Unfavorable Glasgow Outcome Scale Research Articles

The importance of additional intracranial injuries in epidural hematomas: detailed clinical analysis, long-term outcome, and literature review in surgically managed epidural hematomas.

Epidural hematomas (EDH) occur in up to 8.2% of all traumatic brain injury patients, with more than half needing surgical treatment. In most patients suffering from this perilous disease, good recovery with an excellent clinical course is possible. However, the clinical course is mainly dependent on the presence of additional intracerebral injuries. Few studies comparing isolated and combined EDH in detail exist. We performed a retrospective single-center study from April 2002 to December 2014. The mean follow-up time was more than 6 years. In addition to analyzing diverse clinicoradiological data, we performed a systematic literature review dealing with a detailed comparison of patients with (combined) and without (isolated) additional intracerebral injuries. We included 72 patients in the study. With increasing age, combined EDH had a higher incidence than isolated EDH. The mortality rate of the patients in the cohort was 10%, of which 0% had isolated EDH and 10% had combined EDH. Good recovery was achieved in 69% of patients, of which 91% had isolated EDH and 50% had combined EDH. A subgroup analysis of the different additional intracerebral injuries in combined EDH demonstrated no significant difference in outcome. A systematic literature review only identified six studies. Patients with isolated EDH had a statistically significantly lower mortality risk [relative risk (RR): 0.22; 95% CI: 0.12-0.39] and a statistically significantly lower risk of unfavorable Glasgow outcome scale score (RR: 0.21; 95% CI: 0.14-0.31) than patients with combined EDH. An excellent outcome in patients with surgically treated isolated EDH is possible. Furthermore, patients with combined EDH or isolated EDH with a low Glasgow coma scale (GCS) score may have favorable outcomes in 50% of the cases. Therefore, every possible effort for treatment should be made for this potentially lethal injury.

The association of radiologic body composition parameters with clinical outcomes in level-1 trauma patients

PurposeThe present study aims to assess whether CT-derived muscle mass, muscle density, and visceral fat mass are associated with in-hospital complications and clinical outcome in level-1 trauma patients.MethodsA retrospective cohort study was conducted on adult patients admitted to the University Medical Center Utrecht following a trauma between January 1 and December 31, 2017. Trauma patients aged 16 years or older without severe neurological injuries, who underwent a CT that included the abdomen within 7 days of admission, were included. An artificial intelligence (AI) algorithm was used to retrieve muscle areas to calculate the psoas muscle index and to retrieve psoas muscle radiation attenuation and visceral fat (VF) area from axial CT images. Multivariable logistic and linear regression analyses were performed to assess associations between body composition parameters and outcomes.ResultsA total of 404 patients were included for analysis. The median age was 49 years (interquartile range [IQR] 30–64), and 66.6% were male. Severe comorbidities (ASA 3–4) were seen in 10.9%, and the median ISS was 9 (IQR 5–14). Psoas muscle index was not independently associated with complications, but it was associated with ICU admission (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.65–0.95), and an unfavorable Glasgow Outcome Scale (GOS) score at discharge (OR 0.62, 95% CI 0.45–0.85). Psoas muscle radiation attenuation was independently associated with the development of any complication (OR 0.60, 95% CI 0.42–0.85), pneumonia (OR 0.63, 95% CI 0.41–0.96), and delirium (OR 0.49, 95% CI 0.28–0.87). VF was associated with developing a delirium (OR 1.95, 95% CI 1.12–3.41).ConclusionIn level-1 trauma patients without severe neurological injuries, automatically derived body composition parameters are able to independently predict an increased risk of specific complications and other poor outcomes.

The efficacy of tranexamic acid treatment with different time and doses for traumatic brain injury: a systematic review and meta-analysis

ObjectiveTranexamic acid (TXA) plays a significant role in the treatment of traumatic diseases. However, its effectiveness in patients with traumatic brain injury (TBI) seems to be contradictory, according to the recent publication of several meta-analyses. We aimed to determine the efficacy of TXA treatment at different times and doses for TBI treatment.MethodsPubMed, MEDLINE, EMBASE, Cochrane Library, and Google Scholar were searched for randomized controlled trials that compared TXA and a placebo in adults and adolescents (≥ 15 years of age) with TBI up to January 31, 2022. Two authors independently abstracted the data and assessed the quality of evidence.ResultsOf the identified 673 studies, 13 involving 18,675 patients met our inclusion criteria. TXA had no effect on mortality (risk ratio (RR) 0.99; 95% confidence interval (CI) 0.92–1.06), adverse events (RR 0.93, 95% Cl 0.76–1.14), severe TBI (Glasgow Coma Scale score from 3 to 8) (RR 0.99, 95% Cl 0.94–1.05), unfavorable Glasgow Outcome Scale (GOS < 4) (RR 0.96, 95% Cl 0.82–1.11), neurosurgical intervention (RR 1.11, 95% Cl 0.89–1.38), or rebleeding (RR 0.97, 95% Cl 0.82–1.16). TXA might reduce the mean hemorrhage volume on subsequent imaging (standardized mean difference, -0.35; 95% CI [-0.62, -0.08]).ConclusionTXA at different times and doses was associated with reduced mean bleeding but not with mortality, adverse events, neurosurgical intervention, and rebleeding. More research data is needed on different detection indexes and levels of TXA in patients with TBI, as compared to those not receiving TXA; although the prognostic outcome for all harm outcomes was not affected, the potential for harm was not ruled out.Trial registrationThe review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42022300484).

