Recalibrating the Glasgow Coma Score as an Age-Adjusted Risk Metric for Neurosurgical Intervention.

BACKGROUND: The Glasgow Coma Scale (GCS) score is the most frequently used neurologic assessment in traumatic brain injury (TBI). The risk for neurosurgical intervention based on GCS is heavily modified by age. The objective is to create a recalibrated Glasgow Coma Scale (GCS) score that accounts for an interaction by age and determine the predictive performance of the recalibrated GCS (rGCS) compared to the standard GCS for predicting neurosurgical intervention. METHODS: This retrospective cohort study utilized the National Trauma Data Bank and included all patients admitted from 2010-2015 with TBI (ICD9 diagnosis code 850-854.19). The study population was divided into 2 subsets: a model development dataset (75% of patients) and a model validation dataset (remaining 25%). In the development dataset, logistic regression models were used to calculate conditional probabilities of having a neurosurgical intervention for each combination of age and GCS score, to develop a point-based risk score termed the rGCS. Model performance was examined in the validation dataset using area under the receiver operating characteristic (AUROC) curves and calibration plots. RESULTS: There were 472,824 patients with TBI. The rGCS ranged from 1-15, where rGCS 15 denotes the baseline risk for neurosurgical intervention (4.4%) and rGCS 1 represents the greatest risk (62.6%). In the validation dataset there was a statistically significant improvement in predictive performance for neurosurgical intervention for the rGCS compared to the standard GCS (AUROC: 0.71 versus 0.67, difference, -0.04, P<0.001), overall and by trauma level designation. The rGCS was better calibrated than the standard GCS score. CONCLUSIONS: The relationship between GCS score and neurosurgical intervention is significantly modified by age. A revision to the GCS that incorporates age, the rGCS, provides risk of neurosurgical intervention that has better predictive performance than the standard ED GCS score.

Headache and Its Approach in Today's NeuroIntensive Care Unit.

Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.

Safety and tolerability of gabapentin for aneurysmal subarachnoid hemorrhage (sah) headache and meningismus.

BACKGROUND: Headache after aneurysmal subarachnoid hemorrhage (SAH) is very common and is often described as the "worst headache imaginable." SAH-associated headache can persist for days to weeks and is traditionally treated with narcotics. However, narcotics can have significant adverse effects. We hypothesize that gabapentin (GBP), a non-narcotic neuropathic pain medication, would be safe and tolerable and would reduce narcotic requirements after SAH. METHODS: We retrospectively reviewed the clinical, radiographic, and laboratory data of SAH patients at the neuroscience intensive care unit at Mayo Clinic in Jacksonville, Florida, from January 2011 through February 2013. Headache intensity was quantified by a visual analog scale score. Total opioid use per day was tabulated using an intravenous morphine equivalents scale. Cerebrospinal fluid was also reviewed when available. RESULTS: There were 53 SAH patients who were treated with GBP along with other analgesics for headache. Among these SAH patients, 34 (64 %) were women, with a mean age of 54 years (SD 12.3). Severe headache was observed in all SAH patients. GBP dosing was rapidly escalated within days of SAH up to a median of 1,200 mg/day, with a range of 300 mg three times a day to 900 mg three times a day. Approximately 6 % of patients treated with GBP had nausea (95 % CI 1-16 %), and only one patient (1.8 %) had to discontinue GBP. CONCLUSIONS: GBP appears to be relatively safe and tolerable in SAH patients with headache and may be a useful narcotic-sparing agent to prevent narcotics-associated complications, such as gastrointestinal immobility, ileus, and constipation.

Creating and validating a neurosurgical intervention rule-out tool for patients with mild traumatic brain injury and isolated subdural hematoma: a 5-year, six-center retrospective cohort study.

