Outcome of traumatic extradural haematoma in Hong Kong

AIM: Traumatic extradural haematoma (EDH) is a neurosurgical emergency and timely surgical intervention for significant EDH is the gold standard. This study aims to determine the incidence and mortality of consecutive patients with traumatic EDH admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH), a University Hospital Trauma Centre in Hong Kong. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data for all consecutive trauma cases admitted through the ED during 2001-2004. EDH was diagnosed by CT in all cases. Both primary and delayed onset EDH were included, as were patients with combined EDH and other intracranial lesions (e.g. subdural haematoma). Age, sex, cause of injury, associated intracranial lesions, skull fracture, Glasgow Coma Scale, pupil reactivity, treatment, length of stay and clinical outcome were determined. RESULTS: Two thousand and two hundred and eight patients were in the trauma registry for 2001-2004. Total 1080 head injured patients; 89 patients had traumatic EDH, mean of 1.9 patients per month. Seventy (79%) patients were male, with a mean age of 37.7 years. Fifty (56%) patients were from road traffic crashes, 27 (30%) sustained falls, 10 (11%) had direct head trauma. On admission, 62 (70%) patients were GCS 13-15, 9 (10%) GCS 9-12 and 18 (20%) GCS 3-8. Sixty-six (74%) patients had a skull fracture. Thirty (34%) patients underwent neurosurgical operation. Overall, nine patients (10%) died; eight patients were GCS<8; five had bilateral fixed and dilated pupils; one had a single fixed and dilated pupil. Four patients died after neurosurgical operation, three of whom had fixed dilated pupils and were GCS 3 prior to surgery. Median length of hospital stay for survivors was 10.4 days. CONCLUSION: Survival from traumatic EDH was 90% (80/89) and 91% (73/80) of survivors had a Glasgow Outcome Score of 4 or 5 (good or moderate). The combination of bilateral fixed dilated pupils and GCS 3 suggests severe primary brain injury. Emergency evacuation of intracranial haematomas is unlikely to improve the outcome for these patients. Even in an urban environment with short prehospital times and rapid access to neurosurgery, outcome in patients who are GCS 3 following EDH is likely to be poor.     

The impact of hyperglycemia on patients with severe brain injury

BACKGROUND: This study aimed to analyze the relation of hyperglycemia to outcome in cases of severe traumatic brain injury, and to examine factors that may be responsible for the hyperglycemic state. METHODS: A retrospective analysis in an intensive care unit of a level 1 trauma center investigated 77 patients with severe traumatic brain injury. Patients with a Glasgow Coma Scale (GCS) of 8 or lower who survived more than 5 days were reviewed. Serum glucose, base deficit, GCS, use of steroids, and amounts of insulin and carbohydrates were recorded for 5 days, along with age. The Injury Severity Score (ISS) and the Abbreviated Injury Score (AIS) for the head, chest, and abdomen also were recorded. A hyperglycemia score (HS) was calculated as follows. A value of 1 was assigned each day the glucose exceeded 170 mg/dL (range, 0-5). A hyperglycemia score for days 3, 4, and 5 (HS day 3-5) also was calculated (range, 0-3). Outcomes included mortality, day 5 GCS, intensive care unit length of stay, and hospital length of stay. RESULTS: Of the 77 patients, 24 (31.2%) died. Nonsurvivors had higher glucose levels each day. The HS was higher for those who died: 2.4 +/- 1.7 versus 1.5 +/- 1.4 (p = 0.02). Univariate analysis showed that only HS and ISS correlated with all four outcome variables studied. Cox's regression analysis showed that mortality was related to age and ISS. Head AIS and HS were independent predictors of lower day 5 GCS, whereas HS 3-5 and day 4 GCS were related to prolonged hospital length of stay. Older age, diabetes, and lower day 1 GCS were associated with higher HS, whereas carbohydrate infusion rate, ISS, head AIS, and steroid administration were not. CONCLUSIONS: Early hyperglycemia is associated with poor outcomes for patients with severe traumatic brain injury. Tighter control of serum glucose without reduction of nutritional support may improve the prognosis for these critically ill patients.     

