Predicting outcome after aneurysmal subarachnoid hemorrhage by exploitation of signal complexity: a prospective two-center cohort study.

BACKGROUND: Signal complexity (i.e. entropy) describes the level of order within a system. Low physiological signal complexity predicts unfavorable outcome in a variety of diseases and is assumed to reflect increased rigidity of the cardio/cerebrovascular system leading to (or reflecting) autoregulation failure. Aneurysmal subarachnoid hemorrhage (aSAH) is followed by a cascade of complex systemic and cerebral sequelae. In aSAH, the value of entropy has not been established yet. METHODS: aSAH patients from 2 prospective cohorts (Zurich-derivation cohort, Aachen-validation cohort) were included. Multiscale Entropy (MSE) was estimated for arterial blood pressure, intracranial pressure, heart rate, and their derivatives, and compared to dichotomized (1-4 vs. 5-8) or ordinal outcome (GOSE-extended Glasgow Outcome Scale) at 12 months using uni- and multivariable (adjusted for age, World Federation of Neurological Surgeons grade, modified Fisher (mFisher) grade, delayed cerebral infarction), and ordinal methods (proportional odds logistic regression/sliding dichotomy). The multivariable logistic regression models were validated internally using bootstrapping and externally by assessing the calibration and discrimination. RESULTS: A total of 330 (derivation: 241, validation: 89) aSAH patients were analyzed. Decreasing MSE was associated with a higher likelihood of unfavorable outcome independent of covariates and analysis method. The multivariable adjusted logistic regression models were well calibrated and only showed a slight decrease in discrimination when assessed in the validation cohort. The ordinal analysis revealed its effect to be linear. MSE remained valid when adjusting the outcome definition against the initial severity. CONCLUSIONS: MSE metrics and thereby complexity of physiological signals are independent, internally and externally valid predictors of 12-month outcome. Incorporating high-frequency physiological data as part of clinical outcome prediction may enable precise, individualized outcome prediction. The results of this study warrant further investigation into the cause of the resulting complexity as well as its association to important and potentially preventable complications including vasospasm and delayed cerebral ischemia.

Day-to-Day Change in Pulsatility Index Describes Anterior Cerebral Circulation Disturbance and Functional Outcomes in Pediatric Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is a significant source of morbidity and mortality in children. Transcranial Doppler (TCD) ultrasound measures the cerebral arterial circulation allowing for the calculation of pulsatility indices (PIs) that provide an assessment of cerebral blood flow alterations. However, the use of PI in children with TBI is poorly understood and may be an important measure for the nursing care of children. OBJECTIVES: The purpose of this article is to define day-to-day PI change and to describe its relationship to injury characteristics and functional outcomes in children with TBI. METHOD: We performed a secondary analysis of a prospective observational parent study of 40 children aged 2 months to 15 years with mild or moderate-severe TBI who had serial TCDs. Sequential TCD PI measurements of day-to-day change revealed several consistencies among the TBI severity groups. RESULTS: Day-to-day PI change was higher in children with a moderate-severe injury (40%) when compared with those with a mild injury (21%). Greater day-to-day PI change was seen in children whose Glasgow Outcome Scale-Extended Pediatrics scores worsened (25%) compared with those who had an improved (19%) or unchanged (23%) scores. DISCUSSION: This study is the first to report day-to-day PI change in children with TBI and provides early insights into anterior cerebral artery circulation alterations of children with TBI. Although further research is needed, this study provides early evidence that TCD may be a valuable noninvasive neuromonitoring option in the management of children with TBI.

Association of systemic secondary brain insults and outcome in patients with convulsive status epilepticus: A post hoc study of a randomized controlled trial.

