The Neuropathology of the Vegetative State and Severe Disability After Non-Missile Head Injury

Object The aim of this study was to investigate the incidence of elevated (≥ 75%) jugular venous oxygen saturation (SjvO2) and its relationship to cerebral hemodynamic and metabolic parameters and to outcome after severe head injury. Methods Data from 450 severely head injured patients admitted to the Neurosurgical Intensive Care Unit of Ben Taub General Hospital were analyzed retrospectively. The SjvO2 was measured in blood obtained from indwelling jugular bulb catheters. Patients were classified into the following categories: high (Group I), normal (Group II), or low SjvO2 (Group III) if their mean SjvO2 over the duration of monitoring was 75% or higher, 74 to 56%, or 55% or lower, respectively. A high SjvO2 occurred in 19.1% of patients. There was no consistent relationship between SjvO2 and simultaneous cerebral blood flow (CBF) or cerebral perfusion pressure measurements. Compared with Groups II and III, the patients in Group I had a significantly higher CBF and lower cerebral metabolic rate of oxygen (CMRO2). In Group I, the out- comes were death or persistent vegetative state in 48.8% of patients and severe disability in 25.6%. These outcomes were significantly worse than for patients in Group II. Within Group I, the patients with a poor neurological outcome were older and more likely to have suffered a focal head injury; they demonstrated a lower CMRO2 and a greater rate of cerebral lactate production than the patients who attained a favorable outcome. Conclusions Posttraumatic elevation of SjvO2 is common but cannot be automatically equated with hyperemia. Instead, elevated SjvO2 is a heterogeneous condition that is associated with poor outcome after head injury and may carry important implications for the management of comatose patients.

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HM-PAO-SPECT in persistent vegetative state after head injury: Prognostic indicator of the likelihood of recovery?

Intensive Care Medicine ◽

10.1007/bf01704718 ◽

1991 ◽

Vol 17 (3) ◽

pp. 149-153 ◽

Cited By ~ 23

Author(s):

W. Oder ◽

G. Goldenberg ◽

I. Podreka ◽

L. Deecke

Keyword(s):

Head Injury ◽

Vegetative State ◽

Persistent Vegetative State ◽

Prognostic Indicator

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Pediatric patients with poor neurological status and arteriovenous malformation hemorrhage: an outcome analysis

Journal of Neurosurgery Pediatrics ◽

10.3171/2011.2.peds10355 ◽

2011 ◽

Vol 7 (5) ◽

pp. 462-467 ◽

Cited By ~ 13

Author(s):

Ash Singhal ◽

Tara Adirim ◽

Doug Cochrane ◽

Paul Steinbok

Keyword(s):

Arteriovenous Malformation ◽

Pediatric Patients ◽

Vegetative State ◽

Cerebral Performance Category ◽

Neurological Status ◽

Severe Disability ◽

Outcome Analysis ◽

Performance Category ◽

Mild Disability

Object In general, patients who present with low Glasgow Coma Scale (GCS) scores and/or fixed and dilated pupils are not expected to do well following arteriovenous malformation (AVM) hemorrhage. However, there is a sense among neurosurgeons that pediatric patients may make a better recovery than adults following such an event. There have been few studies focusing on the outcome of pediatric patients with poor neurological status following AVM hemorrhage. The purpose of this study was to characterize functional outcome in pediatric patients with severe disability after AVM hemorrhage. Methods This was a retrospective analysis of clinical presentation and outcome in 15 patients seen at the authors' pediatric hospital presenting with low GCS scores (defined as GCS ≤ 8) following AVM hemorrhage. Results Initial GCS scores ranged from 3 to 6, and 11 of 14 patients had fixed pupils on clinical examination (data were not available in 1 patient). Eight of 15 patients suffered primarily a lobar hemorrhage, 3 suffered primarily infratentorial bleeding, 2 suffered primarily hemorrhages of the basal ganglia, and 2 suffered intraventricular hemorrhage. The overall mortality rate was 20% (3 of 15 patients). The clinical outcome of survivors was defined by the Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) scores at follow-up. One year after AVM hemorrhage, 7 (58%) of the 12 surviving patients showed normal or mild disability (PCPC Score 1 or 2), whereas 5 (42%) of 12 patients had moderate or severe disability (PCPC Score 3 or 4). No patients were in a coma or vegetative state, and 11 (92%) of the 12 patients were functioning independently (POPC Score 1, 2, or 3) 1 year after AVM hemorrhage. All patients were functionally independent by last follow-up, with 8 patients (67%) in the normal or mild disability PCPC category, and 4 in the moderate category (PCPC Score 3). All 12 survivors made a meaningful recovery and went on to live independent lives. Conclusions Pediatric patients suffering AVM hemorrhage have a good outcome and are able to function independently, despite a poor neurological state initially.