Early prediction of mortality in isolated head injury patients: a new predictive model

BACKGROUND: To construct a predictive model of survival in isolated head injury patients, on the basis of easily available parameters that are independent risk factors for survival outcome. METHODS: Trauma registry-based study of head injury patients who had no other major extracranial injuries and were not hypotensive at admission. A predictive model of probability of death was constructed using discriminant analysis, on the basis of admission Glasgow Coma Scale (GCS) score, head Abbreviated Injury Score (AIS), age, and mechanism of injury. RESULTS: The study included 7,191 patients with head trauma. The overall correct classification rate of the proposed predictive model was 94.2% as compared with 89.0% of the admission GCS score (p < 0.05) and 92.8% of the head AIS (p < 0.05). The correct classification rate of the predictive model developed for the severe head trauma (GCS score 4-8) patients was 79.9%, as compared with 72.6% using the admission GCS score alone or 75.1% (p < 0.05). A one-page, easy to use table summarizing the predicted mortality on the basis of GCS score, head AIS, mechanism of injury, and age was developed. CONCLUSIONS: The proposed model has a significantly better predictive power, especially in severe head trauma, than the extensively used GCS and head AIS. A simple table on the probability of death of a particular patient based on admission GCS score, head AIS, mechanism of injury and age of patient can provide instant information.     

The presence of the adult respiratory distress syndrome does not worsen mortality or discharge disability in blunt trauma patients with severe traumatic brain injury

PURPOSE: To evaluate the prevalence of the acute respiratory distress syndrome (ARDS) among blunt trauma patients with severe traumatic brain injury (TBI) and to determine if ARDS is associated with higher mortality, morbidity and worse discharge outcome. METHODS: Blunt trauma patients with TBI (head abbreviated injury score (AIS)> or =4) who developed predefined ARDS criteria between January 2000 and December 2004 were prospectively collected as part of an ongoing ARDS database. Each patient in the TBI+ARDS group was matched with two control TBI patients based on age, injury severity score (ISS) and head AIS. Outcomes including complications, mortality and discharge disability were compared between the two groups. RESULTS: Among 362 TBI patients, 28 (7.7%) developed ARDS. There were no differences between the two groups with respect to age, sex, ISS, Glasgow coma score (GCS), head, abdomen and extremity AIS. The TBI+ARDS group had significantly more patients with chest AIS> or =3 (57.1% versus 32.1%, p=0.03). There was no difference with respect to overall mortality between the TBI+ARDS group (50.0%) and the TBI group (51.8%) (OR 0.79: 95% CI 0.31-2.03, p=0.63). There was no significant difference with respect to discharge functional capacity between the two groups. There were significantly more overall complications in the TBI+ARDS group (42.9%) compared to the TBI group (16.1%) (OR 3.66: 95% CI 1.19-11.24, p=0.02). The TBI+ARDS group had an overall mean intensive care unit (ICU) length of stay of 15.6 days, versus 8.4 days in the TBI group (p<0.01). The TBI+ARDS group had significantly higher hospital charges than the TBI group ($210,097 versus $115,342, p<0.01). CONCLUSION: The presence of ARDS was not associated with higher mortality or worse discharge disability. It was, however, associated with higher hospital morbidity, longer ICU and hospital length of stay.     

Early indicators of prognosis in 846 cases of severe traumatic brain injury

A number of factors, including Glasgow coma scale (GCS) score, age, pupillary response and size, hypoxia, hyperthermia, and high intracranial pressure, may play an important role in predicting the outcome of traumatic brain injury. Eight hundred forty-six cases of severe traumatic brain injury (GCS < or = 8) were analyzed retrospectively to clarify the effects of multiple factors on the prognosis of patients. At 1 year after injury, the outcomes in these cases were as follows: good recovery, 31.56%; moderate disability, 14.07%; severe disability 24.35%; vegetative status, 0.59%; and death, 29.43%. The outcomes were strongly correlated (p < 0.05) with GCS score, age, pupillary response and size, hypoxia, hyperthermia, and high intracranial pressure (ICP). These findings indicate that prevention of hypoxia, control of high ICP, and prevention of hyperthermia may be useful means for improving the outcome of patients with severe head injury.     

