Glasgow coma scale pupil score (GCS-P) and the hospital mortality in severe traumatic brain injury: analysis of 1,066 Brazilian patients.

BACKGROUND: Pupil reactivity and the Glasgow Coma Scale (GCS) score are the most clinically relevant information to predict the survival of traumatic brain injury (TBI) patients. OBJECTIVE: We evaluated the accuracy of the GCS-Pupil score (GCS-P) as a prognostic index to predict hospital mortality in Brazilian patients with severe TBI and compare it with a model combining GCS and pupil response with additional clinical and radiological prognostic factors. METHODS: Data from 1,066 patients with severe TBI from 5 prospective studies were analyzed. We determined the association between hospital mortality and the combination of GCS, pupil reactivity, age, glucose levels, cranial computed tomography (CT), or the GCS-P score by multivariate binary logistic regression. RESULTS: Eighty-five percent (n = 908) of patients were men. The mean age was 35 years old, and the overall hospital mortality was 32.8%. The area under the receiver operating characteristic curve (AUROC) was 0.73 (0.70-0.77) for the model using the GCS-P score and 0.80 (0.77-0.83) for the model including clinical and radiological variables. The GCS-P score showed similar accuracy in predicting the mortality reported for the patients with severe TBI derived from the International Mission for Prognosis and Clinical Trials in TBI (IMPACT) and the Corticosteroid Randomization After Significant Head Injury (CRASH) studies. CONCLUSION: Our results support the external validation of the GCS-P to predict hospital mortality following a severe TBI. The predictive value of the GCS-P for long-term mortality, functional, and neuropsychiatric outcomes in Brazilian patients with mild, moderate, and severe TBI deserves further investigation.

ANTECEDENTES: A reatividade pupilar e o escore da Escala de Coma de Glasgow (ECG) representam as informações clínicas mais relevantes para predizer a sobrevivência de pacientes com traumatismo cranioencefálico (TCE). OBJETIVO: Avaliar a acurácia da ECG com resposta pupilar (ECG-P) como índice prognóstico para predizer mortalidade hospitalar em pacientes brasileiros acometidos por TCE grave e compará-lo com um modelo combinando ECG e resposta pupilar com fatores prognósticos radiológicos. MéTODOS: Foram analisados dados de 1.066 pacientes com TCE grave de 5 estudos prospectivos. Foi determinada a associação entre mortalidade hospitalar e a combinação de ECG, reatividade pupilar, idade, níveis glicêmicos, tomografia computadorizada (TC) de crânio ou o escore ECG-P por regressão logística binária multivariada. RESULTADOS: Oitenta e cinco por cento (n = 908) dos pacientes eram homens. A média de idade foi de 35 anos e a mortalidade hospitalar geral foi de 32,8%. A AUROC (em português, Curva Característica de Operação do Receptor) foi de 0,73 (0,70­0,77) para o modelo utilizando o escore ECG-P e de 0,80 (0,77­0,83) para o modelo incluindo variáveis clínicas e radiológicas. O escore ECG-P mostrou acurácia semelhante na previsão da mortalidade relatada para pacientes com TCE grave derivados dos estudos International Mission for Prognosis and Clinical Trials in TBI (IMPACT, na sigla em inglês) e Corticosteroid Randomization After Significant Head Injury (CRASH, na sigla em inglês). CONCLUSãO: Nossos resultados apoiam a validação externa da ECG-P para prever a mortalidade hospitalar após um TCE grave. O valor preditivo da ECG-P para mortalidade a longo prazo, resultados funcionais e neuropsiquiátricos em pacientes brasileiros com TCE leve, moderado e grave precisam ser investigados.

