Abstract 32: Optimal Threshold for Defining Early Clinical Deterioration as a Predictor of Poor Outcome in Acute Intracerebral Hemorrhage

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Nerses Sanossian ◽  
May A Kim-Tenser ◽  
David S Liebeskind ◽  
Adrian M Burgos ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Glasgow Coma Scale ◽  
Intracerebral Hemorrhage ◽  
Functional Outcome ◽  
Final Outcome ◽  
Clinical Deterioration ◽  
Coma Scale ◽  
Poor Outcome ◽  
Scale Scores ◽  
Acute Intracerebral Hemorrhage ◽  
Gcs Score

Background: Many patients with acute intracerebral hemorrhage (ICH) clinically deteriorate between the time of paramedic assessment in the field and Emergency Department (ED) arrival. Cohort studies have used decline in the Glasgow Coma Scale (GCS) score from prehospital assessment to ED assessment to identify patients with early clinical deterioration (ECD), but the degree of GCS decline that best correlates with poor final functional outcome has not been delineated. Methods: Consecutive cases with primary ICH on initial imaging were identified from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 clinical trial of intravenous magnesium vs. placebo. All subjects underwent GCS evaluation in the field by paramedics within 2 hours from symptom onset, and again in the ED by study research coordinators. Poor outcome was defined as a modified Rankin Scale of 4 to 6 at 3-months. Deteriorations in GCS from one point through 10 points were evaluated in relation to poor final functional outcome through receiver operating characteristic (ROC) and area under curve (AUC). Results: Among the 369 (22%) patients with primary ICH, mean [SD] age was 65 [13] years, 34% were women, 79% White race, 34% Hispanic ethnicity, 80% had pre-existing hypertension, 20% diabetes, 18% smokers. Paramedic on scene time was a median [IQR] of 23 [15-40] minutes from last known well and time of GCS assessment in the ED was a median of 140 [119-175] minutes after last known well. Glasgow Coma Scale scores were mean 14.4 (SD 1.5) and median 15 [15-15] in the field and mean 12.1 (SD 4.5) and median 15 [10-15] in the ED, and 59% had a poor outcome at 3 months. Frequency of deteriorations on the GCS included: ≥1 point - 38%, ≥2points - 31%, ≥3 points - 27%, ≥5 points - 21%, and ≥10 points - 13%. The best performing cutpoints on the the ROC for predicting poor final outcome were ECD definitions of GCS decline of >=1: sensitivity 54% and specificity 85%; and GCS decline of >=2: sensitivity 46% and specificity 91%. The c statistic for ECD defined as a 1 point GCS decline as a predictor of poor final outcome was 0.71 (95%CI 0.66, 0.76). Conclusions: Early clinical deterioration of GCS is common and its presence may be helpful in predicting poor outcome.

scholarly journals Effects of Not Intubating Non-Trauma Patients With Low Glasgow Coma Scale Scores: a Retrospective Study

2022 ◽  
Vol 2 (1) ◽  
pp. 83-90
Author(s):  
Loui K Alsulimani ◽  
Ohoud Baajlan ◽  
Khalid Alghamdi ◽  
Raghad Alahmadi ◽  
Abdullah Bakhsh ◽  
...  
Keyword(s):  
Glasgow Coma Scale ◽  
Clinical Characteristics ◽  
Tertiary Care ◽  
Altered Mental Status ◽  
Trauma Patients ◽  
Tertiary Care Centre ◽  
Mortality And Morbidity ◽  
Coma Scale ◽  
Scale Scores ◽  
Gcs Score

Background: Endotracheal intubation (EI) is a critical life-saving procedure commonly performed on emergency department (ED) patients who present with altered mental status (AMS).  Aims: We aimed to investigate the safety of observing, without EI, patients who present to the ED with decreased levels of consciousness (LOC).  Methods: We reviewed the data of all adult ED patients with a Glasgow Coma Scale (GCS) score ≤ 8, during the period between 2012 and 2018, in an academic tertiary care centre. Trauma patients were excluded. The patients were divided into two groups for comparison: those who were intubated and those who were not. Data on mortality, morbidity, and baseline clinical characteristics were collected and analysed.  Results: After screening 6334 electronic medical records of patients presenting to the ED with decreased LOC, only 257 patients met the inclusion criteria. 173 (67.3%) patients were intubated, while 84 (32.7%) were not. Among the intubated patients, 165 (95.4%) were intubated early (within two hours of presentation). Mortality, morbidity and length of stay for the intubated group were higher, although the baseline clinical characteristics were the same.  Conclusion: It might be safe to observe non-trauma emergency patients with a GCS score ≤ 8 without intubation. However, such decision should be taken carefully, as delayed intubation can be associated with higher mortality and morbidity

scholarly journals A Delayed Modified ICH Score Outperforms Baseline Scoring in Acute Intracerebral Hemorrhage

