Enhanced specificity of prognosis in severe head injury

Prognosis value of pupillometry in COVID-19 patients admitted in intensive care unit

INTRODUCTION

ICU patients with SARS-CoV-2-related pneumonia are at risk to develop a central dysautonomia which can contribute to mortality and respiratory failure. The pupillary size and its reactivity to light are controlled by the autonomic nervous system. Pupillometry parameters (PP) allow to predict outcomes in various acute brain injuries. We aim at assessing the most predictive PP of in-hospital mortality and the need for invasive mechanical ventilation (IV).

MATERIAL AND METHODS

We led a prospective, two centers, observational study. We recruited adult patients admitted to ICU for a severe SARS-CoV-2 related pneumonia between April and August 2020. The pupillometry was performed at admission including the measurement of baseline pupillary diameter (PD), PD variations (PDV), pupillary constriction velocity (PCV) and latency (PDL).

RESULTS

Fifty patients, 90 % males, aged 66 (60-70) years were included. Seven (14 %) patients died in hospital. The baseline PD (4.1 mm [3.5; 4.8] vs 2.6 mm [2.4; 4.0], P = 0.009), PDV (33 % [27; 39] vs 25 % [15; 36], P = 0.03) and PCV (3.5 mm.s^-1 [2.8; 4.4] vs 2.0 mm.s^-1 [1.9; 3.8], P = 0.02) were significantly lower in patients who will die. A PD value <2.75 mm was the most predictive parameter of in-hospital mortality, with an AUC = 0.81, CI 95 % [0.63; 0.99]. Twenty-four (48 %) patients required IV. PD and PDV were significantly lower in patients who were intubated (3.5 mm [2.8; 4.4] vs 4.2 mm [3.9; 5.2], P = 0.03; 28 % [25; 36 %] vs 35 % [32; 40], P = 0.049, respectively).

CONCLUSIONS

A reduced baseline PD is associated with bad outcomes in COVID-19 patients admitted in ICU. It is likely to reflect a brainstem autonomic dysfunction.

Evaluating the Reliability of Neurological Pupillary Index as a Prognostic Measurement of Neurological Function in Critical Care Patients

Background

Neurological pupil index (NPi) is a novel method of assessing pupillary size and reactivity using pupillometry to reduce human subjectivity. This paper aims to evaluate the use of NPi as a potential prognostic tool in a broad population of neurocritical care patients by observing the correlation between NPi, modified Rankin Scale (mRS), and Glasgow Coma Scale (GCS).

Methods

Our data was collected from 194 patients in the neurosurgical intensive care unit (ICU) at Arrowhead Regional Medical Center (ARMC), as determined by the power calculation. We utilized the Kolmogorov-Smirnova and Shapiro-Wilk normality tests with Lilliefors significance correction. Pearson product-moment correlation was performed between average final NPi and final GCS. Multi-variate linear regression and analysis of variance (ANOVA) were used to evaluate the association and predictive capabilities of NPi on GCS and discharge mRS. Finally, we evaluated whether age, ethnicity, sex, length of stay (LOS), or discharge location were significantly associated with NPi. 

Results

We observed a significant correlation between final GCS and NPi (r=0.609, p<0.001). Our regression analysis revealed that NPi significantly predicted GCS and mRS scores; however, no associations were found between age, ethnicity, sex, LOS, or discharge location. Limitations of our study include a single institutional study with a lack of disease subtyping and the inability to quantify the predictive ability of NPi.

Conclusion

The analysis revealed a strong correlation between final GCS and average final NPi. NPi was also able to significantly predict GCS and mRS scores. The correlation between NPi and established methods to determine neurological function, such as mRS and GCS, suggests that NPi can be a good prognostication tool for neurological diseases.

Measuring pupil size and light response through closed eyelids

Monitoring pupillary size and light-reactivity is a key component of the neurologic assessment in comatose patients after stroke or brain trauma. Currently, pupillary evaluation is performed manually at a frequency often too low to ensure timely alert for irreversible brain damage. We present a novel method for monitoring pupillary size and reactivity through closed eyelids. Our method is based on side illuminating in near-IR through the temple and imaging through the closed eyelid. Successfully tested in a clinical trial, this technology can be implemented as an automated device for continuous pupillary monitoring, which may save staff resources and provide earlier alert to potential brain damage in comatose patients.

Prediction of early mortality after primary decompressive craniectomy in patients with severe traumatic brain injury

Objectives

Traumatic brain injury (TBI) is a worldwide major health problem associated with a high rate of morbidity and mortality. Intracranial hypertension following TBI is the main but not the only cause of early mortality. Decompressive craniectomy (DC) is used to decrease the intracranial pressure (ICP) and prevent brain herniation following TBI; however, the clinical outcome after DC for patients with TBI generates continuous debate. Prediction of early mortality after DC will help in making the surgery decision.

The aim of this study is to predict early mortality after DC based on the initial clinical and radiological findings.

Methods

In this study, 104 patients with severe traumatic brain injury have been treated by decompressive craniectomy and were retrospectively analyzed. Patients were divided into two groups; group I involved 32 patients who died within 28 days while group II involved 72 patients who survived after 28 days. The relationship between initial Glasgow Coma Scale score (GCS), pupil size and reactivity, associated injuries, and radiological findings were analyzed as predictor factors for early mortality.

Results

A total of 104 patients with severe TBI have been treated by DC and were analyzed; the early mortality occurred in 32 patients, 30.77%. There is a significant difference between groups in gender, mean GCS, Marshall scale, presence of isochoric pupils, and lung injury.

After stratification, odds of early mortality increases with the lower GCS, higher Marshall scale, lung injury, and abdominal injury while male gender and the presence of isochoric pupils decrease the odds of mortality. After univariate regression, the significant impact of GCS disappears except for GCS-8 which decreases the odds of mortality in comparison to other GCS scores while higher Marshall scale, presence of isochoric pupils, and lung injury increase the odds of mortality, but most of these effects disappear after multiple regressions except for lung injury and isochoric pupils.

Conclusion

Prediction of early mortality after DC is multifactorial, but the odds of early mortality after decompressive craniectomy in severe traumatic brain injury are progressively increased with the lower GCS, higher Marshall scale, and the presence of lung or abdominal injury.

Automated Pupillometry and Detection of Clinical Transtentorial Brain Herniation: A Case Series

Introduction

Transtentorial herniation (TTH) is a life-threatening neurologic condition that typically results from expansion of supratentorial mass lesions. A change in bedside pupillary examination is central to the clinical diagnosis of TTH. Materials and.

Methods

To quantify the changes in the pupillary examination that precede and accompany TTH and its treatment, we evaluated 12 episodes of herniation in three patients with supratentorial mass lesions using automated pupillometry (NeurOptics, Inc., Irvine, CA). Herniation was defined clinically by the onset of fixed and dilated pupils in association with decreased levels of consciousness. Automated pupillometry was measured simultaneously with the bedside clinical examination, but the clinical team was blinded to these results and could not act on the data. Data from the pupillometer were downloaded 1-2 times per week onto a secured laptop, and data processing was facilitated by the use of Mathematica 8.0.