Factors Influencing Outcome and Mortality of Brain Abscess in Mosul City

Background: Brain abscess by definition is a crucial pus collection inside the brain, resulted from the infection by a variety of bacteria, fungi, and parasite. It can be single or multiple. The size, position, and number of lesions, as well as the organism's pathogenicity, host reactions, and the severity of cerebral edema, all influence the presentation. Objective: To assess how well a brain abscess was managed and to evaluate the patients with favorable and unfavorable Glasgow outcome scale (GOS). Patients and methods: From January 2014 to January 2021, the study was achieved and conducted in the Neurosurgical Department of Ibn-Sina Teaching Hospital on Mosul's left coast. The neurosurgery unit managed a case series investigation of 70 patients who had a brain abscess. Age, sex, duration of illness, initial neurosurgical status, and abscess features are among the clinical data. A comparison was performed between patient with Favorable Glasgow outcome scale (GOS), moderate disability or those with good recovery and those with Unfavorable GOS, death or persist vegetate status outcome at discharge. Results: The study involved 48 male and 22 female patients (male / female ratios 2.2:1). The series consist of 52 patients who experienced favorable outcome and 18 resulted from an unfavorable outcome. The mean of age for those patients was 20 years. The difference between males and females regarding favorable and unfavorable outcomes is insignificant. P-value was significant in cyanotic congenital heart diseases as cause of brain abscess were particularly prevalent among the children (adult VS children = 1:9). The most common site for single abscesses was the frontal lobe (25 patients), and majority of patients treated with burr hole drainage, which had the best results. Conclusion: Although there were technological improvement of imaging and antibiotics treatment, the mortality of brain abscesses is still relatively high, especially among those with decreased level of consciousness on admission.

Accuracy of Optic Nerve Sheath Diameter Measurement as a Predictor of Intracranial Pressure in Traumatic Brain Injury

Background: Ultrasound assessment of optic nerve sheath diameter (ONSD) has been used as a promising tool to aid in the diagnosis of elevated intracranial pressure (ICP). Optic nerve sheath is contiguous with the dura matter surrounding the brain and contains cerebrospinal fluid, which allows transmission of pressure from the cranium. Objective: To determine the diagnostic accuracy of measurement of ONSD by using ocular ultrasonography to detect elevated ICP in patients with TBI in Emergency Department. Patients and methods: This prospective cross-sectional observational study that was carried out on 99 patients presented and admitted to Mansoura University Emergency Hospital with traumatic brain injury (TBI) over a year from June 2020 to June 2021. Results: The clinical features of raised ICP had low specificity (38%), positive predictive value (PPV) (61.7%), and accuracy (69%) for diagnosis of raised ICP with high significant statistical difference (62% vs 100%) towards group 2. The ONSD were much higher (P 5 mm with sensitivity of 100 %, specificity of 96%, and accuracy of 99%. The optimal cutoff value to predict mortality rate was >6.8 mm with modest sensitivity and accuracy. While the optimal value to predict unfavorable Glasgow Outcome Scale (GOS) was >6.05 mm with high sensitivity and accuracy. Conclusion: ONSD measurement via bedside ocular ultrasound is a useful, non-invasive method for early diagnosis of elevated ICP in adult patients with TBI in the Emergency Department.

Tranexamic acid is associated with reduced mortality, hemorrhagic expansion, and vascular occlusive events in traumatic brain injury \u2013 meta-analysis of randomized controlled trials