2019 ◽  
Vol 10 (3) ◽  
pp. 217-220
Author(s):  
Ronda Lun ◽  
Vignan Yogendrakumar ◽  
Dylan Blacquiere ◽  
Michel Shamy ◽  
Grant Stotts ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Functional Outcome ◽  
Area Under The Curve ◽  
Predictive Ability ◽  
Patient Characteristics ◽  
Prognostic Scores ◽  
Secondary Outcome ◽  
Predictive Values ◽  
Poor Outcome ◽  
Acute Intracerebral Hemorrhage

The Modified Intracerebral Hemorrhage (MICH) score is a simple tool created to provide prognostication in basal ganglia hemorrhages. Current prognostic scores, including the MICH, are based on the assessment of baseline patient characteristics, failing to account for significant developments, such as intraventricular extension and clinical deterioration, which may occur over the first 72 hours. We propose to validate the MICH in all hemorrhage locations and hypothesize that its calculation at 72 hours will outperform its baseline counterpart with respect to predicting mortality and functional outcome. We performed a retrospective analysis of collated data from the Virtual International Stroke Trials Archive database. Primary outcome was 90-day mortality. Secondary outcome was poor outcome (modified Rankin Scale 4-6) at 90 days. Receiver operating characteristic curves were generated looking at the predictive ability of the MICH score for mortality and poor outcome, at baseline and at 72 hours. Competing curves were assessed with nonparametric methods. A total of 226 patients were included, with a 90-day mortality of 22.5%. The MICH scores calculated at 72 hours were more predictive of mortality than at baseline (area under the curve [AUC]: 0.89 [95% confidence interval [CI]: 0.83-0.94] vs 0.78 [95% CI: 0.70-0.85]), P < .01. The MICH scores at 72 hours similarly better predicted functional outcome (AUC: 0.78 [95% CI: 0.72-0.84] vs AUC: 0.72 [95% CI: 0.66-0.78]), P = .047. The MICH score has positive prognostic value for mortality and poor functional outcome in all hemorrhage locations. Delaying its calculation resulted in higher predictive values for both and suggests that delaying discussions around withdrawal of care may result in more accurate prognostication in acute intracerebral hemorrhage.

Primary Intracerebral Hemorrhage in Izumo City, Japan: Incidence Rates and Outcome in Relation to the Site of Hemorrhage

Neurosurgery ◽  
2003 ◽  
Vol 53 (6) ◽  
pp. 1283-1298 ◽  
Author(s):  
Tetsuji Inagawa ◽  
Naohiko Ohbayashi ◽  
Akihiko Takechi ◽  
Masaaki Shibukawa ◽  
Kaita Yahara
Keyword(s):  
Glasgow Coma Scale ◽  
Intracerebral Hemorrhage ◽  
Survival Rates ◽  
Case Fatality ◽  
Incidence Rates ◽  
Coma Scale ◽  
Scale Scores ◽  
Adjusted Incidence ◽  
Age And Sex

Abstract OBJECTIVE The aim of this community-based study was to investigate the incidence rates and outcome of primary intracerebral hemorrhage (ICH) in relation to the site of hemorrhage. METHODS The subjects were 350 patients with primary first-ever ICH who were treated during the 8-year period 1991 to 1998 in Izumo City, Japan. RESULTS The crude and age- and sex-adjusted incidence rates for all types of ICH were 52 and 47 per 100,000 population, respectively, for all ages. The most common site of ICH was the putamen (120 patients, 34%), followed by the thalamus (115, 33%), lobar areas (53, 15%), brainstem (30, 9%), cerebellum (25, 7%), and caudate nucleus (7, 2%). The crude and age- and sex-adjusted annual incidence rates per 100,000 population were 18 and 16 for putaminal, 17 and 15 for thalamic, 8 and 7 for lobar, 4 and 3 for cerebellar, 4 and 4 for brainstem, and 1 and 1 for caudate hemorrhages, respectively. The Glasgow Coma Scale scores on admission were best in patients with cerebellar hemorrhage and worst in those with brainstem hemorrhage. Surgery was performed for 34% of putaminal, 9% of thalamic, 14% of caudate, 21% of lobar, and 32% of cerebellar hemorrhages but not for brainstem hemorrhages. The 30-day case fatality rate was 11% for putaminal, 9% for thalamic, 14% for caudate, 11% for lobar, 0% for cerebellar, and 53% for brainstem hemorrhages. When patients with ICH were analyzed as a whole, the overall survival rates at 30 days, 3 months, and 3 years were 87, 83, and 73%, respectively. Both the short-term and long-term outcomes after ICH were directly related to the site of hemorrhage and the severity of bleeding, which was assessed by the hematoma volume and Glasgow Coma Scale score. Overall, 190 (54%) of 350 patients had a favorable outcome, and 55 (16%) had died at discharge. CONCLUSION Marked differences were observed in the incidence rates and outcome of primary ICH in relation to the site of hemorrhage. The differences in outcome were primarily a result of differences in the severity of bleeding for each ICH subtype.

