Neuroendocrine challenges and clinical outcomes in men with chronic traumatic brain injury: a cross-sectional study.

BACKGROUND AND OBJECTIVES: Marked changes in the hypothalamic-pituitary axis have been documented in patients with traumatic brain injury (TBI). These enduring endocrine challenges could significantly influence the physical and psychological outcomes thereby impacting overall recovery. This study aimed to determine the prevalence and types of endocrine dysfunction in men with chronic TBI and to determine the association of endocrine dysfunction with clinical outcomes. METHODOLOGY: A cross-sectional study that included male participants of 25-45 years (N = 66) with moderate to severe TBI within 6-24 months of injury. Serum Cortisol, Free T4, TSH, Luteinizing hormone, Testosterone, ACTH, Prolactin and IGF-1 were assessed. Glasgow Outcome Scale Extended (GOS-E) and Modified Barthel Index (MBI) scores were also assessed in them. RESULTS: The study cohort comprised male patients with a mean ± age of 32.8 ± 5.7 years. Low IGF-1 levels were most commonly encountered, followed by hypogonadism. Hypopituitarism was present in 56.1%. The proportion of hypogonadism was significantly higher in the group with moderate-total dependence (13/26) as compared to the functionally independent (8/40) group (50% vs. 20%; P = 0.011). Univariate and multivariate logistic regression analysis was used to determine the factors associated with hypopituitarism, revealing that severity of injury (OR = 2.6;) and GOS-E (OR = 3.1) were significant (P < 0.10) on univariate analysis. CONCLUSIONS: This study emphasizes the need to screen TBI patients for neuroendocrine dysfunction during the chronic phases and to establish screening criteria.

The impact of perfusion computed tomography on the diagnosis and outcome of delayed cerebral ischemia after subarachnoid hemorrhage.

BACKGROUND: Delayed cerebral ischemia (DCI) is a preventable cause of poor neurological outcome in aneurysmal subarachnoid hemorrhage (aSAH). Advances in radiological methods, such as cerebral perfusion computed tomography (CTP), could help diagnose DCI earlier and potentially improve outcomes in aSAH. The objective of this study was to assess whether the use of CTP to diagnose DCI early could reduce the risk of infarction related to DCI. METHODS: Retrospective cohort study of patients in the intensive care unit of Erasme Hospital (Brussels, Belgium) between 2004 and 2021 with aSAH who developed DCI. Patients were classified as: "group 1" - DCI diagnosed based on clinical deterioration or "group 2" - DCI diagnosed using CTP. The primary outcome was the development of infarction unrelated to the initial bleeding or surgery. RESULTS: 211 aSAH patients were diagnosed with DCI during the study period: 139 (66%) in group 1 and 72 (34%) in group 2. In group 1, 109 (78%) patients developed a cerebral infarction, compared to 45 (63%) in group 2 (p = 0.02). The adjusted cumulative incidence of DCI over time was lower in group 2 than in group 1 [hazard ratio 0.65 (95% CI 0.48-0.94); p = 0.02]. The use of CTP to diagnose DCI was not independently associated with mortality or neurological outcome. CONCLUSIONS: The use of CTP to diagnose DCI might help reduce the risk of developing cerebral infarction after aSAH, although the impact of such an approach on patient outcomes needs to be further demonstrated.

Isotonic balanced fluid versus 0.9% saline in patients with moderate to severe traumatic brain injury: A double-blinded randomised controlled trial.

BACKGROUND AND IMPORTANCE: Traumatic brain injury (TBI) is a global health concern with significant economic impact. Optimal fluid therapy aims to restore intravascular volume, maintain cerebral perfusion pressure and blood flow, thus preventing secondary brain injury. While 0.9% saline (NS) is commonly used, concerns about acid-base and electrolyte imbalance and development of acute kidney injury (AKI) lead to consideration of balanced fluids as an alternative. OBJECTIVES: This study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS. DESIGN, SETTINGS AND PARTICIPANTS: A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019. INTERVENTION OR EXPOSURE: Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type. OUTCOMES MEASURE AND ANALYSIS: The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated. MAIN RESULTS: A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months. CONCLUSIONS: In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.

Finnish paediatric study found a low incidence of bacterial meningitis from 2011 to 2018 but a substantial proportion of nosocomial meningitis.

