Outcomes of Patients with Severe Traumatic Brain Injury Who Have Glasgow Coma Scale Scores of 3 or 4 and Are Over 65 Years Old

Bražinová, Alexandra; Mauritz, W; Leitgeb, Johannes; Wilbacher, Ingrid; Majdán, Marek; Janciak, Ivan; Rusňák, Martin

doi:10.1089/neu.2010.1315

Cited by 71 publications

(52 citation statements)

References 35 publications

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“…Factors that are associated with poor survival include hypoxia, extremes of age, hypotension, hypercarbia, hyperglycemia, mechanism of injury, and hypothermia. 6,21,25,28,36,39,43,51,53 Other factors that may be independent predictors of outcome in severe TBI patients include prehospital deterioration, duration of coma, time to "follow commands" duration of amnesia, time to resume oral feeding, and measurement of the efficacy of interventions designed to lower ICP. 17,20,40,45 As most of the published studies evaluated adults, we sought to examine a relatively large cohort of children presenting with a postresuscitation GCS (modified for pediatric patients) score of 3 or 4.…”

Section: Discussionmentioning

confidence: 99%

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Fulkerson

White

Rees

et al. 2015

PED

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OBJECT Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. METHODS A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a “normal” outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. RESULTS Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. CONCLUSIONS In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.

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Section: Discussionmentioning

confidence: 99%

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Fulkerson

White

Rees

et al. 2015

PED

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“…Unfortunately, increasing age is strongly associated with a poor prognosis both in experimental trauma models and following TBI in humans (Livingston et al, 2005;Onyszchuk et al, 2008;Rothweiler et al, 1998;Sendroy-Terrill et al, 2010;Susman et al, 2002). Confirmed factors of poor prognosis for patients with GCS 3 or 4 and older than 65 years are closed basal cisterns and midline shift > 15 mm on the first CT (Brazinova et al, 2010). The worse outcomes in elderly human subjects occur despite what appears to be less severe TBI, as measured by a higher GCS upon admission (Livingston et al, 2005;Susman et al, 2002).…”

Section: Discussionmentioning

confidence: 99%

The Cerebral Extracellular Release of Glycerol, Glutamate, and FGF2 Is Increased in Older Patients following Severe Traumatic Brain Injury

Mellergård

Sjögren

Hillman

2012

Journal of Neurotrauma

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Old age is associated with a poor recovery from traumatic brain injury (TBI). In a retrospective study we investigated if the biochemical response following TBI is age dependent. Extracellular fluids were continuously sampled by microdialysis in 69 patients admitted to our NSICU following severe TBI. The concentrations of glycerol, glutamate, lactate, pyruvate, and eight different cytokines (IL-1b, IL-6, IL-10, IL-8, MIP-1b, RANTES, FGF2, and VEGF) were determined by fluorescence multiplex bead technology. Patients in the oldest age group ( ‡ 65 years) had significantly higher microdialysate concentrations of glycerol and glutamate compared to younger patients: the mean microdialysate concentration of glycerol increased from 55.9 lmol/L (25-44 year) to 252 lmol/L ( ‡ 65 years; p < 0.0001); similarly glutamate increased from 15.8 mmol/L to 92.2 mmol/L ( p < 0.0001). The lactate-pyruvate ratio was also significantly higher in the patients ‡ 65 years of age (63.9) compared with all the other age groups. The patterns of cytokine responses varied. For some cytokines (IL-1b, IL-10, and IL-8) there were no differences between age groups, while for others (MIP-1b, RANTES, VEGF, and IL-6) some differences were observed, but with no clear correlation with increasing age. For FGF2 the mean microdialysate concentration was 43 pg/mL in patients ‡ 65 years old, significantly higher compared to all other age groups ( p < 0.0001). Increased concentrations of glycerol and glutamate would indicate more extensive damaging processes in the elderly. An increase in concentration of FGF2 could serve a protective function, but could also be related to a dysregulation of the timing in the cellular response in elderly patients.

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“…3,6,7,13 Sorrentino et al 25 found differences in cerebral autoregulation and cerebral pressure reactivity index in elderly patients with TBI. However, there is also evidence that older patients may be more responsive to intracranial hypertension treatment.…”

Section: Factors Influencing the Decision To Monitormentioning

confidence: 99%

Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Farahvar

Gerber²,

Chiu³

et al. 2012

JNS

174

128

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Object. Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor.Methods. From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score < 9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension.Results. Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality.Conclusions. In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring. (http://thejns.org/doi/abs/10.3171/2012.7.JNS111816) KeY WorDs • intracranial pressure • mortality rate • traumatic brain injury • evidence-based guidelines 729Abbreviations used in this paper: AANS = American Association of Neurological Surgeons; BTF = Brain Trauma Foundation; CNS = Congress of Neurological Surgeons; GCS = Glasgow Coma Scale; ICP = intracranial pressure; TBI = traumatic brain injury.

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Outcomes of Patients with Severe Traumatic Brain Injury Who Have Glasgow Coma Scale Scores of 3 or 4 and Are Over 65 Years Old

Cited by 71 publications

References 35 publications

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

The Cerebral Extracellular Release of Glycerol, Glutamate, and FGF2 Is Increased in Older Patients following Severe Traumatic Brain Injury

Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

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