Prevalence of persistent vegetative state compared to recovery, disability, and death in subjects with severe traumatic brain injury: A meta-analysis.

BACKGROUND: The persistent vegetative state has drawn considerable attention since it is the poorest result apart from mortality in subjects with severe traumatic brain injury. This meta-analysis was performed to evaluate its prevalence compared to recovery, disability, and death 6 months post severe traumatic brain injury. METHODS: A systematic-literature search up to May 2020 was performed and 19 studies were detected with 10 368 subjects. They contained data about the subject's status 6 months post severe traumatic brain injury (recovery, disability, persistent vegetative state, and death). Odds ratio (OR) with 95% confidence intervals (CIs) was calculated comparing the prevalence of persistent vegetative state to that of recovery, disability, and death; 6 months post severe traumatic brain injury using the dichotomous method with a random- or fixed-effect model. RESULTS: Significantly higher prevalence was found of recovery (OR, 0.08; 95% CI, 0.03-0.20, P < .001); disability (OR, 0.09; 95% CI, 0.06-0.15, P < .001); and death (OR, 0.07; 95% CI, 0.04-0.11, P < .001) compared to the prevalence of persistent vegetative state. The prevalence of persistent vegetative state was variable over time. Also, the prevalence of persistent vegetative states in developing countries was much higher than in developed countries. CONCLUSIONS: However, persistent vegetative state is the poorest result apart from mortality in subjects with severe traumatic brain injury. Its prevalence is lower than the recovery, disability, and death even in developing counties with its lower healthcare services. The prevalence was variable over time and higher in developing countries. This relationship forces us to recommend improving healthcare services to the extent that a persistent vegetative state could be avoided as much as possible.

Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension.

BACKGROUND: The effect of decompressive craniectomy on clinical outcomes in patients with refractory traumatic intracranial hypertension remains unclear. METHODS: From 2004 through 2014, we randomly assigned 408 patients, 10 to 65 years of age, with traumatic brain injury and refractory elevated intracranial pressure (>25 mm Hg) to undergo decompressive craniectomy or receive ongoing medical care. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOS-E) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 6 months. The primary-outcome measure was analyzed with an ordinal method based on the proportional-odds model. If the model was rejected, that would indicate a significant difference in the GOS-E distribution, and results would be reported descriptively. RESULTS: The GOS-E distribution differed between the two groups (P<0.001). The proportional-odds assumption was rejected, and therefore results are reported descriptively. At 6 months, the GOS-E distributions were as follows: death, 26.9% among 201 patients in the surgical group versus 48.9% among 188 patients in the medical group; vegetative state, 8.5% versus 2.1%; lower severe disability (dependent on others for care), 21.9% versus 14.4%; upper severe disability (independent at home), 15.4% versus 8.0%; moderate disability, 23.4% versus 19.7%; and good recovery, 4.0% versus 6.9%. At 12 months, the GOS-E distributions were as follows: death, 30.4% among 194 surgical patients versus 52.0% among 179 medical patients; vegetative state, 6.2% versus 1.7%; lower severe disability, 18.0% versus 14.0%; upper severe disability, 13.4% versus 3.9%; moderate disability, 22.2% versus 20.1%; and good recovery, 9.8% versus 8.4%. Surgical patients had fewer hours than medical patients with intracranial pressure above 25 mm Hg after randomization (median, 5.0 vs. 17.0 hours; P<0.001) but had a higher rate of adverse events (16.3% vs. 9.2%, P=0.03). CONCLUSIONS: At 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. The rates of moderate disability and good recovery were similar in the two groups. (Funded by the Medical Research Council and others; RESCUEicp Current Controlled Trials number, ISRCTN66202560 .).

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care.

