Epidemiology and clinical characteristics of patients discharged from the ICU in a vegetative or minimally conscious state.

PURPOSE: A significant percentage of patients are discharged from intensive care units (ICU) with disorders of counciousness (DoC). The aim of this retrospective, case-control study was to compare patients discharged from the ICU in a vegetative state (VS) or minimally conscious state (MCS) and the rest of ICU survivors, and to identify independent predictors of DoC among ICU survivors. METHODS: Data from 14,368 adult ICU survivors identified in a Silesian Registry of Intensive Care Units (active in the Silesian Region of Poland between October 2010 and December 2019) were analyzed. Patients discharged from the ICU in a VS or MCS were compared to the remaining ICU survivors. Pre-admission and admission variables that independently influence ICU discharge with DoC were identified. RESULTS: Among the 14,368 analyzed adult ICU survivors, 1,064 (7.4%) were discharged from the ICU in a VS or MCS. The percentage of patients discharged from the ICU with DoC was similar in all age groups. Compared to non- DoC ICU patients, they had a higher mean APACHE II and SAPS III score at admission. Independent variables affecting ICU discharge with DoC included unconsciousness at ICU admission, cardiac arrest and craniocerebral trauma as primary cause of ICU admission, as well as a history of previous chronic neurological disorders and cerebral stroke (p<0.001). CONCLUSION: Discharge in a VS and MCS was relatively frequent among ICU survivors. Discharge with DoC was more likely among patients who were unconscious at admission and admitted to the ICU due to cardiac arrest or craniocerebral trauma.

Demographical and clinical indices for long-term evolution of patients in vegetative or in minimally conscious state.

Objective. To evaluate the prognostic value of demographical, anamnestic, and clinical findings on long-term outcome (up to 36 months) in individuals with severe brain injury in vegetative state (VS) or in minimally conscious state (MCS).Participants. Patients (N = 216) in VS (N = 159) or in MCS (N = 57) consecutively admitted to a neurorehabilitation unit within 1-3 months after severe anoxic (n = 71), vascular (n = 96), or traumatic (n = 49) brain injury.Main outcome. Mortality and improvements in clinical diagnosis at 12, 24, and 36 months after brain injury. Multivariable logistic regression analyses were performed to verify independent relationships of variables collected at study entry with outcome measures.Results. In patients in VS, at the 12-month follow-up, higher level of responsiveness assessed by the Coma Recovery Scale-Revised (CRS-R) total scores at study entry predicted a higher likelihood of both survival and clinical improvement, whereas younger age predicted survival only. At 24 months, female sex and higher CRS-R total scores tended to be associated with clinical improvements. In patients in MCS, younger age and female predicted consciousness recovery at 12 months.Conclusions. Several patients' features easy to collect in rehabilitation setting might help clinicians in prognostication of long-term mortality and clinical evolution of VS and MCS.

Clinical Outcomes and Prognostic Factors for Spontaneous Intracerebral Hemorrhage in Pediatric ICU: A 12-Year Experience.

BACKGROUND: In the pediatric population, spontaneous intracerebral hemorrhage (sICH) is as common as ischemic stroke and accounts for significant mortality and morbidity. Differently from the ischemic stroke, there are few guidelines for directing management of sICH. This article aims to analyze both clinical outcomes and prognostic factors in order to produce tools for the design of prospective randomized studies addressed to implement treatment of pediatric sICH. METHODS: Twelve-year retrospective review of a single-center consecutivesICH pediatric cases admitted to the pediatric intensive care unit (PICU). Selected end points were survival, PICU stay, and dichotomized Glasgow Outcome Score (GOS), with recovery and moderate disability (GOS 4-5) classified as favorable outcome and vegetative state or severe disability (GOS 2-3) classified as unfavorable. RESULTS: Data of 107 children younger than 14 years admitted to our PICU due to sICH were analyzed. Overall PICU mortality was 24.2%. On multivariate analysis, the single factor markedly influencing survival was the presence of midline shift (P = .002). In PICU survivors, there were 42 GOS 2-3 and 39 GOS 4-5. A low Glasgow Coma Scale (GCS) on PICU admission was predictive of severe neurological impairment in survivors (P = .003). Intraventricular hemorrhage and infratentorial origin did not influence outcome in this series. CONCLUSION: The severity of presentation of sICH expressed by the midline shift and the GCS at PICU admission are significant prognostic factors for survival and neurological outcome. Some prognostic factors of the adult population have not been confirmed.

Long-term recovery profile of patients with severe disability or in vegetative states following severe primary intracerebral hemorrhage.

