A medical/vocational case coordination system for persons with brain injury: an evaluation of employment outcomes

OBJECTIVE: To evaluate initial placement and 1-year employment outcomes of a Medical/Vocational Case Coordination System (MVCCS) for persons with brain injury (BI) that provides: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) supported employment interventions including job coaching. PARTICIPANTS: One hundred fourteen Minnesota residents, ages 18 to 65 years, with acquired BI. MAIN OUTCOME MEASURES: Outcome: Five levels of Vocational Independence Scale (VIS). Predictor: Preinjury employment status (VIS) and years of education, severity of initial injury, time since injury, current impairment/disability as measured by the Rasch-analyzed Staff Mayo-Portland Adaptability Inventory (MPAI), and impaired self-awareness measured by staff rating and the difference between Staff MPAI and Survivor MPAI. RESULTS: At placement, 46% in independent work; 25% in transitional placements; 9% in long-term supported employment; 10% in sheltered work; and 10% not placed. At 1-year follow-up (n = 101), 53% in independent work; 19% in transitional placement; 9% in supported work; 6% in sheltered work; and 13% unemployed. Regression analyses showed time since injury and Rasch Staff MPAI predicted VIS at placement; only VIS at placement independently predicted VIS at 1-year follow-up; Rasch Staff MPAI and preinjury education level predicted time to placement. CONCLUSIONS: The MVCCS optimized vocational outcome after BI. Time since injury and impairment/disability best predicted vocational placement. Level of initial placement best predicted employment status at follow-up. Persons with greater disability required more extended time and more extensive rehabilitation services before placement.     

Traumatic brain injury rehabilitation,the programs applied in French UEROS units,and the specificity of the Limoges experience

First created in 1996, the French evaluation, retraining, social and vocational orientation units (UEROS) now play a fundamental role in the social and vocational rehabilitation of patients with brain injury. As of today, there exist 30 UEROS centers in France. While their care and treatment objectives are shared, their means of assessment and retraining differ according to the experience of each one. The objective of this article is to describe the specific programs and the different tools put to work in the UEROS of Limoges. The UEROS of Limoges would appear to offer a form of holistic rehabilitation management characterized by the importance of psycho-education and its type of approach towards vocational reintegration.     

Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury

Objective: To assess which social activities were still impaired 5 years after a traumatic brain injury (TBI) in adults, and which neuropsychological impairments were associated with this loss of social autonomy.Design: Cross-sectional study of 79 patients selected from the follow-up cohort of an epidemiologic survey of 2,116 TBI patients.Setting: The present study was of ambulatory patients seen at hospital or at their homes. The inception cohort was from the trauma center of a university hospital and from a general hospital that is representative of level II trauma centers in Aquitaine, France.Patients: Seventy-nine patients selected from a representative sample of 407 patients who were included in the 5-year follow-up study of the initial cohort (convenience sample).Main Outcome Measures: Glasgow Outcome Scale (GOS) and loss of social autonomy as assessed by the European Brain Injury Society's European Head Injury Evaluation Chart; assessment of neurobehavioral impairments by means of the Neurobehavioral Rating Scale-Revised.Results: Up to 16 patients suffered disability for at least one social skill because of cognitive/behavioral reasons. Seven needed full-time supervision. Performing administrative tasks and financial management, writing letters and calculating, driving, planning the week, and using public transport were the most impaired social abilities. Loss of social autonomy was mainly observed in severely injured patients. Univariate analysis showed that mental fatigability, motor slowing, memory difficulties, and disorders of executive function were associated with low scores on the GOS, unemployment, and difficulties in shopping, using public transport, and performing financial management and administrative tasks.Conclusion: Persistent impairments of executive functions and speed of psychomotor processing are major factors associated with loss of social autonomy and inability to return to work long after TBI in adults. Improving these impairments in concrete social situations represents a major challenge for cognitive rehabilitation.     