Glasgow coma scale pupil score (GCS-P) and the hospital mortality in severe traumatic brain injury: analysis of 1,066 Brazilian patients / Escala de coma de Glasgow com resposta pupilar (ECC-P) e mortalidade hospitalar em traumatismo cranioencefálico grave: análise de 1.066 pacientes brasileiros

Abstract Background Pupil reactivity and the Glasgow Coma Scale (CCS) score are the most clinically relevant information to predict the survival of traumatic brain injury (TBI) patients. Objective We evaluated the accuracy of the CCS-Pupil score (CCS-P) as a prognostic index to predict hospital mortality in Brazilian patients with severe TBI and compare it with a model combining CCS and pupil response with additional clinical and radiological prognostic factors. Methods Data from 1,066 patients with severe TBI from 5 prospective studies were analyzed. We determined the association between hospital mortality and the combination of CCS, pupil reactivity, age, glucose levels, cranial computed tomography (CT), or the CCS-P score by multivariate binary logistic regression. Results Eighty-five percent (n = 908) of patients were men. The mean age was 35 years old, and the overall hospital mortality was 32.8%. The area under the receiver operating characteristic curve (AUROC) was 0.73 (0.70-0.77) for the model using the CCS-P score and 0.80 (0.77-0.83) for the model including clinical and radiological variables. The CCS-P score showed similar accuracy in predicting the mortality reported for the patients with severe TBI derived from the International Mission for Prognosis and Clinical Trials in TBI (IMPACT) and the Corticosteroid Randomization After Significant Head Injury (CRASH) studies. Conclusion Our results support the external validation of the CCS-P to predict hospital mortality following a severe TBI. The predictive value of the CCS-P for long-term mortality, functional, and neuropsychiatric outcomes in Brazilian patients with mild, moderate, and severe TBI deserves further investigation.

Resumo Antecedentes A reatividade pupilar e o escore da Escala de Coma de Glasgow (ECC) representam as informações clínicas mais relevantes para predizer a sobrevivência de pacientes com traumatismo cranioencefálico (TCE). Objetivo Avaliar a acurácia da ECC com resposta pupilar (ECC-P) como índice prognóstico para predizer mortalidade hospitalar em pacientes brasileiros acometidos por TCE grave e compará-lo com um modelo combinando ECC e resposta pupilar com fatores prognósticos radiológicos. Métodos Foram analisados dados de 1.066 pacientes com TCE grave de 5 estudos prospectivos. Foi determinada a associação entre mortalidade hospitalar e a combinação de ECC, reatividade pupilar, idade, níveis glicêmicos, tomografia computadorizada (TC) de crânio ou o escore ECC-P por regressão logística binária multivariada. Resultados Oitenta e cinco por cento (n = 908) dos pacientes eram homens. A média de idade foi de 35 anos e a mortalidade hospitalar geral foi de 32,8%. A AUROC (em português, Curva Característica de Operação do Receptor) foi de 0,73 (0,70-0,77) para o modelo utilizando o escore ECC-P e de 0,80 (0,77-0,83) para o modelo incluindo variáveis clínicas e radiológicas. O escore ECC-P mostrou acurácia semelhante na previsão da mortalidade relatada para pacientes com TCE grave derivados dos estudos International Mission for Prognosis and Clinical Trials in TBI (IMPACT, na sigla em inglês) e Corticosteroid Randomization After Significant Head Injury (CRASH, na sigla em inglês). Conclusão Nossos resultados apoiam a validação externa da ECC-P para prever a mortalidade hospitalar após um TCE grave. O valor preditivo da ECC-P para mortalidade a longo prazo, resultados funcionais e neuropsiquiátricos em pacientes brasileiros com TCE leve, moderado e grave precisam ser investigados.

Clinical Utility of Preoperative Bilingual Language fMRI Mapping in Patients with Brain Tumors.

