Basal ganglia haemorrhages: efficacy and limits of different surgical strategies

To assess the role of surgery in patients with spontaneous basal ganglia haemorrhages, we evaluated poor outcome (mortality and prolonged unawareness) one month after 'open' surgery in patients with haematomas larger than 30 cm(3). One hundred and twenty-seven patients were traced over a 5-year period. Excluding deeply comatose patients (Glasgow Coma Scale [GCS] 3-4, n?=?39), we analysed the remaining 88 patients, dividing them into two homogeneous groups according to the modality of treatment: aggressive or palliative. Multivariate analysis was applied both to the overall population and to the two groups in order to determine factors prognostic for poor outcome. Aggressive treatment was defined as surgery as the first-choice treatment modality aimed at 'complete' evacuation. Palliative treatment was defined as delayed surgery and/or surgery aimed at clot removal only to obtain internal decompression. Efficacy was assessed in patients having the same initial GCS score in both groups. Factors significantly associated with outcome were preoperative complications, volume, timing of operation, residual clots and postoperative complications. Outcomes were significantly better for aggressive surgery (17% vs. 68%, p?相似文献   

Brain abscess in 142 patients: factors influencing outcome and mortality

BACKGROUND: With the introduction of CT, stereotactic techniques, and broad-spectrum antibiotics, the outcome for brain abscess has dramatically improved. The purpose of this study was to identify prognostic factors by reviewing data on 142 patients with brain abscess. METHODS: Clinical data, including age, sex, medical history, duration of symptoms, initial neurological status, associated predisposing factors, laboratory data, treatment, and abscess characteristics, were considered as potential prognostic factors. A comparison was made between patients with favorable (GOS: moderate disability or good recovery) and those with unfavorable (GOS: death, persistent vegetative status, or severe disability) outcomes at discharge. Univariate (chi(2) analysis or Fisher's exact test) and multivariate logistic regression analyses were used to identify prognostic factors. Data were considered significant when the 2-tailed P value was lower than .05. RESULTS: There were 98 male and 44 female patients (male/female ratio, 2.2). Their average age at diagnosis was 41.5 years (range, 2-84 years). There were 105 patients with a favorable outcome and 37 with an unfavorable outcome. Both univariate and multivariate analyses indicated that patients who were male, had an initial GCS score >12, had no other septic complication, or had Gram-positive cocci grown in abscess cultures had better outcomes. No association was found between outcome and other factors, including age, focal neurological deficits, seizures, laboratory findings, characteristics of the abscesses, associated factors, and treatment modalities. CONCLUSIONS: With the advancement of imaging studies and broad-spectrum antibiotic therapies, the outcome of brain abscess depends on prompt awareness of the diagnosis and effective infection control.     

Toxoplasmic encephalitis in patients with acquired immunodeficiency syndrome--four case reports

Four patients, all males aged 40-64 years, presented with toxoplasmic encephalitis associated with human immunodeficiency virus (HIV) infection manifesting as nonspecific neurological deficits such as epilepsy or hemiparesis. Magnetic resonance imaging showed single or multiple lesions with ring enhancement, mimicking metastatic brain tumor or brain abscess. Marked eosinophilia was noted in three patients. Two patients who received anti-toxoplasma chemotherapy in the early stage had a good outcome. However, the other two patients suffered rapid neurological deterioration and needed decompressive surgery, resulting in a poor outcome. Toxoplasma diffusely infects the whole central nervous system from the early stage. The outcome for patients who needed emergency surgery was poor. Therefore, this rare but increasingly common infectious disease must be considered in the differential diagnosis of a patient with neuroimaging findings similar to those of metastatic tumor or brain abscess. Appropriate chemotherapy should be started immediately after HIV-positive reaction is identified in patients with single or multiple mass lesions with ring enhancement.     

Craniocerebral gunshot injuries in South Africa--a suggested management strategy.