Health-related quality of life and disability in survivors of multiple trauma one year after intensive care unit discharge

OBJECTIVE: To evaluate health-related quality of life and disability in multiple-trauma patients requiring intensive care unit management. DESIGN: A total of 87 survivors of multiple trauma, with a median age of 31 yrs and a median Injury Severity Score of 22, were enrolled in the present study. The Nottingham Health Profile, Glasgow Outcome Scale, and Rosser Disability Scale were used to assess the functional consequences of trauma 1 yr after intensive care unit discharge. RESULTS: A total of 64 of 87 patients had a problem in at least one of the six domains related to subjective health status. The most prevalent complaint was related to somatic subdimensions, but emotional functioning was also affected. Nottingham Health Profile part 2 showed that 63 of the survivors experienced problems in at least one of the daily activities. Of particular importance, inability to work was reported by 47% of the patients. Fifty-nine percent experienced moderate-to-severe disability as evaluated by Glasgow Outcome Scale and Rosser Disability Scale. High aggregate injury severity score along with severe head trauma were independent predictors of poor health-related quality of life and disability. CONCLUSIONS: The majority of survivors of major trauma exhibit considerable levels of disability and impairment in health-related quality of life. Global injury severity score and degree of brain trauma determine functional limitations. This information may help in organizing long-term rehabilitation of multiple-trauma patients.     

Review of the use of somatosensory evoked potentials in the prediction of outcome after severe brain injury

OBJECTIVE: Review the predictive powers of somatosensory evoked potentials (SEPs) in severe brain injury. DATA SOURCES: Publications in the scientific literature, manual review of article bibliographies, and questioning workers in the field. STUDY SELECTION: Studies addressing the prediction of outcome after severe brain injury using SEPs. DATA EXTRACTION: To determine the outcome of patients with either normal or bilaterally absent SEPs as categorized using the Glasgow Outcome Scale into favorable outcomes (good or moderate disability) or unfavorable outcomes (severe disability, vegetative, or dead). Studies were included if they were in English and allowed the determination of outcomes for all patients with normal or bilaterally absent SEPs. Papers were not considered if subjects were neonates, consisted of abstracts where all necessary details were unavailable, were case reports or duplications of other published studies, or dealt only with brain dead subjects. DATA SYNTHESIS: For all studies (n = 44), positive likelihood ratio, positive predictive value, and sensitivity were 4.04, 71.2%, and 59.0%, respectively, for normal SEPs (predicting favorable outcome) and 11.41, 98.5%, and 46.2%, respectively, for bilaterally absent SEPs (predicting unfavorable outcome). Summary receiver operating characteristic curve analysis detected a cut-off criterion effect for only blinded studies of bilaterally absent SEPs. Twelve patients (12/777) were identified with bilaterally absent SEPs who had favorable outcomes. These false positives are typically pediatric patients or have suffered traumatic brain injuries. We suggest criteria for the use of bilaterally absent SEPs in the prediction of poor outcome, which include absence of focal lesions, subdural or extradural fluid collections, and no decompressive craniotomy in previous 48 hrs. Using these criteria the data suggest that the false-positive rate is <0.5% for bilaterally absent SEPs. CONCLUSIONS: SEPs are powerful predictors of outcome, particularly poor outcome, if patients with focal lesions, subdural effusions, and those who have had recent decompressive craniotomies are excluded.     

Spontaneous subarachnoid hemorrhage. Prognostic factors for social readjustment

Sixty-seven patients surviving spontaneous subarachnoid haemorrhage (SAH) have been followed up for 2-12 years (mean: 7 years) in order to determine prognostic factors concerning the long-term disability in familial and social functioning. A correlation was found between the severity of the neurological deficit at the time of admission and the degree of familial and social disability at the end of the observation period. In addition, the Barthel-Index on discharge was shown to be of prognostic value for readjustment for social--but not for familial--functioning. Other clinical variables in the acute stage, however, including source of bleeding, sex, age, interval between SAH and admission, level of consciousness, cognitive functions, as well as initial Hunt and Hess grading and Glasgow Coma Scale scoring, did not influence the long-term social prognosis. Furthermore, residual neurological signs, cognitive dysfunctions, and the Glasgow Outcome score on discharge were not related to the extent of social handicap in the long-term outcome. At the end of the observation period, significant correlations were found between the presence of persisting neurological and cognitive deficits but also disability in ADL functions and occupational capacity and the decline in familial and social functioning.     

