Validation of chest trauma scoring systems in polytrauma: a retrospective study with 1,038 patients in Korea.

Purpose: Appropriate scoring systems can help classify and treat polytrauma patients. This study aimed to validate chest trauma scoring systems in polytrauma patients. Methods: Data from 1,038 polytrauma patients were analyzed. The primary outcomes were one or more complications: pneumonia, chest complications requiring surgery, and mortality. The Thoracic Trauma Severity Score (TTSS), Chest Trauma Score, Rib Fracture Score, and RibScore were compared using receiver operating characteristic (ROC) analysis in patients with or without head trauma. Results: In total, 1,038 patients were divided into two groups: those with complications (822 patients, 79.2%) and those with no complications (216 patients, 20.8%). Sex and body mass index did not significantly differ between the groups. However, age was higher in the complications group (64.1±17.5 years vs. 54.9±17.6 years, P<0.001). The proportion of head trauma patients was higher (58.3% vs. 24.6%, P<0.001) and the Glasgow Coma Scale score was worse (median [interquartile range], 12 [6.5-15] vs. 15 [14-15]; P<0.001) in the complications group. The number of rib fractures, the degree of rib fracture displacement, and the severity of pulmonary contusions were also higher in the complications group. In the area under the ROC curve analysis, the TTSS showed the highest predictive value for the entire group (0.731), head trauma group (0.715), and no head trauma group (0.730), while RibScore had the poorest performance (0.643, 0.622, and 0.622, respectively). Conclusions: Early injury severity detection and grading are crucial for patients with blunt chest trauma. The chest trauma scoring systems introduced to date, including the TTSS, are not acceptable for clinical use, especially in polytrauma patients with traumatic brain injury. Therefore, further revisions and analyses of chest trauma scoring systems are recommended.

Computed Tomography Optic Nerve Sheath Diameter-to-Eyeball Transverse Diameter Ratio as a Novel Noninvasive Parameter for Prognostication in Traumatic Brain Injury.

Background Traumatic brain injury (TBI) remains a foremost cause of death and disability globally, with elevated intracranial pressure (ICP) being a crucial factor in patient outcomes. While invasive monitoring is the gold standard for assessing ICP, it carries risks and is not always feasible. This study proposes a novel noninvasive parameter using computed tomography (CT) imaging. Aims and objectives The study aims to determine the efficacy of the optic nerve sheath diameter (ONSD)-to-eyeball transverse diameter (ETD) ratio from CT scans in predicting TBI patients' prognosis. The primary objective is to study the ONSD/ETD ratio's efficacy in assessing TBI's severity. The secondary objective is to correlate the ONSD/ETD ratio with the Glasgow Coma Scale (GCS) and Rotterdam computed tomography scoring (RCTS) and assess its clinical benefit. Materials and methods This combined retrospective and prospective analytical study included 308 consecutive patients who underwent CT imaging for TBI at a tertiary care center with a dedicated trauma and neurosurgical unit. We evaluated bilateral ONSD and ETD using axial CT scans. The ONSD/ETD ratio correlated with the GCS, RCTS, and clinical outcomes. Results The cut-off values for elevated ICP were ONSD of >5.17 mm, ETD of <22.2 mm, and ONSD/ETD ratio of >0.21. Variables between GCS (<12 and >12) and the ONSD/ETD ratio (<0.21 and >0.21) were statistically significant (chi-square {χ2} = 18.52, p = 0.000). The ONSD shows a strong positive correlation with RCTS (r = 0.82, p = 0.01), ETD shows a moderate negative correlation with RCTS (r = -0.50), and the ONSD/ETD ratio shows a strong negative correlation with GCS (r = -0.783, p = 0.01). The area under the curve for the ONSD/ETD ratio (0.920) was higher than that for ONSD (0.932) and ETD (0.490). The ONSD/ETD ratio's sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 95.6%, 72.0%, and 100%, respectively, demonstrating that it is an excellent predictor of raised ICP. Conclusion The CT-ONSD/ETD ratio correlates with the severity of TBI as assessed by GCS and RCTS. It could serve as a noninvasive parameter for monitoring ICP and guiding the need for sequential CT in TBI patients, potentially aiding in prognostication and clinical management.

