Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis.

Introduction: Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making. Methods: Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model. Results: The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure. Conclusion: The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.

Epidemiology and Outcomes of Severe Traumatic Brain Injury: Regional Trauma Center in Incheon, Korea, 2018-2022.

Objective: This study aims to explore the epidemiology and outcomes of severe traumatic brain injury (TBI) in Incheon, focusing on regional characteristics using data from a local trauma center. Methods: From January 2018 to December 2022, 559 patients with severe TBI were studied. We analyzed factors related to demography, prehospitalization, surgery, complications, and clinical outcomes, including intensive care unit stay, ventilator use, hospital stay, mortality, and Glasgow outcome scale (GOS) scores at discharge and after 6 months. Results: In this study, most severe TBI patients were in the 60-79 age range, constituting 37.4% of cases. Most patients (74.1%) used public emergency medical services for transportation, and 75.3% arrived directly at the hospital, a significantly higher proportion compared to transferred patients. Timewise, 40.0% reached the hospital within an hour of injury. Complication rates stood at 16.1%, with pneumonia being the most common. The mortality rate was 44.0%, and at discharge, 81.2% of patients had unfavorable outcomes (GOS 1-3), reducing to 70.1% at 6 months. Conclusion: As a pioneering study at Incheon's trauma center, this research provides insights into severe TBI outcomes, enhancing understanding by contrasting local and national data.

Traumatic Brain Injury Outcomes After Recreational Cannabis Use.

Purpose: Basic science data indicate potential neuroprotective effects of cannabinoids in traumatic brain injury (TBI). We aimed to evaluate the effects of pre-TBI recreational cannabis use on TBI outcomes. Patients and Methods: We used i2b2 (a scalable informatics framework; www.i2b2.org) to identify all patients presenting with acute TBI between 1/1/2014 and 12/31/2016, then conducted a double-abstraction medical chart review to compile basic demographic, urine drug screen (UDS), Glasgow Coma Scale (GCS), and available outcomes data (mortality, modified Rankin Scale (mRS), duration of stay, disposition (home, skilled nursing facility, inpatient rehabilitation, other)) at discharge and at specific time points thereafter. We conducted multivariable nested ordinal and logistic regression analyses to estimate associations between cannabis use, other UDS results, demographic factors, and selected outcomes. Results: i2b2 identified 6396 patients who acutely presented to our emergency room with TBI. Of those, 3729 received UDS, with 22.2% of them testing positive for cannabis. Mortality was similar in patients who tested positive vs negative for cannabis (3.9% vs 4.8%; p = 0.3) despite more severe GCS on admission in the cannabis positive group (p = 0.045). Several discharge outcome measures favored the cannabis positive group who had a higher rate of discharge home vs other care settings (p < 0.001), lower discharge mRS (p < 0.001), and shorter duration of hospital stay (p < 0.001) than the UDS negative group. Multivariable analyses confirmed mostly independent associations between positive cannabis screen and these post-TBI short- and long-term outcomes. Conclusion: This study adds evidence about the potentially neuroprotective effects of recreational cannabis for short- and long-term post-TBI outcomes. These results need to be confirmed via prospective data collections.

Assessment of GCS and FOUR Score as Prognostic Indicators for Hospital Stay and Morbidity in Traumatic Brain Injury Patients: An Observational Study.

Aim: The objective of the present research was to evaluate variations in hospital stay as well as morbidity based on the Glasgow Coma Scale (GCS) and Full Outline of Un-Responsive (FOUR) scores for patients who had traumatic brain injury (TBI). Materials and Methods: A total of 107 patients with TBI patients who attended the emergency department of MES Medical College, Perinthalmanna, were enrolled into the study. FOUR and GCS scoring systems were used to assess the patients within 24 hours of the presentation to the emergency department. Both FOUR and GCS scoring systems were assessed at the same time. The outcome was measured in terms of length of hospital stay and morbidity, which was assessed using modified Rankin score. Chi-square test was used to calculate sensitivity, specificity, positive predictive value, and negative predictive value. The area under the curve (AUC) was calculated using receiver operating characteristic curve analysis. A P value <0.05 was considered significant. Results: We found a strong positive correlation between GCS and FOUR score with a Spearman coefficient of 0.9. Comparison of AUC between GCS score and FOUR score showed a statistically significant difference (P = 0.0044), predicting that FOUR score was a better predictor of hospital stay (>15 days) than GCS score. Comparison of AUC between GCS score and FOUR score showed a significant statistical difference (P = 0.0002), showing that FOUR score was a better predictor of morbidity than GCS. Conclusion: FOUR score was a better predictor of hospital stay and morbidity as compared to GCS score.