Results

Neurologic Pupil Index measurements, values generated by the pupillometer based on an algorithm that incorporates pupillary size and reactivity in a normal population, were found to be abnormal before 73% of TTHs. This abnormality occurred at a median of 7.4 h before TTH. All episodes of TTH were reversed after clinical intervention at a median of 43 min after the event. The value did not fall to 0 in 42% of clinical herniations, but it did decrease to very abnormal values of 0.5-0.8.

Conclusions

The potential of automated pupillometry to guide the management of severely injured neurologic patients is intriguing and warrants further study in the critical care unit and beyond. The utility of a portable device in the combat setting may allow for triage of patients with severe neurologic injury.

Traumatic Pediatric Extradural Hematoma: An Institutional Study of 228 Patients in Tertiary Care Center

BACKGROUND

Extradural hematoma (EDH) is one of the most common causes of mortality and morbidity after traumatic brain injury in pediatric patients. Early surgical intervention in these patients produces excellent results.

OBJECTIVE

We reviewed surgical experience at our center, examining and presenting symptomatology and outcome analysis.

MATERIALS AND METHODS

A retrospective study of 228 pediatric patients of EDH from July 2007 to August 2017 was performed. Patients were evaluated in terms of demographic profile, clinical features, pupillary size and reaction, computed tomography findings, operative measures, and several other parameters. Neurological status was assessed using motor component (M) of Glasgow Coma Scale score. Best motor response was considered as a criterion to classify severity of traumatic brain injury and for the assessment of outcome.

RESULTS

Most of the patients were in the age group of 13-18 years (n = 122, 53.5%). Majority of them were male (n = 182, 79.8%). The commonest mode of injury was fall from height (n = 116, 50.9%) followed by road traffic accident (n = 92, 40.4%). Most common site of hematoma was frontal region (n = 66, 28.9%) followed by parietal region (n = 54, 23.7%). The volume of hematoma was between 30 and 50 mL in majority of the patients (n = 186, 81.6%), and most of the patients had a motor responses of M5 (n = 88, 38.6%) and M6 (n = 108, 47.4%). The association between hematoma site and volume was not significant (χ2 = 5.910, p = 0.749), whereas statistically significant association was noted between volume of hematoma and motor response (χ2 = 93.468, p ≤ 0.001), volume and age (χ2 = 7.380, p ≤ 0.05), and volume to time between trauma and surgery (χ2 = 8.469, p ≤ 0.05). Maximum mortality was in patients of low motor (M1-M3) response and who were operated 24 h after injury.

CONCLUSION

Mortality in patients of EDH can be significantly reduced with gratifying results if operated early. Best motor response at presentation, pupillary abnormalities, time between injury to surgery, and location of hematoma have been identified as the important factors determining outcome in patients of EDH.

Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury

OBJECTIVE Early withdrawal of life-sustaining treatment due to expected poor prognosis is responsible for the majority of in-house deaths in severe traumatic brain injury (TBI). With increased focus on the decision and timing of withdrawal of care in patients with severe TBI, data on early neurological recovery in patients with a favorable outcome is needed to guide physicians and families. METHODS The authors reviewed prospectively collected data obtained in 1241 patients with head injury who were treated between 1986 and 2012. Patients with severe TBI, motor Glasgow Coma Scale (mGCS) score < 6 on admission, and those who had favorable outcomes (Glasgow Outcome Scale [GOS] score of 4 or 5, indicating moderate disability or good recovery) at 6 months were selected. Baseline demographic, clinical, and imaging data were analyzed. The time from injury to the first record of following commands (mGCS score of 6) after injury was recorded. The temporal profile of GOS scores from discharge to 6 months after the injury was also assessed. RESULTS The authors studied 218 patients (183 male and 35 female) with a mean age of 28.9 ± 11.2 years. The majority of patients were able to follow commands (mGCS score of 6) within the 1st week after injury (71.4%), with the highest percentage of patients in this group recovering on Day 1 (28.6%). Recovery to the point of following commands beyond 2 weeks after the injury was seen in 14.8% of patients, who experienced significantly longer durations of intracranial pressure monitoring (p = 0.001) and neuromuscular blockade (p < 0.001). In comparison with patients with moderate disability, patients with good recovery had a higher initial GCS score (p = 0.01), lower incidence of anisocoria at admission (p = 0.048), and a shorter ICU stay (p < 0.001) and total hospital stay (p < 0.001). There was considerable improvement in GOS scores from discharge to follow-up at 6 months. CONCLUSIONS Up to 15% of patients with a favorable outcome after severe TBI may begin to follow commands beyond 2 weeks after the injury. These data caution against early withdrawal of life-sustaining treatment in patients with severe TBI.

Differential effects of the Glasgow Coma Scale Score and its Components: An analysis of 54,069 patients with traumatic brain injury

INTRODUCTION

The Glasgow Coma Scale (GCS) is widely used in the assessment of clinical severity and prediction of outcome after traumatic brain injury (TBI). The sum score is frequently applied, but the differential influence of the components infrequently addressed. We aimed to investigate the contribution of the GCS components to the sum score, floor and ceiling effects of the components, and their prognostic effects.

METHODS

Data on adult TBI patients were gathered from three data repositories: TARN (n=50,064), VSTR (n=14,062), and CRASH (n=9,941). Data on initial hospital GCS-assessment and discharge mortality were extracted. A descriptive analysis was performed to identify floor and ceiling effects. The relation between GCS and outcome was studied by comparing case fatality rates (CFR) between different component-profiles adding up to identical sum scores using Chi²-tests, and by quantifying the prognostic value of each component and sum score with Nagelkerke's R² derived from logistic regression analyses across TBI severities.

RESULTS

In the range 3-7, the sum score is primarily determined by the motor component, as the verbal and eye components show floor-effects at sum scores 7 and 8, respectively. In the range 8-12, the effect of the motor component attenuates and the verbal and eye components become more relevant. The motor, eye and verbal scores reach their ceiling-effects at sum 13, 14 and 15, respectively. Significant variations were exposed in CFR between different component-profiles despite identical sum scores, except in sum scores 6 and 7. Regression analysis showed that the motor score had highest R² values in severe TBI patients, whereas the other components were more relevant at higher sum scores. The prognostic value of the three components combined was consistently higher than that of the sum score alone.

CONCLUSION

The GCS-components contribute differentially across the spectrum of consciousness to the sum score, each having floor and ceiling effects. The specific component-profile is related to outcome and the three components combined contain higher prognostic value than the sum score across different TBI severities. We, therefore, recommend a multidimensional use of the three-component GCS both in clinical practice, and in prognostic studies.

Prognostication in critically ill patients with severe traumatic brain injury: the TBI-Prognosis multicentre feasibility study

OBJECTIVE

Severe traumatic brain injury is a significant cause of morbidity and mortality in young adults. Assessing long-term neurological outcome after such injury is difficult and often characterised by uncertainty. The objective of this feasibility study was to establish the feasibility of conducting a large, multicentre prospective study to develop a prognostic model of long-term neurological outcome in critically ill patients with severe traumatic brain injury.