BACKGROUND: The probability of favorable outcome after traumatic brain injury (TBI) decreases with age. Elderly, ≥ 60 years, are an increasing part of our population. Recent studies have shown an increase of favorable outcome in elderly over time. However, the optimal patient selection and neurointensive care (NIC) treatments may differ in the elderly and the young. The aims of this study were to examine outcome in a larger group of elderly TBI patients receiving NIC and to identify demographic and treatment related prognostic factors. METHODS: Patients with TBI ≥ 60 years receiving NIC at our department between 2008 and 2014 were included. Demographics, co-morbidity, admission characteristics, and type of treatments were collected. Clinical outcome at around 6 months was assessed. Potential prognostic factors were included in univariate and multivariate regression analysis with favorable outcome as dependent variable. RESULTS: Two hundred twenty patients with mean age 70 years (median 69; range 60-87) were studied. Overall, favorable outcome was 46% (Extended Glasgow Outcome Scale (GOSE) 5-8), unfavorable outcome 27% (GOSE 2-4), and mortality 27% (GOSE 1). Significant independent negative prognostic variables were high age (p < 0.05), multiple injuries (p < 0.05), GCS M ≤ 3 on admission (p < 0.05), and mechanical ventilation (p < 0.001). CONCLUSIONS: Overall, the elderly TBI patients > 60 years receiving modern NIC in this study had a fair chance of favorable outcome without large risks for severe deficits and vegetative state, also in patients over 75 years of age. High age, multiple injuries, GCS M ≤ 3 on admission, and mechanical ventilation proved to be independent negative prognostic factors. The results underline that a selected group of elderly with TBI should have access to NIC.

Deep Brain Stimulation for Recovery of Consciousness in Minimally Conscious Patients After Traumatic Brain Injury: A Systematic Review.

OBJECTIVES: Minimally conscious state (MCS) is a disorder of consciousness in which minimal but definite behavioral evidence of self-awareness or environmental awareness is demonstrated. Deep brain stimulation (DBS) of various targets has been used to promote recovery in patients with disorders of consciousness with varying results. The aim of this systematic review was to assess the effects of DBS in MCS following traumatic brain injury (TBI). MATERIALS AND METHODS: A systematic literature review was carried out using a number of electronic bibliographic data bases to identify relevant studies. We included all studies describing applications of DBS on patients in MCS following TBI. RESULTS: Eight studies were identified, including a total of ten patients, aged 15-58 years. The time from injury to stimulation ranged from 3 to 252 months, with the duration of follow-up post-DBS ranging from 10 to 120 months. Seven patients improved their postsurgical outcome score measures (three patients with the coma recovery scale, one with the near coma scale, and three with the Glasgow outcome score). A descriptive favorable outcome was reported in one patient. Two patients were reported not to have shown any improvements following the intervention. CONCLUSIONS: Current evidence is based on a small population of heterogeneous patients. The time from injury to stimulation was significantly variable and problematic, as spontaneous recovery can occur within the first year of injury. Although seven patients showed promising results in validated outcome measures, evidence supporting the use of DBS in MCS patients following TBI is lacking. There is need for controlled and randomized studies.

Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital.

BACKGROUND: No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS: Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS: Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale <13 and a length of stay in the ICU >48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%-50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%-35.9%) a severe disability (GOS 3), 0.6% (0%-3.2%) a vegetative state (GOS 2), and 27.6% (21.5%-34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43-79 years). Life-prolonging therapies were limited in 95.6% (85.2%-99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%-99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%-100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%-27.3%) of the patients, and 34.9% (22.4%-49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS: At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged.

Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study.

BACKGROUND: The outcome of patients with severe traumatic brain injury (TBI) and acute traumatic subdural hematoma (aSDH) admitted to the emergency room with bilaterally dilated, unreactive pupils (bilateral mydriasis) is notoriously poor. METHODS: Of 2074 TBI patients consecutively admitted to our facility between 1997 and 2012, 115 had a first CT scan with aSDH, unreactive bilateral mydriasis, and a Glasgow Coma Score of 3 or 4. Sixty-two patients were unoperated and died within hours or a few days. The remaining 53 patients (2.5% of the 2074 consecutive patients) were scheduled for emergent evacuation of the aSDH. We compared three different dosages of mannitol to landmark different comprehensive levels of treatment: (1) a "basic" level of treatment characterized by a single conventional dose (18 to 36 g), (2) "reinforced" treatment landmarked by a single high dose (54 to 72 g), and (3) "aggressive" treatment landmarked by a single high dose (90 to 106 g). Doses above 36 g were administered intravenously over a period of 5 min. RESULTS: Of the 53 selected patients, 7 were aggressively managed (13.2%) and 24 (45.3%) received reinforced treatment. Rates of hyperventilation and barbiturate bolus administration were appropriately associated with increasing doses of mannitol. After adjustment for age, aggressive management was significantly associated with a lower risk of death and persistent vegetative state [adjusted OR 0.016 (95% 0.001-0.405)]. Patients surviving after aggressive management suffered more severe disability at 1 year. CONCLUSION: The study shows an association between reduced mortality and persistent vegetative state, albeit at the cost of increased long-term severe disability in survivors, and aggressive medical preoperative management of mydriatic patients with aSDH following TBI.