Clinical features and predictors of delayed neurological syndrome in carbon monoxide poisoning: the AMICO study. / Caracterización clínica y factores predictivos de desarrollo de síndrome neurológico tardío en la intoxicación por monóxido de carbono: estudio AMICO.

OBJECTIVES: To identify predictors for developing delayed neurological syndrome (DNS) after an initial episode of carbon monoxide (CO) poisoning in the interest of detecting patients most likely to develop DNS so that they can be followed. MATERIAL AND METHODS: Retrospective review of cases of CO poisoning treated in the past 10 years in the emergency departments of 4 hospitals in the AMICO study (Spanish acronym for the multicenter analysis of CO poisoning). We analyzed demographic characteristics of the patients and the clinical characteristics of the initial episode. The records of the cohort of patients with available follow-up information were reviewed to find cases of DNS. Data were analyzed by multivariant analysis to determine the relationship to characteristics of the initial exposure to CO. RESULTS: A total of 240 cases were identified. The median (interquartile range) age of the patients was 36.2 years (17.6-49.6 years); 108 patients (45.0%) were men, and the poisoning was accidental in 223 cases (92.9%). The median carboxyhemoglobin concentration on presentation was 12.7% (6.2%-18.7%). Follow-up details were available for 44 patients (18.3%). Eleven of those patients (25%) developed DNS. A low initial Glasgow Coma Scale score predicted the development of DNS with an odds ratio (OR) of 0.61 (95% CI, 0.41-0.92) and an area under the receiver operating characteristic curve of 0.876 (95% CI, 0.761-0.990) (P .001). CONCLUSION: The initial Glasgow Coma Scale score seems to be a clinical predictor of DNS after CO poisoning. We consider it important to establish follow-up protocols for patients with CO poisoning treated in hospital EDs.

OBJETIVO: Identificar factores pronósticos de desarrollo de síndrome neurológico tardío (SNT) después de un episodio inicial de intoxicación por monóxido de carbono (ICO), con el fin detectar precozmente a la población más susceptible y facilitar su acceso a un seguimiento específico. METODO: Revisión retrospectiva de todos los casos de ICO que acudieron a los servicios de urgencias (SU) de 4 hospitales durante los últimos 10 años. Se analizaron datos demográficos y características clínicas en el momento del episodio. En la cohorte de pacientes con datos de seguimiento disponibles, se evaluó la aparición de SNT y su relación con diferentes variables en la exposición inicial al CO a través de técnicas de análisis multivariante. RESULTADOS: Se identificaron 240 pacientes. La mediana de edad fue de 36,2 años (17,6-49,6). De ellos 108 (45,0%) eran hombres y 223 casos (92,9%) fueron accidentales. El nivel medio de COHb fue del 12,7% (6,2-18,7). En 44 (18,3%) episodios se disponía de datos de un seguimiento específico. En esta cohorte, 11 (25%) pacientes desarrollaron SNT. Una puntuación inicial más baja en la Escala Coma de Glasgow (GCS) (OR: 0,61, IC 95%: 0,41-0,92) fue predictor independiente del desarrollo del SNT, con un ABC en la curva COR de 0,876 (IC 95%: 0,761-0,990, p 0,001). CONCLUSIONES: Una puntuación inicial baja en la GCS parece ser un predictor clínico de desarrollo de SNT en la ICO. Dada la incidencia de SNT, consideramos fundamental establecer protocolos de seguimiento específico de estos pacientes tras su asistencia inicial en los SU.

Comparison of nine trauma scoring systems in prediction of inhospital outcomes of pediatric trauma patients: a multicenter study.