BACKGROUND AND PURPOSE: Previous literature has demonstrated disparity in the postoperative recovery of first and second language function of bilingual neurosurgical patients. However, it is unclear to whether preoperative brain mapping of both languages is needed. In this study, we aimed to evaluate the clinical utility of language task functional MRI (fMRI) implemented in both languages in bilingual patients. METHODS: We retrospectively examined fMRI data of 13 bilingual brain tumor patients (age: 23 to 59 years) who performed antonym generation task-based fMRIs in English and non-English language. The usefulness of bilingual language mapping was evaluated using a structured survey administered to 5 neurosurgeons. Additionally, quantitative comparison between the brain activation maps of both languages was performed. RESULTS: Survey responses revealed differences in raters' surgical approach, including asleep versus awake surgery and extent of resection, after viewing the language fMRI maps. Additional non-English fMRI led to changes in surgical decision-making and bettered localization of language areas. Quantitative analysis revealed an increase in laterality index (LI) in non-English fMRI compared to English fMRI. The Dice coefficient demonstrated fair overlap (.458 ± .160) between the activation maps. CONCLUSION: Bilingual fMRI mapping of bilingual patients allows to better appreciate functionally active language areas that may be neglected in single language mapping. Utility of bilingual mapping was supported by changes in both surgical approach and LI measurements, suggesting its benefit on preoperative language mapping.

Perfil dos pacientes acometidos com Acidente Vascular Cerebral Isquêmico hospitalizados no Hospital Governador Celso Ramos / Descriptive characteristics of patients with Ischemic Stroke hospitalized at Hospital Governador Celso Ramos

Introdução: O Acidente Vascular Encefálico (AVE) éuma das principais causas de morte no mundo e a primeirano Brasil, resultando em milhares de pacientescom sequelas neurológicas, incapazes de manter suasatividades de vida diária normalmente. O presente estudoteve como objetivo identificar e definir o perfilepidemiológico dos pacientes acometidos com AVE,atendidos em hospital terciário de referência em Neurologia.Métodos: Foram incluídos no estudo os pacientesque sofreram AVE isquêmicos e que foram internadosno Hospital Governador Celso Ramos no período de01 de março a 31 de agosto de 2010. Foram coletadasvariáveis clínicas e demográficas, além de escalas específicaspara avaliação da gravidade do AVE. Resultados:Foram avaliados 47 pacientes, com média de idade de66 anos, sendo 53.2% do sexo feminino, e 87.2% caucasianos.Hipertensão arterial sistêmica foi encontradaem 78.7% dos pacientes, dislipidemia em 40.4% e diabetesmellitus em 29.8%. Hemiparesia foi o sintomade apresentação em 89.4% dos pacientes, e o NIHSSde admissão teve média de 12 pontos, reduzindo paramédia de 6 pontos na alta hospitalar. Da amostra estudada,apenas 6 pacientes foram submetidos à trombólise.Conclusão: No presente estudo foi observada maiorincidência de AVE com o avançar da idade, além dapresença de fatores de risco como hipertensão arterialsistêmica e dislipidemia. Atribuímos a baixa incidênciade trombólise pelo tempo ictus-porta ter sido maior de4.5h na maioria dos pacientes.

Background: Stroke is a leading cause of death worldwideand the first in Brazil, resulting in thousands ofpatients with neurological impairment, unable to maintaintheir daily activities normally. This study aimed toidentify and define the epidemiological profile of affectedpatients with ischemic stroke treated at a tertiaryhospital in Neurology. Methods: The study includedpatients who experienced ischemic stroke and were admittedto the Hospital Governador Celso Ramos in theperiod from 01 March to 31 August 2010. We collecteddemographic and clinical variables, and specific scalesfor assessment of stroke severity. Results: We evaluated47 patients with a mean age of 66 years, 53.2%female and 87.2% Caucasian. Hypertension was foundin 78.7% of patients, dyslipidemia in 40.4% and diabetesmellitus in 29.8%. Hemiparesis was the presentingsymptom in 89.4% of patients, and admission NIHSShad a mean of 12 points, falling to mean of 6 pointsat discharge. Out of the sample, only 6 patients underwentthrombolysis. Conclusion: In this study therewas a higher incidence of stroke with advancing age,and the presence of risk factors such as hypertensionand dyslipidemia. We attribute the low incidence ofstroke thrombolysis by time ictus-gate being greaterthan 4.5h in most patients.