OBJECTIVE: To determine the outcome of craniocerebral gunshot injuries, analyse factors that affect prognosis and suggest a management protocol. DESIGN: A retrospective analysis of civilian craniocerebral gunshot injuries treated over a 7-year period. SETTING: Groote Schuur Hospital's neurosurgery and trauma unit service. PATIENTS: One hundred and eighty-one patients with craniocerebral gunshot injuries were admitted to the Department of Neurosurgery, Groote Schuur Hospital, University of Cape Town, over a 7-year period and a retrospective analysis of these patient records with regard to outcome and prognostic factors was carried out. RESULTS: Seventy-six patients sustained non-penetrating injuries, 8 (11%) of whom had underlying cerebral injury on computed tomography (CT) scan. The prognosis was good in the case of non-penetrating injuries. One hundred and five patients sustained penetrating injuries and 57% (62) had a poor outcome. A Glasgow Coma Score (GCS) of 5 or less following resuscitation was associated with a 98% mortality rate. CT scan evidence of transventricular injury was associated with 100% mortality, bihemispheric injury with 90% mortality, and diffuse cerebral swelling with 81% mortality. CONCLUSION: Patients with non-penetrating craniocerebral gunshot injuries should all undergo a CT scan as 10% will have cerebral injury. The prognosis is normally good. In penetrating craniocerebral gunshot injuries a GCS of 5 or less, or a GCS of 8 or less with CT scan findings of transventricular or bihemispheric injury have such a poor outcome that conservative treatment is indicated.     

Early Glasgow Outcome Scale scores predict long-term functional outcome in patients with severe traumatic brain injury

Patients sustaining severe traumatic brain injury (TBI) have variable long-term outcomes. We examined the association between Glasgow Outcome Scale (GOS) assessed at 3 months and long-term outcomes at 12 months after TBI. We studied 159 patients with severe, closed traumatic brain injuries (Glasgow Coma Scale [GCS] 相似文献   

Traumatic intracerebellar hemorrhage: clinicoradiological analysis of 81 patients

OBJECTIVE: We report 81 patients with a traumatic intracerebellar hemorrhagic contusion or hematoma managed between 1996 and 1998 at 13 Italian neurosurgical centers. METHODS: Each center provided data about patients' clinicoradiological findings, management, and outcomes, which were retrospectively reviewed. RESULTS: A poor result occurred in 36 patients (44.4%). Forty-five patients (55.6%) had favorable results. For the purpose of data analysis, patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (39/81 cases; GCS score, > or =8), the outcome was favorable in 95% of cases. In Group 2 (42/81 cases; GCS score, <8), the outcome was poor in 81% of cases. Twenty-seven patients underwent posterior fossa surgery. Factors correlating with outcome were GCS score, status of the basal cisterns and the fourth ventricle, associated supratentorial traumatic lesions, mechanism of injury, and intracerebellar clot size. Multivariate analysis showed significant independent prognostic effect only for GCS score (P = 0.000) and the concomitant presence of supratentorial lesions (P = 0.0035). CONCLUSION: This study describes clinicoradiological findings and prognostic factors regarding traumatic cerebellar injury. A general consensus emerged from this analysis that a conservative approach can be considered a viable, safe treatment option for noncomatose patients with intracerebellar clots measuring less than or equal to 3 cm, except when associated with other extradural or subdural posterior fossa focal lesions. Also, a general consensus was reached that surgery should be recommended for all patients with clots larger than 3 cm. The pathogenesis, biomechanics, and optimal management criteria of these rare lesions are still unclear, and larger observational studies are necessary.     

Multiple cerebral abscesses because of Listeria monocytogenes: three case reports and a literature review of supratentorial listerial brain abscess(es)