OBJECTIVE: Because there is no reliable method on admission to predict whether a patient will require neurosurgical intervention in the future, the general approach remains to treat each patient with mild traumatic brain injury (mTBI) and subdural hematoma (SDH) as if they will require such an intervention. Consequently, there is a growing population of patients with mTBI and SDH that is overtriaged despite having a low probability of needing neurosurgical intervention. This study aimed to train and validate a predictive rule-out tool for neurosurgical intervention in patients with mTBI and SDH. METHODS: This was a retrospective cohort study of all trauma patients admitted to six level I trauma centers in three states. Patients were included if they met the following criteria: admitted between 2016 and 2020, ≥ 18 years of age, ICD-10 diagnosis of isolated SDH, initial head imaging available, initial Glasgow Coma Scale score of 13-15, and arrived within 48 hours of injury. Exclusion criteria included skull fracture, intracranial hemorrhage other than an SDH, and no neurosurgical consultation. Prediction variables included 34 demographic, clinical, and radiographic variables. The study outcome was neurosurgical intervention within 48 hours of hospital admission. Seventy-five percent of the data were used for training, and 25% for testing. Multivariable logistic regression with fivefold cross-validation was used on the training set to identify covariates with the highest specificity while holding sensitivity at 100%. Results were validated on the testing set. RESULTS: In total, 1000 patients were in the training set and 333 in the testing set. The overall neurosurgical intervention rate was 8.8%. For the fivefold cross-validation process, three variables were selected that maximized specificity while holding sensitivity at 100%: maximum hematoma thickness, initial Glasgow Coma Scale score, and preinjury antithrombotic use (sensitivity 100%, specificity 56%, area under the receiver operating characteristic curve 0.94). With a cutoff probability of neurosurgical intervention set at 1.88%, the final model was validated to predict neurosurgical intervention with a sensitivity of 100% (95% CI 88.4%-100%) and specificity of 55.1% (95% CI 49.3%-60.8%). CONCLUSIONS: In this study, the largest of its kind to date, the authors successfully developed and validated a new tool for ruling out the necessity of neurosurgical intervention in patients with mTBI and isolated SDH. By successfully identifying more than half of patients who are unlikely to require neurosurgery within the first 2 days of admission, this tool can be used to improve treatment efficiency and provide patients and clinicians with valuable prognostic information.

Risk factors for neurosurgical intervention within 48 hours of admission for patients with mild traumatic brain injury and isolated subdural hematoma.

OBJECTIVE: The objective was to identify demographic, clinical, and radiographic risk factors for neurosurgical intervention within 48 hours of admission in patients with mild traumatic brain injury and isolated subdural hematoma. METHODS: The authors conducted a multicenter retrospective cohort study of all trauma patients admitted to 6 level I/II trauma centers who met the following criteria: admitted between January 1, 2016, and December 31, 2020, age ≥ 18 years, ICD-10 diagnosis code for isolated subdural hematoma, available initial head imaging, initial Glasgow Coma Scale score of 13-15, and arrival at the hospital within 48 hours of injury. Patients were excluded for skull fracture, non-subdural hematoma, and absence of neurosurgical consultation. The study outcome was neurosurgical intervention within 48 hours of hospital admission. Multivariable logistic regression with backward selection examined 30 demographic, clinical, and radiographic risk factors for neurosurgery. RESULTS: In total, 1333 patients were included, of whom 117 (8.8%) received a neurosurgical intervention. When only demographic and clinical variables were considered, sex, mechanism of injury, and hours from injury to initial head imaging were significant covariates (area under the receiver operating characteristic curve [AUROC] [95% CI] 0.70 [0.65-0.75]). When only radiographic risk factors were considered, only maximum hemorrhage thickness (in mm) and midline shift (in mm) were independent risk factors for the outcome (AUROC 0.95 [0.92-0.97]). When all demographic, clinical, and radiographic variables were considered together, advanced directive, Injury Severity Score, midline shift, and maximum hemorrhage thickness were identified as significant risk factors for neurosurgical intervention within 48 hours of hospital admission (AUROC 0.95 [0.94-0.97]). CONCLUSIONS: In the setting of mild traumatic brain injury with isolated subdural hematoma, radiographic risk factors were shown to be stronger than demographic and clinical variables in understanding future risk of neurosurgical intervention. These final radiographic risk factors should be considered in the creation of future prediction models and used to increase the efficiency of existing management guidelines.

