Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis

Introduction

Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making.

Methods

Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model.

Results

The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure.

Conclusion

The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.

The impact of perfusion computed tomography on the diagnosis and outcome of delayed cerebral ischemia after subarachnoid hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI) is a preventable cause of poor neurological outcome in aneurysmal subarachnoid hemorrhage (aSAH). Advances in radiological methods, such as cerebral perfusion computed tomography (CTP), could help diagnose DCI earlier and potentially improve outcomes in aSAH. The objective of this study was to assess whether the use of CTP to diagnose DCI early could reduce the risk of infarction related to DCI.

METHODS

Retrospective cohort study of patients in the intensive care unit of Erasme Hospital (Brussels, Belgium) between 2004 and 2021 with aSAH who developed DCI. Patients were classified as: "group 1" - DCI diagnosed based on clinical deterioration or "group 2" - DCI diagnosed using CTP. The primary outcome was the development of infarction unrelated to the initial bleeding or surgery.

RESULTS

211 aSAH patients were diagnosed with DCI during the study period: 139 (66%) in group 1 and 72 (34%) in group 2. In group 1, 109 (78%) patients developed a cerebral infarction, compared to 45 (63%) in group 2 (p = 0.02). The adjusted cumulative incidence of DCI over time was lower in group 2 than in group 1 [hazard ratio 0.65 (95% CI 0.48-0.94); p = 0.02]. The use of CTP to diagnose DCI was not independently associated with mortality or neurological outcome.

CONCLUSIONS

The use of CTP to diagnose DCI might help reduce the risk of developing cerebral infarction after aSAH, although the impact of such an approach on patient outcomes needs to be further demonstrated.

Development of a Novel Neurological Score Combining GCS and FOUR Scales for Assessment of Neurosurgical Patients with Traumatic Brain Injury: GCS-FOUR Scale

BACKGROUND

Consciousness assessment is crucial for patients with traumatic brain injury. In this study, we developed a novel scoring system combining the Glasgow coma scale (GCS) and the full outline of unresponsiveness (FOUR) and evaluated its association with the intensive care unit (ICU) length of stay, mortality, and functional outcome.

METHODS

We retrospectively analyzed the data from patients with traumatic brain injury admitted to the neurosurgical ICU of our institution during a 2-year period. The eye and motor components of the GCS and the brainstem reflex component of the FOUR were used to compute the GCS-FOUR. We performed statistical analysis to demonstrate the association between the GCS, FOUR, and GCS-FOUR and the ICU length of stay, mortality, the development of a persistent vegetative state, and desirable recovery.

RESULTS

A total of 140 patients were included. The mean age was 30.6 years, and 89.3% were male. All 3 scores were associated with the ICU length of stay, mortality, a persistent vegetative state, and good recovery. In terms of predicting mortality, the GCS score exhibited a slight superiority compared with the other indexes, and the GCS-FOUR score showed a slight superiority over the other indexes in predicting for good recovery.

CONCLUSIONS

The GCS-FOUR is a novel scoring system comparable to the GCS and FOUR regarding its association with functional status after injury, ICU length of stay, and mortality. The GCS-FOUR score provides greater neurological detail than the GCS due to the inclusion of brainstem reflexes, in addition to using the experience of healthcare providers with the GCS score compared with the FOUR in most settings.

PREDICT-TBI: Comparison of Physician Predictions with the IMPACT Model to Predict 6-Month Functional Outcome in Traumatic Brain Injury

BACKGROUND

Predicting functional outcome in critically ill patients with traumatic brain injury (TBI) strongly influences end-of-life decisions and information for surrogate decision makers. Despite well-validated prognostic models, clinicians most often rely on their subjective perception of prognosis. In this study, we aimed to compare physicians' predictions with the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic model for predicting an unfavorable functional outcome at 6 months after moderate or severe TBI.

METHODS

PREDICT-TBI is a prospective study of patients with moderate to severe TBI. Patients were admitted to a neurocritical care unit and were excluded if they died or had withdrawal of life-sustaining treatments within the first 24 h. In a paired study design, we compared the accuracy of physician prediction on day 1 with the prediction of the IMPACT model as two diagnostic tests in predicting unfavorable outcome 6 months after TBI. Unfavorable outcome was assessed by the Glasgow Outcome Scale from 1 to 3 by using a structured telephone interview. The primary end point was the difference between the discrimination ability of the physician and the IMPACT model assessed by the area under the curve.

RESULTS

Of the 93 patients with inclusion and exclusion criteria, 80 patients reached the primary end point. At 6 months, 29 patients (36%) had unfavorable outcome. A total of 31 clinicians participated in the study. Physicians' predictions showed an area under the curve of 0.79 (95% confidence interval 0.68-0.89), against 0.80 (95% confidence interval 0.69-0.91) for the laboratory IMPACT model, with no statistical difference (p = 0.88). Both approaches were well calibrated. Agreement between physicians was moderate (κ = 0.56). Lack of experience was not associated with prediction accuracy (p = 0.58).

CONCLUSIONS

Predictions made by physicians for functional outcome were overall moderately accurate, and no statistical difference was found with the IMPACT models, possibly due to a lack of power. The significant variability between physician assessments suggests prediction could be improved through peer reviewing, with the support of the IMPACT models, to provide a realistic expectation of outcome to families and guide discussions about end-of-life decisions.

Clinical outcomes and prognostic factors of traumatic basal ganglia hematomas: A 4-year single-center study

BACKGROUND

Traumatic basal ganglia hematomas (TBGH) are rare entities. They are situated in the deep cerebral parenchyma and have also been termed as intermediate coup contusions. Available literature is sparse with regards to the characteristics and prognosis of TBGH. We aim to share our experience in the management, outcomes, and prognostic factors of TBGH.

METHODS

A 4-year retrospective study which included all cases of TBGH, except dot contusions (<2 mL) and those with coagulopathies. Admission variables were correlated with Glasgow Outcome Scale score at discharge and 12 months.

RESULTS

Thirty-two patients were analyzed. The mean age was 39.2 years. Two-thirds were due to road traffic accidents. Around 60% were severe head injuries. The mean Glasgow coma scale (GCS) score at presentation was 8.5. Twenty patients had moderate-to-severe hemiparesis. The mean hematoma volume was 18.1 mL. Associated traumatic intracranial lesions were seen in 28 cases. Only 7 patients (22%) underwent surgery. The mean follow-up was 17.4 months (range 14-34 months). The mortality rate was 12.5% (n = 4). Among the survivors, only 39% (n = 11) had good outcomes at discharge which showed modest improvement to 54% (n = 15) at 12 months.

CONCLUSION

Our study noted that poor admission GCS scores, poor motor response, presence of significant hemiparesis, and larger hematoma volumes (>20 mL) correlated with poor outcomes at 12 months. The overall outcomes have been mostly unfavorable as observed in majority of studies due to deeper location of these hematomas, high proportion of severe head injuries, and high proportion of residual weakness in survivors.

Effect of Dexmedotomdine hydrochloride (Percedex®) on functional outcome of patients with moderate and severe traumatic brain injury

Traumatic brain injury (TBI) is considered among the leading causes of morbidity and mortality worldwide being associated with significant social and economic burden. The best sedative regimen in TBI patients is yet to be identified. This study was designed to determine the effects of dexmedotomdine hydrochloride (Percedex®, DEX) on functional outcome of patients with moderate and severe traumatic brain injury (TBI). This was a retrospective cohort study including patients with severe (3-8) and moderate (9-13) TBI referring to a level I trauma center. We studied two groups of patients, those receiving DEX or routine sedation regimen in neurointensive care unit (NICU). The main outcome measures were the Glasgow outcome scale extended (GOSE) at 3 and 6-month. We have also recorded ICU and hospital length of stay (LOS) and the tracheostomy rate. We included 138 patients in two study groups (each including 69). The baseline characteristics were comparable between groups. DEX was associated with lower LOS in hospital (p = 0.002) and NICU (p = 0.003). The GOSE was comparable between two study groups at 3 (p = 0.245) and 6-month (p = 0.497). Multivariate regression analysis revealed that after LOS of NICU and hospital stay adjustment, DEX group experienced significantly improved 6-month GOSE with the average improvement in score of 0.92 compared to the control group (p = 0.041). DEX administration in patients with moderate and severe TBI was associated with decreased NICU and hospital LOS and improved functional outcome at 6-month.

Classification of neurologic outcomes from medical notes using natural language processing

Neurologic disability level at hospital discharge is an important outcome in many clinical research studies. Outside of clinical trials, neurologic outcomes must typically be extracted by labor intensive manual review of clinical notes in the electronic health record (EHR). To overcome this challenge, we set out to develop a natural language processing (NLP) approach that automatically reads clinical notes to determine neurologic outcomes, to make it possible to conduct larger scale neurologic outcomes studies. We obtained 7314 notes from 3632 patients hospitalized at two large Boston hospitals between January 2012 and June 2020, including discharge summaries (3485), occupational therapy (1472) and physical therapy (2357) notes. Fourteen clinical experts reviewed notes to assign scores on the Glasgow Outcome Scale (GOS) with 4 classes, namely 'good recovery', 'moderate disability', 'severe disability', and 'death' and on the Modified Rankin Scale (mRS), with 7 classes, namely 'no symptoms', 'no significant disability', 'slight disability', 'moderate disability', 'moderately severe disability', 'severe disability', and 'death'. For 428 patients' notes, 2 experts scored the cases generating interrater reliability estimates for GOS and mRS. After preprocessing and extracting features from the notes, we trained a multiclass logistic regression model using LASSO regularization and 5-fold cross validation for hyperparameter tuning. The model performed well on the test set, achieving a micro average area under the receiver operating characteristic and F-score of 0.94 (95% CI 0.93-0.95) and 0.77 (0.75-0.80) for GOS, and 0.90 (0.89-0.91) and 0.59 (0.57-0.62) for mRS, respectively. Our work demonstrates that an NLP algorithm can accurately assign neurologic outcomes based on free text clinical notes. This algorithm increases the scale of research on neurological outcomes that is possible with EHR data.

