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Jan-Erik Starmark, Daniel Stålhammar, Eddy Holmgren and Björn Rosander

T he Glasgow Coma Scale (GCS) sum score is the combination of three scales (the eye, motor, and verbal scales), and is the method most frequently used to measure overall responsiveness of patients with acute cerebral disorders. 23 The GCS has also been suggested as an international standard for grading the severity of head injuries, 14 in spite of certain problems encountered in its application. 23 The Reaction Level Scale (RLS85) is a single scale in eight steps for assessment of overall patient responsiveness. It is based on the same concepts as the GCS

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Kiyoshi Takagi, Akira Tamura, Tadayoshi Nakagomi, Hitoshi Nakayama, Osamu Gotoh, Kensuke Kawai, Mamoru Taneda, Nobuyuki Yasui, Hiromu Hadeishi and Keiji Sano

on SAH have involved the use of the Hunt and Hess grading system 9, 10 or the World Federation of Neurosurgical Societies (WFNS) Committee scale 5 as the grading scale for SAH. 30 Although the Hunt and Hess grading system has a long history and has been widely used, there are no significant differences in outcome between Grades I and II. 5, 8 Another drawback is observer variability. 14, 15 To overcome observer variability, the WFNS proposed a new SAH grading scale, which was primarily based on scores of the Glasgow Coma Scale (GCS). 26 However, in a study by

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Roukoz B. Chamoun, Claudia S. Robertson and Shankar P. Gopinath

findings specified in this paper. References 1 Alexander E Jr : Global Spine and Head Injury Prevention Project (SHIP) . Surg Neurol 38 : 478 – 479 , 1992 2 Chesnut RM , Marshall LF , Klauber MR , Blunt BA , Baldwin N , Eisenberg HM , : The role of secondary brain injury in determining outcome from severe head injury . J Trauma 34 : 216 – 222 , 1993 3 Demetriades D , Kuncir E , Velmahos GC , Rhee P , Alo K , Chan LS : Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3

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Daniel H. Fulkerson, Ian K. White, Jacqueline M. Rees, Maraya M. Baumanis, Jodi L. Smith, Laurie L. Ackerman, Joel C. Boaz and Thomas G. Luerssen

T raumatic brain injury (TBI) is a leading cause of death and morbidity in pediatric patients. Approximately 1.5 million people in the United States suffer TBI annually, resulting in an estimated 50,000 deaths and 500,000 patients with permanent disability. 44 , 49 The Glasgow Coma Scale (GCS) score is a well-accepted measure of the severity of the injury. 47 There are modifications of the adult GCS for children. 27 , 42 , 46 Adult patients with a GCS score of ≤ 8 are considered to have “severe” TBI. In children, a GCS score of 5 may be the critical

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Michael L. Levy

In an attempt to assess admission Glasgow Coma Scale (GCS) scores and other radiographic variables after penetrating craniocerebral injury in relationship to outcome, the author evaluated a series of 294 patients with penetrating injuries who presented with a GCS score of 6 to 15 over a 6-year period. Entrance criteria required a replicable neurological examination that was not altered by the presence of hypotension, drugs/toxins, or systemic injury. All patients underwent surgical intervention and aggressive perioperative management, including resuscitative protocols, in the neurosurgical intensive care unit.

The author previously devised prospective models of outcome remained unchanged in this series. The variables most predictive of death include admission GCS score and subarachnoid hemorrhage in one model and admission GCS score and pupillary changes in a second when pupillary response was definitive at admission (p ≤ 0.00005). Other important variables related to morbidity include admission GCS, bihemispheric injury when associated with intraventricular hemorrhage, and diffuse fragmentation (p ≤ 0.001).

In this study a significant relationship between operative intervention and survival (p ≤ 0.01) was found in patients with an admission GCS scores of 6 to 8. No significant relationships between operative intervention and survival were found in patients with admission GCS scores of 9 to 12 and 13 to 15. A significant relationship between operative intervention and morbidity (p ≤ 0.01) was also demonstrated in patients with an admission GCS score of 12 to 15. No significant relationships between operative intervention and morbidity were found in patients with an admission GCS score of 6 to 8 and 9 to 12.