AIM: This study examined the predisposing factors, clinical picture, bacterial aetiology and clinical outcomes of infants and children with bacterial meningitis (BM). METHODS: The medical records of patients under 16 years of age, treated by Turku University Hospital, Finland, from 2011 to 2018, were screened for meningitis using the International Classification of Diseases, Tenth Revision codes. Patients were included if bacteria were detected in cerebrospinal fluid (CSF) or other predefined laboratory variables indicated BM, despite CSF testing negative for bacteria. The Glasgow Outcome Scale (GOS) was used to determine outcomes. RESULTS: We identified 37 children with BM: 22 infants aged 0-89 days and 15 children aged 90 days to 15 years. The overall incidence was approximately 5.7/100 000/year. Nosocomial meningitis was documented in 51%. Bacterial growth was detected in the CSF or blood cultures of the majority of patients (57%). Escherichia coli (14%), group B streptococcus (11%) and Streptococcus pneumoniae (8%) were the most common pathogens. There were 14% of patients with unfavourable outcomes, namely GOS scores of 1-4, but no deaths. CONCLUSION: The incidence of paediatric BM was low during the study period, but the proportion of nosocomial meningitis was substantial. The frequency of unfavourable long-term outcomes was relatively low.

Effect of low fibrinogen level on in-hospital mortality and 6-month functional outcome of TBI patients, a single center experience.

In patients affected by traumatic brain injury (TBI), hypofibrinogenemia within the initial hours of trauma can be expected due to vascular and inflammatory changes. In this study, we aimed to evaluate the effect of hypofibrinogenemia on the in-hospital mortality and 6-month functional outcomes of TBI patients, admitted to Rajaee Hospital, a referral trauma center in Shiraz, Iran. This study included all TBI patients admitted to our center who had no prior history of coagulopathy or any systemic disease, were alive on arrival, and had not received any blood product before admission. On admission, hospitalization, imaging, and 6-month follow-up information of included patients were extracted from the TBI registry database. The baseline characteristics of patients with fibrinogen levels of less than 150 mg/dL were compared with the cases with higher levels. To assess the effect of low fibrinogen levels on in-hospital mortality, a uni- and multivariate was conducted between those who died in hospital and survivors. Based on the 6-month GOSE score of patients, those with GOSE < 4 (unfavorable outcome) were compared with those with a favorable outcome. A total of 3049 patients (84.3% male, 15.7% female), with a mean age of 39.25 ± 18.87, met the eligibility criteria of this study. 494 patients had fibrinogen levels < 150 mg/dl, who were mostly younger and had lower average GCS scores in comparison to cases with higher fibrinogen levels. By comparison of the patients who died during hospitalization and survivors, it was shown that fibrinogen < 150 mg/dl is among the prognostic factors for in-hospital mortality (OR:1.75, CI: 1.32:2.34, P-value < 0.001), while the comparison between patients with the favorable and unfavorable functional outcome at 6-month follow-up, was not in favor of prognostic effect of low fibrinogen level (OR: 0.80, CI: 0.58: 1.11, P-value: 0.19). Hypofibrinogenemia is associated with in-hospital mortality of TBI patients, along with known factors such as higher age and lower initial GCS score. However, it is not among the prognostic factors of midterm functional outcome.

Prognostic value of computed tomography and magnetic resonance imaging findings in acute traumatic brain injury in prediction of poor neurological outcome and mortality: a systematic review and meta-analysis.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality, impacting healthcare systems and economies. Early identification of poor outcomes is crucial for effective treatment. This systematic review assesses the prognostic value of computed tomography (CT) and magnetic resonance imaging (MRI) findings in predicting poor neurological outcomes and mortality in the acute phase of TBI. A comprehensive search of Scopus, MEDLINE, and Web of science databases was performed to identify studies examining CT and MR-based imaging findings and their association with poor outcomes as assessed by Glasgow outcome score as well as mortality within the early acute phase of TBI following injury/admission. Qualitative evaluation of included studies revealed several imaging sequences that modify the outcome of the patients, including extra-axial and intra-axial hemorrhage, swirl sign, contrast extravasation, midline shift, closed and open cranial cisterns, signs of edema, presence of cranial fractures, intracranial hemorrhage, cerebral microbleeds, diffuse axonal injury, apparent diffusion coefficient and fractional anisotropy in diffusion tensor imaging, as well as, concentrations of brain metabolites(N-acetyl aspartate, Creatinine, Choline, Myo-inositol, glutamate, and glutamine) in magnetic resonance spectroscopy. Among these markers, subarachnoid hemorrhage (SAH) and subdural hematoma (SDH) emerged as the most predictive of poor outcomes based on meta-analysis findings. SAH was significantly associated with an increased risk of mortality (OR: 3.35, 95% CI: 2.41-4.65, I²=51.3%) and poor outcomes (OR: 2.69, 95% CI: 2.44-2.96, I²=0%). Similarly, SDH correlated with higher mortality risk (OR: 2.44, 95% CI: 2.14-2.78, I²=0%) and worse outcomes (OR: 2.00, 95% CI: 1.12-3.59, I²=60.9%). In contrast, epidural hematoma (EDH) was linked to better outcomes (OR: 0.60, 95% CI: 0.52-0.68, I²=0%) but not significantly associated with mortality (OR: 0.38, 95% CI: 0.09-1.65, I²=73.7%). The results of this systematic review and meta-analysis provide an overview of clinically feasible imaging markers of prognostic value and may inform clinical decision-making in the future.