Global traumatic brain injury intracranial pressure: from monitoring to surgical decision.

Traumatic brain injury (TBI) is a significant global public health issue, heavily impacting human health, especially in low-and middle-income areas. Despite numerous guidelines and consensus statements, TBI fatality rates remain high. The pathogenesis of severe TBI is closely linked to rising intracranial pressure (ICP). Elevated intracranial pressure can lead to cerebral herniation, resulting in respiratory and circulatory collapse, and ultimately, death. Managing intracranial pressure (ICP) is crucial in neuro-intensive care. Timely diagnosis and precise treatment of elevated ICP are essential. ICP monitoring provides real-time insights into a patient's condition, offering invaluable guidance for comprehensive management. ICP monitoring and standardization can effectively reduce secondary nerve damage, lowering morbidity and mortality rates. Accurately assessing and using true ICP values to manage TBI patients still depends on doctors' clinical experience. This review discusses: (a) Epidemiological disparities of traumatic brain injuries across countries with different income levels worldwide; (b) The significance and function of ICP monitoring; (c) Current status and challenges of ICP monitoring; (d) The impact of decompressive craniectomy on reducing intracranial pressure; and (e) Management of TBI in diverse income countries. We suggest a thorough evaluation of ICP monitoring, head CT findings, and GCS scores before deciding on decompressive craniectomy. Personalized treatment should be emphasized to assess the need for surgical decompression in TBI patients, offering crucial insights for clinical decision-making.

The Comparative Impact of Liberal Versus Conservative Oxygenation in Critically Ill COVID-19 Patients: A Retrospective Study.

Objectives Whether a higher or lower partial pressure of oxygen (PaO2) could impact outcomes in patients with coronavirus disease 2019 (COVID-19) remains a matter of debate. So, we planned this retrospective analysis to determine if a higher or lower partial pressure of oxygen in blood had any effect on outcomes in COVID-19 patients. Material and method The records of COVID-19 patients from the beginning of 2020 to the end of 2022 were scanned. Patients were sub-grouped into two groups based on the partial pressure of oxygen (PaO2) values on arterial blood gas (ABG), i.e., high PaO2 group, PaO2 value of 80-100 mm Hg, and low PaO2 group, PaO2 value of 60-80 mm Hg for the first 48 hours after the initiation of oxygenation and/or mechanical ventilation. The two groups were compared in terms of partial pressure of oxygen in arterial blood to the fraction of inspiratory oxygen (FiO2) concentration (P/F ratio), Sequential Organ Failure Assessment (SOFA) score at presentation and after 48 hours, and clinical outcomes, including mortality, time of mortality, extubation, acute kidney injury (AKI), and change in Glasgow Coma Scale (GCS). Results SOFA score was significantly higher in the low PaO2 group as compared to the high PaO2 group both at baseline (4.59 {1.79} versus 5.51 {1.15}; p-value: 0.005) and at 48 hours (3.06 {1.39} versus 5.11 {2.13}; p-value: 0.007). However, the change in SOFA score over 48 hours did not achieve statistical significance (-1.000 {0.97} versus 0.53 {2.34}; p-value: 0.257). Out of a total of 37 patients, 21 patients died in the high PaO2 group, while 18 patients died in the low PaO2 group. Conclusion Our study highlights that targeting either low or high arterial oxygen content while considering oxygen therapy for COVID-19 patients did not significantly alter the outcomes.

Neurosurgical intervention in ultra-severe closed traumatic brain injury: Is it worth the effort?

