Peri—operative treatment of most severely head—injured patients

ＴＤｅｐａｒｔｍｅｎｔｏｆＮｅｕｒｏｓｕｒｇｅｒｙ ,ＨｕａｓｈａｎＨｏｓｐｉｔａｌ,ＳｈａｎｇｈａｉＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ ,Ｓｈａｎｇｈａｉ 2 0 0 0 40 ,Ｃｈｉｎａ (ＸｕＷ ,ＧｕＳＸ ,ＰａｎｇＬ ,ＪｉＹＤ ,ＺｈｏｕＬＦ ,ＧａｏＬ ,ＣａｏＸＹａｎｄＨｕＤＺ)ｈｅｍｏｒｔａｌｉｔｙｒａｔｅｏｆｍｏｓｔｓｅｖｅｒｅｌｙｈｅａｄ ｉｎｊｕｒｅｄｐａｔｉｅｎｔｓｗｉｔｈＧＣＳｓｃｏｒｅ 3 5ｉｓｖｅｒｙｈｉｇｈａｎｄｍｏｓｔｏｆｔｈｅｐａｔｉｅｎｔｓｈａｖｅｐｏｏｒｐｒｏｇｎｏｓｉｓ .Ｈｏｗｔｏｉｍ…     

Mild to moderate hypothermia：the hope for improving outcome of severe head injured patients

ＴＤｅｐａｒｔｍｅｎｔｏｆＮｅｕｒｏｓｕｒｇｅｒｙ,ＣｈａｎｇｚｈｅｎｇＨｏｓｐｉｔａｌ,ＳｈａｎｇｈａｉＮｅｕｒｏｓｕｒｇｉｃａｌＩｎｓｔｉｔｕｔｅ,Ｓｈａｎｇｈａｉ200003,Ｃｈｉｎａ(ＪｉａｎｇＪＹａｎｄＺｈｕＣ)ｒａｕｍａｔｉｃｂｒａｉｎｉｎｊｕｒｙ(ＴＢＩ)ｉｓａｍａｊｏｒｐｕｂｌｉｃｈｅａｌｔｈｐｒｏｂｌｅｍｔｈｒｏｕｇｈｏｕｔｔｈｅｗｏｒｌｄ.Ｍｏｒｅｔｈａｎ400000ｐａｔｉｅｎｔｓｗｉｔｈＴＢＩｉｎｔｈｅＵｎｉｔｅｄＳｔａｔｅｓｏｆＡｍｅｒｉｃａａｎｄｍｏｒｅｔｈａｎａｍｉｌｌｉｏｎｐａｔｉ…     

Does oncotype DX recurrence score affect the management of patients with early-stage breast cancer?

BACKGROUND: Oncotype DX is a 21-gene assay that calculates a risk of distant recurrence in women with estrogen-receptor-positive, lymph node-negative breast cancer. The purpose of this study was to determine whether the results of Oncotype DX influence the decision to administer chemotherapy. METHODS: A retrospective study was performed on 85 consecutive patients with estrogen-receptor-positive, lymph node-negative breast cancer who had an Oncotype DX recurrence score (RS) obtained. Tumor size, tumor grade, and treatment were then compared within each risk category. Statistical analysis was performed using STATA software. RESULTS: Tumors that were high grade and Her-2/neu positive more frequently had a high RS. Treatment was changed as a result of Oncotype DX in 44% of patients. CONCLUSIONS: Oncotype DX RS is significantly related to tumor grade and Her2/neu status. In this study, the treatment of 44% of patients was altered as a consequence of Oncotype DX RS.     

PPG, APG, duplex: which noninvasive tests are most appropriate for the management of patients with chronic venous insufficiency?

Numerous noninvasive tests have been described for assistance in the diagnosis and treatment of patients with chronic venous insufficiency (CVI). These tests include venous duplex ultrasound examination in the supine and standing positions, photoplethysmography (PPG), and air plethysmography (APG). The goal of these studies is to provide accurate information describing the anatomic or the hemodynamic characteristics of the patient with CVI, precluding the need for invasive studies. These tests will be reviewed including the typical information obtained, the usefulness of this information, and the relevance for clinical management of patients with CVI. Based on the clinical class, recommendations for a noninvasive testing protocol are outlined.     