The impact of early surgery on mortality and functional recovery in older adults with traumatic intracranial lesions: a propensity score-based analysis.

BACKGROUND: There is skepticism about the benefit of surgery in elderly patients affected by traumatic brain injury (TBI) due to the negative effect of age on the outcome and surgical complications. However, there are few studies that have investigated differences in patient's outcome between surgically and conservatively managed patients after adjusting for the imbalance in preinjury characteristics and clinical and radiological features. The primary aim of this study was to evaluate the effect of early surgery on mortality and functional recovery in a cohort of older adults with acute traumatic intracranial lesions after adjustment by Propensity Score (PS) matching.     MATERIALS AND METHODS: We conducted a retrospective cohort study on older adult patients (≥ 65 years) admitted for TBI between 2013 and 2023 to a single level 1 trauma center. Patients were categorized based on whether they underwent early surgery (< 48 h after TBI) for a space-occupying lesion evacuation. PS model was constructed based on age, frailty, comorbidities (Charlson comorbity index and American Society of Anaesthesiologists score), anticoagulants, hypoxia, shock, pupillary abnormalities and GCS motor response upon admission, midline shift, basal cistern effacement, volume of subdural and intracerebral hematomas, and limitation of life-sustaining treatment decisions.The effect of early surgery on 30-day mortality and unfavorable functional outcomes (GOSE 1-3) at 6 and 12 months were investigated after matching by paired test. RESULTS: We identified and reviewed 301 patients who met all inclusion criteria and contained no exclusions. After matching, 62 patients (31 pairs of conservative and surgical patients) remained as the matched datasets. Our key finding was that older adult TBI patients who underwent early surgery had a statistically significant reduction in the risk of 30-day mortality (OR 0.313, 95% CI 0.114-0.853, p = 0.023) and unfaourable outcome at 12 months after TBI (OR 0.286, 95% CI 0.094-0.868, p = 0.027). CONCLUSIONS: Early surgery was associated with decreased 30-day mortality and better functional outcome at 12 months after TBI in older adults with few comorbidities and good functionality when clinically affected by acute traumatic intracranial lesions with mass effect.

Acute-Phase Neurofilament Light and Glial Fibrillary Acidic Proteins in Cerebrospinal Fluid Predict Long-Term Outcome After Severe Traumatic Brain Injury.

BACKGROUND: This study investigated trajectory profiles and the association of concentrations of the biomarkers neurofilament light (NfL) and glial fibrillary acidic protein (GFAP) in ventricular cerebrospinal fluid (CSF) with clinical outcome at 1 year and 10-15 years after a severe traumatic brain injury (sTBI). METHODS: This study included patients with sTBI at the Neurointensive Care Unit at Sahlgrenska University Hospital, Gothenburg, Sweden. The injury was regarded as severe if patients had a Glasgow Coma Scale ≤ 8 corresponding to Reaction Level Scale ≥ 4. CSF was collected from a ventricular catheter during a 2-week period. Concentrations of NfL and GFAP in CSF were analyzed with enzyme-linked immunosorbent assay. The Glasgow Outcome Scale (GOS) was used to assess the 1-year and 10-15-year outcomes. After adjustment for age and previous neurological diseases, logistic regression was performed for the outcomes GOS 1 (dead) or GOS 2-5 (alive) and GOS 1-3 (poor) or GOS 4-5 (good) versus the independent continuous variables (NfL and GFAP). RESULTS: Fifty-three patients with sTBI were investigated; forty-seven adults are presented in the article, and six children (aged 7-18 years) are described in Supplement 1. The CSF concentrations of NfL gradually increased over 2 weeks post trauma, whereas GFAP concentrations peaked on days 3-4. Increasing NfL and GFAP CSF concentrations increased the odds of GOS 1-3 outcome 1 year after trauma (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.07-2.80, p = 0.025; and OR 1.61, 95% CI 1.09-2.37, p = 0.016, respectively). Similarly, increasing CSF concentrations of NfL and GFAP increased the odds for GOS 1-3 outcome 10-15 years after trauma (OR 2.04, 95% CI 1.05-3.96, p = 0.035; and OR 1.60, 95% CI 1.02-2.00, p = 0.040). CONCLUSIONS: This study shows that initial high concentrations of NfL and GFAP in CSF are both associated with higher odds for GOS 1-3 outcome 1 year and 10-15 years after an sTBI, implicating its potential usage as a prognostic marker in the future.