scholarly journals Comparison of Glasgow Outcome Scale (GOS) and Glasgow Coma Scale (GCS) between Surgical and Conservative Management of Spontaneous Supratentorial Intracerebral Hemorrhage Patients: A Randomized Control Trial

2018 ◽  
Vol 5 (2) ◽  
pp. 49-54 ◽  
Author(s):  
Mohammad Rafiqul Islam ◽  
Md Shafiqul Kabir Khan ◽  
Md Mahfuzur Rahman ◽  
Moajjam Hossain Talukder ◽  
Md Rezaul Karim ◽  
...  
Keyword(s):  
Glasgow Coma Scale ◽  
Intracerebral Hemorrhage ◽  
Conservative Management ◽  
Glasgow Outcome Scale ◽  
Randomized Control Trial ◽  
Coma Scale ◽  
Group I ◽  
Randomized Control ◽  
Gcs Score

Background: Glasgow outcome scale (GOS) and Glasgow Coma Scale (GCS) were the important parameter for the proper management of spontaneous supratentorialintracerebral hemorrhage patients.Objective: The purpose of the present study was to compare the GOS and GCS between surgical and conservative management of spontaneous supratentorialintracerebral hemorrhage patients.Methodology: This randomized control trial was conducted in the Department of Neurosurgery at Dhaka Medical College and Hospital from January 2010 to October 2011 for a period of one year and ten months. All hypertensive patients with spontaneous supratentorial intracerebral hemorrhage who were admitted within 48 hours of stroke in Neurosurgery Department during the study period were considered as a study population. Patients underwent surgery was considered as group I and patients those who did not give the consent for operation were treated conservatively was considered as group II.Result: A total of 31 patients were enrolled in this study of which 14 patients underwent surgical evacuation and 17 patients were selected for conservative therapy. Significant positive correlation was found between the GCS score on admission and GOS at 30 days follow-up in surgery group (r=0.649; p<0.05). But a positive significant correlation (r=0.613; P=0.020) was between GCS follow up with GCS on admission in surgery patients and (r=0.575; P=0.016) in conservative group.Conclusion: In conclusion both GOS and GCS are essential during the management of surgical and conservative spontaneous supratentorialintracerebral hemorrhage patients.Journal of Current and Advance Medical Research 2018;5(2):49-54

scholarly journals Timing of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Single-Center Analysis

Medicina ◽  
2019 ◽  
Vol 55 (2) ◽  
pp. 31
Author(s):  
Mustafa Kilic ◽  
Devrimsel Harika Ertem ◽  
Burak Ozdemir
Keyword(s):  
Glasgow Coma Scale ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Demographic Data ◽  
High Morbidity ◽  
Middle Cerebral Artery Infarction ◽  
Coma Scale ◽  
Scale Scores ◽  
Gcs Score

Background and aim: Malignant middle cerebral artery infarction (MMCAI) usually leads to brain edema that may result in transtentorial herniation and brainstem compression. The prognosis of MMCAI is generally poor. The aim of this study was to discuss our experience with surgical decompression for MMCAI, and determine the association between timing of craniectomy and neurological outcomes. Methods: We identified consecutive patients diagnosed with MMCAI who underwent decompressive craniectomy (DC). Clinical and demographic data were obtained from electronic medical records, including: age, sex, preoperative Glasgow Coma Scale (GCS) score, surgery timing, postoperative GCS scores, and modified Rankin Scale (mRS) scores. Results: This study included 27 stroke patients (aged 38–80 years) operated within 72 h of the onset of neurological symptoms. Sixteen, five, and six patients underwent DC within 24 h, between 24 and 48 h, and after 48 h after onset of symptoms, respectively. Five patients died after the surgery. Patients who underwent DC within 24 h and 24–48 h had better mean GCS scores than those who underwent DC after 48 h (p = 0.000, p = 0.015). In addition, patients who underwent DC within 24 h had better mean postoperative mRS scores (p = 0.000) than other patients. Patients older than 60 years had significantly lower GCS scores (p = 0.027) and higher mRS scores (p = 0.033) than younger patients. Conclusion: Our findings support that DC had satisfying outcomes in patients who underwent DC within 24 h. Older age and lower Glasgow Coma Scale scores among DC patients with MMCAI are associated with high morbidity and mortality.

