Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management

The lack of a common, widely acceptable criterion for the definition of trivial, minor, or mild head injury has led to confusion and difficulty in comparing findings in published series. This review proposes that acute head-injured patients previously described as minor, mild, or trivial are defined as "mild head injury," and that further groups are recognized and classified as "low-risk mild head injury," "medium risk mild head injury," or "high-risk mild head injury." Low-risk mild injury patients are those with a Glasgow Coma Score (GCS) of 15 and without a history of loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is definitively less than 0.1:100. These patients can be sent home with written recommendations. Medium risk mild injury patients have a GCS of 15 and one or more of the following symptoms: loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is in the range of 1-3:100. Where there is one computed tomography (CT) scanner available in an area for 100,000 people or less, a CT scan should be obtained for such patients. If CT scanning is not so readily available, adults should have a skull x-ray and, if this shows a fracture, should be moved to the "high-risk" category and undergo CT scanning. High-risk mild head injury patients are those with an admission GCS of 14 or 15, with a skull fracture and/or neurological deficits. The risk of intracranial hematoma requiring surgical evacuation is in the range 6-10:100. If a CT scan is available for 500,000 people or less, this examination must be obtained. Patients with one of the following risk factors--coagulopathy, drug or alcohol consumption, previous neurosurgical procedures, pretrauma epilepsy, or age over 60 years--are included in the high-risk group independent of the clinical presentation.     

Comparison of clinical, radiologic, and serum marker as prognostic factors after severe head injury

BACKGROUND: S-1OOB, a protein of astroglial cells, is described as a marker for neuronal damage. Reliable outcome prediction from severe head injury is still unresolved. Clinical scores such as the Glasgow Coma Scale score (GCS) and diagnostic scores such as the Marshall Computed Tomographic Classification are well established and investigated, but there are still some concerns about these tools. The aim of this study was to investigate the predictive value of the initial serum level of S-100B compared with the predictive value of the GCS score and the Marshall Computed Tomographic Classification to outcome after severe head injury. METHODS: Forty-four patients with severe head injury (GCS score < 9) were included. Blood samples were drawn within 1 to 6 hours of injury. After a period of 11 months, their outcome was correlated by using the Glasgow Outcome Scale. Patients with an S-100B serum level above 2 microg/L, a GCS score between 3 and 5, and a computed tomographic scan in the categories 4 to 6 are predicted to have an unfavorable outcome. The predictive values of these tools were calculated according to these definitions. RESULTS: The protein S-100B had with 17% the lowest total misclassification rate. When compared with the GCS score and Marshall Computed Tomographic Classification the S-100B serum level calculated on admission had the highest positive predictive value (87%) and negative predictive value (77%). CONCLUSION: The serum level of S-100B calculated within 1 to 6 hours of a severe head injury is a useful additional outcome predictor.     

The management of head injury and intracranial pressure

Severe head injury occurs predominantly in the young population. Although the incidence is decreasing in the United Kingdom, the eventual outcome of these patients has major social and economic implications. Damage to brain tissue during head injury is both primary, due to the initial insult, or secondary, which occurs later. Because little can be done about the primary injury, the intensive care management is targeted at reducing the secondary insults which may cause further brain damage. The prevention of secondary injury involves prompt airway management and treatment of hypoxia and hypotension. Severe head injury often causes raised intracranial pressure (ICP). The management is focused on maintaining cerebral perfusion pressure, which should be maintained above 70 mmHg by adequate fluid replacement or by the judicious use of inotropes. The methods to control ICP include general measures (15° head up position, avoidance of jugular venous obstruction, prevention of hyperthermia and hypercarbia) and neurospecific measures. The neurospecific measures are particularly useful in patients with refractory intracranial hypertension. The patient may need sedation, paralysis, use of barbiturate coma, osmotherapy, moderate cooling, controlled hyperventilation or surgical intervention. This review focuses on the rationale for the use of these interventions, outlining their benefits and their pitfalls.     

