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To assess the actual presence of underlying depressed skull fractures and traumatic brain injuries (TBI) on computed tomography (CT) in children with and without palpable skull fractures on physical examination following minor head trauma. This was a secondary analysis of a prospective, observational multicenter study enrolling 42,412 children

Background: Traumatic brain injury (TBI) is a significant public health concern. Advancing age and comorbidities are associated with a reduced probability of being transferred to neurotrauma centres (NTCs) from non-neurosurgical acute care trauma hospitals (ACTHs). However, the extent to which these decisions reflect well-considered treatment-limiting decisions and which influence other factors have on the decision-making process remains unclear. Objective: To increase the understanding of adults' access to NTC care by exploring the decision-making process for interhospital transfer of patients with isolated TBI, elucidating factors influencing these decisions. Methods: Fifteen surgeons and neurosurgeons from four hospitals in Norway were recruited through purposive sampling to four semi-structured focus group interviews. Surgeons represented ACTHs and neurosurgeons NTCs, and all participants were responsible for TBI patients' initial care and transfer decisions. Interviews were thematically analysed. Results: We identified several factors influencing transfer decisions, captured in six main themes under one overarching theme; 'The chance of a favourable outcome'. The six main themes reflect surgeons' and neurosurgeons' decision-making process, which included clinical and system-level factors: (A) 'Establish TBI severity: Glasgow Coma Scale score and head CT', (B) 'Preinjury health status: comorbidity, functioning, and age', (C) 'Distance from ACTH to NTC: distance is time and time is brain', (D) 'Uncertainty and insecurity', (E) 'Capacity at NTC', and (F) 'Next of kin involvement'. Conclusion: On-call surgeons and neurosurgeons responsible for making transfer decisions for TBI patients emphasise the importance of patient-centred decisions, including individual patients' risk factors and overall health status. [ABSTRACT FROM AUTHOR]

Background and purpose: Intracerebral hemorrhage remains a significant cause of death and disability worldwide, highlighting the urgent need for accurate prognostic assessments to optimize patient management. This study aimed to develop a practical nomogram for risk prediction of poor prognosis after 90 days in patients with intracerebral hemorrhage. Methods: A retrospective study was conducted on 638 patients with intracerebral hemorrhage in the Second Hospital of Fujian Medical University, China, who were divided into a training set (n = 446) and a test set (n = 192) by random splitting. Then the data on demographics, clinical symptoms, imaging characteristics, and laboratory findings were collected. In this study, adverse outcomes were defined as a Modified Rankin Scale (mRS) score of 3–6 at 90 days post-ICH onset, as assessed during follow-up. Later, least absolute shrinkage and selection operator (LASSO) regression and multifactorial logistic regression were used to screen the variables and construct a nomogram. Next, the evaluation was performed using the Receiver Operating Characteristic (ROC) curve, calibration curve, and decision curve analysis. Finally, the external validation was completed using the data of 496 patients with intracerebral hemorrhage from the Jinjiang Hospital of Traditional Chinese Medicine. Results: In the training and test sets of intracerebral hemorrhage, the incidence of poor prognosis was 60.53 and 61.46%, respectively. Through variable screening, this study identified age, Glasgow Coma Scale (GCS), blood glucose, uric acid, hemoglobin, and hematoma location as independent predictors of poor prognosis in intracerebral hemorrhage. The developed dynamic nomogram was easy to use and demonstrated strong predictive performance (training set AUC: 0.87; test set AUC: 0.839; external validation set AUC: 0.774), excellent calibration, and clinical applicability. Conclusion: The dynamic nomogram we developed using five independent risk factors serves as a practical tool for real-time risk assessment and can help facilitate early intervention and personalized patient management, thereby improving clinical outcomes in high-risk patients. [ABSTRACT FROM AUTHOR]

Background: The systemic immune–inflammation index (SII) is a composite and easily available inflammation index, which can quantitatively reflect the degree of inflammation. This study aims to investigate the predictive value of admission SII for outcomes of large artery occlusion treated with mechanical thrombectomy (MT). Methods: This retrospective study was conducted at Suining Central Hospital, Sichuan, China. Patients were stratified into quartiles based on their SII. The investigating outcomes included hemorrhagic transformation (HT), malignant brain edema (MBE), 90-day functional outcome, and mortality. The adverse function was defined as the modified Rankin Scale (mRS) score > 2 at the 90-day follow-up. Multivariate analysis was performed to explore the relationships between SII and outcomes. In addition, cases (distinguished from the aforementioned patients) treated with MT + mild hypothermia (MH) were also included to elucidate the relationships between SII/MH and outcomes in a new cohort. Results: A total of 323 patients treated with MT were included. The observed HT, MBE, adverse function, and mortality rates were 31.9, 25.7, 59.4, and 27.9%, respectively. Multivariate analysis demonstrated that heightened SII was significantly related to HT (odds ratio [OR]: 1.061, 95% confidence interval [CI]: 1.035–1.086, p < 0.001), MBE (OR: 1.074, 95% CI: 1.045–1.103, p < 0.001), adverse function (OR: 1.061, 95% CI: 1.031–1.092, p < 0.001), and mortality (OR: 1.044, 95% CI: 1.018–1.070, p = 0.001), after adjusting sex, age, Glasgow Coma Scale (GCS) score at admission, initial National Institutes of Health Stroke Scale (NIHSS) score, baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS), present HMCAS, occluded vessel region, collateral score and successful revascularization. HT and MBE may partially account for patients with elevated SII's adverse function and mortality. In addition, with the criterion of baseline ASPECTS ≤ 7, a total of 42 patients treated with MT + MH were enrolled to build up a new cohort combined with 72 patients treated with mere MT. The risk role of SII and protect effect of MH were identified for HT (SII—OR: 1.037, 95% CI: 1.001–1.074; MH—OR: 0.361, 95% CI: 0.136–0.957), MBE (SII—OR: 1.063, 95% CI: 1.019–1.109; MH—OR: 0.231, 95% CI: 0.081–0.653), and mortality (SII—OR: 1.048, 95% CI: 1.011–1.087; MH—OR: 0.343, 95% CI: 0.118–0.994). Conclusion: Elevated SII was related to HT, MBE, 90-day adverse function, and mortality after MT. The MH may improve prognosis under high inflammation status. [ABSTRACT FROM AUTHOR]

AbstractNomograms represent powerful predictive tools that could be easily applied to guide managing acutely intoxicated patients. Thus, several nomograms were developed and validated in the last few decades to predict various outcomes following acute poisoning. However, the adopted nomograms remain sporadic efforts of researchers that limited their usefulness in clinical settings. We aimed to bridge the gap between theoretical formulation and hands-on application of the developed nomograms to benefit acutely poisoned patients. In this context, this systematic review was conducted to be a reference guide for implementing these nomograms in clinical toxicology practice. This review included 27 studies that were published over 60 years. A total of 60,883 patients ranging between 2 and 91 years were enrolled. These studies elaborated 38 nomograms; 13 nomograms addressed acute poisoning in general, and 25 nomograms were specially designed for six poisons/categories, including pesticides (n = 9), psychotropic drugs (n = 5), alcohol (n = 4), analgesics, and anti-inflammatory medications (n = 3), carbon monoxide (n = 2), and digoxin (n = 2). Despite the first nomogram was published in 1960, 81.5% of nomograms emerged after 2016, with a significant increase in the trend of published nomograms (p < .001). The Glasgow Coma Scale, patient age, poison concentration, bicarbonate level, and blood pressure were the most frequently used predictors. The nomograms were designed to predict eight outcomes, including mortality (n = 14, 36.8%), need for intensive care unit (ICU) admission (n = 9, 23.7%), complications of poisoning (n = 6, 15.8%), optimization of therapy (n = 4, 10.5%), and poisoning severity (n = 2, 5.3%). Also, the need for mechanical ventilation (MV), diagnosis of poisoning, and suicidal poisoning were predicted by one nomogram for each of them. The developed nomograms’ performances were tested using receiver operating characteristic analysis and the area under a curve of 26 derived nomograms ranged between 0.839 and 0.999. External validation was conducted on 16 nomograms only; 15 nomograms were validated using validation cohorts within the same studies that developed the nomograms. However, only one nomogram was subjected to external validation by other studies. The externally validated nomograms consist of 10 nomograms for managing particular poisoning and, six nomograms for un-specified poisoning. The poison-specific nomograms were concerned with acute poisoning with pesticides (n = 4), methanol (n = 2), opioid (n = 1), clozapine (n = 1), carbon monoxide (n = 1), and digoxin (n = 1). Regarding six validated nomograms in a general poisoning approach, two nomograms predicted mortality. Nevertheless, four separate nomograms were concerned with the prediction of poisoning complications, the need for ICU admission, the need for MV, and suicidal poisoning. The external validation of the established nomograms ensured their performance and reliability for universal applicability in clinical settings. Meanwhile, the remaining 22 nomograms lacking external validation represent promising research opportunities. [ABSTRACT FROM AUTHOR]