Hereby, we aimed to comprehensively compare different scoring systems for pediatric trauma and their ability to predict in-hospital mortality and intensive care unit (ICU) admission. The current registry-based multicenter study encompassed a comprehensive dataset of 6709 pediatric trauma patients aged ≤ 18 years from July 2016 to September 2023. To ascertain the predictive efficacy of the scoring systems, the area under the receiver operating characteristic curve (AUC) was calculated. A total of 720 individuals (10.7%) required admission to the ICU. The mortality rate was 1.1% (n = 72). The most predictive scoring system for in-hospital mortality was the adjusted trauma and injury severity score (aTRISS) (AUC = 0.982), followed by trauma and injury severity score (TRISS) (AUC = 0.980), new trauma and injury severity score (NTRISS) (AUC = 0.972), Glasgow coma scale (GCS) (AUC = 0.9546), revised trauma score (RTS) (AUC = 0.944), pre-hospital index (PHI) (AUC = 0.936), injury severity score (ISS) (AUC = 0.901), new injury severity score (NISS) (AUC = 0.900), and abbreviated injury scale (AIS) (AUC = 0.734). Given the predictive performance of the scoring systems for ICU admission, NTRISS had the highest predictive performance (AUC = 0.837), followed by aTRISS (AUC = 0.836), TRISS (AUC = 0.823), ISS (AUC = 0.807), NISS (AUC = 0.805), GCS (AUC = 0.735), RTS (AUC = 0.698), PHI (AUC = 0.662), and AIS (AUC = 0.651). In the present study, we concluded the superiority of the TRISS and its two derived counterparts, aTRISS and NTRISS, compared to other scoring systems, to efficiently discerning individuals who possess a heightened susceptibility to unfavorable consequences. The significance of these findings underscores the necessity of incorporating these metrics into the realm of clinical practice.

Verbal Glasgow Coma Scale as predictor of persistent disorder of consciousness: Insights for improving accuracy and reliability in clinical practice.

This brief report discusses the relationship between verbal function, disorders of consciousness, and neurological follow-up after acute brain injury. It provides valuable insights for improving the accuracy and reliability of Verbal Glasgow Coma Scale scoring in clinical practice. The report addresses the need for standardized training and underlines the importance of physiological stabilization before assessment. Clarity in communication, recognition of non-verbal cues, and serial assessments are emphasized as critical factors to reduce the Verbal Glasgow Coma Scale inconsistencies. It also promotes interdisciplinary collaboration and cultural sensitivity to refine the Verbal Glasgow Coma Scale evaluation, improving the prediction of long-term neurological outcomes after acute brain injury and optimizing effective rehabilitation programs. Possible strategies to implement in the routine clinical practice the provided tips are discussed.

Caracterización clínica y factores predictivos de desarrollo de síndrome neurológico tardío en la intoxicación por monóxido de carbono: estudio AMICO / Clinical features and predictors of delayed neurological syndrome in carbon monoxide poisoning: the AMICO study

Objetivos. Identificar factores pronósticos de desarrollo de síndrome neurológico tardío (SNT) después de un episodio inicial de intoxicación por monóxido de carbono (ICO), con el fin detectar precozmente a la población más susceptible y facilitar su acceso a un seguimiento específico. Métodos. Revisión retrospectiva de todos los casos de ICO que acudieron a los servicios de urgencias (SU) de 4 hospitales durante los últimos 10 años. Se analizaron datos demográficos y características clínicas en el momento del episodio. En la cohorte de pacientes con datos de seguimiento disponibles, se evaluó la aparición de SNT y su relación con diferentes variables en la exposición inicial al CO a través de técnicas de análisis multivariante. Resultados. Se identificaron 240 pacientes. La mediana de edad fue de 36,2 años (17,6-49,6). De ellos 108 (45,0%) eran hombres y 223 casos (92,9%) fueron accidentales. El nivel medio de COHb fue del 12,7% (6,2-18,7). En 44 (18,3%) episodios se disponía de datos de un seguimiento específico. En esta cohorte, 11 (25%) pacientes desarrollaron SNT. Una puntuación inicial más baja en la Escala Coma de Glasgow (GCS) (OR: 0,61, IC 95%: 0,41-0,92) fue predictor independiente del desarrollo del SNT, con un ABC en la curva COR de 0,876 (IC 95%: 0,761-0,990, p < 0,001). Conclusiones. Una puntuación inicial baja en la GCS parece ser un predictor clínico de desarrollo de SNT en la ICO. Dada la incidencia de SNT, consideramos fundamental establecer protocolos de seguimiento específico de estos pacientes tras su asistencia inicial en los SU. (AU)

