Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series.

Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.

The state of art of awake craniotomy in Latin American countries: a scoping review.

BACKGROUND AND OBJECTIVE: Awake craniotomy (AC) is a valuable technique for surgical interventions in eloquent areas, but its adoption in low- and middle-income countries faces challenges like limited infrastructure, trained personnel shortage, and inadequate funding. This scoping review explores AC techniques in Latin American countries, focusing on patient characteristics, tumor location, symptomatology, and outcomes. METHODS: A scoping review followed PRISMA guidelines, searching five databases in English, Spanish, and Portuguese. We included 28 studies with 258 patients (mean age: 43, range: 11-92). Patterns in AC use in Latin America were analyzed. RESULTS: Most studies were from Brazil and Mexico (53.6%) and public institutions (70%). Low-grade gliomas were the most common lesions (55%), most of them located in the left hemisphere (52.3%) and frontal lobe (52.3%). Gross-total resection was achieved in 34.3% of cases. 62.9% used an Asleep-Awake-Asleep protocol, and 14.8% used Awake-Awake-Awake. The main complication was seizures (14.6%). Mean post-surgery discharge time was 68 h. Challenges included limited training, infrastructure, and instrumentation availability. Strategies discussed involve training in specialized centers, seeking sponsorships, applying for awards, and multidisciplinary collaborations with neuropsychology. CONCLUSION: Improved accessibility to resources, infrastructure, and adequate instrumentation is crucial for wider AC availability in Latin America. Despite disparities, AC implementation with proper training and teamwork yields favorable outcomes in resource-limited centers. Efforts should focus on addressing challenges and promoting equitable access to this valuable surgical technique in the region.

Improvement in neurological outcome and brain hemodynamics after late cranioplasty.

BACKGROUND: Early cranioplasty has been encouraged after decompressive craniectomy (DC), aiming to reduce consequences of atmospheric pressure over the opened skull. However, this practice may not be often available in low-middle-income countries (LMICs). We evaluated clinical improvement, hemodynamic changes in each hemisphere, and the hemodynamic balance between hemispheres after late cranioplasty in a LMIC, as the institution's routine resources allowed. METHODS: Prospective cohort study included patients with bone defects after DC evaluated with perfusion tomography (PCT) and transcranial Doppler (TCD) and performed neurological examinations with prognostic scales (mRS, MMSE, and Barthel Index) before and 6 months after surgery. RESULTS: A final sample of 26 patients was analyzed. Satisfactory improvement of neurological outcome was observed, as well as significant improvement in the mRS (p = 0.005), MMSE (p < 0.001), and Barthel Index (p = 0.002). Outpatient waiting time for cranioplasty was 15.23 (SD 17.66) months. PCT showed a significant decrease in the mean transit time (MTT) and cerebral blood volume (CBV) only on the operated side. Although most previous studies have shown an increase in cerebral blood flow (CBF), we noticed a slight and nonsignificant decrease, despite a significant increase in the middle cerebral artery flow velocity in both hemispheres on TCD. There was a moderate correlation between the MTT and contralateral muscle strength (r = - 0.4; p = 0.034), as well as between TCD and neurological outcomes ipsilateral (MMSE; r = 0.54, p = 0.03) and contralateral (MRS; p = 0.031, r = - 0.48) to the operated side. CONCLUSION: Even 1 year after DC, cranioplasty may improve cerebral perfusion and neurological outcomes and should be encouraged.

Incremental Prognostic Value of Coagulopathy in Addition to the Crash Score in Traumatic Brain Injury Patients.