BackgroundThis systematic review and meta-analysis aimed to synthesize the latest evidence on the efficacy and safety of tranexamic acid (TXA) on traumatic brain injury (TBI).MethodsWe performed a systematic literature search on topics that compared intravenous TXA to placebo in patients with TBI up until January 2020 from several electronic databases.ResultsThere were 30.522 patients from 7 studies. Meta-analysis showed that TXA was associated with reduced mortality (RR 0.92 [0.88, 0.97], p = 0.002; I2: 0%) and hemorrhagic expansion (RR 0.79 [0.64, 0.97], p = 0.03; I2: 0%). Both TXA and control group has a similar need for neurosurgical intervention (p = 0.87) and unfavourable Glasgow Outcome Scale (GOS) (p = 0.59). The rate for vascular occlusive events (p = 0.09), and its deep vein thrombosis subgroup (p = 0.23), pulmonary embolism subgroup (p = 1), stroke subgroup (p = 0.38), and myocardial infarction subgroup (p = 0.15) were similar in both groups. Subgroup analysis on RCTs with low risk of bias showed that TXA was associated with reduced mortality and hemorrhagic expansion. TXA was associated with reduced vascular occlusive events (RR 0.85 [0.73, 0.99], p = 0.04; I2: 4%). GRADE was performed for the RCT with low risk of bias subgroup, it showed a high certainty of evidence for lower mortality, less hemorrhage expansion, and similar need for neurosurgical intervention in TXA group compared to placebo group.ConclusionTXA was associated with reduced mortality and hemorrhagic expansion but similar need for neurosurgical intervention and unfavorable GOS. Vascular occlusive events were slightly lower in TXA group on subgroup analysis of RCTs with low risk of bias.

Assessment of Recovery Following Pediatric Traumatic Brain Injury.

We analyzed a prospective database of pediatric traumatic brain injury patients to identify predictors of outcome and describe the change in function over time. We hypothesized that neurologic status at hospital discharge would not reflect the long-term neurologic recovery state. This is a descriptive cohort analysis of a single-center prospective database of pediatric traumatic brain injury patients from 2001 to 2012. Functional outcome was assessed at hospital discharge, and the Glasgow Outcome Scale Extended Pediatrics or Glasgow Outcome Scale was assessed on average at 15.8 months after injury. Children's Medical Center Dallas, a single-center PICU and Level 1 Trauma Center. Patients, 0-17 years old, with complicated-mild/moderate or severe accidental traumatic brain injury. Dichotomized long-term outcome was favorable in 217 of 258 patients (84%), 80 of 82 patients (98%) with complicated-mild/moderate injury and 133 of 172 severe patients (77%). In the bivariate analysis, younger age, motor vehicle collision as a mechanism of injury, intracranial pressure monitor placement, cardiopulmonary resuscitation at scene or emergency department, increased hospital length of stay, increased ventilator days (all with p < 0.01) and occurrence of seizures (p = 0.03) were significantly associated with an unfavorable outcome. In multiple regression analysis, younger age (p = 0.03), motor vehicle collision (p = 0.01), cardiopulmonary resuscitation (p < 0.01), and ventilator days (p < 0.01) remained significant. Remarkably, 28 of 60 children (47%) with an unfavorable Glasgow Outcome Scale at hospital discharge improved to a favorable outcome. In severe patients with an unfavorable outcome at hospital discharge, younger age was identified as a risk factor for remaining in an unfavorable condition (p = 0.1). Despite a poor neurologic status at hospital discharge, many children after traumatic brain injury will significantly improve at long-term assessment. The factors most associated with outcomes were age, cardiopulmonary resuscitation, motor vehicle collision, intracranial pressure placement, days on a ventilator, hospital length of stay, and seizures. The factor most associated with improvement from an unfavorable neurologic status at discharge was being older.

The Prognostic Value of MRI in Moderate and Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Traumatic brain injury is a major cause of death and disability, yet many predictors of outcome are not precise enough to guide initial clinical decision-making. Although increasingly used in the early phase following traumatic brain injury, the prognostic utility of MRI remains uncertain. We thus undertook a systematic review and meta-analysis of studies evaluating the predictive value of acute MRI lesion patterns for discriminating clinical outcome in traumatic brain injury. MEDLINE, EMBASE, BIOSIS, and CENTRAL from inception to November 2015. Studies of adults who had MRI in the acute phase following moderate or severe traumatic brain injury. Our primary outcomes were all-cause mortality and the Glasgow Outcome Scale. Two authors independently performed study selection and data extraction. We calculated pooled effect estimates with a random effects model, evaluated the risk of bias using a modified version of Quality in Prognostic Studies and determined the strength of evidence with the Grading of Recommendations, Assessment, Development, and Evaluation. We included 58 eligible studies, of which 27 (n = 1,652) contributed data to meta-analysis. Brainstem lesions were associated with all-cause mortality (risk ratio, 1.78; 95% CI, 1.01-3.15; I = 43%) and unfavorable Glasgow Outcome Scale (risk ratio, 2.49; 95% CI, 1.72-3.58; I = 81%) at greater than or equal to 6 months. Diffuse axonal injury patterns were associated with an increased risk of unfavorable Glasgow Outcome Scale (risk ratio, 2.46; 95% CI, 1.06-5.69; I = 74%). MRI scores based on lesion depth demonstrated increasing risk of unfavorable neurologic outcome as more caudal structures were affected. Most studies were at high risk of methodological bias. MRI following traumatic brain injury yields important prognostic information, with several lesion patterns significantly associated with long-term survival and neurologic outcome. Given the high risk of bias in the current body of literature, large well-controlled studies are necessary to better quantify the prognostic role of early MRI in moderate and severe traumatic brain injury.