Objectives. To identify predictors for developing delayed neurological syndrome (DNS) after an initial episode of carbon monoxide (CO) poisoning in the interest of detecting patients most likely to develop DNS so that they can be followed. Methods. Retrospective review of cases of CO poisoning treated in the past 10 years in the emergency departments of 4 hospitals in the AMICO study (Spanish acronym for the multicenter analysis of CO poisoning). We analyzed demographic characteristics of the patients and the clinical characteristics of the initial episode. The records of the cohort of patients with available follow-up information were reviewed to find cases of DNS. Data were analyzed by multivariant analysis to determine the relationship to characteristics of the initial exposure to CO. Results. A total of 240 cases were identified. The median (interquartile range) age of the patients was 36.2 years (17.6-49.6 years); 108 patients (45.0%) were men, and the poisoning was accidental in 223 cases (92.9%). The median carboxyhemoglobin concentration on presentation was 12.7% (6.2%-18.7%). Follow-up details were available for 44 patients (18.3%). Eleven of those patients (25%) developed DNS. A low initial Glasgow Coma Scale score predicted the development of DNS with an odds ratio (OR) of 0.61 (95% CI, 0.41-0.92) and an area under the receiver operating characteristic curve of 0.876 (95% CI, 0.761-0.990) (P <.001). Conclusions. The initial Glasgow Coma Scale score seems to be a clinical predictor of DNS after CO poisoning. We consider it important to establish follow-up protocols for patients with CO poisoning treated in hospital EDs. (AU)

Cutoff of the reverse shock index multiplied by the Glasgow coma scale for predicting in-hospital mortality in adult patients with trauma: a retrospective cohort study.

BACKGROUND: Early identification of patients at risk of potential death and timely transfer to appropriate healthcare facilities are critical for reducing the number of preventable trauma deaths. This study aimed to establish a cutoff value to predict in-hospital mortality using the reverse shock index multiplied by the Glasgow Coma Scale (rSIG). METHODS: This multicenter retrospective cohort study used data from 23 emergency departments in South Korea between January 2011 and December 2020. The outcome variable was the in-hospital mortality. The relationship between rSIG and in-hospital mortality was plotted using the shape-restricted regression spline method. To set a cutoff for rSIG, we found the point on the curve where mortality started to increase and the point where the slope of the mortality curve changed the most. We also calculated the cutoff value for rSIG using Youden's index. RESULTS: A total of 318,506 adult patients with trauma were included. The shape-restricted regression spline curve showed that in-hospital mortality began to increase when the rSIG value was less than 18.86, and the slope of the graph increased the most at 12.57. The cutoff of 16.5, calculated using Youden's index, was closest to the target under-triage and over-triage rates, as suggested by the American College of Surgeons, when applied to patients with an rSIG of 20 or less. In addition, in patients with traumatic brain injury, when the rSIG value was over 25, in-hospital mortality tended to increase as the rSIG value increased. CONCLUSIONS: We propose an rSIG cutoff value of 16.5 as a predictor of in-hospital mortality in adult patients with trauma. However, in patients with traumatic brain injury, a high rSIG is also associated with in-hospital mortality. Appropriate cutoffs should be established for this group in the future.

Traumatic Brain Injury Outcome Associations With Computed Tomography and Glasgow Coma Scale Score Interactions: A Retrospective Study.