Introduction: A subgroup of severe Traumatic Brain Injury (TBI) patients, known as ultra-severe (us-TBI), is most commonly defined as a post-resuscitation Glasgow Coma Scale (GCS) of 3-5. There is uncertainty on whether these critically injured patients can benefit from neurosurgical intervention. Research question: The available evidence regarding the decision-making and outcome following management of us-TBI patients is critically reviewed. Material and methods: Selected databases (PubMed, Google Scholar, Scopus and Cochrane Library) were searched from 1979 to May 2024 for publications on us-TBI patients, with a focus on treatment strategy, mortality and functional outcomes. Inclusion criteria were adult patients >18 years old with closed head trauma and admission post-resuscitation GCS 3-5. Studies were independently assessed for inclusion by two reviewers, and potential disagreements were solved by consensus. Results: Where such data could be extracted, mortality rate was 27-100%, and favorable outcome was observed in 4-30% of us-TBI patients. While early aggressive neurosurgical management was associated with decreased mortality, a high proportion of patients survived with unfavorable functional status. Discussion and conclusion: With supportive care only, outcome of patients with us-TBI is almost universally poor. Early and aggressive neurosurgical intervention in addition to best medical management can lead to favorable functional outcome in selected cases particularly in younger patients with an initial GCS>3 and traumatic mass lesions. There is insufficient data regarding the effectiveness of neurosurgical management on the outcome of us-TBI patients. and the decision to initiate treatment should be based on an individual basis.

The Glasgow Coma Scale and Full Outline of Unresponsiveness score evaluation to predict patient outcomes with neurological illnesses in intensive care units in West Bank: a prospective cross-sectional study.

BACKGROUND: Determining the clinical neurological state of the patient is essential for making decisions and forecasting results. The Glasgow Coma Scale and the Full Outline of Unresponsiveness (FOUR) Scale are commonly used tools for measuring behavioral consciousness. This study aims to compare scales among patients with neurological disorders in intensive care units (ICUs) in the West Bank. METHODS: A prospective cross-sectional design was employed. All patients admitted to ICUs who met inclusion criteria were involved in this study. Data were collected from from An-Najah National University, Al-Watani, and Rafedia Hospital. Both tools were used to collect data. RESULTS: A total of 84 patients were assessed, 69.0% of the patients were male, and the average length of stay was 6.4 days. The mean score on the Glasgow Coma scale was 11.2 on admission 11.6 after 48 hours, and 12.2 on discharge. The mean FOUR Scale score was 12.2 on admission, 12.4 after 48 hours, and 12.5 at discharge. CONCLUSIONS: This study indicates that both the Glasgow Coma Scale and the FOUR scale are effective in predicting outcomes for neurologically deteriorated critically ill patients. However, the FOUR scale proved to be more reliable when assessing outcomes in ICU patients.

Mild Traumatic Brain Injury by the Glasgow Coma Scale Score and Early CT-Brain Findings in Acute Alcohol Intoxication Patients: A Prospective Observational Study.

Introduction Traumatic brain injuries (TBI) in recent years have proved to be a significant public health problem, with potentially life-changing consequences for the individual and their family. Alcohol consumption is a regular, well-documented problem among persons sustaining TBI due to road traffic accidents and accidental falls. The primary objective of this study was to find out the correlation between the Glasgow Coma Scale (GCS) score and CT brain findings among mild TBI patients under acute alcohol intoxication and determine if early CT-brain is indicated in this group. Methods A prospective observational study was conducted involving 111 alcohol-intoxicated patients with mild head injuries admitted to the surgical wards of Thanjavur Medical College Hospital over a period of three months. The Glasgow Coma Scale was used to assess the patient's neurological status and determine the severity of the brain injury. A semi-structured CT-brain findings chart and a severity of alcohol intoxication objective-based scoring system were developed and validated by experts. Descriptive statistics tools such as frequency, percentage, and mean were used, along with inferential statistics tools like the Chi-squared test, Fisher exact test, and Pearson's correlation coefficient test. Results The study findings showed that the comparison of GCS with early CT-brain was significant at a p-value of 0.012, and a negative correlation (r=-0.253) was found between GCS and CT-brain findings. A comparison of CT-brain findings with the severity of alcohol intoxication was non-significant at a p-value of 0.433. Conclusions Early CT-brain in intoxicated mild TBI patients may have a positive impact on early diagnosis and management, even in centers with limited resources catering to low-income population groups. The results of our short-term study show that early CT-Brain picks up lesions and helps initiate early management while it is up to the attending physician to keep in mind an adverse cost-benefit ratio in overuse of hospital resources and misdiagnosis leading to undertreatment causing long-term sequelae and morbidity before prescribing early CT-brain in this cohort of patients.

