Predictive Validity and Inter-Rater Reliability of the Persian Version of Full Outline of Unresponsiveness Among Unconscious Patients with Traumatic Brain Injury in an Intensive Care Unit.

INTRODUCTION: The Glasgow Coma Scale (GCS) has some limitations when evaluating the unconscious patient. This study aims to validate the Persian version of the FOUR (Full Outline of Unresponsiveness) score as a proposed substitute. METHODS: Two nurses, two nursing students, and two physicians scored the prepared Persian version of the FOUR and GCS in 84 patients with acute brain injury. The inter-rater agreement for the FOUR and the GCS scores was evaluated by the weighted kappa (κ w). The outcome prediction power of the scales was assessed by the area under the curve (AUC) in the ROC curve. RESULTS: The inter-rater agreement of the FOUR was excellent (κ w = 0.923, 95 % CI, 0.874-0.971) and comparable with the one of the GCS (κ w = 0.938, 95 % CI, 0.889-0.987). The area under the curve (AUC) for predicting in-hospital mortality (modified Rankin Scale: 6) was 0.835 for the FOUR (95 % CI, 0.739-0.907) and 0.772 for the GCS (95 % CI, 0.668-0.856) (P = 0.01). AUC for predicting poor outcome (modified Rankin Scale: 3-6) for the total FOUR score was 0.983 (95 % CI, 0.928-0.999), which is comparable with 0.987 for the total GCS score (95 % CI, 0.934-1.000). CONCLUSIONS: The researchers conclude that the Persian version of the FOUR score is a reliable and valid scale to assess unconscious patients with traumatic brain injury and can be substituted for the GCS.

Right Median Nerve Electrical Stimulation for Acute Traumatic Coma Patients.

The right median nerve as a peripheral portal to the central nervous system can be electrically stimulated to help coma arousal after traumatic brain injury (TBI). The present study set out to examine the efficacy and safety of right median nerve electrical stimulation (RMNS) in a cohort of 437 comatose patients after severe TBI from August 2005 to December 2011. The patients were enrolled 2 weeks after their injury and assigned to the RMNS group (n=221) receiving electrical stimulation for 2 weeks or the control group (n = 216) treated by standard management according to the date of birth in the month. The baseline data were similar. After the 2-week treatment, the RMNS-treated patients demonstrated a more rapid increase of the mean Glasgow Coma Score, although statistical significance was not reached (8.43 ± 4.98 vs. 7.47 ± 5.37, p = 0.0532). The follow-up data at 6-month post-injury showed a significantly higher proportion of patients who regained consciousness (59.8% vs. 46.2%, p = 0.0073). There was a lower proportion of vegetative persons in the RMNS group than in the control group (17.6% vs. 22.0%, p = 0.0012). For persons regaining consciousness, the functional independence measurement (FIM) score was higher among the RMNS group patients (91.45 ± 8.65 vs. 76.23 ± 11.02, p < 0.001). There were no unique complications associated with the RMNS treatment. The current study, although with some limitations, showed that RMNS may serve as an easy, effective, and noninvasive technique to promote the recovery of traumatic coma in the early phase.

Long-lasting coma.

In this report, we describe the case of a patient who has remained in a comatose state for more than one year after a traumatic and hypoxic brain injury. This state, which we refer to as long-lasting coma (LLC), may be a disorder of consciousness with significantly different features from those of conventional coma, the vegetative state, or brain death. On the basis of clinical, neurophysiological and neuroimaging data, we hypothesize that a multilevel involvement of the ascending reticular activating system is required in LLC. This description may be useful for the identification of other patients suffering from this severe disorder of consciousness, which raises important ethical issues.

[Peculiarities of disorders of brain bioelectrical activity spatial-time organization in patients with different consciousness depression after severe head injury].

Specific changes of bioelectrical brain activity was found in 27 patients with different level of posttraumatic consciousness depression by the methods of crosscorrelation, coherence and factor analysis of EEG. The changes of activity of morphofunctional systems of intracerebral integrations were revealed partially by decreasing of unspecific activity from brainstem structures reflected with increasing of slow wave activity and decreasing of EEG coherence in alpha- and beta-range. Depression of system organization of interconnections of bioelectrical brain activity in frontal and occipital regions of both hemispheres was also detected, and testified about decreasing of intercortical and thalamocortical brain system action under brain dislocation. The changes of integrative brain system activity, provides interhemispheric interaction, had the specific characted. Our results propose a "facilitation" of activity of system, providing "direct" interhemispheric connections through corpus callosum and other commissural tracts of telencephalon as a sequel of mesodiencephalon structures depression with steady reciprocal, antiphase relations of slow weve activity in symmetrical areas of hemispheres in coma II patients. The data of our research had shown no complete disintegration of system brain activity in coma II patients in spite of consciousness and brainstem reflexes depression.