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Patterns and Outcome of Traumatic Brain Injury Patients: A Study in a Tertiary Level Military Hospital

Journal of Armed Forces Medical College Bangladesh ◽

10.3329/jafmc.v15i1.48649 ◽

2020 ◽

Vol 15 (1) ◽

pp. 75-78

Author(s):

Md Shohidul Islam ◽

Md Fashiur Rahman ◽

Md Aminul Islam

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Head Injury ◽

Brain Injuries ◽

Surgical Intervention ◽

Vegetative State ◽

Persistent Vegetative State ◽

Public Health Problem ◽

Armed Forces ◽

Military Hospital

Introduction: A traumatic brain injury (TBI) is an injury to the brain caused by an impact to the head. TBI represents a huge global medical and public health problem across all ages and in both civilian and military populations. TBI is characterized by great heterogeneity in terms of etiology, mechanism, pathology, severity and treatment with widely varying outcomes. Objective: To determine the pattern and outcome of traumatic brain injuries in victims reported to emergency and casualty (E&C) department following intensive care with or without surgical intervention. Materials and Methods: This prospective type of observational study was conducted at Neurosurgery department of Combined Military Hospital, Dhaka from October 2013 to March 2017. A total of 675 head injury patients with TBI were assessed with gender, age, cause and type of trauma, GCS on admission, associated other injuries, time lapsed from trauma to hospitalization and care given. The outcome was measured after 72 hours using Glasgow Outcome Scale (GOS). Results: The incidence of TBI was 47.03% among the head injury patients. Common age group was 21-30 years (43.7%) and male victims (66.55%). RTA was the most frequent cause (50.05%) of TBI and the most common pathophysiological cause of TBI was subdural haemorrhage (SDH)(35%) followed by extradural haemorrhage (EDH)(27%). Most patients (45%) had mild TBI. Surgical intervention was required in 45% patients of TBI mainly for the SDH, EDH which had significant positive effect on the TBI patient’s outcome. The majority of patients (77%) had good outcome which included recovery (51.85%) and moderate disability (25.48%). The poor outcome was observed in 23% patients which included death (7.40%), persistent vegetative state (3.11%), severe disability (12.14%) and it was associated with older age, severe TBI (GCS<8 on admission), associated other injuries and delayed resuscitative care and interventions. Conclusion: TBI was common among the young adults male. The RTA was the leading cause of TBI. The factors that influence the outcome of TBI include patient’s age, severity of TBI, associated injuries and delayed resuscitative care. Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 75-78

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Surgical Outcome between Early and Delayed Surgery of Extradural Haematoma (EDH) in Closed Head Injury

Journal of National Institute of Neurosciences Bangladesh ◽

10.3329/jninb.v5i1.42164 ◽

2019 ◽

Vol 5 (1) ◽

pp. 24-28

Author(s):

Md Abdus Salam ◽

Md Mahfuzur Rahman ◽

Kalim Uddin ◽

Md Rafiqul Islam ◽

Md Ashraful Hoque ◽

...

