Prognostic implications of hyperglycaemia in paediatric head injury

Fifty children with head injury were evaluated in an attempt to estabilish a correlation between post-traumatic hyperglycaemia and long-term outcome. In all the patients, the blood glucose level was measured on admission and on the days following the trauma (threshold of normal value set at 150 mg/dl). Hyperglycaemia was seen more frequently in children with severe head injury than in those with mild and moderate head injury. It was present in 87.5% of the patients with a Glasgow Coma Score (GCS) ≤8 (the average blood glucose level on admission was 237.8±92 mg/dl), in 60% of the patients with a GCS of 9–12 (178±78.7 mg/dl) and only in 25% of those with a GCS of 13–15 (131.5±39 mg/dl). A close correlation was also seen between the outcome and the blood glucose level. In fact, the blood glucose on admission was higher in the patients with a poor outcome, i.e. in those having a Glasgow Outcome Score (GOS) of 2 or 3 and in those who died (GOS 1), than in the patients with a good outcome (GOS of 4 or 5). Finally, hyperglycaemia persisted beyond the first 24 h after trauma in all the children who died or who survived with a poor outcome. Hyperglycaemia, and especially its persistence over time, appears to be an important negative prognostic factor in children with head injury. Received: 14 May 1998     

Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years

BACKGROUND: Age and the Glasgow Coma Scale (GCS) score on admission are considered important predictors of outcome after traumatic brain injury. We investigated the predictive value of the GCS in a large group of patients whose computerised multimodal bedside monitoring data had been collected over the previous 10 years. METHODS: Data from 358 subjects with head injury, collected between 1992 and 2001, were analysed retrospectively. Patients were grouped according to year of admission. Glasgow Outcome Scores (GOS) were determined at six months. Spearman's correlation coefficients between GCS and GOS scores were calculated for each year. RESULTS: On average 34 (SD: 7) patients were monitored every year. We found a significant correlation between the GCS and GOS for the first five years (overall 1992-1996: r = 0.41; p<0.00001; n = 183) and consistent lack of correlations from 1997 onwards (overall 1997-2001: r = 0.091; p = 0.226; n = 175). In contrast, correlations between age and GOS were in both time periods significant and similar (r = -0.24 v r = -0.24; p<0.002). CONCLUSIONS: The admission GCS lost its predictive value for outcome in this group of patients from 1997 onwards. The predictive value of the GCS should be carefully reconsidered when building prognostic models incorporating multimodality monitoring after head injury.     

Prognostic factors and outcome of children with severe head injury: an 8-year experience

OBJECTIVES: Our aim was to analyze prognostic factors and their association with outcome among children with severe head injury. METHODS: We conducted a retrospective study among children with severe head injury admitted to our Pediatric Intensive Care Unit (PICU) from November 1992 to December 2000. The patients were immediately evaluated for the severity of head injury (Glasgow Coma Score, GCS), clinical presentation, cerebral axial tomography, early complications (hypoxia and hypotension), metabolic and hematological alterations and early post-traumatic seizures. Six months after injury we applied the Glasgow Outcome Score (GOS). Correlations with GOS were evaluated using univariate and multivariate logistic models. RESULTS: In all, 122 children with severe head injury were identified. The patients presented the following scores: 18 (14.7.0%) children had a GOS of 1; 2 had a GOS of 2 (1.6%); 27 (22.2%) a GOS of 3 and 75 (61.5%) a GOS of 4 or 5. A low GOS was significantly and independently associated with low GCS, multiple trauma, the presence of hypoxia and hypotension, disseminated intravascular coagulation (DIC), hyperglycemia and early post-traumatic seizures. Hematological alterations (white blood cells) were also associated with a low GOS, though not significantly. CONCLUSION: In addition to GCS, types of trauma and brain lesion, hypoxia and hypotension, hemocoagulative disorders (DIC), hyperglycemia and early post-traumatic seizures are predictors of GOS. A knowledge of these prognostic factors and the correct management of children with severe head injury helps clinicians to improve outcome and to reduce morbidity and mortality.     

