OBJECT: The authors prospectively studied the occurrence of clinical and nonclinical electroencephalographically verified seizures during treatment with an intracranial pressure (ICP)-targeted protocol in patients with traumatic brain injury (TBI). METHODS: All patients treated for TBI at the Department of Neurosurgery, University Hospital Umeå, Sweden, were eligible for the study. The inclusion was consecutive and based on the availability of the electroencephalographic (EEG) monitoring equipment. Patients were included irrespective of pupil size, pupil reaction, or level of consciousness as long as their first measured cerebral perfusion pressure was > 10 mm Hg. The patients were treated in a protocol-guided manner with an ICP-targeted treatment based on the Lund concept. The patients were continuously sedated with midazolam, fentanyl, propofol, or thiopental, or combinations thereof. Five-lead continuous EEG monitoring was performed with the electrodes at F3, F4, P3, P4, and a midline reference. Sensitivity was set at 100 muV per cm and filter settings 0.5-70 Hz. Amplitude-integrated EEG recording and relative band power trends were displayed. The trends were analyzed offline by trained clinical neurophysiologists. RESULTS: Forty-seven patients (mean age 40 years) were studied. Their median Glasgow Coma Scale score at the time of sedation and intubation was 6 (range 3-15). In 8.5% of the patients clinical seizures were observed before sedation and intubation. Continuous EEG monitoring was performed for a total of 7334 hours. During this time neither EEG nor clinical seizures were observed. CONCLUSIONS: Our protocol-guided ICP targeted treatment seems to protect patients with severe TBI from clinical and subclinical seizures and thus reduces the risk of secondary brain injury.
This study assesses the influence of socio-demographic, psychosocial, clinical and radiological variables on the outcome of patients with mild traumatic brain injury (MTBI) in an acute care inpatient setting.
Retrospective cohort study.
A total of 2127 inpatients with MTBI were included. Outcomes measured were Extended Glasgow Outcome Scale (GOS-E), the FIM® instrument, length of stay (LOS) and discharge destination.
Fifty-four per cent of patients with MTBI with a median GOS-E of 2 were discharged home with no need for further follow-up. Age, LOS, lower Glasgow score (GCS) at admission, insurance coverage and positive CT scans were associated with rehabilitation referrals on discharge. Age, LOS, alcohol and drug abuse, motor vehicle collision and lower GCS at admission were associated with greater physical disabilities and functional impairment at discharge. FIM® cognitive functional scores were higher in women, younger patients and patients without psychiatric disorders. Brain lesions were correlated with longer LOS. CT scan findings in patients with MTBI may help clinicians predict the final outcome and resources required for patient care during their hospitalization and on discharge.
This study can help healthcare professionals in treating and planning future care of patients with MTBI.
Traditionally acute life-saving evacuations of extracerebral haematomas are performed by general surgeons on vital indication in county hospitals in the Uppsala-Örebro health care region in Sweden, a region characterized by long distances and a sparsely distributed population. Recently, it was stated in the guidelines for prehospital care of traumatic brain injury from the Scandinavian Neurosurgical Society that acute neurosurgery should not be performed in smaller hospitals without neurosurgical expertise. The aim of this study was to investigate: how often does acute decompressive neurosurgery occur in county hospitals in the Uppsala-Örebro region today, what is the indication for surgery, and what is the clinical outcome? Finally, the goal was to evaluate whether the current practice in the Uppsala-Örebro region should be revised.
Patients referred to the neurointensive care unit at the Department of Neurosurgery in Uppsala after acute evacuation of intracranial haematomas in the county hospitals 2005-2010 were included in the study. Data was collected retrospectively from the medical records following a predefined protocol. The presence of vital indication, radiological and clinical results, and long-term outcome were evaluated.
A total of 49 patients (17 epidural haematomas and 32 acute subdural haematomas) were included in the study. The operation was judged to have been performed on vital indication in all cases. The postoperative CT scan was improved in 92% of the patients. The reaction level and pupillary reactions were significantly improved after surgery. Long-term outcomes showed 51% favourable outcome, 33% unfavourable outcome, and in 16% the outcome was unknown.
Looking at the indication for acute neurosurgery, the postoperative clinical and radiological results, and the long-term outcome, it appears that our regional policy regarding life-saving decompressive neurosurgery in county hospitals by general surgeons should not be changed. We suggest a curriculum aimed at educating general surgeons in acute neurosurgery.
a) To examine the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Glasgow Coma Scores as predictors of the outcome of patients following resuscitation from cardiac arrest; b) to study the impact of the components of APACHE II on the prediction.