To assess the analytical performances of Snibe Maglumi® S100 assay and compare it with the Roche Elecsys® S100B assay in adults with mild traumatic brain injury (mTBI) focusing on reducing unnecessary cranial computed tomography (CT) scans per Scandinavian and French guidelines.Analytical performance of the Maglumi® S100 kit was assessed using quality controls from both Snibe and Roche, as well as pooled serums. Clinical performances were assessed using serum from 89 adult mTBI patients presenting to the adult emergency department of Clermont-Ferrand University Hospital with a Glasgow Coma Scale score of 14–15. CT scans were performed according to the Elecsys® S100 measurement, with a decision threshold of 0.10 μg/L.Repeatability and reproducibility coefficients of variation determined using Elecsys® S100B, Maglumi® S100 controls and pooled serums were below 8 %. Six (7 %) mTBI patients included had clinically relevant intracranial lesions observed on CT scan (CT+), and eighty-three (93 %) patients had no lesions (CT-). S100B medians in CT- and CT+ patients were significantly different: 0.125 (0.085–0.219) vs. 0.368 (0.231–0.489) (p=0.006) for Elecsys®, and 0.073 (0.046–0.140) vs. 0.327 (0.230–0.353) for Maglumi® (p=0.004). The areas under the ROC curves for intracranial lesion detection were similar: 0.82 (0.73–0.91; p=0.0084) and 0.83 (0.75–0.92; p=0.0063) for Elecsys® and Maglumi®, respectively.The Maglumi® S100B assay can be used in the management of mTBI patients to exclude unnecessary CT scans. Further studies are needed to validate a clinical decision threshold for CT scan decisions. [ABSTRACT FROM AUTHOR]

Background: Despite recent advances in neuroimaging and neurocritical care, severe traumatic brain injury (TBI) is still a major cause of severe disability and mortality, with increasing incidence worldwide. Antisecretory factor (AF), commercially available as Salovum®, has been shown to lower intracranial pressure (ICP) in experimental models of, e.g., TBI and herpes encephalitis. The aim of this study is to assess the effect of antisecretory factors in adult patients with severe TBI on ICP and inflammatory mediators in extracellular fluid and plasma. Methods/design: This is a single-center, randomized, placebo-controlled clinical phase 2 trial, investigating the clinical superiority of Salovum® given as a food supplement during 5 days to adults with severe TBI (Glasgow Coma Scale (GCS) < 9), admitted to the neurocritical intensive care unit (NICU) at Skane university hospital, Lund, Sweden. All patients with GCS < 9 and clinical indication for insertion of ICP-monitor and microdialysis catheter will be screened for inclusion and assigned to either the treatment group (n = 10) or placebo group (n = 10). In both groups, the primary outcome will be ICP (mean values and change from baseline during intervention), registered from high-frequency data monitoring for 5 days. Secondary outcomes will be inflammatory mediators in plasma and intracerebral microdialysis perfusate days 1, 3, and 5 during trial treatment. Trial registration: ClinicalTrials.gov NCT04117672. Registered on September 17, 2017. Protocol version 6 from October 24, 2023. [ABSTRACT FROM AUTHOR]

Background: Epidural hematomas (EDH) are associated with a high rate of mortality and morbidity. Good clinical outcome depends on initial Glasgow Coma Scale (GCS), pupillary abnormalities, hematoma volume, age and time to surgery. The latter is mostly influenced by distance to the next level-1-trauma center. Objective: The aim of this study was to evaluate the surgical care and the influence of a potential interhospital transport of patients with acute EDH. Material & methods: A retrospective analysis of data from 2009 to 2020 was carried out. All patients who underwent surgical evacuation of an EDH were included. Time and distance to surgery, pupillary abnormalities, initial GCS, age at surgery, direct or indirect transport, outcome (GOS) and comorbidities were collected. The effect on outcome was analyzed by multivariate analysis. Results: One hundred and thirty-one patients (106 men, 25 women) with EDH were surgical treated at our department. 54% were transported directly to our hospital. Median time to surgery was 4 h (2–336 h) and mean distance was 50 km (road kilometers). There was no difference in surgical treatment between admission patterns. Secondarily transferred patients have been operated at least as fast than primary hospital admissions (median 10 h vs. 11 h, respectively). Direct or indirect transport of patients had no statistically significant influence on outcome (p = 0.72), like sex (p = 0.33) and time to surgery (p = 0.75). Conclusion: Interhospital transport did not cause a significant delay of surgical treatment and outcome was comparable between direct and indirect transport to specialized neurosurgical care. Direct transport was more common on severe TBI and in patients with pupillary abnormalities, but secondary transport also allowed for adequate care. [ABSTRACT FROM AUTHOR]

Objective: To explore the correlation between changes in serum neurofilament light chain protein and clinical prognosis in patients with hypertensive intracerebral hemorrhage, combined with other clinical indicators. This article provides evidence for clinicians to effectively evaluate the prognosis of patients with hypertensive intracerebral hemorrhage and formulate diagnosis and treatment plans. Methods: We selected 202 patients with hypertensive intracerebral hemorrhage admitted to different hospital from 2021 to 2022, and the clinical data of the patients were collected immediately after admission. Blood samples of the patients were collected, centrifuged, and the upper serum layer was collected and stored in the freezer at -80℃. During the same period, the sera of 30 age-matched healthy subjects were collected as the control group. The serum values of light chain protein of the experimental group and control group were measured by enzyme-linked immunosorbent assay. The Glasgow Outcome Scale of enrolled patients at 30 days of onset was recorded, and the collected data were statistically analyzed. Results: After statistical treatment, systolic blood pressure, admission Glasgow coma scale score, hematoma volume, and serum light chain protein values on day 3 and day 7 were statistically significant between the groups with good prognosis and those with poor prognosis (all P <.001). Conclusion: The serum light chain protein level of patients with hypertensive intracerebral hemorrhage was significantly higher than that of healthy people. The prognosis of the experimental group was correlated with the change trend of serum light chain protein. [ABSTRACT FROM AUTHOR]

Background: Pre-injury frailty among older adults with trauma injuries is a predictor of increased morbidity and mortality. Objectives: We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED). Methods: Using a retrospective cohort design, we pooled trauma data from a single institutional trauma database from August 2020 to June 2023. We limited the data to adults 65 years and older, who had trauma injuries and frailty screening at ED presentation (N = 2,862). The predictor variable was frailty status, measured as either robust (score 0), pre-frail (score 1–2), or frail (score 3–5) using the FRAIL index. The outcome variables were measures of clinical care trajectory: trauma team activation, inpatient admission, ED discharge, length of hospital stay, in-hospital death, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, health insurance type, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories. Results: The mean (SD) age of the study population was 80 (8.9) years, and the population was predominantly female (64%) and non-Hispanic White (60%). Compared to those classified as robust, those categorized as frail had 2.5 (95% CI: 1.86–3.23), 3.1 (95% CI: 2.28–4.12), and 0.3 (95% CI: 0.23–0.42) times the adjusted odds of trauma team activation, inpatient admission, and ED discharge, respectively. Also, those classified as frail had significantly longer lengths of hospital stay as well as 3.7 (1.07–12.62), 0.4 (0.28–0.47), and 2.2 (95% CI: 1.71–2.91) times the odds of in-hospital death, home discharge, and discharge to rehabilitation, respectively. Conclusion: Pre-injury frailty is a predictor of clinical care trajectories for older adults with trauma injuries. [ABSTRACT FROM AUTHOR]

Purpose: Pediatric cervical spine injury (PCSI) can result in devastating neurologic disability. While computed tomography (CT) imaging is both sensitive and specific in detecting clinically significant injuries, indiscriminate utilization can lead to excessive ionizing radiation exposure. A routine institutional audit revealed CTs were inappropriately obtained 54% of the time. This study evaluates the effects of an updated protocol to reduce radiation exposure in pediatric trauma patients. Methods: Data were retrospectively analyzed from a pediatric level 1 trauma center from 2021 to 2022. The data were divided into two cohorts, pre-implementation (2021) and post-implementation (2022). Inclusion criteria were patients 0–14 years old with a Glasgow Coma Scale (GCS) ranging 9–15. Outside-hospital transfers were excluded. The primary study endpoints were guideline compliance and CT utilization. Results: A total of 82 subjects were enrolled in this study. In 2021, there were 38 subjects (female/male 15/23, mean age 5.9 years old) with an average GCS of 13.6. In 2022, there were 44 subjects (female/male 19/25, mean age 5.2 years old) with an average GCS of 14.0. In 2021, the overall protocol adherence rate was 81.6%, and post-implementation in 2022, compliance was 93.2% (p = 0.109). Following implementation, the rate of inappropriate (protocol non-adherent CT) use decreased from 58.6 to 6.8% (p < 0.05). Conclusions: Implementation of a new evidence-based institutional protocol for PCSI was associated with improved adherence and reduction of unnecessary CT orders. Ongoing monitoring will help determine if these improvements are sustained. [ABSTRACT FROM AUTHOR]

Background: Older persons comprise most traumatic brain injury (TBI)-related hospitalizations and deaths and are particularly susceptible to fall-induced TBIs. The combination of increased frailty and susceptibility to clinical decline creates a significant ongoing challenge in the management of geriatric TBI. As the population ages and co-existing medical conditions complexify, so does the need to improve the quality of care for this population. Utilizing early hospital admission variables, this study will create and validate a multinomial decision tree that predicts the discharge disposition of older patients with fall-related TBI. Methods: From the National Trauma Data Bank, we retrospectively analyzed 11,977 older patients with a fall-related TBI (2017–2021). Clinical variables included Glasgow Coma Scale (GCS) score, intracranial pressure monitor use, venous thromboembolism (VTE) prophylaxis, and initial vital signs. Outcomes included hospital discharge disposition re-categorized into home, care facility, or deceased. Data were split into two sets, where 80% developed a decision tree, and 20% tested predictive performance. We employed a conditional inference tree algorithm with bootstrap (B = 100) and grid search options to grow the decision tree and measure discrimination ability using the area under the curve (AUC) and calibration plots. Results: Our decision tree used seven admission variables to predict the discharge disposition of older TBI patients. Significant non-modifiable variables included total GCS and injury severity scores, while VTE prophylaxis type was the most important interventional variable. Patients who did not receive VTE prophylaxis treatment had a higher probability of death. The predictive performance of the tree in terms of AUC value (95% confidence intervals) in the training cohort for death, care, and home were 0.66 (0.65–0.67), 0.75 (0.73–0.76), and 0.77 (0.76–0.79), respectively. In the test cohort, the values were 0.64 (0.62–0.67), 0.75 (0.72–0.77), and 0.77 (0.73–0.79). Conclusions: We have developed and internally validated a multinomial decision tree to predict the discharge destination of older patients with TBI. This tree could serve as a decision support tool for caregivers to manage older patients better and inform decision-making. However, the tree must be externally validated using prospective data to ascertain its predictive and clinical importance. [ABSTRACT FROM AUTHOR]