BACKGROUND/OBJECTIVE: Multivariable prognostic scores play an important role for clinical decision-making, information giving to patients/relatives, benchmarking and guiding clinical trial design. Coagulopathy has been implicated on trauma and critical care outcomes, but few studies have evaluated its role on traumatic brain injury (TBI) outcomes. Our objective was to verify the incremental prognostic value of routine coagulopathy parameters in addition to the CRASH-CT score to predict 14-day mortality in TBI patients. METHODS: This is a prospective cohort of consecutive TBI patients admitted to a tertiary university hospital Trauma intensive care unit (ICU) from March/2012 to January/2015. The prognostic performance of the coagulation parameters platelet count, prothrombin time (international normalized ratio, INR) and activated partial thromboplastin time (aPTT) ratio was assessed through logistic regression adjusted for the original CRASH-CT score. A new model, CRASH-CT-Coag, was created and its calibration (Brier scores and Hosmer-Lemeshow (H-L) test), discrimination [area under the receiver operating characteristic curve (AUC-ROC) and the integrated discrimination improvement (IDI)] and clinical utility (net reclassification index) were compared to the original CRASH-CT score. RESULTS: A total 517 patients were included (median age 39 years, 85.1% male, median admission glasgow coma scale 8, neurosurgery on 44.9%). The 14-day mortality observed and predicted by the original CRASH-CT was 22.8% and 26.2%, respectively. Platelet count < 100,000/mm3, INR > 1.2 and aPTT ratio > 1.2 were present on 11.3%, 65.0% and 27.2%, respectively, (at least one of these was altered on 70.6%). All three variables maintained statistical significance after adjustment for the CRASH-CT score. The CRASH-CT-Coag score outperformed the original score on calibration (brier scores 0.122 ± 0.216 vs 0.132 ± 0.202, mean difference 0.010, 95% CI 0.005-0.019, p = 0.036, respectively) and discrimination (AUC-ROC 0.854 ± 0.020 vs 0.813 ± 0.024, p = 0.014; IDI 5.0%, 95% CI 1.3-11.0%). Both scores showed the satisfactory H-L test results. The net reclassification index favored the new model. Considering the strata of low (< 10%), moderate (10-30%) and high (> 30%) risk of death, the CRASH-CT-Coag model yielded a global net correct reclassification of 22.9% (95% CI 3.8-43.4%). CONCLUSIONS: The addition of early markers of coagulopathy-platelet count, INR and aPTT ratio-to the CRASH-CT score increased its accuracy. Additional studies are required to externally validate this finding and further investigate the coagulopathy role on TBI outcomes.

Safety and costs analysis of early hospital discharge after brain tumour surgery: a pilot study.

BACKGROUND: A daily algorithm for hospital discharge (DAHD) is a key point in the concept of Enhanced Recovery After Surgery (ERAS) protocol. We aimed to evaluate the length of stay (LOS), rate of complications, and hospital costs variances after the introduction of the DAHD compared to the traditional postoperative management of brain tumour patients. METHODS: This is a cohort study with partial retrospective data collection. All consecutive patients who underwent brain tumour resection in 2017 were analysed. Demographics and procedure-related variables, as well as clinical outcomes, LOS and healthcare costs within 30 days after surgery were compared in patients before/pre-implementation and after/post-implementation the DAHD, which included: stable neurological examination; oral feeding without aspiration risk; pain control with oral medications; no intravenous medications. The algorithm was applied every morning and discharge was considered from day 1 after surgery if criteria was fulfilled. The primary outcome (LOS after surgery) analysis was adjusted for the preoperative performance status on a multivariable logistic regression model. RESULTS: A total of 61 patients were studied (pre-implementation 32, post-implementation 29). The baseline demographic characteristics were similar between the groups. After the DAHD implementation, LOS decreased significantly (median 5 versus 3 days; p = 0.001) and the proportion of patients who were discharged on day 1 or 2 after surgery increased (44.8% vs 3.1%; p < 0.001). Major and minor complications rates, readmission rate, and unplanned return to hospital in 30-day follow-up were comparable between the groups. There was a significant reduction in the median costs of hospitalization in DAHD group (US$2135 vs US$2765, p = 0.043), mainly due to a reduction in median ward costs (US$922 vs US$1623, p = 0.009). CONCLUSIONS: Early discharge after brain tumour surgery appears to be safe and inexpensive. The LOS and hospitalization costs were reduced without increasing readmission rate or postoperative complications.