孕酮治疗急性重型颅脑损伤疗效和作用机制的临床研究

目的 探讨孕酮治疗急性重型颅脑损伤病人的作用机制和疗效。方法56例急性重型颅脑损伤病人随机分成常规治疗组（／1=30）和孕酮治疗组（／1=26）,比较两组患者急性治疗期格拉斯哥昏迷评分（GCS）和格拉斯哥预后评分（GOS）、神经功能恢复和生活质量状况（KPS）。患者入院当时、第5天和第10天,分别抽取静脉血,采用放射免疫分析法测定血清孕酮和TNF-α ,酶标放射免疫法测定15-F2t-isoprostane（15-F2t-IPs）。结果 两组患者死亡率、急性治疗期GCS评分、治疗第10天COS评分和语言及运动障碍程度分级评估,均无显著差异（P〉0．05）;治疗后3个月随访,孕酮治疗组患者COS评分、语言障碍程度分级评估和远期生活质量评估,均明显优于常规治疗组（P〈0．05）;两组患者运动功能障碍程度分级评估无显著差异（P〉0．05）。入院第5天,常规治疗组患者血清15-F2t-IPs和TNF-α 均有增高,第10天下降。与常规治疗组比较,孕酮治疗组患者入院第5、10天血清孕酮显著增高（P〈0．05）;血清TNF-α 和15-F2t-IPs显著减低（P〈0．05）。结论应用孕酮治疗急性重型颅脑损伤,可以促进病人神经功能康复,改善预后;孕酮对急性重型颅脑损伤病人的神经保护作用与其抑制脑损伤后脂质过氧化反应和炎症反应有关。     

The development of acute lung injury is associated with worse neurologic outcome in patients with severe traumatic brain injury

OBJECTIVE: The purpose of this study was to determine the incidence of acute lung injury (ALI) in trauma patients with severe traumatic brain injury (TBI), to evaluate the impact of ALI on mortality and neurologic outcome after severe traumatic brain injury (TBI), and to identify whether the development of ALI correlates with the severity of TBI. METHODS: Clinical data were collected prospectively over a 4-year period in a Level I trauma center. Patients included in the study met the following criteria: mechanical ventilation > 24 hours, head Abbreviated Injury Scale score >or= 3, no other body region Abbreviated Injury Scale score >or= 3, and age between 18 and 54 years. ALI was defined using international consensus criteria. Glasgow Outcome Scale scores were assessed at 3 and 12 months. Bivariate comparisons were made between ALI and non-ALI groups. Multivariate analysis with stepwise logistical regression was used to assess independent factors on mortality. The patient's admission head computed tomographic (CT) scan was graded using the Marshall system, and the presence and size of specific intracranial abnormality was noted. Glasgow Coma Scale (GCS) score, Marshall CT scan score, and intracranial abnormality were correlated with the development of ALI. RESULTS: One hundred thirty-seven patients with isolated head trauma were enrolled in the study over a 4-year period. Thirty-one percent of patients with severe TBI developed ALI. Head trauma patients with ALI had a significantly higher ISS, a greater number of days on the ventilator, and a worse neurologic outcome for those who survived their hospitalization. Mortality was 38% in the ALI group and 15% in the non-ALI group (p = 0.004). Only 3 of 16 (19%) of the deaths within the ALI group were directly related to ALI. By multivariate analysis, only the presence of ALI, older age, and lower initial GCS score were associated with higher mortality. There was no association between ISS, the presence of arterial hypotension (arterial systolic pressure < 90 mm Hg) at admission to the hospital, or the amount of blood transfused and mortality. No correlation was found between the severity of head injury (GCS score, Marshall score, or intracranial abnormality) and development of ALI. CONCLUSION: The development of ALI is a critical independent factor affecting mortality in patients suffering traumatic brain injury and is associated with a worse long-term neurologic outcome in survivors. The risk of developing ALI is not associated with specific anatomic lesions diagnosed by cranial CT scanning.     