BACKGROUND: Central nervous system involvement often follows bacteremia because of Listeria monocytogenes. Meningitis is clinically the most common manifestation, while brain abscess occurs in about 1% of patients. Brain abscess is usually solitary but in recent years, probably in part because of the availability of computerized tomography and magnetic resonance imaging, several reports have described two or more separate supratentorial abscesses. METHODS: We have described three patients with listerial brain abscesses and reviewed the North American and European literature of brain abscess(es) because of L. monocytogenes through December 2001. We have evaluated the role of underlying diseases and therapeutic immunosuppression on the development of solitary or greater than one brain abscess. RESULTS: In contrast to meningitis, where immunosuppression does not predispose either to disease incidence or to higher mortality, patients with solitary and particularly those with more than one supratentorial abscess usually are immunosuppressed either by disease or by therapy. Corticosteroids in particular are significant predisposing factors, especially in those patients with two or more brain abscesses. Mortality resulting from listerial brain abscess, whether solitary or multiple, is nearly three times higher than nonlisterial brain abscess, probably in part because of both underlying diseases and immunosuppressive therapy. CONCLUSIONS: Therapy with high-dose ampicillin in combination with gentamicin appear to be the drugs of choice, followed by trimethoprim/sufamethoxazole and vancomycin. In general, antimicrobial therapy appears to be satisfactory treatment without surgical intervention.     

Severe head injury in children: impact of risk factors on outcome.

BACKGROUND: Outcome after severe head injury has been shown in some studies to be more favorable in children than in adults. Mortality rates reported range between 20% and 40% for children. Only contradicting data are available regarding the impact of trauma modalities on long-term outcome, or the relative influence of head fractures, intracranial hemorrhages, and brain edema on survival or neurologic sequelae in children. METHODS: A retrospective study in a tertiary care facility of long-term outcome of children after severe head injury, and analysis of risk factors for poor outcome. All children up to 16 years of age with severe head injury (Glasgow Coma Scale [GCS] score < or = 8), which have been treated in the pediatric intensive care unit from 1977 until 1994 in a single institution. RESULTS: A total of 150 children with severe head injury (GCS score < or = 8) were treated, 92 of them (61.3%) had traffic-related injuries. The median age was 6.6 years (SD +/- 3.6). There were 96 boys (64%) and 54 girls (36%). Sixty-five children (43.3%) had skull fractures, 87 patients (58.0%) developed an intracranial hemorrhage, and 79 patients (52.7%) developed a diffuse brain swelling/edema visible in computed tomographic scans within 72 hours after trauma. Of 150 children treated, 33 died (22%). In most cases, death was related to the development of secondary brain edema. Fifty-nine children (39.3%) had severe neurologic impairments at the time of discharge. The most significant risk factors for adverse outcome, shown by multivariate analysis, were primary areflexia and secondary brain edema. The risk for development of brain edema and poor prognosis was well predicted by the GCS score. CONCLUSION: The overall death rate in this study of children with severe head injury was low (22%) compared with other studies. However, the incidence of severe neurologic impairment at discharge remained high. The major risks for death or neurologic impairment were primary areflexia and the development of secondary brain swelling/edema, indicated by a low GCS score.     

Current Treatment Strategies and Factors influencing Outcome in Patients with Bacterial Brain Abscess

Summary  We clearly determined the key to managing patients with brain abscess by retrospectively evaluating the factors affecting poor outcome in these patients. This study included 113 patients with brain abscess diagnosed in the CT era. Basic characteristics and therapeutic parameters were estimated as independent predictors of poor outcome by using univariate and multivariate logistic regression analysis. Patients with poor outcomes more frequently had deeply-located abscesses (p<0.02), IVROBA (intraventricular rupture of brain abscess) (p<0.001) and were in a severely deteriorated neurological state (p<0.001) than those with good outcomes. Multiple logistic regression analysis predicted that IVROBA (ORs, 24.5; 95% CI, 3.04 to 197.9) and severely deteriorated cases (ORs, 13.7; 95% CI, 2.34 to 80.8) resulting from IVROBA increased the relative risk of poor outcome. Patients with IVROBA more frequently had also deeply-located abscesses (p<0.005), positively immunocompromised states (p<0.05) an (p<0.003) than those without IVROBA. Patients with metastatic abscess had also IVROBA (p<0.006). Multiple logistic regression analysis anticipated that deeply-located abscess (ORs, 3.90; 95% CI, 1.38 to 11.04), and metastatic abscess (ORs, 12.26; 95% CI, 1.35 to 111.2) increased the relative risk of IVROBA. Patients in an obtunded state and with marked neurological deficit had IVROBA more often than patients in an alert state and/or mild neurological deficit (ORs, 3.23; 95% CI, 1.17 to 8.86, (p<0.03) before treatment. Our findings suggest that IVROBA strongly influences poor outcome in patients with brain abscess. The key to decreasing poor outcomes may be the prevention and management of IVROBA, by evaluating intracranial pressure pathophysiology. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with appropriate intravenous and intrathecial administration of antibiotics.     