A nationwide study in Finland with prospectively collected data on all patients admitted to intensive care after cardiac arrest during a 14-month period. Two thirds of the cardiac arrest patients included in the study were randomly selected to derive predictive models, and the remaining one third constituted the validation sample.
A total of 25 medical and surgical ICUs in Finland (13 in tertiary referral centers).
Six-hundred nineteen consecutive cardiac arrest patients. Fifteen patients less than 16 yrs were excluded.
Variables included in the APACHE II or Glasgow Coma Scores were collected at the time of ICU admission and then three times after admission, at 24-hr intervals. ICU- and hospital-mortality rates and a 6-month mortality rate after ICU admission were studied.
Of 604 study patients, 370 (61.3%) patients died in the hospital. The most accurate prediction of hospital outcome was based on data collected after the first day of ICU care, not on the admission values. Twenty-one (21.9%) of 96 patients with a low APACHE II score (less than or equal to 9) died compared with 66 (84.6%) of 78 patients with a high APACHE II score (greater than or equal to 25) (p less than .001). Of 160 patients with a normal Glasgow Coma Score (14 to 15), 45 (28.1%) died, whereas there were 114 (81.4%) nonsurvivors among 140 patients with a low Glasgow Coma Score of 3 (p less than .001). The performance of predictive models, including age, the Chronic Health Evaluation, and either the Acute Physiology Score (Acute Physiology Score model) or the Glasgow Coma Score (Glasgow Coma Score model) were compared with the prediction according to the APACHE II in the validation sample. When using 80% probability of death as a decision rule, the Acute Physiology Score model determined 35 of 153 patients to have high risk of death, 29 of whom died (the positive predictive value being 82.9%). The Glasgow Coma Score model predicted 34 patients to die, 26 of whom died (positive predictive value 76.5%), and the APACHE II score predicted seven deaths, five of whom actually died (positive predictive value 71.4%).
The APACHE II scoring system cannot be recommended as a prognostic tool to support clinical judgement in cardiac arrest patients, but by modifying it, a more accurate prediction of poor outcome could be achieved. The Glasgow Coma Score explained to a great extent the predictive power of the APACHE II.
Comment In: Crit Care Med. 1991 Dec;19(12):1460-11959362
Comment In: Crit Care Med. 1992 Dec;20(12):1736-81458955
Despite recent progress, prognosis for the elderly (defined as aged =70 years) afflicted by traumatic brain injury (TBI) is unfavorable and surgical intervention remains controversial. Research during the past decade on the mortality rates or prognostic factors for survival in the elderly is limited.
We analyzed 97 patients aged =70 years who were treated surgically for closed TBI at our neurosurgical unit between January 1, 2003 and December 31, 2012. In addition, we analyzed 22 patients aged =70 years who had sustained a closed TBI and on whom no neurosurgical intervention was performed. Outcome in both groups was measured as 30-, 90- and 180-day mortality.
Surgically treated patients: median age, 76 years' 30-day overall mortality rate, 36%. Higher mortality was seen with lower level of consciousness, high energy trauma, one pupil fixed and dilated, and more extensive intracranial pathology. Presence of warfarin, more advanced age, or degree of midline shift were not associated with worsened outcome. Patients not treated neurosurgically: median age. 81.5 years; 30-day overall mortality rate, 23%. Mortality for patients with Glasgow coma scale (GCS) 10-15 was 6%, GCS 6-9 67%, and GCS 3-5 100%.
Selected patients aged =70 years can benefit from surgical intervention for closed TBI. Level of consciousness, radiologic type of injury, mechanism of injury, and pupil abnormalities should be carefully evaluated. There also seems to exist a group of patients in whom surgical intervention offers little benefit, as mortality rate is low without surgical intervention.
Research in traumatic brain injury (TBI) is challenging for several reasons; in particular, the heterogeneity between patients regarding causes, pathophysiology, treatment, and outcome. Advances in basic science have failed to translate into successful clinical treatments, and the evidence underpinning guideline recommendations is weak. Because clinical research has been hampered by non-standardised data collection, restricted multidisciplinary collaboration, and the lack of sensitivity of classification and efficacy analyses, multidisciplinary collaborations are now being fostered. Approaches to deal with heterogeneity have been developed by the IMPACT study group. These approaches can increase statistical power in clinical trials by up to 50% and are also relevant to other heterogeneous neurological diseases, such as stroke and subarachnoid haemorrhage. Rather than trying to limit heterogeneity, we might also be able to exploit it by analysing differences in treatment and outcome between countries and centres in comparative effectiveness research. This approach has great potential to advance care in patients with TBI.