Clinical experience of the management for the most severely head—injured patients with GCS score of 3

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Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity

OBJECTIVE: The purpose of this study was to compare data obtained from a statewide data set for elderly patients (age > 64 years) that presented with traumatic brain injury with data from nonelderly patients (age > 15 and < 65 years) with similar injuries. METHODS: The New York State Trauma Registry from January 1994 through December 1995, from trauma centers and community hospitals excluding New York City (45,982 patients), was examined. Head-injured patients were identified by International Classification of Diseases, Ninth Revision diagnosis codes. A relative head injury severity scale (RHISS) was constructed on the basis of groups of these codes (range, 0 = none to 3 = severe). Comparisons were made with nonelderly patients for mortality, Glasgow Coma Scale (GCS) score at admission and discharge, Injury Severity Score, New Injury Severity Score, and RHISS. Outcome was assessed by a Functional Independence Measure score in three major domains: expression, locomotion, and feeding. Data were analyzed by the chi2 test and Mann-Whitney U test, with p < 0.05 considered significant. RESULTS: There were 11,772 patients with International Classification of Diseases, Ninth Revision diagnosis of head injury, of which 3,244 (27%) were elderly. There were more male subjects in the nonelderly population (78% male subjects) compared with the elderly population (50% men). Mortality was 24.0% in the elderly population compared with 12.8% in the nonelderly population (risk ratio, 2.2; 95% confidence interval, 1.99-2.43). The elderly nonsurvivors were statistically older, and mortality rate increased with age. Stratified by GCS score, there was a higher percentage of nonsurvivors in the elderly population, even in the group with only moderately depressed GCS score (GCS score of 13-15; risk ratio, 7.8; 95% confidence interval, 6.1-9.9 for elderly vs. nonelderly). Functional outcome in all three domains was significantly worse in the elderly survivors compared with the nonelderly survivors. CONCLUSION: Elderly traumatic brain injury patients have a worse mortality and functional outcome than nonelderly patients who present with head injury even though their head injury and overall injuries are seemingly less severe.     

Management and hospital outcome of the severely head injured elderly patient

Introduction: Severe traumatic head injury in the elderly has been associated with poor outcomes. However, there is currently no consensus to direct management in these patients. This study outlines the demographics, injury characteristics, management and outcome of the elderly trauma patients with severe head injury across a defined population. Materials and Methods: A retrospective review of all elderly patients (age >64 years) with a Glasgow Coma Scale (GCS) score of 8 or less, and confirmed intracranial pathology or fractured skull, was undertaken over a period of 40 months from July 2001 to September 2005. Data on patient demographics, injury cause, presenting clinical features and interventions were collected. In‐hospital mortality was used as the primary outcome. Results: There were 96 patients who met the inclusion criteria. One‐third of the patients were managed palliatively, one‐third supportively without surgery and another third underwent surgery. Overall mortality was 70.8% (n = 68). Older age and brainstem injuries were identified as independent predictors of mortality. Mortality was reported in all patients aged 85 years or older. Conclusions: Although overall outcomes were poor, careful consideration should be given to active treatment as favourable outcomes were possible even in the presence of extremely low GCS scores. Prediction of outcome on the basis of age and anatomical diagnoses may help in this decision‐making.     

Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly.

In order to determine the factors influencing outcome following craniotomy for trauma in patients over the age of 65 and to establish criteria for surgical intervention, the authors carried out a retrospective analysis of the hospital and general practice records of all head injury patients over the age of 65 who underwent a craniotomy for evacuation of a post-traumatic haematoma within 7 days of injury at Frenchay Hospital during a 10-year period (1980-89). Outcome was measured using the Glasgow Outcome Scale and patients were allotted to a good outcome group (good recovery or moderate disability but independent) or a poor outcome group (severe disability, vegetative state of death). There were 35 men and 31 women with a mean age of 72.5 years (range 65-85 years). The mortality rate was 61% and 9% of patients survived in a severely disabled or vegetative state. All 20 (30%) patients with a good outcome had a Glasgow Coma Score (GCS) of 5 or more immediately before surgery. All 18 (27%) patients with a GCS of 4 or less and all 22 (33%) patients with unilateral or bilateral pupillary dilatation had a poor outcome. Outcome was significantly worse in the older patients (75-85 years) compared with the younger patients (65-74 years) and in those patients requiring craniotomy within 24 hours of injury, but the mechanism of injury (fall or road traffic accident), the presence or absence of skull fractures and limb fractures and the pre-operative CT scan appearances did not influence outcome. This study confirms the high probability of poor outcome following surgical evacuation of traumatic intracranial haematomas for elderly head-injured patients with pupillary dilatation or extensor motor responses. Craniotomy under these circumstances is not justified.     