Use of somatosensory-evoked potentials and cognitive event-related potentials in predicting outcomes of patients with severe traumatic brain injury

OBJECTIVE: This study was performed to evaluate the usefulness of somatosensory-evoked potentials (SEPs) and cognitive event-related potentials (ERPs) in predicting functional outcomes of severe traumatic brain injury patients. DESIGN: Prospective study of 22 patients with severe traumatic brain injury. Demographic information, Glasgow Coma Scale, and electrophysiologic measurements were recorded. Functional outcomes, as quantified by the Glasgow Outcome Scale-Extended, were obtained. RESULTS: Bilateral absence of median nerve SEP was strongly predictive of the worst functional outcome. The specificity and positive predictive value of absent SEP for predicting death or persistent vegetative state at 6 mo after traumatic brain injury were as high as 100%. If the definition of unfavorable outcome was expanded to include Glasgow Outcome Scale-Extended 1-4, absence of ERP was equivalent to the absence of SEP in specificity and positive predictive value. On the other hand, normal ERPs showed higher sensitivity and negative predictive value for prognosticating the best outcomes compared with normal SEPs. If the definition of favorable outcome was expanded to include Glasgow Outcome Scale-Extended 5-8, ERP was still superior to SEP for prognosticating good outcome. Interestingly, the highest sensitivity and negative predictive value for favorable outcomes were associated with the presence of any discernible waveform. CONCLUSIONS: Although median nerve SEP continues to make reliable prediction of ominous outcome in severe traumatic brain injury, the addition of the speech-evoked ERPs may be helpful in predicting favorable outcomes. The strength of the latter test seems to complement the weakness of the former.     

重型脑弥漫性轴索损伤的诊断与治疗

目的 探讨重型脑弥漫性轴索损伤的发病机制、临床特点、诊断、治疗和预后。方法 回顾性分析200例重型脑弥漫性轴索损伤患者的临床资料。结果 伤后6个月根据格拉斯哥预后分级：恢复良好30例（15％）、中残30例（15％）、重残38例（19％）、植物生存12例（6％）、死亡90例（45％）。结论 重型脑弥漫性轴索损伤是重型颅脑损伤患者死亡的主要原因，致残率高；意识障碍是其典型临床表现。其诊断MRI检壹优于CT；大部分采取保守治疗。格拉斯哥昏迷评分越低，患者昏迷持续时间越长，预后越差。     

Comparisons among measurement tools in traumatic brain injury outcomes

Traumatic brain injury (TBI) is considered the most important cause of disability among young people and the most common neurological cause of morbidity. Consequently, there is increasing interest in scales to monitor recovery in TBI. Among these scales, two have been widely adopted: the Glasgow Outcome Scale (GOS) and the Disability Rating Scale (DRS). The purpose of this paper is to compare the results found in DRS and in the original and extended GOS. Sixty-three closed-head injury victims, aged between 12 and 65, on an outpatient follow-up program at a trauma center in the city of S?o Paulo, with 6 months to 3 years post-TBI, had their characteristics and outcomes assessed. When comparing the results obtained by the scales, it was concluded that although the three of them were strongly correlated, extended GOS showed to be more sensitive in detecting changes in victims with better post-traumatic conditions.     

Years to employment after spinal cord injury

OBJECTIVE: To identify factors related to the length of time between spinal cord injury (SCI) onset and return to work among 259 participants with SCI, all of whom have worked at some point since SCI onset. DESIGN: All data were cross-sectional and collected by survey methodology. SETTING: A midwestern university hospital and private hospital in the same metropolitan area. PARTICIPANTS: Participants were identified from outpatient records of 2 participating hospitals. They met 4 exclusion and inclusion criteria: (1) traumatic SCI; (2) 18 years of age or older; (3) a minimum of 2 years postinjury; and (4) had been employed at some time since SCI. The 259 participants' average age was 46.4 years at the time of the study, with an average of 23.5 years having passed since SCI onset. INTERVENTIONS: Not applicable. Main Outcome Measures: Years from injury onset to beginning first postinjury job, years to the first full-time postinjury job, and the Life Situation Questionnaire. RESULTS: Participants averaged 4.8 years from the time of SCI onset to their first postinjury job and 6.3 years until their first full-time postinjury job. However, these figures varied greatly depending on whether the individual returned to the preinjury job, was working as a professional at the time of injury, had a noncervical injury, and the amount of education by the time of injury. CONCLUSION: There are 2 general tracks to employment after SCI-a fast track where people return to their preinjury job or preinjury profession and a slower track that is generally associated with needs for further reeducation and training. Working to return the individual to the preinjury job or to a position related to their preinjury occupation may substantially shorten the interval to return to work. In cases where this is not possible, counselors must work with individuals to understand the timeline of return to work and identify realistic educational goals that fit both the individual's interest pattern and postinjury abilities.     

