1 Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 2 Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD. 3 Division of Neurosciences Critical Care, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD. 4 Division of Neurosciences Critical Care, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD.
BACKGROUND: The prediction of neurologic outcome is a fundamental concern in the resuscitation of patients with severe brain injury.
OBJECTIVE: To provide an evidence-based update on neurologic prognosis following traumatic brain injury and hypoxic-ischemic encephalopathy after cardiac arrest.
DATA SOURCE: Search of the PubMed database and manual review of bibliographies from selected articles to identify original data relating to prognostic methods and outcome prediction models in patients with neurologic trauma or hypoxic-ischemic encephalopathy.
DATA SYNTHESIS AND CONCLUSION: Articles were scrutinized regarding study design, population evaluated, interventions, outcomes, and limitations. Outcome prediction in severe brain injury is reliant on features of the neurologic examination, anatomical and physiological changes identified with CT and MRI, abnormalities detected with electroencephalography and evoked potentials, and physiological and biochemical derangements at both the brain and systemic levels. Use of such information in univariable association studies generally lacks specificity in classifying neurologic outcome. Furthermore, the accuracy of established prognostic classifiers may be affected by the introduction of outcome-modifying interventions, such as therapeutic hypothermia following cardiac arrest. Although greater specificity may be achieved with scoring systems derived from multivariable models, they generally fail to predict outcome with sufficient accuracy to be meaningful at the single patient level. Discriminative models which integrate knowledge of genetic determinants and biologic processes governing both injury and repair and account for the effects of resuscitative and rehabilitative care are needed.
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"Indeed, these features highlight the importance of repeated examination and integration of findings from diverse diagnostic modalities. Recent reviews have summarized current prognostic markers in the assessment of comatose survivors of cardiac arrest (Sandroni et al., 2013a, b) (Table 1) and traumatic brain injury (Table 2) (Stevens and Sutter, 2013). Despite these indicators , a subset of patients retains an indeterminate prognosis and novel prognostic indicators—particularly those that predict neurological recovery—would be valuable. "
"Therefore, there exist wide variations of treatment protocols as well as prognostic methods among different centers and warrant future trials to formulate better prognostic criteria as well as standardized protocols. Further to this, the effects of genetic and biological variables on prognosis/outcome needs to be re-integrated for the development of better resuscitative and rehabilitative management protocols. "
[Show abstract][Hide abstract] ABSTRACT: Traumatic brain injury (TBI) is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation (BTF) 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.