Inaccurate Early Assessment of Neurological Severity in Head Injury

Abstract

Intubation, which requires sedation and myorelaxants, may lead to inaccurate neurological evaluation of severely head-injured patients. Aims of this study were to describe the early clinical evolution of traumatic brain injured (TBI) patients admitted to intensive care unit (ICU), to identify cases of over-estimated neurological severity, and to quantify the risk factors for this over-estimation. A total of 753 TBI patients consecutively admitted to ICU of three academic neurosurgical hospitals (NSH) were assessed. Cases whose severity was potentially over-estimated were identified by four criteria and indicated as "mistakenly severe" (MS): (1) no surgical intracranial masses; (2) could not follow commands at neurological assessment; (3) were dismissed from the ICU in Յ3 days to a regular ward; and (4) had regained the ability to obey commands. A total of 675 patients were intubated and/or sedated-paralyzed at the post-stabilization evaluation. In all, 304 patients had surgically treated intracranial masses. Among the 449 non-surgical cases, 58 patients fulfilling the criteria for MS were identified. The main features distinguishing MS from truly severe cases were younger age, higher Glasgow Coma Scale (GCS) score at all time points, Marshall classification of Computerized Tomographic (CT) scan mostly Diffuse Injury I and II, fewer pupillary abnormalities, and a lower frequency of hypoxia, hypotension, and extra-cranial injuries. In a certain proportion of non-surgical TBI patients, mostly intubated and sedated, neurological examination is difficult and severity can be over-estimated. Risk factors for this inaccurate evaluation can be identified, and clinical decisions should be based on further examination.

Functional Level During the First Year After Moderate and Severe Traumatic Brain Injury: Course and Predictors of Outcome

“…GCS scores in the acute phase provide guidance for early care and prediction of early outcome such as mortality and morbidity [25][26][27][28][29]. GCS is also used in predicting late global outcome such as functional level and return to employment [31,32]. There is controversy about which GCS score should be recorded since interventions in the early medical management of moderate and severe TBI, may complicate GCS assessment and provide inaccurate prognostic predictions for some patients [25,32].…”

αII-Spectrin Breakdown Products (SBDPs): Diagnosis and Outcome in Severe Traumatic Brain Injury Patients

“…The GCS score is universally accepted in the assessment of neurological function and level of consciousness of patients with head injury after trauma (Rowley and Fielding, 1991). Despite the limitations of the GCS in assessing severity of injury (Stocchetti et al, 2004), hospital enrollment GCS is recommended by the IMPACT study investigators for prognostic analyses (Marmorou et al, 2007). Pre-hospitalization GCS score and SBDPs, though they had a similar trend, did not show a statistically significant correlation, an observation possibly related to the reduced accuracy of pre-hospitalization GCS.…”

“…The GCS is often confounded by intubation and use of sedatives and muscle relaxants in TBI patients (Balestreri et al, 2004;Stocchetti et al, 2004). Neuroimaging techniques such as CT scanning capture only momentary snapshots of significant lesions, and lesions such as diffuse axonal injury (DAI) cannot be accurately visualized (Levi et al, 1990).…”

Predicting Outcome after Pediatric Traumatic Brain Injury by Early Magnetic Resonance Imaging Lesion Location and Volume

“…Inaccurate evaluation of neurological severity is associated with intubation and pharmacological sedation and 89-98% of children with sTBI will present to the tertiary trauma center with an endotracheal tube in place having received sedative medications. [11][12][13] Extended traumatic coma can further obscure outcome prognostication in the initial injury period given that 30-70% of children with prolonged disturbances in traumatic consciousness may recover with acceptable outcomes at 1 year. [14][15][16] Novel therapies from clinical, translational, and basic science advances in pediatric TBI will require clinical trial testing, emphasizing the need for reliable early neuroimaging biomarkers of outcome.…”