Spontaneous cerebellar hemorrhage—experience with 57 surgically treated patients and review of the literature

The treatment of spontaneous cerebellar hemorrhage is still discussed controversially. We analyzed a series of 57 patients who underwent surgical evacuation of a cerebellar hematoma at our department. Preoperative clinical and radiological parameters were assessed and correlated with the clinical outcome in order to identify factors with impact on outcome. The overall clinical outcome according to the Glasgow Outcome Scale at the last follow-up was good (GOS 4??) in 27 patients (47%) and poor (GOS 2??) in 16 patients (28%). Fourteen patients (25%) died. The initial neurological condition and the level of consciousness proved to be significant factors determining clinical outcome (p????.0032 and p????.0001, respectively). Among radiological parameters, brain stem compression and a tight posterior fossa solely showed to be predictive for clinical outcome (p????.0113 and p????.0167, respectively). Overall, our results emphasize the predictive impact of the initial neurological condition on clinical outcome confirming the grave outcome of patients in initially poor state as reported in previous studies. The hematoma size solely, in contrast to previous observations, showed not to be predictive for clinical outcome. Especially for the still disputed treatment of patients in good initial neurological condition, a suggestion can be derived from the present study. Based on the excellent outcome of patients with good initial clinical condition undergoing surgery due to secondary deterioration, we do not recommend preventive evacuation of a cerebellar hematoma in these patients.     

Sentinel lymph node mapping for patients with Merkel cell carcinoma—experience of 5 years

Merkel cell carcinoma (MCC) is a rare, highly malignant carcinoma of the neuroendocrinological system (Bayrou et al., J Am Acad Dermatol 24:198–207, 1992). It is a fast-growing, aggressive tumor with a high rate of local recurrence and early metastases. A radical surgical procedure is the therapy of choice. In case of lymph node metastases, regional lymphadenectomy is mandatory. Sentinel lymph node (SLN) mapping is a standard diagnostic technique to detect micrometastases in certain patients with malignant melanoma and breast cancer. The question is, can the SLN technique provide information as a prognostic factor and can the prognosis of the MCC be improved by detecting micrometastases in SLN at an early stage?     

Decompressive craniectomy for the management of patients with refractory hypertension: should it be reconsidered?

Summary. Summary.   Introduction: The management of refractory post-traumatic cerebral oedema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension.   Method and Material: In this retrospective study we have evaluated the efficacy of decompressive craniectomy as a last resort therapy, from the data of nine patients with severe brain injury and delayed cerebral oedema (diffuse injury type III), treated between January 1997 and September 1999. The following parameters were considered: age, Glascow Coma Scale, injury severity, intracranial pressure, CT findings, pupil reaction/posturing. Follow-up period was over at least 2 years and outcome measured on the GOS.   Results: Patients have been operated on post-trauma median day 3, mean age 26±9, GCS 7±3.7, mean APACHE II 16±6.4, mean ISS 27.8±16.1, mean preoperative ICP 37.7±10.0, mean postoperative ICP 18.1±16.01. Seven patients have been operated by a frontotemporoparietal approach (six of them bilateral, one unilateral) and two patients have been operated on by a bilateral subtemporal approach. Mortality rates 22%, severe disability 11%, good recovery 66%.   Discussion: Patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when current medical treatment has failed. The encouraging results of outcome in this and more recent studies, indicate the need for a multi-institutional randomized prospective study evaluating early indicators of raised ICP, timing, efficacy of treatment, operative technique and complications of decompressive craniectomy. Published online August 12, 2002     

Head-injured adult patients with GCS of 3 on admission — Who have a chance to survive?

Summary The authors analysed a series of 111 adult patients admitted to the Department of Neurosurgery, Medical University of ód directly after trauma with initial GCS of 3 points. 74% of them had intracranial haematoma, mainly subdural, and were treated surgically within the first 3 hours after trauma. 8 patients had no abnormalities on CT scans.99 (89%) patients died 2 to 30 days after injury, 8 (7%) survived in a vegetative state, and only in 4 (4%) was a satisfactory result noted, but 2 of them had a stable neurological deficit. 3 of these 4 patients had epidural haematomas and 1 had not abnormalities on repeated CT examinations.We conclude, that among patients with GCS of 3 on admission, only those without major CT abnormalities or with epidural haematoma have a chance of survival. Cases with cerebral leasions on the initial CT examination have an invariably bad prognosis. They could be taken into account as a potential organ donor from the very moment of admission, but only after cerebral circulatory arrest occured and brain death has been proved according to internationally accepted standarts.     