DESIGN

A prospective cohort study.

SETTING

9 Canadian intensive care units enrolled patients suffering from acute severe traumatic brain injury. Clinical, biological, radiological and electrophysiological data were systematically collected during the first week in the intensive care unit. Mortality and functional outcome (Glasgow Outcome Scale extended) were assessed on hospital discharge, and then 3, 6 and 12 months following injury.

OUTCOMES

The compliance to protocolised test procedures was the primary outcome. Secondary outcomes were enrolment rate and compliance to follow-up.

RESULTS

We successfully enrolled 50 patients over a 12-month period. Most patients were male (80%), with a median age of 45 years (IQR 29.0-60.0), a median Injury Severity Score of 38 (IQR 25-50) and a Glasgow Coma Scale of 6 (IQR 3-7). Mortality was 38% (19/50) and most deaths occurred following a decision to withdraw life-sustaining therapies (18/19). The main reasons for non-enrolment were the time window for inclusion being after regular working hours (35%, n=23) and oversight (24%, n=16). Compliance with protocolised test procedures ranged from 92% to 100% and enrolment rate was 43%. No patients were lost to follow-up at 6 months and 2 were at 12 months.

CONCLUSIONS

In this multicentre prospective feasibility study, we achieved feasibility objectives pertaining to compliance to test, enrolment and follow-up. We conclude that the TBI-Prognosis prospective multicentre study in severe traumatic brain injury patients in Canada is feasible.

Acute brain trauma, lung injury, and pneumonia: more than just altered mental status and decreased airway protection

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Even when patients survive the initial insult, there is significant morbidity and mortality secondary to subsequent pulmonary edema, acute lung injury (ALI), and nosocomial pneumonia. Whereas the relationship between TBI and secondary pulmonary complications is recognized, little is known about the mechanistic interplay of the two phenomena. Changes in mental status secondary to acute brain injury certainly impair airway- and lung-protective mechanisms. However, clinical and translational evidence suggests that more specific neuronal and cellular mechanisms contribute to impaired systemic and lung immunity that increases the risk of TBI-mediated lung injury and infection. To better understand the cellular mechanisms of that immune impairment, we review here the current clinical data that support TBI-induced impairment of systemic and lung immunity. Furthermore, we also review the animal models that attempt to reproduce human TBI. Additionally, we examine the possible role of damage-associated molecular patterns, the chlolinergic anti-inflammatory pathway, and sex dimorphism in post-TBI ALI. In the last part of the review, we discuss current treatments and future pharmacological therapies, including fever control, tracheostomy, and corticosteroids, aimed to prevent and treat pulmonary edema, ALI, and nosocomial pneumonia after TBI.

A Critical Review for Developing Accurate and Dynamic Predictive Models Using Machine Learning Methods in Medicine and Health Care

Recently, Artificial Intelligence (AI) has been used widely in medicine and health care sector. In machine learning, the classification or prediction is a major field of AI. Today, the study of existing predictive models based on machine learning methods is extremely active. Doctors need accurate predictions for the outcomes of their patients' diseases. In addition, for accurate predictions, timing is another significant factor that influences treatment decisions. In this paper, existing predictive models in medicine and health care have critically reviewed. Furthermore, the most famous machine learning methods have explained, and the confusion between a statistical approach and machine learning has clarified. A review of related literature reveals that the predictions of existing predictive models differ even when the same dataset is used. Therefore, existing predictive models are essential, and current methods must be improved.

Comparative Outcomes of Traumatic Brain Injury from Biking Accidents With or Without Helmet Use

OBJECTIVE

To determine if health outcomes and demographics differ according to helmet status between persons with cycling-related traumatic brain injuries (TBI).

METHODS

This is a retrospective study of 128 patients admitted to the Montreal General Hospital following a TBI that occurred while cycling from 2007-2011. Information was collected from the Quebec trauma registry and the coroner's office in cases of death from cycling accidents. The independent variables collected were socio-demographic, helmet status, clinical and neurological patient information. The dependent variables evaluated were length of stay (LOS), extended Glasgow outcome scale (GOS-E), injury severity scale (ISS), discharge destination and death.

RESULTS

25% of cyclists wore a helmet. The helmet group was older, more likely to be university educated, married and retired. Unemployment, longer intensive care unit (ICU) stay, severe intracranial bleeding and neurosurgical interventions were more common in the no helmet group. There was no significant association between the severity of the TBI, ISS scores, GOS-E or death and helmet wearing. The median age of the subjects who died was higher than those who survived.

CONCLUSION

Cyclists without helmets were younger, less educated, single and unemployed. They had more severe TBIs on imaging, longer LOS in ICU and more neurosurgical interventions. Elderly cyclists admitted to the hospital appear to be at higher risk of dying in the event of a TBI.

Management of Elevated Intracranial Pressure

Elevated intracranial pressure (ICP) is a primary cause of morbidity and mortality for many neurologic disorders. The relationship between ICP and brain volume is influenced by autoregulatory processes that can become dysfunctional. As a result, neurologic damage can occur by systemic and intracranial insults such as ischemia and excitatory amino acids. Therefore, survival is dependent on optimizing ICP and cerebral perfusion pressure. Treatment of intracranial hypertension requires intensive monitoring and aggressive therapy. Intracranial pressure monitoring techniques such as intraventricular catheters are useful for determining ICP elevations before changes in vital signs and neurologic status. Therapeutic modalities, generally aimed at reducing cerebral blood volume, brain tissue, and cerebrospinal fluid (CSF) volume, include nonpharmacologic (CSF removal, controlled hyperventilation, and elevating the patient’s head) and pharmacologic management. Mannitol and sedation are first-line agents used to lower ICP. Barbiturate coma may be beneficial in patients with elevated ICP refractory to conventional treatment. The use of prophylactic antiseizure therapy and optimal nutrition prevents significant complication. Currently, investigations are directed at discovering useful neuroprotective agents that prevent secondary neurologic injury.

Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma

OBJECTIVE

The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma.

METHODS

This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes.

RESULTS

We enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI.

CONCLUSIONS

The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.

Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study

Background

In critical care units, pupil examination is an important clinical parameter for patient monitoring. Current practice is to use a penlight to observe the pupillary light reflex. The result seems to be a subjective measurement, with low precision and reproducibility. Several quantitative pupillometer devices are now available, although their use is primarily restricted to the research setting. To assess whether adoption of these technologies would benefit the clinic, we compared automated quantitative pupillometry with the standard clinical pupillary examination currently used for brain-injured patients.

Methods

In order to determine inter-observer agreement of the device, we performed repetitive measurements in 200 healthy volunteers ranging in age from 21 to 58 years, providing a total of 400 paired (alternative right eye, left eye) measurements under a wide variety of ambient light condition with NeuroLight Algiscan pupillometer. During another period, we conducted a prospective, observational, double-blinded study in two neurocritical care units. Patients admitted to these units after an acute brain injury were included. Initially, nursing staff measured pupil size, anisocoria and pupillary light reflex. A blinded physician subsequently performed measurement using an automated pupillometer.