Red Blood Cell Transfusion Guided by Near Infrared Spectroscopy in Neurocritically Ill Patients with Moderate or Severe Anemia: A Randomized, Controlled Trial.

In neurocritically ill patients (NCPs), the use of hemoglobin level as the sole indicator for red blood cell transfusion (RBCT) can result in under- or over-transfusion. This randomized controlled trial was conducted to ascertain whether a transcranial oxygen saturation (rSO2) threshold, as measured by near-infrared spectroscopy, reduces RBCT requirements in anemic NCPs (closed traumatic brain injury, subarachnoid, or intracerebral hemorrhage), compared with a hemoglobin threshold alone. Patients with hemoglobin 70-100 g/L received RBCTs to attain an rSO2 > 60% (rSO2 arm) or to maintain hemoglobin between 85 and 100 g/L (hemoglobin arm). A total of 102 NCPs (51 in each group) were included in the intention-to-treat analysis, and 97 were included in the per-protocol analysis (51 and 46, respectively). Compared with those from the hemoglobin arm, patients in rSO2 arm received fewer RBC units (1.0 ± 0.1 vs. 1.5 ± 1.4 units/patient; p < 0.05) and showed lower hemoglobin levels while in protocol. There were no differences between the study arms regarding the percentage of transfused patents (59% vs. 71%; relative risk 0.83 [95% CI 0.62-1.11]), stay on neurocritical care unit (21 vs. 20 days), unfavorable Glasgow Outcome Scale scores on hospital discharge (57% vs. 71%), in-hospital mortality (6% vs. 10%), or 1 year mortality (24% vs. 24%). Among NCPs with hemoglobin concentrations of 70-85 g/L, withholding transfusion until rSO2 is <60% may result in reduced RBCs requirements compared with routinely transfusing to attain a hemoglobin level >85 g/L. Further studies are required to confirm this finding and its possible impact on clinically significant outcomes.

Head Injury in the Elderly: What Are the Outcomes of Neurosurgical Care?

Epidemiologic studies show that an increasing proportion of those presenting with head trauma are elderly. This study details the outcomes of elderly patients with head trauma admitted to a regional United Kingdom neurosurgical unit. The notes and imaging were reviewed of all patients with head injury aged ≥75 years, admitted from 1 January 2007 to 31 December 2010, including mortality data up to at least 2 years after discharge. Outcomes comprised death as an inpatient, by 30 days and 1 year after discharge; Glasgow Outcome Score; discharge Glasgow Coma Scale (GCS) score; recurrence; readmission; reoperation; and complication. A total of 263 patients were admitted: 26 with acute subdural hematoma (ASDH); 175 with chronic subdural hematoma (CSDH); and 46 with mixed subdural collections (ACSDH). Sixteen patients had other head injury diagnoses. Patients with ASDH had a significantly lower survival rate than did those with CSDH or ACSDH: the odds of inpatient death for patients with ASDH was 15.38 (vs. those with CSDH). For all subdural hematomas (SDHs), low American Society of Anesthesiologists score was an independent predictor of early death. Death at 1 year was predicted by head injury severity measured by admission GCS score (P= 0.028), long anesthetic (P= 0.002), and the presence of bilateral SDH (P= 0.002). Unfavorable Glasgow Outcome Scale score (1-3) was predicted by age greater than 85 years (P= 0.029); larger depth of subdural (P < 0.001); and presence of any complication (P= 0.003). Those aged greater than 90 years with presentation GCS score lower than 10 all had poor outcomes. Most elderly patients admitted under neurosurgery after head injury have SDHs. Our results are better than many previously reported; however, the rate of death for those with ASDH is still high.

Perioperative Predictors of Extubation Failure and the Effect on Clinical Outcome After Infratentorial Craniotomy.

BackgroundThe purpose of the study was to analyze the risk factors for failed extubation in subjects submitted to infratentorial craniotomy.Material/MethodsPatients aged over 18 years who received infratentorial craniotomy for brain tumor resection were consecutively included in this study. Perioperative variables were collected and analyzed. Univariate analyses and multiple logistic regression were used to derive factors related to failed extubation. Patients had follow-up care until either out of hospital or death.ResultsThroughout the course of the study, 2118 patients were eligible and 94 (4.4%) suffered from extubation failure at some point during their hospital stay. Five factors were recognized as independent risk factors for postoperative failed extubation: craniotomy history, preoperative lower cranial nerve dysfunction, tumor size, tumor position, and maximum change in blood pressure (BP) during the operation. Failed extubation was related to a higher incidence rate of pneumonia, mortality, unfavorable Glasgow Outcome Scale score, longer stay in the neuro-intensive care unit (ICU) and hospitalization, and higher hospitalization costs compared with successful extubation.ConclusionsHistory of craniotomy, preoperative lower cranial nerve dysfunction, tumor size, tumor position, and maximum change in BP during the operation were independent risk factors related to postoperative failed extubation in patients submitted to infratentorial craniotomy. Extubation failure raises the incidences of postoperative pneumonia, mortality, and higher hospitalization costs, and prolongs neuro-ICU and postoperative length of stay.