前交通动脉瘤的显微手术治疗

目的:探讨经翼点入路显微外科手术治疗前交通动脉瘤的手术方法及疗效。方法:对2004年9月~2007年5月我科收治的98例前交通动脉瘤采用经翼点入路行显微外科手术治疗。结果:94例行瘤颈夹闭术,4例行动脉瘤包裹术;术中动脉瘤破裂8例(8.2%)。手术效果按Glasgow Outcome Score(GOS评分):恢复良好83例(84.7%),中度残疾8例(8.2%),重度残疾4例(4.1%),植物状态1例(1.0%),死亡2例(2.0%)。结论:经翼点入路显微外科手术治疗前交通动脉瘤,术中暴露清楚,夹闭瘤颈可靠,疗效满意。     

经外侧裂脑池开放减压治疗额颞对冲性脑挫裂伤

目的总结经外侧裂脑池开放在对冲性脑挫裂伤减压术中的应用效果。方法对31例额颢对冲性脑挫裂伤术中经外侧裂入路施行鞍旁脑池和基底池开放的患者进行临床资料的进行回顾性分析。结果术后动态复查头颅CT，全部患者额颞脑挫裂伤区域未见明显脑水肿现象，2例死于脑功能衰竭，2例死于严重并发症。其余随访3～6个月，按GOS评分，良好20例，中残5例，植物状生存2例。结论额颢对冲性脑挫裂伤术中经外侧裂施行鞍旁脑池和基底池开放减压可减轻继发性脑水肿，提高临床效果。     

Factor analysis of an outcome interview for use in clinical trials of traumatically brain-injured patients: a preliminary study

OBJECTIVE: To study the factor structure, internal consistency, concurrent validity, and sensitivity to detect change in patient report of problems of a structured interview in relationship with accepted outcome measures. DESIGN: Outcome status of patients with severe traumatic brain injury participating in a randomized, phase III, multicenter clinical trial was assessed at 6 mo postinjury using the Glasgow Outcome Scale, the Disability Rating Scale, and the Severe Traumatic Brain Injury Outcome Interview. RESULTS: Exploratory factor analysis of the Severe Traumatic Brain Injury Outcome Interview produced a meaningful five-factor model: (1) activities of daily living; (2) cognitive; (3) affective; (4) behavioral; and (5) instrumental activities of daily living. The internal consistency of the factors ranged from moderate (0.61 instrumental activities of daily living) to high (0.94 activities of daily living); the interfactor correlations were moderate. The summed factor scores were significantly correlated with measures of global outcome: the Glasgow Outcome Scale (r = 0.66; P < 0.0001) and the Disability Rating Scale (r = 0.61; P < 0.0001). Patient report of cognitive problems correlated moderately with the neuropsychological tests. The summed factor scores were sensitive to change over time. CONCLUSIONS: Overall, the interview assessed the major important features of outcome pertinent to traumatic brain injury and demonstrated greater sensitivity to subtle changes over time than the unidimensional approaches, such as the Glasgow Outcome Scale and Disability Rating Scale.     

Prognostic factors of long-term functioning and productivity after traumatic brain injury: a systematic review of prospective cohort studies

OBJECTIVE: To systematically review prospective cohort studies that investigated prognostic factors associated with long-term activity limitations or participation restrictions and productivity after a traumatic brain injury. DATA SOURCES: PubMed and Psychinfo were searched from 1995 to April 2005, and references were checked. REVIEW METHODS: Publications were selected if the study assessed prognostic factors for activity limitations or participation restrictions at least one year post injury; outcome was measured with another or additional measure besides the Glasgow Outcome Scale; the design was a prospective cohort study of adult traumatic brain injury patients; the article was a full-text article written in English, French, German or Dutch. Two reviewers independently assessed methodological quality. A study was considered as 'high quality' if it satisfied at least half of the maximum available quality score. RESULTS: Thirty-five articles reporting on 14 cohorts were included. Due to heterogeneity in prognostic factors and outcome measures, a best-evidence synthesis was performed. All cohorts were of high quality. Strong evidence for predicting disability was found for older age, pre-injury unemployment, pre-injury substance abuse, and more disability at rehabilitation discharge. Strong prognostic factors for being non-productive were pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission, and pre-injury substance abuse. CONCLUSION: Older age, pre-injury unemployment, pre-injury substance abuse and more disability at rehabilitation discharge are important predictors of long-term disability. Pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission and pre-injury substance abuse are important predictors of being non-productive.     