scholarly journals Outcome prediction following penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 6 to 15

2000 ◽  
Vol 8 (1) ◽  
pp. 1-6 ◽  
Author(s):  
Michael L. Levy
Keyword(s):  
Glasgow Coma Scale ◽  
Significant Relationship ◽  
Pupillary Response ◽  
Operative Intervention ◽  
Craniocerebral Injury ◽  
Coma Scale ◽  
Significant Relationships ◽  
Scale Scores ◽  
Gcs Score ◽  
Admission Glasgow Coma Scale

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.

scholarly journals Modulated Neuroprotection in Unresponsive Wakefulness Syndrome after Severe Traumatic Brain Injury

2021 ◽  
Vol 11 (8) ◽  
pp. 1044
Author(s):  
Cristina Daia ◽  
Cristian Scheau ◽  
Aura Spinu ◽  
Ioana Andone ◽  
Cristina Popescu ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Severe Traumatic Brain Injury ◽  
Functional Independence ◽  
Unresponsive Wakefulness Syndrome ◽  
Coma Scale ◽  
Severe Tbi ◽  
Neuroprotective Treatment ◽  
Gcs Score

Background: We aimed to assess the effects of modulated neuroprotection with intermittent administration in patients with unresponsive wakefulness syndrome (UWS) after severe traumatic brain injury (TBI). Methods: Retrospective analysis of 60 patients divided into two groups, with and without neuroprotective treatment with Actovegin, Cerebrolysin, pyritinol, L-phosphothreonine, L-glutamine, hydroxocobalamin, alpha-lipoic acid, carotene, DL-α-tocopherol, ascorbic acid, thiamine, pyridoxine, cyanocobalamin, Q 10 coenzyme, and L-carnitine alongside standard treatment. Main outcome measures: Glasgow Coma Scale (GCS) after TBI, Extended Glasgow Coma Scale (GOS E), Disability Rankin Scale (DRS), Functional Independence Measurement (FIM), and Montreal Cognitive Assessment (MOCA), all assessed at 1, 3, 6, 12, and 24 months after TBI. Results: Patients receiving neuroprotective treatment recovered more rapidly from UWS than controls (p = 0.007) passing through a state of minimal consciousness and gradually progressing until the final evaluation (p = 0.000), towards a high cognitive level MOCA = 22 ± 6 points, upper moderate disability GOS-E = 6 ± 1, DRS = 6 ± 4, and an assisted gait, FIM =101 ± 25. The improvement in cognitive and physical functioning was strongly correlated with lower UWS duration (−0.8532) and higher GCS score (0.9803). Conclusion: Modulated long-term neuroprotection may be the therapeutic key for patients to overcome UWS after severe TBI.

408: Scene Glasgow Coma Scale Scores Can Help Predict Mortality in Pediatric Blunt Trauma

2008 ◽  
Vol 52 (4) ◽  
pp. S166
Author(s):  
C.B. Irvin ◽  
K.E. Duemling ◽  
T. Oberg ◽  
A.M. Ads
Keyword(s):  
Glasgow Coma Scale ◽  
Blunt Trauma ◽  
Coma Scale ◽  
Scale Scores

Missile injury to the pediatric brain in conflict zones

2011 ◽  
Vol 7 (3) ◽  
pp. 276-281 ◽  
Author(s):  
Abrar A. Wani ◽  
Altaf U. Ramzan ◽  
Nayil K. Malik ◽  
Abdul Qayoom ◽  
Furqan A. Nizami ◽  
...  
Keyword(s):  
Glasgow Coma Scale ◽  
Pediatric Population ◽  
Developed Countries ◽  
Multinomial Regression ◽  
Chi Square ◽  
Conflict Zones ◽  
Coma Scale ◽  
Hemodynamic Status ◽  
Missile Injury ◽  
Gcs Score

Object This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world Methods Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well. Results On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability. Conclusions There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

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