Blood mitochondrial enzymatic assay as a predictor of long-term outcome in severe traumatic brain injury

Recent studies have observed the central role of mitochondrial dysfunction in severe traumatic brain injury (sTBI). One hundred and seven sTBI patients (18–65years old, presenting within 8hours of injury) were randomised for a placebo controlled phase II trial of progesterone with or without hypothermia. We serially analysed blood mitochondrial enzymes (Complex I [C1], Complex IV [C4] and pyruvate dehydrogenase complex [PDH]) using a dipstick assay at admission and 7days later for 37 patients, irrespective of assigned group. Favorable Glasgow Outcome Scale (GOS) at 1year was associated with admission C1 levels above 0.19μg, admission C4 levels above 0.19μg and day 7 C1 levels above 0.17μg, all per 25μl of blood. Unfavorable GOS at 1year was associated with admission serum PDH levels above 0.23μg/25μl of blood. Survivors at 1year had significantly higher admission serum C1 levels above 0.19μg/25μl and day 7 C1 levels above 0.17μg/25μl. To our knowledge this is the first clinical trial associating blood mitochondrial enzymes with long-term outcome in sTBI. Serial monitoring and optimisation of blood C1, C4 and PDH levels could aid in prognostication and potentially guide in using mitochondrial targeted therapies. Blood mitochondrial enzymatic assay might suggest global reduction–oxidation status.

Chronic Inflammation After Severe Traumatic Brain Injury: Characterization and Associations With Outcome at 6 and 12 Months Postinjury.

Examine associations between chronic inflammatory profiles and outcome 6 to 12 months following severe traumatic brain injury (TBI). University-affiliated level 1 trauma center and community. Adults with severe TBI (n = 87); healthy controls (n = 7). Prospective cohort study. Glasgow Outcome Scale; serum cytokines (interleukin [IL]-1β, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, tumor necrosis factor α), 2 weeks to 3 months, 4- to 6-month averages, 6- and 12-month levels. Serum levels of IL-1β, IL-6, IL-8, IL-10, and tumor necrosis factor α were elevated over 3 months following TBI. Multivariate analysis showed that increased cytokine load score was associated with a 1.21 (95% confidence interval, 1.06-1.38) and 1.18 (95% confidence interval, 1.02-1.37) increase in odds of unfavorable Glasgow Outcome Scale score at 6 and 12 months, respectively. Also, elevated IL-6/IL-10 ratios were associated with increased odds of unfavorable outcomes at 6 months (adjusted odds ratio = 1.76; 95% confidence interval, 1.08-2.88). Chronic inflammation has not been well characterized following TBI. Our subacute cytokine load score classifies individuals at risk for unfavorable outcomes following injury. Higher proinflammatory burden with IL-6, relative to the anti-inflammatory marker IL-10, is significantly associated with outcome. Further research should examine whether inflammatory genes and other inflammatory biomarkers affect risk for unfavorable outcomes and TBI complications.

Cerebrospinal Fluid Markers of Macrophage and Lymphocyte Activation After Traumatic Brain Injury in Children.