Background Numerous investigators have shown that early postinjury Glasgow Coma Scale (GCS) values are associated with later clinical outcomes in patients with traumatic brain injury (TBI), in-hospital mortality, and post-hospital discharge Glasgow Outcome Scale (GOS) results. Following TBI, early GCS, and brain computed tomography (CT) scores have been associated with clinical outcomes. However, only one previous study combined GCS scores with CT scan results and demonstrated an interaction with in-hospital mortality and GOS results. We aimed to determine if interactive GCS and CT findings would be associated with outcomes better than GCS and CT findings alone. Methodology Our study included TBI patients who had GCS scores of 3-12 and required mechanical ventilation for ≥five days. The GCS deficit was determined as 15 minus the GCS score. The mass effect CT score was calculated as lateral ventricular compression plus basal cistern compression plus midline shift. Each value was 1 for present. A prognostic CT score was the mass effect score plus subarachnoid hemorrhage (2 if present).The CT-GCS deficit score was the sum of the GCS deficit and the prognostic CT score. Results One hundred and twelve consecutive TBI patients met the inclusion criteria. Patients with surgical decompression had a lower GCS score (6.0±3.0) than those without (7.7±3.3; Cohen d=0.54). Patients with surgical decompression had a higher mass effect CT score (2.8±0.5) than those without (1.7±1.0; Cohen d=1.4). The GCS deficit was greater in patients not following commands at hospital discharge (9.6±2.6) than in those following commands (6.8±3.2; Cohen d=0.96). The prognostic CT score was greater in patients not following commands at hospital discharge (3.7±1.2) than in those following commands (3.1±1.1; Cohen d=0.52). The CT-GCS deficit score was greater in patients not following commands at hospital discharge (13.3±3.2) than in those following commands (9.9±3.2; Cohen d=1.06). Logistic regression stepwise analysis showed that the failure to follow commands at hospital discharge was associated with the CT-GCS deficit score but not with the GCS deficit. The GCS deficit was greater in patients not following commands at three months (9.7±2.8) than in those following commands (7.4±3.2; Cohen d=0.78). The CT-GCS deficit score was greater in patients not following commands at three months (13.6±3.1) than in those following commands (10.5±3.4; Cohen d=0.94). Logistic regression stepwise analysis showed that failure to follow commands at three months was associated with the CT-GCS deficit score but not with the GCS deficit. The proportion not following commands at three months was greater with a GCS deficit of 9-12 (50.9%) than with a GCS deficit of 3-8 (21.1%; odds ratio=3.9; risk ratio=2.1). The proportion of not following commands at three months was greater with a CT-GCS deficit score of 13-17 (56.0%) than with a CT-GCS deficit score of 4-12 (18.3%; OR=5.7; RR=3.1). Conclusion The mass effect CT score had a substantially better association with the need for surgical decompression than did the GCS score. The degree of association for not following commands at hospital discharge and three months was greater with the CT-GCS deficit score than with the GCS deficit. These observations support the notion that a mass effect and subarachnoid hemorrhage composite CT score can interact with the GCS score to better prognosticate TBI outcomes than the GCS score alone.

Intoxication and Glasgow coma scale scores in patients with head trauma.

INTRODUCTION: The Glasgow Coma Scale (GCS) is an assessment tool commonly used by emergency department (ED) clinicians to objectively describe level of consciousness, especially in trauma patients. This study aims to assess the effect of drug and alcohol intoxication on GCS scores in cases of traumatic head injury. METHODS: In this retrospective chart review study, data were extracted from The Pennsylvania Trauma Systems Foundation Data Base Collection System. Eligible subjects included trauma patients aged 18 years and older, with head trauma, who presented between January 2019 and August 2023. Subjects were matched to controls who did not test positive for drugs or alcohol, matched by Injury Severity Score (ISS) category. RESULTS: Among 1088 subjects, the mean age was 63 (95% CI 62-64). The mean Injury Severity Score was 21 (95% CI 21-22). The median GCS among all subjects was 14 (IQR 6-15). Cases with alcohol or drug use were matched to controls without alcohol or drug use, and were matched by categories of Injury Severity Score. Cases with alcohol or drug use had lower GCS (median 13; IQR 3-15), compared to cases without alcohol or drug use (median 15; IQR 13-15) (p < 0.0001, Wilcoxon Rank Sum Test). CONCLUSIONS: Among patients with head trauma, intoxicated patients had statistically significant lower GCS scores as compared to matched patients with similar Injury Severity Scores.

The Glasgow Coma Scale: 50-year anniversary.

In 1974, Sir Graham Teasdale and Bryan Jennett wrote the "Assessment of coma and impaired consciousness, A practical scale," which has become one of the most influential papers in the history of traumatic brain injury, with more than 10,000 citations as of January 2024. Today, it is one of the most widely used tools in emergency departments, providing a reliable general overview of the patient's consciousness status.