OBJECTIVE: To evaluate the association between systemic factors (mean arterial blood pressure, arterial partial pressures of carbon dioxide and oxygen, body temperature, natremia, and glycemia) on day 1 and neurologic outcomes 90 days after convulsive status epilepticus. METHODS: This was a post hoc analysis of the Evaluation of Therapeutic Hypothermia in Convulsive Status Epilepticus in Adults in Intensive Care (HYBERNATUS) multicenter open-label controlled trial, which randomized 270 critically ill patients with convulsive status epilepticus requiring mechanical ventilation to therapeutic hypothermia (32°C-34°C for 24 hours) plus standard care or standard care alone between March 2011 and January 2015. The primary endpoint was a Glasgow Outcome Scale score of 5, defining a favorable outcome, 90 days after convulsive status epilepticus. RESULTS: The 172 men and 93 women had a median age of 57 years (45-68 years). Among them, 130 (49%) had a history of epilepsy, and 59 (29%) had a primary brain insult. Convulsive status epilepticus was refractory in 86 (32%) patients, and total seizure duration was 67 minutes (35-120 minutes). The 90-day outcome was unfavorable in 126 (48%) patients. In multivariate analysis, none of the systemic secondary brain insults were associated with outcome; achieving an unfavorable outcome was associated with age >65 years (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.20-3.85; p = 0.01), refractory convulsive status epilepticus (OR 2.00, 95% CI 1.04-3.85; p = 0.04), primary brain insult (OR 2.00, 95% CI 1.02-4.00; p = 0.047), and no bystander-witnessed seizure onset (OR 2.49, 95% CI 1.05-5.59; p = 0.04). CONCLUSIONS: In our population, systemic secondary brain insults were not associated with outcome in critically ill patients with convulsive status epilepticus. CLINICALTRIALSGOV IDENTIFIER: NCT01359332.

A high Glasgow prognostic score (GPS) or modified Glasgow prognostic score (mGPS) predicts poor prognosis in gynecologic cancers: a systematic review and meta-analysis.

PURPOSE: The Glasgow Prognostic Score or modified Glasgow Prognostic Score (GPS/mGPS), a novel inflammatory indicator, which acts as a prognostic predictor in various cancers. However, these results are still controversial. In this meta-analysis, we aimed to investigate the prognostic role of GPS/mGPS in patients with gynecologic cancers. METHODS: We explored eligible studies by searching the databases PubMed, the Cochrane Library, EMBASE, and Web of Science. The hazard ratio (HR) and odds ratios (OR) with 95% confidence intervals (CIs) were extracted to investigate the correlation between GPS/mGPS and overall survival (OS) and progression-free survival (PFS). Additionally, we performed subgroup analyses to detect the potential heterogeneity in our study. RESULTS: 11 studies involving 2830 patients were enrolled in this meta-analysis. The results revealed that a high GPS was significantly related to a shorter OS (pooled HR = 1.94; 95% CI = 1.54-2.43; P < 0.001) and PFS (pooled HR = 1.92; 95% CI = 1.56-2.35; P < 0.001) in patients with gynecologic cancers. Moreover, mGPS also predicted poor OS (pooled HR = 1.67; 95% CI = 1.41-1.96; P < 0.001) and PFS (pooled HR = 1.73; 95% CI = 1.47-2.04; P < 0.001) in gynecologic cancers patients. CONCLUSION: A higher GPS/mGPS is correlated with poor survival outcomes in patients with gynecologic cancers. Pretreatment GPS/mGPS is a valid prognostic predictor in gynecologic cancers.

Impact of a posttraumatic cerebral infarction on outcome in patients with TBI: the Italian multicenter cohort INCEPT study.

BACKGROUND: Post-traumatic cerebral infarction (PTCI) is common after traumatic brain injury (TBI). It is unclear what the occurrence of a PTCI is, how it impacts the long-term outcome, and whether it adds incremental prognostic value to established outcome predictors. METHODS: This was a prospective multicenter cohort study of moderate and severe TBI patients. The primary objective was to evaluate if PTCI was an independent risk factor for the 6-month outcome assessed with the Glasgow Outcome Scale (GOS). We also assessed the PTCI occurrence and if it adds incremental value to the International Mission for Prognosis and Clinical Trial design in TBI (IMPACT) core and extended models. RESULTS: We enrolled 143 patients, of whom 47 (32.9%) developed a PTCI. In the multiple ordered logistic regression, PTCI was retained in both the core and extended IMPACT models as an independent predictor of the GOS. The predictive performances increased significantly when PTCI was added to the IMPACT core model (AUC = 0.73, 95% C.I. 0.66-0.82; increased to AUC = 0.79, 95% CI 0.71-0.83, p = 0.0007) and extended model (AUC = 0.74, 95% C.I. 0.65-0.81 increased to AUC = 0.80, 95% C.I. 0.69-0.85; p = 0.00008). Patients with PTCI showed higher ICU mortality and 6-month mortality, whereas hospital mortality did not differ between the two groups. CONCLUSIONS: PTCI is a common complication in patients suffering from a moderate or severe TBI and is an independent risk factor for long-term disability. The addition of PTCI to the IMPACT core and extended predictive models significantly increased their performance in predicting the GOS. TRIAL REGISTRATION: The present study was registered in ClinicalTrial.gov with the ID number NCT02430324.