Introduction: Amantadine has been shown to accelerate cognitive and functional brain recovery after cerebrovascular accidents. However, the efficacy of this drug in TBI patients remains poorly defined. Methods: We performed a systematic review and meta-analysis of randomized trials (RCTs) evaluating the effects of amantadine in TBI patients. The Cochrane, Embase, and PubMed databases were systematically searched for trials published up to March 24, 2024. Data from previous RCTs were extracted and quality assessed according to Cochrane recommendations. Means and standard deviations with 95% confidence intervals were aggregated across studies. The primary outcomes assessed were Glasgow Coma Scale (GCS), Mini Mental State Examination (MMSE) and the Disability Rating Scale (DRS). Results: From 1,292 database results, 6 studies with 426 patients were included, of which 205 received amantadine (48.12%). The Glasgow Coma Scale score on day 7 (MD 1.50; 95% CI 0.08–2.92; p = 0.038; I 2 = 68%) was significantly higher in patients treated with amantadine than those treated with placebo. The Mini Mental State Examination (MD 3.23; 95% CI 0.53–5.94; p = 0.019; I 2 = 0%) was also better in patients treated with amantadine. No significant differences in Disability Rating Scale, day 3 GCS, Glasgow Outcome Scale (GOS), length of hospital stay, or duration of mechanical ventilation were observed between amantadine and placebo groups. Conclusion: In our analysis, TBI patients benefit from the use of amantadine in the day 7 GCS score and show better results in the MMSE test, but placebo patients benefit from not using amantadine in the DRS between weeks 3 and 4. No other statistically significant results were found related to the use of this medication. Systematic review registration : https://www.crd.york.ac.uk/prospero/display%5f record.php?ID=CRD42024538110, CRD42024538110. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to define clinically meaningful phenotypes of intracerebral hemorrhage (ICH) using machine learning. Methods: We used patient data from two US medical centers and the Antihypertensive Treatment of Acute Cerebral Hemorrhage-II clinical trial. We used k-prototypes to partition patient admission data. We then used silhouette method calculations and elbow method heuristics to optimize the clusters. Associations between phenotypes, complications (e.g., seizures), and functional outcomes were assessed using the Kruskal–Wallis H-test or χ2 test. Results: There were 916 patients; the mean age was 63.8 ± 14.1 years, and 426 patients were female (46.5%). Three distinct clinical phenotypes emerged: patients with small hematomas, elevated blood pressure, and Glasgow Coma Scale scores > 12 (n = 141, 26.6%); patients with hematoma expansion and elevated international normalized ratio (n = 204, 38.4%); and patients with median hematoma volumes of 24 (interquartile range 8.2–59.5) mL, who were more frequently Black or African American, and who were likely to have intraventricular hemorrhage (n = 186, 35.0%). There were associations between clinical phenotype and seizure (P = 0.024), length of stay (P = 0.001), discharge disposition (P < 0.001), and death or disability (modified Rankin Scale scores 4–6) at 3-months' follow-up (P < 0.001). We reproduced these three clinical phenotypes of ICH in an independent cohort (n = 385) for external validation. Conclusions: Machine learning identified three phenotypes of ICH that are clinically significant, associated with patient complications, and associated with functional outcomes. Cerebellar hematomas are an additional phenotype underrepresented in our data sources. [ABSTRACT FROM AUTHOR]

Background: Rational prediction of the probability of decannulation in tracheotomy patients is of great importance to clinicians and patients' families. This study aimed to develop a prediction model for decannulation in tracheotomized patients with neurological injury using routine clinical data and blood tests. Methods: We developed a prediction model based on 186 tracheotomized patients, and data were collected from January 2018 to March 2021. The least absolute shrinkage and selection operator (LASSO) regression model was used to optimize feature selection for the decannulation risk model. The performance of the prediction model was evaluated in terms of discrimination, calibration, and clinical utility using measures such as C-index, calibration plot, and decision curve analysis (DCA). Internal validation was performed through bootstrapping validation. Results: A total of 66.13% (123/186) of patients were decannulated. Predictors included in the prediction nomogram were age, gender, subtype of neurological injury, Glasgow Coma Scale (GCS) score, swallowing function, duration of tracheotomy, procalcitonin (PCT) level, white blood cell (WBC) count, and serum albumin (ALB) level. The predictive model showed good discrimination, with a C-index of 0.755 (95% confidence interval: 0.68–0.83). Internal validation also confirmed a satisfactory C-index of 0.690. The DCA indicated that the nomogram added substantial value in predicting decannulation risk for patients with threshold probabilities falling between >21% and <98% compared to the existing scheme. Conclusions: This predictive model serves as a valuable instrument for clinicians to quantitatively assess the probability of decannulation in patients with neurological injury, aiding in informed decision-making and patient management. [ABSTRACT FROM AUTHOR]

Introduction: Open traumatic brain injury (OTBI) is associated with high mortality and morbidity; however, the classification of these injuries and the determination of patient prognosis remain uncertain, hindering the selection of optimal treatment strategies. This study aimed to develop and validate a novel OTBI classification system and a prognostic model for poor prognosis. Methods: This retrospective study included patients with isolated OTBI who received treatment at three large medical centers in China between January 2020 and June 2022 as the training set. Data on patients with OTBI collected at the Fuzong Clinical Medical College of Fujian Medical University between July 2022 and June 2023 were used as the validation set. Clinical parameters, including clinical data at admission, radiological and laboratory findings, details of surgical methods, and prognosis were collected. Prognosis was assessed through a dichotomized Glasgow Outcome Scale (GOS). A novel OTBI classification was proposed, categorizing patients based on a combination of intracranial hematoma and midline shift observed on imaging, and logistic regression analyses were performed to identify risk factors associated with poor prognosis and to investigate the association between the novel OTBI classification and prognosis. Finally, a nomogram suitable for clinical application was established and validated. Results: Multivariable logistic regression analysis identified OTBI classification type C (p < 0.001), a Glasgow Coma Scale score (GCS) ≤ 8 (p < 0.001), subarachnoid hemorrhage (SAH) (p = 0.004), subdural hematoma (SDH) (p = 0.011), and coagulopathy (p = 0.020) as independent risk factors for poor prognosis. The addition of the OTBI classification to a model containing all the other identified prognostic factors improved the predictive ability of the model (Z = 1.983; p = 0.047). In the validation set, the model achieved an area under the curve (AUC) of 0.917 [95% confidence interval (CI) = 0.864–0.970]. The calibration curve closely approximated the ideal curve, indicating strong predictive performance of the model. Conclusions: The implementation of our proposed OTBI classification system and its use alongside the other prognostic factors identified here may improve the prediction of patient prognosis and aid in the selection of the most suitable treatment strategies. [ABSTRACT FROM AUTHOR]

The editorial discusses the global public health issue of ophthalmic trauma, which results in significant visual loss and blindness, particularly in lower- and middle-income countries. The document highlights the socioeconomic burden, consequences, and risk factors associated with ocular and adnexal injuries, emphasizing the importance of prevention and comprehensive care. It also introduces various classification systems for grading, scoring, and prognostication of ophthalmic trauma, aiming to improve patient outcomes and rehabilitation. The author, Dr. Gangadhara Sundar, advocates for universal standards, education, advocacy, and collaboration among ophthalmologists to address the challenges posed by ophthalmic trauma effectively. [Extracted from the article]

Purpose/Objective: The aim of this article is to evaluate the measurement invariance (MI) of the Patient Health Questionnaire-9 (PHQ-9) in a sample of individuals during the first 2 years after traumatic brain injury (TBI). MI was examined among racial/ethnic groups and over time to determine the utility of the PHQ-9 across these dimensions. Research Method/Design: In total, N = 3,227 (20% of the total sample) at 1 year and N = 3,153 (19% of the total sample) at 2 years were included for cross-sectional analyses. For the longitudinal analyses, participants with the PHQ-9 at both time points (N = 2,234; 14% of the total study sample) were included. Results: Results were that the PHQ-9 is fully invariant and maintains its unidimensional factorial structure across racial/ethnic groups during the first 2 years after TBI, suggesting the scale measures the same construct equally well for participants from each group. Conclusion/Implications: Based on these results, clinicians should feel confident using the PHQ-9 with diverse TBI patient populations, and researchers can reliably and validly employ it in TBI studies across racial/ethnic groups in the United States. Given the high rates of depression among individuals after TBI and its negative impact on their lives, this instrument will continue to be a key tool to measure the prognosis and success of rehabilitation programs. Impact and Implications: The Patient Health Questionnaire-9 (PHQ-9) is one of the most common measures of depressive symptomology in individuals with traumatic brain injury (TBI), although its measurement invariance (MI) has not been evaluated in this population over time or across racial/ethnic groups. This study found that the PHQ-9 is fully invariant and maintains its unidimensional factorial structure across racial/ethnic groups during the first 2 years after TBI, suggesting the scale measures the same construct equally well for participants from each group. Clinicians should feel confident using the PHQ-9 with diverse TBI patient populations, and researchers can reliably and validly employ it in TBI studies across racial/ethnic groups in the United States. [ABSTRACT FROM AUTHOR]