Neuroimaging with Rotterdam Scoring System and long-term outcomes in severe traumatic brain injury patients.

PURPOSE: The Rotterdam Scoring System (RSS) attempts to prognosticate early mortality and early functional outcome in patients with traumatic brain injury (TBI) based on non-contrast head computed tomography (CT) imaging findings. The purpose of this study was to identify the relationship between RSS scores and long-term outcomes in patients with severe TBI. METHODS: Consecutively treated patients with severe TBI enrolled between 2008 and 2011, in the prospective, observational, Brain Trauma Research Center database were included. The Glasgow Outcome Scale (GOS) was used to measure long-term functional outcomes at three, six, 12, and 24 months. GOS scores were categorized into favorable (GOS = 4-5) and unfavorable (GOS = 1-3) outcomes. RSS scores were calculated at the time of image acquisition. RESULTS: Of the 89 patients included, 74 (83.4%) were male, 81 (91.0%) were Caucasian, and the mean age of the cohort was 41.9 ± 18.5 years old. Patients with an RSS score of 3 and lower were more likely to have a favorable outcome with increased survival rates than patients with RSS scores greater than 3. CONCLUSIONS: The RSS score determined on the head CT scan acquired at admission in a cohort of patients with severe TBI correlated with long-term survival and functional outcomes up to two years following injury.

Analysis on Short-Term Outcomes for Cerebral Protection Treatment in Post Severe Traumatic Brain Injury Patients: A Single Neurosurgical Centre Study.

Background: Severe traumatic brain injury (TBI) is a leading cause of disability worldwide and cerebral protection (CP) management might determine the outcome of the patient. CP in severe TBI is to protect the brain from further insults, optimise cerebral metabolism and prevent secondary brain injury. This study aimed to analyse the short-term Glasgow Outcome Scale (GOS) at the intensive care unit (ICU) discharge and a month after ICU discharge of patients post CP and factors associated with the favourable outcome. Methods: This is a prospective cohort study from January 2021 to January 2022. The short-term outcomes of patients were evaluated upon ICU discharge and 1 month after ICU discharge using GOS. Favourable outcome was defined as GOS 4 and 5. Generalised Estimation Equation (GEE) was adopted to conduct bivariate GEE and subsequently multivariate GEE to evaluate the factors associated with favourable outcome at ICU discharge and 1 month after discharge. Results: A total of 92 patients with severe TBI with GOS of 8 and below admitted to ICU received CP management. Proportion of death is 17% at ICU discharge and 0% after 1 month of ICU discharge. Proportion of favourable outcome is 26.1% at ICU discharge and 61.1% after 1 month of ICU discharge. Among factors evaluated, age (odds ratio [OR] = 0.96; 95% CI: 0.94, 0.99; P = 0.004), duration of CP (OR = 0.41; 95% CI: 0.20, 0.84; P = 0.014) and hyperosmolar therapy (OR = 0.41; CI 95%: 0.21, 0.83; P = 0.013) had significant association. Conclusion: CP in younger age, longer duration of CP and patient not receiving hyperosmolar therapy are associated with favourable outcomes. We recommend further clinical trial to assess long term outcome of CP.

[The use of transcranial micropolarization in the acute period of severe traumatic brain injury in children]. / Primenenie transkranial'noi mikropolyarizatsii v ostrom periode tyazheloi cherepno-mozgovoi travmy u detei.