Comparison of revised Functional Capacity Index scores with Abbreviated Injury Scale 2008 scores in predicting 12-month severe trauma outcomes.

INTRODUCTION: Anatomical injury as measured by the AIS often accounts for only a small proportion of variability in outcomes after injury. The predictive Functional Capacity Index (FCI) appended to the 2008 AIS claims to provide a widely available method of predicting 12-month function following injury. OBJECTIVES: To determine the extent to which AIS-based and FCI-based scoring is able to add to a simple predictive model of 12-month function following severe injury. METHODS: Adult trauma patients were drawn from the population-based Victorian State Trauma Registry. Major trauma and severely injured orthopaedic trauma patients were followed up via telephone interview including Glasgow Outcome Scale-Extended, the EQ-5D-3L and return to work status. A battery of AIS-based and FCI-based scores, and a simple count of AIS-coded injuries were added in turn to a base model using age and gender. RESULTS: A total of 20 813 patients survived to 12 months and had at least one functional outcome recorded, representing 85% follow-up. Predictions using the base model varied substantially across outcome measures. Irrespective of the method used to classify the severity of injury, adding injury severity to the model significantly, but only slightly improved model fit. Across the outcomes evaluated, no method of injury severity assessment consistently outperformed any other. CONCLUSIONS: Anatomical injury is a predictor of trauma outcome. However, injury severity as described by the FCI does not consistently improve discrimination, or even provide the best discrimination compared with AIS-based severity scores or a simple injury count.

Predicting outcome in patients with moderate to severe traumatic brain injury using electroencephalography.

BACKGROUND: Better outcome prediction could assist in reliable quantification and classification of traumatic brain injury (TBI) severity to support clinical decision-making. We developed a multifactorial model combining quantitative electroencephalography (qEEG) measurements and clinically relevant parameters as proof of concept for outcome prediction of patients with moderate to severe TBI. METHODS: Continuous EEG measurements were performed during the first 7 days of ICU admission. Patient outcome at 12 months was dichotomized based on the Extended Glasgow Outcome Score (GOSE) as poor (GOSE 1-2) or good (GOSE 3-8). Twenty-three qEEG features were extracted. Prediction models were created using a Random Forest classifier based on qEEG features, age, and mean arterial blood pressure (MAP) at 24, 48, 72, and 96 h after TBI and combinations of two time intervals. After optimization of the models, we added parameters from the International Mission for Prognosis And Clinical Trial Design (IMPACT) predictor, existing of clinical, CT, and laboratory parameters at admission. Furthermore, we compared our best models to the online IMPACT predictor. RESULTS: Fifty-seven patients with moderate to severe TBI were included and divided into a training set (n = 38) and a validation set (n = 19). Our best model included eight qEEG parameters and MAP at 72 and 96 h after TBI, age, and nine other IMPACT parameters. This model had high predictive ability for poor outcome on both the training set using leave-one-out (area under the receiver operating characteristic curve (AUC) = 0.94, specificity 100%, sensitivity 75%) and validation set (AUC = 0.81, specificity 75%, sensitivity 100%). The IMPACT predictor independently predicted both groups with an AUC of 0.74 (specificity 81%, sensitivity 65%) and 0.84 (sensitivity 88%, specificity 73%), respectively. CONCLUSIONS: Our study shows the potential of multifactorial Random Forest models using qEEG parameters to predict outcome in patients with moderate to severe TBI.

The Inflammation-Based Glasgow Prognostic Score as a Prognostic Factor in Patients with Intensive Cardiovascular Care Unit.