Prognostic Factors and Outcome of Surgically Treated Supratentorial versus Infratentorial Epidural Hematoma in Pediatrics: A Comparative Study of 350 Patients at a Tertiary Center of a Developing Country

PURPOSE

In children, epidural hematomas (EDHs) constitute around 2% to 3% of all head traumas. The aim of this study is to compare the manifestation, prognostic factors, and outcome of surgically treated supratentorial with infratentorial EDHs in pediatric patients.

METHODS

This is a hospital-based single-center, retrospective study of 350 pediatric patients admitted between January 2016 and December 2021. All pediatric patients to 18 years of age with posttraumatic EDHs with or without other intracranial/extracranial injuries who underwent surgical evacuation were included in the study. Posttraumatic EDHs treated conservatively during the hospital stay and any EDH unrelated to head trauma were excluded. Glasgow Outcome Scale (GOS) score was used to assess functional outcomes at discharge. The status of the patients at 3-month follow-up was assessed by using the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds) Score.

RESULTS

Out of 350 patients, 310 had supratentorial EDH and 40 had infratentorial EDH. In supratentorial EDH, the volume of hematoma, mass effect, and the time interval between trauma and surgery correlated with functional outcome (GOS) at discharge. Anisocoria, hypotension, and intradural injury were associated with functional as well as behavioral outcomes (GOS-E Peds) in the supratentorial EDH group. The severity of the injury was correlated with the functional and behavioral outcomes in both groups.

CONCLUSIONS

Infratentorial EDH has better clinical outcomes than supratentorial EDH in surgically treated pediatric patients. The most significant and consistent factor influencing the outcome in both groups was the Glasgow Coma Score on admission.

Comparison of Outcomes at Trauma Centers versus Non-Trauma Centers for Severe Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) is one of the most common injuries in patients with multiple trauma, and it associates with high post-traumatic mortality and morbidity. A trauma center was established to provide optimal treatment for patients with severe trauma. This study aimed to compare the treatment outcomes of patients with severe TBI between non-trauma and trauma centers based on data from the Korean Neuro-Trauma Data Bank System (KNTDBS).

METHODS

From January 2018 to June 2021, 1122 patients were enrolled in the KNTDBS study. Among them, 253 patients from non-traumatic centers and 253 from trauma centers were matched using propensity score analysis. We evaluated baseline characteristics, the time required from injury to hospital arrival, surgery-related factors, neuromonitoring, and outcomes.

RESULTS

The time from injury to hospital arrival was shorter in the non-trauma centers (110.2 vs. 176.1 minutes, p=0.012). The operation time was shorter in the trauma centers (156.7 vs. 128.1 minutes, p0.003). Neuromonitoring was performed in nine patients (3.6%) in the non-trauma centers and 67 patients (26.5%) in the trauma centers (p<0.001). Mortality rates were lower in trauma centers than in non-trauma centers (58.5% vs. 47.0%, p=0.014). The average Glasgow coma scale (GCS) at discharge was higher in the trauma centers (4.3 vs. 5.7, p=0.011). For the Glasgow outcome scale-extended (GOSE) at discharge, the favorable outcome (GOSE 5-8) was 17.4% in the non-trauma centers and 27.3% in the trauma centers (p=0.014).

CONCLUSION

This study showed lower mortality rates, higher GCS scores at discharge, and higher rates of favorable outcomes in trauma centers than in non-trauma centers. The regional trauma medical system seems to have a positive impact in treating patients with severe TBI.

Long-term outcomes of major trauma patients with concussion

INTRODUCTION

Concussion may be sustained in the setting of injuries to multiple body regions and persistent effects of concussion may impact recovery. This project aimed to evaluate the association between concussion and 6-month and 12-month functional outcomes in survivors after major trauma.

METHODS

This was a registry-based cohort study that included adult patients with major trauma who presented to hospital between 01 Jan 2008 and 31 Dec 2017 and survived to hospital discharge. We excluded patients presenting with a Glasgow Coma Scale score <13 and those diagnosed with other intracranial injuries. Additionally, from the non-concussed group, patients with fractured skull and/or face were excluded, with the assumption that such patients may have had undiagnosed concussion. A good recovery was considered for Glasgow Outcome Scale-Extended (GOS-E) scores of 7 or 8. In addition, we assessed for patient reported anxiety and/or depression measured using the 3-level EuroQol 5 dimensions questionnaire. A modified mixed effects Poisson models with random intercepts for participant was used to assess the association between concussion and outcome.

RESULTS

There were 28,161 eligible patients and 12,822 met inclusion criteria. Concussion was diagnosed in 1860 patients (14.5%; 95%CI: 13.9-15.1). There was no association between concussion and good recovery at 12 months (aRR 1.05 (95%CI: 0.99-1.11). There was no association between concussion and anxiety and/or depression at 12 months (aRR 1.03; 95%CI: 0.99-1.07).

CONCLUSIONS

Concussion was sustained among 14.5% of included patients in the setting of major trauma but not associated with longer-term adverse outcomes using GOS-E. Concussed patients did not report differential rates of anxiety and/or depression.

Decompressive Craniectomy for the Treatment of Severe Diffuse Traumatic Brain Injury: A Randomized Controlled Trial

Background  Severe traumatic brain injury (TBI) is one of the leading public health problems across the world. TBI is associated with high economic costs to the healthcare system specially in developing countries. Decompressive craniectomy is a procedure in which an area of the skull is removed to increase the volume of intracranial compartment. There are various techniques of decompressive craniectomy used that include subtemporal and circular decompression, and unilateral or bilateral frontotemporoparietal decompression. Objective  The aim of this study was to compare the outcome of decompressive craniectomy for the management of severe TBI versus conservative management alone at the Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan. Methods  The study (randomized controlled trial) was conducted from February 1, 2014, till June 30, 2017. Results  A total of 136 patients were included after following the inclusion criteria. They were randomly assigned to two groups, making it 68 patients in each study group. There were 89 males and 47 females. All the patients received standard care recommended by the Brain Trauma Foundation. The mortality rate observed at 6 months in decompressive craniectomy was 22.05%, while among conservative management group, it was 45.58%. Difference in mortality of both groups at 6 months was significant. Total 61.76% (42) of patients from decompressive craniectomy group had a favorable outcome (Glasgow outcome scale: 4-5) at 6 months. While among conservative management group, total 35.29% (24) had a favorable outcome (Glasgow outcome scale: 4-5). Difference in Glasgow outcome scale at 6 months of both groups was significant. Conclusion  In conclusion, decompressive craniectomy is simple, safe, and better than conservative management alone.

The Impact of Invasive Brain Oxygen Pressure Guided Therapy on the Outcome of Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Traumatic brain injury (TBI) is a major public health burden, causing death and disability worldwide. Intracranial hypertension and brain hypoxia are the main mechanisms of secondary brain injury. As such, management strategies guided by intracranial pressure (ICP) and brain oxygen (PbtO₂) monitoring could improve the prognosis of these patients. Our objective was to summarize the current evidence regarding the impact of PbtO₂-guided therapy on the outcome of patients with TBI. We performed a systematic search of PubMed, Scopus, and the Cochrane library databases, following the protocol registered in PROSPERO. Only studies comparing PbtO₂/ICP-guided therapy with ICP-guided therapy were selected. Primary outcome was neurological outcome at 3 and 6 months assessed by using the Glasgow Outcome Scale; secondary outcomes included hospital and long-term mortality, burden of intracranial hypertension, and brain tissue hypoxia. Out of 6254 retrieved studies, 15 studies (n = 37,245 patients, of who 2184 received PbtO₂-guided therapy) were included in the final analysis. When compared with ICP-guided therapy, the use of combined PbO₂/ICP-guided therapy was associated with a higher probability of favorable neurological outcome (odds ratio 2.21 [95% confidence interval 1.72-2.84]) and of hospital survival (odds ratio 1.15 [95% confidence interval 1.04-1.28]). The heterogeneity (I²) of the studies in each analysis was below 40%. However, the quality of evidence was overall low to moderate. In this meta-analysis, PbtO₂-guided therapy was associated with reduced mortality and more favorable neurological outcome in patients with TBI. The low-quality evidence underlines the need for the results from ongoing phase III randomized trials.

Dynamics of neutrophil-to-lymphocyte ratio can be associated with clinical outcomes of children with moderate to severe traumatic brain injury: A retrospective observational study

BACKGROUND

The neutrophil to lymphocyte ratio (NLR) has been reported to be associated with clinical outcomes of patients with severe traumatic brain injury (TBI). This study aimed to evaluate the correlation between the dynamics of NLR and clinical outcomes of pediatric patients with moderate to severe TBI.