Results

In 200 healthy volunteers, intra-class correlation coefficient for maximum resting pupil size was 0.95 (IC: 0.93-0.97) and for minimum pupil size after light stimulation 0.87 (0.83–0.89). We found only 3-pupil asymmetry (≥1 mm) in these volunteers (1.5 % of the population) with a clear pupil asymmetry during clinical inspection. The mean pupil light reactivity was 40 ± 7 %. In 59 patients, 406 pupillary measurements were prospectively performed. Concordance between measurements for pupil size collected using the pupillometer, versus subjective assessment, was poor (Spearmen's rho = 0.75, IC: 0.70-0.79; P < 0.001). Nursing staff failed to diagnose half of the cases (15/30) of anisocoria detected using the pupillometer device. A global rate of discordance of 18 % (72/406) was found between the two techniques when assessing the pupillary light reflex. For measurements with small pupils (diameters <2 mm) the error rate was 39 % (24/61).

Conclusion

Standard practice in pupillary monitoring yields inaccurate data. Automated quantitative pupillometry is a more reliable method with which to collect pupillary measurements at the bedside.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1239-z) contains supplementary material, which is available to authorized users.

Outcome of pediatric head injury patients admitted as unknown at a level-i apex trauma centre

Objective:

Patients with head injury who are not identified at admission are a challenge to manage and in this backdrop we decided to analyze our data of such pediatric patients for their outcome.

Materials and Methods:

It was a retrospective study conducted at the level-I trauma center. A total of 12 consecutive pediatric (<20 years) age group patients whose identities were not known at the time of admission were included in the study.

Results:

All 12 patients were male. The road traffic accident was the most common cause of injury (8, 67%). Mean age of the patients were 16.75 ± 4.45 years. Computerized tomography (CT) scan showed cerebral contusion in four (33%) patients. Six (50%) patients needed surgery and others were treated conservatively. During the course of hospital treatment, one (8%) patient died, two (16%) had good recovery, and four (33%) were moderately disabled. Among the 12 patients identity, eight (67%) could be ascertained. Seven (58%) patients were sent home with their relatives, one (8%) was referred to a district hospital and three (25%) remained as unknown and were referred to destitute home for rehabilitation.

Conclusion:

Unidentified patients of pediatric age group have better outcome if proper care is provided in time.

Outcome prediction model for severe traumatic brain injury

Aim

Treatment of severe traumatic brain injury is aided by better prediction of outcomes. The purpose of the present study was to develop and validate a prediction model using retrospective analysis of prospectively collected clinical data from two tertiary critical care medical centers in Japan.

Methods

Data were collected from 253 patients with a Glasgow Coma Scale score of <9. Within 24 h of their admission, 15 factors possibly related to outcome were evaluated. The dataset was randomly split into training and validation datasets using the repeated random subsampling method. A logistic regression model was fitted to the training dataset and predictive accuracy was assessed using the validation data.

Results

The best model included the variables age, pupillary light reflex, extensive subarachnoid hemorrhage, intracranial pressure, and midline shift. The estimated area under the curve for the model development data was 0.957, with a 95% confidence interval of 0.926-0.987, and that for validation data was 0.947, with a 95% confidence interval of 0.909-0.980.

Conclusion

Our predictive model was shown to have high predictive value. It will be useful for review of treatment, family counseling, and efficient allocation of resources for patients with severe traumatic brain injury.

Evaluation of the clinical usefulness of critical patient severity classification system and glasgow coma scale for neurological patients in intensive care units

PURPOSE

The purpose of this study was to evaluate the clinical usefulness of the Critical Patient Severity Classification System (CPSCS) and Glasgow Coma Scale (GCS) for critically ill neurological patients and to determine the applicability of CPSCS and GCS in predicting their mortality.

METHODS

Data were collected from the medical records of 187 neurological patients who were admitted to the intensive care unit of C university hospital. The data were analyzed through chi-square test, t test, Mann-Whitney, Kruskal-Wallis, goodness-of-fit test, and receiver operating characteristic curve.

RESULTS

In accordance with patients' general and clinical characteristics, patient mortality turned out to be significantly different depending on intensive care unit stay, endotracheal intubation, central venous catheter, and severity by CPSCS. Hosmer-Lemeshow goodness-of-fit tests were applied to CPSCS and GCS. The results of the discrimination test using the receiver operating characteristic curve were CPSCS0, .743, GCS0 .583, CPSCS24, .734, GCS24 .612, CPSCS48, .591, GCS48 .646, CPSCS72, .622, and GCS72 .623. Logistic regression analysis showed that each point on the CPSCS score signifies a 1.034 higher likelihood of dying.

CONCLUSION

Applied to neurologically ill patients, early CPSCS scores can be regarded as a useful tool.

Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury

BACKGROUND

The purpose of this study was to determine the relationship between coagulopathy and outcome after traumatic brain injury.

METHODS

Patients admitted with a traumatic brain injury were enrolled prospectively and admission blood samples were obtained for kaolin-activated thrombelastogram and standard coagulation assays. Demographic and clinical data were obtained for analysis.

RESULTS

Sixty-nine patients were included in the analysis. A total of 8.7% of subjects showed hypocoagulability based on a prolonged time to clot formation (R time, > 9 min). The mortality rate was significantly higher in subjects with a prolonged R time at admission (50.0% vs 11.7%). Patients with a prolonged R time also had significantly fewer intensive care unit-free days (8 vs 27 d), hospital-free days (5 vs 24 d), and increased incidence of neurosurgical intervention (83.3% vs 34.9%).

CONCLUSIONS

Hypocoagulability as shown by thrombelastography after traumatic brain injury is associated with worse outcomes and an increased incidence of neurosurgical intervention.

Relationship between, sleep spindles and clinical recovery in patients with traumatic brain injury: a simultaneous EEG and MEG study

Few methods can predict the prognosis and outcome of traumatic brain injury. Electroencephalographic (EEG) examinations have prognostic significance in the acute stage of posttraumatic coma, and some EEG variables have been correlated with outcome. Furthermore, spindle activity and reactivity in the acute stage have been associated with good recovery. Assessments of consciousness based on EEG and magnetoencephalographic (MEG) recordings provide valuable information for evaluating residual function, forming differential diagnoses and estimating prognosis. This study objectively investigated how fast spindles could relate to the recovery of consciousness and cognitive function during the post-acute to chronic stages of diffuse axonal injuries (DAIs). Sleep stage 2 was examined in 7 healthy participants and 8 patients with DAIs. Simultaneous EEG and MEG recordings were performed in the post-acute (mean 80 days) and chronic (mean 151 days) stages of recovery. Magnetoencephalography enabled equivalent current dipole estimates of fast spindle sources. Clinical recovery was evaluated by consciousness, neuropsychological examination, and outcome. Six severe and two moderate injuries were studied in patients with favorable 1-year outcomes. In the sub-acute stage, significant decreases were detected in the frequency, amplitude, and cortical activation source strengths of spindle activities, but these recovered during the chronic stage. In the chronic stage, the Wechsler adult intelligence factor scale and subset patterning revealed significant improvement in cognitive function. These results suggested that spindles may reflect recovery of consciousness and cognitive function following a DAI.

Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index

Background

This paper introduces the 7/5/2011al Pupil index (NPi), a sensitive measure of pupil reactivity and an early indicator of increasing intracranial pressure (ICP). This may occur in patients with severe traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage (ICH).

Methods

134 patients (mean age 46 years, range 18–87 years, 54 women and 80 men) in the intensive care units at eight different clinical sites were enrolled in the study. Pupillary examination was performed using a portable hand-held pupillometer.

Results

Patients with abnormal pupillary light reactivity had an average peak ICP of 30.5 mmHg versus 19.6 mmHg for the normal pupil reactivity population (P = 0.0014). Patients with “nonreactive pupils” had the highest peaks of ICP (mean = 33.8 mmHg, P = 0.0046). In the group of patients with abnormal pupillary reactivity, we found that the first evidence of pupil abnormality occurred, on average, 15.9 hours prior to the time of the peak of ICP.

Conclusions

Automated pupillary assessment was used in patients with possible increased ICP. Using NPi, we were able to identify a trend of inverse relationship between decreasing pupil reactivity and increasing ICP. Quantitative measurement and classification of pupillary reactivity using NPi may be a useful tool in the early management of patients with causes of increased ICP.

150 years of treating severe traumatic brain injury: a systematic review of progress in mortality

Considerable effort and resources have been devoted to preserving life in patients with severe closed traumatic brain injury (TBI). We sought to identify temporal trends in mortality rates of these patients from the late 1800s to the present. We searched the literature for articles on severe TBI, abstracting numbers of patients studied, numbers of deaths, and years of patient entry. Mortality rates were calculated for each study, and meta-regression was used to pool data and to test for significant temporal trends. We reviewed 207 case series comprising more than 140,000 cases of severe closed TBI admitted to hospital over a span of almost 150 years. Since the late 1800s mortality has fallen by almost 50%. However, the rate has varied considerably among the four epochs chosen. Between 1885 and 1930, mortality decreased at a rate of 3% per decade. From 1970 to 1990, mortality declined at a rate of 9% per decade. Both changes are significant. There was no observed improvement in mortality between 1930 and 1970, nor is progress evident since 1990. The authors discuss possible reasons for the apparently intermittent progress in TBI survival over time.

Global outcome in acute phase of treatment following moderate-to-severe traumatic brain injury from motor vehicle collisions vs assaults

PRIMARY OBJECTIVE

To compare socio-demographic, medical characteristics and acute outcomes between patients with traumatic brain injuries (TBIs) from motor vehicle collision (MVC) or assault in an acute care setting.

RESEARCH DESIGN

This descriptive, comparative retrospective cohort study included 415 patients with moderate and severe TBI secondary to an assault (n¼91) vs a motor vehicle collision (n=324).

METHODS AND PROCEDURES

Outcome measures were length of stay (LOS) in the intensive care unit and in hospital, Extended Glasgow Outcome Scale (GOS-E), FIM® instrument (‘FIM’) and discharge destination.

MAIN OUTCOMES AND RESULTS

Patients with TBI from MVC had a higher percentage of polytrauma, higher injury severity scores, required more orthopaedic surgeries and thoracic drain insertions. Patients with TBI from assault were more often non-Caucasian, young single men, less educated with higher unemployment rates and criminal records, with a history of alcohol and drug abuse and were more often intoxicated on admission. There was no significant group difference in the LOS and FIM ratings, but patients with assault-related TBI were more often discharged home and had a more favourable GOS-E.

CONCLUSION

Variables such as injury severity, age, level of intoxication on admission and presence of surgeries should be considered when determining acute outcome.

Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury

OBJECT

Despite being common practice for decades and being recommended by national guidelines, aggressive monitoring and treatment of patients with severe traumatic brain injury (TBI) have not been supported by convincing evidence.

METHODS

The authors reviewed trials and case series reported after 1970 in which patients were treated for severe closed TBI, and mortality rates and favorable outcomes at 6 months after injury were analyzed. The patient groups were divided into those with and without intracranial pressure (ICP) monitoring and intensive therapy, and the authors performed a meta-analysis to assess the effects of treatment intensity on outcome.

RESULTS

Although the mortality rate fell during the years reviewed, it was consistently approximately 12% lower among patients in the intense treatment group (p < 0.001). Favorable outcomes did not change significantly over time, and were 6% higher among the aggressively treated patients (p = 0.0105).

CONCLUSIONS

Aggressive ICP monitoring and treatment of patients with severe TBI is associated with a statistically significant improvement in outcome. This improvement occurs independently of temporal effects.

Early prognosis in traumatic brain injury: from prophecies to predictions

Traumatic brain injury (TBI) is a heterogeneous condition that encompasses a broad spectrum of disorders. Outcome can be highly variable, particularly in more severely injured patients. Despite the association of many variables with outcome, prognostic predictions are notoriously difficult to make. Multivariable analysis has identified age, clinical severity, CT abnormalities, systemic insults (hypoxia and hypotension), and laboratory variables as relevant factors to include in models to predict outcome in individual patients. Advances in statistical modelling and the availability of large datasets have facilitated the development of prognostic models that have greater performance and generalisability. Two prediction models are currently available, both of which have been developed on large datasets with state-of-the-art methods, and offer new opportunities. We see great potential for their use in clinical practice, research, and policy making, as well as for assessment of the quality of health-care delivery. Continued development, refinement, and validation is advocated, together with assessment of the clinical impact of prediction models, including treatment response.

Judgments of critical care nurses about risk for secondary brain injury

BACKGROUND

Interdisciplinary care for patients with traumatic brain injury focuses on treating the primary brain injury and limiting further brain damage from secondary injury. Intensive care unit nurses have an integral role in preventing secondary brain injury; however, little is known about factors that influence nurses' judgments about risk for secondary brain injury.

OBJECTIVE

To investigate which physiological and situational variables influence judgments of intensive care unit nurses about patients' risk for secondary brain injury, management solely with nursing interventions, and management by consulting another member of the health care team.

METHODS

A multiple segment factorial survey design was used. Vignettes reflecting the complexity of real-life scenarios were randomly generated by using different values of each independent variable. Surveys containing the vignettes were sent to nurses at 2 level I trauma centers. Multiple regression was used to determine which variables influenced judgments about secondary brain injury.

RESULTS

Judgments about risk for secondary brain injury were influenced by a patient's oxygen saturation, intracranial pressure, cerebral perfusion pressure, mechanism of injury, and primary diagnosis, as well as by nursing shift. Judgments about interventions were influenced by a patient's oxygen saturation, intracranial pressure, and cerebral perfusion pressure and by nursing shift. The initial judgments made by nurses were the most significant variable predictive of follow-up judgments.