Traumatic brain injury, which is often considered as a silent epidemic, is a public health problem. The duration of acute recovery period remains a commonly used criterion for injury severity and clinical management. In this connection, the first stage of medical rehabilitation is carried out in the conditions of resuscitation and neurosurgery department in the hospital providing specialized care. Rehabilitation techniques such as postural training, phase verticalization, individual kinesiotherapy, transcranial micropolarization and etc. are used. OBJECTIVE: To assess the effectiveness of using transcranial micropolarization in acute period of severe traumatic brain injury in children. MATERIAL AND METHODS: The study on the effectiveness of using transcranial micropolarization in acute period of severe traumatic brain injury in 85 children, divided into 2 groups, was carried out. The study group (42 patients) received the transcranial micropolarization on the 2nd day after severe traumatic brain injury. The control group (43 patients) received only rehabilitation in neurosurgery department. The neurological status in the patients of both groups was assessed on the 2nd day after severe traumatic brain injury in resuscitation department, and after 1, 3 and 6 months. RESULTS AND CONCLUSION: The inclusion of transcranial micropolarization in the early medical rehabilitation of children with severe traumatic brain injury increases consciousness level in a shorter period of time, that predicts early patient's socialization.

Selection of a statistical analysis method for the Glasgow Outcome Scale-Extended endpoint for estimating the probability of favorable outcome in future severe TBI clinical trials.

The Glasgow outcome scale-extended (GOS-E), an ordinal scale measure, is often selected as the endpoint for clinical trials of traumatic brain injury (TBI). Traditionally, GOS-E is analyzed as a fixed dichotomy with favorable outcome defined as GOS-E ≥ 5 and unfavorable outcome as GOS-E < 5. More recent studies have defined favorable vs unfavorable outcome utilizing a sliding dichotomy of the GOS-E that defines a favorable outcome as better than a subject's predicted prognosis at baseline. Both dichotomous approaches result in loss of statistical and clinical information. To improve on power, Yeatts et al proposed a sliding scoring of the GOS-E as the distance from the cutoff for favorable/unfavorable outcomes, and therefore used more information found in the original GOS-E to estimate the probability of favorable outcome. We used data from a published TBI trial to explore the ramifications to trial operating characteristics by analyzing the sliding scoring of the GOS-E as either dichotomous, continuous, or ordinal. We illustrated a connection between the ordinal data and time-to-event (TTE) data to allow use of Bayesian software that utilizes TTE-based modeling. The simulation results showed that the continuous method with continuity correction offers higher power and lower mean squared error for estimating the probability of favorable outcome compared to the dichotomous method, and similar power but higher precision compared to the ordinal method. Therefore, we recommended that future severe TBI clinical trials consider analyzing the sliding scoring of the GOS-E endpoint as continuous with continuity correction.

Bacterial meningitis in adults: a retrospective study among 148 patients in an 8-year period in a university hospital, Finland.

BACKGROUND: Bacterial meningitis (BM) causes significant morbidity and mortality. We investigated predisposing factors, clinical characteristics, spectrum of etiological bacteria, and clinical outcome of community-acquired and nosocomial BM. METHODS: In this retrospective study we analyzed data of 148 adults (age > 16 years) with BM treated in Turku University Hospital, Southwestern Finland, from 2011 to 2018. Besides culture- or polymerase chain reaction (PCR)-positive cases we also included culture-negative cases with laboratory parameters strongly suggestive of BM and those with meningitis-related findings in imaging. We used Glasgow Outcome Scale (GOS) score 1-4 to determine unfavorable outcome. RESULTS: The median age of patients was 57 years and 48.6% were male. Cerebrospinal fluid (CSF) culture for bacteria showed positivity in 50 (33.8%) cases, although pre-diagnostic antibiotic use was frequent (85, 57.4%). The most common pathogens in CSF culture were Streptococcus pneumoniae (11, 7.4%), Staphylococcus epidermidis (7, 4.7%), Staphylococcus aureus (6, 4.1%) and Neisseria meningitidis (6, 4.1%). Thirty-nine patients (26.4%) presented with the triad of fever, headache, and neck stiffness. A neurosurgical procedure or an acute cerebral incident prior BM was recorded in 74 patients (50%). Most of the patients had nosocomial BM (82, 55.4%) and the rest (66, 44.6%) community-acquired BM. Ceftriaxone and vancomycin were the most used antibiotics. Causative pathogens had resistances against the following antibiotics: cefuroxime with a frequency of 6.8%, ampicillin (6.1%), and tetracycline (6.1%). The case fatality rate was 8.8% and the additional likelihood of unfavorable outcome 40.5%. Headache, decreased general condition, head computed tomography (CT) and magnetic resonance imaging (MRI), hypertension, altered mental status, confusion, operative treatment, neurological symptoms, pre-diagnostic antibiotic use and oral antibiotics on discharge were associated with unfavorable outcome. CONCLUSIONS: The number of cases with nosocomial BM was surprisingly high and should be further investigated. The usage of pre-diagnostic antibiotics was also quite high. Headache was associated with unfavorable outcome. The frequency of unfavorable outcome of BM was 40.5%, although mortality in our patients was lower than in most previous studies.