METHODS

We retrospectively evaluated the clinical data of a total of 374 pediatric patients with moder-ate to severe TBI who were treated in our department between May 2016 and May 2020. Clinical and laboratory data including the NLR upon admission and the NLR on hospital day four were collected. Poor clinical outcome was defined as Glasgow Outcome Scale (GOS) of 1-3. Multivariable logistic regression analyses were performed to investigate the correlation between the dynamics of NLR and clinical outcome.

RESULTS

Three hundred seventy-four pediatric patients (mean age 7.37 ± 3.11, 52.7% male) were evaluated. Based on the ROC curves, a value of 5 was determined as the NLR cut-off value. The corresponding cutoff value for delta NLR was 1. The Glasgow Coma Scale (GCS) (OR, 3.42; 95% CI: 1.88-5.28; P <0.001), the light reflex (OR, 1.79; 95% CI: 1.34- 2.84; P = 0.027), the Rotterdam CT score (OR, 2.71; 95% CI: 1.72-4.13; P = 0.021), and delta NLR (OR, 1.71; 95% CI: 1.13- 2.52; P = 0.034) were identified as independent predictors for unfavorable outcomes in multivariable logistic regression analysis.

CONCLUSIONS

The result of the present study suggest that delta NLR could be a predictor of poor clinical outcome of pediatrics with moderate to severe TBI. This cost-effective and easily available biomarker could be used to predict clinical outcomes in these patients.

The Outcome Predictors of the Patients with Traumatic Brain Injury; A Cross-Sectional Study

Objective

To probe the factors associated with the outcomes of traumatic brain injury (TBI) patients admitted to emergency department (ED).

Methods

This is a cross-sectional study that data gathering was performed via census methods, retrospectively. During one year, all head injury's patients who admitted to the ED of a tertiary center in Tehran, Iran were included. Age, gender, mechanism of injury, Glasgow coma scale (GCS) and injury severity score (ISS) on admission, presence of extra-cranial injuries, findings of brain computed tomography (CT), duration of hospitalization, and in hospital outcomes were recorded. Outcome's assessment for survivors was performed within a 6 months-period after discharge based on Glasgow outcome scale (GOS). The variables and outcomes' association were assessed.

Results

Totally, 506 patients were evaluated with the mean age of 36.77±21.1 years that 411 (81.2%) were men. Follow up at 6-months post injury was feasible in 487 (96.2%) patients; 59 (11.7%) out of 506 eligible patients died. Logistic regression analysis showed the association between assessed variables and patients' outcome as follows: age>65 years (OR: 12.21; p<0.001), GCS on admission <8 (OR: 62.99; p<0.001), presence of traumatic Intracerebral hemorrhage (ICH) in brain CT scan (OR: 20.11; p=0.010), duration of hospitalization ≥ 5 days (OR: 0.28; p=0.001).

Conclusion

The findings of the current study distinguished some variables that were associated with the poor outcome of the patients with TBI. Therefore, TBI patients with any of these risk factors may need close continues monitoring, early ICU admission, and some other special extra care in ED.

Predictive Value of the Serum Albumin Level on Admission in Patients With Spontaneous Subarachnoid Hemorrhage

Objective: To determine the effect of the serum albumin level on admission in patients with spontaneous subarachnoid hemorrhage (SAH).

Methods: A total of 229 patients with SAH were divided into control and hypoalbuminemia groups. The serum albumin levels were measured. The data, including age, gender, co-existing medical conditions, risk factors, Hunt-Hess (H-H) grade on admission, Glasgow coma score (GCS) on admission, complications during hospitalizations, length of hospital stay, length of intensive care unit (ICU) stay, in-hospital mortality, survival rate, outcome at discharge, and the 6-month follow-up outcome, were compared between the two groups.

Results: Older age, an increased number of patients who consumed an excess of alcohol, and a lower GCS on admission were findings in the hypoalbuminemia group compared to the control group (p < 0.001). The ratio of patients with H-H grade I on admission in the hypoalbuminemia group was decreased compared to the control group (p < 0.05). Patients with hypoalbuminemia were more likely to be intubated, and have pneumonia and cerebral vasospasm than patients with a normal albumin level on admission (p < 0.001). Furthermore, the length of hospital and ICU stays were longer in the hypoalbuminemia group than the control group (p < 0.001). Hypoalbuminemia on admission significantly increased poor outcomes at discharge (p < 0.001). The number of patients with severe disability was increased and the recovery rate was decreased with respect to in-hospital outcomes in the hypoalbuminemia group than the control group (p < 0.001).

Conclusion: Hypoalbuminemia was shown to be associated with a poor prognosis in patients with SAH.

Prognostic Value of a Combination of Circulating Biomarkers in Critically Ill Patients with Traumatic Brain Injury: Results from the European CREACTIVE Study

Individualized patient care is essential to reduce the global burden of traumatic brain injury (TBI). This pilot study focused on TBI patients admitted to intensive care units (ICUs) and aimed at identifying patterns of circulating biomarkers associated with the disability level at 6 months from injury, measured by the extended Glasgow Outcome Scale (GOS-E). The concentration of 107 biomarkers, including proteins related to inflammation, innate immunity, TBI, and central nervous system, were quantified in blood samples collected on ICU admission from 80 patients. Patients were randomly selected among those prospectively enrolled in the Collaborative Research on Acute Traumatic Brain Injury in Intensive Care Medicine in Europe (CREACTIVE) observational study. Six biomarkers were selected to be associated with indicators of primary or secondary brain injury: three glial proteins (glial cell-derived neurotrophic factor, glial fibrillary acidic protein, and S100 calcium-binding protein B) and three cytokines (stem cell factor, fibroblast growth factor [FGF] 23 and FGF19). The subjects were grouped into three clusters according to the expression of these proteins. The distribution of the 6-month GOS-E was significantly different across clusters (p < 0.001). In two clusters, the number of 6-month deaths or vegetative states was significantly lower than expected, as calculated according to a customization of the corticosteroid randomization after significant head injury (CRASH) scores (observed/expected [O/E] events = 0.00, 95% confidence interval [CI]: 0.00-0.90 and 0.00, 95% CI: 0.00-0.94). In one cluster, less-than-expected unfavorable outcomes (O/E = 0.50, 95% CI: 0.05-0.95) and more-than-expected good recoveries (O/E = 1.55, 95% CI: 1.05-2.06) were observed. The improved prognostic accuracy of the pattern of these six circulating biomarkers at ICU admission upon established clinical parameters and computed tomography results needs validation in larger, independent cohorts. Nonetheless, the results of this pilot study are promising and will prompt further research in personalized medicine for TBI patients.

Neutrophil-to-Lymphocyte Ratios and Infections after Traumatic Brain Injury: Associations with Hospital Resource Utilization and Long-Term Outcome

Traumatic brain injury (TBI) induces immune dysfunction that can be captured clinically by an increase in the neutrophil-to-lymphocyte ratio (NLR). However, few studies have characterized the temporal dynamics of NLR post-TBI and its relationship with hospital-acquired infections (HAI), resource utilization, or outcome. We assessed NLR and HAI over the first 21 days post-injury in adults with moderate-to-severe TBI (n = 196) using group-based trajectory (TRAJ), changepoint, and mixed-effects multivariable regression analysis to characterize temporal dynamics. We identified two groups with unique NLR profiles: a high (n = 67) versus a low (n = 129) TRAJ group. High NLR TRAJ had higher rates (76.12% vs. 55.04%, p = 0.004) and earlier time to infection (p = 0.003). In changepoint-derived day 0–5 and 6–20 epochs, low lymphocyte TRAJ, early in recovery, resulted in more frequent HAIs (p = 0.042), subsequently increasing later NLR levels (p ≤ 0.0001). Both high NLR TRAJ and HAIs increased hospital length of stay (LOS) and days on ventilation (p ≤ 0.05 all), while only high NLR TRAJ significantly increased odds of unfavorable six-month outcome as measured by the Glasgow Outcome Scale (GOS) (p = 0.046) in multivariable regression. These findings provide insight into the temporal dynamics and interrelatedness of immune factors which collectively impact susceptibility to infection and greater hospital resource utilization, as well as influence recovery.

When the Bone Flap Expands Like Bellows of Accordion: Feasibility Study Using Novel Technique of Expansile (Hinge) Craniotomy for Severe Traumatic Brain Injury

Background

Decompressive craniectomy (DC) is a rescue operation performed for reduction of intracranial pressure due to progressive brain swelling, mandating the need for cranioplasty.

Objective

To describe expansile craniotomy (EC) as a noninferior technique that may be effectively utilized in situations requiring standard DC.

Materials and Methods

A decision to perform DC or EC was taken by consecutively allocation to either of the procedures. The bone flap was divided into three pieces, which were tied loosely to each other and to the skull using silk threads. The primary outcome included functional assessment using Glasgow outcome scale (GOS) score at 1 year.

Results and Conclusions

Total 67 patients were included in the analyses, of which, 31 underwent EC and 36 underwent DC. Both the cohorts were matched in terms of baseline determinants for age, Glasgow coma scale, and Rotterdam score at admission. There was no significant difference in GOS scores and the extent of volume expansion obtained by EC as compared to DC. Complication rates though less in EC group did not differ significantly between the groups. EC appears to be the safe and effective alternative to DC in the management of brain swelling due to TBI with a potential to obviate the need of cranioplasty.

General health condition of patients hospitalized after an incident of in-hospital or out-of hospital sudden cardiac arrest with return of spontaneous circulation

Background

Sudden cardiac arrest (SCA) is one of the main reasons for admission to the intensive care unit (ICU), which influences discharge in a good neurological state.