Background: Anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor encephalitis (Anti-AMPAR-E) is a very rare subtype of autoimmune encephalitis, typically presenting with memory decline, seizures, and changes in psychosis and behavior. Anti-AMPAR-E is often associated with the presence of neoplasms and generally has a poor prognosis. Currently, cases of severe anti-AMPAR-E, particularly those accompanied by hyperammonemia, are exceedingly rare. Case presentation: A 66-year-old man was admitted to the hospital, complaining of deterioration in memory and confusion for at least 10 days and worsening for 3 days. The patient's condition rapidly progressed to coma, which persisted for 2 months, manifesting as a fulminant course. At that time, his Glasgow Coma Scale (GCS) score was 6, and AMPAR antibodies were strongly positive in both serum and cerebrospinal fluid (CSF). Additionally, his serum ammonia levels consistently exceeded reference values during his hospital stay. Consequently, he was diagnosed with severe anti-AMPAR-E with prolonged hyperammonemia and treated with intravenous methylprednisolone pulse (IVMP) therapy, intravenous immunoglobulin (IVIG), and rituximab therapy until he regained consciousness. However, 10 months after discharge, he was readmitted to the hospital due to seizures and subsequently diagnosed with lung cancer. The patient eventually passed away at home. Conclusions: Even if the short-term prognosis is good, regular tumor-related screening is essential for patients with severe anti-AMPAR-E to detect potential tumors early and improve long-term outcomes. Moreover, it is necessary to perform repeated ammonia level assessments and to adequately treat hyperammonemia. [ABSTRACT FROM AUTHOR]

Background: Leukocytes play an important role in inflammatory response after a traumatic brain injury (TBI). We designed this study to identify TBI phenotypes by clustering blood levels of various leukocytes. Methods: TBI patients from the Medical Information Mart for Intensive Care-III (MIMIC-III) database were included. Blood levels of neutrophils, lymphocytes, monocytes, basophils, and eosinophils were collected by analyzing the first blood sample within 24 h since admission. Overall, TBI patients were divided into clusters following the K-means clustering method using blood levels of five types of leukocytes. The correlation between identified clusters and mortality was tested by univariate and multivariate logistic regression analyses. The Kaplan–Meier method was used to verify the survival difference between identified TBI clusters. Results: A total of 172 (cluster 1), 791 (cluster 2), and 636 (cluster 3) TBI patients were divided into three clusters with the following percentages, 10.8%, 49.5%, and 39.8%, respectively. Cluster 1 had the lowest Glasgow Coma Scale (GCS) and the highest Injury Severity Score (ISS) while cluster 2 had the highest GCS and the lowest ISS. The mortality rates of the three clusters were 25.6%, 13.3%, and 18.1%, respectively. The multivariate logistic regression indicated that cluster 1 had a higher mortality risk (OR = 2.211, p = 0.003) than cluster 2, while cluster 3 did not show a significantly higher mortality risk than cluster 2 (OR = 1.285, p = 0.163). Kapan–Meier analysis showed that cluster 1 had shorter survival than cluster 2 and cluster 3. Conclusion: Three TBI phenotypes with different inflammatory statuses and mortality rates were identified based on blood levels of leukocytes. This classification is helpful for physicians to evaluate the prognosis of TBI patients. [ABSTRACT FROM AUTHOR]

Objective: Acute cerebral infarction is a common complication of intracranial tuberculosis (TB), causing irreversible damage to brain tissue and significantly affecting patient prognosis. This study aims to explore the risk factors associated with acute cerebral infarction in patients with intracranial tuberculosis. Methods: We retrospectively analyzed data from eligible intracranial TB patients treated at our hospital between January 2020 and March 2023. Based on MRI findings, patients were categorized into a cerebral infarction group and a non-infarction group. Clinical data, cerebrospinal fluid (CSF) examinations, and imaging features (such as hydrocephalus, cerebral arteritis, and meningeal thickening) were compared between the two groups. Binary logistic regression analysis was used to identify risk factors for acute cerebral infarction in patients with intracranial TB. Results: A total of 102 patients were included, with 24 in the cerebral infarction group and 78 in the non-infarction group. Male patients accounted for 87.5% in the infarction group and 58.3% in the non-infarction group. Patients with a Glasgow Coma Scale (GCS) score of 3–10 accounted for 45.8% in the infarction group compared to 15.4% in the non-infarction group. The incidence of hydrocephalus, cerebral arteritis, and meningeal thickening was significantly higher in the infarction group (37.5, 54.2, and 79.2%, respectively) compared to the non-infarction group (6.4, 6.4, and 43.6%, respectively) (p < 0.05). The parenchymal type of intracranial TB was less frequent in the infarction group (20.8%) than in the non-infarction group (56.4%), while the mixed type was more frequent in the infarction group (62.5%) compared to the non-infarction group (26.9%) (p < 0.05). Patients with meningeal thickening involving the cisterns and basal cisterns had a higher risk of cerebral infarction (p < 0.05). Multivariate binary logistic regression analysis revealed that male sex (OR = 13.56; 95% CI 1.25–38.30) and cerebral arteritis (OR = 19.32; 95% CI 0.94–37.64) were independent risk factors for cerebral infarction in intracranial TB patients. Conclusion: Male sex and the presence of cerebral arteritis are independent risk factors for acute cerebral infarction in patients with intracranial tuberculosis. [ABSTRACT FROM AUTHOR]

Objective: Intracerebral hemorrhage (ICH) is a common cerebrovascular disease characterized by high mortality and disability rates. Neuritin, significantly expressed in injured brain tissues, is implicated in the molecular mechanisms underlying acute brain injury. We aimed to explore the prognostic and predictive value of serum neuritin in ICH. Methods: In this prospective cohort study, serum neuritin levels were measured at admission in 202 patients, on post-ICH days 1, 3, 5, 7, and 10 in 54 of these patients, and at the time of enrollment in 100 healthy controls. The Glasgow Coma Scale (GCS) and hematoma volume were used as severity indicators. A poor prognosis was defined as a modified Rankin Scale (mRS) score of 3–6 at 90 days after ICH. END was defined as a decrease of ≥2 points in the GCS score within 24 h of admission. A multivariate logistic regression model was used to assess the independent relationships between serum neuritin levels, END, and poor prognosis. Results: Serum neuritin levels were significantly increased at the time of patient admission, continued to rise on day 1, peaked on day 3, and then gradually diminished from day 5 until day 10. The levels remained substantially higher in patients compared to healthy controls throughout the 10-day period. The levels were independently related to GCS scores and hematoma volume. In subgroup analyses, the levels showed a linear relationship with the likelihood of experiencing END and poor prognosis at the 90-day mark after ICH. Additionally, the levels were independently associated with END, ordinal mRS scores, and poor prognosis. Under receiver operating characteristic (ROC) curve analysis, serum neuritin levels effectively predicted both END and poor prognosis. Two models incorporating GCS, hematoma volume, and serum neuritin levels were developed and represented using two nomograms separately to estimate END risks and poor prognosis. These models demonstrated clinical efficiency, stability, and validity in ROC, calibration, and decision curve analyses. Internal validation of the models was conducted using a randomly extracted subset of 101 patients. Furthermore, two specific weighted scoring systems were developed to optimize clinical prediction of poor prognosis and END after ICH. Conclusion: Elevated serum neuritin levels are strongly associated with disease severity, END, and 90-day poor neurological outcomes following ICH, establishing serum neuritin as a potential prognostic biomarker for ICH. [ABSTRACT FROM AUTHOR]

Background: Disorders of consciousness (DoC) in non-traumatic ICU-patients are often treated with amantadine, although evidence supporting its efficacy is limited. Methods: This retrospective study analyzed non-traumatic DoC-patients treated with amantadine between January 2016 and June 2021. Data on patient demographics, clinical characteristics, treatment specifications, and outcomes were extracted from electronic medical records. Patients were classified as responders if their Glasgow Coma Scale (GCS) improved by ≥3 points within 5 days. Good outcome was defined as a modified Rankin Scale (mRS) of 0–2. Machine learning techniques were used to predict response to treatment. Results: Of 442 patients (mean age 73.2 ± 10.7 years, 41.0% female), 267 (60.4%) were responders. Baseline characteristics were similar between groups, except that responders had lower baseline GCS (7 [IQR 5–9] vs. 8 [IQR 5–10], p = 0.030), better premorbid mRS (2 [IQR 1–2] vs. 2 [IQR 1–3], p < 0.001) and fewer pathological cerebral imaging findings (45.7% vs. 61.1%, OR 0.56, 95% CI: 0.36–0.86, p = 0.008). Responders exhibited significantly lower mortality at discharge (13.5% vs. 27.4%, OR 0.41, 95% CI: 0.25–0.67, p < 0.001) and follow-up (16.9% vs. 32.0%, OR 0.43, 95% CI: 0.24–0.77, p = 0.002). Good outcomes were more frequent in responders at follow-up (4.9% vs. 1.1%, OR 6.14, 95% CI: 1.35–28.01, p = 0.004). In multivariate analysis higher premorbid mRS (OR 0.719, 95% CI 0.590–0.875, p < 0.001), pathological imaging results (OR 0.546, 95% CI 0.342–0.871, p = 0.011), and experiencing cardiac arrest (OR 0.542, 95% CI 0.307–0.954, p = 0.034) were associated with lower odds of response. Machine learning identified key predictors of response, with the Stacking Classifier achieving the highest performance (accuracy 64.5%, precision 66.6%, recall 64.5%, F1 score 61.3%). Conclusion: This study supports the potential benefits of intravenous amantadine in non-traumatic DOC-patients. Higher premorbid mRS, and pathological cerebral imaging were key predictors of non-response, offering potential avenues for patient selection and treatment customization. Findings from this study informed the design of our ongoing prospective study, which aims to further evaluate the long-term efficacy of amantadine. [ABSTRACT FROM AUTHOR]