Trauma to the mandible can potentially increase our predictive accuracy for intracranial injuries (ICIs) because of the mandible's strength, anatomic proximity, and direct connection to the skull base. Our goals were to: 1) investigate the association of mandible fractures with traumatic brain injury (TBI) and intracranial lesions (ICLs); and 2) determine predictors of ICIs in a level 1 Canadian trauma center with distinct patient demographics and fracture etiologies.
A retrospective chart review was performed of medical records of mandible-fracture patients treated at our institution from 1997 to 2003. Patients who had undergone postinjury computed tomography (CT) of the head with a minimum of 4 weeks' follow-up were considered eligible. Data collected included patient and fracture characteristics, neurologic evaluation, and the presence of concomitant injuries.
One hundred eighty-one patients were reviewed, of whom 86 were found eligible, with demographics representative of an urban-trauma population. The incidence of TBI was 68.6%, and of ICLs, 27%. Logistic regression identified alcohol (odds ratio [OR], 3.97), concomitant facial fracture (OR, 2.77), and other systemic injury (OR, 2.59) as independent predictors of an ICI in mandibular fracture patients. Importantly, ICIs were observed in 19% of mandible-fracture patients, satisfying the criteria for mild TBI, and in 17% of patients without any evidence of TBI.
Some authors have advocated treating mandible fractures on an outpatient basis, with a focused workup. Our results of significant concomitant ICI in mandible-fracture patients, conversely, suggest that such management may inadvertently result in the oversight of potentially life-threatening injuries. Thus, we recommend mandatory intracranial CT imaging if the patient's neurologic status at time of injury is unknown or meets the criteria of TBI, or if positive predictors for ICL are present.
Assessment of the reaction level is the single most important investigation in patients with acute cerebral disorders. The Reaction Level Scale, RLS-85, a recently developed and scientifically based method, is recommended for introduction in Sweden.
There are two independent head injury outcome studies using the "Lund concept", and both showed a mortality rate of about 10%, and a favourable outcome (Glasgow outcome scale, GOS 4 and 5) of about 70%. The Lund concept aims at controlling intracranial pressure, and improving microcirculation around contusions. Intracranial pressure is controlled by maintaining a normal colloid osmotic pressure and reducing the hydrostatic capillary pressure. Microcirculation is improved by ensuring strict normovolaemia and reducing sympathetic discharge. The endogenous substance prostacyclin with its antiaggregatory/antiadhesive effects may further improve microcirculation, which finds support from a microdialysis-based clinical study and an experimental brain trauma study. The present clinical outcome study aims at evaluating whether the previously obtained good outcome with the Lund therapy can be reproduced, and whether the addition of prostacyclin has any adverse side-effects.
All 31 consecutive patients with severe head injury, Glasgow coma scale (GCS) 10 months after the injury.
One patient died, another suffered vegetative state and 7 severe disability. Of the 22 patients with favourable outcome, 19 showed good recovery and 3 moderate disability. No adverse side-effects of prostacyclin were observed.
The outcome results from previous studies using the Lund therapy were reproduced, and no adverse side-effects of low-dose prostacyclin were observed.
Worldwide, the use of bicycles, for both recreation and commuting, is increasing. S100B, a suggested protein biomarker for cerebral injury, has been shown to correlate to extracranial injury as well. Using serum levels of S100B, we aimed to investigate how S100B could be used when assessing injuries in patients suffering from bicycle trauma injury. As a secondary aim, we investigated how hospital length of stay and injury severity score (ISS) were correlated to S100B levels.
We performed a retrospective, database study including all patients admitted for bicycle trauma to a level 1 trauma center over a four-year period with admission samples of S100B (n = 127). Computerized tomography (CT) scans were reviewed and remaining data were collected from case records. Univariate- and multivariate regression analyses, linear regressions and comparative statistics (Mann-Whitney) were used where appropriate.
Both intra- and extracranial injuries were correlated with S100B levels. Stockholm CT score presented the best correlation of an intracranial parameter with S100B levels (p 15 had higher S100 levels than patients with ISS
Cites: Health Promot Int. 2005 Mar;20(1):33-4015668215