Early prediction of outcome in very severe closed head injury

BACKGROUND: People with severe head injury and admission Glasgow Coma Scale (GCS) score < or =5 have a poor outcome and greatly strain limited resources. AIM: To identify patients with the best chances of survival, using routine clinical measures. METHODS: People attending the trauma intensive care unit, who had isolated blunt head injury and GCS< or =5 and who had survived > or =4h, were included in the study, resuscitated and clinically assessed. The GCS score was followed serially after admission. Bivariate analysis of various parameters with outcome was performed using the chi-square test. Serial GCS scores were compared with admission GCS by paired t-testing. RESULTS: Of the 102 patients who were studied prospectively, 78 (76.5%) died and 24 (23.5%) survived. Age, gender, pre-hospital delay and admission GCS scores were comparable between the two groups. Adequate spontaneous respiration, brisk pupillary light reactivity on admission and increase in GCS by at least 2 at 24h after admission significantly affected the outcome (p<0.05). In the presence of all these factors, the survival rate increased from 6.1% to 57.1% (p<0.001). CONCLUSIONS: People with GCS score < or =5 still have a reasonable chance of survival, so all patients should be aggressively managed initially. Better survival was observed among those with adequate spontaneous respiration, good pupillary reaction and improvement in GCS of at least 2 at 24h. These clinical parameters can help to predict survival and thus make best use of limited resources.     

Outcome prediction in early management of severe head injury: an experience in Malaysia.

The outcome of 109 patients with severe head injury was studied in relation to clinical and computed tomographic (CT) criteria on admission, after resuscitation. Age, Glasgow Coma Score (GCS) and state of pupils strongly correlated with outcome. The presence of hypothalamic disturbances, hypoxia and hypotension were associated with an adverse outcome. The CT indicators associated with poor outcome were perimesencephalic cistern (PMC) obliteration, subarachnoid haemorrhage, diffuse axonal injury and acute subdural haematoma. The prognostic value of midline shift and mass effect were influenced by concomitant presence of diffuse brain injury. For the subset of patients aged < 20 years, with GCS 6-8 and patent PMC (n = 21), 71.4% correct predictions were made for a good outcome. For the subset of patients aged > 20 years, with GCS 3-5 and partial or complete obliteration of PMC (n = 28), 89.3% correct predictions were made for a poor outcome.     

Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?

BACKGROUND: Low Glasgow Coma Scale score (GCS) and pupillary status predict poor outcomes in head injury (HI) patients. We compared the mortality of GCS 3 patients having bilateral fixed and dilated pupils (BFDP) with GCS 3 patients having reactive pupils (RP). We then determined if trauma system or patient factors were responsible for the difference in mortality. METHODS: We reviewed all adult, blunt HI patients with GCS=3, admitted to our institution from January 1, 2001 to December 31, 2003. Demographics, injury data, prehospital times, procedures, and outcomes were recorded. RESULTS: During this period, 245 patients were admitted with GCS of 3, and met inclusion criteria. In all, 173 patients were analyzed, after excluding 23 patients who were dead-on-arrival, and 45 others, who were intoxicated with alcohol, or received paralytic agents in the trauma room. All BFDP patients died, whereas 42.0% of reactive pupil (RP) patients died (p < 0.0001). With regards to patient factors, BFDP patients were more likely to be unstable, have extra-axial bleeding, and evidence of midline shift and/or herniation. Trauma system factors, however, may also have had an impact on outcome. Despite having more extra-axial bleeding, BFDP patients were less likely to have a neurosurgical operation than RP patients. CONCLUSION: Patients with GCS of 3 and BFDP have a dismal prognosis. These patients have suffered devastating brain injuries and tend to be hemodynamically unstable. Clinicians, however, are less likely to aggressively treat BFDP patients than RP patients. Further prospective studies are required to determine which patients with GCS of 3 and BFDP are likely to benefit from aggressive treatment.     