Improved hemodynamic parameters in middle cerebral artery infarction after decompressive craniectomy.

BACKGROUND AND PURPOSE: Decompressive craniectomy (DC) reduces mortality and improves functional outcome in patients with malignant middle cerebral artery infarction. However, little is known regarding the impact of DC on cerebral hemodynamics. Therefore, our goal was to study the hemodynamic changes that may occur in patients with malignant middle cerebral artery infarction after DC and to assess their relationship with outcomes. METHODS: Twenty-seven patients with malignant middle cerebral artery infarction who were treated with DC were studied. The perfusion CT hemodynamic parameters, mean transit time, cerebral blood flow, and cerebral blood volume were evaluated preoperatively and within the first 24 hours after DC. RESULTS: There was a global trend toward improved cerebral hemodynamics after DC. Preoperative and postoperative absolute mean transit times were associated with mortality at 6 months, and the ratio of post- and preoperative cerebral blood flow was significantly higher in patients with favorable outcomes than those with unfavorable outcomes. Patients who underwent surgery 48 hours after stroke, those with midline brain shift>10 mm, and those who were >55 years showed no significant improvement in any perfusion CT parameters. CONCLUSIONS: DC improves cerebral hemodynamics in patients with malignant middle cerebral artery infarction, and the level of improvement is related to outcome. However, some patients did not seem to experience any additional hemodynamic benefit, suggesting that perfusion CT may play a role as a prognostic tool in patients undergoing DC after ischemic stroke.

Monoblock external ventricular drainage system in the treatment of patients with acute hydrocephalus: a pilot study.

BACKGROUND: Infection is a major complication in patients undergoing external ventricular drainage (EVD). Our study aimed to evaluate the incidence of infection in a series with the monoblock EVD system. MATERIAL AND METHODS: 46 patients treated with EVD at our emergency department were analyzed prospectively to research the incidence of infections with a new EVD system. RESULTS: The average rate of infection was 8.7%. When we stratified the patients according to the exclusive use of EVD without craniotomies, we identified a reduction in the overall incidence of ventriculitis from 8.7% to 2.3%. Age, etiology, and the presence of ventricular bleeding were not statistically significant risk factors. CONCLUSIONS: Despite the small sample examined in this study, we believe that the monoblock system is a simple, inexpensive device that reduces accidental disconnection of the system.

Treatment of traumatic acute posterior fossa subdural hematoma: report of four cases with systematic review and management algorithm.

BACKGROUND: Traumatic posterior fossa subdural hematomas (SDHs) are rare lesions. Despite improvements in intensive care and surgical management of traumatic brain injuries over the last decades, the outcome for posterior fossa subdural hematomas remains poor. METHODS: We conduct a retrospective study over a 2-year period of patients sustaining traumatic brain injury and posterior fossa SDH. Additionally, a systematic review of case series published to date was performed. RESULTS: The incidence of posterior fossa SDH was 0,01% (4/326). All patients in this current series had poor prognosis. Three out of four exhibited ischemic/edema lesions in postoperative CT scans leading to fourth ventricle effacement and persistent brainstem compression. Our literature review retrieved 57 patients from only seven case series. Unfavorable outcomes were seen in 63% of patients. CONCLUSIONS: Our data and data from the literature do not provide sufficient evidence to establish an optimal treatment strategy for posterior fossa SDH. However, based on lessons learned with these four cases, together with results from review of the literature, we propose an algorithm for the management of this rare condition.

Evaluation of hematological changes and immune response biomarkers as a prognostic factor in critical patients with COVID-19.