Hypothesis

To analyze patients who had recovery of spontaneous circulation (ROSC) during hospitalization in the ICU using the Glasgow Outcome Scale (GOS).

Methods

The study group comprised 78 patients after SCA (35 after out‐of‐hospital cardiac arrest [OHCA] and 43 after in‐hospital cardiac arrest [IHCA]) with ROSC who were admitted to the ICU of Regional Hospital No. 5 in Sosnowiec from January 1, 2016 to December 31, 2016. GOS was used to assess neurological status. Basic anthropological data, with, arterial blood pH, lactate concentration (LAC), and catecholamine treatment were also collected.

Results

In the study group, 32.1% (n = 25/78) of patients survived until ICU discharge and 30.8% (n = 24/78) until discharge from the hospital. SCA in cardiac mechanism was more common in OHCA than in the IHCA group (OHCA vs. IHCA: 85.7% vs. 62.8%, p = .02). There was no statistically significant difference between the two groups for neurological status assessed using GOS. There was no statistically significant difference between LAC or arterial blood pH and survival to ICU discharge, survival to hospital discharge, or mortality. The need for using catecholamines increased the mortality rate (GOS 1) (p < .001).

Conclusions

Most patients after RSOC were assigned to a group other than GOS 1, and 25% of all subjects belonged to GOS 4–5. Treatment with catecholamines was more common in patients who do not survive hospital or ICU discharge.

Treelet transform analysis to identify clusters of systemic inflammatory variance in a population with moderate-to-severe traumatic brain injury

BACKGROUND

Inflammatory cascades following traumatic brain injury (TBI) can have both beneficial and detrimental effects on recovery. Single biomarker studies do not adequately reflect the major arms of immunity and their relationships to long-term outcomes. Thus, we applied treelet transform (TT) analysis to identify clusters of interrelated inflammatory markers reflecting major components of systemic immune function for which substantial variation exists among individuals with moderate-to-severe TBI.

METHODS

Serial blood samples from 221 adults with moderate-to-severe TBI were collected over 1-6 months post-injury (n = 607 samples). Samples were assayed for 33 inflammatory markers using Millipore multiplex technology. TT was applied to standardized mean biomarker values generated to identify latent patterns of correlated markers. Treelet clusters (TC) were characterized by biomarkers related to adaptive immunity (TC1), innate immunity (TC2), soluble molecules (TC3), allergy immunity (TC4), and chemokines (TC5). For each TC, a score was generated as the linear combination of standardized biomarker concentrations and cluster load for each individual in the cohort. Ordinal logistic or linear regression was used to test associations between TC scores and 6- and 12-month Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), and covariates.

RESULTS

When adjusting for clinical covariates, TC5 was significantly associated with 6-month GOS (odds ratio, OR = 1.44; p-value, p = 0.025) and 6-month DRS scores (OR = 1.46; p = 0.013). TC5 relationships were attenuated when including all TC scores in the model (GOS: OR = 1.29, p = 0.163; DRS: OR = 1.33, p = 0.100). When adjusting for all TC scores and covariates, only TC3 was associated with 6- and 12-month GOS (OR = 1.32, p = 0.041; OR = 1.39, p = 0.002) and also 6- and 12-month DRS (OR = 1.38, p = 0.016; OR = 1.58, p = 0.0002). When applying TT to inflammation markers significantly associated with 6-month GOS, multivariate modeling confirmed that TC3 remained significantly associated with GOS. Biomarker cluster membership remained consistent between the GOS-specific dendrogram and overall dendrogram.

CONCLUSIONS

TT effectively characterized chronic, systemic immunity among a cohort of individuals with moderate-to-severe TBI. We posit that chronic chemokine levels are effector molecules propagating cellular immune dysfunction, while chronic soluble receptors are inflammatory damage readouts perpetuated, in part, by persistent dysfunctional cellular immunity to impact neuro-recovery.

Efficacy of an intervention program to prevent patient safety indicators in aneurysmal subarachnoid haemorrhage

OBJECTIVE

Patient safety indicators (PSI) are a set of potentially preventable events related to patient safety and opportunities for improvement. Eight pertinent PSI have been identified in patients with aneurysmal subarachnoid haemorrhage (ASAH), such as decubitus ulcer, and central line-related bacteraemia. Our aim was to evaluate the efficacy of a health care quality protocol to prevent the appearance of PSI in ASAH patients.

METHODS

Adult patients treated for ASAH were included in a retrospective control group of 35 patients and a prospective experimental group of 35 patients when the prevention program was implemented. We evaluated the occurrence of PSI, and its relation to age, sex, Hunt and Hess scale grade, type of aneurysm treatment, length of hospital stay, and Glasgow Outcome Scale scores.

RESULTS

Both groups had similar characteristics except for a longer hospital stay in the control group. The overall PSI prevalence decreased significantly in the experimental group compared to the control group. The experimental group had a decreased risk for having at least one PSI: OR = 0.21 (0.08-0.57, CI 95%). The absolute risk reduction is 37.1% (58.9%-15.4%), the preventable fraction for the population is 28.3% (10.6%-40.0%), and the number needed to treat is 2.69.

CONCLUSIONS

The health care quality protocol is effective to prevent ISP in ASAH patients. Implementing this prevention program has no effect on the neurological state of the patient at the hospital discharge. Still, it is successful in decreasing the PSI prevalence and the days of hospital stay.

Complications and Neurological Outcome following Intraoperative Aneurysm Rupture in Adult Patients Undergoing Intracranial Aneurysmal Clipping: A Retrospective Study

Background  Intraoperative aneurysmal rupture (IAR) is a catastrophic complication; however, its impact on neurological outcome is debatable. We studied the effects of IAR on intraoperative and postoperative complications and neurological outcome. Methods  In this retrospective study, adult patients who underwent aneurysmal clipping over a period of 2 years were divided as follows: group R (with IAR) and group N (without IAR). Various perioperative parameters, intraoperative and postoperative complications were noted. Glasgow outcome scale (GOS) was noted at discharge from hospital and categorized as favorable (GOS IV and V) and unfavorable (GOS I, II and III). Collected data was statistically analyzed. Univariate and multiple logistic regression analyses were performed to identify predictors of IAR. A p value < 0.05 was considered significant. Results  Thirty-two out of 195 (16.41%) patients suffered IAR, with majority involving anterior communicating artery aneurysm (46.88%). Duration of temporary clipping ( p < 0.001), volume of blood loss, and fluid and blood transfusion were significantly more in group R. Postoperatively, significantly more patients in group R developed intracranial hematoma, cerebral infarct, and required prolonged ventilatory support (≥5 days). Unfavorable neurological outcome was observed more in group R ( p = 0.013). In univariate analysis, blood loss > 500 mL, use of colloids, and duration of surgery > 5 hours were found to be associated with IAR. After multiple logistic regression analysis, only use of colloids and duration of surgery > 5 hours were the most predictive variables for IAR. Conclusions  IAR is associated with serious intraoperative and postoperative complications and unfavorable neurological outcome.

The Prognostic Role of Lactate Concentrations after Aneurysmal Subarachnoid Hemorrhage

Blood lactate concentrations are often used to assess global tissue perfusion in critically ill patients; however, there are scarce data on lactate concentrations after subarachnoid hemorrhage (SAH). We aimed to assess the prognostic role of serial blood lactate measurements on hospital mortality and neurological outcomes at 3 months after SAH. We reviewed all SAH patients admitted to the intensive care unit from 2007 to 2019 and recorded the highest daily arterial lactate concentration for the first 6 days. Patients with no lactate concentration were excluded. Hyperlactatemia was defined as a blood lactate concentration >2.0 mmol/L. A total of 456 patients were included: 158 (35%) patients died in hospital and 209 (46%) had an unfavorable outcome (UO) at 3 months. The median highest lactate concentration was 2.7 (1.8–3.9) mmol/L. Non-survivors and patients with UO had significantly higher lactate concentrations compared to other patients. Hyperlactatemia increased the chance of dying (OR 4.19 (95% CI 2.38–7.39)) and of having UO in 3 months (OR 4.16 (95% CI 2.52–6.88)) after adjusting for confounding factors. Therefore, initial blood lactate concentrations have prognostic implications in patients with SAH; their role in conjunction with other prognostic indicators should be evaluated in prospective studies.

The effect of anaesthetic exposure in presurgical period on delayed cerebral ischaemia and neurological outcome in patients with aneurysmal subarachnoid haemorrhage undergoing clipping of aneurysm: A retrospective analysis

Background and Aims:

Delayed cerebral ischaemia is one of the major contributors to morbidity in aneurysmal subarachnoid haemorrhage (aSAH). General anaesthesia (GA) in the presurgical period may have a preconditioning effect. The primary aim was to assess the effect of preoperative exposure to GA during digital subtraction angiography (DSA) on neurological outcome in patients presenting with aSAH.

Methods:

After Ethical Committee approval, we conducted a retrospective analysis of the data of patients with aSAH treated surgically. Patients, admitted to neurosurgical ICU (June 2014 and December 2017) with a computed tomography (CT) diagnosis of aSAH and underwent DSA, were included. DSA, done with or without exposure to a general anaesthetic, was classified to GA group and LA group, respectively. Propensity score matching was done on the baseline variables. Appropriate statistical methods were applied.