高血糖-弥漫性轴索损伤患者神经损伤严重度和预后的指示剂

目的研究外伤性弥漫性轴索损伤患者高血糖与预后的关系。方法前瞻性对 118例中、重型外伤性弥漫性轴索损伤患者进行研究, 监测入院时、入院后 3 d、7 d 和两周时的神经元特异性烯醇化酶(NSE)、血糖、GCS, 于出院时和三个月后作 GOS 预后评分, 分析血糖水平与损伤严重度和神经功能预后的关系。结果死亡患者入院时血糖水平显著高于存活患者 (260mg/dLvs 130 mg/dL,P<0.005)。入院时血糖≥260 mg/dL 的患者均死亡。结论弥漫性轴索损伤常发生应激反应性早期高血糖, 它是损伤严重度的指示剂和可靠的预后预测指标。     

3000 head injuries: a prospective study of patients admitted to Brisbane neurosurgical units

A prospective epidemiological study of 3095 patients with head injury admitted to Brisbane neurosurgical units is presented. Falls were the commonest cause of injury overall (42%) but traffic accidents were the leading cause of severe head injury Glasgow Coma Scale ([GCS] 8 or less) and had a higher mortality (5.6%). Outcome was closely related to GCS, presence or absence and type of skull fracture, computed tomography (CT) scan findings and age. Overall mortality was 4.4%. Mortality for mild head injury (GCS 13-15) was 0.4%, moderately severe head injury (GCS 9-12) 10.5% and severe head injury (GCS 3-8) 34.5%. The poor outcome in old patients who fall and sustain a mild head injury is highlighted. Low risk criteria are identified and recommendations regarding admission and management policies are made.     

The Westmead head injury project: Outcome prediction in acute subdural haematoma

A prospective two year study of a consecutive sample of patients with an acute subdural haematoma who were admitted to Westmead Hospital, New South Wales, Australia was undertaken. There were 103 patients with an acute subdural haematoma admitted in the period. Twenty-four of these scored 9 or greater on the Glasgow Coma Scale (GCS) and of these all made a functional recovery, i.e. Glasgow Outcome Scale (GOS 1 or 2). The remaining 79 patients scored 8 or less on admission and of these 30% made a functional recovery. Of the 70% remaining, 4% were moderately or severely disabled (GOS 3 or 4) while 66% died (GOS 5). Age, hypoxia, hypotension, response to intracranial pressure control and two CT scan features, midline shift as measured from the septum pellucidum and cerebral oedema, were all significant in predicting outcome. Time from injury to treatment, initial pupil response, lucid interval and compression of brainstem cisterns on CT scans statistically failed to predict outcome. The data were analysed using logistic regression which showed age and midline shift to predict death or disability with an accuracy of 80% at twelve months after the injury (sensitivity 58%, specificity 89%).     

Emotional and cognitive consequences of head injury in relation to the glasgow outcome scale

OBJECTIVE: There is current debate over the issue of the best way of assessing outcome after head injury. One criticism of scales of disability and handicap such as the Glasgow outcome scale (GOS) is that they fail to capture the subjective perspective of the person with head injury. The aims of the study were to investigate aspects of the validity of structured interviews for the GOS, and address the issue of the relation between the GOS and subjective reports of health outcome. METHODS: A total of 135 patients with head injury were assessed using the GOS and an extended GOS (GOSE) and other measures of outcome and clinical status at 6 months after injury. RESULTS: There were robust correlations between the GOS and measures of initial injury severity (particularly post-traumatic amnesia) and outcome assessed by disability scales (particularly the disbility rating scale (DRS)); however, associations with cognitive tests were generally modest. There were also strong correlations with self report measures of health outcome: both the GOS and GOSE were related to depression measured by the Beck depression inventory, mental wellbeing assessed by the general health questionnaire, and to all subscales of the short form-36. The GOS scales were also strongly associated with frequency of reported symptoms and problems on the neurobehavioural functioning inventory. CONCLUSIONS: The GOS and GOSE show consistent relations with other outcome measures including subjective reports of health outcome; they thus remain useful overall summary assessments of outcome of head injury.     