Traumatic head injury in children: physiopathology and clinical management

Traumatic brain injury (TBI) constitutes a major health and economic problem for developed countries, being one of the main causes of mortality and morbidity in children. In a busy traumatology center, a child will be admitted daily in the emergency department with head trauma injury. The anaesthesiologist must have a complete understanding of the pathophysiology and develop a practical knowledge of initial management of such patients. Traumatic brain injury may have intracranial and systemic effects that combine to give global cerebral ischaemia. Injury to the nervous system, irrespective of the primary injury, initiates a multitude of inflammatory cascades resulting in secondary brain injury. The consequence of these secondary brain injuries is most often as important, if not, more important than the primary injury. This period of brain inflammation can last up to three weeks and renders the brain more susceptible to the effects of systemic insults such as hypotension, hypoxia and or pyrexia. It has been shown in post-mortem examination of patients dying from severe traumatic brain injury that more than 91% had evidence of secondary ischaemic damage. These secondary injuries may be responsible for the clinical presentation of the "child who talk and die". The concept of "cerebral protection" has been extended to encompass the active treatment of secondary injury and the prevention of cerebral ischaemia. Initial care focuses on achieving oxygenation, airway control and treatment of arterial hypotension.     

Risk factors predicting operable intracranial hematomas in head injury.

A study was performed to examine the incidence of operable traumatic intracranial hematomas accompanying head injuries of differing degrees of severity, and to see if factors predicting operable mass lesions could be identified. Logistic analysis was used to identify independent predictors of operable traumatic intracranial hematomas. Data were gathered prospectively on 1039 patients admitted with head injury between January, 1986, and December, 1990. Patient age, Glasgow Coma Scale (GCS) score, pupillary inequality, and injury by falling were all independent predictors of the presence of operable intracranial hematomas (p = 0.0000, 0.0000, 0.0182, and 0.0001, respectively). Injury to vehicle occupants was less likely to result in operable mass lesions (p = 0.0001) than injury by other means. The incidence of traumatic intracranial hematomas in patients over 50 years old was three to four times higher than in those under 30 years of age. Not surprisingly, the incidence of operable hematomas increased with decreasing GCS scores. However, even at a GCS score of 13 to 15, patients with other risk factors had a substantial incidence of operable mass lesions. There was a 29% incidence of operable intracranial hematomas for patients with a GCS score of 13 to 15, aged over 40 years and injured in a fall. It is suggested that patients who are middle-aged or older, or those injured in falls, are at particular risk for traumatic intracranial hematomas even if their GCS score is high. These patients should have early definitive investigation with computerized tomography in order to identify operable hematomas and to initiate surgical treatment prior to neurological deterioration from mass effect.     

Multidisciplinary management of pyogenic spondylodiscitis: epidemiological and clinical features,prognostic factors and long-term outcomes in 207 patients

Purpose

Pyogenic spondylodiscitis (PS) is a potentially life-threatening infection burdened by high morbidity rates. Despite the rising incidence, the proper management of PS is still controversial. Aim of this study was to describe the clinical features of PS and to evaluate the prognostic factors and the long-term outcomes of a large population of patients.

Methods

207 cases of PS treated from 2008 to 2016 with a 2-year follow-up were enrolled. Clinical data from each patient were recorded. The primary outcome was the rate of healing without residual disability. Secondary outcomes included length of stay, healing from infection, death, relapse, and residual disability. Binomial logistic regression and multivariate analysis were used to evaluate prognostic factors.

Results

Median diagnostic delay was 30 days and the rate of onset neurological impairment was 23.6%. Microbiological diagnosis was established in 155 patients (74.3%) and the median duration of total antibiotic therapy was 148 days. Orthopedic treatment was conservative for 124 patients and surgical in 47 cases. Complete healing without disability was achieved in 142 patients (77.6%). Statistically confirmed negative prognostic factors were: negative microbiological culture, neurologic impairment at diagnosis and underlying endocarditis (p?≤?0.05). Healing from infection rate was 90.9%, while residual disabilities occurred in 23.5%. Observed mortality rate was 7.8%.