Electrolyte Imbalance in Acute Traumatic Brain Injury: Insights from the First 24 h.

BACKGROUND/OBJECTIVES: Electrolyte disturbances are common in patients with traumatic brain injury (TBI), particularly affecting sodium, potassium, chloride, and calcium levels. This study aims to provide insights into these disturbances within the first 24 h post-injury. METHODS: We conducted a cross-sectional analysis of 50 TBI patients, excluding those with conditions affecting electrolyte balance. Electrolyte levels were measured, and correlations with demographic data, trauma mechanisms, imaging findings, and Glasgow Coma Scale (GCS) scores were analyzed. RESULTS: The results indicated that chloride levels inversely correlated with GCS scores (ρ = -0.515; p = 0.002), suggesting that elevated chloride may indicate severe neurological impairment. Potassium levels were significantly associated with subdural hematoma (p = 0.032) and subarachnoid hemorrhage (p = 0.043), highlighting their potential as markers for severe brain injuries. No significant associations were found between sodium or calcium levels and the studied variables. CONCLUSIONS: These findings underscore the importance of early monitoring of chloride and potassium levels in TBI patients to improve management and outcomes. Future research should focus on larger, multi-center studies to validate these findings and develop comprehensive guidelines for managing electrolyte imbalances in TBI patients.

Association Between Admission Systolic Blood Pressure and Outcomes in Patients with Isolated Traumatic Brain Injury: A Cross-National Multicenter Cohort Study.

The optimal prehospital blood pressure in patients following traumatic brain injury (TBI) remains controversial. We aimed to assess the association between the systolic blood pressure (SBP) at emergency department triage and patient outcomes following isolated moderate-to-severe TBI. We conducted a cross-national multicenter retrospective cohort study using the Pan-Asia Trauma Outcomes Study database from January 1, 2016, to November 30, 2018. The enrollees were adult patients with isolated moderate-to-severe TBI defined by the International Classification of Diseases code, a Glasgow Coma Scale (GCS) <13 at triage, and a nonhead Abbreviated Injury Scale ≤3. The studied variables were SBPs at triage categorized into different ranges. The primary outcome was 30-day mortality, and the secondary outcome was poor functional status at hospital discharge defined by the modified Rankin Scale ≥4. Multivariable logistic regression was applied to adjust for confounders including country, sex, age, mechanism of injury, prehospital vascular access, respiratory rate, GCS, oxygen saturation, intubation, Injury Severity Score, head surgery, intensive care unit admission, and length of hospital stay. Subgroup analyses were performed on different severity of TBI. A total of 785 patients (median age, 42 years; male patients 77.5%; mean SBP at triage, 136.3 ± 33.1 mmHg) were included in the primary analysis. The lowest 30-day mortality rate existed in patients with SBP of 100-119 mmHg. Taking it as baseline, the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of SBP <100 mmHg, 120-139 mmHg, 140-159 mmHg, and ≥160 mmHg were 7.05 (2.51-19.78), 3.14 (1.14-8.65), 2.91 (1.04-8.17), and 3.28 (1.14-9.42). As for the secondary outcome, the aORs and 95% CIs were 1.36 (0.68-2.68) of <100 mmHg, 0.99 (0.57-1.70) of 120-139 mmHg, 1.23 (0.67-2.25) of 140-159 mmHg, and 1.52 (0.78-2.95) of ≥160 mmHg. Subgroup analyses revealed trends of the best outcomes in both moderate and severe TBI patients with SBP 100-119 mmHg, whereas statistical significance appeared only in patients with severe TBI. SBP of 110-119 mmHg at triage is associated with the lowest 30-day mortality in patients following isolated moderate-to-severe TBI and possibly related to a better functional outcome.