Effect of mild head injury on intelligence in Zahedan, Iran

Objective： To investigate the effects of mild head injury （HI） on the victims＇ intelligence by measuring their intelligence quotient （IQ）.Methods： This cohort study was performed in Khatamol-Anbia Hospital, Zahedan, Iran and the IQs of 30 mild HI patients were measured right after the injury （IQ0） and six months later （IQ6）. The IQs of 90 close relatives of the patients were also measured at the same period of time as the non-exposure group. The IQs were measured with Wechsler adult intelligence scale-revised （WAIS-R）. The IQ0, IQ6 and their differences （IQ change） were compared in HI patients and their relatives using the Student＇s t test.Results： The mean IQ0 of the HI patients was similar to their relatives. The IQ6 of HI patients appeared to be less than those of their relatives. Moreover, the IQ6 of the HI patients appeared to be less than their initial scores. HI was associated with more decrease in IQ6 compared with IQ0and the female subjects showed more decrease in IQ6 compared with their IQ0.Conclusion： HI seems to be associated with decrease in IQ six months after the injury and it is more evident in female HI patients.     

Repeat cranial tomography in patients with mild head injury and stable neurological examination ---- a perspective from a developing country

Objective: To determine the frequency of altered findings on repeat cranial tomography (CT) in patients with mild head injury along with stable neurological examination at tertiary care hospital.Methods: Cross-sectional study was done in the Department of Radiology, Liaquat National Hospital, Karachi from January 2008 to September 2010. All patients with mild head injury in terms of Glasgow Coma Scale (GCS) who underwent repeat scan without clinical or neurological deterioration in the emergency department of a tertiary care centre were included. The collected data were accordingly entered and analyzed by the principal investigator using Statistical Package for Social Sciences (SPSS) version 16.0.Results: In all 275 patients, only 17 (6％) of the patients were found worseing on repeat CT, 120 (43.63％)scans improved, 138 (50.18％) unchanged and 17 (6.18％)worsened. None of these patients showed signs of clinical deterioration.Conclusion: Our results suggest that for patients with mild head injury and stable neurological examination, only 6％ of them show deterioration on repeat CT, especially when patients' GCS is below 13.     

Significance of serum neuron-specific enolase in patients with acute traumatic brain iniurv

Objective: To study the association between serum neuron-specific enolase ( NSE) and the extent of brain damage and the outcome after acute traumatic brain injury (TBI).Methods: The release patterns of serum NSE in 78 patients after acute TBI were analyzed by using the enzyme linked immunosobent assay. The levels of NSE were compared with Glasgow coma scale, the category of brain injury and the outcome after 6 months of injury.Results: There were different NSE values in patients with minor ( 12.96 μg/L ±2.39 μg/L ), moderate ( 23.44 μg/L ±5.33 μg/L ) and severe brain injury ( 42.68 μg/L ±4.57 μg/L ). After severe TBI, the concentration of NSE in patients with epidural hematomas was 13.38 μg/L±4.01 μg/L, 24.03 μg/L±2.85 μg/L in brain contusion without surgical intervention group, 55.20 μg/L ±6.35 μg/L in brain contusion with surgical intervention group, and 83.85 μg/L ± 15.82 μg/L in diffuse brain swelling group. There were close correlations between NSE values and Glasgow coma scale     

Significance of serum neuron-specific enolase in patients with acute traumatic brain injury

OBJECTIVE: To study the association between serum neuron-specific enolase (NSE) and the extent of brain damage and the outcome after acute traumatic brain injury (TBI). METHODS: The release patterns of serum NSE in 78 patients after acute TBI were analyzed by using the enzyme linked immunosorbent assay. The levels of NSE were compared with Glasgow coma scale, the category of brain injury and the outcome after 6 months of injury. RESULTS: There were different NSE values in patients with minor (12.96 microg/L+/-2.39 microg/L), moderate (23.44 microg/L+/-5.33 microg/L) and severe brain injury (42.68 microg/L+/-4.57 microg/L). After severe TBI, the concentration of NSE in patients with epidural hematomas was 13.38 microg/L+/-4.01 microg/L, 24.03 microg/L+/-2.85 microg/L in brain contusion without surgical intervention group, 55.20 microg/L+/-6.35 microg/L in brain contusion with surgical intervention group, and 83.85 microg/L+/-15.82 microg/L in diffuse brain swelling group. There were close correlations between NSE values and Glasgow coma scale (r=-0.608, P<0.01) and the extent of brain injury (r=0.75, P<0.01). Patients with poor outcome had significantly higher initial and peak NSE values than those with good outcome (66.40 microg/L+/-9.46 microg/L, 94.24 microg/L+/-13.75 microg/L vs 32.16 microg/L+/-4.21 microg/L, 34.08 microg/L+/-4.40 microg/L, P<0.01, respectively). Initial NSE values were negatively related to the outcome (r=-0.501, P<0.01). Most patients with poor outcomes had persisting or secondary elevated NSE values. CONCLUSIONS: Serum NSE is one of the valuable neurobiochemical markers for assessment of the severity of brain injury and outcome prediction.     