Traumatic brain injury in anticoagulated patients

BACKGROUND: Coumadin is widely used in the elderly population. Despite its widespread use, little is known about its effect on the outcome of elderly traumatic brain-injured patients. This study was undertaken to describe the outcomes of such a cohort. METHODS: Clinical material was identified from a Level I trauma center prospective head injury database, and a database obtained from the American College of Surgeons Committee on Trauma Verification and Review Committee from 1999 to 2002. Both databases contain many relevant variables, including age, sex, Glasgow Coma Scale (GCS) score, mechanism of injury, Injury Severity Score, International Normalized Ratio (INR), computed tomography (CT) findings, operative procedure, time to operating room, complications, length of stay, and outcome at hospital discharge. RESULTS: For patients with GCS scores less than 8, average INR was 6.0, with almost 50% having an initial value greater than 5.0. Overall mortality was 91.5%. For the 77 patients with GCS scores of 13 to 15, average INR was 4.4. Overall mortality for this group was 80.6%. A subset of patients deteriorated to a GCS score of less than 10 just hours after injury, despite most having normal initial CT scans. Mortality in this group was 84%. CONCLUSIONS: All patients on warfarin should have an INR performed, and a CT scan should be done in most anticoagulated patients. All supratherapeutically anticoagulated patients, as well as any anticoagulated patient with a traumatic CT abnormality, should be admitted for neurologic observation and consideration given to short term reversal of anticoagulation. Routine repeat CT scanning at 12 to 18 hours or when even subtle signs of neurologic worsening occur is a strong recommendation. A multi-institutional, prospective trial using these guidelines would be a first step toward demonstrating improved outcomes in the anticoagulated patient population after head trauma.     

Treatment for severe craniocerebral trauma combined with transtentorial hernia in children

Objective:To explore the treating method for severe craniocerebral trauma combined with transtentorial hernia in children. Methods: We treated 58 children with severe craniocerebral trauma combined with transtentorial hernia through evacuating the hematomas, incising the tentorium but preserving the floating bone flap between January 1996 and January 2002. Results .- GCS was 3-5 in 17 cases and 6-8 in 41 cases. After treatment, 46 patients (79.30%) recovered well, 6 (10.30%) suffered from mild disability, 1 (1.72%)suffered from severe disability, 1 (1.72%) was in vegetative state, and 4 ( 6.90 % ) died. Conclusions: Evacuating hematomas and incising tentorium can effectively treat the child patients with severe craniocerebral trauma combined with transtentorial hernia, which can decrease the disability and mortality rates greatly, preserve the skull, exempt reoperation for cranioplasty and relieve the psychologic and physiologic burden of the child patients.     

The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury

BACKGROUND: Several studies have demonstrated that the success rate of prehospital intubation is improved by the use of neuromuscular blocking agents (NMBAs). However, a recent study has reported that prehospital intubation with NMBAs worsens outcome after traumatic brain injury (TBI). We sought to determine the effect of the use of NMBAs to facilitate prehospital intubation on outcome after TBI. METHODS: All patients admitted to our Level I trauma center with a head Abbreviated Injury Scale score >/= 3 were identified by the trauma registry (January 1998-June 2003). Patient records were matched with prehospital databases. Patients were further stratified on the basis of prehospital Glasgow Coma Scale (GCS) score into mild (GCS score of 14/15), moderate (GCS score of 9-13), and severe (GCS score < 9) TBI. Outcome included mortality and good outcome (survival to discharge with a GCS score of 14/15). RESULTS: There were 3,052 patients who were identified as having been transported directly from the field. Complete prehospital data were available for 2,012 patients (66%). Of these, 920 were mild TBI (intubation rate, 17.4%), 293 moderate TBI (intubation rate, 57.7%), and 799 severe TBI (intubation rate, 95%). Overall, 72% of intubated patients received NMBAs. There were no significant differences in demographics or injury severity between the groups. Patients not receiving NMBAs were more likely to be hypotensive and have prehospital cardiopulmonary resuscitation (p = 0.001). The unadjusted mortality for the patients intubated with NMBAs was 25% versus 37% for those not receiving NMBAs (p < 0.001). When adjusted for confounding variables, patients intubated with NMBAs were more likely to survive (odds ratio, 0.63; 95% confidence interval, 0.41-0.97; p = 0.04) and have a good outcome (odds ratio, 1.7; 95% confidence interval, 1.2-2.6; p = 0.006) than those in the no-NMBA group. CONCLUSION: The use of NMBAs to facilitate prehospital intubation improves outcome for patients with TBI. The value of prehospital intubation for TBI remains to be determined; however, any trial evaluating nonintubation for TBI must be compared with NMBA-facilitated intubation to be valid.     