Characterizing Interhospital Variability in Neurosurgical Interventions for Patients with Mild Traumatic Brain Injury and Intracranial Hemorrhage.

The objective of this study was to quantify nation-wide interhospital variation in neurosurgical intervention risk by intracranial hemorrhage (ICH) type in the setting of mild traumatic brain injury (mTBI). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the National Trauma Data Bank from 2007 to 2019 with an emergency department Glasgow Coma Scale score 13-15, diagnosed ICH, no skull fracture. The primary outcome was neurosurgical intervention. Interhospital variation was assessed by examining the best linear unbiased predictors (BLUPs) obtained from mixed-effects logistic regression with random slopes and intercepts for hospitals and covariates for time and 14 demographic, injury, and hospital characteristics; one model per ICH type. Intercept BLUPs are estimates of how different each hospital is from the average hospital (after covariate adjustment). The study population included 49,220 (7%) neurosurgical interventions among 666,842 patients in 1060 hospitals. In 2019, after adjusting for patient case-mix and hospital characteristics, the percentage of hospitals with hemorrhage-specific neurosurgical intervention risk significantly different from the average hospital was as follows: isolated unspecified hemorrhage (0% of 995 hospitals); isolated contusion/laceration (0.54% of 929); isolated epidural hemorrhage (0.39% of 778); isolated subarachnoid hemorrhage (0.10% of 1002); multiple hemorrhages (2.49% of 963); and isolated subdural hemorrhage (16.25% of 1028). In the setting of mTBI, isolated subdural hemorrhages were the only ICH type to have considerable interhospital variability. Causes for this significant variation should be elucidated and might include changing hemorrhage characteristics and practice patterns over time.

Significant National Declines in Neurosurgical Intervention for Mild Traumatic Brain Injury with Intracranial Hemorrhage: A 13-Year Review of the National Trauma Data Bank.

There have been large changes over the past several decades to patient demographics in those presenting with mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH; complicated mTBI) with the potential to affect the use of neurosurgical interventions. The objective of this study was to characterize long-term trends of neurosurgical interventions in patients with complicated mTBI using 13 years of the National Trauma Data Bank (NTDB). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the NTDB from 2007 to 2019 who had an emergency department Glasgow Coma Scale score 13-15, an intracranial hemorrhage (ICH), and no skull fracture. Neurosurgical intervention time trends were quantified for each ICH type using mixed-effects logistic regression with random slopes and intercepts for hospitals, as well as covariates for time and 14 demographic, injury, and hospital characteristics. In total, 666,842 ICH patients across 1060 hospitals were included. The four most common hemorrhages were isolated subdural hemorrhage (36%), isolated subarachnoid hemorrhage (24%), multiple hemorrhage types (24%), and isolated unspecified hemorrhages (9%). Overall, 49,220 (7%) patients received a neurosurgical intervention. After adjustment, the odds of neurosurgical intervention significantly decreased every 10 years by the following odds ratios (odds ratio [95% confidence interval]): 0.85 [0.78, 0.93] for isolated subdural, 0.63 [0.51, 0.77] for isolated subarachnoid, 0.50 [0.41, 0.62] for isolated unspecified, and 0.79 [0.73, 0.86] for multiple hemorrhages. There were no significant temporal trends in neurosurgical intervention odds for isolated epidural hemorrhages (0.87 [0.68, 1.12]) or isolated contusions/lacerations (1.03 [0.75, 1.41]). In the setting of complicated mTBI, the four most common ICH types were associated with significant declines in the odds of neurosurgical intervention over the past decade. It remains unclear whether changing hemorrhage characteristics or practice patterns drove these trends.