Results:

Of the 278 patients, 116 (41.7%) patients had received GA during DSA. Propensity matching yielded 114 (57 in each group) matched patients. In a logistic regression model, the odds ratio (OR) for poor outcome at discharge in GA group as compared to LA group was 4.4 (CI: 2.7–7.4), P = 0.001, whereas, in the matched data, the OR for poor outcome at discharge in GA group as compared to LA group was 1.2 (CI: 0.6–2.6), P = 0.57.

Conclusion:

The presurgical exposure to GA did not offer any neuroprotection and the odds of poor outcome were higher compare to non-exposure to GA group.

Surgery for spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products.

Several surgical techniques have been considered, such as open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis. Open craniotomy is the most studied approach in this clinical scenario, the first randomized controlled trial dating from the early 1960s. Since then, a large number of studies have been published, which included two large, well-designed, well-powered, multicenter, multinational, randomized clinical trials. These studies, The International Surgical Trial in Intracerebral Hemorrhage (STICH), and the STICH II have shown no clinical benefit for early surgical evacuation of intraparenchymal hematoma in patients with spontaneous supratentorial hemorrhage when compared with best medical management plus delayed surgery if necessary. However, the results of STICH trials may not be generalizable, because of the high rates of patients’ crossover from medical management to the surgical group. Without these high crossover percentages, the rates of unfavorable outcome and death with conservative management would have been higher. Additionally, comatose patients and patients at risk of cerebral herniation were not included. In these cases, surgery may be lifesaving, which prevented those patients of being enrolled in such trials. This article reviews the clinical evidence of surgical hematoma evacuation, and its role to decrease mortality and improve long-term functional outcome after spontaneous intracerebral hemorrhage.

Early prognostication of neurological outcome by heart rate variability in adult patients with out-of-hospital sudden cardiac arrest

Background

Most deaths of comatose survivors of out-of-hospital sudden cardiac arrest result from withdrawal of life-sustaining treatment (WLST) decisions based on poor neurological prognostication and the family’s intention. Thus, accurate prognostication is crucial to avoid premature WLST decisions. However, targeted temperature management (TTM) with sedation or neuromuscular blockade against shivering significantly affects early prognostication. In this study, we investigated whether heart rate variability (HRV) analysis could prognosticate poor neurological outcome in comatose patients undergoing hypothermic TTM.

Methods

Between January 2015 and December 2017, adult patients with out-of-hospital sudden cardiac arrest, successfully resuscitated in the emergency department and admitted to the intensive care unit of the Niigata University in Japan, were prospectively included. All patients had an initial Glasgow Coma Scale motor score of 1 and received hypothermic TTM (at 34 °C). Twenty HRV-related variables (deceleration capacity; 4 time-, 3 geometric-, and 7 frequency-domain; and 5 complexity variables) were computed based on RR intervals between 0:00 and 8:00 am within 24 h after return of spontaneous circulation (ROSC). Based on Glasgow Outcome Scale (GOS) at 2 weeks after ROSC, patients were divided into good outcome (GOS 1–2) and poor outcome (GOS 3–5) groups.

Results

Seventy-six patients were recruited and allocated to the good (n = 22) or poor (n = 54) outcome groups. Of the 20 HRV-related variables, ln very-low frequency (ln VLF) power, detrended fluctuation analysis (DFA) (α1), and multiscale entropy (MSE) index significantly differed between the groups (p = 0.001), with a statistically significant odds ratio (OR) by univariate logistic regression analysis (p = 0.001). Multivariate logistic regression analysis of the 3 variables identified ln VLF power and DFA (α1) as significant predictors for poor outcome (OR = 0.436, p = 0.006 and OR = 0.709, p = 0.024, respectively). The area under the receiver operating characteristic curve for ln VLF power and DFA (α1) in predicting poor outcome was 0.84 and 0.82, respectively. In addition, the minimum value of ln VLF power or DFA (α1) for the good outcome group predicted poor outcome with sensitivity = 61% and specificity = 100%.

Conclusions

The present data indicate that HRV analysis could be useful for prognostication for comatose patients during hypothermic TTM.

Intake of NOAC is associated with hematoma expansion of intracerebral hematomas after traumatic brain injury

PURPOSE

Novel oral anticoagulants are increasingly replacing vitamin K antagonists in the prophylaxis of thromboembolism as they are associated with lower incidence of spontaneous intracerebral hematomas and they do not require drug level monitoring. However, management dilemmas are apparent in patients on novel oral anticoagulants who have developed intracerebral hematomas after traumatic brain injury, since clinical experience with their reversal strategies is limited.

METHODS

We retrospectively studied 90 patients with traumatic intracerebral hematomas undergoing treatment at the surgical intensive care unit of the BG University Clinic Bergmannsheil in Bochum between 2015 and 2018. We analyzed potential prognostic factors for their radiological (expansion of intracerebral hematoma) and clinical (patients' outcome) course, in particular the role of novel oral anticoagulants.

RESULTS

71.1% of patients were male; mean age was 67.3 years. Hematoma's expansion occurred in 35.9% of our patients, whereas 62.2% of our cohort showed a favorable outcome, defined as Glasgow Outcome Scale 4 and 5. Intake of novel oral anticoagulants was associated with a higher rate of hematoma's expansion compared to patients on vitamin K antagonists (p = 0.05) or to patients with normal coagulation status (p = 0.002). A younger age (p < 0.001) was identified as the sole independent prognostic factor for a more favorable outcome, after excluding our cases, who underwent a cardiopulmonary resuscitation.

CONCLUSIONS

Our data showed a higher rate of hematoma's expansion in patients with traumatic intracerebral hematomas on novel oral anticoagulants vs. vitamin K antagonists and recommend the consideration of prophylactic reversal of the novel oral anticoagulants at admission. Larger prospective trials are warranted to conclude whether the current specific reversal protocols are safe and effective.

The relationship between the time of cerebral desaturation episodes and outcome in aneurysmal subarachnoid haemorrhage: a preliminary study

In this preliminary study we investigated the relationship between the time of cerebral desaturation episodes (CDEs), the severity of the haemorrhage, and the short-term outcome in patients with aneurysmal subarachnoid haemorrhage (aSAH). Thirty eight patents diagnosed with aneurysmal subarachnoid haemorrhage were analysed in this study. Regional cerebral oxygenation (rSO₂) was assessed using near infrared spectroscopy (NIRS). A CDE was defined as rSO₂ < 60% with a duration of at least 30 min. The severity of the aSAH was assessed using the Hunt and Hess scale and the short-term outcome was evaluated utilizing the Glasgow Outcome Scale. CDEs were found in 44% of the group. The total time of the CDEs and the time of the longest CDE on the contralateral side were longer in patients with severe versus moderate aSAH [h:min]: 8:15 (6:26–8:55) versus 1:24 (1:18–4:18), p = 0.038 and 2:05 (2:00–5:19) versus 0:48 (0:44–2:12), p = 0.038. The time of the longest CDE on the ipsilateral side was longer in patients with poor versus good short–term outcome [h:min]: 5:43 (3:05–9:36) versus 1:47 (0:42–2:10), p = 0.018. The logistic regression model for poor short-term outcome included median ABP, the extent of the haemorrhage in the Fisher scale and the time of the longest CDE. We have demonstrated that the time of a CDE is associated with the severity of haemorrhage and short-term outcome in aSAH patients. A NIRS measurement may provide valuable predictive information and could be considered as additional method of neuromonitoring of patients with aSAH.

Predictive Factors of 2-Year Postoperative Outcomes in Patients with Spontaneous Cerebellar Hemorrhage

Spontaneous cerebellar hemorrhage (SCH) is associated with high patient mortality and morbidity, but the clinical and radiographic predictors of the postoperative outcome have not been widely addressed in the literature. The purpose of this study was to define the prognostic factors for the two-year postoperative outcome in patients with SCH. We conducted a retrospective study of 48 consecutive patients with SCH who underwent neurosurgical intervention. Correlation analysis was performed to examine the possible link between clinical and radiographic parameters, and the National Institutes of Health Stroke Scale (NIHSS) score at each patient’s discharge and the two-year postoperative outcome as defined according to the Glasgow outcome scale (GOS). A total of 48 patients with SCH underwent neurological surgery, which included suboccipital craniectomy and/or external ventricular drainage (EVD). The mean patient age was 63 years. Nine patients underwent suboccipital craniectomy only; 38 underwent both suboccipital craniectomy and EVD. The overall mortality rate was 35.4%. Fourteen patients (29.2%) had good outcomes. A good outcome on the GOS at 2 years after surgical treatment of SCH was associated with the NIHSS score at discharge. An increase of one point in a patient’s NIHSS score at discharge following neurological surgery will increase the probability of a poor two-year postoperative outcome by 28.5%.

Effects of Trauma Center Establishment on the Clinical Characteristics and Outcomes of Patients with Traumatic Brain Injury : A Retrospective Analysis from a Single Trauma Center in Korea

Objective

To investigate the effects of trauma center establishment on the clinical characteristics and outcomes of trauma patients with traumatic brain injury (TBI).

Methods

We enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.

Results

Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICU) admissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.

Conclusion

We confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary.

A mathematical model of neuroinflammation in severe clinical traumatic brain injury

Background

Understanding the interdependencies among inflammatory mediators of tissue damage following traumatic brain injury (TBI) is essential in providing effective, patient-specific care. Activated microglia and elevated concentrations of inflammatory signaling molecules reflect the complex cascades associated with acute neuroinflammation and are predictive of recovery after TBI. However, clinical TBI studies to date have not focused on modeling the dynamic temporal patterns of simultaneously evolving inflammatory mediators, which has potential in guiding the design of future immunomodulation intervention studies.

