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Paul M. Brennan, Gordon D. Murray and Graham M. Teasdale

OBJECTIVE

Glasgow Coma Scale (GCS) scores and pupil responses are key indicators of the severity of traumatic brain damage. The aim of this study was to determine what information would be gained by combining these indicators into a single index and to explore the merits of different ways of achieving this.

METHODS

Information about early GCS scores, pupil responses, late outcomes on the Glasgow Outcome Scale, and mortality were obtained at the individual patient level by reviewing data from the CRASH (Corticosteroid Randomisation After Significant Head Injury; n = 9,045) study and the IMPACT (International Mission for Prognosis and Clinical Trials in TBI; n = 6855) database. These data were combined into a pooled data set for the main analysis.

Methods of combining the Glasgow Coma Scale and pupil response data varied in complexity from using a simple arithmetic score (GCS score [range 3–15] minus the number of nonreacting pupils [0, 1, or 2]), which we call the GCS-Pupils score (GCS-P; range 1–15), to treating each factor as a separate categorical variable. The content of information about patient outcome in each of these models was evaluated using Nagelkerke’s R2.

RESULTS

Separately, the GCS score and pupil response were each related to outcome. Adding information about the pupil response to the GCS score increased the information yield. The performance of the simple GCS-P was similar to the performance of more complex methods of evaluating traumatic brain damage. The relationship between decreases in the GCS-P and deteriorating outcome was seen across the complete range of possible scores. The additional 2 lowest points offered by the GCS-Pupils scale (GCS-P 1 and 2) extended the information about injury severity from a mortality rate of 51% and an unfavorable outcome rate of 70% at GCS score 3 to a mortality rate of 74% and an unfavorable outcome rate of 90% at GCS-P 1. The paradoxical finding that GCS score 4 was associated with a worse outcome than GCS score 3 was not seen when using the GCS-P.

CONCLUSIONS

A simple arithmetic combination of the GCS score and pupillary response, the GCS-P, extends the information provided about patient outcome to an extent comparable to that obtained using more complex methods. The greater range of injury severities that are identified and the smoothness of the stepwise pattern of outcomes across the range of scores may be useful in evaluating individual patients and identifying patient subgroups. The GCS-P may be a useful platform onto which information about other key prognostic features can be added in a simple format likely to be useful in clinical practice.

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Gordon D. Murray, Paul M. Brennan and Graham M. Teasdale

OBJECTIVE

Clinical features such as those included in the Glasgow Coma Scale (GCS) score, pupil reactivity, and patient age, as well as CT findings, have clear established relationships with patient outcomes due to neurotrauma. Nevertheless, predictions made from combining these features in probabilistic models have not found a role in clinical practice. In this study, the authors aimed to develop a method of displaying probabilities graphically that would be simple and easy to use, thus improving the usefulness of prognostic information in neurotrauma. This work builds on a companion paper describing the GCS-Pupils score (GCS-P) as a tool for assessing the clinical severity of neurotrauma.

METHODS

Information about early GCS score, pupil response, patient age, CT findings, late outcome according to the Glasgow Outcome Scale, and mortality were obtained at the individual adult patient level from the CRASH (Corticosteroid Randomisation After Significant Head Injury; n = 9045) and IMPACT (International Mission for Prognosis and Clinical Trials in TBI; n = 6855) databases. These data were combined into a pooled data set for the main analysis. Logistic regression was first used to model the combined association between the GCS-P and patient age and outcome, following which CT findings were added to the models. The proportion of variability in outcomes “explained” by each model was assessed using Nagelkerke’s R2.

RESULTS

The authors observed that patient age and GCS-P have an additive effect on outcome. The probability of mortality 6 months after neurotrauma is greater with increasing age, and for all age groups the probability of death is greater with decreasing GCS-P. Conversely, the probability of favorable recovery becomes lower with increasing age and lessens with decreasing GCS-P. The effect of combining the GCS-P with patient age was substantially more informative than the GCS-P, age, GCS score, or pupil reactivity alone. Two-dimensional charts were produced displaying outcome probabilities, as percentages, for 5-year increments in age between 15 and 85 years, and for GCS-Ps ranging from 1 to 15; it is readily seen that the movement toward combinations at the top right of the charts reflects a decreasing likelihood of mortality and an increasing likelihood of favorable outcome.

Analysis of CT findings showed that differences in outcome are very similar between patients with or without a hematoma, absent cisterns, or subarachnoid hemorrhage. Taken in combination, there is a gradation in risk that aligns with increasing numbers of any of these abnormalities. This information provides added value over age and GCS-P alone, supporting a simple extension of the earlier prognostic charts by stratifying the original charts in the following 3 CT groupings: none, only 1, and 2 or more CT abnormalities.