Psychiatric disorders and health-related quality of life after severe traumatic brain injury: a prospective study.

Traumatic brain injury (TBI) is a major cause of death and disability and impairs health-related quality of life (HRQOL). Psychiatric disorders have been recognized as major components of TBI morbidity, yet few studies have addressed the relationship between these outcomes. Sample size, selection bias, and retrospective design, are methodological limitations for TBI-related psychiatric studies. For this study, 33 patients with severe TBI were evaluated prospectively regarding demographic, clinical, radiological, neurosurgical, laboratory, and psychosocial characteristics, as well as psychiatric manifestations and HRQOL, 18 months after hospitalization. Psychiatric manifestations were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Hospital Anxiety and Depression Scale (HADS), the Brief Psychiatric Rating Scale (BPRS), and the Apathy Evaluation Scale (AES). HRQOL was determined using the Medical Outcomes Study's 36-item Short-Form Health Survey (SF-36). Following TBI, a significant increase in the prevalence of major depressive disorder (MDD) and generalized anxiety disorder (p=0.02), and a significant decrease in the prevalence of alcohol and cannabinoid abuse (p=0.001) were observed. The most frequent psychiatric disorders following severe TBI were found to be MDD (30.3%), and personality changes (33.3%). In comparison to patients without personality changes, patients with personality changes experienced a decline in general health and impairments in physical and social functioning. Patients with MDD showed impairment in all SF-36 domains compared to non-depressed patients. This prospective TBI-related psychiatric study is the first to demonstrate a significant association between MDD, personality changes, and HRQOL, following severe TBI in a well-defined sample of patients.

Plasma levels of oxidative stress biomarkers and hospital mortality in severe head injury: a multivariate analysis.

INTRODUCTION: The association between biomarkers of oxidative stress and the prognosis of patients with traumatic brain injury (TBI) remains inconclusive. OBJECTIVE: The objective was to investigate the association between plasma levels of lipid peroxidation (thiobarbituric acid reactive species [TBARS]) and protein oxidation (carbonyl) biomarkers and the hospital mortality of patients with severe TBI. METHODS: Plasma levels of TBARS and carbonyl were determined in 79 consecutive patients with severe TBI (Glasgow Coma Scale [GCS] ≤8) at a median of 12 hours (interquartile range [IQ] 25-75, 6.5-19.0), 30 hours (IQ 25-75, 24.7-37.0), and 70 (IQ 25-75, 55.0-78.5) hours after TBI and were compared with age- and sex-matched controls. The association between the TBARS and carbonyl levels and the hospital mortality was analyzed by multiple logistic regression analysis. RESULTS: The mean age of patients was 34.8 years. Eighty-six percent were male. The TBARS and carbonyl levels were significantly higher in patients than in controls. There was a trend (P = .09) for higher plasma levels of TBARS and carbonyl proteins at 12 hours, but not at 30 or 70 hours, after trauma in nonsurvivors than in survivors. These findings were not confirmed after the adjustments by multiple logistic regression analysis. The final model showed a higher adjusted odds ratio for death for patients with admission GCS lower than 5 (odds ratio [OR] = 4.04; 95% confidence interval [CI], 1.33-12.13; P = .01) than those with higher GCS scores. Abnormal pupils were also associated with higher mortality (OR = 3.97; 95% CI, 1.22-12.13; P = .02). There was a nonsignificant trend for association between glucose greater than or equal to 150 mm/dL in the first 12 hours and death than levels between 70 and 149 mg/dL (OR = 2.92; 95% CI, 0.96-9.02; P = .06). CONCLUSIONS: Plasma levels of TBARS and carbonyl increase significantly in the first 70 hours after severe TBI but are not independently associated with the hospital mortality.

Hospital mortality of patients with severe traumatic brain injury is associated with serum PTX3 levels.

