 and 60 days after trauma the 5-HIAA concentrations in unconscious patients decreased remarkably, but they were still significantly higher than in the conscious patients. It can be concluded that during unconsciousness serotonergic neurons have a high rate of turnover, but that both neurotransmitter systems are damaged by the direct or indirect consequences of the injury.

Oculographic research by caloric stimulation in severe head-injured patients

Oculographic research by caloric stimulation in severe head-injured patients