COVID-19 disease has been a challenge for health systems worldwide due to its high transmissibility, morbidity, and mortality. Severe COVID-19 is associated with an imbalance in the immune response, resulting in a cytokine storm and a hyperinflammation state. While hematological parameters correlate with prognosis in COVID patients, their predictive value has not been evaluated specifically among those severely ill. Therefore, we aim to evaluate the role of hematological and immune response biomarkers as a prognostic factor in critically ill patients with COVID-19 admitted to the intensive care unit. From May 2020 to July 2021, a retrospective cohort study was conducted in a reference hospital in Manaus, which belongs to the Brazilian public health system. This study was carried out as single-center research. Clinical and laboratory parameters were analyzed to evaluate the association with mortality. We also evaluated the role of neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein-to-lymphocyte ratio (CLR). We gathered information from medical records, as well as from prescriptions and forms authorizing the use of antimicrobial medications. During the study period, 177 patients were included, with a mean age of 62.58 ± 14.39 years. The overall mortality rate was 61.6%. Age, mechanical ventilation (MV) requirement, leukocytosis, neutrophilia, high c-reactive protein level, NLR, and CLR showed a statistically significant association with mortality in the univariate analysis. In the multivariate logistic regression analysis, only MV (OR 35.687, 95% CI: 11.084-114.898, p< 0.001) and NLR (OR 1.026, 95% CI: 1.003-1.050, p = 0.028) remained statistically associated with the outcome of death (AUC = 0.8096). While the need for mechanical ventilation is a parameter observed throughout the hospital stay, the initial NLR can be a primary risk stratification tool to establish priorities and timely clinical intervention in patients with severe COVID-19 admitted to the ICU.

Non-invasive Intracranial Pressure Waveform Analysis in Chiari Malformation Type 1: A Pilot Trial.

OBJECTIVE: This pilot study aimed to investigate the role of Posterior Fossa Decompression (PFD) on the intracranial pressure (ICP) waveform in patients with Chiari Malformation type 1 (CM1). It also sought to explore the relationship between symptom improvement and ICP waveform behavior. METHODS: This exploratory cohort study evaluated adult patients diagnosed with CM1. The patients underwent PFD using a standard technique at our institution, which involved a 3 × 3 cm posterior craniectomy and excision of the posterior arch of C1. The ICP waveform was measured using an external strain-gauge device connected to a pin attached to the skull. Measurements were collected pre- and post-PFD, and the P2/P1 ratio was calculated pre- and postoperatively. RESULTS: The pilot study comprised 6 participants, 3 men and 3 women, with ages ranging from 39 to 68 years. The primary symptoms were cerebellar ataxia and typical headaches. The study found that most patients who showed clinical improvement, as judged by the Gestalt method, had a postoperative decrease in the P2/P1 ratio. However, 1 patient did not show an improvement in the P2/P1 ratio despite a good clinical outcome. CONCLUSIONS: This study suggests that the P2/P1 ratio may decrease after PFD. However, we highlight the need for further research with a larger sample size to confirm these preliminary results.

New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment.

Background: Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. Methods: This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. Results: There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). Conclusion: Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.

Long-term disability after cerebral ischemic stroke following a Bothrops atrox snakebite in the Brazilian Amazon.

Bothrops atrox envenomations in the Brazilian Amazon are responsible for a number of local and systemic effects. Among these, stroke presents the worst prognosis for the patient since it may evolve into disabilities and/or premature death. This complication is caused by coagulation disorders and generates hemorrhagic and thrombotic conditions. This study presents a case report of a 54-year-old female patient who presented extensive cerebral ischemia after a B. atrox envenomation that occurred in the state of Amazonas, Brazil. The patient was hospitalized for 102 days, which included a stay in the intensive care unit. Clinical and laboratory findings indicated a thrombogenic coagulopathy. On discharge, the patient had no verbal response, partial motor response, and right hemiplegia. The assessment carried out four years after discharge evidenced incapacitation, global aphasia and bilateral lower and upper limbs showed hypotrophy with a global decrease in strength. Ischemic stroke is a possible complication of B. atrox snakebites even after antivenom treatment, with the potential to cause debilitating long-term consequences.