Conclusion

The microbiological diagnosis is the main predictive factor for successful treatment. Early diagnosis and multidisciplinary management are also needed to identify underlying aggressive conditions and to avoid neurological complications associated with poorer long-term outcomes. Despite high healing rates, PS may lead to major disabilities still representing a difficult challenge.

Graphical abstract

These slides can be retrieved under Electronic Supplementary material.

Open image in new window

     

Bladder cancer: a review of clinical management and prognostic factors

Bladder cancer is a heterogeneous disease that offers a unique challenge for the patient and the physician as treatment paradigms are continually evolving. There are multiple factors that can influence how each individual is treated, including lymphovascular invasion, micropapillary histology, and p53 nuclear accumulation which have demonstrated a worse prognosis in patients with bladder cancer. They can influence the use of neoadjuvant and adjuvant chemotherapy, which in itself can affect the timing of extirpative surgery. This review will focus on the contemporary management and treatment of bladder cancer focusing on areas of clinical decision making.     

Temperature regulation as possible prognostic indicator in patients with acute intracranial lesions

Summary 24 patients, 16 after severe head injury and 8 after spontaneous intracranial haematoma, were investigated by external cold load in order to determine their thermoregulatory capabilities.Tympanic temperature, several skin temperatures and oxygen consumption were measured. The patients where examined for SSEP and AEP. The cold induced thermoregulatory threshold temperature was determined by calculating the mean body temperature and by determining mean body temperature at which oxygen consumption increased due to the external cold load.In all patients core temperature and mean body temperature were significantly elevated by 1 °C compared to controls. There was no difference of the course of the various body temperatures during cold load in the patient groups. In the trauma group 8 patients were able to increase oxygen use (VO₂) during cold exposure, the other 8 patients showed no physiological thermoregulatory reaction. The heatproduction threshold temperature was increased by 1 °C in the patient groups compared to controls. There was no significant correlation of AEP and SSEP findings to a preserved or disturbed thermoregulatory reaction. In the trauma patients, who were able to respond to a cold load, the outcome was significantly better (GOS=3–5), than in those patients, who did not show a physiological increase of VO₂ due to the cold load (GOS=1–2).In conclusion, measurement of body temperatures alone is not sufficient to determine termoregulatory capacities. An examination using thermophysiological methods however provides more information about the function and structure damaged after severe head injury. An intact thermoregulatory systems seems to be correlated with a better prognosis after head injury.Dedicated to Prof. Dr. K. Brück, Former Head of the Institute of Physiology of the University of Giessen, Federal Republic of Germany.     

Relationship between hyperventilation and intracranial pressure in patients with severe head injury

ＷＤｅｐａｒｔｍｅｎｔｏｆＮｅｕｒｏｓｕｒｇｅｒｙ ,15 5ｔｈＨｏｓｐｉｔａｌｏｆＰＬＡ ,Ｋａｉｆｅｎｇ 475 0 0 3,Ｃｈｉｎａ (ＸｉＷＢ ,ＨｕＪ ,ＺｈｅｎｇＤＨ ,ＨｕｉＬＳ ,ＷａｎｇＢａｎｄＬｉｕＧＦ)ＤｅｐａｒｔｍｅｎｔｏｆＥｍｅｒｇｅｎｃｙ ,15 5ｔｈＨｏｓｐｉｔａｌｏｆＰＬＡ ,Ｋａｉｆｅｎｇ475 0 0 3 ,Ｃｈｉｎａ (ＳｕｎＬＤ)ＤｅｐａｒｔｍｅｎｔｏｆＡｎｅｓｔｈｅｓｉａ ,15 5ｔｈＨｏｓｐｉｔａｌｏｆＰＬＡ ,Ｋａｉｆｅｎｇ475 0 0 3 ,Ｃｈｉｎａ (ＹａｏＪＨ)ｉｔｈｈｉｇｈｆａｔａｌｉｔｙｒａｔｅａｎｄ…     