Outcome Prediction for Patients with Traumatic Brain Injury with Dynamic Features from Intracranial Pressure and Arterial Blood Pressure Signals: A Gaussian Process Approach.

Previous work has been demonstrated that tracking features describing the dynamic and time-varying patterns in brain monitoring signals provide additional predictive information beyond that derived from static features based on snapshot measurements. To achieve more accurate predictions of outcomes of patients with traumatic brain injury (TBI), we proposed a statistical framework to extract dynamic features from brain monitoring signals based on the framework of Gaussian processes (GPs). GPs provide an explicit probabilistic, nonparametric Bayesian approach to metric regression problems. This not only provides probabilistic predictions, but also gives the ability to cope with missing data and infer model parameters such as those that control the function's shape, noise level and dynamics of the signal. Through experimental evaluation, we have demonstrated that dynamic features extracted from GPs provide additional predictive information in addition to the features based on the pressure reactivity index (PRx). Significant improvements in patient outcome prediction were achieved by combining GP-based and PRx-based dynamic features. In particular, compared with the a baseline PRx-based model, the combined model achieved over 30 % improvement in prediction accuracy and sensitivity and over 20 % improvement in specificity and the area under the receiver operating characteristic curve.

Prevalence differences of patients in vegetative state in The Netherlands and Vienna, Austria: a comparison of values and ethics.

OBJECTIVE: Little is known about prevalence of persistent vegetative state/unresponsive wakefulness syndrome and comparisons between countries. The aim of this column was to explore reasons for the comparable count of patients in vegetative state found in prevalence studies in nursing homes in 1 European country (Netherlands) compared with a single European city (Vienna, Austria). DESIGN: The column is based on a literature review of vegetative state in The Netherlands and Vienna in the period 2007-2008, in the context of professional interactions with families and physicians of patients in vegetative state. In addition, in both countries, families and physicians were interviewed to illustrate views. RESULTS: Comparable between the 2 settings are the population characteristics and the definition of, and criteria, for vegetative state. A difference can be found in the development of authoritative policy guidelines in the Netherlands, after public debates and jurisdiction, which did not exist in Vienna at the time. There also seem to be different societal values concerning rehabilitation and end-of-life decisions for patients in vegetative state. DISCUSSION: The most important explanation for the vegetative state prevalence differences between the Netherlands and Vienna can be found in the different societal values about patients in vegetative state and their treatment and rehabilitation. In the Netherlands, life prolonging medical treatment, including artificial nutrition and hydration, is considered futile and can be withdrawn if there is no prospect of recovery. In Vienna, however, patients in vegetative state are regarded as severely disabled and in need of long-term rehabilitation and social reintegration. There is no end-of-life discussion in this context.

[Epidemiological Investigation of Patients in Persistent Vegetative States in Aomori, Japan].