BACKGROUND: Traumatic brain injury (TBI) is a worldwide cause of morbidity and mortality. Pentraxin 3 (PTX3) is a humoral component of the innate immune system which has been studied as a marker of inflammatory, infections or cardiovascular pathologies. To investigate the association between serum levels of PTX3 and the hospital mortality of patients with severe TBI. METHODS: The independent association between serum PTX3 levels after severe TBI (Glasgow Coma Scale, GCS ≤ 8) and hospital mortality was analyzed in a prospective study of 83 consecutive patients by a multiple logistic regression analysis. The leukocyte count in the same sample was analyzed as another marker of inflammatory response. RESULTS: The mean age of patients was 35 years and 85% were male. Serum PTX3 levels were determined 18.0 (SD ± 17.0) h after TBI. Patients who died showed a mean serum PTX3 level of 9.95 µg/ml (SD ± 6.42) in comparison to 5.46 µg/ml (SD ± 4.87) of the survivor group (P = 0.007). Elevated serum PTX3 levels remain significantly associated with mortality (P = 0.04) in the subset of patients with isolated TBI (n = 34). There were no differences in the leukocytes count measured in the same blood sample used for PTX3 determination in survivors and non-survivors (P = 0.56). The final multiple logistic regression model including age, pupillary examination, GCS, associated trauma, and PTX3 levels shows that serum levels of PTX3 which were higher than 10 µg/ml were independently associated with the patients mortality (adjusted OR 3.06, CI 95% 1.03-9.15, P = 0.04). CONCLUSIONS: Serum PTX3 levels after severe TBI are independently associated with higher hospital mortality and may be a useful marker of TBI and its prognosis.

Mortality in severe traumatic brain injury: a multivariated analysis of 748 Brazilian patients from Florianópolis City.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of incapacity and mortality worldwide, with most of the burden occurring in low-income and middle-income countries. A number of clinical, demographic, and neurosurgical variables of patients with TBI were associated with their outcome. METHODS: We investigated the mortality of Brazilian patients with severe TBI at the time of discharge, using a multiple logistic regression analysis. Clinical, demographic, radiologic, and neurosurgical variables, and mortality at time of discharge of all consecutive patients (n = 748) with severe TBI (admission Glasgow scale < or = 8) treated in our intensive care unit were analyzed. The variables were collected in a prospective manner between January 1994 and December 2003. RESULTS: Eighty-four percent (n = 631) of the patients were men. The mean age was 34.8 (+/-16.3) years and the mortality was 33.3%. After the multiple logistic regression, the adjusted odds ratio (OR) for death was higher in older (> 60 years) than younger (up to 30 years) patients (OR = 2.51, 95% confidence interval [CI] 1.31-4.79, p = 0.006). The mortality was also associated with sub-arachnoid hemorrhage (OR = 1.86, 95% CI = 1.23-2.81, p = 0.003) on computed tomography (CT) scan; admission Glasgow Scale of 3 or 4 in comparison to 7 or 8 (OR = 3.97, 95% CI = 2.49- 6.31, p < 0.001); bilateral midryasis (OR = 11.52, 95% CI = 5.56-23.87, p < 0.0001), or anisocoria (OR = 2.65, 95% CI = 1.69-4.17, p < 0.0001) in comparison to isocoric pupils. There was a trend for higher mortality in patients with type III injury on the Marshall classification of CT (OR = 3.63, 95% CI = 0.84-15.76, p = 0.08) than in patients with normal CT. Patients without thoracic trauma disclose higher mortality than patients with associated thoracic trauma do (OR = 2.02, 95% CI = 1.19-3.41, p = 0.009). The final model presented disclosed 76.9% of overall correct prediction with the survival and death predicted at 87.6% and 55.6%, respectively. CONCLUSION: Age, CT findings, Glasgow coma scale, pupil examination, and the presence of thoracic trauma at admission were independently associated with mortality at the time of discharge in Brazilian patients with severe TBI.