Glasgow Coma Scale on admission is correlated with postoperative Glasgow Outcome Scale in chronic subdural hematoma

OBJECTIVE: To evaluate the correlation between admission Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) in chronic subdural hematoma (CSDH). METHODS: 128 consecutive patients (107 men and 21 women) with CSDH were studied and the correlation between GCS on admission and postoperative GOS was determined. RESULTS: GCS and GOS were correlated with a Spearman rank correlation coefficient of 0.557 (p<0.01). CONCLUSION: GCS and GOS are well-correlated in CSDH.     

Traumatic brain stem lesions in children

Glasgow Coma Scale (GCS) scores on admission may be predictors of outcome in patients with brain injuries. This study correlated the outcomes of children with traumatic brain stem lesions with their initial GCS scores and morphological patterns of injury as shown on computed tomography (CT) or magnetic resonance (MR) imaging. During the last 16 years, we have treated 1,108 children with brain injuries. The entire series included only 21 (1.9%) children who had clinical signs of brain stem lesions with morphological correlates on CT or MR imaging. Clinical findings were assessed according to the GCS and compared with scores on the Glasgow Outcome Scale (GOS). Of these 21 children, 16 (76%) had morphological lesions seen on CT scans. In 5 (24%) of the children only the MR images revealed brain stem lesions and their CT scans were negative. Generalized severe brain swelling was present in 6 cases (28%). There was a significant difference in GOS scores between patients with initial GCS scores of 3 and 4 and those with GCS scores between 5 and 7 (P<0.02). Children with intracranial pressure higher than 40 mmHg had poorer outcomes than patients whose intracranial pressure was lower, but the differences were not significant. Outcome did not correlate significantly with morphological patterns of injury or the presence of extracranial injuries. The GCS is a reliable indicator of severity of injury and of outcome in children with brain stem injuries. MR imaging was more sensitive than CT in detecting brain stem lesions. Received: 9 March 1999     

Early post-traumatic seizures in children with head injury

Post-traumatic seizures (PTS) can be a serious complication of head injury, because they can cause secondary brain damage through increased metabolic requirements, raised intracranial pressure, cerebral hypoxia, and/or excessive release of neurotransmitters. In children, early PTS are more frequent than late ones. In this retrospective study we conducted an epidemiological analysis and tried to identify potential risk factors for the onset of early PTS in children hospitalized for head injury in our Paediatric Intensive Care Unit. The severity of injury was assessed using the Glasgow Coma Scale (GCS), while the outcome of traumatized children was defined using the Glasgow Outcome Score (GOS). Early PTS were diagnosed in 15 out of the 125 children hospitalized (12%). Most of the children (73.3%), developed seizures within 24 h of the trauma (immediate PTS). Among the risk factors, a very important role was played by the severity of the injury; in fact, the incidence of early PTS among patients with GCS≤8 was ten times greater than that among children with GCS 13–15. Other risk factors that significantly influenced the onset of early PTS, were age (60% of children with early PTS were less than 3 years old) and severe cerebral edema. Overall, children with early PTS had a worse outcome than the other patients. In fact, 53% had a GOS of ≤3 compared to 19.1% of those without early PTS (P<001). In particular, considering children with severe head injury, 80% of those with early PTS had a GOS of ≤ 3, compared to 41% of those without early PTS (P<0.05). In conclusion, PTS can be a serious complication of head injury in children, because they can worsen secondary brain damage. Appropriate management of head-trauma patients must include suitable and immediate prophylaxis with anti-epileptic drugs. Received: 27 April 2000 Revised: 7 June 2000     

The prognostic factors related to traumatic brain stem injury

Objective

This study was conducted to assess the clinical significance of traumatic brain stem injury (TBSI) reflected on Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) by various clinical variables.

Methods

A total of 136 TBSI patients were selected out of 2695 head-injured patients. All initial computerized tomography and/or magnetic resonance imaging studies were retrospectively analyzed according to demographic- and injury variables which result in GCS and GOS.