[Epilepsy by bovine (zebu) goring: a case report in Burkina Faso]. / Epilepsie par encornement bovin (zébu): a propos d'un cas au Burkina Faso.

The post-traumatic epilepsy is responsible for 20% of the symptomatic epilepsies. Accidents on public highway constitute more than 70% of the causes. We report a singular case of fronto-polar post-traumatic epilepsy by zebu goring which appeared two years after the traumatism. The neurological examination of the patient was normal apart from a inconspicuous expansiveness of humor underlined by an excess of familiarity and hypersyntony. The cerebral scanner revealed a left fronto-basal cortico-under-cortical low density up to the homolateral fronto-polar area. The electroencephalogram (EEG) showed some left fronto-polar bursts of spike and wave on a normal bottom line. This clinical observation draws our attention on the fact that in Sahelian tropical environment where bovine breeding holds a major place, the cranio-encephalic traumatism by goring is not rare and can be responsible for epilepsy in the same way as accidents on public highway, or ballistic traumatism.

[Coma after lucid interval--severe secondary alteration of consciousness following multiple trauma]. / Koma nach luzidem Intervall--schwere sekundäre Bewusstseinseinschränkung nach Polytrauma.

A 71-year-old man sustains multiple fractures in an accident; after a lucid interval he deteriorates neurologically and becomes comatose. Intracranial hemorrhage, status epilepticus, adverse drug reactions, toxic-metabolic, ischemic or infectious causes are subsequently ruled out. Development of petechiae and thrombopenia raises the possibility of fat embolism syndrome, which is confirmed in a MRI of the head 72 hours after the accident. We discuss current aetiologic concepts as well as diagnosis and clinical course of the cerebral fat embolism syndrome.

Post-traumatic mutism in children.

OBJECTIVE: To explore the pathological mechanism of post-traumatic mutism (PTM) in children. METHODS: A retrospective study of 16 children who suffered from severe head injury and developed PTM. RESULTS: Post-traumatic coma lasted from 2-72 days, average 15.5 days; while post-traumatic mutism lasted from 2-56 days, average 11.94 days. The correlation between duration of coma and mutism was significant (p < 0.001). SPECT found that multiple persistent ischaemic brain regions occurred in all patients; the mean number of regions was 5.6. The patients were sub-divided into three groups based on the number of ischaemic regions: group 1, < or = 4; group 2, 5 approximately 6; group 3, > or = 7. The duration of mutism did not differ significantly between groups 1 and 2, but the difference between group 3 and the other two groups combined was significant (p < 0.05). CONCLUSION: Most PTM occurred in patients with diffuse brain injury. The duration of mutism was related to the number of ischaemic brain regions and the duration of post-traumatic coma.

Facial fracture repair in the traumatic brain injury patient.

PURPOSE: To review the surgical complications of patients who had facial fractures repairs in the setting of a traumatic brain injury (TBI). PATIENTS AND METHODS: A review of all individuals admitted with the diagnosis of TBI based on an evaluation by the neurotrauma service who also underwent facial fracture repair was performed. More than 600 charts were reviewed and 99 patients met study criteria. Univariate and mulitvariate logistic regression model analysis were performed comparing the complication rate in the immediate postoperative period to the patients' age, gender, mechanism of injury, zone of facial injury, preoperative Glasgow Coma score, presence of multisystem injury, mechanism of TBI and treatment, length of time from injury to surgical repair and length of surgical procedure. RESULTS: Of the 99 individuals studied, there was an 11% complication rate (8 minor, 3 major) in the immediate postoperative period. After univariate analysis, the length of time from injury to surgical repair, zone 1 facial injury and low Glasgow Coma score were all factors associated with increased complications. Multivariate logistic regression model analysis revealed that the odds of a patient sustaining a postoperative complication was 1.298 as the hour of procedure increased by 1 hour (95% CI, 1.065-1.582) and was 1.152 as the days of repair increased by 1 day (95% CI, 1.030-1.288). CONCLUSIONS: The overall complication rate of facial fracture repair in the TBI patient was 11%. A prolonged surgical procedure and delay in surgical repair were associated with higher complication rates as identified by multivariate logistical regression analysis.

Traumatic and non-traumatic coma in children in the referral hospital, Al-Hasa, Saudi Arabia.

Fahad Hospital, which is the only referral centre for Al-Hasa region, Saudi Arabia.

How does information influence hope in family members of traumatic coma patients in intensive care unit?