The magnitude and role of the cellular immune response following pediatric traumatic brain injury remains unknown. We tested the hypothesis that macrophage/microglia and T-cell activation occurs following pediatric traumatic brain injury by measuring cerebrospinal fluid levels of soluble cluster of differentiation 163 and ferritin and soluble interleukin-2 receptor α, respectively, and determined whether these biomarkers were associated with relevant clinical variables and outcome. Retrospective analysis of samples from an established, single-center cerebrospinal fluid bank. PICU in a tertiary children's hospital. Sixty-six pediatric patients after severe traumatic brain injury (Glasgow Coma Scale score < 8) who were 1 month to 16 years old and 17 control patients who were 1 month to 14 years old. None. Cerebrospinal fluid levels of soluble cluster of differentiation 163, ferritin, and soluble interleukin-2 receptor α were determined by enzyme-linked immunosorbent assay at two time points (t1 = 17 ± 10 hr; t2 = 72 ± 15 hr) for each traumatic brain injury patient. Cerebrospinal fluid levels of soluble cluster of differentiation 163, ferritin, and soluble interleukin-2 receptor α after traumatic brain injury were compared with controls and analyzed for associations with age, patient sex, initial Glasgow Coma Scale score, diagnosis of abusive head trauma, the presence of hemorrhage on CT scan, and Glasgow Outcome Scale score. Cerebrospinal fluid level of soluble cluster of differentiation 163 was increased in traumatic brain injury patients at t2 versus t1 and controls (median, 95.4 ng/mL [interquartile range, 21.8-134.0 ng/mL] vs 31.0 ng/mL [5.7-77.7 ng/mL] and 27.8 ng/mL [19.1-43.1 ng/mL], respectively; p < 0.05). Cerebrospinal fluid level of ferritin was increased in traumatic brain injury patients at t2 and t1 versus controls (8.3 ng/mL [<7.5-19.8 ng/mL] and 8.9 ng/mL [<7.5-26.7 ng/mL] vs <7.5 ng/mL below lower limit of detection, respectively; p < 0.05). Cerebrospinal fluid levels of soluble interleukin-2 receptor α in traumatic brain injury patients at t2 and t1 were not different versus controls. Multivariate regression revealed associations between high ferritin and age 4 years or younger, lower Glasgow Coma Scale score, abusive head trauma, and unfavorable Glasgow Outcome Scale score. Children with traumatic brain injury demonstrate evidence for macrophage activation after traumatic brain injury, and in terms of cerebrospinal fluid ferritin, this appears more prominent with young age, initial injury severity, abusive head trauma, and unfavorable outcome. Further study is needed to determine whether biomarkers of macrophage activation may be used to discriminate between aberrant and adaptive immune responses and whether inflammation represents a therapeutic target after traumatic brain injury.

Validation of a New Clinico-Radiological Grading for Compound Head Injury: Implications on the Prognosis and the Need for Surgical Intervention

Lack of risk stratification among patients with varying severities of compound head injury has resulted in too-inconsistent and conflicting results to support any management strategy over another. The purpose of this study was to validate a new clinico-radiological grading scheme with implications on outcome and the need for surgical debridement. Patients who sustained an external compound head injury with no serious systemic injury and no pre-established infection and who continued the entire treatment were studied prospectively for their proposed grade of compound injury in relation to infective complications, unfavorable Glasgow Outcome Scale (GOS), delayed seizures, mortality, and hospital stay for 3 months. Appropriate univariate and multivariate analyses were performed. Among a total of 344 patients, 182 (53%) had no dural violation or midline shift (Grade 1), 56 (16%) had cerebrospinal fluid leak or pneumocephalus (Grade 2), 34 (10%) had exposed brain (Grade 3), 47 (14%) had midline shift (Grade 4), and 25 (7%) had both exposed brain and midline shift (Grade 5). Each successive grade of compound injury had significant incremental impact on all the outcome measures studied. Infective complications in Grades 1 to 5 were noted among 7%, 9%, 27%, 28%, and 36% of patients, respectively (P < 0.001). There was a significant difference in unfavorable GOS (23% vs. 56%, odds ratio [OR] 4.3, P < 0.001) and mortality (17% vs. 42%, OR 3.5, P < 0.001) between Grades 1-2 and Grades 3-5. Delayed seizures were noted in 4%, 4%, 9%, 13%, and 16% of patients in Grades 1-5 (P = 0.04). The median hospital stay was 1, 3, 6, 6, and 8 days, respectively (P < 0.001). All patients in Grades 4-5 (72) underwent surgery. Only 32 of 182 (18%) patients in Grade 1, 9 of 56 (16%) patients in Grade 2, and 23 of 34 (68%) patients in Grade 3 underwent surgical debridement, whereas the rest were managed conservatively. Patients who were managed conservatively had significantly lower infective complications (3% vs. 25%, OR 9.67, P < 0.001) in Grade 1, and (2% vs. 44%, OR 36.8, P = 0.002) in Grade 2, compared with those who underwent surgical debridement. In multivariate analysis, the proposed grade had significant independent association with infection (P < 0.001), unfavorable GOS (P = 0.01), delayed seizures (P = 0.001), and hospital stay (P < 0.001), and each successive grade had significant incremental impact on both infective complications and unfavourable GOS, independent of GCS and other prognostic factors. The new grading scheme appears to be of practical clinical significance. It shows significant statistical associations with the rates of infection, unfavorable neurologic outcome, delayed seizures, mortality, and duration of hospital stay. The incremental impact of each successive grade on infective complications and unfavorable GOS was independent of GCS and other prognostic factors. Conservative management had significantly lower infection compared to surgical debridement, at least in patients with Grades 1 and 2.

Acute CSF interleukin-6 trajectories after TBI: associations with neuroinflammation, polytrauma, and outcome.