Methods

We derived a mathematical model consisting of ordinary differential equations (ODE) to represent interactions between pro- and anti-inflammatory cytokines, M1- and M2-like microglia, and central nervous system (CNS) tissue damage. We incorporated variables for several cytokines, interleukin (IL)-1β, IL-4, IL-10, and IL-12, known to have roles in microglial activation and phenotype differentiation. The model was fit to cerebrospinal fluid (CSF) cytokine data, collected during the first 5 days post-injury in n = 89 adults with severe TBI. Ensembles of model fits were produced for three patient subgroups: (1) a favorable outcome group (GOS = 4,5) and (2) an unfavorable outcome group (GOS = 1,2,3) both with lower pro-inflammatory load, and (3) an unfavorable outcome group (GOS = 1,2,3) with higher pro-inflammatory load. Differences in parameter distributions between subgroups were ranked using Bhattacharyya metrics to identify mechanistic differences underlying the neuroinflammatory patterns of patient groups with different TBI outcomes.

Results

Optimal model fits to data showed different microglial and damage responses by patient subgroup. Upon comparison of model parameter distributions, unfavorable outcome groups were characterized by either a prolonged, pathophysiological or a transient, sub-physiological course of neuroinflammation.

Conclusion

By developing a mathematical characterization of inflammatory processes informed by clinical data, we have created a system for exploring links between acute neuroinflammatory components and patient outcome in severe TBI.

Electronic supplementary material

The online version of this article (10.1186/s12974-018-1384-1) contains supplementary material, which is available to authorized users.

Is Mechanical Ventilation Mandatory for the Management of Severe Head Injury? Outcome in 53 Medically Managed Severe Head Injury Patients, Without Ventilatory Support: A Prospective Study

Background:

Severe head injury (SHI) is a major cause of mortality and morbidity across the world. The current paradigm of management of SHI involves admission in Intensive Care Unit (ICU), mechanical ventilation (MV), and intracranial pressure (ICP) monitoring. Such resources are expensive and often unavailable in the developing world.

Objective:

MV or ICP monitoring was unavailable for our patients due to the scarcity of resources. Hence, other alternatives were considered to prevent secondary brain injury due to hypoxia. This study assessed the outcome after SHI when managed with an early tracheostomy (ET).

Methods:

This prospective observational study over 13 months included all medically managed SHI patients without MV or ICP monitoring. The Glasgow outcome scale (GOS) was assessed at discharge and compared with published historical data reported after treatment in an ICU environment.

Results:

Our study included 53 unoperated patients with SHI among 1862 patients with traumatic brain injury. Overall mortality was 24.5% (13/53) and compared favorably with reported mortality of 25%–40% reported from centers using intensive management. At discharge, the favorable outcome with a GOS of 4 or 5 was seen in 39.6% (21/53).

Conclusion:

With ET, the results of management of SHI in our patients were comparable to results reported after MV in an ICU environment. Hence, ET is a cost-effective alternative when resources are scarce. MV should be used if hypoxia persists after tracheostomy. Although MV effectively prevents hypoxia, it has complications. We conclude that although MV was unavailable for our patients, they did not have the complications associated with it.

Clinical Features of Interhemispheric Subdural Hematomas

Objective

Interhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively.

Methods

From 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes.

Results

The male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment.

Conclusion

IHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.

Effect of sex and age on traumatic brain injury: a geographical comparative study

Background

Traumatic brain injury (TBI) is a much researched topic in medical health, which requires additional studies to understand various effects of demographic and geographic factors that can assist in developing the most effective treatments. Thousands of people of different ages are suffering from lifelong disabilities, either mild or severe, from TBI and the number is increasing. This study aims to increase our understanding of the effect of sex and age by applying five different statistical methods to evaluate the effect of these covariates on two independent TBI data sets representing patients from different geographical cohorts. A primary data was collected from Bangladesh and it was compared with CRASH (Corticosteroid Randomisation after Significant Head Injury) data, representing various countries around the world.

Methods

The outcome variable for TBI considered in this paper is Glasgow Outcome Scale, which is a four point scale. It was converted to a binary outcome scale for fitting of Fisher’s exact test, a test of proportions and a binary linear model. For analyzing ordinal outcomes, the proportional odds model and the sliding dichotomy model were fitted. As the sample size of the Bangladeshi data set was small, parametric bootstrapping was applied for the consistency of results.

Results

Females were the worse sufferers of TBI compared to men, according to CRASH data set. The old (aged above 58 years) followed by adults (age 25 to 58) were the most vulnerable victims. Interaction effects concluded that old women tended to endure the worst outcomes of TBI. This conclusion came from the CRASH data set representing the world in general, whereas such effects were not present in the Bangladesh data set. Additional application of parametric bootstrapping for the smaller Bangladesh data set did not result into any significant outcome.

Conclusion

The effect of gender and age could be stronger in some countries than others which is driving the significance in CRASH and was not found in Bangladesh. It reflects the necessity of incorporating geographic patterns as well as demographic features of patients while developing treatments and designing clinical trials.

Traumatic Brain Injury in Children under Age 24 Months: Analysis of Demographic Data, Risk Factors, and Outcomes of Post-traumatic Seizure

OBJECTIVE

Traumatic brain injury (TBI) in children under age 24 months has characteristic features because the brain at this age is rapidly growing and sutures are opened. Moreover, children this age are completely dependent on their parents. We analyzed the demographic data and risk factors for outcomes in TBI patients in this age group to elucidate their clinical characteristics.

METHODS

We retrospectively reviewed the medical records and radiological films of children under 24 months who were admitted to Kyungpook National University Hospital from January 2004 to December 2013 for TBI. Specifically, we analyzed age, cause of injury, initial Glasgow coma scale (GCS) score, radiological diagnosis, seizure, hydrocephalus, subdural hygroma, and Glasgow outcome scale (GOS) score, and we divided outcomes into good (GOS 4-5) or poor (GOS 1-3). We identified the risk factors for post-traumatic seizure (PTS) and outcomes using univariate and multivariate analyses.

RESULTS

The total number of patients was 60, 39 males and 21 females. Most common age group was between 0 to 5 months, and the median age was 6 months. Falls were the most common cause of injury (n=29, 48.3%); among them, 15 were falls from household furniture such as beds and chairs. Ten patients (16.7%) developed PTS, nine in one week; thirty-seven patients (61.7%) had skull fractures. Forty-eight patients had initial GCS scores of 13-15, 8 had scores of 12-8, and 4 had scored 3-7. The diagnoses were as follows: 26 acute subdural hematomas, 8 acute epidural hematomas, 7 focal contusional hemorrhages, 13 subdural hygromas, and 4 traumatic intracerebral hematomas larger than 2 cm in diameter. Among them, two patients underwent craniotomy for hematoma removal. Four patients were victims of child abuse, and all of them had PTS. Fifty-five patients improved to good-to-moderate disability. Child abuse, acute subdural hematoma, and subdural hygroma were risk factors for PTS in univariate analyses. Multivariate analysis found that the salient risk factor for a poor outcome was initial GCS on admission.

CONCLUSION

The most common cause of traumatic head injury in individuals aged less than 24 months was falls, especially from household furniture. Child abuse, moderate to severe TBI, acute subdural hematoma, and subdural hygroma were risk factors for PTS. Most of the patients recovered with good outcomes, and the risk factor for a poor outcome was initial mental status.

Serum albumin level in spontaneous subarachnoid haemorrhage: More than a mere nutritional marker!

BACKGROUND

The role of nutritional markers on outcome following subarachnoid hemorrhage (SAH) has been scarcely described.

METHODS

This is a prospective study of 273 patients with SAH, in which haemoglobin, serum protein and albumin were measured within 24 hours and again at one week following ictus, and analysed with respect to other variables. New neurologic deficits (NND), infarct, mortality and Glasgow outcome scale (GOS) at 3 months were assessed.

RESULTS

The values of haemoglobin, total protein and albumin showed significant (p < .001) decline over the first week of SAH. Patients who developed NND had significantly lower serum albumin levels at admission compared to others (median 3.6 vs 3.9 g/dL, p < .001). Patients having lower albumin (≤3.5 gm/dL) levels at admission had significantly higher rates of NND (52% vs 20%), infarct (35% vs 23%), mortality (28% vs 16%) and unfavourable GOS (38% vs 25%). Hunt & Hess (H&H) grade and Fisher grade also affected all the outcome parameters significantly. Percentage decrease in albumin levels at one week following ictus significantly affected mortality and unfavourable GOS. On multivariate analyses, Fisher grade and lower admission albumin levels had significant impact on NND, while percentage decrease in albumin levels had significant impact on mortality and unfavourable GOS, independent of other nutritional markers and known prognostic variables.

CONCLUSIONS

Serum albumin levels following SAH can be useful to predict development of NND, while its further weekly decrease correlates independently with unfavourable outcome at 3 months. Albumin assessment being readily available may serve as more than a mere nutritional parameter in SAH.