Comparison of machine learning models to predict long-term outcomes after severe traumatic brain injury.

OBJECTIVE: An estimated 1.5 million people die every year worldwide from traumatic brain injury (TBI). Physicians are relatively poor at predicting long-term outcomes early in patients with severe TBI. Machine learning (ML) has shown promise at improving prediction models across a variety of neurological diseases. The authors sought to explore the following: 1) how various ML models performed compared to standard logistic regression techniques, and 2) if properly calibrated ML models could accurately predict outcomes up to 2 years posttrauma. METHODS: A secondary analysis of a prospectively collected database of patients with severe TBI treated at a single level 1 trauma center between November 2002 and December 2018 was performed. Neurological outcomes were assessed at 3, 6, 12, and 24 months postinjury with the Glasgow Outcome Scale. The authors used ML models including support vector machine, neural network, decision tree, and naïve Bayes models to predict outcome across all 4 time points by using clinical information available on admission, and they compared performance to a logistic regression model. The authors attempted to predict unfavorable versus favorable outcomes (Glasgow Outcome Scale scores of 1-3 vs 4-5), as well as mortality. Models' performance was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC) with 95% confidence interval and balanced accuracy. RESULTS: Of the 599 patients in the database, the authors included 501, 537, 469, and 395 at 3, 6, 12, and 24 months posttrauma. Across all time points, the AUCs ranged from 0.71 to 0.85 for mortality and from 0.62 to 0.82 for unfavorable outcomes with various modeling strategies. Decision tree models performed worse than all other modeling approaches for multiple time points regarding both unfavorable outcomes and mortality. There were no statistically significant differences between any other models. After proper calibration, the models had little variation (0.02-0.05) across various time points. CONCLUSIONS: The ML models tested herein performed with equivalent success compared with logistic regression techniques for prognostication in TBI. The TBI prognostication models could predict outcomes beyond 6 months, out to 2 years postinjury.

Machine learning algorithms for improved prediction of in-hospital outcomes after moderate-to-severe traumatic brain injury: a Chinese retrospective cohort study.

AIM: Controversy remains high over the superiority of advanced machine learning (ML) algorithms to conventional logistic regression (LR) in the prediction of prognosis after traumatic brain injury (TBI). This study aimed to compare the performance of ML and LR models in predicting in-hospital prognosis after TBI. METHOD: In a single-center retrospective cohort of adult patients hospitalized for moderate-to-severe TBI (Glasgow coma score ≤12) in our hospital from 2011 to 2020, LR and three ML algorithms (XGboost, lightGBM, and FT-transformer) were run to build prediction models for in-hospital mortality and the Glasgow Outcome Scale (GOS) functional outcomes using either all 19 clinical and laboratory features or the 10 non-laboratory ones collected at admission to the neurological intensive care unit. The Shapley (SHAP) value was used for model interpretation. RESULT: In total, 482 patients had an in-hospital mortality rate of 11.0%. A total of 23.0% of the patients had good functional scores (GOS ≥ 4) at discharge. All ML models performed better than the LR model in predicting in-hospital prognosis after TBI, among which the lightGBM model showed the best performance: When predicting mortality, the lightGBM model yielded an area under the curve (AUC) of 0.953 using all 19 features (the LR model: 0.813) and an AUC of 0.935 using 10 non-laboratory features (the LR model: 0.803); when predicting GOS functional outcomes, it yielded an AUC of 0.913 using all 19 features (the LR model: 0.832) and an AUC of 0.889 using non-laboratory data (the LR model: 0.818). The SHAP method identified key contributors to explain the lightGBM models. Finally, the integration of the lightGBM models with different prediction purposes was found to provide refined prognostic information, particularly for patients who survived moderate-to-severe TBI. CONCLUSION: The study supported the superiority of ML to LR in predicting prognosis after moderate-to-severe TBI and highlighted its potential use for clinical application.

Serum neurofilament light as a predictor of outcome in subarachnoid haemorrhage.