Effects of hyperbaric oxygen combined cabin ventilator on critically ill patients with liberation difficulty after tracheostomy.

BACKGROUND: Critically ill patients undergoing liberation often encounter various physiological and clinical complexities and challenges. However, whether the combination of hyperbaric oxygen and in-cabin ventilator therapy could offer a comprehensive approach that may simultaneously address respiratory and potentially improve outcomes in this challenging patient population remain unclear. METHODS: This retrospective study involved 148 patients experiencing difficulty in liberation after tracheotomy. Inclusion criteria comprised ongoing mechanical ventilation need, lung inflammation on computed tomography (CT) scans, and Glasgow Coma Scale (GCS) scores of ≤ 9. Exclusion criteria excluded patients with active bleeding, untreated pneumothorax, cerebrospinal fluid leakage, and a heart rate below 50 beats per minute. Following exclusions, 111 cases were treated with hyperbaric oxygen combined cabin ventilator, of which 72 cases were successfully liberated (SL group) and 28 cases (NSL group) were not successfully liberated. The hyperbaric oxygen chamber group received pressurization to 0.20 MPa (2.0 ATA) for 20 min, followed by 60 min of ventilator oxygen inhalation. Successful liberation was determined by a strict process, including subjective and objective criteria, with a prolonged spontaneous breathing trial. GCS assessments were conducted to evaluate consciousness levels, with scores categorized as normal, mildly impaired, moderately impaired, or severely impaired. RESULTS: Patients who underwent treatment exhibited improved GCS, blood gas indicators, and cardiac function indexes. The improvement of GCS, partial pressure of oxygen (PaO2), oxygen saturation of blood (SaO2), oxygenation index (OI) in the SL group was significantly higher than that of the NSL group. However, there was no significant difference in the improvement of left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), and stroke volume (SV) between the SL group and the NSL group after treatment. CONCLUSIONS: Hyperbaric oxygen combined with in-cabin ventilator therapy effectively enhances respiratory function, cardiopulmonary function, and various indicators of critically ill patients with liberation difficulty after tracheostomy.

A rare case of chikungunya encephalitis and its management: A case report and literature review.

Key Clinical Message: Chikungunya encephalitis, though rare, warrants clinical attention due to its severe complications. Early identification and appropriate management are crucial for improved outcomes in patients with this rare manifestation of chikungunya virus (CHIKV) infection. Abstract: CHIKV infection is commonly associated with fever and joint pains, but neurological complications such as encephalitis are rare. Here, we present a unique case of confirmed chikungunya encephalitis in a 12-year-old male exhibiting atypical neurological symptoms. The diagnostic journey involved comprehensive neuroimaging and serological investigations, revealing intriguing findings on magnetic resonance imaging and positive CHIKV RNA in serum and cerebrospinal fluid. We discuss the clinical presentation, radiological characteristics, and management strategies, emphasizing the importance of recognizing this uncommon neurological manifestation of CHIKV infection.

Unveiling the Complexity of Traumatic Brain Injury: Insights from Clinical Scoring Systems.

Krishnakumar M. Unveiling the Complexity of Traumatic Brain Injury: Insights from Clinical Scoring Systems. Indian J Crit Care Med 2024;28(3):193-195.

Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury.

Background: Glasgow coma scale (GCS) score is the most widely used clinical score for the initial assessment of neurologically injured patients and is also frequently used for prognostication. Other scores such as the Full Outline of UnResponsivness (FOUR) score and the Glasgow Coma Scale-Pupils (GCS-P) score have been more recently developed and are gaining popularity. This prospective cohort study was conducted to compare various scores in terms of their ability to predict outcomes at 3 months in patients with traumatic brain injury (TBI). Materials and methods: The study was carried out between October 2020 and March 2022. Patients who presented to the hospital with TBI were assessed for inclusion. Initial coma scores were assessed in the emergency department and again after 48 hours of admission. Outcome was assessed using the extended Glasgow outcome score (GOSE) at 3 months after injury. The receiver operating curve (ROC) was plotted to correlate coma scores with the outcome, and the area under the curve (AUC) was compared. Results: A total of 355 patients with TBI were assessed for eligibility, of which 204 patients were included in the study. The AUC values to predict poor outcomes for initial GCS, FOUR, and GCS-P scores were 0.75 each. The AUC values for 48-hour coma scores were 0.88, 0.87, and 0.88, respectively. Conclusion: The GCS, FOUR, and GCS-P scores were found to be comparable in predicting the functional outcome at 3 months as assessed by GOSE. However, coma scores assessed at 48 hours were better predictors of poor outcomes at 3 months than coma scores recorded initially at the time of hospital admission. How to cite this article: Chawnchhim AL, Mahajan C, Kapoor I, Sinha TP, Prabhakar H, Chaturvedi A. Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury. Indian J Crit Care Med 2024;28(3):256-264.