Is aura around citicoline fading? A systemic review

Stroke and traumatic brain injury (TBI) are the critical public health and socioeconomic problems throughout the world. At present, citicoline is used as a coadjuvant for the management of acute ischemic stroke (AIS) and TBI in various countries. This systemic review analyzes the beneficial role of citicoline in AIS and TBI. This systemic review is based on "PubMed" and "Science Direct" search results for citicoline role in stroke and TBI. In this systemic review, we included 12 human trials. A meta-analysis was performed on the basis of neurological evaluation, functional evaluation and Glasgow outcome scale, domestic adaptation evaluation outcomes, and cognitive outcome individually. In neurological evaluation, domestic adaptation evaluation, and cognitive outcomes, there was no significant difference in both the citicoline and placebo groups (odds ratio [OR] = 1.04 [0.9-1.2, P = 0.583]; OR = 1.1 [0.94-1.27, P = 0.209]; OR = 0.953 [0.75-1.2, P = 0.691]). In evaluation of functional outcomes, there was significant difference in both groups and OR was 1.18 (1.04-1.34, P = 0.01). Functional outcomes were significantly improved by citicoline, but the positive role of this drug in neurological recovery, domestic adaptation, and cognitive outcomes is still a topic of discussion for future.

Spectrum and outcome of traumatic brain injury in children <15 years: A tertiary level experience in India

BACKGROUND

Though, traumatic brain injury (TBI) has been documented as the single most common cause of morbidity and mortality in infancy and childhood, the exact incidence is unavailable in India. Moreover, modes of injury, mechanisms of damage, and management differ significantly from that of an adult.

AIMS AND OBJECTIVES

To analyze the epidemiological factors, the spectrum of TBI, modes of injury, types of injury, and the outcome in the children <15 years with TBI.

MATERIALS AND METHODS

This is a retrospective study from August 2012 to May 2013 at Department of Neurosurgery, S.C.B. Medical College, Cuttack, Odisha, India. All the pertinent details from case records of hundred and forty-seven children <15 years with TBI were analyzed. Follow-up was done for 6 months at outpatients department.

RESULTS

Age wise, incidence and severity of TBI is more common in 10-15 years. Males outnumber females with a male: female ratio 2.19:1. Overall, road traffic accident (RTA) is the commonest mode of injury. Assault is not uncommon (7.48% cases). Falls is common in <5 years while RTA is common in 5-15 years. The extradural hematoma was the most common injury pattern; however, surgical consideration was maximal for fracture skull. Overall mortality was 7.48%. Diffuse axonal injury has the maximum individual potential for mortality. We noticed excellent recovery in 68.7%, disabilities in 17.68%, and persistent vegetative state in 5.45% cases.

CONCLUSION

TBI in children carries good outcome, if resuscitated and referred early to a neurotrauma center, and managed subsequently on an individualized basis with a well-organized team approach. Severe TBI in children has a poor outcome.

Bilateral Traumatic Intracranial Hematomas and its Outcome: a Retrospective Study

The objective of this study was to evaluate the age distribution, mode of injury, type of hematomas, and their surgical outcome in patients with bilateral traumatic head injuries. The present study included 669 cases of traumatic head injury who presented at the neurosurgery emergency out of which 94 cases had bilateral head injuries from the period of August 2009 to April 2014. The data from the hospital computerized database were retrospectively analysed. Cases of bilateral traumatic head injury included 94 patients out of which 88.29 % (n = 83) were males and 11.70 % (n = 11) were females. Commonest mode of injury was road traffic accident in 56.38 % (n = 53) followed by fall from height in 29.78 % (n = 28). In our study, 25.53 % patients had epidural hematoma (EDH) with intracerebral hematoma (ICH) or contusion (n = 24), followed by EDH with subarachnoid hemorrhage (SAH) in 18.08 % (n = 17). At the time of discharge, all those patients managed conservatively had good Glasgow outcome scale (GOS) while with surgical intervention 58 % patients had good GOS, 19 % had moderate disability, and 9 % remained with severe disability. In cases of bilateral hematomas, EDH is most common and should be managed in neurosurgical emergency. Other combinations of bilateral intracranial hematomas should be managed according to the surgical indication and serial CT imaging.

Development of prognostic models for patients with traumatic brain injury: a systematic review

Outcome prediction following traumatic brain injury (TBI) is a widely investigated field of research. Several outcome prediction models have been developed for prognosis after TBI. There are two main prognostic models: International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) prognosis calculator and the Corticosteroid Randomization after Significant Head Injury (CRASH) prognosis calculator. The prognosis model has three or four levels: (1) model A included age, motor GCS, and pupil reactivity; (2) model B included predictors from model A with CT characteristics; and (3) model C included predictors from model B with laboratory parameters. In consideration of the fact that interventions after admission, such as ICP management also have prognostic value for outcome predictions and may improve the models' performance, Yuan F et al developed another prediction model (model D) which includes ICP. With the development of molecular biology, a handful of brain injury biomarkers were reported that may improve the predictive power of prognostic models, including neuron-specific enolase (NSE), glial fibrillary acid protein (GFAP), S-100β protein, tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), myelin basic protein (MBP), cleaved tau protein (C-tau), spectrin breakdown products (SBDPs), and ubiquitin C-terminal hydrolase-L1 (UCH-L1), and sex hormones. A total of 40 manuscripts reporting 11 biomarkers were identified in the literature. Many substances have been implicated as potential biomarkers for TBI; however, no single biomarker has shown the necessary sensitivity and specificity for predicting outcome. The limited number of publications in this field underscores the need for further investigation. Through fluid biomarker analysis, the advent of multi-analyte profiling technology has enabled substantial advances in the diagnosis and treatment of a variety of conditions. Application of this technology to create a bio-signature for TBI using multiple biomarkers in combination will hopefully facilitate much-needed advances. We believe that further investigations about brain injury biomarkers may improve the predictive power of the contemporary outcome calculators and prognostic models, and eventually improve the care of patients with TBI.

Management and Outcome of Spontaneous Cerebellar Hemorrhage

Objective

Spontaneous cerebellar hemorrhage (SCH) is less common than supratentorial intracerebral hemorrhage. This study investigated the treatment of SCH and the relation between its clinical and radiological manifestation and outcome.

Materials and Methods

We presented a SCH management protocol in our institute and analyzed the clinical and radiological findings in 41 SCH patients. The outcomes of each method (surgery and conservative treatment) were compared among patients with initial Glasgow Coma Scale (GCS) score of 9-13 and hematoma volume greater than 10 mL.

Results

Two (4.9%), 16 (39%), and 23 (56.1%) patients had an initial GCS score of 3-8, with 3-8, 9-13, and 14-15, respectively. Initial GCS score showed significant correlation with Glasgow Outcome Scale (GOS) score (p = 0.005). The mean largest hematoma diameter was 3.2 ± 1.5 cm, and the mean volume was 11.0 ± 11.5 mL. Both of them showed significant inverse correlation with GOS score (p < 0.001). Among patients with an initial GCS score of 9-13 and hematoma volumes greater than 10 mL, 3 (50%) had good outcome and 3 (50%) had poor outcome in the surgical, and all of those in the conservative treatment group had poor outcomes. The outcome distribution differed significantly in the surgical and conservative groups (p = 0.030).

Conclusion

Initial GCS score and largest hematoma diameter and volume on brain computed tomography are important determinants of outcome in SCH patients. The surgery group showed better outcome than the conservative treatment group among those with an intermediate neurological status and large hematomas.

Outcome of surgery for operable supratentorial mass lesions in patients presenting with decerebration following severe head injury: A retrospective analysis of factors affecting outcome

AIM

Abnormal motor response in the form of decerebration signifies either injury or compression of brain stem. The presence of decerebrate rigidity following head injury is a grave prognostic sign. Mortality may increase up to 70% in patients showing signs of decerebration. Although many studies have identified the prognostic factors in severe head injuries, few studies have focused on the operated patients with decerebration in predicting the long-term outcome. This study was planned to determine the outcome in this group of patients for prognostication and to help plan further line of management.

MATERIALS AND METHODS

All the patients admitted with severe head injury with decerebration (M2 motor response) admitted in neurosurgery department from September 2009 to January 2011 were included in the study. All the patients had operable supratentorial mass lesions with no direct evidence of brain stem damage. Patients with penetrating injury and diffuse injury with no operative mass lesions were excluded from the study. Clinical and computerized tomography (CT) data were correlated with outcome retrospectively. Glasgow outcome scale (GOS) was used as a measure of functional outcome.

RESULTS

The patients admitted with decerebration (M2 motor response) comprised 8% of the total head injury related operative procedures performed at our institute during the period. Of the 72 patients, 14 (19%) patients were more than 60 years old and 21% (15) were females. The surgical mass lesions comprised extradural hematoma in 27 (38%), cerebral contusions in 19 (26%), acute Subdural Hematoma alone in 7 (10%), and acute Subdural Hematoma (SDH) with cerebral contusion in 19 (26%) of the patients. Of the 72 patients, 36(50%) were operated within 24 hours of injury Follow-up of all, but 2 (3%) was obtained. Favorable outcome (GOS 4 and 5) was obtained in 14% (n = 10) of the patients with 83% (n = 60) mortality rate. The favorable outcome rate among the patients operated for Extradural Hematoma was 26% and for cerebral contusions was 11%. Only 5% of the patients operated for acute SDH survived.

CONCLUSION

Radiological diagnosis (type of lesion), followed by duration of decerebration and age of the patient are the most important prognostic factors determining the outcome of surgery in decerebrating patients. Our results confirm that despite the poor prognosis in decerebrate patients, a significant number of patients may still survive and have a good outcome.

Supratentorial extradural hematoma in children: An institutional clinical experience of 65 cases

Aim and Objective:

To survey the epidemiology, management, and severity of extradural hematoma (EDH) in children.