Paediatric head injury: incidence, aetiology and management

Trauma is the commonest cause of hospital admission in children. Head injuries are present in 75% of children with trauma and 70% of all traumatic deaths are due to the head injury. The mechanism of brain injury is examined, resulting from the effects of the primary insult and secondary ischaemic damage. Therapeutic interventions will be discussed with specific emphasis on outcome studies. However, institution of adequate oxygen delivery and haemodynamic stability in the child at the earliest moment remains the most important aspect of the management plan.     

Primary gastrointestinal sarcomas: analysis of prognostic factors and results of surgical management

BACKGROUND: This study was done to review the clinical presentation, surgical management, and prognostic factors for primary gastrointestinal sarcomas. METHODS: We reviewed medical records of 55 patients who were treated for primary gastrointestinal sarcomas from 1981 through 1996. Mean follow-up time was 32 months. RESULTS: Clinical findings included gastrointestinal bleeding (51%), palpable mass (36%), and abdominal pain (33%). The stomach was the most common site of disease (53%), followed by the small intestine (33%). Tumors were high grade in 76% of patients and low-grade in 24% of patients. Complete resection of all gross disease was accomplished in 35 patients (64%), incomplete resection in 17 patients (31%), and biopsy only in 3 patients (5%). Adjacent organ resection was required in 19 patients (35%). Overall actuarial survival was 22% (median survival, 32 months). Unfavorable prognostic factors were incomplete resection, high-grade histologic features, and tumor size of 5 cm or more (P<.05). En bloc resection of contiguous organs did not adversely effect survival. In patients with complete resections, tumor grade was the most important prognostic factor (median survival, 55 months vs 19 months for low-grade vs high-grade tumors; P<.05). CONCLUSIONS: Aggressive surgical resection, including en bloc resection of locally advanced tumors, appears warranted. Despite complete resections, patients with high-grade tumors remain at risk for recurrence.     

重型颅脑损伤后脑组织氧分压和颅内压监测及其临床意义

目的探求重型颅脑损伤患者颅内压(ICP)和脑组织氧分压(PbtO2)的变化及临床意义。方法选择重型脑损伤患者(GCS<8)28例,PbtO2持续监测,同时行颅内压(ICP)、血电解质、动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)测定;分析ICP和PbtO2的变化规律及意义。结果(1)伤后24小时PbtO2≤5mmHg,ICP≥40mmHg无法降压者预后不良;(2)伤后ICP、PaO2、PaCO2明显影响患者PbtO2;(3)没有发生与插入监测电极相关的并发症。结论脑组织氧分压测定是一种安全、可靠、灵敏的脑组织氧合程度监测方法,可反映出重型脑损伤后的脑组织缺血缺氧情况,提示预后,对临床治疗具有重要的指导作用。     

Relative incidence of intracranial mass lesions and severe torso injury after accidental injury: implications for triage and management

In a previous study of head injury patients we found that old age, low Glasgow Coma Scale (GCS) score, pupillary inequality, and falls were significant predictors of intracranial mass lesions (IMLs). Injury to motor vehicle occupants was less likely to result in IML. The present study defines predictors of severe torso injury (STI) in 646 patients admitted to a trauma unit and compares these with predictors of IML obtained in the previous study. Tachycardia and low blood pressure were associated with an increased incidence of STI (p = 0.003, p = 0.0000). The incidence of STI in falls differed from that of IML (13.2% vs. 47.7%, p less than 0.001). There was a greater incidence of STI than IML in MVAs (33.6% vs. 14.8%, p less than 0.001). Patients 70 years of age or older had a higher incidence of IMLs than STIs (p less than 0.001). Patients less than 30 years old had a significantly greater incidence of STIs than IMLs (p less than 0.001). These data suggest that in MVA victims who are less than 30 years old, are hypotensive, and tachycardic, the diagnosis and emergent treatment of severe torso injury should take precedence over measures designed to detect and treat intracranial mass lesions. The converse is true for older patients injured in falls.     

