Midline Shift is Unrelated to Subjective Pupillary Reactivity Assessment on Admission in Moderate and Severe Traumatic Brain Injury

Outcomes of Traumatic Brain-Injured Patients With Glasgow Coma Scale < 5 and Bilateral Dilated Pupils Undergoing Decompressive Craniectomy

Objective: Decompressive craniectomy (DC) plays an important role in the treatment of patients with severe traumatic brain injury (sTBI) with mass lesions and intractably elevated intracranial hypertension (ICP). However, whether DC should be performed in patients with bilateral dilated pupils and a low Glasgow Coma Scale (GCS) score is still controversial. This retrospective study explored the clinical outcomes and risk factors for an unfavorable prognosis in sTBI patients undergoing emergency DC with bilateral dilated pupils and a GCS score <5. Methods: The authors reviewed the data from patients who underwent emergency DC from January 2012 to March 2019 in a medical center in China. All data, such as patient demographics, radiological findings, clinical parameters, and preoperative laboratory variables, were extracted. Multivariate logistic regression analysis was performed to determine the factors associated with 30-day mortality and 6-month negative neurological outcome {defined as death or vegetative state [Glasgow Outcome Scale (GOS) score 1-2]}. Results: A total of 94 sTBI patients with bilateral dilated pupils and a GCS score lower than five who underwent emergency DC were enrolled. In total, 74 patients (78.7%) died within 30 days, and 84 (89.4%) had a poor 6-month outcome (GOS 1-2). In multivariate analysis, advanced age (OR: 7.741, CI: 2.288-26.189), prolonged preoperative activated partial thromboplastin time (aPTT) (OR: 7.263, CI: 1.323-39.890), and low GCS (OR: 6.162, CI: 1.478-25.684) were associated with a higher risk of 30-day mortality, while advanced age (OR: 8.812, CI: 1.817-42.729) was the only independent predictor of a poor 6-month prognosis in patients undergoing DC with preoperative bilateral dilated pupils and a GCS score <5. Conclusions: The mortality and disability rates are extremely high in severe TBI patients undergoing emergency DC with bilateral fixed pupils and a GCS score <5. DC is more valuable for younger patients.

Death after discharge: prognostic model of 1-year mortality in traumatic brain injury patients undergoing decompressive craniectomy

Background

Despite advances in decompressive craniectomy (DC) for the treatment of traumatic brain injury (TBI), these patients are at risk of having a poor long-term prognosis. The aim of this study was to predict 1-year mortality in TBI patients undergoing DC using logistic regression and random tree models.

Methods

This was a retrospective analysis of TBI patients undergoing DC from January 1, 2015, to April 25, 2019. Patient demographic characteristics, biochemical tests, and intraoperative factors were collected. One-year mortality prognostic models were developed using multivariate logistic regression and random tree algorithms. The overall accuracy, sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs) were used to evaluate model performance.

Results

Of the 230 patients, 70 (30.4%) died within 1 year. Older age (OR, 1.066; 95% CI, 1.045–1.087; P < 0.001), higher Glasgow Coma Score (GCS) (OR, 0.737; 95% CI, 0.660–0.824; P < 0.001), higher d-dimer (OR, 1.005; 95% CI, 1.001–1.009; P = 0.015), coagulopathy (OR, 2.965; 95% CI, 1.808–4.864; P < 0.001), hypotension (OR, 3.862; 95% CI, 2.176–6.855; P < 0.001), and completely effaced basal cisterns (OR, 3.766; 95% CI, 2.255–6.290; P < 0.001) were independent predictors of 1-year mortality. Random forest demonstrated better performance for 1-year mortality prediction, which achieved an overall accuracy of 0.810, sensitivity of 0.833, specificity of 0.800, and AUC of 0.830 on the testing data compared to the logistic regression model.

Conclusions

The random forest model showed relatively good predictive performance for 1-year mortality in TBI patients undergoing DC. Further external tests are required to verify our prognostic model.

Pupillary light reflex as a diagnostic aid from computational viewpoint: A systematic literature review

This work presents a detailed and complete review of publications on pupillary light reflex (PLR) used to aid diagnoses. These are computational techniques used in the evaluation of pupillometry, as well as their application in computer-aided diagnoses (CAD) of pathologies or physiological conditions that can be studied by observing the movements of miosis and mydriasis of the human pupil. A careful survey was carried out of all studies published over the last 10 years which investigated, electronic devices, recording protocols, image treatment, computational algorithms and the pathologies related to PLR. We present the frontier of existing knowledge regarding methods and techniques used in this field of knowledge, which has been expanding due to the possibility of performing diagnoses with high precision, at a low cost and with a non-invasive method.

Supratentorial intracerebral hemorrhage volume and other CT variables predict the neurological pupil index

OBJECTIVES

There is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity.

METHODS

This study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher's Exact X2, and multivariate modeling with constructed MAX-R models.

RESULTS

Data were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r² = 0.48, p < 0.0001, contralateral [(r² = 0.39, p < 0.0001]). Horizontal midline shift of the septum pellucidum also correlated with NPi (ipsilateral [r² = 0.25, p = 0.0006], contralateral [r² = 0.15, p = 0.0106]), as did shift of the pineal gland (ipsilateral [r² = 0.21, p = 0.0017], contralateral[r² = 0.11, p = 0.0328]). ICH volume was the most predictive of abnormal NPi (AUC = 0.85 for ipsilateral and 0.88 for contralateral NPi), and multivariate modeling identified additional independent predictors of NPi.

CONCLUSION

ICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.

Prognostic factors for adult patients with hemorrhagic moyamoya disease in the acute stage

OBJECTIVES

Hemorrhagic moyamoya disease (MMD) is one common subtype in adult patients. However, the study about outcome of hemorrhagic MMD patients in the acute stage is still lacking. This study is aimed to explore the short-term prognostic factors for adult patients with hemorrhagic MMD in the acute stage.

PATIENTS AND METHODS

Adult hemorrhagic MMD patients in the acute stage awere retrospectively analyzed. Both clinical and imaging data were collected. Unfavorable functional outcome at discharge was considered when modified Rankin Scale score ≥3. Multivariate logistic regression was used to investigate the prognostic factors in patients with hemorrhagic MMD in the acute stage.

RESULTS

A total of 107 patients were included in this study. Among these patients, 17 died and 59 had unfavorable functional outcome at 9.6 ± 7.8 days. In multivariate logistic regression, admission blood glucose (odds ratio (OR) = 1.457, 95% confidence interval (CI) 1.156-1.836, P = 0.001), midline shift >5 mm (OR = 24.268, 95%CI 4.324-136.191, P < 0.001), and subarachnoid hemorrhage (OR = 13.067, 95%CI 2.020-84.512, P = 0.007) were independently associated with death at discharge. Moreover, admission Glasgow Coma Scale (GCS) score (OR = 0.420, 95%CI 0.296-0.598, P < 0.001), midline shift >5 mm (OR = 6.685, 95%CI 1.226-36.455, P = 0.028), and intraparenchymal hemorrhage (OR = 4.790, 95%CI 1.184-19.381, P = 0.028) were independently associated with unfavorable functional outcome at discharge.

CONCLUSION

This study shows that admission blood glucose, midline shift >5 mm, and subarachnoid hemorrhage are independent predictors of short-term mortality in hemorrhagic MMD in the acute stage. In addition, admission GCS score, midline shift >5 mm, and intraparenchymal hemorrhage are independent predictors of short-term unfavorable functional outcome in hemorrhagic MMD in the acute stage.