Traumatic brain injury (TBI) results in a significant inflammatory burden that perpetuates the production of inflammatory mediators and biomarkers. Interleukin-6 (IL-6) is a pro-inflammatory cytokine known to be elevated after trauma, and a major contributor to the inflammatory response following TBI. Previous studies have investigated associations between IL-6 and outcome following TBI, but to date, studies have been inconsistent in their conclusions. We hypothesized that cohort heterogeneity, temporal inflammatory profiles, and concurrent inflammatory marker associations are critical to characterize when targeting subpopulations for anti-inflammatory therapies. Toward this objective, we used serial cerebrospinal fluid (CSF) samples to generate temporal acute IL-6 trajectory (TRAJ) profiles in a prospective cohort of adults with severe TBI (n=114). We examined the impact of injury type on IL-6 profiles, and how IL-6 profiles impact sub-acute (2weeks-3months) serum inflammatory marker load and long-term global outcome 6-12months post-injury. There were two distinct acute CSF IL-6 profiles, a high and low TRAJ group. Individuals in the high TRAJ had increased odds of unfavorable Glasgow Outcome Scale (GOS) scores at 6months (adjusted OR=3.436, 95% CI: 1.259, 9.380). Individuals in the high TRAJ also had higher mean acute CSF inflammatory load compared to individuals in the low TRAJ (p⩽0.05). The two groups did not differ with respect acute serum profiles; however, individuals in the high CSF IL-6 TRAJ also had higher mean sub-acute serum IL-1β and IL-6 levels compared with the low TRAJ group (p⩽0.05). Lastly, injury type (isolated TBI vs. TBI+polytrauma) was associated with IL-6 TRAJ group (χ(2)=5.31, p=0.02). Specifically, there was 70% concordance between those with TBI+polytrauma and the low TRAJ; in contrast, isolated TBI was similarly distributed between TRAJ groups. These data provide evidence that sustained, elevated levels of CSF IL-6 are associated with an increased inflammatory load, and these increases are associated with increased odds for unfavorable global outcomes in the first year following TBI. Future studies should explore additional factors contributing to IL-6 elevations, and therapies to mitigate its detrimental effects on outcome.

Electrographic status epilepticus and long-term outcome in critically ill children

Electrographic seizures (ES) and electrographic status epilepticus (ESE) are common in children in the pediatric intensive care unit (PICU) with acute neurologic conditions. We aimed to determine whether ES or ESE was associated with worse long-term outcomes. Three hundred children with an acute neurologic condition and encephalopathy underwent clinically indicated EEG monitoring and were enrolled in a prospective observational study. We aimed to obtain follow-up data from 137 subjects who were neurodevelopmentally normal before PICU admission. Follow-up data were collected for 60 of 137 subjects (44%) at a median of 2.7 years. Subjects with and without follow-up data were similar in clinical characteristics during the PICU admission. Among subjects with follow-up data, ES occurred in 12 subjects (20%) and ESE occurred in 14 subjects (23%). Multivariable analysis indicated that ESE was associated with an increased risk of unfavorable Glasgow Outcome Scale (Extended Pediatric Version) category (odds ratio 6.36, p = 0.01) and lower Pediatric Quality of Life Inventory scores (23 points lower, p = 0.001). Among subjects without prior epilepsy diagnoses ESE was associated with an increased risk of subsequently diagnosed epilepsy (odds ratio 13.3, p = 0.002). ES were not associated with worse outcomes. Among children with acute neurologic disorders who were reported to be neurodevelopmentally normal before PICU admission, ESE but not ES was associated with an increased risk of unfavorable global outcome, lower health-related quality of life scores, and an increased risk of subsequently diagnosed epilepsy even after adjusting for neurologic disorder category, EEG background category, and age.

Chronic subdural hematoma in patients under age 65 years: A comparative study of age cohort

Chronic subdural hematoma (CSDH) in patients 65 years old is not uncommon, but its exact situation is not well-clarified. In this study, we compare the clinical variables between two age groups (≤65 years and >65 years), and focus on the characteristics of younger adults. In this 2-year retrospective study, 98 patients with CSDH were enrolled and subdivided into younger (≤65 years) and older (>65 years) groups. Information about presenting symptoms and neuroimages was recorded. We also investigated recurrence, morbidity, mortality, and neurological outcome after burr hole craniotomy. The patients ≤65 years accounted for 29% of the CSDH cases. Younger adults had a lower incidence of hemiparesis than older patients (p = 0.03). Analysis of the computerized tomography (CT) scans on admission revealed differences in layering of the hematoma (p = 0.009) and multiplicity of hematoma cavities (p = 0.001). The recurrence rate was 18% for the younger group and 13% for the older group (p = 0.53). The occurrence of postoperative morbidity and mortality was similar in the two age groups (p > 0.99 and p = 0.56, respectively). An unfavorable Glasgow Outcome Scale was not observed in any of the younger patients, but was seen in six of the older patients; however, there was no statistically significant difference between the age groups (p = 0.18). The clinical presentations and CT features of patients ≤65 years of age varied from those of older patients. Clinicians should note this variability to facilitate proper management.