Survival and prognostic factors in chondrosarcoma: results in 115 patients with long-term follow-up

Background and purpose

There have been few long-term studies on the outcome of chondrosarcoma and the findings regarding prognostic factors are controversial. We examined a homogeneous group of patients with primary central chondrosarcoma of bone who were treated according to a uniform surgical protocol at our institution, in order to determine the factors that influence survival and identify potential improvements to our therapeutic algorithm.

Patients and methods

We performed a retrospective analysis of 115 patients with primary central chondrosarcoma of bone who presented with localized disease and who had a minimum follow-up of 5 years after diagnosis. 68 tumors were localized in the extremities and 47 in the axial skeleton or pelvis. 59 patients had a high-grade (II and III) and 56 a low-grade (I) tumor. 94 patients underwent surgical resection with adequate (wide or radical) margins, while 21 patients had inadequate (marginal or intralesional) margins.

Results

Tumor grade and localization were found to be statistically significant independent predictors of disease-related deaths in multivariate analysis. The quality of surgical margins did not influence survival. The AJCC staging system was able to predict prognosis in patients with chondrosarcoma of the extremities, but not in those with tumors of the axial skeleton and pelvis. Long-term survival after secondary metastatic disease was only observed when metastases were resected with wide margins. Patients with metastases who received further treatment with conventional chemotherapy, radiotherapy, and/or further surgery had significantly better survival compared to those who received best supportive care.

Interpretation

The outcome in patients with primary central chondrosarcoma of bone who present with localized disease is mostly affected by tumor-related parameters.Chondrosarcoma is the second most common primary malignant solid tumor of bone, and accounts for approximately 25% of all bone sarcomas (Bertoni et al. 2002). It is largely considered to be resistant to conventional chemotherapy and radiotherapy (Healey and Lane 1986, Campanacci 1999, Gelderbloom et al. 2008). As such, surgical resection has been the cornerstone of treatment for over 50 years (Dahlin and Henderson 1956, Healey and Lane 1986, Gelderbloom et al. 2008). However, in recent years several novel therapeutic approaches have been evaluated in experimental studies (Morioka et al. 2003, Gouin et al. 2006, Klenke et al. 2007, Delaney et al. 2009, Schrage et al. 2009, 2010).There is no consensus on prognostic factors to determine which patients have a higher risk of treatment failure and disease-related deaths, although several papers have addressed this issue (Evans et al. 1977, Pritchard et al. 1980, Gitelis et al. 1981, Björnsson et al. 1998, Lee et al. 1999, Rizzo et al. 2001, Fiorenza et al. 2002). One reason may be that most studies have included patients treated over several decades, with no account for the different surgical criteria, indications, and methods applied over the years. Furthermore, most studies have included patients with short follow-up, despite the fact that a high rate of late recurrence and metastasis has been reported for chondrosarcoma patients compared to those with other primary bone sarcomas (Evans et al. 1977, Pritchard et al. 1980), as well as patients with rare histopathological subtypes that have a distinct biologic behavior (Lee et al. 1999, Bertoni et al. 2002, Gelderbloom et al. 2008) such as dedifferentiated chondrosarcoma, mesenchymal chondrosarcoma, and clear cell chondrosarcoma, thus reducing the validity of the results.The purpose of this long-term retrospective study was to examine a group of patients with primary central chondrosarcoma of bone who presented with localized disease and were treated with a uniform surgical protocol at our institution, in order to determine the factors that influence overall and event-free survival. We further aimed at identifying potential improvements to our therapeutic algorithm.