BACKGROUND: Prognostication of clinical outcome in patients suffering from aneurysmal subarachnoid haemorrhage (SAH) is a challenge. There are no biochemical markers in routine use that can aid in prognostication. Neurofilament light (NFL) measured in cerebrospinal fluid (CSF) has been associated with clinical outcome in previous studies. OBJECTIVE: To investigate if serum levels of NFL correlate with CSF levels and long-term clinical outcome in patients suffering from SAH. METHODS: We conducted an observational cohort study of 88 patients treated for SAH at Umeå University Hospital in 2014-2018. Serum and CSF samples were analysed using an enzyme-linked immunosorbent assay to quantify NFL levels. Outcome was assessed using Glasgow Outcome Scale Extended and dichotomised as favourable or unfavourable. Differences in NFL levels between outcome groups were analysed using repeated measurements ANOVA. Relationship between CSF and serum NFL levels was analysed using Pearson's correlation. A multivariate binary logistic regression model and a receiver operation characteristic curve were used to assess the predictive value of serum NFL. RESULTS: A significant correlation between serum and CSF-NFL levels could be seen (Pearson's correlation coefficient = 0.7, p < .0001). Mean level of serum NFL was higher in the unfavourable outcome group than the favourable outcome group (p < .0001), in all epochs of SAH, and correlated with initial disease severity on the World Federation of Neurosurgical Societies scale. Serum NFL in the late phase displayed the best predictive potential in a receiver operation characteristic curve analysis (AUC=0.845, p < .0001). CONCLUSION: Levels of NFL in serum and CSF are correlated. Early serum NFL levels seem to reflect initial tissue damage and serum NFL levels in the late phase may reflect secondary events such as vasospasm or delayed cerebral ischemia. Serum NFL may be used as a prognostic marker of clinical outcome in SAH.

Validity of Glasgow outcome scale-extended (GOSE) mobile application for assessment of outcome in traumatic brain injury patients.

PURPOSE: To develop the Glasgow Outcome Scale-Extended (GOSE) mobile application and examine the validity of the application against GOSE scoring based on traditional interview method. METHODS: Concurrent validity was determined by comparing two independent raters' scoring for GOSE of 102 patients with traumatic brain injury, who had attended outpatient department of a tertiary neuro hospital. Agreement was assessed between the traditional interview-based pen and paper scoring and algorithm based mobile application scoring of GOSE. RESULTS: Agreement was tested using Cohen's kappa, and the analysis revealed near perfect agreement between two raters (0.89) (p < 0.01). CONCLUSION: The GOSE mobile application can measure GOSE Score similar to the traditional interview method. This application may help fasten the process of assessing outcome in TBI patients in clinical practice and in research.

PREDICT-TBI: Comparison of Physician Predictions with the IMPACT Model to Predict 6-Month Functional Outcome in Traumatic Brain Injury.

BACKGROUND: Predicting functional outcome in critically ill patients with traumatic brain injury (TBI) strongly influences end-of-life decisions and information for surrogate decision makers. Despite well-validated prognostic models, clinicians most often rely on their subjective perception of prognosis. In this study, we aimed to compare physicians' predictions with the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic model for predicting an unfavorable functional outcome at 6 months after moderate or severe TBI. METHODS: PREDICT-TBI is a prospective study of patients with moderate to severe TBI. Patients were admitted to a neurocritical care unit and were excluded if they died or had withdrawal of life-sustaining treatments within the first 24 h. In a paired study design, we compared the accuracy of physician prediction on day 1 with the prediction of the IMPACT model as two diagnostic tests in predicting unfavorable outcome 6 months after TBI. Unfavorable outcome was assessed by the Glasgow Outcome Scale from 1 to 3 by using a structured telephone interview. The primary end point was the difference between the discrimination ability of the physician and the IMPACT model assessed by the area under the curve. RESULTS: Of the 93 patients with inclusion and exclusion criteria, 80 patients reached the primary end point. At 6 months, 29 patients (36%) had unfavorable outcome. A total of 31 clinicians participated in the study. Physicians' predictions showed an area under the curve of 0.79 (95% confidence interval 0.68-0.89), against 0.80 (95% confidence interval 0.69-0.91) for the laboratory IMPACT model, with no statistical difference (p = 0.88). Both approaches were well calibrated. Agreement between physicians was moderate (κ = 0.56). Lack of experience was not associated with prediction accuracy (p = 0.58). CONCLUSIONS: Predictions made by physicians for functional outcome were overall moderately accurate, and no statistical difference was found with the IMPACT models, possibly due to a lack of power. The significant variability between physician assessments suggests prediction could be improved through peer reviewing, with the support of the IMPACT models, to provide a realistic expectation of outcome to families and guide discussions about end-of-life decisions.