Outcome of head injuries in general surgical units with an off-site neurosurgical service

INTRODUCTION: In order to cope with bed shortages in the only neurosurgical unit (NSU) in KwaZulu-Natal, it has become necessary to manage head injured patients in a general surgical unit (GSU) at the referral hospitals in consultation with the NSU. This study was undertaken to assess the outcome of patients with head injuries managed in a GSU in consultation with a regional NSU. PATIENTS AND METHODS: A prospective pilot study was carried out in a single surgical unit over an 18-month period (July 1997-December 1998), followed by a larger prospective study over a 6-month period (January-June 2001). All patients with head injuries severe enough to warrant admission to hospital (GCS < or =15 or 15 with localising signs) were included. RESULTS: The pilot study comprised 86 patients and the subsequent study comprised 230 patients, giving a total of 316 patients in the whole study. The mean age was 31 +/- 12 years. Following consultation with the NSU, 265 (84%) patients were managed in the GSU and 51 (16%) required transfer to the NSU. Forty-one patients died giving a mortality rate of 13%. Twenty eight of the 42 patients with GCS < or =8 died (67%) compared to 13 out of 274 with GCS >8 (5%) (p<0.0001). Eleven of the 51 patients destined to the NSU died (22%) compared to 30 of 265 in the GSU (11%) (p=0.046). The average hospital stay was 10 +/- 18 days. Forty surviving patients (17%) from the GSU and 20 from the NSU (51%) were discharged with neurological sequelae (p<0.001). CONCLUSION: Head trauma is associated with high morbidity and mortality. Non-surgical treatment of traumatic brain injury at the referral hospital by the GSU is acceptable practice. Outcome is determined primarily by the GCS on presentation. NSU patients had a significantly higher mortality rate. A delay before surgery did not seem to affect outcome.     

Low-dose aspirin prophylaxis and risk of intracranial hemorrhage in patients older than 60 years of age with mild or moderate head injury: a prospective study

OBJECT: The goal of this paper was to investigate a possible relationship between the consumption of low-dose aspirin (LDA) and traumatic intracranial hemorrhage in an attempt to determine whether older patients receiving prophylactic LDA require special treatment following an incidence of mild-to-moderate head trauma. METHODS: Two hundred thirty-one patients older than 60 years of age, who arrived at the emergency department with a mild or moderate head injury (Glasgow Coma Scale [GCS] Scores 13-15 and 9-12, respectively), were included in the study. One hundred ten patients were receiving prophylactic LDA (100 mg/day) and these formed the aspirin-treated group. One hundred twenty-one patients were receiving no aspirin, and these formed the control group. There was no statistically significant difference between the two groups with respect to age, sex, mechanism of trauma, or GCS score on arrival at the emergency department. Most of the patients sustained the head injury from falls (88.2% of patients in the aspirin-treated group and 85.1% of patients in the control group), and had external signs of head trauma such as bruising or scalp laceration (80.9% of patients in the aspirin-treated group and 86.8% of patients in the control group). All patients underwent similar neurological examinations and computerized tomography (CT) scanning of the head. The CT scans revealed evidence of traumatic intracranial hemorrhage in 27 (24.5%) patients in the aspirin-treated group and in 31 patients (25.6%) in the control group. Surgical intervention was required for five patients in each group (4.5% of patients in the aspirin-treated group and 4.1% of patients in the control group). A surprising number of the patients who arrived with GCS Score 15 were found to have traumatic intracranial hemorrhage, as revealed by CT scanning (11.5% of patients in the aspirin-treated group and 16.5% of patients in the control group). Surgery, however, was not necessary for any of these patients. CONCLUSIONS: There was no statistically significant difference in the frequency or types of traumatic intracranial hemorrhage between patients who had received aspirin prophylaxis and those who had not. The authors conclude that LDA does not increase surgically relevant parenchymal or meningeal bleeding following moderate and minor head injury in patients older than 60 years of age.     