CONCLUSIONS

Nurses need standardized, evidence-based content for management of secondary brain injury in critically ill patients with traumatic brain injury.

A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit

INTRODUCTION

Trauma centers successfully save lives of severely injured patients who would have formerly died. However, survivors often have multiple complications and morbidities associated with prolonged intensive care unit (ICU) stays. Because the reintegration of patients into the society to lead an active and a productive life is the ultimate goal of trauma center care, we questioned whether our "success" may condemn these patients to a fate worse than death?

METHODS

Charts on all patients > or =18 years with ICU stay > or =10 days, discharged alive between June 1, 2002, and May 31, 2005, were reviewed. Patients with complete spinal cord injuries were excluded. Demographics, Injury Severity Score (ISS), presence of severe traumatic brain injury (TBI; Head Abbreviated Injury Scale [AIS] score = 4 or 5), presence of extremity fractures, need for operative procedures, ventilator days, complications, and discharge disposition were collected. Glasgow Outcome Scale score was calculated on discharge. Patients were contacted by phone to determine general health, work status, and using this data, Glasgow Outcome Scale score and a modified Functional Independence Measure (FIM) score were calculated.

RESULTS

Two hundred and forty-one patients met inclusion criteria. Thirty-three patients died postdischarge from the hospital and 39 were known to be alive from the electronic medical records but were unable to be contacted. Sixty-nine patients could not be tracked down and were ultimately considered as lost to follow-up. The remaining 100 patients who were successfully contacted participated in the study. Eighty-one percent were men with a mean age of 42 years, mean and median ISS of 28. Severe TBI was present in 50 (50%) patients. Mean and median follow-up was 3.3 years from discharge. At the time of follow-up, 92 (92%) patients were living at home, 5 in nursing homes, and 3 in assisted living, a shelter, or halfway house. FIM scores ranged from 6 to 12 with 55% reached a maximal FIM score of 12. One quarter of patients had FIM scores < or =10 and 10% had locomotion scores of < or =2 (very dependent). Seventy percent considered themselves to be less active. Seventy-six patients were either working or in full-time school before their trauma. Of the 24 patients not working preinjury, 12 were > or =55 years of age. At the time of follow-up, 37 patients (49%) were back to work or school. Severe TBI patients (57%, 21 of 37) were less likely to return to work when compared with 38% (12 of 38; p = 0.03) without severe TBI. There was no relationship with age, ISS, presence of any TBI, head AIS, presence of any extremity fracture, extremity AIS, or ventilator days in patients who did or did not return to work.

CONCLUSIONS

These data demonstrate that ICU survivors >3 years after severe injury have significant impairments including inability to return to work or regain previous levels of activity and that the goal of reintegrating patients back into the society is not being met. Further studies better defining the limitations and barriers to improved quality of life are necessary. Survival, although important, is no longer a sufficient outcome to measure trauma center success.

Knowledge of Glasgow coma scale by air-rescue physicians

Objective

To assess the theoretical and practical knowledge of the Glasgow Coma Scale (GCS) by trained Air-rescue physicians in Switzerland.

Methods

Prospective anonymous observational study with a specially designed questionnaire. General knowledge of the GCS and its use in a clinical case were assessed.

Results

From 130 questionnaires send out, 103 were returned (response rate of 79.2%) and analyzed. Theoretical knowledge of the GCS was consistent for registrars, fellows, consultants and private practitioners active in physician-staffed helicopters. The clinical case was wrongly scored by 38 participants (36.9%). Wrong evaluation of the motor component occurred in 28 questionnaires (27.2%), and 19 errors were made for the verbal score (18.5%). Errors were made most frequently by registrars (47.5%, p = 0.09), followed by fellows (31.6%, p = 0.67) and private practitioners (18.4%, p = 1.00). Consultants made significantly less errors than the rest of the participating physicians (0%, p < 0.05). No statistically significant differences were shown between anesthetists, general practitioners, internal medicine trainees or others.

Conclusion

Although the theoretical knowledge of the GCS by out-of-hospital physicians is correct, significant errors were made in scoring a clinical case. Less experienced physicians had a higher rate of errors. Further emphasis on teaching the GCS is mandatory.

Prediction of the level of cognitive functional independence in acute care following traumatic brain injury

PRIMARY OBJECTIVE

To determine a predictive model for cognitive functional outcome of patients with traumatic brain injury (TBI) at discharge from acute care.

METHODS AND PROCEDURE

Three hundred and thirty-five patients were included in this analysis. Variables considered were age, education, initial score on the Glasgow Coma Scale (GCS), duration of post-traumatic amnesia (PTA), cerebral imaging results and the need for neurosurgical intervention.

EXPERIMENTAL INTERVENTIONS

Functional Independence Measure (FIM).

MAIN OUTCOMES AND RESULTS

Results of this analysis indicated better cognitive FIM at discharge from acute care settings for patients with TBI when PTA was less than 24 hours, when level of education was higher, when no parietal lesion was identified, when no neurosurgical intervention was required, for patients with TBI who were younger and who presented with a higher GCS score upon admission.

CONCLUSIONS

This model will help to plan resource allocation for treatment and discharge planning within the first weeks following TBI.

Prehospital management of traumatic brain injury

The aim of this study was to review the current protocols of prehospital practice and their impact on outcome in the management of traumatic brain injury. A literature review of the National Library of Medicine encompassing the years 1980 to May 2008 was performed. The primary impact of a head injury sets in motion a cascade of secondary events that can worsen neurological injury and outcome. The goals of care during prehospital triage, stabilization, and transport are to recognize life-threatening raised intracranial pressure and to circumvent cerebral herniation. In that process, prevention of secondary injury and secondary insults is a major determinant of both short- and longterm outcome. Management of brain oxygenation, blood pressure, cerebral perfusion pressure, and raised intracranial pressure in the prehospital setting are discussed. Patient outcomes are dependent upon an organized trauma response system. Dispatch and transport timing, field stabilization, modes of transport, and destination levels of care are addressed. In addition, special considerations for mass casualty and disaster planning are outlined and recommendations are made regarding early response efforts and the ethical impact of aggressive prehospital resuscitation. The most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of prehospital care is a major determinant of long-term outcome for patients with traumatic brain injury.