Results

In univariate analysis, mode of injury showed a significant effect on combined injury (p<0.001), as were the cases with skull fracture on radiologic finding (p<0.000). The GCS showed a various correlation with radiologic finding (p<0.000), mode of injury (p<0.002), but less favorably with impact site (p<0.052), age (p<0.054) and skull fracture (p<0.057), in order of statistical significances. However, only GOS showed a definite correlation to radiologic finding (p<0.000). In multivariate analysis, the individual variables to enhance an unfavorable effect on GCS were radiologic finding [odds ratio (OR) 7.327, 95% confidence interval (CI)], mode of injury (OR; 4.499, 95% CI) and age (OR; 3.141, 95% CI). Those which influence an unfavorable effect on GOS were radiologic finding (OR; 25.420, 95% CI) and age (OR; 2.674, 95% CI).

Conclusion

In evaluation of TBSI on outcome, the variables such as radiological finding, mode of injury, and age were revealed as three important ones to have an unfavorable effect on early stage outcome expressed as GCS. However, mode of injury was shown not to have an unfavorable effect on late stage outcome as GOS. Among all unfavorable variables, radiological finding was confirmed as the only powerful prognostic variable both on GCS and GOS.     

Incidence and prognostic significance of fever following intracerebral hemorrhage

OBJECTIVE: To investigate the incidence and prognostic significance of fever on presentation and during the subsequent 72 hours in patients with spontaneous supratentorial intracerebral hemorrhage (ICH). METHODS: We analyzed 251 patients. On admission, body temperature, Glasgow Coma Scale (GCS) score, age, sex, blood pressure, blood glucose level, and presumed origin of hemorrhage were analyzed. From the initial CT scan, hematoma volume, location, and presence of intraventricular hemorrhage were determined. From the first 72 hours, hematoma enlargement, duration of increased temperatures, blood pressure, and blood glucose level were determined. Outcome was classified on discharge with the Glasgow Outcome Scale (GOS) score. RESULTS: Outcomes included no symptoms in 23 (9%), moderate disability in 64 (26%), severe disability in 104 (41%), vegetative state in 5 (2%), and death in 55 (22%) patients. Prognostic factors retained from a logistic regression model with a dichotomized GOS scale (GOS score of 1 or 2 versus GOS score of 3 to 5) as response variables were GCS score of 7 or less, age older than 75 years, hematoma volume of more than 60 cm3, ventricular hemorrhage, and presence of a coagulation disorder (p < 0.05). Fever was associated with intraventricular hemorrhage. From 196 patients, data from the first 72 hours were analyzed. A total of 18 patients (9%) had normal temperatures throughout the study. The duration of fever (> or =37.5 degrees C) was less than 24 hours in 66 (34%), 24 to 48 hours in 70 (36%), and more than 48 hours in 42 patients (21%). Independent prognostic factors during the first 72 hours were duration of fever, secondary hemorrhage, GCS score of 7 or less, ventricular hemorrhage, hematoma volume of more than 60 cm3, duration of increased blood pressure of more than 48 hours, and duration of increased blood glucose of more than 48 hours. CONCLUSIONS: The incidence of fever after supratentorial ICH is high, especially in patients with ventricular hemorrhage. In patients surviving the first 72 hours after hospital admission, the duration of fever is associated with poor outcome and seems to be an independent prognostic factor in these patients.     

Traumatic subarachnoid hemorrhage in acute severe head injury

Traumatic subarachnoid hemorrhage (TSAH) is a frequent occurrence resulting from acute severe head injury. Computerized tomography (CT) accurately identifies the region, extent and nature of TSAH following trauma. But, to our knowledge, there have been few series detailing the characteristics of TSAH in acute severe head injury. The purpose of this study is to describe the findings, nature and prognosis of TSAH. Over a six and a half year period between April 1977 and September 1983, 414 severely head injured patients were examined by CT within 24 hours of the injury in the Department of Neurological Surgery and Critical Care Medicine, Nippon Medical School. Among them, 97 (23.4%) patients showed the appearance of TSAH in the Sylvian fissures, tentorium cerebelli, cortical sulci, basal cisterns and interhemispheric fissures. Conscious state on admission was defined using the Glasgow Coma Scale (GCS) and clinical outcome was defined using Glasgow Outcome Scale. There were 77 men and 20 women, ranging from 4 months to 83 years in age (means 44.3 years). TSAH therefore appears to be seen in all age groups, but especially in middle age groups. The GCS on admission was 8 or less in all cases; the GCS was 8 in 10 cases, 7 in 7 cases, 6 in 15 cases, 5 in 16 cases, 4 in 23 cases, 3 in 26 cases. The lower GCS scores, the more frequently TSAH was identified, and 67% of the patients had a GCS of 6 or less.(ABSTRACT TRUNCATED AT 250 WORDS)     