The actual number and condition of Japanese patients in persistent vegetative states have not yet been fully understood. The aim of this study is to investigate the epidemiology of patients in persistent vegetative states in the Aomori prefecture. We sent questionnaires regarding gender, age, cause of persistent vegetative state, and residence of patient to all medical institutions in the Aomori prefecture (n=682). Two hundreds and seventeen institutions (31.8%) replied to the questionnaire, and eleven hundred ninety-eight patients(Male/Female=381/817) were included. Patients over 80 years-old were the most common (63.4%), and cerebrovascular stroke was the major cause (64.4%) of persistent vegetative state. Nursing homes (48.1%) and hospitals (34.6%) were the main care institutions. Population based analysis revealed that 869 persistent vegetative state patients per million were cared for in the Aomori prefecture. This result was twice as many as was previously reported in Miyagi prefecture. The number of patients in persistent vegetative states will increase in the future, due to an increasing elderly population and a high incidence of stroke in this demographic. We therefore predict that increased medical and administrative support will be required in the future.

The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies.

One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed 'unresponsive wakefulness syndrome' (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross-sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain 'grey data' like government reports. Relevant publications underwent quality assessment and data-extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications' methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.

The prevalence of vegetative and minimally conscious states: a systematic review and methodological appraisal.

OBJECTIVES: To systematically review prevalence studies of vegetative state (VS) and minimally conscious state (MCS) in geographically defined populations, to appraise study methods and assess sources of heterogeneity. METHODS: MEDLINE, EBM Reviews, and EMBASE databases were searched using key terms. Two reviewers independently identified pertinent articles and screened the references for additional studies. Studies measuring the prevalence of VS and/or MCS in a defined population were included, and information on characteristics, methods, and results was extracted. Heterogeneity was quantified through the statistic I. RESULTS: We identified 5 cross-sectional prevalence surveys of VS and 1 of MCS. Prevalence ranged from 0.2 cases per 100,000 inhabitants to 3.4 for VS and was 1.5 per 100,000 for MCS. Relevant heterogeneity (I = 99.0%) prevented us from calculating a summary estimate. The prevalence of trauma cases varied from 21.9% to 53.8%. Variability pertaining to diagnostic criteria, definition of case, and methods of ascertainment was found. CONCLUSION: In the few prevalence studies of VS and MCS that were identified, the estimates showed high variability and could not be pooled. Future studies should consider using comparable methods for the definition, ascertainment, and confirmation of cases.

Rate of disorders of consciousness in a prospective population-based study of adults with traumatic brain injury.

OBJECTIVE: Establish rate of disorders of consciousness (DOC) and course of recovery in adults who have sustained severe traumatic brain injury (sTBI). SETTING: Four Norwegian neurosurgical departments. PARTICIPANTS: Vegetative or minimally conscious patients. DESIGN: Prospective, longitudinal population-based study of adults with sTBI with follow-ups at 3, 12, and 24-36 months postinjury. MAIN MEASURES: Coma Recovery Scale-Revised, Glasgow Coma Scale, Extended Glasgow Outcome Scale, and Disability Rating Scale. RESULTS: Three months postinjury, 2% of the sTBI population remained in a vegetative or minimally conscious state, reduced by the half after 1 year, corresponding to average annual age-adjusted incidence rates of DOC of 0.09 per 100 000 3 months post-sTBI. At 3 and 12 months, the incidence was 0.06 and 0.01 per 100 000 for the vegetative state and 0.03 and 0.04 per 100 000 for the minimally conscious state. Diagnostic categorization was stable between 12 and 24-36 months, although clinically relevant improvements were observed in minimally conscious patients. CONCLUSION: The data suggest that prolonged DOC is rare following sTBI in Norway, contrary to the commonly held belief that improvements in intensive care treatment have resulted in an increased incidence of DOC. Prolonged DOC was associated with severity of injury, subcortical lesions, and diffuse axonal injury.

Physical and mental health, anxiety and depressive symptoms in caregivers of patients in vegetative state and minimally conscious state.