Classification of traumatic brain injury for targeted therapies

The heterogeneity of traumatic brain injury (TBI) is considered one of the most significant barriers to finding effective therapeutic interventions. In October, 2007, the National Institute of Neurological Disorders and Stroke, with support from the Brain Injury Association of America, the Defense and Veterans Brain Injury Center, and the National Institute of Disability and Rehabilitation Research, convened a workshop to outline the steps needed to develop a reliable, efficient and valid classification system for TBI that could be used to link specific patterns of brain and neurovascular injury with appropriate therapeutic interventions. Currently, the Glasgow Coma Scale (GCS) is the primary selection criterion for inclusion in most TBI clinical trials. While the GCS is extremely useful in the clinical management and prognosis of TBI, it does not provide specific information about the pathophysiologic mechanisms which are responsible for neurological deficits and targeted by interventions. On the premise that brain injuries with similar pathoanatomic features are likely to share common pathophysiologic mechanisms, participants proposed that a new, multidimensional classification system should be developed for TBI clinical trials. It was agreed that preclinical models were vital in establishing pathophysiologic mechanisms relevant to specific pathoanatomic types of TBI and verifying that a given therapeutic approach improves outcome in these targeted TBI types. In a clinical trial, patients with the targeted pathoanatomic injury type would be selected using an initial diagnostic entry criterion, including their severity of injury. Coexisting brain injury types would be identified and multivariate prognostic modeling used for refinement of inclusion/exclusion criteria and patient stratification. Outcome assessment would utilize endpoints relevant to the targeted injury type. Advantages and disadvantages of currently available diagnostic, monitoring, and assessment tools were discussed. Recommendations were made for enhancing the utility of available or emerging tools in order to facilitate implementation of a pathoanatomic classification approach for clinical trials.

A systematic review finds methodological improvements necessary for prognostic models in determining traumatic brain injury outcomes

OBJECTIVES

To describe the modeling techniques used for early prediction of outcome in traumatic brain injury (TBI) and to identify aspects for potential improvements.

STUDY DESIGN AND SETTING

We reviewed key methodological aspects of studies published between 1970 and 2005 that proposed a prognostic model for the Glasgow Outcome Scale of TBI based on admission data.

RESULTS

We included 31 papers. Twenty-four were single-center studies, and 22 reported on fewer than 500 patients. The median of the number of initially considered predictors was eight, and on average five of these were selected for the prognostic model, generally including age, Glasgow Coma Score (or only motor score), and pupillary reactivity. The most common statistical technique was logistic regression with stepwise selection of predictors. Model performance was often quantified by accuracy rate rather than by more appropriate measures such as the area under the receiver-operating characteristic curve. Model validity was addressed in 15 studies, but mostly used a simple split-sample approach, and external validation was performed in only four studies.

CONCLUSION

Although most models agree on the three most important predictors, many were developed on small sample sizes within single centers and hence lack generalizability. Modeling strategies have to be improved, and include external validation.

Assessment of mitochondrial impairment in traumatic brain injury using high-resolution proton magnetic resonance spectroscopy

Object

The goal of this study was to demonstrate the posttraumatic neurochemical damage in normal-appearing brain and to assess mitochondrial dysfunction by measuring N-acetylaspartate (NAA) levels in patients with severe head injuries, using proton (1H) magnetic resonance (MR) spectroscopy.

Methods

Semiquantitative analysis of NAA relative to creatine-containing compounds (Cr) and choline (Cho) was carried out from proton spectra obtained by means of chemical shift (CS) imaging and single-voxel (SV) methods in 25 patients with severe traumatic brain injuries (TBIs) (Glasgow Coma Scale scores ≤ 8) using a 1.5-tesla MR unit. Proton MR spectroscopy was also performed in 5 healthy volunteers (controls).

Results

The SV studies in patients with diffuse TBI showed partial reduction of NAA/Cho and NAA/Cr ratios within the first 10 days after injury (means ± standard deviations 1.59 ± 0.46 and 1.44 ± 0.21, respectively, in the patients compared with 2.08 ± 0.26 and 2.04 ± 0.31, respectively, in the controls; nonsignificant difference). The ratios gradually declined in all patients as time from injury increased (mean minimum values NAA/Cho 1.05 ± 0.44 and NAA/Cr 1.05 ± 0.30, p < 0.03 and p < 0.02, respectively). This reduction was greater in patients with less favorable outcomes. In patients with focal injuries, the periphery of the lesions revealed identical trends of NAA/Cho and NAA/Cr decrease. These reductions correlated with outcome at 6 months (p < 0.01). Assessment with multivoxel methods (CS imaging) demonstrated that, in diffuse injury, NAA levels declined uniformly throughout the brain. At 40 days postinjury, initially low NAA/Cho levels had recovered to near baseline in patients who had good outcomes, whereas no recovery was evident in patients with poor outcomes (p < 0.01).

Conclusions

Using 1H-MR spectroscopy, it is possible to detect the posttraumatic neurochemical damage of the injured brain when conventional neuroimaging techniques reveal no abnormality. Reduction of NAA levels is a dynamic process, evolving over time, decreasing and remaining low throughout the involved tissue in patients with poor outcomes. Recovery of NAA levels in patients with favorable outcomes suggests marginal mitochondrial impairment and possible resynthesis from vital neurons.

Severe traumatic brain injury in Austria III: prehospital status and treatment

OBJECTIVES

The goal of this paper is to describe prehospital status and treatment of patients with severe TBI in Austria.

PATIENTS AND METHODS

Data sets from 396 patients with severe TBI (Glasgow Coma Scale score < 9) included by 5 Austrian hospitals were available. The analysis focused on incidence and/or degree of severity of typical clinical signs, frequency of use of different management options, and association with outcomes for both. ICU mortality, 90-day mortality, final outcome (favorable = good recovery or moderate disability; unfavorable = severe disability, vegetative state, or death) after 6 or 12 months, and ratio of observed (90-day) to predicted mortality (O/E ratio) are reported for the selected parameters. Chi2 -test, t-test, Fisher's exact test, and logistic regression were used to identify significant (p < 0.05) differences for association with survival and favorable outcome (both coded as 1).

RESULTS

The majority of patients were male (72%), mean age was 49 +/- 21 years, mean injury severity score (ISS) was 27 +/- 17, mean first GCS score was 5.6 +/- 2.9, and expected hospital survival was 63 +/- 30%. ICU mortality was 32%, 90-day mortality was 37%, and final outcome was favorable in 35%, unfavorable in 53%, unknown in 12%. We found that age > 60 years, ISS > 50 points, GCS score < 4, bilateral changes in pupil size and reactivity, respiratory rate < 10/min, systolic blood pressure (SBP) < 90 mm Hg, and heart rate < 60/min were associated with significantly higher ICU and 90-day mortality rates, and lower rates of favorable outcome. With regard to prognostic value the GCS motor response score is identical to the full GCS score. Administration of > 1000 ml of fluid and helicopter transport were associated with better outcomes than expected, while endotracheal intubation in the field had neither a positive nor a negative effect on outcomes. Administration of no or < 500 ml of fluids was associated with worse outcomes than expected. Outcomes were better than expected in the few patients (5%) who received hypertonic saline.

CONCLUSIONS

Age, ISS, and initial neuro status are the factors most closely associated with outcome. Hypotension must be avoided. Fluids should be given to restore and/or maintain SBP > 110 mm Hg. Helicopter transport should be arranged for more seriously injured patients.

Prognostic Study of Using Different Monitoring Modalities in Treating Severe Traumatic Brain Injury

OBJECTIVE

To determine whether or not multimodality monitoring technique would result in a better outcome score than single modality monitoring in severely head injured patients.