高血压性脑出血的CT分级与预后

目的 探讨高血压件脑出血的环池、脑干的形态学改变,研究其与预后的关系.方法 回顾性分析165例高血压性脑出血患者的头颅CT资料,以环池、脑于的形态学改变分为4级,记录入院时GCS和发病后6月GOS评分.对数据加以统计分析.结果 对所得的数据进行等级资料的Spearman相关性检验,提示GCS评分与CT分级、CT分级与GOS转归均显著相关(r=0.753,P<0.01;r=0.675,P<0.01).结论 高血压性脑出血的CT分级足早期判断预后的有效指标.     

Hyperbaric oxygen therapy for the treatment of traumatic brain injury: a meta-analysis

Compelling evidence suggests the advantage of hyperbaric oxygen therapy (HBOT) in traumatic brain injury. The present meta-analysis evaluated the outcomes of HBOT in patients with traumatic brain injury (TBI). Prospective studies comparing hyperbaric oxygen therapy vs. control in patients with mild (GCS 13–15) to severe (GCS 3–8) TBI were hand-searched from medical databases using the terms “hyperbaric oxygen therapy, traumatic brain injury, and post-concussion syndrome”. Glasgow coma scale (GCS) was the primary outcome, while Glasgow outcome score (GOS), overall mortality, and changes in post-traumatic stress disorder (PTSD) score, constituted the secondary outcomes. The results of eight studies (average age of patients, 23–41 years) reveal a higher post-treatment GCS score in the HBOT group (pooled difference in means = 3.13, 95 % CI 2.34–3.92, P < 0.001), in addition to greater improvement in GOS and lower mortality, as compared to the control group. However, no significant change in the PTSD score was observed. Patients undergoing hyperbaric therapy achieved significant improvement in the GCS and GOS with a lower overall mortality, suggesting its utility as a standard intensive care regimen in traumatic brain injury.     

Prediction of global outcome with acute neuropsychological testing following closed-head injury.

Delaying assessment until emergence from post-traumatic amnesia increases completion rates, but this practice causes variable time delays from the date of injury to testing, which can complicate the interpretation of research findings. In the current study, the performance of 105 head injury survivors on simple tests of language comprehension and attention was used to predict global outcome. It was hypothesized that 1 month performance on these measures would aid in the prediction of Disability Rating Scale (DRS) and Glasgow Outcome Scale (GOS) scores collected at 6 months post injury. Only raw scores on the modified Test of Complex Ideational Material accounted for a significant amount of the variance in DRS scores (4.4%) above that accounted for by age, education, Glasgow Coma Scale score, and pupil response. However, testability at 1 month post injury on all four tests consistently accounted for a larger portion of the variance in DRS scores (10.1-13.2%) and significantly improved prediction of GOS scores. Galveston Orientation and Amnesia Test scores collected at 1 month post injury accounted for substantially less variance in DRS scores (7.7-8.4%). Neuropsychological data, including the testability of patients, collected uniformly at 1 month following injury can contribute to the prediction of global outcome.     

Cobalt-55 positron emission tomography in traumatic brain injury: a pilot study.

Traumatic brain injury is usually assessed with the Glasgow coma scale (GCS), CT, or MRI. After such injury, the injured brain tissue is characterised by calcium mediated neuronal damage and inflammation. Positron emission tomography with the isotope cobalt-55 (Co-PET) as a calcium tracer enables imaging of affected tissue in traumatic brain injury. The aim was to determine whether additional information can be gained by Co-PET in the diagnosis of moderate traumatic brain injury and to assess any prognostic value of Co-PET. Five patients with recent moderately severe traumatic brain injury were studied. CT was performed on the day of admission, EEG within one week, and MRI and Co-PET within four weeks of injury. Clinical assessment included neurological examination, GCS, neuropsychological testing, and Glasgow outcome scale (GOS) after one year. Co-PET showed focal uptake that extended beyond the morphological abnormalities shown by MRI and CT, in brain regions that were actually diagnosed with EEG. Thus Co-PET is potentially useful for diagnostic localisation of both structural and functional abnormalities in moderate traumatic brain injury.     