Caregivers of patients in vegetative state and minimally conscious state play a crucial role in the process of taking care and, as previous studies reported, they can suffer of high burden and negative health outcomes. The aim of this national cross-sectional study was to assess whether physical and mental health of caregivers, considering gender differences, is related to the presence of depressive symptoms, anxiety, age and patient's disease duration. Four-hundred and eighteen caregivers, 294 women and 124 men, completed the State Trait Anxiety Inventory-Y, Beck Depression Inventory, second version and Short Form-12. Hierarchical multiple regression analyses were performed to evaluate to which extent depressive and anxiety symptoms predict physical and mental health. Men reported higher levels of mental health state, whereas physical health was not different across gender. High levels of anxiety symptoms were associated to negative mental health outcomes in both genders, whereas depressive symptoms were found to impact on female's mental and physical health only. A comprehensive and cost-effective screening of anxiety and depressive symptoms may help to identify determinants of health worsening in order to plan, when necessary, caregivers' support. KEY PRACTITIONER MESSAGES: Female caregivers of patients in vegetative state and minimally conscious state have poorer levels of mental health, whereas physical health is similar to men's. Anxiety symptoms are related to negative mental health outcomes in both male and female caregivers, whereas depressive symptoms are found to impact on female mental and physical health only. It is essential to consider and assess depressive and anxiety symptoms as they may contribute to caregivers' health worsening. This knowledge can lead to plan more comprehensive and tailored caregivers' supports and a better care for patients.

Neuromodulation of vegetative state through spinal cord stimulation: where are we now and where are we going?

BACKGROUND: Vegetative state (VS) is a complex condition that represents a challenging frontier for medicine and neuroscience research. Nowadays there is no scientifically validated treatment for VS patients, and their chronic long-term assistance is very demanding for healthcare systems worldwide. OBJECTIVES: The present paper is a systematic review of the role of spinal cord stimulation (SCS) as a treatment of patients with VS. METHODS: Published literature on this topic was analyzed systematically. Clinical and epidemiological characteristics of VS, present therapeutic options and social costs of VS were also evaluated. RESULTS: Only 10 papers have been published since 1988, and overall 308 VS patients have been treated with SCS worldwide; 51.6% displayed a clinical improvement and an amelioration of the environmental interaction. These effects are probably mediated by the stimulation of the reticular formation-thalamus-cortex pathway and by cerebral blood flow augmentation induced by SCS. CONCLUSIONS: The experience on this topic is still very limited, and on this basis it is still hard to make any rigorous assessment. However, the most recent experiments represent significant progress in the research on this topic and display SCS as a possible therapeutic tool in the treatment of VS.

Surrogate expectations in severe brain injury.

OBJECTIVE: To understand what influences surrogate decision-makers' expectation that a patient with a disorder of consciousness (DOC; those in a coma, the vegetative state or the minimally conscious state) will recover. SUBJECTS: Forty-one surrogates representing 37 DOC patients completed a survey about their experiences in having a family member with a DOC. METHODS: A quantitative questionnaire assessed surrogate and patient's demographic, medical and psychosocial features that may explain surrogate's expectation of patient recovery. RESULTS: Surrogates who were more relationally enmeshed with the patient thought the patient could communicate better and thought technology would improve treatment of patients with brain injury had greater expectations of recovery. Source of injury and patient's current diagnosis did not explain expectations. CONCLUSION: Relational factors between the patient and the surrogate may explain the surrogate's expectation that the patient will recover more than factors that matter to clinicians such as the source of injury or the patient's diagnosis.

Causes and outcomes of persistent vegetative state in a Chinese versus American referral hospital.