Fungal brain abscess in transplant recipients: epidemiologic,microbiologic, and clinical features

Fungal brain abscess is an unusual but serious complication associated with solid organ and hematopoietic stem cell transplantation. To examine the epidemiology and clinical features of fungal brain abscess in transplant recipients, we reviewed retrospectively all cases of fungal brain abscess diagnosed during a 3-yr period among 1,620 adult patients who underwent allogeneic or autologous stem cell, liver, heart, lung, or renal transplantation at one institution. Seventeen cases of fungal brain abscess were identified and occurred a median of 140 d post-transplantation. Fungal brain abscess was more common among allogeneic stem cell transplant recipients (p < 0.01). Aspergillus species were most commonly isolated, but unusual, opportunistic molds were also identified. Altered mental status was present in 65% of patients, and multiple brain lesions were commonly seen on imaging studies. Although fungal brain abscess is an uncommon disease in this population, outcome was poor, suggesting that early recognition of this disease might be helpful.     

Prognostic factors in acute subdural hematoma and the significance of serum FDP measurement

Sixty-two cases of acute subdural hematoma were clinically analyzed with special reference to such prognostic factors as age, Glasgow Coma Scale (GCS) score on admission, pupillary signs, decerebration, and initial computed tomography (CT) findings. Intraparenchymal lesions demonstrated by CT were evaluated according to Yamaura's classification. In 19 cases, serum fibrin and fibrinogen degradation products (FDP) were measured at the time of admission. Emergency surgery was performed in 46 cases, and the remaining 16 patients were treated conservatively. The final outcome was judged according to the Glasgow Outcome Scale, and patients were divided into a "good outcome" group (good recovery or moderate disability) and a "poor outcome" group (severe disability, vegetative state, or death). In general, the outcomes proved to be unsatisfactory. Forty-four patients (71%) had a poor outcome, with 32/62 (52%) mortality, and only 18 (29%) had a good outcome. The clinical factors associated with a poor outcome were age over 64 years, a GCS score on admission of less than 7, decerebration, and absence of pupillary reaction to light. Initial CT scans showed brain damage in 46 patients (74%), 39 (85%) of whom had a poor outcome. This indicates that the outcome was significantly related to brain injury complicating the acute subdural hematoma. A high serum FDP level was similarly related to a poor outcome, which suggests that the serum FDP level reflects the degree of both primary and secondary brain injury. Thus, measurement of serum FDP may be valuable both in assessing clinical status and in evaluating the extent of brain injury in acute subdural hematoma.     

The prognostic reliability of the Glasgow coma score in traumatic brain injuries: evaluation of MRI data

Purpose

To clarify the predictive power of the Glasgow coma score (GCS) after traumatic brain injury (TBI) and in the context of brain stem lesions.

Methods

In 143 patients who had suffered severe TBI, the GCS was correlated to brain damage as visualized by cranial magnetic resonance imaging (MRI). This technique evaluates the damage to the brain stem in particular. The Brussels coma score (BCS) was also used.

Results

The GCS was not significantly correlated to brain stem lesions when it was only scored at the time of admission. When MRI was not used later on, the GCS showed a poor ability to predict the outcome. After 24 h, and on the day of MRI screening, the GCS was significantly correlated with two parameters: outcome (the higher the GCS, the better the outcome) and the frequency of patients without injuries to the brainstem in MRI (the higher the GCS, the higher this frequency). These correlations were much more evident when the BCS was used. The prognostic power of the GCS was found to vary over time; for example: a GCS of 3 at admission was associated with a favorable prognosis; a GCS of 4 signified a poor prognosis, irrespective of the time point at which the GCS was scored; and the prognostic power of a GCS of 5 deteriorated from the day of the MRI onwards, whereas the prognostic power of a GCS of 6 or 7 varied little over time.

Conclusions

We only recommend the use of the GCS for prognostic evaluation in a multidimensional model. Study protocols should contain additional brain stem function parameters (BCS, pupil condition, MRI).     