Status migrainosus as a potential stressor leading to takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy is a form of non-ischemic cardiomyopathy that may be acutely precipitated by stress. A number of neurologic conditions have been implicated in precipitating this disease such as subarachnoid hemorrhage, stroke, and seizures. Its association with status migrainosus, however, has never been described before. CASE: We report a case of a 25-year-old female presenting with status migrainosus followed by takotsubo cardiomyopathy. Supportive management was instituted in this patient and she made an excellent recovery. CONCLUSION: The intense pain associated with migraine may have acted as a stressor, thereby precipitating takotsubo cardiomyopathy. To our knowledge, this is the first reported case demonstrating a relationship between status migrainosus and takotsubo cardiomyopathy.

Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury.

BACKGROUND: The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories. METHODS: The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves. RESULTS: The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients. DISCUSSION: We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury. LEVEL OF EVIDENCE: III epidemiologic/prognostic.

Safety, Tolerability, and Efficacy of Pain Reduction by Gabapentin for Acute Headache and Meningismus After Aneurysmal Subarachnoid Hemorrhage: A Pilot Study.

Introduction: Severe, often sudden-onset headache is the principal presenting symptoms of aneurysmal subarachnoid hemorrhage (aSAH). We hypothesized that gabapentin would be safe and tolerable for aSAH-induced headaches and would reduce concurrent opioid use. Methods: We performed a single-center, double-blind, randomized, placebo-controlled trial (registered at ClinicalTrials.gov; NCT02330094) from November 24, 2014, to June 24, 2017, where aSAH patients received either dose-escalating gabapentin or oral placebo, both alongside a standard of care pain regimen. After 7 days, patients had the option to continue in an open-label period until 14 days after enrollment or until discharge from the intensive care unit. Our primary endpoint was the efficacy of gabapentin in reducing headache numeric pain scores and opioid usage in patients with aSAH compared to the placebo group. We identified 63 potential patients with aSAH for the study. After applying stringent exclusion criteria, 16 eligible patients were enrolled into one of two arms. Results: The study ended prematurely after reaching a pre-specified funding period and an unexpected drop in aSAH cases. There was a trend toward lower headache numeric pain scores and opioid use in the gabapentin treated arm; however this was not significantly different. Gabapentin was well tolerated by participants and no adverse effects were reported. Conclusions: While there was a trend toward lower pain scores and opioid requirement in the gabapentin group, the study was underpowered to detect a difference. Larger multicenter trials are required to evaluate the efficacy of gabapentin to reduce opioid requirements after aSAH.

Hemorrhagic conversion after alteplase administration in a patient with vasculitis and acute ischemic stroke.

PURPOSE: A case of alteplase administration to a patient with vasculitis and acute ischemic stroke (AIS) is reported. SUMMARY: A 38-year-old woman with a recent diagnosis of granulomatosis with polyangiitis (GPA) received alteplase for AIS and developed symptomatic hemorrhagic conversion. Published reports regarding the safety of thrombolytic therapy in patients with a high inflammatory burden are inconsistent. The current case adds to the literature on the topic. CONCLUSION: More data regarding alteplase treatment in patients with GPA are needed to further establish the safety of this therapy.

In-Vitro Biofilm Formation and Antimicrobial Resistance of Escherichia coli in Diabetic and Nondiabetic Patients.