Background: The effect of targeted temperature management (TTM) combined with decompressive craniectomy (DC) on poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has not been previously addressed in the literature. This study aims to investigate the therapeutic outcomes of the combination of TTM and DC in patients with poor-grade aSAH. Methods: This study represents a secondary analysis of the Multicenter Clinical Research on Targeted Temperature Management of Poor-grade Aneurysmal Subarachnoid Hemorrhage (High-Quality TTM for PaSAH), a multicenter prospective study conducted in China. The High-Quality TTM for PaSAH study enrolled patients aged 18 years and older who were transported to the intensive care units (ICU) of three tertiary care hospitals in China between April 2022 and April 2024. Among these patients, those who underwent DC were included in the present analysis. Patients were divided into two groups: the DC-alone group and the TTM combined with the DC (TTM-DC) group. The DC-alone group maintained normothermia. The TTM-DC group used automated devices with a temperature feedback system (TFS). TTM was initiated with core temperatures between 36°C-37°C immediately after diagnosing poor-grade aSAH, and concurrent emergency aneurysm repair. This was followed by a rapid induction to 34°C-35°C, maintained for a minimum of 72 h. Subsequently, a slow rewarming process reached 36°C-37°C, which was maintained for at least 48 h. Primary outcomes were evaluated using the Modified Rankin Scale (mRS) score at 3 months. Secondary outcomes included the Glasgow Coma Scale (GCS) at discharge, ICU stay duration, length of hospitalization, proportion of external ventricular drainage (EVD), mechanical ventilation time, tracheostomy, midline shift, hydrocephalus, and delayed cerebral ischemia (DCI) on the 7th day. Safety outcomes comprised the incidence of pneumonia, myocardial infarction, stress hyperglycemia, thrombocytopenia, acute liver injury, hypokalemia, hypoproteinemia, and death at 90 days. Results: Of the 141 patients enrolled in the High-Quality TTM for PaSAH study, 43 (25 in the TTM-DC group and 18 in the DC-alone group) were eligible for this secondary analysis. The TTM-DC group had a higher proportion of favorable outcomes (mRS 0–3: 56% vs. 22%, aOR 5.97, 95%CI 0.96–52.2, p = 0.071). After propensity score matching, the TTM combined with DC improved favorable outcome at 3 months (mRS 0–3: 61% vs. 22%, OR 5.50, 95%CI 1.36–26.3, p = 0.022). In addition, the TTM-DC group increased GCS score at discharge compared with the DC-alone group (9 vs. 3, β 2.58, 95%CI 0.32–4.84, p = 0.032). The incidence of safety outcomes was not increased in the TTM-DC group. Conclusion: TTM combined with DC can improve clinical conditions at discharge and ameliorate short-term neurological outcomes in poor-grade aSAH patients. TTM should be considered one of the main treatments for poor-grade aSAH patients who underwent DC. [ABSTRACT FROM AUTHOR]

Objective: Neurological deterioration after mild traumatic brain injury (TBI) has been recognized as a poor prognostic factor. Early detection of neurological deterioration would allow appropriate monitoring and timely therapeutic interventions to improve patient outcomes. In this study, we developed a machine learning model to predict the occurrence of neurological deterioration after mild TBI using information obtained on admission. Methods: This was a retrospective cohort study of data from the Think FAST registry, a multicenter prospective observational study of elderly TBI patients in Japan. Patients with an admission Glasgow Coma Scale (GCS) score of 12 or below or who underwent surgical treatment immediately upon admission were excluded. Neurological deterioration was defined as a decrease of 2 or more points from a GCS score of 13 or more within 24 h of hospital admission. The model predictive accuracy was judged with the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC), and the Youden index was used to determine the cutoff value. Results: A total of 421 of 721 patients registered in the Think FAST registry between December 2019 and May 2021 were included in our study, among whom 25 demonstrated neurological deterioration. Among several machine learning algorithms, eXtreme Gradient Boosting (XGBoost) demonstrated the highest predictive accuracy in cross-validation, with an AUROC of 0.81 (±0.07) and an AUPRC of 0.33 (±0.08). Through SHapley Additive exPlanations (SHAP) analysis, five important features (D-dimer, fibrinogen, acute subdural hematoma thickness, cerebral contusion size, and systolic blood pressure) were identified and used to construct a better performing model (cross-validation AUROC of 0.84 and AUPRC of 0.34; testing data AUROC of 0.77 and AUPRC of 0.19). At the cutoff value from the Youden index, the model showed a sensitivity, specificity, and positive predictive value of 60, 96, and 38%, respectively. When neurosurgeons attempted to predict neurological deterioration using the same testing data, their values were 20, 94, and 19%, respectively. Conclusion: In this study, our predictive model showed an acceptable performance in detecting neurological deterioration after mild TBI. Further validation through prospective studies is necessary to confirm these results. [ABSTRACT FROM AUTHOR]

Objective: Fluctuations in sodium levels (SLs) may increase mortality, severity, and prolonged length of stay (LOS) in critically ill patients. We aim to study the effect of SL on various clinical outcomes in patients with severe traumatic brain injury (TBI). Methods: This is a single-center, retrospective study of patients with severe TBI from 1 January 2020 to 31 December 2023, inclusive. Patients were identified using Abbreviated Injury Severity (AIS) scores and International Classification of Diseases (ICD) injury descriptions. Result: Variations in hospital (H) admission SLs were statistically significant across four age ranges (pediatric, young adult, older adults, and elderly). Intensive care unit (ICU) admission, H discharge, and death also showed significance. A statistical difference was noted in ICU discharge levels while comparing blunt versus penetrating injury. We found statistically significant differences in SLs at H admission, ICU admission, and ICU discharge when compared to the Injury Severity Score (ISS) and the Glasgow Coma Scale (GCS) at admission. A linear regression analysis revealed a statistically significant positive correlation between ICU admission SLs and ISS. We discovered statistically significant differences when comparing ICU admission levels to H LOS, ventilator days, and mortality. Conclusions: SL upon ICU admission is correlated with ISS, GCS, and mortality rates. The elevated admission SL was linked to adverse hospital outcomes, including prolonged LOS at the H, ICU, and mechanical ventilation. Moreover, variability in serum SLs is independently associated with mortality throughout the hospital stay, irrespective of the absolute serum sodium concentration. [ABSTRACT FROM AUTHOR]

Objective: This study aims to evaluate the clinical significance of ultrasound-based measurement of optic nerve sheath diameter (ONSD) in predicting intracerebral hemorrhage (ICH) complicated by cerebral-cardiac syndrome (CCS). Methods: Patients with ICH and who were treated in the intensive care unit (ICU) at Shijiazhuang People's Hospital between October 2021 and November 2022 were included in this study. Participants were divided into two groups: those with CCS and those without. Various clinical parameters, including sex, age, electrocardiogram (ECG) findings, myocardial markers, B-type natriuretic peptide (BNP) levels, Glasgow Coma Scale (GCS) score, ONSD, hematoma volume, and midline shift, were assessed. A binary logistic regression model and receiver operating characteristic (ROC) curve analysis were employed to determine the predictive value of each risk factor for ICH complicated by CCS. Results: ONSD measurements differed significantly between males and females, with males exhibiting larger ONSD values. Additionally, significant differences were observed in ONSD, hematoma volume, midline shift, and GCS scores between the CCS and non-CCS groups. A direct correlation was identified between ONSD and both hematoma volume and midline shift. Multiple regression analysis demonstrated that ONSD, hematoma volume, and GCS score are independent risk factors for predicting ICH complicated by CCS. ROC curve analysis for ONSD in predicting ICH with CCS revealed an area under the curve (AUC) of 0.80, with an optimal cutoff value of 5.88 cm, yielding a sensitivity of 83% and a specificity of 79%. When ONSD, hematoma volume, and GCS score were combined, the predictive accuracy improved, with an AUC of 0.880. Conclusion: Males tend to have larger ONSD measurements compared to females. Ultrasound is a valuable tool for measuring ONSD, comparable to computed tomography, and is useful in detecting intracranial hypertension and mass effect. ONSD, hematoma volume, and GCS score are independent predictors of ICH complicated by CCS, and their combined use enhances predictive accuracy. [ABSTRACT FROM AUTHOR]