Early enteral nutrition and clinical outcomes of severe traumatic brain injury patients in acute stage: a multi-center cohort study

Guidelines for patients with severe traumatic brain injury (sTBI) published in 2007 recommend providing early nutrition after trauma. Early enteral nutrition (EN) started within 48 h post-injury reduces clinical malnutrition, prevents bacterial translocation from the gastrointestinal tract, and improves outcome in sTBI patients sustaining hypermetabolism and hypercatabolism. The aim of this study was to examine the effect of early EN support on survival rate, Glasgow Coma Scale (GCS) score, and clinical outcome of sTBI patients. Medical records of sTBI patients with GCS scores 4-8 were recruited from 18 hospitals in Taiwan, excluding patients with GCS scores ≤3. During 2002-2010, data from 145 EN patients receiving appropriate calories and nutrients within 48 h post-trauma were collected and compared with 152 non-EN controls matched for gender, age, body weight, initial GCS score, and operative status. The EN patients had a greater survival rate and GCS score on the 7th day in the intensive care unit (ICU), and a better outcome at 1 month post-injury. After adjusting for age, gender, initial GCS score, and recruitment period, the non-EN patients had a hazard ratio of 14.63 (95% CI 8.58-24.91) compared with EN patients. The GCS score during the first 7 ICU days was significantly improved among EN patients with GCS scores of 6-8 compared with EN patients with GCS scores of 4-5 and non-EN patients with GCS scores of 6-8. This finding demonstrates that EN within 48 h post-injury is associated with better survival, GCS recovery, and outcome among sTBI patients, particularly in those with a GCS score of 6-8.     

Brain abscesses--the Groote Schuur experience, 1993-2003

OBJECTIVE: To review management and outcome of patients with brain abscess treated at Groote Schuur Hospital (GSH) between 1993 and 2003. PATIENTS AND METHODS: Case notes, radiological results and laboratory records were reviewed retrospectively for 121 patients at GSH who underwent a neurosurgical procedure for treatment of a brain abscess between 1993 and 2003. Patients not treated surgically were excluded. Follow-up with serial computed tomography (CT) scans, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels and the temperature chart were used to determine the duration of parenteral antibiotic treatment and the need for repeat surgical evacuation of pus by either aspiration or excision of the capsule. RESULTS: The mean patient age was 33 years, with a male-to-female ratio of 5:1. Headache, depressed level of consciousness and pyrexia were the commonest presenting symptoms. Other symptoms included seizures and hemiparesis. The frontal lobe was the commonest site (44%); the majority of abscesses occurred as a result of infection following trauma. Mastoiditis (21%) and sinusitis (8%) were the second and third most common causes. Organisms were identified in 81% of cases; polymicrobial infections occurred in half of these. Thirty-three different organisms were identified, the majority of which were Gram-positive bacteria. Anaerobes were present in 23%, while methicillin-resistant Staphylococcus aureus was identified in 1 patient. Nocardia was seen in 3 patients, 2 of whom were diabetic. The average duration of parenteral antibiotic therapy was 15 and 19 days for excision and aspiration respectively. Accurate ESR records were available in 75% of cases, with a positive predictive value in 81%, while CRP (in use since 1999) was helpful in 92% of cases. OUTCOME: Sixteen patients (13%) died, 12 of whom had been admitted with a Glasgow Coma Score (GCS) of less than 4T/15. Thirteen patients developed epilepsy. On discharge, patients continued to take oral antibiotics for another 4 weeks, at the end of which they were reviewed at the neurosurgery outpatient department. CONCLUSION: Compared with previous studies from this hospital, mortality and morbidity have been diminishing progressively. GCS at the time of admission remains the most important prognostic factor.     

Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury

Objective

To analyse the association between the Glasgow Coma Scale (GCS) score at intensive care unit (ICU) discharge and the 1-year outcome of patients with severe traumatic brain injury (TBI).

Design

Retrospective analysis of prospectively collected observational data.