Background: The Glasgow prognostic score (GPS), which is obtained from a combination of C-reactive protein (CRP) and serum albumin level, predicts poor prognoses in many cancer types. Systemic inflammation also plays an important role in pathogenesis of cardiovascular diseases. In this study, we aimed to investigate the effect of inflammation-based GPS on in-hospital and long-term outcomes in patients hospitalized in intensive cardiovascular care unit (ICCU). Methods: A total of 1004 consecutive patients admitted to ICCU were included in the study, and patients were divided into three groups based on albumin and CRP values as GPS 0, 1, and 2. Patients' demographic, clinic, and laboratory findings were recorded. In-hospital and one-year mortality rates were compared between groups. Results: Mortality occurred in 109 (10.8%) patients in in-hospital period, 82 (8.1%) patients during follow-up period, and thus, cumulative mortality occurred in 191 (19.0%) patients. Patients with a high GPS score had a higher rate of comorbidities and represented increased inflammatory evidence. In the multivariate regression model there was independent association with in-hospital mortality in GPS 1 patients compared to GPS 0 patients (Odds ratio, (OR); 5.52, 95% CI: 1.2⁻16.91, p = 0.025) and in GPS 2 patients compared to GPS 0 patients (OR; 7.01, 95% CI: 1.39⁻35.15, p = 0.018). A higher GPS score was also associated with a prolonged ICCU and hospital stay, and increased re-hospitalization in the follow-up period. Conclusion: Inflammation based GPS is a practical tool in the prediction of worse prognosis both in in-hospital and one-year follow-up periods in ICCU patients.

Functional Outcomes 6 Months After Severe Traumatic Brain Injury Following Admission Into Intensive Care Unit: A Cohort Study in Two Tertiary Hospitals.

Severe traumatic brain injury (TBI) survivors show physical and functional improvements but continue to have cognitive and psychosocial problems throughout recovery. However, the functional outcome of severe TBI in Malaysia is unknown. The objective of this study is to measure the functional outcomes of severe TBI within 6 months post-injury. A cohort study was done on 33 severe TBI survivors. The Glasgow Outcome Scale-Extended (GOSE) was used in this study. The mean age of the participants was 31.79 years (range: 16-73 years). The logistic regression model was statistically significant, χ²(5, N = 33) = 29.09, p < .001. The length of stay (LOS) in incentive care unit (p = .049, odds ratio = 6.062) and duration on ventilator (p = .048, odds ratio = 0.083) were good predictors of the functional outcomes. Future research should focus on larger sample size of severe TBI in Malaysia.

Predictors of Change in Functional Outcome at six months and twelve months after Severe Injury: A Retrospective Cohort Study.

Background: There is increasing focus on long-term survival, function and quality-of-life for trauma patients. There are few studies tracking longitudinal changes in functional outcome over time. The goal of our study was to compare the Glasgow Outcome Scale-Extended (GOSE) at 6 months and 12 months in blunt trauma survivors with an Injury Severity Score (ISS) of more than 15. Methods: Using the Singapore National Trauma Registry 2011-2013, patients with 6-month GOSE and 12-month GOSE scores were analysed. Patients were grouped into three categories-those with the same score at 6 months and 12 months, an improvement in score, and a worse score at 12 months. Ordinal regression was used to identify risk factors for improved score. Patients with missing scores at either 6 months or 12 months were excluded. Results: We identified 478 patients: 174 had an improvement in score, 233 stayed the same, and 71 had worse scores at 12 months compared to 6 months. On univariate ordinal regression, the following variables were associated with same or better function at 12-months compared to 6-months: male gender, being employed pre-injury, thoracic Abbreviated Injury Scale (AIS) of 3 or more, anatomical polytrauma (AIS of 3 or more in 2 or more body regions), and road traffic injury mechanism. Older age, low fall, increasing Charlson comorbidity scores, new injury severity score, and head and neck AIS of 3 or more were associated with worse function at 12 months compared to 6 months. ISS and revised trauma score were not significant predictors on univariate or multivariable analysis.On multivariable ordinal regression, motor vehicle mechanism (OR 2.78, 1.51-5.12, p = 0.001) was associated with improved function, while male gender (OR 1.36, 95% CI 1.02-1.82, p = 0.039) predicted improved function at 12 months. Conclusions: Females experience worse functional outcomes at 12 months, potentially due to majority of female injuries being low falls in the elderly. In contrast, motor vehicle injury patients had better functional outcomes at 12 months. Additional interventional strategies for high-risk groups should be explored.

Diagnostic value of serum glial fibrillary acidic protein and S100B serum levels in emergency medicine patients with traumatic versus nontraumatic intracerebral hemorrhage.