Utilizing ultra-early continuous physiologic data to develop automated measures of clinical severity in a traumatic brain injury population.

Determination of prognosis in the triage process after traumatic brain injury (TBI) is difficult to achieve. Current severity measures like the Trauma and injury severity score (TRISS) and revised trauma score (RTS) rely on additional information from the Glasgow Coma Scale (GCS) and the Injury Severity Score (ISS) which may be inaccurate or delayed, limiting their usefulness in the rapid triage setting. We hypothesized that machine learning based estimations of GCS and ISS obtained through modeling of continuous vital sign features could be used to rapidly derive an automated RTS and TRISS. We derived variables from electrocardiograms (ECG), photoplethysmography (PPG), and blood pressure using continuous data obtained in the first 15 min of admission to build machine learning models of GCS and ISS (ML-GCS and ML-ISS). We compared the TRISS and RTS using ML-ISS and ML-GCS and its value using the actual ISS and GCS in predicting in-hospital mortality. Models were tested in TBI with systemic injury (head abbreviated injury scale (AIS) ≥ 1), and isolated TBI (head AIS ≥ 1 and other AIS ≤ 1). The area under the receiver operating characteristic curve (AUROC) was used to evaluate model performance. A total of 21,077 cases (2009-2015) were in the training set. 6057 cases from 2016 to 2017 were used for testing, with 472 (7.8%) severe TBI (GCS 3-8), 223 (3.7%) moderate TBI (GCS 9-12), and 5913 (88.5%) mild TBI (GCS 13-15). In the TBI with systemic injury group, ML-TRISS had similar AUROC (0.963) to TRISS (0.965) in predicting mortality. ML-RTS had AUROC (0.823) and RTS had AUROC 0.928. In the isolated TBI group, ML-TRISS had AUROC 0.977, and TRISS had AUROC 0.983. ML-RTS had AUROC 0.790 and RTS had AUROC 0.957. Estimation of ISS and GCS from machine learning based modeling of vital sign features can be utilized to provide accurate assessments of the RTS and TRISS in a population of TBI patients. Automation of these scores could be utilized to enhance triage and resource allocation during the ultra-early phase of resuscitation.

The Message of the Glasgow Coma Scale: A Comprehensive Bibliometric Analysis and Systematic Review of Clinical Practice Guidelines Spanning the Past 50 years.

BACKGROUND: Despite the ubiquitous use of the Glasgow Coma Scale (GCS) worldwide, no study to date has objectively and quantitatively assessed its impact on the scientific literature and clinical practice. Therefore, we comprehensively analyzed scientific publications and clinical practice guidelines employing the GCS to gauge its clinical and academic impact, identify research hotspots, and inform future research on the topic. METHODS: A cross-sectional bibliometric analysis was performed on Scopus to obtain relevant publications incorporating the GCS from 1974 to 2022. In addition, a systematic review of existing clinical practice guidelines in PubMed, Scopus, Web of Science, and Trip Database was performed. Validated bibliometric parameters including article title, journal, publication year, authors, citation count, country, institution, keywords, impact factor, and references were assessed. When evaluating clinical practice guidelines, the sponsoring organization, country of origin, specialty, and publication year were assessed. RESULTS: A total of 37,633 articles originating from 3924 different scientific journals spanning 1974-2022 were included in the final analysis. The compound annual growth rate of publications referencing the GCS was 16.7%. Of 104 countries, the United States had the highest total number of publications employing the GCS (n = 8517). World Neurosurgery was the scientific periodical with the highest number of publications on the GCS (n = 798). The top trending author-supplied keyword was "traumatic brain injury" (n = 3408). The 97 included clinical practice guidelines most commonly employed the GCS in the fields of internal medicine (n = 22, 23%), critical care (n = 21, 22%), and neurotrauma (n = 19, 20%). CONCLUSIONS: At the turn of the 50th anniversary of the GCS, we provided a unique and detailed description of the "path to success" of the GCS both in terms of its scientific and clinical impact. These results have not only a historical but also an important didactic value. Ultimately our detailed analysis, which revealed some of the factors that led the GCS to become such a widespread and highly influential score, may assist future researchers in their development of new outcome measures and clinical scores, especially as such tools become increasingly relevant in an evidence-based data-driven age.