METHODS

This was a prospective randomized study that included all adults with traumatic severe head injury who had a Glasgow Coma Score < 9 and computed tomography scan features that did not reveal significant infratentorial pathology. Subjects were randomized into a multimodality group where they received multiple cerebral monitoring or into a standard single modality group where they received only intracranial pressure monitoring. The outcome was analysed 6 months post treatment using the Barthel Index.

RESULTS

The outcome at 6 months post treatment between the two groups was not statistically significant (p < 0.48). However, the percentage of subjects who were independent at 6 months was higher in the multimodality group (21.2%) compared with the single modality group (17.3%).

CONCLUSION

Multimodality monitoring for severely head-injured patients has no effect on outcome. However, study with a larger sample size and improvement in groups comparison are required to ascertain the above findings.

Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis

We studied the prognostic strength of the individual components of the Glasgow Coma Scale (GCS) and pupil reactivity to Glasgow Outcome Score (GOS) at 6 months post-injury. A total of 8721 moderate or severe traumatic brain injury (TBI) patient data from the IMPACT database on traumatic brain injury comprised the study cohort. The associations between motor score and pupil reactivity and 6-month GOS were analyzed by binary logistic regression and proportional odds methodology. The strength of prognostic effects were expressed as the unadjusted odds ratios presented for all individual studies as well as in meta-analysis. We found a consistent strong association between motor score and 6-month GOS across all studies (OR 1.74-7.48). The Eye and Verbal components were also strongly associated with GOS. In the pooled population, one or both un-reactive pupils and lower motor scores were significantly associated with unfavorable outcome (range 2.71-7.31). We also found a significant change in motor score from pre-hospital direct to study hospital enrollment ( p < 0.0001) and from the first in-hospital to study enrollment scores (p < 0.0001). Pupil reactivity was more robust between these time points. It is recommended that the study hospital enrollment GCS and pupil reactivity be used for prognostic analysis.

Traumatic brain injury: assessment, resuscitation and early management

This review examines the evidence base for the early management of head-injured patients. Traumatic brain injury (TBI) is common, carries a high morbidity and mortality, and has no specific treatment. The pathology of head injury is increasingly well understood. Mechanical forces result in shearing and compression of neuronal and vascular tissue at the time of impact. A series of pathological events may then ensue leading to further brain injury. This secondary injury may be amenable to intervention and is worsened by secondary physiological insults. Various risk factors for poor outcome after TBI have been identified. Most of these are fixed at the time of injury such as age, gender, mechanism of injury, and presenting signs (Glasgow Coma Scale and pupillary signs), but some such as hypotension and hypoxia are potential areas for medical intervention. There is very little evidence positively in favour of any treatments or packages of early care; however, prompt, specialist neurocritical care is associated with improved outcome. Various drugs that target specific pathways in the pathophysiology of brain injury have been the subject of animal and human research, but, to date, none has been proved to be successful in improving outcome.

A Review of the Predictive Ability of Glasgow Coma Scale Scores in Head-Injured Patients

According to 1999 data from the Centers for Disease Control and Prevention, traumatic brain injuries (TBI) caused by motor vehicle accidents, firearms, and falls are recorded as a leading cause of death and lifelong disability for young adults in the United States. Researchers have investigated if correlations exist between variables in the acute stage of injury and outcome measures in TBI patients. The Glasgow Coma Scale (GCS) score is one variable that was extensively studied for its ability to predict outcome in TBI patients. However, the use of different designs and methodologies in these studies makes the interpretation of the cumulative findings difficult. Therefore the purpose of this review was to provide a summary of the research findings on the ability of the GCS scores to predict outcome in TBI patients. A search was done on MEDLINE and CINAHL to identify studies that investigated the predictive ability of the GCS score. Studies that used the GCS as a variable in predicting outcome with adult patients who had sustained some type of head injury were included. GCS scores are most accurate at predicting outcome in head-injured patients when they are combined with patient age and pupillary response and when broad outcome categories are used. The motor component of the GCS yields similar prediction rates as the summed GCS score, and better prediction occurs with very high or very low GCS scores. Information about the cumulative research findings on the predictive ability of GCS scores aids nurses in providing support and education to family members during the acute stage of injury, and in coordinating the services of members of the healthcare team, which could result in improved outcomes for both patient and family.

Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury

PRIMARY OBJECTIVE

To compare functional physical and cognitive outcome of patients in three age groups with mild, moderate and severe traumatic brain injury (TBI) at discharge from acute care.

RESEARCH DESIGN

Retrospective database review.

METHODS AND PROCEDURES

Scores on the Extended Glasgow Outcome Scale (GOSE) and on the FIM instrument,1 discharge destination and length-of-stay (LOS) were gathered and compared for 2327 patients with TBI admitted to a level 1 trauma hospital from 1997-2003 divided into three age groups; 971 patients between 18-39 years, 672 between 40-59 years and 684 aged 60-99 years.

MAIN OUTCOMES AND RESULTS

Relative to younger adults with similar TBI severity, elderly patients showed worse outcome on the GOSE and FIM instrument (physical and cognitive ratings) and longer LOS. No difference was observed between the young and middle-aged groups except for cognitive FIM ratings and LOS for severe TBI. A higher percentage of elderly patients went to in-patient rehabilitation, to long-term care facilities or died compared to young and middle-aged patients. A higher number of young and middle-aged patients were discharged home.

CONCLUSIONS

Further development of services in early rehabilitation as well as post-rehabilitation geared to the specific needs of the elderly patient with TBI is required as the population ages.

A Brief Review of Traumatic Brain Injury Rehabilitation

Introduction: This article aims to provide an overview of the epidemiology, medical and rehabilitation issues, current evidence for traumatic brain injury (TBI) rehabilitation, recent advances and emerging practices. Special TBI population groups will also be addressed. Materials and Methods: We included publications indexed in Medline and the Cochrane Database of Systemic Reviews from 1974 to 2006, relevant chapters in major rehabilitation texts and Physical Medicine and Rehabilitation Clinics of North America and accessed Internet publications. Results: TBI has been implicated by the World Health Organisation to be a 21st century epidemic similar to malaria and HIV/AIDS, not restricted to the developed world. One third of patients may suffer severe TBI with long-term cognitive and behavioural disabilities. Injuries to the brain do not only damage the cerebrum but may give rise to a multisystem disorder due to associated injuries in 20% of cases, which can include complex neurological impairments, neuroendocrine and neuromedical complications. There is promising evidence of improved outcome and functional benefits with early induction into a transdisciplinary brain injury rehabilitation programme. However, TBI research is fraught with difficulties because of an intrinsically heterogeneous population due to age, injury severity and type, functional outcome measures and small samples. Recent advances in TBI rehabilitation include task-specific training of cognitive deficits, computer-aided cognitive remediation and visual-spatial and visual scanning techniques and body weight-supported treadmill training for motor deficits. In addition, special rehabilitation issues for mild TBI, TBI-related vegetative states, elderly and young TBI, ethical issues and local data will also be discussed. Key words: Disability, Head injury, Impairment, Neurorehabilitation, Vegetative state