BACKGROUND: Glial fibrillary acidic protein (GFAP) is a brain-specific astroglial protein that is released into the blood soon after traumatic brain injury by mature astrocytes. S100B is rapidly released into the cerebrospinal fluid and bloodstream after brain damage. We compared the serum concentrations of these proteins in patients with severe head trauma (bleeding and/or fracture) or nontraumatic intracerebral hemorrhage and healthy individuals. MATERIALS AND METHODS: The study included 63 patients (33 males and 30 females) with traumatic cerebral hemorrhage and/or cranial bone fractures or nontraumatic cerebral hemorrhage and 30 healthy control subjects. The reasons for attending the emergency department were as follows: fall from a height (n = 32), traffic accident (n = 18), nontraumatic intracerebral hemorrhage (n = 6), animal kick to the head (n = 4), and blow to the head (n = 3). RESULTS: Of the 63 patients included in the study, 33 (52.4%) were male and 30 (47.6%) were female. Of the 30 healthy controls, 12 (40%) were male and 18 (60%) were female. The average age of the patients was 27 years (range, 1 month to 86 years) and the average age of the control group was 21 years (range, 18-30 years). The mean serum GFAP concentrations were 86.37 ng/mL in the patients and 38.07 ng/mL in the controls (P < 0.05). The mean serum S100B concentrations were 428.37 pg/mL in the patients and 103.44 pg/mL in the controls (P < 0.05). Eight (12.7%) patients died in the hospital; of those, the mean GCS score was 4.6, and the mean GFAP and S100B levels were 127.8 ng/mL and 860.6 pg/mL, respectively. CONCLUSION: The GFAP and S100B concentrations were significantly higher in patients with traumatic or nontraumatic brain injury than in healthy individuals, indicating that serum levels of these biomarkers may provide an alternative to computed tomography for the diagnosis of brain injury.

Temporal changes in outcome following intensive care unit treatment after traumatic brain injury: a 17-year experience in a large academic neurosurgical centre.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of morbidity and mortality. However, it remains undetermined whether long-term outcomes after TBI have improved over the past two decades. METHODS: We conducted a retrospective analysis of consecutive TBI patients admitted to an academic neurosurgical ICU during 1999-2015. Primary outcomes of interest were 6-month all-cause mortality (available for all patients) and 6-month Glasgow Outcome Scale (GOS, available from 2005 onwards). GOS was dichotomized to favourable and unfavourable functional outcome. Temporal changes in outcome were assessed using multivariate logistic regression analysis, adjusting for age, sex, GCS motor score, pupillary light responsiveness, Marshall CT classification and major extracranial injury. RESULTS: Altogether, 3193 patients were included. During the study period, patient age and admission Glasgow Coma Scale score increased, while the overall TBI severity did not change. Overall unadjusted 6-month mortality was 25% and overall unadjusted unfavourable outcome (2005-2015) was 44%. There was no reduction in the adjusted odds of 6-month mortality (OR 0.98; 95% CI 0.96-1.00), but the adjusted odds of favourable functional outcome significantly increased (OR 1.08; 95% CI 1.04-1.11). Subgroup analysis showed outcome improvements only in specific subgroups (conservatively treated patients, moderate-to-severe TBI patients, middle-aged patients). CONCLUSIONS: During the past two decades, mortality after significant TBI has remained largely unchanged, but the odds of favourable functional outcome have increased significantly in specific subgroups, implying an improvement in quality of care. These developments have been paralleled by notable changes in patient characteristics, emphasizing the importance of continuous epidemiological monitoring.

Neurocritical Patient Characteristics Related to Brain Death.

BACKGROUND: The lack of viable organs for transplantation led to the creation in Argentina of the Glasgow 7 Program based on the detection and follow-up of acute neurologic patients admitted with Glasgow scores ≤7 in selected hospitals. The objective of this study was to determine the likelihood of hospitalized acute neurologic patients progressing to brain death (BD) based on several variables, including age, sex, and admission diagnosis. METHODS: This study was a retrospective cohort analysis of data obtained from the SINTRA (Procurement and Transplantation National Information System) database between 2006 and 2015. Independent variables included the following: age, sex, and diagnosis at admission; ischemic stroke; spontaneous intracerebral hematoma (SIH); subarachnoid hemorrhage (SH); anoxia, meningitis; penetrating head injury (PHI); closed head injury; and tumors. A multivariate analysis was performed adjusting the diagnosis at admission according to age and sex. RESULTS: A total of 31,877 patients were included: 19,308 (61%) patients died and 9736 (30%) evolved to BD. Overall, 36% of women and 28% of men evolved to BD (relative risk, 0.87 [95% confidence interval (CI), 0.86-0.89]; P < .001). In the multivariate analysis adjusted for age and sex, we observed the following: SIH OR, 1.79 (95% CI, 1.69-1.9; P < .001); ischemic stroke OR, 0.82 (95% CI, 0.73-0.92; P < .001); SH OR, 2.33 (95% CI, 2.16-2.52; P < .001); anoxia OR, 0.71 (95% CI, 0.64-0.79; P < .001); closed head injury OR, 0.41 (95% CI, 0.38-0.43; P < .001); PHI OR, 2.64 (95% CI, 2.38-2.94; P < .001); and tumors OR, 1.07 (95% CI, 0.93-1.24; P = .31). CONCLUSIONS: Thirty percent of the patients who entered the Glasgow 7 Program evolved with BD. The characteristics most likely to result in BD were age, female sex, PHI, SH, and SIH.