Mapping Glasgow Coma scale to AVPU scores among adults in the prehospital setting.

OBJECTIVE: To develop a translation between the Glasgow Come Scale and the Alert-Verbal-Pain-Unresponsive (AVPU) scale among adults with out-of-hospital emergencies. METHODS: We performed a retrospective analysis of adults (≥18 years) from the 2022 National Emergency Medical Services (EMS) Information System with a ground scene encounter with a concurrently documented GCS and AVPU assessment. Using a training partition of 2.5 million encounters, we performed a grid search to identify all combinations of mutually exclusive cutpoints which divided the GCS into four segments. We identified the combination with the highest Kappa statistic and reported metrics of performance in this sample in the test partition. RESULTS: We identified 16,321,299 encounters with a concurrent AVPU and GCS. Using the AVPU scale, 93.3 % were classified as Alert; 2.9 % as Verbal; 1.5 % as Pain; and 2.3 % as Unresponsive. Using a grid-based search, optimal cutpoints were identified when using a GCS of 14-15 for Alert, 10-13 for Verbal, 7-9 for Pain, and 3-6 for Unresponsive. Cohen's Kappa was 0.63 in the test partition, indicating substantial agreement. Intraclass F1 score varied across different alertness levels and were 0.97 for "Alert", 0.43 for "Verbal", 0.49 for "Pain", and 0.83 for "Unresponsive". Findings were similar in analyses performed by age group and by the presence or absence of trauma. CONCLUSION: We report an optimal crosswalk between the AVPU and GCS scales. Performance in the Verbal and Pain categories was lower than the Alert and Unresponsive categories. These findings may facilitate clinician handovers between EMS and non-EMS clinicians.

"Biomarkers in severe traumatic brain injury: enhancing prognostic accuracy and therapeutic strategies".

This study examines the emerging role of biomarkers in the prognosis and management of severe traumatic brain injury (sTBI). Key findings highlight the significance of serum RIP-3, STC1, Nrf2, and cerebrospinal fluid galectin-3 and cytokines in predicting disease severity, mortality, and functional outcomes in sTBI patients. Elevated levels of RIP-3 and STC1 were linked to poor prognosis and increased mortality, with RIP-3 associated with necroptosis and inflammation, and STC1 with neuroprotective properties. Nrf2 was found to correlate with oxidative stress and adverse outcomes, while elevated CSF galectin-3 and IL-6 indicated neuroinflammation and neurodegeneration. These biomarkers show promise not only as prognostic tools but also as potential therapeutic targets. The study suggests further validation through multicenter research to enhance clinical applications and improve treatment strategies for sTBI.

Circulating soluble CD163 is associated with reduced Glasgow Coma Scale Score and 1-year all-cause mortality in traumatized patients.

Soluble CD163 (sCD163) is a biomarker of macrophage activation, not previously investigated in the circulation of traumatized patients. A biobank of 398 adult trauma patients was analyzed. Patients with an Injury Severity Score (ISS) >8 served as trauma patients (n = 195) and those with ISS ≤8 as trauma controls (n = 203). Serum samples obtained upon admission, 15h and 72h after were analyzed for sCD163 using an in-house ELISA. Multiple linear regression was used to analyze the association between admission levels of sCD163 with, 1: overall trauma severity (ISS), and 2: severity of injury to specified organs using Abbreviated Injury Score (AIS) and Glasgow Coma Scale (GCS). The association between the peak level of sCD163 with 1-year all-cause mortality was analyzed by logistic regression analysis. Median admission levels of sCD163 were higher in trauma patients than trauma controls [2.32 (IQR 1.73 to 2.86) vs. 1.92 (IQR 1.41 to 2.51) mg/L, p < 0.01]. Worsening GCS score was associated with a 10.3% (95% CI: 17.0 to 3.1, p < 0.01) increase in sCD163. Increasing Head-AIS score was associated with a 5.1% (95% CI: -0.5 to 11.0, p = 0.07) increase in sCD163. The remaining AIS scores and ISS were not consistently associated with sCD163 admission levels. Each mg/L increase in sCD163 peak level had an odds ratio 1.34 (95%CI: 0.98 to 1.83), p = 0.06) after adjustment for age, sex, and GCS. Circulating sCD163 is increased in traumatized patients and associated with worsening GCS. Our findings suggest an association between circulating sCD163 levels with 1-year all-cause mortality.