Background: Numerous noncontrast computed tomography (NCCT) markers have been reported and validated as effective predictors of hematoma expansion (HE). Our objective was to develop and validate a score based on NCCT markers and clinical characteristics to predict risk of HE in acute intracerebral hemorrhage (ICH) patients. Methods: We prospectively collected spontaneous ICH patients at the First Affiliated Hospital of Chongqing Medical University to form the development cohort (n = 395) and at the Third Affiliated Hospital of Chongqing Medical University to establish the validation cohort (n = 139). We adopted a revised HE definition, incorporating the standard definition of HE (> 6 mL or > 33%) and intraventricular hemorrhage (IVH) expansion (any new IVH or IVH expansion ≥ 1 ml). The predictive score was formulated based on the parameter estimates derived from the multivariable logistic regression analysis. Result: The Glasgow Coma Scale, island sign, ventricular hemorrhage and time elapsed from onset to NCCT scan (GIVE) score was created as a total of individual points (0–6) based on Glasgow Coma Scale (2 points for ≤ 11), island sign (1 point for presence), ventricular hemorrhage (1 point for presence), and time elapsed from onset to NCCT scan (2 points for ≤ 2.5 h). The c statistic was 0.72(95% confidence interval [CI], 0.66–0.78) and 0.73(95% CI, 0.63–0.82) in the development and validation cohorts, respectively. Conclusion: A six-point scoring algorithm has been developed and validated to assess the risk of HE in patients with ICH. This scoring system facilitates the rapid and accurate identification of patients at increased risk for HE. [ABSTRACT FROM AUTHOR]

Patients with cerebral venous thrombosis (CVT) may experience poor response to anticoagulant therapy and delayed surgical treatment may lead to clinical deterioration. However, the factors contributing to clinical deterioration remain poorly understood. Patients with CVT from three centers between January 2017 and October 2023 were included and grouped as the development cohort and validation cohort. The danger triangle was defined as the posterior two-thirds of the superior sagittal sinus, confluence of sinuses, straight sinus, and deep venous system. The primary endpoint was clinical deterioration, characterized by new or progressive bleeding or infarctions or worsened neurological conditions post-admission. Using the results of multivariable logistic analysis, the Cerebral venOus thrombosis DEterioration (CODE) score was developed within the development cohort and validated within the validation cohort. The score' performance in predicting clinical deterioration was evaluated using the area under the receiver operating characteristic curve (AUC). The development cohort included 194 CVT patients (101 males, and the median age was 38 years). clinical deterioration occurred in 45 (23.2%) patients. Multivariate logistic analysis defined D-dimer > 1.5 mg/L, Glasgow coma scale ≤ 8, intracerebral hemorrhage, danger triangle as risk factors of clinical deterioration. The CODE score integrating these factors performed well to predict patients suffering from clinical deterioration within the validation cohort (n = 79, 11 deteriorations) with an AUC of 0.83 (95%CI, 0.71–0.96) and an accuracy of 88.6% (95%CI, 81.4–95.8%). CODE score could evaluate the risk of clinical deterioration in CVT patients and may serve as a useful tool for decision-making for CVT. Clinical Deterioration in Cerebral Venous Thrombosis: A Predictive Study (CVT deterioration cohort), ClinicalTrials.gov number: NCT06266585, link: https://classic.clinicaltrials.gov/ct2/show/NCT06266585) [ABSTRACT FROM AUTHOR]

Objective: Increased intracranial pressure (ICP) can worsen the clinical condition of traumatic brain injury (TBI) patients. One non-invasive and easily bedside-performed technique to estimate ICP is ultrasonographic measurement of optic nerve sheath diameter (ONSD). This study aimed to analyze ONSD and correlate it with ICP values obtained by intraparenchymal monitoring to establish the ONSD threshold value for elevated ICP and reference range of ONSD in severe TBI patients. Methods: Forty severe TBI patients (Glasgow Coma Scale Score ≤ 8) were included. Ultrasonographic measurement of ONSD was performed and compared with intraparenchymal ICP monitoring to assess their association and determine the ONSD threshold value. Exclusion criteria included individuals under eighteen years old, penetrating TBI, or direct ocular trauma. Results: Fifty-three ONSD measurements were conducted in all patients. The mean ONSD value in the group with intracranial pressure < 20 mmHg was 5.4 mm ± 1.0, while in the group with intracranial pressure ≥ 20 mmHg, it was 6.4 mm ± 0.7 (p = 0.0026). A positive and statistically significant correlation, albeit weak (r = 0.33), was observed between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring. The statistical analysis of the ROC curve identified the best cut-off as 6.18 mm, with 77.8% sensitivity and 81.8% specificity. Conclusion: Our results reveal a positive, albeit weak, correlation between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring, with an ONSD threshold value of 6.18 mm. Achieving only 77.8% sensitivity and considering the substantial variability between ONSD measurements (standard deviation at 1.0) might limit the reliability of ICP assessment based solely on ONSD measurements. [ABSTRACT FROM AUTHOR]

Background: Sepsis-associated encephalopathy (SAE) may be worsened by early systemic insults. We aimed to investigate the association of early systemic insults with outcomes of critically ill patients with severe SAE. Methods: We performed a retrospective analysis using data from the French OUTCOMEREA prospective multicenter database. We included patients hospitalized in intensive care unit (ICU) for at least 48 h with severe SAE (defined by a score on the Glasgow Coma Scale (GCS) ≤ 13 and severe sepsis or septic shock (SEPSIS 2.0 criteria)) requiring invasive ventilation and who had no primary brain injury. We analyzed early systemic insults (abnormal glycemia (< 3 mmol/L or ≥ 11 mmol/L), hypotension (diastolic blood pressure ≤ 50 mmHg), temperature abnormalities (< 36 °C or ≥ 38.3 °C), anemia (hematocrit < 21%), dysnatremia (< 135 mmol/L or ≥ 145 mmol/L), oxygenation abnormalities (PaO2 < 60 or > 200 mmHg), carbon dioxide abnormalities (< 35 mmHg or ≥ 45 mmHg), and the impact of their correction at day 3 on day-28 mortality and awakening, defined as a recovery of GCS > 13. Results: We included 995 patients with severe SAE, of whom 883 (89%) exhibited at least one early systemic insult that persisted through day 3. Compared to non-survivors, survivors had significantly less early systemic insults (hypoglycemia, hypotension, hypothermia, and anemia) within the first 48 h of ICU admission. The absence of correction of the following systemic insults at day 3 was independently associated with mortality: blood pressure (adjusted hazard ratio (aHR) = 1.77, 95% confidence interval (CI) 1.34–2.34), oxygenation (aHR = 1.78, 95% CI 1.20–2.63), temperature (aHR = 1.46, 95% CI 1.12–1.91) and glycemia (aHR = 1.41, 95% CI 1.10–1.80). Persistent abnormal blood pressure, temperature and glycemia at day 3 were associated with decreased chances of awakening. Conclusions: In patients with severe SAE, the persistence of systemic insults within the first three days of ICU admission is associated with increased mortality and decreased chances of awakening. Key points: Question: Sepsis-associated encephalopathy (SAE) may be worsened by early systemic insults. We aimed to investigate the association of early systemic insults with outcomes of critically ill patients with severe SAE. Findings: In patients with a severe sepsis-associated encephalopathy, early systemic insults were frequent and failure to correct them (especially blood pressure, oxygenation, temperature and glycemia) within the first 3 days of ICU admission was associated with increased mortality and decreased chances of awakening at day 28. Meaning: Early correction of systemic insults in patients with SAE may be one of the targets for better outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Spinal neurotrauma (sNT), including spinal cord injury (SCI), poses a significant public health challenge with a variety of downstream sequelae. During the COVID-19 pandemic, Elmhurst, Queens in New York City (NYC) was an initial hotspot dubbed the "epicenter of the epicenter" of the crisis, necessitating large-scale adjustments in healthcare resource allocation. This study aimed to analyze the impact of the COVID-19 pandemic on sNT incidence, severity, and outcomes in this geographical area in light of these stressors. Methods: sNT admissions to NYC Health + Hospitals/Elmhurst, a Level 1 trauma center, during the first 26 weeks of 2019, 2020, and 2021 were retrospectively analyzed. Data were grouped into three periods: Group 1, the pre-pandemic baseline (1/1/19–6/30/19 and 1/1/20–2/29/20); Group 2, the first COVID-19 wave in NYC (3/1/20–6/30/20); and Group 3, which included the beginning of the second COVID-19 wave in NYC (1/1/21–6/30/21). Univariate analyses were conducted to examine potential associations between variables with clinically significant variables (p < 0.05) included in binary logistic regression analysis. Results: Analysis of 232 sNT patients (median age 62 [40, 80] years; mean admissions/week 2.9 ± 1.8) demonstrated no statistically significant differences in age (H = 0.46; p = 0.25), sex (χ2 = 2.22; p = 0.06), or ethnicity (χ2 = 17.10; p = 0.16) across groups. Average weekly admission rates for Groups 1–3 were 2.9 ± 1.6, 2.4 ± 1.8, and 3.3 ± 1.9, respectively (p = 0.24). Uninsured patients decreased from 5.7 to 0%, while Medicaid coverage increased from 25.5 to 35.9% (p = 0.003) during the pandemic. Binary logistic regression dichotomized by discharge outcome demonstrated that each additional year of age decreased the odds of a good outcome by approximately 6% (OR = 0.94; 95% CI 0.92, 0.96; p < 0.001). Admission injury severity score (ISS) (OR = 0.91; 95% CI 0.864, 0.962; p < 0.001) and GCS score (OR = 1.20; 95% CI 1.07, 1.34; p < 0.001) were both significantly associated with discharge outcome. While it did not reach statistical significance, there was a trend towards poorer outcomes for those with public health insurance (Medicaid/Medicare) coverage (OR = 0.77; 95% CI 0.59, 1.02; p = 0.07). However, group designation, patient sex, COVID-19 status, and need for neurosurgical intervention were not associated with outcome (p > 0.05). Conclusion: Despite the immense strain on healthcare resources in Elmhurst, Queens during the COVID-19 pandemic, neurosurgical intervention and outcomes for sNT patients did not appear to be significantly affected. While discharge outcomes were primarily influenced by injury severity, there was a statistical trend towards poorer outcomes in those with public health insurance. [ABSTRACT FROM AUTHOR]