Improvement on the Coma Recovery Scale-Revised During the First Four Weeks of Hospital Stay Predicts Outcome at Discharge in Intensive Rehabilitation After Severe Brain Injury.

OBJECTIVES: To evaluate the prognostic utility of serial assessment on the Coma Recovery Scale-Revised (CRS-R) during the first 4 weeks of intensive rehabilitation in patients surviving a severe brain injury. DESIGN: Prospective cohort study. SETTING: An intensive rehabilitation unit. PARTICIPANTS: Patients (N=110) consecutively admitted to the intensive rehabilitation unit. Inclusion criteria were (1) a diagnosis of unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) caused by an acquired brain injury, and (2) aged >18 years. INTERVENTIONS: All patients underwent clinical evaluations using the Italian version of the CRS-R during the first month of hospital stay. MAIN OUTCOME MEASURES: Behavioral classification on the CRS-R and the score on the Glasgow Outcome Scale (GOS) at final discharge. Patients transitioning from UWS to MCS or emergence from MCS (E-MCS), and from MCS to E-MCS were classified as patients with improved responsiveness (IR). RESULTS: After a mean ± SD hospital stay of 5.3±2.7 months, 59 of 110 patients (53.6%) achieved IR. In the multivariable analysis, a higher CRS-R score change at week 4 (odds ratio =1.99; 95% confidence interval [CI], 1.49-2.66; P<.001) was the only significant predictor of IR at discharge. Fifty-three patients (48.2%) were classified as severely impaired at discharge (GOS=3). In the multivariable analysis, higher GOS scores were related to a higher CRS-R score at admission (B=.051; 95% CI, .027-.074; P<.001), a higher CRS-R score change at week 4 (B=.087; 95% CI, .064-.110; P<.001), and an absence of severe infections (B=-.477; 95% CI, -.778 to -.176; P=.002). CONCLUSIONS: An improvement on the total CRS-R score and on different subscales across the first 4 weeks of inpatient rehabilitation discriminates patients who will have a better outcome at discharge, providing information for rehabilitation planning and for communication with patients and their caregivers.

Traumatic brain injury (TBI) outcomes in an LMIC tertiary care centre and performance of trauma scores.

BACKGROUND: This study evaluates post-ICU outcomes of patients admitted with moderate and severe Traumatic Brain Injury (TBI) in a tertiary neurocritical care unit in an low middle income country and the performance of trauma scores: A Severity Characterization of Trauma, Trauma and Injury Severity Score, Injury Severity Score and Revised Trauma Score in this setting. METHODS: Adult patients directly admitted to the neurosurgical intensive care units of the National Hospital of Sri Lanka between 21st July 2014 and 1st October 2014 with moderate or severe TBI were recruited. A telephone administered questionnaire based on the Glasgow Outcome Scale Extended (GOSE) was used to assess functional outcome of patients at 3 and 6 months after injury. The economic impact of the injury was assessed before injury, and at 3 and 6 months after injury. RESULTS: One hundred and one patients were included in the study. Survival at ICU discharge, 3 and 6 months after injury was 68.3%, 49.5% and 45.5% respectively. Of the survivors at 3 months after injury, 43 (86%) were living at home. Only 19 (38%) patients had a good recovery (as defined by GOSE 7 and 8). Three months and six months after injury, respectively 25 (50%) and 14 (30.4%) patients had become "economically dependent". Selected trauma scores had poor discriminatory ability in predicting mortality. CONCLUSIONS: This observational study of patients sustaining moderate or severe TBI in Sri Lanka (a LMIC) reveals only 46% of patients were alive at 6 months after ICU discharge and only 20% overall attained a good (GOSE 7 or 8) recovery. The social and economic consequences of TBI were long lasting in this setting. Injury Severity Score, Revised Trauma Score, A Severity Characterization of Trauma and Trauma and Injury Severity Score, all performed poorly in predicting mortality in this setting and illustrate the need for setting adapted tools.