Patients

Between 01/2001 and 12/2005, 13 European centres enrolled 1,172 patients with severe TBI. Data on accident, treatment and outcomes were collected. According to the GCS score at ICU discharge, survivors were classified into four groups: GCS scores 3–6, 7–9, 10–12 and 13–15. Using the Glasgow Outcome Scale (GOS), 1-year outcomes were classified as “favourable” (scores 5, 4) or “unfavourable” (scores <4). Factors that may have contributed to outcomes were compared between groups and for favourable versus unfavourable outcomes within each group.

Main results

Of the 538 patients analysed, 308 (57 %) had GCS scores 13–15, 101 (19 %) had scores 10–12, 46 (9 %) had scores 7–9 and 83 (15 %) had scores 3–6 at ICU discharge. Factors significantly associated with these GCS scores included age, severity of trauma, neurological status (GCS, pupils) at admission and patency of the basal cisterns on the first computed tomography (CT) scan. Favourable outcome was achieved in 74 % of all patients; the rates were significantly different between GCS groups (93, 83, 37 and 10 %, respectively). Within each of the GCS groups, significant differences regarding age and trauma severity were found between patients with favourable versus unfavourable outcomes; neurological status at admission and CT findings were not relevant.

Conclusion

The GCS score at ICU discharge is a good predictor of 1-year outcome. Patients with a GCS score <10 at ICU discharge have a poor chance of favourable outcome.     

Patients beyond salvation?: Various categories of trauma patients with a minimal Glasgow Coma Score

Introduction

Trauma patients in an unresponsive state upon presentation to the Emergency Department have a poor prognosis. Rapid assessment of injuries combined with life-preserving therapy is required but defining the optimal strategy can be complicated when multiple organ systems are involved. This study analysed various categories of trauma patients with a Glasgow Coma Scale (GCS) of 3 on admission and evaluated the relation between injuries, clinical condition, treatment and outcome.

Patients and methods

A retrospective cohort-study, performed at a level 1 Trauma Center from 2002 to 2005. Trauma patients of all ages with GCS of 3 (without sedation) and Injury Severity Score (ISS) ≥16 were included. The collected patient data comprised data on demographics, mechanism of injury, physiological condition on admission, diagnosis, ISS, treatment, admission to Intensive Care Unit, complications and outcome.

Results

Ninety-seven patients were included and divided into three groups based on the pathology that caused the GCS of 3: traumatic brain injury N = 48 (49%), anoxic brain injury N = 27 (28%) and haemorrhagic shock N = 22 (23%). The overall mortality was 81%; 91% of the haemorrhagic shock patients, 81% of the ABI patients and 77% of the TBI patients died. Eighteen patients survived of whom five patients (5%) made a good recovery. The pupillary light response and pH on admission were related to mortality. No relation with ISS, age or hypothermia was found.

Discussion

Distinguishing salvageable patients from those beyond salvation remains problematic. This study illustrated the diversity of patients, their injuries and their condition upon presentation to the hospital as well as the limitations of therapy.

Conclusion

Trauma patients with a GCS of 3 have a poor outcome. Despite aggressive treatment only 5% of the patients made a good recovery. Pupil reactivity and the pH on admission were found to be related to mortality.     

Two cases of Nocardia farcinica brain abscess

Brain abscess caused by Nocardia is a relatively rare disease, but its prognosis is poor, with the fatality being 3 times as high as that of other types of brain abscess. Nocardiosis caused by N. farcinica has higher fatality rates than nocardiosis caused by the other bacteria of the genus Nocardia. We report two cases of brain abscess caused by N. farcinica. Case 1: 72-year-old immunocompetent man. In this case, the disease healed in response to burr hole drainage and treatment with antibiotics (pazufloxacin, ciprofloxacin). Case 2: A 78-year-old woman with a history of liver cirrhosis. This patient received burr hole drainage and treatment with multiple antibiotics (sulfamethoxazole/trimethoprim, pazufloxacin, meropenem, amikacin, minocycline, and linezolid). Her brain abscess tended to alleviate but her general condition worsened, leading to death. N. farcinica is often resistant to multiple antibiotics. For treatment of brain abscess caused by this bacterium, it is essential to perform pathogen identification and a drug sensitivity test immediately, and to select optimum antibiotics, taking into account the general condition of individual patients.