Importance There is limited information about the effect of erythropoietin or a high transfusion threshold in traumatic brain injury (TBI). Objective To compare the effects of erythropoietin and two transfusion thresholds (7 and 10 g/dl) on neurological recovery after TBI. Design Randomized trial using a factorial design to test: i.) whether erythropoietin would fail to improve favorable outcomes by 20%, and ii.) whether a transfusion threshold of >10 g/dl would increase favorable outcomes without increasing complications. Setting Neurosurgical intensive care units of two Houston level 1 trauma centers Participants Between May 2006 and August 2012, 200 patients with closed head injury who were unable to follow commands were enrolled within 6 hours of injury; 102 patients received erythropoetin and 98 received placebo. Erythropoetin or placebo was initially dosed daily for 3 days and then weekly for 2 more weeks (n=74) and then the 24h and 48h doses were dropped for the remainder (n=126). Ninety-nine and 101 patients were assigned to the 7g/dl and 10g/dl transfusion thresholds. Intervention Intravenous erythropoietin 500 IU/kg or saline per dose. Transfusion threshold maintained with packed red blood cell transfusion. Main Outcome Glasgow Outcome Scale dichotomized as favorable (good recovery and moderate disability) and unfavorable (severe disability, vegetative, or dead) at 6 months post-injury. Results There was no erythropoeitin-transfusion threshold interaction. Compared to placebo (favorable outcome rate: 34/89 [38.2%]; 95%CI=28.2-49.1%), both erythropoetin groups were futile (first dosing regimen: 17/35 [48.6%]; 95%CI=31.4-66.0%, p=0.13, and second dosing regimen: 17/57 [29.8%]; 95%CI=18.4-43.4%, p<0.001). Favorable outcome rates were 37/87 (42.5%) and 31/94 (33.0%) in the 7 and 10 g/dl threshold groups (95%CI for the difference = − 0.05 to 0.25, p=0.28). There was a higher incidence of thromboembolic events in the 10 g/dl threshold group (22/101 [21.8%] vs. 8/99 [8.1%], p=0.009). Conclusions and Relevance In patients with closed head injury, neither the administration of erythropoietin nor maintaining hemoglobin concentration > 10 g/dl resulted in improved neurological outcome at 6 months and the 10 g/dl threshold was associated with a higher incidence of adverse events.. These findings do not support either approach in this setting.

Background In order to assess the depressant effects of alcohol on the level of consciousness of patients admitted with head injuries, this study examined the changes that occur in the Glasgow Coma Scale (GCS) of traumatic brain injury patients over time. Methods The records of 269 head trauma patients consecutively admitted to the neurosurgery ICU were examined retrospectively. 81 patients were excluded due to incomplete data. The remaining 188 patients were divided further into an intoxicated group (BAC ≥ 0.08%, n= 100 [53%]) and a non-intoxicated group (BAC < 0.08%, n= 88 [47%]). The GCS in the prehospital setting, in the emergency room, and the highest GCS achieved during the first 24 hours post-injury were compared. Results The change between ER GCS and the best day 1 GCS in the intoxicated group was greater than the non-intoxicated group and deemed clinically and statistically significant; median change (3 vs. 0) p value< 0.001. To assess if these results were directly related to the BAC%, piecewise regression using a general linear model was utilized to assess the intercept and slope of alcohol on the changes of GCS with cutting point at BAC%=0.08. The analysis showed that in the non-intoxicated range, the effect of alcohol was not significantly related to the changes of GCS. But in the intoxicated range BAC% was significantly positively related to the changes of GCS. Conclusion This study concludes that the GCS increases significantly over time in alcohol intoxicated patients with TBI.

Alcohol intoxication is a major predisposing factor for trauma in general and head injury in particular. The management of the head-injured patient is highly contingent on the accurate assessment of this patient's consciousness, which is invariably impaired if the patient is intoxicated. This complicates the decision-making process and impedes the promptness needed in management when the head injury is severe. Furthermore, the prognosis of the head injury can depend on the patient's degree and pattern of intoxication. This article presents some of the latest epidemiological data about the association of alcohol and head injury. It also highlights some of the challenges posed by alcohol intoxication in the management of head-injured patients, and examines the importance of documenting intoxication in head-injured patients.

No abstract

No abstract

Electroconvulsive therapy (ECT) is a routine treatment for multiple psychiatric disorders including treatment-refractory mood and psychotic disorders. Although ECT is generally a safe and well-tolerated intervention, rare cerebrovascular and cardiovascular complications have been reported. The hemodynamic changes during the ECT seizure are well-recognized, with an initial parasympathetically mediated decrease in heart rate and blood pressure followed by a sympathetically mediated increase in these parameters. Despite intraoperative or postoperative blood pressure fluctuations, the risk of a hypertensive intracerebral bleed during ECT is very low and the risk of ischemic stroke after ECT appears to be even rarer. The authors present a case of a patient who developed an ischemic stroke after ECT treatment. Before stroke, the patient had been undergoing ECT routinely for over 2 years without alarming complications. Ischemic strokes are a rare but serious complication of ECT treatment.