A prospective outcome study observing patients with severe traumatic brain injury over 10-15 years.

BACKGROUND: Severe traumatic brain injury (sTBI) can be divided into primary and secondary injuries. Intensive care protocols focus on preventing secondary injuries. This prospective cohort study was initiated to investigate outcome, including mortality, in patients treated according to the Lund Concept after a sTBI covering 10-15 years post-trauma. METHODS: Patients were included during 2000-2004 when admitted to the neurointensive care unit, Sahlgrenska University Hospital. Inclusion criteria were: Glasgow coma scale score of ≤8, need for artificial ventilation and intracranial monitoring. Glasgow Outcome Scale (GOS) was used to evaluate outcome both at 1-year and 10-15 years post-trauma. RESULTS: Ninety-five patients, (27 female and 68 male), were initially included. Both improvement and deterioration were noted between 1- and 10-15 years post-injury. Mortality rate (34/95) was higher in the studied population vs. a matched Swedish population, (Standard mortality rate (SMR) 9.5; P < 0.0001). When dividing the cohort into Good (GOS 4-5) and Poor (GOS 2-3) outcome at 1-year, only patients with Poor outcome had a higher mortality rate than the matched population (SMR 7.3; P < 0.0001). Further, good outcome (high GOS) at 1-year was associated with high GOS 10-15 years post-trauma (P < 0.0001). Finally, a majority of patients demonstrated symptoms of mental fatigue. CONCLUSION: This indicates that patients with severe traumatic brain injury with Good outcome at 1-year have similar survival probability as a matched Swedish population and that high Glasgow outcome scale at 1-year is related to good long-term outcome. Our results further emphasise the advantage of the Lund concept.

Outcome Trends after US Military Concussive Traumatic Brain Injury.

Care for US military personnel with combat-related concussive traumatic brain injury (TBI) has substantially changed in recent years, yet trends in clinical outcomes remain largely unknown. Our prospective longitudinal studies of US military personnel with concussive TBI from 2008-2013 at Landstuhl Regional Medical Center in Germany and twp sites in Afghanistan provided an opportunity to assess for changes in outcomes over time and analyze correlates of overall disability. We enrolled 321 active-duty US military personnel who sustained concussive TBI in theater and 254 military controls. We prospectively assessed clinical outcomes 6-12 months later in 199 with concussive TBI and 148 controls. Global disability, neurobehavioral impairment, depression severity, and post-traumatic stress disorder (PTSD) severity were worse in concussive TBI groups in comparison with controls in all cohorts. Global disability primarily reflected a combination of work-related and nonwork-related disability. There was a modest but statistically significant trend toward less PTSD in later cohorts. Specifically, there was a decrease of 5.9 points of 136 possible on the Clinician Administered PTSD Scale (-4.3%) per year (95% confidence interval, 2.8-9.0 points, p = 0.0037 linear regression, p = 0.03 including covariates in generalized linear model). No other significant trends in outcomes were found. Global disability was more common in those with TBI, those evacuated from theater, and those with more severe depression and PTSD. Disability was not significantly related to neuropsychological performance, age, education, self-reported sleep deprivation, injury mechanism, or date of enrollment. Thus, across multiple cohorts of US military personnel with combat-related concussion, 6-12 month outcomes have improved only modestly and are often poor. Future focus on early depression and PTSD after concussive TBI appears warranted. Adverse outcomes are incompletely explained, however, and additional studies with prospective collection of data on acute injury severity and polytrauma, as well as reduced attrition before follow-up will be required to fully address the root causes of persistent disability after wartime injury.

Utility of neuron-specific enolase in traumatic brain injury; relations to S100B levels, outcome, and extracranial injury severity.

