Correlation between neutrophil lymphocyte count ratio and outcomes of severe traumatic head injury

Background: Raised peripheral neutrophil lymphocyte ratio is associated with poorer outcomes in conditions such as severe brain injury, ICH, cardiovascular conditions, cancer.Methods: Retrospective analysis of 96 severe Traumatic Brain injury data treated at our institute over a period of 1 year. The patients were followed up for a period of at least 1 month. The primary outcome of the study was 1 month GOS and the various variables which may be associated with the poor GOS at 1 month follow up. Model based analysis was done for NLCR <24 hrs at 48 hrs and GCS at the time of presentation and discriminative ability of the models were studied by the Area under the curve.Results: Univariate analysis were done of 96 patients of severe traumatic brain injury for various variables such as age, sex, mode of head injury, type of head injury, presenting GCS and NLCR at 24 hrs and 48 hrs to that of GOS at 1 month follow up. Initial GCS <7 (p=0.0138) with AUC=0.6689 and peak NLCR (<24 hr) of > 9.6 (AUC=0.931) with a p value of <0.001 with sensitivity of 100% and specificity of 79.27% and peak NLCR (48 hrs) of >12.4 (AUC= 0.973) with a p value of <0.001 with sensitivity of 100% and specificity of 89.02% were associated with unfavourable outcome.Conclusions: High NLCR and initial poor GCS are independent unfavourable prognostic factors in 1 month GOS following severe traumatic head injury.

Assessing the effectiveness of the full outline of unresponsiveness scale and the Glasgow coma scale in patients of traumatic head injury

Background: The Glasgow coma scale (GCS) is the most commonly used scale while the full outline of unresponsiveness (FOUR) score is a new validated coma scale in the evaluation of the level of consciousness in head injury patients. The aim of the study was to compare and assess the effectiveness of the FOUR score and the GCS in patients of traumatic head injury.Methods: This was a prospective observational study conducted in the department of surgery, Gandhi medical college, Bhopal during a 2 year period in which 100 patients of traumatic head injury were evaluated. The FOUR score and GCS score of these patients were assessed on admission and outcome followed for 2 weeks.Results: The mean age group of 100 patients was 25-45 years with 79% male and 21% female patients. The FOUR scale was found to have a marginally higher sensitivity of 65.6% while the GCS had a sensitivity of 64.2%. The FOUR scale however had a higher specificity of 71.5% compared to 66.4% of GCS. The Youden index showed that FOUR scale (46%) has a better prediction for death than GCS (35%). FOUR had a higher accuracy of 75% than GCS with an accuracy of 65%.Conclusions: Both FOUR score and GCS are valuable scales in assessment of traumatic head injury. The FOUR scale however is more accurate than the GCS in predicting outcome of head injury patients.

Rapid resolution of a traumatic venous epidural hematoma in a 3-year-old child: illustrative case

BACKGROUND Posterior fossa epidural hematoma rarely occurs in children after traumatic head injury. There is ongoing discussion about appropriate treatment, yet the radiological features regarding the time to resorption of the hematoma or required follow-up imaging are rarely discussed. OBSERVATIONS The authors presented the case of a 3-year-old child who was under clinical observation and receiving analgetic and antiemetic treatment in whom near-complete hematoma resorption was shown by magnetic resonance imaging as soon as 60 hours after diagnosis. The child was neurologically stable at all times and showed no deficit after observational treatment. Hematoma resorption was much faster than expected. The authors discussed hematoma drainage via the sigmoid sinus. LESSONS Epidural hematomas in children can be treated conservatively and are resorbed in a timely manner.

Treatment of Persistent Post-Traumatic Headache with the Anti-CGRP Receptor Antibody Erenumab: A Case Report

Introduction: Calcitonin gene-related peptide (CGRP) has only recently emerged as a potential target in posttraumatic headache. To our knowledge this is the first description of a patient with persistent posttraumatic headache following severe traumatic head injury who has been treated with the CGRP-receptor-monoclonal antibody erenumab.Case presentation: A 56-year-old man presented with a 30-year history of frequent migraine-like posttraumatic headaches following a high-voltage head injury that he treated with an excessive intake of peripheral analgesics. Although amitriptyline was reasonably effective, it had to be discontinued when the patient developed restless legs syndrome in the second year of treatment. Under therapy with erenumab he achieved a rapid and stable reduction in his symptoms down to only 2–3 headache days per month without adverse events.Conclusions: This case demonstrates that the inhibition of the CGRP-receptor with erenumab could be an effective treatment option in migraine-like post-traumatic headache even decades after the traumatic event.