Keyword(s):

Head Injury ◽

Surgical Outcome ◽

Vegetative State ◽

Persistent Vegetative State ◽

Closed Head Injury ◽

Extradural Haematoma ◽

Delayed Surgery ◽

Closed Head ◽

Group A ◽

Group B

Background: Surgical management of Extradural Haematoma (EDH) in Closed Head Injury is an essential issue. Objective: The purpose of the present study was to compare the surgical outcome between early and delayed surgery of extradural haematoma (EDH) in closed head injury. Methodology: This comparative cross-sectional study was carried out from January 2010 to June 2011 for a period of one year and six months in the Department of Neurosurgery, Dhaka medical College Hospital, Dhaka, Bangladesh. All patients presented with traumatic head injury having extradural haematoma in any age with both sexes who were underwent surgical management were selected as study population. The patients were categorized into groups designated as group A or early surgery group where operation was done within 24 hours of head injury and group B or delayed surgery group where operation was done after 24 hours to 3 days of head injury. Inclusion of patients in group B was not intentional but due to delayed referral from primary and secondary hospitals of` different parts of' the country. Glasgow coma scale (GCS) was used for initial assessment and Glasgow outcome scale (GOS) was applied to assess outcome in terms of neurological recovery in all patients. General and neurological examinations and findings were recorded. Surgical outcome was noted and recorded in the data collection sheet. Result: Eighty (80) patients of traumatic head injury with EDH operation (EDH operated within 24 hours and after 24 hours of head injury) were enrolled in this study. Mean (±SD) age of the patients of group A and group B was 32.66±16.65 and 33.23±13.38 respectively. In this study the patient's age ranged from 3 years to 64 years. In group A, 6 patients were admitted with GCS (14-15) and 01 patient in group B. With GCS (9~13), 19 patients in group A and 22 patients in group B. With GCS (3-8), 15 patients were admitted in group A and 17 patients in group B. Out of all patients’ good recovery occurred in 80.0% in group A and 45.0% in group B. Moderate disability and severe disability in both group A and group B was 12.5% vs 30% and 7.5% vs 12.5% respectively. Furthermore 5.0% persistent vegetative state and 7.5% death occurred only among the patients of group B (p<0.05). Out of all patients good recovery occurred in 82.6% in group A and 54.0% in group B. Moderate disability and severe disability in both group A and group B was 10.0% vs 27.5% and 7.5% vs 13.51% respectively. 5.41% persistent vegetative state occurred only in patients of group B (p<0.05). Conclusion: In conclusion morbidity and mortality rate can be reduced in patients with EDH by early surgical intervention in better GCS score. Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 24-28

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The Effect of Positioning on the Level of Arousal and Awareness in Patients in the Vegetative State or the Minimally Conscious State: A Replication and Extension of a Previous Finding

Brain Impairment ◽

10.1017/brimp.2013.34 ◽

2013 ◽

Vol 14 (3) ◽

pp. 475-479 ◽

Cited By ~ 10

Author(s):

Barbara A. Wilson ◽

Samira Dhamapurkar ◽

Catherine Tunnard ◽

Peter Watson ◽

Gerhard Florschutz

Keyword(s):

Head Injury ◽

Supine Position ◽

Vegetative State ◽

Preliminary Investigation ◽

Minimally Conscious State ◽

Conscious State ◽

Upright Position ◽

Tilt Table ◽

Minimally Conscious ◽

Lying Down

In 2005 Elliott et al. published a paper entitled ‘Effect of posture on levels of arousal and awareness in vegetative and minimally conscious patients: a preliminary investigation’. Twelve patients, of whom 5 were in the vegetative state (VS) and 7 in the minimally conscious state (MCS), were assessed with the Wessex Head Injury Matrix (WHIM) when supine and when upright on a tilt table. The present study replicated and extended these findings by including a third position, sitting, in addition to supine and standing. We assessed 16 patients (8 in the VS and 8 in the MCS) with mixed aetiologies and compared the observed behaviours in three different positions (supine, sitting and standing) using the WHIM. Most patients (75%) showed more behaviours when in the upright position, compared to lying down (p < .003). Our findings are similar to those seen in the study reported by Elliott et al. With regard to sitting, 62.5% of patients were more responsive when assessed sitting in a wheelchair (p < .05) than in a supine position, and almost 69% were more responsive if assessed in an upright position compared to sitting. This was particularly true for patients in the MCS, where 87.5% did better if assessed on a tilt table or standing frame compared to sitting, suggesting that positional changes can have an effect on the level of arousal and awareness among patients in the VS and MCS.

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