BACKGROUND: In order to improve assessment and outcome prediction in patients suffering from traumatic brain injury (TBI), cerebral protein levels in serum have been suggested as biomarkers of injury. However, despite much investigation, biomarkers have yet to reach broad clinical utility in TBI. This study is a 9-year follow-up and clinical experience of the two most studied proteins, neuron-specific enolase (NSE) and S100B, in a neuro-intensive care TBI population. Our aims were to investigate to what extent NSE and S100B, independently and in combination, could predict outcome, assess injury severity, and to investigate if the biomarker levels were influenced by extracranial factors. METHODS: All patients treated at the neuro-intensive care unit at Karolinska University Hospital, Stockholm, Sweden between 2005 and 2013 with at least three measurements of serum S100B and NSE (sampled twice daily) were retrospectively included. In total, 417 patients fulfilled the criteria. Parameters were extracted from the computerized hospital charts. Glasgow Outcome Score (GOS) was used to assess long-term functional outcome. Univariate, and multivariate, regression models toward outcome and what explained the high levels of the biomarkers were performed. Nagelkerke's pseudo-R(2) was used to illustrate the explained variance of the different models. A sliding window assessed biomarker correlation to outcome and multitrauma over time. RESULTS: S100B was found a better predictor of outcome as compared to NSE (area under the curve (AUC) samples, the first 48 hours had Nagelkerke's pseudo-R(2) values of 0.132 and 0.038, respectively), where the information content of S100B peaks at approximately 1 day after trauma. In contrast, although both biomarkers were independently correlated to outcome, NSE had limited additional predictive capabilities in the presence of S100B in multivariate models, due to covariance between the two biomarkers (correlation coefficient 0.673 for AUC 48 hours). Moreover, NSE was to a greater extent correlated to multitrauma the first 48 hours following injury, whereas the effect of extracerebral trauma on S100B levels appears limited to the first 12 hours. CONCLUSIONS: While both biomarkers are independently correlated to long-term functional outcome, S100B is found a more accurate outcome predictor and possibly a more clinically useful biomarker than NSE for TBI patients.

The Glasgow Outcome Scale - 40 years of application and refinement.

The Glasgow Outcome Scale (GOS) was first published in 1975 by Bryan Jennett and Michael Bond. With over 4,000 citations to the original paper, it is the most highly cited outcome measure in studies of brain injury and the second most-cited paper in clinical neurosurgery. The original GOS and the subsequently developed extended GOS (GOSE) are recommended by several national bodies as the outcome measure for major trauma and for head injury. The enduring appeal of the GOS is linked to its simplicity, short administration time, reliability and validity, stability, flexibility of administration (face-to-face, over the telephone and by post), cost-free availability and ease of access. These benefits apply to other derivatives of the scale, including the Glasgow Outcome at Discharge Scale (GODS) and the GOS paediatric revision. The GOS was devised to provide an overview of outcome and to focus on social recovery. Since the initial development of the GOS, there has been an increasing focus on the multidimensional nature of outcome after head injury. This Review charts the development of the GOS, its refinement and usage over the past 40 years, and considers its current and future roles in developing an understanding of brain injury.

Nonshaved cranial surgery in black Africans: technical report and a medium-term prospective outcome study.

Nonshaved neurosurgery, cranial or spinal, is well reported among Caucasians but hardly among native Africans. The ungroomed scalp hairs of black Africans have unique anthropological characteristics needing special attention for shaveless cranial surgery. A technical report of the execution of this surgical procedure among an indigenous patient population in a sub-Sahara African country is presented, as well as an outcome analysis in a prospective cohort over a 7-year period. A total of 303 patients (211 males, 70 %) fulfilled the criteria for this study. The surgical procedure was primary in 278 (92 %) and redo in 8 %. It was emergency surgery in 153 (51 %). They were trauma craniotomies or decompressive craniectomies in 95 cases (31 %), craniotomies for tumour resections in 86 (28 %), and the surgical dissections for other conditions in 122 (41 %). The duration of surgery ranged from 30 min to 8.5 h, mean 2.5 (SD, 1.6), median 2. In-hospital clinical outcome was good (normal status or moderate deficit on dichotomized Glasgow outcome scale (GOS)) in 273 (90.1 %) cases while surgical site infections occurred in only 10 cases (3.3 %). The type of surgery, redo or primary, did not have any significant association with the in-hospital outcome (p = 0.5), nor with the presence of surgical site infection (SSI) (p = 0.7). The length of follow-up ranged from 2 to 63 months (mean, 7) with no untoward complications reported so far. Medium-term outcome of nonshaved neurosurgery in this indigenous black Africans remains favourable with no attendant significant adverse after-effects.