Peri—operative treatment of most severely head—injured patients

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Results of resuscitation in injured elderly patients

This study assessed the results of intensive care in elderly trauma patients and quantified the different factors involved in the final outcome. It included 116 patients, aged 65 years or more, and covered a two year period. The following parameters were obtained for each patient: age, severity of trauma (ISS and SAPS), head injury (GCS), prehospital health status (ESA), survival after three months and quality of survival. Three months after trauma, overall mortality was 45.7%. Survivors were 72.8 +/- 4.9 year old, while those that died were 75.3 +/- 7.5 year old (p = 0.01). Mean ISS was 19.7 +/- 8 and mean SAPS was 9.4 +/- 3.2. The risk of death was 3.6 (1.6 to 8.1) times greater if ISS was over 15. The same risk was 4.7 (2.1 to 11.1) times greater if SAPS was over 9. GCS was 8.8 +/- 4.4 in dead patients and 12.5 +/- 2.4 in survivors (p = 0.001). The risk of death was 10.4 (4.2 to 26.2) times greater if GCS was under 8. The final prognosis could be assessed with the following exponential model: Survival = 1/(1 + exp - (8.7 - 0.07 X age - 0.07 X ISS - 2.9 X GCS*), where GCS is equal to 0 if the real GCS was under 8, and equal to 1 otherwise. The ESA did not affect mortality. Three months after trauma, the degree of independence was the same as before in 87% of survivors. It was concluded that age and the severity of trauma were the most important factors in determining prognosis in geriatric trauma patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Outcome of traumatic brain injuries in 1,508 patients: impact of prehospital care

This article describes the outcome of 1,508 patients with traumatic brain injuries (TBI) treated in a single neurosurgical unit over an 8-year period. Our aim has been to compare those outcomes with our previous results and with other large patient series. Another important goal was to evaluate the effect of the introduction of a 4-year ongoing study initiated in January 1993 using a new strategy of prehospital care on postresuscitation Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS). Results from the 1,508 patients showed good recovery or moderate disability in 69%, severe disability or vegetative state in 11%, and a mortality rate of 20%. When outcome of the most severely injured patients (GCS < or = 8) was compared with those of our previous and other large international patient series, more favorable outcome figures were shown in the present study. To evaluate the impact of the improved prehospital care after half of the study period, a logistic regression analysis showed after January 1993 a significantly increased expected odds/ratio for a postresuscitation GCS 8-15 rather than a GCS 3-4 (odds/ratio: 2.2; p < 0.001). For patients with postresuscitation GCS 5-7 and 8-15, the expected odds/ratio for a GOS 4-5 instead of GOS 1 increased significantly (odds/ratio: 2.2 and 1.7, respectively; p < 0.05-0.01). For patients with GCS 3-4, an increased expected odds/ratio (2.0; p < 0.05) for a GOS 2-3 rather than a GOS 1 was seen. The principal conclusion is that outcome for the severely injured patients in the present study is more favorable than in other large series of TBI. We posit that the introduction of effective prehospital care most likely contributed to the improved postresuscitation neurological status and consequently to the better outcome observed after January 1993.     

颅脑损伤患者早期D-二聚体含量与伤情及预后的关系

目的探讨血浆D-二聚体(D-dimer,DD)含量作为早期观察因子在颅脑损伤患者伤情评估、预后预测中的作用。方法通过对刚入院63例单纯颅脑损伤患者血浆D-二聚体含量的测定,探讨D-二聚体含量与格拉斯哥昏迷分析(GCS)、脑CT扫描中线移位程度及格拉斯哥预后评分(GOS)的关系。结果颅脑损伤早期就出现D-二聚体含量增高;D-二聚体含量与GCS呈负相关,与中线移位程度呈正相关,D-二聚体含量越高伤情越重;D-二聚体含量与GOS呈负相关,D-二聚体含量越高预后越差。结论伤后早期D-二聚体含量测定有助于颅脑损伤患者伤情评估及预后预测。