OBJECTIVE: To compare the etiologies and clinical outcomes of patients in a persistent vegetative state (PVS) between a Chinese and US referral hospital. METHODS: A retrospective, observational study at the Peking Union Medical College Hospital, Beijing, China and Johns Hopkins Hospital, Baltimore, USA (2001-2010) was performed. RESULTS: There were 36 cases of PVS diagnosed. In Beijing, there were 19 cases: mean age 57 years, range 3-86, (42 %) female, with 37 % of patients observed to survive more than 1 year (range >1 month to >28 years, median >6 months). Causes of PVS in Beijing were hemorrhagic stroke (n = 4, 21 %), ischemic stroke (n = 2, 11 %), cardiac arrest (n = 5, 26 %, including 4 with attempted cardiopulmonary resuscitation (CPR)), traumatic brain injury (n = 3, 16 %), and one each of mitochondrial encephalomyopathy, acute disseminated encephalomyelitis, Lennox Gastaut Syndrome, and epilepsy with craniopharyngioma (n = 4, 21 %). In Baltimore, there were 17 cases of PVS: mean age 43 years, range 15-83, 59 % female, with 41 % observed to survive more than 1 year (range >1 month to >10 years, median >3 years). Causes of PVS in Baltimore were ischemic stroke (n = 3, 18 %), cardiac arrest (n = 3, 18 %, including one with attempted CPR), traumatic brain injury (n = 3, 18 %), neurodegenerative conditions (n = 2, 12 %), and hypoxic ischemic encephalopathy due to respiratory arrest (n = 3, 18 %), metabolic derangements (n = 2, 12 %), and meningitis (n = 1, 6 %). CONCLUSIONS: There may be a long survival period for patients with PVS, including in China where resource constraints exist for acute neurologic care. Stroke appears to be the most common underlying cause of PVS in Chinese patients, followed closely by cardiac arrest with attempted CPR. There appear to be more varied causes of PVS in the US referral hospital with a predominance of stroke, cardiac arrest, and traumatic brain injury.

Prevalence of the Minimally Conscious State Among Institutionalized Patients in the Netherlands: A Nationwide Study.

BACKGROUND AND OBJECTIVES: The minimally conscious state (MCS) is a prolonged disorder of consciousness (pDoC) and one of the most severe outcomes of acquired brain injury. Prevalence data are scarce. The aim of this study was to establish the nationwide point prevalence of institutionalized patients in MCS in the Netherlands. METHODS: This was a descriptive cross-sectional study in which all 86 Dutch hospitals, all 5 specialized pDoC rehabilitation facilities, and all 274 nursing homes were asked whether they were treating patients with a pDoC on the point prevalence date of September 15, 2021. Each patient's legal representative provided informed consent for their inclusion. Patient level of consciousness was verified using the Coma Recovery Scale-Revised (CRS-R) in a single assessment session performed in the facility of residence by an experienced physician. Data on patient demographics, etiology, level of consciousness, facility of residence, and clinical status were collected from a questionnaire by the treating physician. The prevalence of institutionalized patients in MCS of per 100,000 members of the Dutch population was calculated, based on actual census data. RESULTS: Seventy patients were reported to have a pDoC, of whom 6 were excluded. The level of consciousness was verified for 49 patients while for 15, it could not be verified. Of the patients verified, 38 had a pDoC, of whom 32 were in MCS (mean age 44.8 years, 68.8% male). The prevalence of institutionalized patients in MCS is 0.2-0.3 per 100,000 Dutch inhabitants. Traumatic brain injury was present in 21 of 32 patients (65.6%). Specialized pDoC rehabilitation was received by 17 of 32 patients (53%), with the rest admitted to nursing homes. The most frequent signs of consciousness on the CRS-R were visual pursuit, reproducible movement to command, and automatic motor response. DISCUSSION: This nationwide study revealed a low prevalence of institutionalized patients in MCS in the Netherlands. These findings are now being used to organize pDoC care in this country.

Long-term outcome of patients presenting with acute infectious encephalitis of various causes in France.

BACKGROUND: A prospective study of infectious encephalitis was conducted in France in 2007. In total, 253 patients were enrolled with a proven etiological diagnosis for 52%. The cohort of surviving patients with encephalitis was assessed for sequelae and impairment 3 years after enrollment. METHODS: Patients, their family, and general practitioners (GPs) were interviewed by phone to document persisting symptoms, return to work, and past and current leisure activities, with standardized questionnaires. The IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly) was completed with relatives. The global outcome was determined in all patients with the Glasgow outcome scale. RESULTS: In 2010, 20 patients (10%) were unavailable for follow-up, 2 (1%) were excluded, and 18 (9%) had died since hospital discharge. Data were available for 167 survivors and 9 patients whose death was related to the encephalitis. The outcome was favorable in 108 of 176 patients (61%) (71 with complete resolution), 31 (18%) were mildly impaired, 25 (14%) were severely impaired, and 3 (1%) were in a vegetative state. The most frequent symptoms were difficulty concentrating (42%), behavioral disorders (27%), speech disorders (20%), and memory loss (19%). Fifteen of 63 patients (24%) previously employed were still unable to resume work. Long-term outcome was significantly associated with comorbid conditions, age, level of education, and the causative agent of encephalitis. CONCLUSIONS: Most patients with encephalitis experienced a favorable outcome 3 years after hospital discharge. However, minor to severe disability persists in a high number of cases with consequences for everyday life. Physical and mental impairment should be evaluated in all patients with encephalitis, and neuropsychological rehabilitation implemented whenever needed.