AIMS: To assess the interplay between hope and the information provided by health care professionals. BACKGROUND: Earlier research learned that hope is crucial for relatives of traumatic coma patients. Also it has been reported that the need for information is extremely important for relatives of critically ill patients. DESIGN: A qualitative approach according to the 'grounded theory' method with constant comparison was used. METHOD: We held 24 in-depth interviews with 22 family members of 16 patients with traumatic coma. Data processing and data analysis took place in a cyclic process wherein the induction of themes was alternated by confrontation with new material. RESULTS: Family members of traumatic coma patients want information that is as accurate as possible, provided by doctors and nurses in an understandable manner and leaving room for hope. At first, family members can do no more than passively absorb the information they receive. After some time, they actively start working with information and learn what to build their hope on. In this way, concrete hope evolves and seems to be strongly determined by information. Information that is more positive than warranted is not appreciated at all. It leads to false hope and once its real nature becomes apparent, to increased distress and loss of trust in the professionals. CONCLUSION: The process of hope is crucial in coping with traumatic coma and information can facilitate this process. RELEVANCE TO CLINICAL PRACTICE: If professionals, especially nurses, keep the process in mind that family members go through in handling information, they can not only facilitate this process but also help them to establish realistic hope.

Cortical synchrony changes detected by scalp electrode electroencephalograph as traumatic brain injury patients emerge from coma.

BACKGROUND: Recent studies show conscious perception is correlated with firing rate synchronization across multiple neuronal assemblies. This study explores the synchrony between multiple cortical surface sites as brain injury patients emerge from coma. METHODS: Scalp electrode EEG recordings were collected and analyzed from 13 traumatic brain injury patients during their stay in a neurosurgical intensive care unit. Neuronal synchrony was calculated between various electrode pairs during comatose and conscious periods defined by the GCS. Frequency bands from 1 to 30 Hz were evaluated in each patient. RESULTS: As patients emerged from coma at GCS 3 to GCS scores > or =8, synchrony values from all electrode pairs revealed a global decrease in synchrony at higher GCS scores. No significant effects were detected relative to the amount of sedation given, but at higher GCS scores significantly increased neuronal synchrony was observed between occipital lobes and right parietal and temporal lobe sites. Synchrony was decreased between frontal-occipital, frontal-parietal, and parietal-occipital electrodes. CONCLUSIONS: In frequencies from 1 to 30 Hz, synchrony between right parietal and temporal lobes, as well as bilateral occipital lobes, tends to be increased as patients emerge from comatose states. However, synchrony between most intrahemispheric cortical sites is decreased at higher GCS scores in most of the above frequency bands. Thus, brain injury patients demonstrate both increased and decreased cortical surface synchrony between different lobes during emergence from coma.

[Cognitive disturbances following severe traumatic brain injury]. / Kognitive forstyrrelser ved svaer traumatisk hjerneskade.

Traumatic brain injury (TBI) very often has extensive effects of cognitive character such as changes in recognition, thought, memory, language and perception. The purpose of this paper is to give a short status of cognitive impairment after severe traumatic brain injury and to illustrate that cognitive impairment varies according to levels of consciousness. The article shortly describes typical observed behaviour in the patient when waking up after severe TBI, including post-traumatic amnesia.

Detected and overlooked cervical spine injury in comatose victims of trauma: report from the Pennsylvania Trauma Outcomes Study.

OBJECT: This study was undertaken to determine whether a clinically useful rule could be formulated for identifying the presence of traumatic brain injury (TBI) in patients who are at exceptionally low risk of cervical spine injury. METHODS: The Pennsylvania Trauma Outcomes Study database was searched for cases of TBI in which the admission Glasgow Coma Scale (GCS) score was less than or equal to 8. Cases of cervical injury were identified based on diagnostic codes. Associations between cervical injury and various clinical variables were tested using chi-square analysis. The probability of cervical injury was modeled using logistic regression. Decision tree models were constructed. Statistical determinants of overlooked cervical injury were examined. The prevalence of cervical injury among 41,142 cases of TBI was 8%. Mechanism of injury, thoracolumbosacral (TLS) fracture, age, limb fracture, admission GCS score, hypotension, and facial fracture were associated with cervical injury and were incorporated into the following logistic regression model: probability = 1/(1 + exp[4.248 - 0.417 X mechanism -0.264 X age - 0.678 X TLS - 0.299 X limb - 0.218 X GCS - 0.231 X hypotension - 0.157 X facial]). The results of applying this model provided a rule for cervical spine clearance applicable to 28% of the cases with a negative predictive value (NPV) of 97.0%. Decision tree analysis yielded a rule applicable to 24% of the cases with an NPV of 98.2%. The prevalence of overlooked cervical injury in all individuals with severe TBI was 0.3%; the prevalence of overlooked cervical injury in patients with cervical injury was 3.9%. Overlooked cervical injury was less common in patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245-0.837). CONCLUSIONS: This analysis identified no acceptable rule to justify relaxing vigilance in the search for cervical injury in patients with severe TBI. Provider vigilance and consequent rates of overlooked cervical injury can be affected by environmental cues and presumably by other behavioral and organizational factors.