Outcomes and Practices of Endotracheal Intubation Using the Glasgow Coma Scale in Acute Non-Traumatic Poisoning: A Systematic Review and Meta-Analysis of Proportions.

BACKGROUND: Acute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation. METHODS: A systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses. RESULTS: 39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I2 = 92%, p < 0.01), GCS 9-15 (1.0%, I2 = 0%, p = 0.91), and mixed GCS (11.0%, I2 = 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I2 = 84%, p < 0.01), GCS 9-15 (4.0%, I2 = 78%, p < 0.01), and mixed group (5.0%, I2 = 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I2 = 0%, p = 0.62), GCS 9-15 (1.0%, I2 = 0%, p = 0.99), and mixed group (2.0%, I2 = 68%, p < 0.01). CONCLUSION: The conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.

Comparison and combined use of NEWS2 and GCS scores in predicting mortality in stroke and traumatic brain injury: a multicenter retrospective study.

Objective: This study aims to assess the effectiveness of the National Early Warning Score 2 (NEWS2) versus Glasgow Coma Scale (GCS) in predicting hospital mortality among patients with stroke and traumatic brain injury (TBI). Location: This multicenter study was conducted at two anonymized tertiary care hospitals in distinct climatic regions of China, with a combined annual emergency admission exceeding 10,000 patients. Patients: The study included 2,276 adult emergency admissions diagnosed with stroke (n = 1,088) or TBI (n = 1,188) from January 2021 to December 2023, excluding those with chronic pulmonary disease, severe cardiac conditions, or a history of brain surgery. Measuring and main outcomes: The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were utilized to analyze the predictive accuracy of NEWS2 and GCS for hospital mortality at 24, 48, and 72 h post-admission and at discharge. Results: Out of 2,276 patients (mean age 61.4, 65.6% male), 1855 survived while 421 succumbed. NEWS2 demonstrated superior predictive accuracy (AUC = 0.962) over GCS (AUC = 0.854) for overall hospital mortality. Specifically, NEWS2 outperformed GCS in predicting mortality at 24 h (0.917 vs. 0.843), 48 h (0.893 vs. 0.803), and 72 h (0.902 vs. 0.763). Notably, despite a higher AUC for NEWS2 at predicting 24-h hospital mortality, the sensitivity and specificity of GCS were considerably lower (12 and 31%, respectively) compared to NEWS2 (sensitivity of 95% and specificity of 81%). Subgroup analysis showed NEWS2 outperforming GCS in predicting in-hospital mortality for TBI and stroke patients. For TBI patients (n = 260), NEWS2 had an AUC of 0.960 (95% CI: 0.948-0.973) vs. GCS's AUC of 0.811 (95% CI: 0.781-0.840). For stroke patients (n = 161), NEWS2 had an AUC of 0.930 (95% CI: 0.908-0.952) vs. GCS's AUC of 0.858 (95% CI, 0.823-0.892). NEWS2 showed greater sensitivity in both groups, highlighting its effectiveness in identifying high-risk neurological patients. Conclusion: NEWS2 scores are more precise and effective in predicting hospital mortality in stroke and TBI patients compared to GCS scores, although slightly less so within the first 24 h. Combining NEWS2 with GCS and clinical findings within the initial 24 h is recommended for a comprehensive prognosis evaluation.

Non-motor role of the cerebellum: Cerebellar mutism syndrome in a child with a small hemorrhagic contusion in the dentate nucleus: A case report and literature review.

