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Impact of traumatic subarachnoid hemorrhage on outcome in nonpenetrating head injury

Part I: A proposed computerized tomography grading scale

Karl A. Greene, Frederick F. Marciano, Blake A. Johnson, Ronald Jacobowitz, Robert F. Spetzler and Timothy R. Harrington

✓ The presence of traumatic subarachnoid hemorrhage (tSAH) on admission computerized tomography (CT) scans obtained from patients suffering from severe, nonpenetrating head injury has been shown to be associated with a worse outcome than the injury alone would warrant. However, no previous study has provided a simple means of relating the amount of tSAH, its location, or other abnormal findings on initial head CT scans to outcome in patients with nonpenetrating head injury. In this study, admission head CT scans from 252 patients with tSAH, treated at a single institution, were reviewed to ascertain thickness of the tSAH; its location; evidence of mass lesion(s); shift of midline structures (≤ 5 mm vs. > 5 mm); basal cistern effacement; and cortical sulcal effacement. The CT scans were then organized into Grades 1 to 4 with 1 indicating thin tSAH (≤ 5 mm); 2, thick tSAH (> 5 mm); 3, thin tSAH with mass lesion(s); and 4, thick tSAH with mass lesion(s). A stepwise regression analysis of CT features ranked them in descending order of contribution to Glasgow Outcome Scale (GOS) scores at the time of discharge from acute hospitalization as follows: basal cistern effacement, thickness of tSAH, cortical sulcal effacement, presence of mass lesion(s), and location of tSAH. A shift of midline structures was not found to be a significant variable. Further analysis comparing CT grades and admission postresuscitation Glasgow Coma Scale (GCS) scores was highly significant. Patients with lower CT grades had better admission GCS values and discharge GOS scores than those with higher CT grades. From their experience, the authors conclude that their CT grading scale is simple and reliable and relates significantly to outcome at the time of discharge from acute hospitalization.

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Elham Rostami, Henrik Engquist, Timothy Howells, Ulf Johnson, Elisabeth Ronne-Engström, Pelle Nilsson, Lars Hillered, Anders Lewén and Per Enblad

OBJECTIVE

Delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH) is one of the major contributors to poor outcome. It is crucial to be able to detect early signs of DCI to prevent its occurrence. The objective of this study was to determine if low cerebral blood flow (CBF) measurements and pathological microdialysis parameters measured at the bedside can be observed early in patients with SAH who later developed DCI.

METHODS

The authors included 30 patients with severe SAH. The CBF measurements were performed at Day 0–3 after disease onset, using bedside xenon-CT. Interstitial glucose, lactate, pyruvate, glycerol, and glutamate were measured using microdialysis.

RESULTS

Nine of 30 patients developed DCI. Patients with DCI showed significantly lower global and regional CBF, and lactate was significantly increased in these patients. A high lactate/pyruvate ratio was also detected in patients with DCI.

CONCLUSIONS

Early low CBF measurements and a high lactate and lactate/pyruvate ratio may be early warning signs of the risk of developing DCI. The clinical value of these findings needs to be confirmed in larger studies.

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Owoicho Adogwa, Terence Verla, Paul Thompson, Anirudh Penumaka, Katherine Kudyba, Kwame Johnson, Erin Fulchiero, Timothy Miller Jr., Kimberly B. Hoang, Joseph Cheng and Carlos A. Bagley

Object

Depression and persistent low-back pain (LBP) are common and disabling problems in elderly patients (> 65 years old). Affective disorders, such as depression and anxiety, are also common in elderly patients, with a prevalence ranging from 4% to 16%. Depressive symptoms are consistently associated with functional disability. To date, few studies have assessed the predictive value of baseline depression on outcomes in the setting of revision spine surgery in elderly patients. Therefore, in this study, the authors assessed the predictive value of preoperative depression on 2-year postoperative outcomes.

Methods

A total of 69 patients undergoing revision neural decompression and instrumented fusion for adjacent-segment disease (ASD, n = 28), pseudarthrosis (n = 17), or same-level recurrent stenosis (n = 24) were included in this study. Preoperative Zung Self-Rating Depression Scale (ZDS) scores were assessed for all patients. Preoperative and 2-year postoperative visual analog scale (VAS) scores for back pain (VAS-BP) and leg pain (VAS-LP) and the Oswestry Disability Index (ODI) were also assessed. The association between preoperative ZDS score and 2-year improvement in disability was assessed via multivariate regression analysis.

Results

Compared with preoperative status, 2-year postoperative VAS-BP was significantly improved after surgery for ASD (9 ± 2 vs 4.01 ± 2.56, respectively; p = 0.001), as were pseudarthrosis (7.41 ± 1 vs 5.0 ± 3.08, respectively; p = 0.02) and same-level recurrent stenosis (7 ± 2.00 vs 5.00 ± 2.34, respectively; p = 0.003). Two-year ODI was also significantly improved after surgery for ASD (29 ± 9 vs 23.10 ± 10.18, respectively; p = 0.001), as were pseudarthrosis (28.47 ± 5.85 vs 24.41 ± 7.75, respectively; p = 0.001) and same-level recurrent stenosis (30.83 ± 5.28 vs 26.29 ± 4.10, respectively; p = 0.003). Independent of other factors—age, body mass index, symptom duration, smoking, comorbidities, severity of preoperative pain, and disability—increasing preoperative ZDS score was significantly associated with lower 2-year improvement in disability (ODI) after revision surgery in elderly patients with symptomatic ASD, pseudarthrosis, or recurrent stenosis.

Conclusions

The extent of preoperative depression is an independent predictor of less functional improvement following revision lumbar surgery in elderly patients with symptomatic ASD, pseudarthrosis, or recurrent stenosis. Timely diagnosis and treatment of depression and somatic anxiety in this cohort of patients may contribute to improvement in postoperative functional status.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010