Cerebral state index versus Glasgow coma scale as a predictor for in-hospital mortality in brain-injured patients

Objective：To compare the value of Glasgow coma scale （GCS） and cerebral state index （CSI）on predicting hospital discharge status of acute braininjured patients.Methods：In 60 brain-injured patients who did not receive sedatives,GCS and CSI were measured daily during the first 10 days of hospitalization.The outcome of prognostic cut-off points was calculated by GCS and CSI using receiver operating characteristic （ROC） curve regarding the time of admission and third day of hospitalization.Sensitivity,specificity and other predictive values for both indices were calculated.Results：Of the 60 assessed patients,14 patients had mild,13 patients had moderate and 33 patients had severe injuries.During the course of the study,17 patients （28.3％） deteriorated in their situation and died.The mean GCS and CSI in patients who deceased during hospitalization was significantly lower than those who were discharged from the hospital.GCS＜4.5 and CSI＜64.5 at the time of admission was associated with higher mortality risk in traumatic brain injury patients and GCS was more sensitive than CSI to predict in-hospital death in these patients.For the first day of hospitalization,the area under ROC curve was 0.947 for GCS and 0.732 for CSI.Conclusion：GCS score at ICU admission is a good predictor of in-hospital mortality.GCS＜4.5 and CSI＜64.5 at the time of admission is associated with higher mortality risk in traumatic brain injury patients and GCS is more sensitive than CSI in predicting death in these patients.     

Moderate hypothermia therapy for patients with severe head injury

ＳＤｅｐａｒｔｍｅｎｔｏｆＮｅｕｒｏｓｕｒｇｅｒｙ ,ＣｈｅｎｇｄｕＧｅｎｅｒａｌＨｏｓｐｉｔａｌｏｆＣｈｅｎｇｄｕＭｉｌｉｔａｒｙＣｏｍｍａｎｄ ,Ｃｈｅｎｇｄｕ 6 10 0 83,Ｃｈｉｎａ (ＣｈｅｎＬＧ ,ＰｉａｏＹＸ ,ＺｅｎｇＦＪ ,ＬｕＭ ,ＫｕａｎｇＹＱａｎｄＬｉＸ)ｉｎｃｅ 1990ｓ ,ｉｔｈａｓｂｅｅｎｐｒｏｖｅｄｂｙｃｌｉｎｉｃａｌｓｔｕｄｉｅｓａｔｈｏｍｅａｎｄａｂｒｏａｄｔｈａｔＭＨＴｉｓａｎｅｆｆｅｃｔｉｖｅａｎｄｓａｆｅｍｅｔｈｏｄ .1 3Ｔｏｂｅｔｔｅｒｕｎｄｅｒｓｔａｎｄｉｔｓｅｆｆｅｃｔａｎ…     

Correlation between Glasgow coma score components and survival in patients with traumatic brain injury

Background

The Glasgow coma scale (GCS) score is used in the initial evaluation of patients with traumatic brain injury (TBI); however, the determination of an accurate score is not possible in all clinical situations. Our aim is to determine if the individual components of the GCS score, or combinations of them, are useful in predicting mortality in patients with TBI.

Methods

The components of the GCS score and the receiver-operating characteristic (ROC) curves were analyzed from 27,625 cases of TBI in Taiwan.

Results

The relationship between the survival rate and certain eye (E), motor (M) and verbal (V) score combinations for GCS scores of 6, 11, 12 and 13 were statistically significant. The areas under ROC curve of E + V, M + V and M alone were 0.904, 0.903 and 0.900, respectively, representing the 3 most precise combinations for predicting mortality. The area under the ROC curve for the complete GCS score (E + M + V) was 0.885. Patients with lower E, M and V score respectively, and lower complete GCS scores had higher hazard of death than those with the highest scores.

Conclusion

The results of this study indicate that the 3 fundamental elements comprising the Glasgow coma scale, E, M, and V individually, and in certain combinations are predictive of the survival of TBI patients. This observation is clinically useful when evaluating TBI patients in whom a complete GCS score cannot be obtained.