Impact of the role of senior dual disability coordinator on the perceived self-efficacy and job satisfaction of mental health clinicians

Abstract

Purpose: This study aimed to evaluate a new service role in mental health services, namely, the senior dual disability coordinator role (SDDC) for its impact on the perceived self-efficacy of mental health clinicians in managing clients with dual disability (mental illness and acquired brain injury and/or intellectual disability) and their job satisfaction. Method: Mental health clinicians from a health service district in Queensland, Australia who contacted the SDDC for clinical consultation and liaison between July 2011 and July 2013 were asked to complete a questionnaire assessing perceived self-efficacy in working with clients with dual disability as well as their job satisfaction, prior to (T1) and following (T2) their contact with the SDDC. Results: Twenty-five clinicians completed and returned pre- and post-measure questionnaires. Self-reported knowledge of dual disability, clinical skills in dual disability, service knowledge in dual disability as well as perceived self-efficacy, and job satisfaction increased significantly from T1 to T2. There were no significant differences across professional discipline or years of service. Conclusions: The delivery of a clinical consultation liaison service as part of the role of SDDC may assist mental health clinicians with self-efficacy and job satisfaction, regardless of the number of years they have worked in the service or their professional discipline. Mental health clinicians with improved self-efficacy for working with clients with dual disability may be more likely to consider the client suitable for services through mental health and follow-up with treatment and linking the client with other identified suitable services.

• Implications for Rehabilitation

• Dual disability (mental illness and acquired brain injury and/or intellectual disability) presents specific challenges for mental health services Specific strategies are needed to build capacity among mental health practitioners in order to meet the needs of people with dual disability and provide appropriate services.

• Introducing dual disability coordinators as a specific position within a health service district may assist to improve self-efficacy and job satisfaction of mental health practitioners assisting people with dual disability.

     

Serum levels of the brain-derived proteins S-100 and NSE predict long-term outcome after cardiac arrest

Background and purpose: patients with cardiac arrest have a high mortality and the long-term outcome is doubtful. The prognosis is mainly dependent on clinical parameters. S-100 and neurone specific enolase (NSE) are established biochemical markers of central nervous system (CNS) injury. The purpose of this study was to validate the use of serum determinations of S-100 and NSE with neurological investigations in regard to brain damage and long-term outcome after cardiac arrest. Methods: neurological examinations were performed on 66 patients after cardiac arrest. Serum levels of S-100 and NSE were determined during the first 3 days of post arrest, using commercial luminescent immunoassays (LIAs). The main outcome variable was the Glasgow Outcome Scale (GOS), while secondary variables were the activity of daily living (ADL) index and mini mental state examination (MMSE). Outcome was determined at 1 year. Results: the serum levels of S-100 and NSE were increased during the first 3 days after the arrest and were related to coma depth, time of anoxia and abnormal brain stem reflexes. High levels predicted a poor outcome, according to the GOS (death, vegetative state and severe disability). The prognostic value of the brain damage markers was comparable with that of traditional clinical parameters. None of the secondary outcome variables (ADL and MMSE) was strongly associated with S-100 or NSE. Discussion: the serum levels of S-100 and NSE increased after cardiac arrest due to the anoxic brain damage. The determination of S-100 and NSE can be used as an adjunct to predict long-term outcome after cardiac arrest.     

Return to work of 87 severely impaired low back pain patients two years after a program of intensive functional restoration

Return to work is the main long-term objective of rehabilitation programs for patients with chronic low back pain (LBP).ObjectivesEvaluation of work status and number of sick leaves in 87 severely impaired LBP patients 2 years after a functional restoration program.Patients and methodsOpen prospective study. Population: 87 chronic LBP patients. Intervention: multidisciplinary functional restoration program. Ergonomic advice on the workplace was performed for 53 patients. Outcome: work status and number of sick leaves due to LBP.ResultsThe characteristics of the 26 patients lost to follow-up did not differ significantly from the rest of the population before the program. In the 61 remaining patients, 48 (78%) were at work at 2 years, 43 full-time and 22 at the same job. Nineteen worked in a different environment. Sick leaves were reduced by 60% compared to the 2 years prior to the program: 128 days (± 200 days) versus 329 days (± 179 days); p < 0.005.ConclusionSick leaves remained significantly reduced and the number of workers who were at work significantly increased at 2 years after an intensive program.     