Predicting the Severity and Discharge Prognosis of Traumatic Brain Injury Based on Intracranial Pressure Data Using Machine Learning Algorithms.

OBJECTIVE: This study aimed to explore the potential of employing machine learning algorithms based on intracranial pressure (ICP), ICP-derived parameters, and their complexity to predict the severity and short-term prognosis of traumatic brain injury (TBI). METHODS: A single-center prospectively collected cohort of neurosurgical intensive care unit admissions was analyzed. We extracted ICP-related data within the first 6 hours and processed them using complex algorithms. To indicate TBI severity and short-term prognosis, Glasgow Coma Scale score on the first postoperative day and Glasgow Outcome Scale-Extended score at discharge were used as binary outcome variables. A univariate logistic regression model was developed to predict TBI severity using only mean ICP values. Subsequently, 3 multivariate Random Forest (RF) models were constructed using different combinations of mean and complexity metrics of ICP-related data. To avoid overfitting, five-fold cross-validations were performed. Finally, the best-performing multivariate RF model was used to predict patients' discharge Glasgow Outcome Scale-Extended score. RESULTS: The logistic regression model exhibited limited predictive ability with an area under the curve (AUC) of 0.558. Among multivariate models, the RF model, combining the mean and complexity metrics of ICP-related data, achieved the most robust ability with an AUC of 0.815. Finally, in terms of predicting discharge Glasgow Outcome Scale-Extended score, this model had a consistent performance with an AUC of 0.822. Cross-validation analysis confirmed the performance. CONCLUSIONS: This study demonstrates the clinical utility of the RF model, which integrates the mean and complexity metrics of ICP data, in accurately predicting the TBI severity and short-term prognosis.

Inter-rater reliability in the assessment of consciousness in patients receiving palliative care in intensive care: A prospective cross sectional observational study.

BACKGROUND: The Glasgow Coma Scale (GCS) is one of the methods that has validity for evaluating the consciousness levels of patients in the literature and is accepted by health authorities. AIM: The purpose of this study was to evaluate the inter-rater reliability of GCS in intensive care patients receiving palliative care. STUDY DESIGN: A prospective cross sectional observational study. The study was conducted in a general intensive care unit with 20 beds with patients receiving palliative care. In the unit, 18 nurses worked in two shifts, day and night. Each patient's primary palliative care nurse and two additional researchers were given one minute to independently record the patient's GCS total and subscale scores. All observations were completed within 5 min as there could be significant changes in the patient's GCS score during observations. RESULTS: A total of 258 assessments were completed. For the GCS total scoring, a moderate agreement was found between palliative care nurses and the first researcher-observer (49.0%) and also between palliative care nurses and the second researcher-observer (47.7%). In addition, there was a substantial agreement between the first and second researchers (78.9%) and also between all observers (61.5%) (all p = .001). CONCLUSIONS: Although there was a near-perfect agreement between the two researcher-observers, we found only moderate agreement among all observers (palliative care nurses and two researcher-observers) in the evaluation of GCS total and subscale scores. RELEVANCE TO CLINICAL PRACTICE: We found that lack of knowledge and training on the standardized use of GCS is still a problem for palliative and intensive care units. Because of the diversity of patients requiring GCS assessment in palliative care units, refresher training programs and hands-on workshops on consciousness assessment should be organized regularly for more experienced nurses.