Background: Although surviving sepsis campaign (SSC) guidelines are the standard for sepsis and septic shock management, outcomes are still unfavourable. Given that perfusion pressure in sepsis is heterogeneous among patients and within the same patient; we evaluated the impact of individualized hemodynamic management via the transcranial Doppler (TCD) pulsatility index (PI) on mortality and outcomes among sepsis-induced encephalopathy (SIE) patients. Methods: In this prospective, single-center randomized controlled study, 112 patients with SIE were randomly assigned. Mean arterial pressure (MAP) and norepinephrine (NE) titration were guided via the TCD pulsatility index to achieve a pulsatility index < 1.3 in Group I, whereas the SSC guidelines were used in Group II to achieve a MAP ≥ 65 mmHg. The primary outcome was intensive care unit (ICU) mortality and the secondary outcomes were; MAP that was measured invasively and values were recorded; daily in the morning, at the end of NE infusion and the end of ICU stay, duration of ICU stay, cerebral perfusion pressure (CPP), sequential organ failure assessment (SOFA) score, norepinephrine titration and Glasgow coma scale (GCS) score at discharge. Results: ICU mortality percentage wasn't significantly different between the two groups (p value 0.174). There was a significant increase in the MAP at the end of norepinephrine infusion (mean value of 69.54 ± 10.42 and p value 0.002) and in the GCS score at ICU discharge (Median value of 15 and p value 0.014) in the TCD group, and episodes of cerebral hypoperfusion with CPP < 60 mmHg, were significantly lower in the TCD group (median value of 2 and p value 0.018). Heart rate values, number of episodes of tachycardia or bradycardia, Total norepinephrine dosing, duration of norepinephrine infusion, SOFA score, serum lactate levels, and ICU stay duration weren't significantly different between the two groups. Conclusions: Individualizing hemodynamic management via the TCD pulsatility index in SIE patients was not associated with significant mortality reduction. However, it reduces episodes of cerebral hypoperfusion and improves GCS outcome but doesn't significantly affect heart rate values, SOFA score, serum lactate level, length of ICU stay, total NE dosing, and duration of NE infusion. Trial registration: The clinical trial was registered on clinucaltrials.gov under the identifier NCT05842616 https://clinicaltrials.gov/study/NCT05842616?cond=NCT05842616&rank=1 on 6-May-2023 before the enrolment of the first patient. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim Methods Results Conclusions This study aimed to compare the prognostic performance of the risk models for patients with hepatocellular carcinoma (HCC) receiving atezolizumab and bevacizumab (Atez/Bev) as first‐line treatment.Among 449 patients included in this retrospective multicenter study, we compared the prognostic performance of 13 risk models for the 12‐month and 18‐month survival status using area under the curve (AUC), net reclassification improvement (NRI), and relative integrated discrimination improvement (IDI) analysis. We also constructed a calibration plot to assess the fitness of each model.Regarding the analysis of the 12‐month survival status, none of the risk models demonstrated AUC values higher than the modified albumin‐bilirubin (mALBI) grade. In the NRI analysis, only the IMmunotherapy with AFP, BCLC staging, mALBI, and DCP evaluation (IMABALI‐De score) exhibited a statistically significant improvement compared with the mALBI grade (p = 0.009). While the modified albumin‐bilirubin grade (mALF) score and prognostic nutritional index (PNI) did not exhibit significant differences compared to the mALBI grade (p = 0.3 and 0.2, respectively), the remaining risk models were inferior to the mALBI grade. In the relative IDI analysis, none of the risk models showed a significant improvement compared with the mALBI grade. The calibration plot of the PNI was unsatisfactory. The results for the 18‐month survival status were consistent with those for the 12‐month survival status. A time‐dependent ROC analysis demonstrated that both the mALBI grade and the mALBI‐based model showed consistent performance over time.The mALBI grade, as well as the IMABALI‐De and mALF scores (both of which are risk models based on mALBI grade), exhibited reliable performance in predicting the prognosis of patients with HCC. [ABSTRACT FROM AUTHOR]

BACKGROUND: Prehospital medication is a reality, and the role of these therapies must be explored to assess their validity, especially for acute respiratory diseases, which are usually associated with increased morbidity. The aim of this study was to examine the association of prehospital medication use with mortality in patients with acute respiratory disease. METHODS: A prospective, multicenter, emergency medical service (EMS) delivery cohort study was carried out in adults with unselected respiratory diseases managed by EMS who were transferred to the emergency department. From January 1, 2019, to October 31, 2023, six advanced life support units, thirty-eight basic life support units, and four hospitals in Spain participated in the study. Demographic data, vital signs, use of mechanical ventilation, prehospital respiratory diagnosis, and prehospital medication were collected. The primary outcome was 30-day in-hospital mortality. RESULTS: A total of 961 patients were included, with a mortality rate of 17.5% (168 patients). Age, an increasing number of comorbidities, the use of invasive mechanical ventilation (IMV), the use of major analgesics, hypnotics, and bicarbonate were risk factors. In contrast, elevated systolic blood pressure and Glasgow Coma Scale scores were found to be protective factors against mortality. The predictive capacity of the model reached an area under the curve (AUC) of 0.857 (95% confidence interval [95% CI] 0.827-0.888). CONCLUSION: Our data revealed that IMV, major analgesics, hypnotics and bicarbonate administration were associated with elevated mortality. Adding prehospital drug therapy information to demographic variables and vital signs could improve EMS decision-making, allowing a better characterization of patients at risk of clinical worsening. [ABSTRACT FROM AUTHOR]

The article explores the association between the use of echocardiography and the prognosis of patients with cardiac arrest in the ICU. A retrospective study based on the MIMIC-IV database was conducted, involving 2,041 adult patients diagnosed with cardiac arrest. The study found that patients who underwent echocardiography had a better prognosis, with lower in-hospital mortality and higher 28-day survival rates. The results suggest that echocardiography may provide valuable information for emergency clinicians in managing cardiac arrest patients. [Extracted from the article]

Introduction: This research explored the factors influencing early neurological outcomes (ENO) in patients who had vertebrobasilar artery occlusion (VBAO) and received endovascular treatment (EVT), as well as examining the causal influence of ENO on the prognosis of VBAO patients. Methods: A retrospective review was carried out on patients from 65 Chinese stroke centers, all within 24 h of the estimated occlusion time. ENO includes early neurological improvement (ENI) and early neurological deterioration (END), defined as a decrease or an increase of at least 4 points in NIHSS score between baseline and 24 h after EVT. Death within 24 h after EVT was also considered as END. END was further divided into explained END and unexplained END (unEND). Independent predictors of ENO and the association between ENO and outcomes in patients with VBAO were determined using center-adjusted analyses. The study developed a multivariate logistic regression model to examine the comparative risk of unEND versus explained END on the clinical outcomes in VBAO patients. Results: A total of 2,257 patients were included. Glasgow Coma Scale (GCS) (OR: 1.16, 95% CI: 1.03–1.30) and successful reperfusion (OR: 1.15, 95% CI: 1.02–1.30) were associated with ENI. Baseline NIHSS (OR: 0.60, 95% CI: 0.53–0.68), successful reperfusion (OR: 0.79, 95% CI: 0.71–0.89), and puncture to reperfusion time (OR: 1.17, 95% CI: 1.03–1.33) were associated with END. When examining 3-month prognostic indexes, both END and ENI were found to be linked to the 3-month outcomes, but in opposite directions. A subgroup analysis of END suggested that unEND typically demonstrated a more favorable prognosis compared to explained END, although the prognosis remained generally unfavorable. Conclusions: ENO, whether they manifested as early improvement or deterioration, were linked to the prognosis of VBAO patients undergoing EVT. The outcomes after unEND were more favorable than those following explained END. [ABSTRACT FROM AUTHOR]

Background: One of the leading causes of death, especially in developing countries, is road traffic accident. The Glasgow coma scale, age, systolic blood pressure (GAP) scoring system is a quantitative method to predict the mortality of trauma patients. Considering the importance of preventing deaths caused by road traffic accidents, this study aims to predict the mortality of road traffic injured patients admitted to a hospital in Isfahan, Iran in 2019 using the GAP score. Materials and Methods: This is a cross-sectional study using the exiting data. The study population included all road traffic injured people transferred to Ayatollah Kashani Hospital in Isfahan by the emergency medical services (EMS) ambulances during November and December, 2019 and January, 2020 (n=2674). The medical files of 1985 injured were finally included in this research. A researcher-made checklist was used to collect data. Descriptive statistics were used to present the data and the receiver operating characteristic (ROC) curve was used to evaluate the accuracy of the scoring system. Results: Based on the GAP score, 19 people (0.98%) were in the high-risk group, 1267(63.81%) in the moderate-risk group, and 699(35.21%) were in the low-risk group. It was found that 4 people from the high-risk group (21%), 7 from the moderate-risk group (1%) and 3 from the low-risk group (1%) had died. The best cut-off point of the GAP score in predicting short-term (24-hour) road traffic mortality was 15 and with a sensitivity of 96%. Conclusion: Most of death cases in road traffic injured patients referred to Ayatollah Kashani Hospital during three months were related to the high-risk groups (GAP score: 3-10). The GAP score can predict the hospital mortality of road traffic injuries accurately and easily. [ABSTRACT FROM AUTHOR]