Influence of definition and location of hypotension on outcome following severe pediatric traumatic brain injury

OBJECTIVE: To examine the influence of definition and location (field, emergency department, or pediatric intensive care unit) of hypotension on outcome following severe pediatric traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: Harborview Medical Center (level I pediatric trauma center), Seattle, WA, over a 5-yr period between 1998 and 2003. PATIENTS: Ninety-three children <14 yrs of age with traumatic brain injury following injury, head Abbreviated Injury Score > or = 3, and pediatric intensive care unit admission Glasgow Coma Scale score <9 formed the analytic sample. Data sources included the Harborview Trauma Registry and hospital records. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The relationship between hypotension and outcome was examined comparing two definitions of hypotension: a) systolic blood pressure <5th percentile for age; and b) systolic blood pressure <90 mm Hg. Hospital discharge Glasgow Outcome Score <4 or disposition of either death or discharge to a skilled nursing facility was considered a poor outcome. Pediatric intensive care unit and hospital length of stay were also examined. Systolic blood pressure <5th percentile for age was more highly associated with poor hospital discharge Glasgow Outcome Score (p = .001), poor disposition (p = .02), pediatric intensive care unit length of stay (rate ratio 9.5; 95% confidence interval 6.7-12.3), and hospital length of stay (rate ratio 18.8; 95% confidence interval 14.0-23.5) than systolic blood pressure <90 mm Hg. Hypotension occurring in either the field or emergency department, but not in the pediatric intensive care unit, was associated with poor Glasgow Outcome Score (p = .008), poor disposition (p = .03), and hospital length of stay (rate ratio 18.7; 95% confidence interval 13.1-24.2). CONCLUSIONS: Early hypotension, defined as systolic blood pressure <5th percentile for age in the field and/or emergency department, was a better predictor of poor outcome than delayed hypotension or the use of systolic blood pressure <90 mm Hg.     

French version of structured interviews for the Glasgow Outcome Scale: guidelines and first studies of validation]

OBJECTIVES: The Glasgow Outcome Scale (GOS) is the most widely used outcome measure after traumatic brain injury. The GOS's reliability is improved by a structured interview. The two aims of this paper were to present a French version of the structured interview for the five-point Glasgow Outcome Scale and the extended eight-point GOS (GOSE) and to study their validity. METHODS: The French version was developed using back-translation. Concurrent validity was studied by comparison with GOS/GOSE without structured interview. Inter-rater reliability was studied by comparison between assignments made by untrained head injury observers and trained head injury observers. Strength of agreement between ratings was assessed using the Kappa statistic. RESULTS: The French version and the guidelines for their use are given in the Appendix. Ratings were made for 25 brain injured patients and 25 relatives. Concurrent validity was good and inter-rater reliability was excellent. CONCLUSION: Using the structured interview for the GOS will give a more reliable assessment of the outcome of brain injured patients by French-speaking rehabilitation teams and a more precise assessment with the extended GOS.     

Recombinant factor VIIa for rapid reversal of warfarin anticoagulation in acute intracranial hemorrhage

OBJECTIVE: To assess the effects of recombinant factor VIIa (rFVIIa) on hemorrhage volume and functional outcomes in warfarin-related acute intracranial hemorrhage (ICH), which has a 30-day mortality of more than 50%. PATIENTS AND METHODS: We reviewed the clinical, laboratory, and radiographic features of a consecutive series of 7 patients (median age, 87 years; 5 women) with symptomatic, nontraumatic warfarin-related acute ICH treated with intravenous rFVIIa at St. Luke's Hospital in Jacksonville, Fla, between December 2002 and September 2003. Prestroke baseline functional status was assessed with the modified Rankin Scale. Outcome was assessed with the Glasgow Outcome Scale. RESULTS: The international normalized ratio decreased from a mean of 2.7 before administration of rFVIIa to 1.08 after administration of rFVIIa. The median prestroke score on the modified Rankin Scale was zero. The median presenting score on the Glasgow Coma Scale was 14 (range, 4-15). The mean time from onset to treatment was 6.2 hours. The mean initial dose of rFVIIa was 62.1 microg/kg. One patient underwent placement of an external ventricular drain, and another underwent craniotomy and hematoma evacuation. Five of the 7 patients survived and were dismissed from the hospital with severe disability (Glasgow Outcome Scale, 3); 2 patients died during hospitalization. CONCLUSIONS: Intravenous bolus administration of rFVIIa can rapidly lower the international normalized ratio and appears to be safe for patients with warfarin-related ICH. Prospective controlled studies are needed to determine whether rFVIIa can prevent hematoma expansion and improve neurologic outcomes in patients with warfarin-related ICH.