Materials and Methods:

All patients of EDH (n = 65) in the age group of 0–16 years admitted to our department during the period of August 13 and July 14 were analyzed retrospectively from the hospital records. In all patients, age, sex, mode of injury, clinical presentation, site of EDH, management, duration of hospitalization, and outcome were evaluated.

Observation and Results:

Of 65 patients, males were 70.76% with a male to female ratio of 2.4:1, most of the victims (47.69%) were in the age group of 11–16 years. Mean duration of hospitalization was 4.32 days. The most common mode of injury was fall from height in 29 cases (44.61%) followed by road traffic accident (RTA) in 23 cases (35.35%). Temporoparietal EDH was the most common computed tomography finding present in 22 (33.84%) patients. 67.69% patients presented to casualty with minor head injury having Glasgow coma scale (GCS) between 14 and 15. Most common presenting feature was vomiting in 52 cases (80%) and next to it was altered sensorium. The mortality rate was 7.69% (n = 5).

Conclusion:

Extradural hematoma is a life-threatening entity encountered in pediatric head injury. Timely intervention and diagnosis decrease mortality to a great degree. Most of the mortality is encountered in patients who presented late at the neurosurgical unit with low GCS.

Endoscopic hematoma evacuation in patients with spontaneous supratentorial intracerebral hemorrhage

BACKGROUND

Surgical evacuation of spontaneous supratentorial intracerebral hemorrhage (ICH) is controversial because the traditional surgical approach sometimes causes further brain injury. The introduction of the neuroendoscope has brought with it the new idea of minimal invasiveness, which may improve the surgical results of ICH.

METHODS

Twenty-one patients with spontaneous supratentorial ICH underwent endoscopic hematoma evacuation between December 2010 and January 2012. Safe entry points could be Kocher's, Keen's, or Frazier's point, depending on the locations of the hemorrhages. The surgical steps were as follows: (1) cortical incision and dilation of the channel; (2) introduction of the transparent sheath; (3) gushing out of the hematoma under high intracranial pressure; (4) changing the angle of the transparent sheath, endoscope, and suction tip to remove residual hematoma; and (5) paving a layer of hemostatic agents after hematoma removal.

RESULTS

The median operative time was 120 minutes (range: 90-190 minutes), and the median blood loss was 160 mL (range: 50-300 mL). The median duration of intensive care unit stay was 6 days (range: 2-18 days). The median hematoma evacuation ratio was 90% (range: 60-99%). Two patients had rebleeding events, and the mortality rate was 9.5% (n = 2/21). The median Glasgow Coma Scale score improved from 8 to 11 within 1 week after surgery, and the median Glasgow Outcome Scale score was 3 after 6 months and 12 months follow-up.

CONCLUSION

With the introduction of the minimally invasive techniques and the evolution of the neuroendoscope and hemostatic agents, the median operative time and blood loss have been significantly decreased. Although the hematoma evacuation rates were similar between the endoscope (90%) and craniotomy (85%) groups, the median intensive care unit stay was decreased from 11 days to 6 days due to reduced surgical invasiveness. This represents an important advancement in treating spontaneous supratentorial ICH, and provides a measured preview of the promising results that can be expected in the future.

Blood pressure changes after aneurysmal subarachnoid hemorrhage and their relationship to cerebral vasospasm and clinical outcome

OBJECTIVE

Cerebral vasospasm (VS) and resulting delayed ischemic brain injury constitute the most severe secondary complication after subarachnoid hemorrhage (SAH). Identification of early clinical predictors of developing vasospasm and poor outcome has remained a major challenge in neurointensive care medicine. Aim of the present study was analyze the relevance of spontaneous changes in blood pressures and their predictive value for predicting vasospasm as well as adverse clinical outcome.

METHODS

98 aneurysmal SAH patients were analyzed retrospectively. Patients were divided into two study groups: (1) VS+ (developing VS) and (2) VS- (not developing VS). Repeat-angiography was routinely performed on day 8 after SAH or earlier if clinical signs were suggestive for overt vasospasm. Systolic, diastolic and mean blood pressures were averaged hourly and plotted over time. Secondly, blood pressure (BP)-progression was analyzed with respect to clinical outcomes as assessed by the Glasgow outcome scale.

RESULTS

Mean, systolic, and diastolic blood pressure values progressed in both VS- and VS+ cohorts over time. However, as early as 4 days after SAH a significant dissociation of RR curves was observed between the groups with patients in the VS+ group displaying a significantly higher slope coefficient of blood pressure elevation. An increase of mean arterial pressure >20% within the first 4 days was predictive of developing vasospasm. Elevation of mean arterial blood pressure in the VS+ group was mainly attributable to changes in diastolic pressure. Elevation of mean arterial blood pressure >25% within the first week after SAH was associated with unfavorable outcome.

CONCLUSIONS

SAH leads to spontaneous and progressive elevations in mean arterial blood pressure. Vasospasm might be anticipated by identifying early elevations of mean arterial blood pressure. Finally, spontaneous elevations of mean arterial blood pressure correlate with poorer outcomes.

Prognostic factors of clinical outcome after neuronavigation-assisted hematoma drainage in patients with spontaneous intracerebral hemorrhage

OBJECTIVE

The prognostic factors that contribute to outcome after navigation-assisted drainage in patients with spontaneous intracerebral hemorrhage (ICH) have not been defined. We compared the characteristics and clinical outcomes of patients with spontaneous ICHs who underwent neuronavigation-assisted hematoma drainage.

METHODS

Forty-seven patients were enrolled from January 2004 to August 2013. The patients were divided into two groups according to Glasgow Outcome Scale (GOS) scores: the good- (GOS 4-5) and poor-outcome (GOS 1-3) groups. A variety of factors, characteristics, and clinical outcomes were analyzed.

RESULTS

Among the 47 patients, 16 and 31 showed good and poor outcomes, respectively. The mortality rate was 4.3%. Patients' ages, horizontal and vertical diameters and volume of the hematoma on the initial brain computed tomography scan, and the initial Glasgow Coma Scale (GCS) scores were significantly different between the two groups (P<0.05). Ages less than 60 years, smaller horizontal and vertical diameters of the hematoma, less initial hematoma volume, higher initial GCS scores, and the absence of intraventricular hemorrhages were significantly associated with good outcome (P<0.05). Among these factors, initial hematoma volume was a borderline prognostic factor (odds ratio [OR], 0.951; 95% confidence interval [CI], 0.904-1.001; P=0.054), whereas initial GCS score was a significant prognostic factor (OR, 2.737; 95% CI, 1.371-5.465; P=0.004), in the multivariate analysis.

CONCLUSION

Initial GCS score and hematoma volume were important prognostic factors of clinical outcome in patients with spontaneous ICHs who underwent navigation-assisted drainage. Such factors should be carefully considered before patients are treated with navigation-assisted hematoma drainage.

Predictors of outcome in hypoglycemic encephalopathy

AIMS

The aim of this study was to investigate factors predicting poor prognosis in patients with hypoglycemic encephalopathy.

METHODS

We retrospectively analyzed data on 165 consecutive patients with hypoglycemic encephalopathy. We evaluated their outcome 1 week after hypoglycemia onset using the Glasgow outcome scale (GOS) and compared the clinical features of patients with good outcomes (GOS = 5) and poor outcomes (GOS ≤ 4).

RESULTS

The poor-outcome group included 38 patients (23%). The initial blood glucose level in the poor-outcome group was lower than that in the good-outcome group (p = 0.002). The duration of hypoglycemia in the poor-outcome group was longer than that in the good-outcome group (p < 0.001). Body temperature during hypoglycemia in the poor-outcome group was higher than that in the good-outcome group (p < 0.001). Furthermore, lactic acid level in the poor-outcome group was lower than in the good-outcome group (p = 0.032). There was no significant difference in the frequency of posttreatment hyperglycemia between the good-outcome and poor-outcome groups (p = 0.984).

CONCLUSION

Profound and prolonged hypoglycemia, normal or higher body temperature, and a low lactic acid level during hypoglycemia may be predictors of a poor outcome in patients with hypoglycemic encephalopathy.

Clinical and predictive significance of hyponatremia after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Hyponatremia after SAH was the object of several studies with conflicting results. The aim of this study was to determine a predictive correlation of hyponatremia with delayed cerebral ischemia (DCI) and poor clinical outcome.

MATERIAL AND METHODS

We have used a retrospective hospital chart review of 82 patients with SAH treated from August 2008 to August 2010. Patients were divided into hyponatremia and normonatremia groups. Hyponatremia was defined as serum sodium level <135 mmol/l. Information compared and analyzed included demographics, preoperative neurological status, aneurysm characteristics, postoperative intensive care, duration of stay, DCI and clinical outcome at hospital discharge. P<0.05 was considered significant.

RESULTS

Thirty-two patients with SAH (39%) developed hyponatremia. In that group we had a significantly higher WFNS score at admission (p=0.03) and longer duration of stay in intensive care (p=0.001). DCI with transit or definitive deficit included 20 patients (62%) in the hyponatremia group, and 19 patients (38%) in the normonatremia group (p=0.03). Binary enter logistic regression revealed a significant correlation of hyponatremia with DCI (p=0.03) and poor clinical outcome (p=0.001).

CONCLUSION

This result revealed a possible use of hyponatremia as an additional predictor of developing DCI and poor clinical outcome.

Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle cerebral artery aneurysms

OBJECTIVE

Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures.

METHODS

A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10-82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome.

RESULTS

The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome.

CONCLUSIONS

Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.