Early Prognosis After Severe Traumatic Brain Injury With Minor or Absent Computed Tomography Scan Lesions

To assess the prognostic value of corpus callosum lesions (CCL) and brain stem lesions (BSL) in diffuse axonal injury (DAI) patients. From December 1989 to December 2008, 102 consecutive patients with pure DAI were admitted to our neurosurgical intensive care unit. Age, gender, Acute Physiology and Chronic Health Evaluation score, Glasgow Coma Score (GCS), pupillary light reactivity on admission, brain magnetic resonance imaging (MRI) 24 hours to 72 hours after trauma and sepsis, shock, adult respiratory distress syndrome, renal failure, neurosurgery, high intracranial pressure during the 6 months posttrauma were studied with multiple logistic regression, and Cox's proportional hazards, respectively, considering the Glasgow Outcome Scale and the time to recovery of consciousness as outcome variables. Four variables predicted unfavorable Glasgow Outcome Scale (likelihood ratio p<0.0001; Area Under the Receiver Operator Curve (AUROC)=0.92; Naglekerke's R=0.64; Goodness-of-Fit p=0.8679): age (5-year odds ratio [OR], 1.44; 95% CI, 1.14-1.82; p=0.002), bilateral absence of light reflexes (OR, 11.11; 95% CI, 2.19-57.67; p=0.004), multiplicity of CCL (OR, 29.23; 95% CI, 7.06-121.01; p<0.001), and multiplicity of BSL (OR, 9.43; 95% CI, 2.44-36.42; p=0.001). Four variables affected time to recovery of consciousness: age (hazard ratio, 0.98; 95% CI, 0.97-0.99; p=0.009), bilateral absence of light reflexes (hazard ratio, 0.51; 95% CI, 0.27-0.97; p=0.041), multiplicity of CCL (hazard ratio, 0.40; 95% CI, 0.25-0.66; p<0.001), and total GCS on admission (hazard ratio, 1.45; 95% CI, 1.23-1.71; p<0.001). In DAI patients, bad outcome is predicted by age, bilateral absence of pupillary light reflexes, multiplicity of CCL, and BSL on MRI. Time to recovery of consciousness is predicted by age, bilateral absence of light reflexes, multiplicity of CCL on MRI, and GCS on admission.

Factors Associated with Neurological Outcome and Lesion Progression in Traumatic Subarachnoid Hemorrhage Patients

Traumatic subarachnoid hemorrhage (tSAH) is a frequent finding after closed-head injuries, and its presence is a powerful factor associated with poor outcome. The exact mechanism linking tSAH and an adverse outcome is poorly understood. The aim of this study was to identify the factors that may predict outcomes and changes in the computed tomographic (CT) scans of lesions in a selected population of tSAH patients. We evaluated 141 patients admitted consecutively from January 1, 1997, to January 31, 1999, with a CT diagnosis of tSAH. The admission and "worst" CT scans were recorded. CT scan changes were reported as "significant CT progression" (changes in the Marshall classification) or "any CT progression." The amount of subarachnoid blood was recorded using a modified Fisher classification. Outcome was assessed at 6 months after injury with the Glasgow Outcome Scale. Twenty-eight patients (19.9%) had an unfavorable Glasgow Outcome Scale outcome. In the univariate analysis, prognosis was significantly related to age, admission Glasgow Coma Scale score, Marshall CT classification score at admission and on the worst CT scan, amount of tSAH, and volume of the associated brain contusions. From multivariate analysis, the only factors independently related to outcome were the Glasgow Coma Scale score (P < 0.01) and size of the tSAH at admission (P < 0.001). Thirty-four patients (24.1%) had significant CT lesion progression, and 66 patients (46.8%) had some lesion progression. Patients having significant progression of the lesion had a higher risk of an unfavorable outcome (32 versus 10%; P = 0.004). Unadjusted factors predicting CT progression were the Glasgow Coma Scale score at admission, the Marshall classification at admission, the amount of subarachnoid blood, and the presence or volume of associated brain contusions at admission. Independent factors associated with significant CT progression were the amount of tSAH (P < 0.001) and the presence or volume of brain contusions at admission (P < 0.001). The outcome of patients with tSAH at admission is related in a logistic regression analysis to the admission Glasgow Coma Scale score and to the amount of subarachnoid blood. These patients also have a significant risk of CT progression. The amount of subarachnoid blood and the presence of associated parenchymal damage are powerful independent factors associated with CT progression, thus linking poor outcomes and CT changes.