Orbito-cerebral penetrating knife-wound.

An orbit-cerebral knife wound is described. Reasons for variation in outcome art discussed.

Early clinical predictive factors during coma recovery.

In severe brain injury patients few studies have examined the role of early clinical factors emerging before recovery of consciousness. Patients suffering from vegetative state and minimally conscious state in fact may need variable periods of time for recovery of the ability to follow commands. In a previous study we retrospectively examined a population of very severe traumatic brain injury patients with coma duration of at least 15 days (prolonged coma), and we found, as significant predictive factors for the final outcome, the time interval from brain injury to the recovery of the following clinical variables: optical fixation, spontaneous motor activity and first safe oral feeding. Psychomotor agitation and bulimia during coma recovery were also favourable prognostic factors for the final outcome. In a further study, also as for the neuropsychological recovery, the clinical variable with the best significant predictive value was the interval from head trauma to the recovery of safe oral feeding. In the present study the presence of psychomotor agitation diagnosed by means of LCF (score 4 = confused-agitated) at the admission time in rehabilitation predicted a statistically significant better outcome at the discharge time in comparison with patients without agitation.

Changes in white matter in long-term survivors of severe non-missile traumatic brain injury: a computational analysis of magnetic resonance images.

The aim of this study was to investigate long-term consequences of severe non-missile traumatic brain injury (nmTBI) in patients without macroscopic focal brain lesions (>1.6 cm(3)) on regional white-matter density (WMd), and possible correlations with days of coma and memory performances. T1-weighted magnetic-resonance images (MRI) were acquired in 19 nmTBI patients, 3-113 months following the injury, and in 19 control subjects matched for age and gender. In addition, nmTBI patients underwent a battery of standardised memory tests. The MRIs were processed in a fully automatic system using voxel-by-voxel methods. Corpus callosum, fornix, anterior limb of the internal capsule, superior frontal gyrus, para-hippocampal gyrus, optic radiation and chiasma showed significant WMd reduction in nmTBI when compared to control subjects. None of the correlations between days of coma and memory performance scores with nmTBI voxels value that showed WMd reduction reached significance, with the exception of a significant negative correlation between WMd in the mid body of corpus callosum and short-story delayed recall. We detected reductions in WM density in several brain locations similar to those described in previous post mortem investigations. In addition, we observed WMd reduction in the optic chiasma and in the optic radiations; this finding may reflect transneural degeneration along the visual pathway. The weak correlations between specific anatomical sites of the reduced WMd and behavior may reflect the diffuse nature of the brain damage and/or the different time of onset between behavioral manifestations and neuropathological modifications occurring in nmTBI.

Clinical predictors and neuropsychological outcome in severe traumatic brain injury patients.

BACKGROUND: The aim of the study was to evaluate the possible significant role of some clinical factors in predicting cognitive outcome in a group of severe traumatic brain injury (TBI) patients, with Glasgow Coma Scale (GCS) lower than 8 and duration of unconsciousness for at least 15 days (prolonged coma). METHOD: A consecutive sample of 25 survivors of severe TBI attending the Physical and Cognitive Rehabilitation program participated in this study. The neuropsychological test battery included: Word-list Learning, Prose recall, Rey Figure Delayed recall, Word fluency, Raven's Progressive Matrices' 47. The clinical variables evaluated in correlation with the neuropsychological outcome were the following: age, duration of unconsciousness, duration of post-traumatic amnesia, interval from head trauma to neuropsychological evaluation, interval from head trauma to recovery of oral feeding, and finally interval from head trauma to first verbal communication. FINDINGS: The clinical variable with a significant predictive value on most neuropsychological scores was the interval from head trauma to the recovery of oral feeding. CONCLUSIONS: If this result is confirmed in larger samples, time interval of oral feeding recovery from head trauma should be considered as a possible predictor of neuropsychological outcome in TBI patients with prolonged coma.

Electrical treatment of coma via the median nerve.

The median nerve is a portal to interact with the injured comatose brain. Peripheral nerve electrical stimulation has a central nervous system effect. Two to three weeks of right median nerve stimulation (RMNS) can hasten awakening from deep coma by increasing the dopamine levels. Three cases of electrically treated GCS-4 teenagers with acute diffuse brain injuries from motor vehicle crashes are presented by video. Pilot studies of RMNS for acute post-traumatic coma states have been done over the last ten years at East Carolina University and the University of Virginia. The neurophysiological effects of RMNS have been well documented at several neurosurgical centers in Japan using neuroimaging and spinal fluid assays. RMNS is a safe, inexpensive, non-invasive therapy for neuro-resuscitation of coma patients. When employed early in the coma, the time in the ICU may be shortened and the quality of the final outcome may be enhanced.