Investigating the Association between Orthopedic Fractures and Head Injury due to Road Traffic Accidents

Background. Traumatic head injury (THI) due to road traffic accidents (RTAs) is a global health problem. Studies exploring the association between RTA-related THI and concurrent orthopedic fractures are lacking. We aim to provide a detailed analysis of this association and its impact on inhospital outcomes. Methods. Retrospective analysis of RTA-related THI associated with orthopedic fractures admitted to a large tertiary center, Southwest, Saudi Arabia, over ten years. Descriptive statistics for participant demographics and clinical outcomes were represented by percentages. The associations between head injury diagnosis or orthopedic fractures region and patient demographics are analyzed using the Chi-square test. Post hoc analysis for the significant Chi-square values was carried out by calculating the significant adjusted residuals. Adjust p value was obtained by using the Benjamini-Hochberg procedure to control for multiplicity testing. A p value less than 0.05 was considered statistically significant. Results. Concurrent orthopedic fractures are present in one-tenth of RTA-related THI. The cohort was dominated by young males, with 46.5% of the population between 18 and 29 years old. There was a significant association between the head injury diagnosis and the region of orthopedic fracture ( p = 0.028 ). The type of head injury had significant associations with mortality and duration of hospital stay ( p = 0.039 and p = 0.037 , respectively). The region of orthopedic fracture significantly ( p = 0.018 ) affected the duration of hospital stay, with fractures in the clavicle/shoulder region significantly ( p = 0.035 ) having a short course of hospital admission. Conclusion. Orthopedic fractures concomitant with RTA-related THI are common. The associations between the two injuries tend to happen in specific patterns. The inhospital stay duration and mortality significantly correlated with the site of the head or orthopedic injury. Knowledge of these patterns improves the care of THI victims, triaging, and resource allocations.

Post-Traumatic Hydrocephalus - A Retrospective Study

BACKGROUND Post-traumatic hydrocephalus (PTH) can occur as an outcome of moderate and severe traumatic head injury. It is one of the causes of delayed worsening of the early symptoms of head injury. A total of 18 cases of PTH diagnosed and treated at tertiary care hospitals from 2012 to 2015 were studied. The purpose of the study was to evaluate the clinicoradiological profile of patients diagnosed with posttraumatic hydrocephalus and determine the outcome of ventriculoperitoneal (VP) shunting in cases of post-traumatic hydrocephalus. METHODS A retrospective study was conducted in the Department of Neurosurgery in a teaching medical college. The clinicoradiological profile of patients diagnosed with PTH was studied. These cases were treated conservatively as well as by surgery. The demography, cause of trauma, GCS score and response rates were studied. RESULTS Among the 18 reviewed patients, 61.1 % were males, fall and RTA constituted the major cause of trauma. Craniotomy was done in 50 % of the patients, 88.89 % of the patients recovered and the mortality rate was 11.11 %. CONCLUSIONS Post-traumatic hydrocephalus is a consequence of traumatic head injury and can occur with various neurological symptoms after the initial trauma. CT scan of the brain is considered the choice of investigation to early diagnose PTH and the patient outcome after VP shunting is good. KEY WORDS Hydrocephalus, Head Injury, Trauma

TP9.1.2We must do better - An audit assessing local compliance with NICE Guidelines (2014) on giving patient discharge advice regarding driving following traumatic brain injury

Introduction Driving is a complex activity involving the coordination of a number of cognitive and physical skills, which may be impaired after head injury. It is a legal requirement that patients’ inform the licensing authority when they have sustained a head injury. Failure to do so results in possible fines, invalid insurance and prosecution. NICE recommends printed patient advice about driving once discharged following a head injury. Methods A retrospective analysis of all traumatic brain injury admissions under the surgical team over a 6 months was performed. The aim was to identify current practice regarding assisting patients to return to safe driving after head injury. Information related to patient demographics, documented driving status and advice (verbal and written) related to driving, was sought. Descriptive statistics were used to portray the results. Results 56 patients were admitted following a traumatic head injury. The average age was 77 (range of 24 to 94) Patients spent on average 4 days in hospital. Only 2 patients had their driving status documented. These two patients also had a documented occupation dependent on driving. No patients received advice specific to DVLA guidelines. Conclusion This study demonstrates that there is poor compliance with NICE guidelines. Indeed, there is a need for change in our practice. We have a duty of care for our patients and in ensuring the safety of the general public. The main limitation of this study relates to the adequacy of documentation. We provide solutions in order to tackle the findings of this audit.