CONCLUSIONS

The important prognostic features in neurotrauma can be brought together to display graphically their combined effects on risks of death or on prospects for independent recovery. This approach can support decision making and improve communication of risk among health care professionals, patients, and their relatives. These charts will not replace clinical judgment, but they will reduce the risk of influences from biases.

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Sam Galbraith and Graham Teasdale

✓ Computerized tomography scanning has shown that acute traumatic intracranial hematomas are more common than was previously realized, but whether all hematomas must be removed remains controversial. About half of this series of 26 patients who were not clinically deteriorating and who were initially managed without operation had to undergo hematoma removal because they subsequently deteriorated. Features present at the time of diagnosis (age, type and site of hematoma, presence of focal signs, level of responsiveness, and degree of midline shift) were not helpful in predicting that operation would be needed. The only discriminatory factor was the level of intracranial pressure (ICP). All the patients with ICP greater than 30 mm Hg deteriorated and required operation, but only one patient whose ICP was less than 20 mm Hg deteriorated. Half the patients with ICP between 20 and 30 mm Hg did not require an operation. Intracranial pressure monitoring can, therefore, be useful in managing patients with an occult intracranial hematoma.

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Graham Teasdale and Peter Macpherson

✓ Four cases are described to illustrate the ability of cavernous sinography to detect coincidental aneurysms or anomalies of the infraclinoid carotid artery. Sinography may be used as a preliminary step before a transsphenoidal operation, in order to identify the small proportion of cases in which arteriography should be performed.

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Joanna M. Wardlaw, Ruth Offin, Graham M. Teasdale and Evelyn M. Teasdale

Object. In this prospective observational study, the authors assess the impact of routine transcranial Doppler (TCD) ultrasound monitoring on the diagnosis, management, and outcome of delayed ischemic neurological deficit complicating subarachnoid hemorrhage (SAH).

Methods. Over a 10-month period 186 patients admitted to a regional neurosciences center were included in the study. Three times a week, routine TCD examinations performed by neuroradiographers made an important positive contribution to the diagnosis of delayed ischemic neurological deficit in 72% of patients with this complication and led to altered management for the benefit of the patient in 43%. In 9% of patients with recent SAH, it was believed that the outcome might have been better if the TCD result had been acted upon appropriately. The TCD results did not adversely influence management or outcome and were generally accurate when compared with those obtained on angiography.

Conclusions. A routine TCD service provided by neuroradiographers is accurate and useful in diagnosing and managing elevated blood velocities and ischemic neurological deficit following SAH. In addition, it is possible that if the information gleaned from TCD findings was used more often in patient management, outcome might be improved; however, a randomized controlled trial is necessary to assess both these points definitively.

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Joanna M. Wardlaw, Ruth Offin, Graham M. Teasdale and Evelyn M. Teasdale

In this prospective observational study, the authors assess the impact of routine transcranial Doppler (TCD) ultrasound monitoring on the diagnosis, management, and outcome of delayed ischemic neurological deficit complicating subarachnoid hemorrhage (SAH). Over a 10-month period 186 patients admitted to a regional neurosciences center were included in the study. Three times a week, routine TCD examinations performed by neuroradiographers made an important positive contribution to the diagnosis of delayed ischemic neurological deficit in 72% of patients with this complication and altered management for the benefit of the patient in 43%. In 9% of patients with recent SAH, it was believed that the outcome might have been better if the TCD result had been acted upon appropriately. The TCD results did not adversely influence management or outcome and were accurate when compared with those obtained on angiography. The authors conclude that a routine TCD service provided by neuroradiographers is accurate and useful in diagnosing and managing elevated blood velocities and ischemic neurological deficit following SAH. In addition, it is possible that if the information gleened from TCD findings was used more often in patient management, outcome might be improved; however, a randomized controlled trial is necessary to assess this definitively.

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Howard M. Eisenberg, John W. Turner, Graham Teasdale, Jack Rowan, Robert Feinstein and Robert G. Grossman

✓ The electrical excitability of the cortex was monitored during craniotomy in 10 patients with ruptured aneurysms, to test their ability to tolerate hypotensive anesthesia. Excitability was assessed by measuring the direct cortical response, a response evoked and recorded from the surface of the brain. Previous animal experiments had shown that this response can be used as an index of cerebral blood flow. In the 10 patients the response progressively declined as the blood pressure was lowered and increased when the pressure was restored. Observation of the direct cortical response during aneurysm operations is a practical method for evaluating the electrophysiological responsiveness of the cortex during hypotension, and the authors suggest that decreases in the amplitude of the response are related to decreases in local cerebral blood flow.

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