Pathophysiology-Based Management of Secondary Injuries and Insults in TBI.

Traumatic Brain Injury (TBI) remains a leading cause of morbidity and mortality among all ages; despite the advances, understanding pathophysiological responses after TBI is still complex, involving multiple mechanisms. Previous reviews have focused on potential targets; however, the research on potential targets has continuously grown in the last five years, bringing even more alternatives and elucidating previous mechanisms. Knowing the key and updated pathophysiology concepts is vital for adequate management and better outcomes. This article reviews the underlying molecular mechanisms, the latest updates, and future directions for pathophysiology-based TBI management.

Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization.

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

Clinical and pharmacological factors associated with mortality in patients with COVID-19 in a high complexity hospital in Manaus: A retrospective study.

COVID-19 is a contagious infection caused by the SARS-CoV-2 virus, responsible for more than 5 million deaths worldwide, and has been a significant challenge for healthcare systems worldwide. Characterized by multiple manifestations, the most common symptoms are fever, cough, anosmia, ageusia, and myalgia. However, several organs can be affected in more severe cases, causing encephalitis, myocarditis, respiratory distress, hypercoagulable state, pulmonary embolism, and stroke. Despite efforts to identify appropriate clinical protocols for its management, there are still no fully effective therapies to prevent patient death. The objective of this study was to describe the demographic, clinical, and pharmacotherapeutic management characteristics employed in patients hospitalized for diagnosis of COVID-19, in addition to identifying predictive factors for mortality. This is a single-center, retrospective cohort study carried out in a reference hospital belonging to the Brazilian public health system, in Manaus, from March 2020 to July 2021. Data were obtained from analyzing medical records, physical and electronic forms, medical prescriptions, and antimicrobial use authorization forms. During the study period, 530 patients were included, 51.70% male, with a mean age of 58.74 ± 15.91 years. The overall mortality rate was 23.58%. The variables age, number of comorbidities, admission to the ICU, length of stay, oxygen saturation, serum aspartate transaminase, and use of mechanical ventilation showed a positive correlation with the mortality rate. Regarding pharmacological management, 88.49% of patients used corticosteroids, 86.79% used antimicrobials, 94.15% used anticoagulant therapy, and 3.77% used immunotherapy. Interestingly, two specific classes of antibiotics showed a positive correlation with the mortality rate: penicillins and glycopeptides. After multivariate logistic regression analysis, age, number of comorbidities, need for mechanical ventilation, length of hospital stay, and penicillin or glycopeptide antibiotics use were associated with mortality (AUC = 0.958).

Neurosurgical Emergencies in the Amazon: An Epidemiologic Study of Patients Referred by Air Transport for Neurosurgical Evaluation at a Referral Center in Amazonas.

BACKGROUND: Amazonas is the largest state in Brazil, covering an area of 1,559,159.148 km2 and primarily occupied by the Amazon rainforest. Fluvial and aerial transport are the primary means of transportation. Studying the epidemiologic profile of patients transported by neurologic emergencies is essential because there is only 1 referral center hospital serving approximately 4 million inhabitants in Amazonas. METHODS: This work studies the epidemiologic profile of patients referred by air transport for evaluation by the neurosurgery team at a referral center in the Amazon. RESULTS: Of the 68 patients transferred, 50 (75.53%) were men. The study covered 15 municipalities in Amazonas. Of the patients, 67.64% had a traumatic brain injury due to various causes, and 22.05% had had a stroke. Of all patients, 67.65% did not undergo surgery and 43.9% evolved with good evolution and without complications. CONCLUSIONS: Air transportation for neurologic evaluation is essential in Amazonas. However, most patients did not require neurosurgical intervention, indicating that investments in medical infrastructures, such as computed tomography scanners and telemedicine, may optimize health costs.