Objective: The increasing number of geriatric admissions to emergency departments (EDs) necessitates a separate study of geriatric admissions for forensic reasons. This study investigated the reasons for geriatric forensic cases presented to the ED, the one-month mortality rates of these cases, and the factors affecting mortality. Methods: This was a retrospective cohort study. All patients 65 years old and older who were reported as forensic cases and presented to the ED of a tertiary care hospital between June 2018 and April 2021 were included. Forensic diagnoses, type of injury, age, gender, Glasgow Coma Scale score, consultation details, outcomes, and 1-month mortality status were recorded. Results: Among the 10.128 adult forensic presentations, 396 (3.9%) geriatric patient presentations were included in the study. The most common forensic diagnoses were motor vehicle accidents (24.2%) and pedestrian accidents (24.2%). Soft tissue injuries were the most common type of injury, followed by extremity fractures. Logistic regression analysis showed that age [odds ratio (OR): 1.095; 95% confidence interval (CI): 1.027-1.169], GCS (OR: 0.655; 95% CI: 0.560-0.765), number of consultations (OR: 1.840; 95% CI: 1.312-2.581), and pedestrian accidents (OR: 0.052; 95% CI: 0.006-0.460) were significantly associated with 1-month mortality. Conclusion: Traffic accidents, including motor vehicle and pedestrian accidents, were the most common type of forensic cases in this group of patients. One-month mortality increased with age, number of consultations, low GCS, and absence of pedestrian accident. [ABSTRACT FROM AUTHOR]

Introduction: Naming difficulties are commonly reported in the acute and subacute stages of recovery of traumatic brain injury (TBI) and across severity levels. Previous studies, however, have used samples of mixed chronicity (acute and chronic) and severity (mild and severe) and then aggregated data across individuals from these distinct groups. Thus, we have little knowledge about the persistence of naming difficulties into the chronic stage of recovery in individuals with moderate--severe TBI. Purpose: To increase the rigor and reproducibility of naming research in TBI, the present study sought to determine the presence and profile of naming disruptions into the chronic stage of moderate--severe TBI using a confrontation naming assessment. Method: Thirty-three individuals aged 24-55 years in the chronic epoch of moderate--severe TBI and 33 demographically matched noninjured comparison (NC) participants completed the Philadelphia Naming Test (PNT). A mixedeffects logistic regression model predicting the probability of a correct response as a function of group was fit to the data. Results: Participants with TBI performed well on the PNT (all participants with TBI had over 90% accuracy). However, participants with TBI were statistically less likely to correctly name an item relative to demographically matched NC participants. Conclusions: This study provides empirical evidence that naming difficulties persist into the chronic epoch of moderate--severe TBI. Despite high accuracy on the PNT, nearly 60% of these individuals with TBI reported continued difficulty with word finding in their daily lives. This discrepancy leaves open the possibility that, at this stage of injury, word-finding issues may be more reliably evoked and studied when the assessment is embedded within cognitively demanding and ecologically valid contexts (i.e., discourse, conversation). Further investigation of naming deficits in chronic moderate--severe TBI using a more naturalistic assessment is warranted. [ABSTRACT FROM AUTHOR]

Background: Early post-traumatic seizures (PTSs) may occur within seven days of traumatic brain injury (TBI). Although levetiracetam is frequently used for early PTS prophylaxis, it is not recommended in current guidelines due to insufficient evidence. The objective of this study was to further evaluate levetiracetam dosing strategies for early PTS prophylaxis. Methods: A single-center retrospective cohort study was conducted utilizing the electronic medical record and a trauma database. The primary outcome was an incidence of seizure within seven days of TBI, defined as any documentation of a seizure when utilizing low-dose levetiracetam (500 mg twice daily), compared to high-dose levetiracetam (>500 mg twice daily). Subgroup analyses were performed based on mechanism of injury, trauma type, baseline Glasgow Coma Scale (GCS), injury severity score (ISS), and Augmented Renal Clearance in Trauma Intensive Care score, administration of a loading dose, and additional head injuries. Only patients who completed a full seven-day course of levetiracetam were included. Results: Of the 203 patients included, 149 patients received low-dose levetiracetam and 54 patients received high-dose. The majority of patients had a GCS < 8 (53.7%) and an ISS > 15 on presentation (92.1%). Twelve of 203 patients (5.9%) experienced a seizure within seven days of TBI, which is similar to the rate seen in previous studies. Six patients in the low-dose group (4.0%) and six patients in the high-dose group (11.1%) experienced a seizure (p = 0.059). There was no statistically significant difference in seizure rate when patients were stratified based on baseline GCS, ISS, or mechanism of injury. Conclusions: There were no statistically significant differences in seizure rates when comparing low-dose to high-dose levetiracetam. Levetiracetam 500 mg twice daily may be as effective as levetiracetam doses >500 mg twice daily for early onset post-traumatic seizure prophylaxis. [ABSTRACT FROM AUTHOR]

Children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) often receive unnecessary imaging and hospital admission, leading to avoidable burdens on patients and health systems. While most of these patients do not develop critical neurological injuries, identifying those at risk would allow for a more optimal determination of the appropriate level of initial emergency care. The Brain Injury Guidelines (BIG) were developed as a triage tool to identify adult patients with mTBI and ICI who can benefit from repeat imaging, hospital admission, or neurosurgical consultation. Here, we sought to validate BIG in children at a Level I trauma center and determine if the BIG algorithm can accurately identify which patients with mTBI/ICI have critical neurosurgical injuries. We hypothesize that the BIG can identify critical neurological injuries more accurately than the Glasgow Coma Scale (GCS) alone and that more severe injury according to BIG is associated with worse patient outcome. We retrospectively reviewed TBI admissions at a single center (2017–2023) using an institutional registry. Patients included (0–17 years) had an initial head computerized tomography scan with ICI and a GCS of 14–15. Patients were retrospectively classified into the BIG categories (BIG 1, 2, or 3). Medical records were reviewed to identify clinically important TBI (ciTBI): death, neurological deterioration, neurosurgical intervention, intubation >24 h, or hospital admission >48 h due to TBI. Repeat imaging studies obtained were evaluated for progression of injury. The incidence of clinically important TBI (ciTBI) and imaging progression were recorded and compared across BIG categories. Outcomes were evaluated using the Glasgow Outcome Score Extended (GOS-E) 6 months after injury. Univariable and chi-square tests were used to analyze comparisons. Overall, 804 subjects were included in the analysis of which 551 (68.5%) were transfers. Overall, 175 (21.8%) patients had a BIG 1, 402 (50.0%) a BIG 2, and 227 (28.2%) a BIG 3 injury. CiTBI occurred among 64 (8.0%) patients overall, and in 1 (0.6%), 4 (1.0%), and 59 (26.0%) of the BIG 1, 2, and 3 injuries (p < 0.0001). Progression on repeat imaging associated with neurological decline, neurosurgical intervention or resulting in additional evaluation was noted in 0 (0%), 2 (0.5%), and 41 (18.0%) of the BIG 1, 2, and 3 injuries (p < 0.001). Amongst 471 patients (58.6%) with available 6-month patient outcomes, 98% had a GOS-E ≥5 and no outcome difference between BIG categories was observed. Risk stratification of mild TBI using BIG allowed for reasonable identification of children who subsequently develop ciTBI, suggesting that BIG classification can aid in triage and management of patients who might benefit from neurosurgical consultation, repeat imaging, and potentially transfer to a dedicated trauma center. More severe injury according to BIG was not associated with a worse patient outcome. [ABSTRACT FROM AUTHOR]

BACKGROUND: The optimal surgical management of penetrating carotid artery injuries (PCAIs) remains controversial. This study aimed to examine the association between operative techniques for PCAI and the incidence of stroke. STUDY DESIGN: This retrospective cohort study used the American College of Surgeons TQIP (2016 to 2021) database. We included patients (age 16 years or older) with severe penetrating injuries to the common or internal carotid arteries (CCA/ICA) who underwent one of the following operative procedures: primary suture repair, ligation, and arterial reconstruction with a graft. Multivariate logistic regression analysis with cluster-adjusted-robust SEs was performed to estimate the adjusted odds ratio (AOR) for postoperative stroke stratified by the initial Glasgow Coma Scale (GCS). RESULTS: A total of 492 patients were included (329 underwent primary suture repair, 82 underwent ligation, and 81 underwent arterial reconstruction with a graft). The median age was 31 years (interquartile range 24 to 43) and median GCS on arrival was 11 (interquartile range 3 to 15). On multivariate analysis after adjusting for potential confounders, ligation of CCA/ICA was significantly associated with increased odds of stroke in patients with initial GCS =9 (AOR: 4.40, 95% CI 1.16 to 16.58, p = 0.029), whereas there was no significant association in patients with GCS <9 (AOR 0.77, 95% CI 0.28 to 2.11, p = 0.37). No significant association was identified between arterial reconstruction with a graft and stroke, irrespective of the initial GCS. CONCLUSIONS: The study findings suggest that the preoperative level of consciousness may help in planning operative strategies for PCAI. In patients with an initial GCS =9, definitive repair of the CCA/ICA, including arterial reconstruction with a graft, should be pursued instead of ligation. [ABSTRACT FROM AUTHOR]