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Pedram Emami, Patrick Czorlich, Friederike S. Fritzsche, Manfred Westphal, Johannes M. Rueger, Rolf Lefering and Michael Hoffmann

T raumatic brain injury (TBI) is the second most common cause of death in children aged 0 to 15 years in Germany and the United States. 9 , 12 Besides its high mortality rate, TBI is also a leading cause of severe disability. 19 Many prognostic factors for predicting death and functional outcome after TBI, such as the Glasgow Coma Scale (GCS) (with special regard to the motor component) and the presence of other injuries or hypotension and hypoxia, have been identified. 1 , 10 , 16 , 18 , 25 , 26 , 32 A recently published study found that the Eppendorf

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Nils Petter Rundhaug, Kent Gøran Moen, Toril Skandsen, Kari Schirmer-Mikalsen, Stine B. Lund, Sozaburo Hara and Anne Vik

T raumatic brain injury (TBI) is a major cause of morbidity and mortality in both low- and high-income countries. 12 Severity classification of TBI is mostly based on the Glasgow Coma Scale (GCS) score, which is the most-used clinical tool to assess patients with reduced consciousness. 3 , 19 , 24 Hence, obtaining valid GCS scores is important to give the patient adequate care at the right treatment level. 3 , 8 , 25 Alcohol intoxication is frequent among adult patients with TBI admitted to emergency departments, 10 , 23 although large studies in

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Julio Cruz, Giulio Minoja, Kazuo Okuchi and Enrico Facco

Object. The authors evaluated long-term clinical outcomes in selected acutely comatose patients with severe diffuse brain swelling and recent clinical signs of impending brain death who received a novel high-dose mannitol treatment compared with those who received conventional-dose mannitol in the emergency room.

Methods. Forty-four adult patients with traumatic, nonmissile-inflicted, acute, severe diffuse brain swelling were prospectively and randomly evaluated. All patients were selected based on the presence of recent clinical signs of impending brain death on the first emergency room evaluation. These signs included bilateral abnormal pupillary widening and lack of motor responses to painful stimulation (Glasgow Coma Scale score of 3). The study group (23 patients) received ultra-early and fast intravenous high-dose mannitol treatment (∼1.4 g/kg), whereas the control group (21 patients) received half that dose (∼0.7 g/kg).

Ultra-early improvement of bilateral abnormal pupillary widening was significantly more frequent in the high-dose mannitol group than in the conventional-dose group (p < 0.02). High-dose mannitol treatment in the emergency room was also associated with significantly better 6-month clinical outcomes (p < 0.02); the best rate of favorable outcomes was 43.5%, compared with only 9.5% in the conventional-dose mannitol group. The two groups of patients were well matched with respect to all emergency room and head computerized tomography findings, as well as the timing of initial mannitol treatment (∼80–90 minutes after the first evaluation at the scene of the injury).

Comparative evaluation of bilateral pupillary widening between the scene of the injury and the emergency room showed no significant differences between groups, whereas mannitol dose dependence was statistically significant (p < 0.05), insofar as early pupillary improvement in the emergency room was concerned.

Conclusions. Ultra-early high-dose mannitol administration in the emergency room is the first known treatment strategy significantly to reverse recent clinical signs of impending brain death, and also to contribute directly to improved long-term clinical outcomes for these patients who have previously been considered unsalvageable.

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Assessment of level of consciousness following severe neurological insult

A comparison of the psychometric qualities of the Glasgow Coma Scale and the Comprehensive Level of Consciousness Scale

Daniel E. Stanczak, James G. White III, William D. Gouview, Kurt A. Moehle, Michael Daniel, Thomas Novack and Charles J. Long

is of considerable clinical use, such subjective impressions are notoriously unreliable and thus present serious methodological drawbacks in research settings. The purpose of the present study is to compare the psychometric qualities, and thus the research utility, of the Glasgow Coma Scale (GCS) and an alternative coma assessment instrument developed at our laboratory to correct what we believed were some of the deficiencies of the GCS. This alternative instrument, the Comprehensive Level of Consciousness Scale (CLOCS), is an eight-item behavioral scale designed

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Christianto B. Lumenta

metabolic-toxic causes. 7–10, 12, 14 We have recorded BAEP's in 19 cases of spontaneous intracerebral hemorrhage (ICH), and evaluate our findings related with both computerized tomography (CT) scanning and clinical signs. Clinical Material and Methods Nineteen patients with spontaneous ICH were examined; 13 of them were deeply comatose (Glasgow Coma Scale (GCS) score less than 7). The cause of the hemorrhage was hypertension in nine cases, aneurysm in five cases, and arteriovenous malformation in four cases. The origin of a pontine hemorrhage in one case was not