Qualitative Evaluation of Intracranial Pressure Slopes in Patients Undergoing Brain Death Protocol.

BACKGROUND: Due to the importance of not mistaking when determining the brain death (BD) diagnostic, reliable confirmatory exams should be performed to enhance its security. This study aims to evaluate the intracranial pressure (ICP) pulse morphology behavior in brain-dead patients through a noninvasive monitoring system. METHODS: A pilot case-control study was conducted in adults that met the BD national protocol criteria. Quantitative parameters from the ICP waveforms, such as the P2/P1 ratio, time-to-peak (TTP) and pulse amplitude (AMP) were extracted and analyzed comparing BD patients and health subjects. RESULTS: Fifteen patients were included, and 6172 waveforms were analyzed. ICP waveforms presented substantial differences amidst BD patients when compared to the control group, especially AMP, which had lower values in patients diagnosed with BD (p < 0.0001) and the TTP median (p < 0.00001), but no significance was found for the P2/P1 ratio (p = 0.8). The area under curve for combination of parameters on the BD prediction was 0.77. CONCLUSIONS: In this exploratory study, noninvasive ICP waveforms have shown potential as a screening method in patients with suspected brain death. Future studies should be carried out in a larger population.

Brainstem injury by penetrating head trauma with a knife.

The authors describe a rare case about a traumatic lesion of brain and brain stem with a knife. In this case the patient had good clinical condition, diagnosed with TBI by infectious complications. We have highlighted the unusual diagnosis, proximity of vascular structures, the technique used in the treatment and the good outcome of the injury.

Decompressive craniectomy and cerebral blood flow regulation in head injured patients: a case studied by perfusion CT.

Previous studies have reported increased cerebral blood flow (CBF) velocity after decompressive craniectomy in traumatic brain injury (TBI) patients. A 27-year-old man presented with clinical and tomographic signs of cerebral herniation secondary to TBI. Prior to decompressive craniectomy, hemodynamic study by perfusion computed tomography (CT) indicated diffuse cerebral hyperperfusion. Following surgical decompression, the patient recovered neurologically and perfusion CT disclosed a decrease in the intensity of cerebral perfusion. The patient's blood pressure levels were similar at both pre- and postoperative perfusion CT examinations. This finding provides indirect evidence that decompressive craniectomy may improve mechanisms of CBF regulation in TBI, providing pathophysiological insights in the cerebral hemodynamics of TBI patients. This is the first report analyzing the hemodynamic changes through perfusion CT (PCT) in a patient with decompressive craniotomy due to TBI.

External validation of the Glasgow coma scale-pupils in low- to middle-income country patients with traumatic brain injury: Could "motor score-pupil" have higher prognostic value?

Background: The objective of this study is to validate the admission Glasgow coma scale (GCS) associated with pupil response (GCS-P) to predict traumatic brain injury (TBI) patient's outcomes in a low- to middle-income country and to compare its performance with that of a simplified model combining the better motor response of the GCS and the pupilar response (MS-P). Methods: This is a prospective cohort of patients with TBI in a tertiary trauma reference center in Brazil. Predictive values of the GCS, GCS-P, and MS-P were evaluated and compared for 14 day and in-hospital mortality outcomes and length of hospital stay (LHS). Results: The study enrolled 447 patients. MS-P demonstrated better discriminative ability than GCS to predict mortality (AUC 0.736 × 0.658; P < 0.001) and higher AUC than GCS-P (0.736 × 0.704, respectively; P = 0.073). For hospital mortality, MS-P demonstrated better discrimination than GCS (AUC, 0.750 × 0.682; P < 0.001) and higher AUC than GCS-P (0.750 × 0.714; P = 0.027). Both scores were good predictors of LHS (r2 = 0.084 [GCS-P] × 0.079 [GCS] × 0.072 [MS-P]). Conclusion: The predictive value of the GCS, GCS-P, and MS-P scales was demonstrated, thus contributing to its external validation in low- to middle-income country.