Key Clinical Message: Our case report highlights that Prompt recognition of cerebellar mutism syndrome (CMS) is critical in clinical practice, as it is often misdiagnosed as just being reduction in the level of consciousness, particularly in pediatrics trauma patients. Abstract: Cerebellar mutism syndrome is defined as transient mutism following posterior fossa surgery, hemorrhage or traumatic insults involving the cerebellum. Cerebellar mutism syndrome (CMS) is now recognized as a form of cerebellar cognitive affective syndrome (CCAS/Schmahmann syndrome). CMS following head injury is exceedingly rare with very few cases reported. Five years old boy with normal developmental milestones and no significant medical history, sustained closed head injury following road traffic accident, the clinical scenario in addition to the radiological findings led to the diagnosis of cerebellar mutism syndrome. CMS is defined as of neurologic and cognitive disorders, mainly speech disorder. Patient non-motor signs recovered in a period of few weeks from the mutism syndrome with remaining mild motor deficit. CMS is a set of neurologic and cognitive disorders, the most distinct of which is speech disorder (usually reversible), what is unique about this case is the selective site of the contusion at the region of the dentate nucleus and superior cerebellar peduncle. Such cases offer a better understanding to the function of the cerebellum and its role in cognition. Additionally, the knowledge of this aspect of cerebellar function helps in better predicting the clinical course of such lesions which in turn helps in communication and explanation to patient's families.

Prognostic Value of Dynamic Segmented Neutrophil to Monocyte (SeMo) Ratio Changes in Patients with Moderate to Severe Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in trauma patients, necessitating reliable prognostic tools. The segmented neutrophil-to-monocyte (SeMo) ratio, indicative of the inflammatory response, has emerged as a valuable biomarker. This study evaluates the prognostic value of dynamic changes in the SeMo ratio in predicting outcomes for patients with moderate to severe TBI. METHODS: A retrospective analysis was conducted on data from 1118 TBI patients admitted to the surgical intensive care unit at a level I trauma center between January 2009 and December 2020. Patients were selected based on an Abbreviated Injury Scale (AIS) score ≥ 3 in the head region. Initial and follow-up SeMo ratios were calculated upon admission and 48-72 h later, respectively. The dynamic SeMo ratio was defined as the difference between the second and initial SeMo ratios. Statistical analyses included receiver operating characteristic (ROC) curve analysis to determine the optimal threshold for mortality prediction, and comparative analysis of clinical outcomes. RESULTS: The study cohort included 121 deceased and 997 surviving patients. Deceased patients had significantly higher second SeMo ratios (20.9 ± 16.1 vs. 15.8 ± 17.2, p = 0.001) and dynamic SeMo ratios (2.4 ± 19.8 vs. -2.1 ± 19.5, p = 0.019) than those survival patients. In the multivariate analysis, the dynamic SeMo is a significant independent risk factor for in-hospital mortality (OR 1.01, 95%CI: 1.01-1.03, p = 0.031). The optimal cut-off for the dynamic SeMo ratio was 5.96, above which patients exhibited higher mortality (21.4% vs. 8.5%, p < 0.001), higher adjusted mortality (adjusted odds ratio: 2.98; 95% confidence interval: 1.95-4.56; p = 0.005), and longer hospital stays (23.6 days vs. 19.7 days, p = 0.005). DISCUSSION: Dynamic SeMo ratio changes serve as a prognostic marker for in-hospital mortality and hospital stay duration in moderate to severe TBI patients. A higher dynamic SeMo ratio indicates increased risk, highlighting the importance of early monitoring and intervention. Future prospective studies should validate these findings and explore integration with other biomarkers for enhanced prognostication.

Pediatric Early Warning Score (PEWS) in predicting prognosis of critical pediatric trauma patients: a retrospective study.