Effects of Sevoflurane and Propofol on Neurological Recovery of Traumatic Brain Injury Patients in the Early Postoperative Stage: A Retrospective Cohort Study.

Objective To investigate the effects of propofol and sevoflurane on neurological recovery of traumatic brain injury (TBI) patients in the early postoperative stage.Methods We retrospectively analyzed the clinical data of TBI patients who underwent craniotomy or decompressive craniectomy. Generalized additive mixed model (GAMM) was used to analyze effects of propofol and sevoflurane on Glasgow Coma Scale (GCS) on postoperative days 1, 3, and 7. Multivariate regression analysis was used to analyze effects of the two anesthetics on Glasgow Outcome Scale (GOS) at discharge.Results A total of 340 TBI patients were enrolled in this study. There were 110 TBI patients who underwent craniotomy including 75 in the propofol group and 35 in the sevoflurane group, and 134 patients who underwent decompressive craniectomy including 63 in the propofol group and 71 in the sevoflurane group. It showed no significant difference in GCS at admission between the propofol and the sevoflurane groups among craniotomy patients (ß = 0.75, 95%CI: -0.55 to 2.05, P = 0.260). However, elevation in GCS from baseline was 1.73 points (95%CI: -2.81 to -0.66, P = 0.002) less in the sevoflurane group than that in the propofol group on postoperative day 1, 2.03 points (95%CI: -3.14 to -0.91, P < 0.001) less on day 3, and 1.31 points (95%CI: -2.43 to -0.19, P = 0.022) less on day 7. The risk of unfavorable GOS (GOS 1, 2, and 3) at discharge was higher in the sevoflurane group (OR = 4.93, 95%CI: 1.05 to 23.03, P = 0.043). No significant difference was observed among two-group decompressive craniectomy patients in GCS and GOS.Conclusions Compared to propofol, sevoflurane was associated with worse neurological recovery during the hospital stay in TBI patients undergoing craniotomy. This difference was not detected in TBI patients undergoing decompressive craniectomy.

Comparison of the predictive value of the Helsinki, Rotterdam, and Stockholm CT scores in predicting 6-month outcomes in patients with blunt traumatic brain injuries.

PURPOSE: Despite advances in modern medicine, traumatic brain injuries (TBIs) are still a major medical problem. Early diagnosis of TBI is crucial for clinical decision-making and prognosis. This study aims to compare the predictive value of Helsinki, Rotterdam, and Stockholm CT scores in predicting the 6-month outcomes in blunt TBI patients. METHODS: This cohort study was conducted on blunt TBI patients of 15 years or older. All of them were admitted to the surgical emergency department of Shahid Beheshti Hospital in Kashan, Iran from 2020 to 2021 and had abnormal trauma-related findings on brain CT images. The patients' demographic data such as age, gender, history of comorbid conditions, mechanism of trauma, Glasgow coma scale, CT images, length of hospital stay, and surgical procedures were recorded. The Helsinki, Rotterdam, and Stockholm CT scores were simultaneously determined according to the existing guidelines. The included patients' 6-month outcome was determined using the Glasgow outcome scale extended. M Data were analyzed by SPSS software version 16.0. Sensitivity, specificity, negative/positive predictive value and the area under the receiver operating characteristic curve were calculated for each test. The Kappa agreement coefficient and Kuder Richardson-20 were used to compare the scoring systems. RESULTS: Altogether 171 TBI patients met the inclusion and exclusion criteria, with the mean age of (44.9 ± 20.2) years. Most patients were male (80.7%), had traffic related injuries (83.1%) and mild TBIs (64.3%). Patients with lower Glasgow coma scale had higher Helsinki, Rotterdam, and Stockholm CT scores and lower Glasgow outcome scale extended scores. Among all the scoring systems, the Helsinki and Stockholm scores showed the highest agreement in predicting patients' outcomes (kappa = 0.657, p < 0.001). The Rotterdam scoring system had the highest sensitivity (90.1%) in predicting death of TBI patients, whereas the Helsinki scoring system had the highest sensitivity (89.8%) in predicting the 6-month outcome in TBI patients. CONCLUSION: The Rotterdam scoring system was superior in predicting death in TBI patients, whereas the Helsinki scoring system was more sensitive in predicting the 6-month outcome.