The impact of initial management on the outcome of children with severe head injury

BACKGROUND: Neurotrauma is one of the most important causes of death in the pediatric age group. Head injury is responsible for both primary and secondary brain damage. The outcome of children with brain injury depends on the nature of the primary damage and on how well secondary brain damage can be limited. Appropriate critical care management at the scene and in hospital can prevent secondary brain damage that would otherwise result from cerebral reactions. Hypoxia and hypotension are major early complications of aggravation of secondary brain damage that are amenable to emergency maneuvers at the scene. In the literature, the influence of initial critical care management and early complications on the outcome of children with severe head injury is not clearly documented. METHODS AND RESULTS: We have prospectively examined the impact of the management at the scene on outcome in 40 children admitted to our Pediatric Intensive Care Unit with severe head injury (Glasgow Coma Scale < or = 8). The outcome of these children was assessed using the Glasgow Outcome Score (GOS). The results were evaluated by univariate and multivariate analysis. In our series the length of time before admission to an intensive care unit appears to have influenced the outcome among survivors, while the severity of injury is the only factor statistically associated with early complications (hypoxia and hypotension). With regard to the impact of early complications on outcome, the multivariate analysis showed that hypoxia and hypotension were significantly associated with GOS, independently of the GCS. CONCLUSION: Our results confirm the need for a precise treatment strategy for the initial management of children with neurotrauma to decrease the incidence of secondary brain damage attributable to hypoxia and hypotension.     

重型颅脑损伤术后大面积脑梗死临床分析

目的 分析重型颅脑损伤开颅术后大面积脑梗死发生的相关因素及治疗效果. 方法 选择东莞市石碣医院神经外科自2002年1月至2008年4月收治的重型颅脑损伤行开颅术治疗的332例患者,其中术后出现大面积脑梗死20例,回顾性分析术后出现或未出现大面积脑梗死这两类患者术前GCS评分,出血量,颅底骨折,瞳孔变化,是否有脑疝存在及持续时间情况;采用标准大骨瓣减压术治疗及常规综合治疗,并对其疗效进行评价. 结果 术前GCS评分<5分、颅内出血量60 mL以上及颅底骨折合并脑疝持续时间长者大面积脑梗死发生率明显增加.本组20例患者随访12月.应用GOS评估预后,其中良好8例,中残3例,重残2例,植物生存3例,死亡4例.结论 开颅术后出现大面积脑梗死是多种因素所致,术前GCS评分越低、颅内出血量大、颅底骨折合并脑疝持续时间长是其发生的重要原因;及时发现并行标准大骨瓣减压、脱水降颅内压、改善脑循环、预防脑血管痉挛、亚低温等治疗可有效降低其致残率和病死率.改善预后.     

Residual complaints of patients two years after severe head injury.

In a follow up study of 57 patients who had sustained a severe closed head injury, 84% still reported some residual deficit in their psychological functioning after two years, with forgetfulness being the most common complaint. Expressing the severity of the injury in terms of both the duration of post-traumatic amnesia (PTA) and the extent to which previous work could be resumed (RTW), principal components analyses showed that the occurrence of "impairment complaints"--viz forgetfulness, slowness, poor concentration and inability to divide attention over two simultaneous activities--was positively related to severity. The other complaints, which in the main could be labelled as "intolerances" were not. The same pattern was found when the analyses were based on deficits of the patients as they were reported by relatives. Severity was not appreciably related to the total number of complaints. The correlation between PTA and RTW was 0.52, indicating that with longer PTA duration, work is likely to be resumed at a lower level, or not at all. Though Russell's cut-off of one week PTA to differentiate between severe and very severe concussion appeared useful, in the present study a further cut-off point at the unlucky number of 13 days was considered.