BACKGROUND: This study aimed to compare the predictive value of Pediatric Early Warning Score (PEWS) to Pediatric Risk of Mortality-3 (PRISM-3), Pediatric Trauma Score (PTS), and Pediatric Glasgow Coma Score (pGCS) in determining clinical severity and mortality among critical pediatric trauma patients. METHOD: A total of 122 patients monitored due to trauma in the pediatric intensive care unit between 2020 and 2023 were included in the study. Physical examination findings, vital parameters, laboratory values, and all scoring calculations for patients during emergency room admissions and on the first day of intensive care follow-up were recorded. Comparisons were made between two groups identified as survivors and non-survivors. RESULTS: The study included 85 (69.7%) male and 37 (30.3%) female patients, with an average age of 75 ± 59 months for all patients. Forty-one patients (33.6%) required Invasive Mechanical Ventilation (IMV) and 11 patients (9%) required inotropic therapy. Logistic regression analysis revealed a significant association between mortality and PEWS (p < 0.001), PRISM-3 (p < 0.001), PTS (p < 0.001), and pGCS (p < 0.001). Receiver operating characteristics curve analysis demonstrated that the PEWS score (cutoff > 6.5, AUC = 0.953, 95% CI 0.912-0.994) was highly predictive of mortality, showing similar performance to the PRISM-3 score (cutoff > 21, AUC = 0.999, 95% CI 0.995-1). Additionally, the PEWS score was found to be highly predictive in forecasting the need for IMV and inotropic therapy. CONCLUSION: The Pediatric Early Warning Score serves as a robust determinant of mortality in critical pediatric trauma patients. Simultaneously, it demonstrates strong predictability in anticipating the need for IMV and inotropic therapy.

A Nomogram to Predict Intracranial Hypertension in Moderate Traumatic Brain Injury Patients.

OBJECTIVE: Patients with moderate traumatic brain injury (mTBI) are under the threat of intracranial hypertension (IHT). However, it is unclear which mTBI patient will develop IHT and should receive intracranial pressure (ICP)-lowering treatment or invasive ICP monitoring after admission. The purpose of the present study was to develop and validate a prediction model that estimates the risk of IHT in mTBI patients. METHODS: Baseline data collected on admission of 296 mTBI patients with Glasgow Coma Scale (GCS) score of 9-11 was collected and analyzed. Multivariable logistic regression modeling with backward stepwise elimination was used to develop a prediction model for IHT. The discrimination efficacy, calibration efficacy, and clinical utility of the prediction model were evaluated. Finally, the prediction model was validated in a separate cohort of 122 patients from 3 hospitals. RESULTS: Four independent prognostic factors for IHT were identified: GCS score, Marshall head computed tomography score, injury severity score, and location of contusion. The C-statistic of the prediction model in internal validation was 84.30% (95% CI: 0.794-0.892). The area under the curve for the prediction model in external validation was 82.80% (95% CI: 0.747-0.909). CONCLUSIONS: A prediction model based on baseline parameters was found to be highly sensitive in distinguishing mTBI patients with GCS score of 9-11 who would suffer IHT. The high discriminative ability of the prediction model supports its use in identifying mTBI patients with GCS score of 9-11 who need ICP-lowering therapy or invasive ICP monitoring.

Performance of the neutrophil-lymphocyte ratio as a predictor of severity and mortality in children and adolescents with traumatic brain injury.

PURPOSE: An inflammatory cascade associated with the systemic neutrophil response can be triggered after traumatic brain injury (TBI), causing neuronal dysfunction, which is considered to be related to the prognosis of the victims. The scope of this research is to identify the performance of the neutrophil-lymphocyte ratio (NLR) as a predictor of prognosis considering TBI severity and death as outcomes in a group of pediatric patients. METHODS: We retrospectively evaluated NLR through a consecutive review of the medical records (cross-sectional study) of children and adolescents aged < 17 years victims of TBI. To determine the highest NLR value identified as a predictor, different cutoff points were tested for each outcome. The cutoff points were defined based on the area under curve (AUC) of the receiver operating characteristic (ROC). RESULTS: Among the 82 children with TBI included in the sample, the performance of AUC-ROC was 0.72 when evaluating NLR as a predictor of TBI severity, with NLR cutoff point of 3, and 0.76 when considering mortality as the outcome, with an increase in the cutoff point to 11. CONCLUSION: NLR can be considered a biomarker of brain injury in children and adolescent victims of TBI. Patients with NLR ≥ 3 had a fivefold higher probability of severe TBI and patients with NLR ≥ 11 experienced a ninefold higher risk of death.