Increased levels of serum MAP-2 at 6-months correlate with improved outcome in survivors of severe traumatic brain injury.

OBJECTIVE: To evaluate microtubule-associated proteins (MAP-2), a dendritic marker of both acute damage and chronic neuronal regeneration after injury, in serum of survivors after severe TBI and examine the association with long-term outcome. METHODS: Serum concentrations of MAP-2 were evaluated in 16 patients with severe TBI (Glasgow Coma Scale score [GCS] ≤ 8) 6 months post-injury and in 16 controls. Physical and cognitive outcomes were assessed, using the Glasgow Outcome Scale Extended (GOSE) and Levels of Cognitive Functioning Scale (LCFS), respectively. RESULTS: Severe TBI patients had significantly higher serum MAP-2 concentrations than normal controls with no history of TBI (p = 0.008) at 6 months post-injury. MAP-2 levels correlated with the GOSE (r = 0.58, p = 0.02) and LCFS (r = 0.65, p = 0.007) at month 6. Significantly lower serum levels of MAP-2 were observed in patients in a vegetative state (VS) compared to non-VS patients (p < 0.05). A trend tracking the level of consciousness was observed. CONCLUSIONS: Severe TBI results in a chronic release of MAP-2 into the peripheral circulation in patients with higher levels of consciousness, suggesting that remodelling of synaptic junctions and neuroplasticity processes occur several months after injury. The data indicate MAP-2 as a potential marker for emergence to higher levels of cognitive function.

[Type 2 diabetes mellitus as a prognostic factor in patients with aneurysm clipping after subarachnoid hemorrhage]. / Diabetes mellitus tipo 2 como factor pronóstico en pacientes con clipaje de aneurisma por hemorragia subaracnoidea.

OBJECTIVE: To evaluate if type 2 diabetes mellitus (DM) constitutes a prognostic factor for death and severe disability in patients with aneurysm clipping after subarachnoid hemorrhage (ASH), in an Intensive Care Unit (ICU). MATERIAL AND METHODS: This is a cohort study in patients who were admitted to the ICU between December-2009 and June-2010; 20 with DM (exposed group) and 40 without DM (non-exposed group). Mortality was quantified during ICU stay. At ICU discharge, severe disability was measured through the Glasgow Outcome Scale (category 2); and Glasgow Coma Scale was used to estimate the difference in consciousness level between ICU arrival and discharge. Descriptive statistics and Kaplan Meier survival curves were performed. RESULTS: Mean age was similar between groups (55.8 +/- 11 and 55.6 +/- 15 years, respectively, p = 0.40). A vegetative state was present in one patient without DM. The Glasgow Coma Scale score at ICU entry was 14.1 +/- 1.4 and at discharge, 12.0 +/- 3.6 in the exposed group (p = 0.01); and 13.9 +/- 2.0 us. 13.5 +/- 2.6, in the non-exposed group, respectively (p = 0.45). There were 3 deaths in patients with DM and 5, in patients without DM (p > 0.05); survival time was 12 (95%CI 7, 16) and 10 days (95%CI 7, 13), respectively. Mean glucose remained higher in patients who died at the ICU (p < 0.001). Hydrocephaly was present in 6 exposed patients and 2, non-exposed (p = 0.007). Additionally, 7 and 5 with and without DM, respectively registered a positive blood culture (p = 0.04). CONCLUSIONS: DM was not associated with higher mortality in ICU patients, but hyperglycemia was; thus, it is essential that the intensive care provider watches closely the glycemic control.