BACKGROUND: Diabetic patients are more susceptible to urinary tract infection compared to nondiabetic patients, Escherichia coli being the most common uropathogen causing UTI. Unreasonable and incorrect antibiotic prescription for UTI in these patients may induce the development of antibiotic-resistant urinary pathogens resulting in delayed recovery and longer hospitalization. In addition to these, biofilm forming capacity of the pathogen may worsen the problem. The main aim of this cross-sectional study (conducted from March to September 2015) is to detect the biofilm forming capacity of UTI causing micro-organisms and compare the antibiotic resistance pattern of Escherichia coli, the most common cause of UTI, which will help the physician in choosing the best antibiotic. METHOD: Total of 1,099 clean-catch mid stream urine (CCMSU) was processed by standard microbiological technique; 182 were from the diabetic group and 917 nondiabetic. Following identification, all isolates were subjected to antibiotic susceptibility testing using modified Kirby-Bauer disc diffusion method. In-vitro biofilm forming capacity of the isolates were detected by Microtitre plate method. The data were analyzed using SPSS software 16. RESULT: Urinary tract infection was found to be significantly higher in diabetic patients (42.9%) compared to nondiabetic patients (17.4%) with Escherichia coli as the most common uropathogen in both diabetic and nondiabetic groups. Similarly, UTI was more common in elderly population (29.5%). Imipenem, nitrofurantoin and amikacin were found to be the most effective drug for uropathogenic E. coli in both diabetic and nondiabetic patients, whereas amoxicillin, ciprofloxacin, and cotrimoxazole were least effective. Of the total bacterial isolates, 43.3% showed positive results for in-vitro biofilm production by the Microtitre plate method. A significantly higher resistance rate was observed among biofilm producing E. coli for quinolones, cotrimoxazole, and third generation cephalosporin ceftriaxone. Most of the biofilm producers (79.5%) were found to be MDR (p-value 0.015). CONCLUSION: Elderly populations with diabetes are at a higher risk of UTI. Higher biofilm production and resistance to in-use antimicrobial agents in this study render its inefficacy for empirical treatment and point out the importance of biofilm screening to ensure the effective management of infection.

Train of four stimulation artifact mimicking a seizure during computerized automated ICU EEG monitoring.

A 54-year-old man was admitted to the intensive care unit with an aneurysmal subarachnoid hemorrhage and subsequently underwent mechanical ventilation and received neuromuscular blocking drugs to control refractory elevated intracranial pressure. During quantitative EEG monitoring, an automated alert was triggered by the train of four peripheral nerve stimulation artifacts. Real-time feedback was made possible due to remote monitoring. This case illustrates how computerized, automated artificial intelligence algorithms can be used beyond typical seizure detection in the intensive care unit for remote monitoring to benefit patient care.

Early Absent Pupillary Light Reflexes After Cardiac Arrest in Patients Treated with Therapeutic Hypothermia.

Loss of pupillary light reactivity is one recognized indicator of poor prognosis after cardiopulmonary resuscitation (CPR). However, drug overdose, low cardiac output, and/or resuscitation drugs can lead to impaired pupillary light reflex. To investigate pupillary light reflex status before therapeutic hypothermia (TH) in relation to neurological outcome, we retrospectively reviewed the data of a prospectively implemented TH protocol in patients with cardiac arrest (CA) at Mayo Clinic in Jacksonville, Florida (January 2006-January 2012), and Mayo Clinic in Scottsdale, Arizona (August 2010-March 2014). During this period, all CA patients who underwent hypothermia were included. These patients were selected from an institutional database and hypothermia data set. The Cerebral Performance Category (CPC) at time of discharge was our primary outcome measure. A CPC of 1 to 2 was defined as good outcome and a CPC from 3 to 5 was defined as poor outcome. We identified 99 patients who had CA treated with TH. Twenty-nine patients (29%) had pupils that were nonreactive to light on admission examination before TH, eight of whom later had return of pupil reactivity by day 3. Two of these 29 patients (6.9%) had good outcome, compared to 24 of 70 patients (34.3%) with pupils that were reactive to light (p = 0.005). Both of these patients had CA after illicit drug overdose. Early nonreactive pupils occurred in almost a third of patients after CPR and before TH in our patient population. Recovery of pupillary light reactivity is possible, and in a small minority of those cases (particularly when CA is preceded by the use of illicit drugs), a good outcome can be achieved.

The "starfield" pattern of cerebral fat embolism from bone marrow necrosis in sickle cell crisis.

Sickle cell disease may manifest with cerebrovascular and systemic complications. Sickle crisis that results in avascular necrosis of long bones with resultant cerebral fat embolism syndrome is rare and has a characteristic "starfield" pattern on MRI. This "starfield" MRI pattern should raise suspicion for sickle cell crisis in patients without a known history of the disease, which can lead to earlier sickle cell red blood cell exchange transfusion and treatment. We present a case of a male who presented emergently with acute seizure, coma with a characteristic MRI pattern, which lead to the diagnosis of avascular bone marrow necrosis and cerebral fat embolism syndrome from sickle cell crisis.