PURPOSE: We conducted a single-center retrospective review to investigate the long-term recovery of patients who were severely disabled or vegetative secondary to primary intracerebral hemorrhage upon discharge from hospital from January 2009 to November 2013. METHODS: Patients were categorized into two groups based on their Glasgow outcome scale (GOS) scores at discharge, namely vegetative state (GOS 2; n = 91) and severely disabled (GOS 3; n = 278). Long-term outcomes at three years post discharge were defined as death, stable, deterioration and improvement from discharge to follow-up. RESULTS: Lower mortality (29% versus 69%) and higher neurological improvement rates at three years (33% versus 10%) were observed in the SD compared to VS group (both p = .0001). Age was a significant predictor of survival in the VS group (p = .03) and the SD group (p = .012). Age was also the only predictor of neurological improvement in the SD group (p = .01). CONCLUSIONS: Neurological status at discharge from hospital was not truly indicative of long-term prognosis for patients who were severely disabled or vegetative. Patients in both groups can potentially improve in the long term and may benefit from prolonged rehabilitation programmes to maximize their recovery potential.

Deaths after feeding-tube withdrawal from patients in vegetative and minimally conscious states: A qualitative study of family experience.

BACKGROUND: Families of patients in vegetative or minimally conscious states are often horrified by the suggestion of withdrawing a feeding tube, even when they believe that their relative would not have wanted to be maintained in their current condition. Very little is known about what it is like to witness such a death. AIM: To understand these families' experience of their relatives' deaths. DESIGN: Qualitative study using in-depth narrative interviews analyzed inductively with thematic analysis. PARTICIPANTS: A total of 21 people (from 12 families) whose vegetative or minimally conscious relative died following court-authorized withdrawal of artificial nutrition and hydration. All had supported treatment withdrawal. FINDINGS: Interviewees were usually anxious in advance about the nature of the death and had sometimes confronted resistance from, and been provided with misinformation by, healthcare staff in long-term care settings. However, they overwhelmingly described deaths as peaceful and sometimes even as a "good death." There was (for some) a significant "burden of witness" associated with the length of time it took the person to die and/or distressing changes in their appearance. Most continued to voice ethical objections to the manner of death while considering it "the least worst" option in the circumstances. CONCLUSION: Staff need to be aware of the distinctive issues around care for this patient group and their families. It is important to challenge misinformation and initiate honest discussions about feeding-tube withdrawal and end-of-life care for these patients. Families (and staff) need better support in managing the "burden of witness" associated with these deaths.

Vegetative state outcomes improved over the last two decades.

OBJECTIVE: To describe late outcomes in patients with prolonged unawareness, and factors affecting them. DESIGN: A retrospective study of 154 patients with traumatic brain injury (TBI) and 52 with non-traumatic brain injury (NTBI), admitted for intensive care and consciousness rehabilitation (ICCR), in a vegetative state (VS) lasting over 1 month. RESULTS: Survival rate (67% total) was higher than in past studies carried out at the same facility (p < 0.01). Consciousness recovery rate (54% total) was higher in NTBI VS patients (p < 0.01) than in earlier cohorts, and similar in TBI VS patients, despite their older age than that of earlier cohorts. No meaningful differences were found in characteristics or in outcomes between the TBI and NTBI groups. Age, length of stay in ICCR, and hydrocephalus were found to affect survival (p < 0.001). Younger age, absence of hydrocephalus, and anti-Parkinsonian medication contributed to consciousness recovery after VS (p < 0.05). CONCLUSIONS: The present study demonstrated an improvement in survival and recovery of consciousness in VS patients over the last two decades, and similar outcomes for both TBI and NTBI VS. Outcomes suggest that acute medical care and ICCR have contributed to advances in VS care.

Survival and consciousness recovery are better in the minimally conscious state than in the vegetative state.

BACKGROUND: The prognosis value of early clinical diagnosis of consciousness impairment is documented by an extremely limited number of studies, whereas it may convey important information to guide medical decisions. OBJECTIVE: We aimed at determining if patients diagnosed at an early stage (<90 days after brain injury) as being in the minimally conscious state (MCS) have a better prognosis than patients in the vegetative state/Unresponsive Wakefulness syndrome (VS/UWS), independent of care limitations or withdrawal decisions. METHODS: Patients hospitalized in ICUs of the Pitié-Salpêtrière Hospital (Paris, France) from November 2008 to January 2011 were included and evaluated behaviourally with standardized assessment and with the Coma Recovery Scale-Revised as being either in the VS/UWS or in the MCS. They were then prospectively followed until 1July 2011 to evaluate their outcome with the GOSE. We compared survival function and outcomes of these two groups. RESULTS: Both survival function and outcomes, including consciousness recovery, were significantly better in the MCS group. This difference of outcome still holds when considering only patients still alive at the end of the study. CONCLUSIONS: Early accurate clinical diagnosis of VS/UWS or MCS conveys a strong prognostic value of survival and of consciousness recovery.

Deep brain stimulation for the early treatment of the minimally conscious state and vegetative state: experience in 14 patients.

OBJECTIVE An effective treatment of patients in a minimally conscious state (MCS) or vegetative state (VS) caused by hypoxic encephalopathy or traumatic brain injury (TBI) is not yet available. Deep brain stimulation (DBS) of the thalamic reticular nuclei has been attempted as a therapeutic procedure mainly in patients with TBI. The purpose of this study was to investigate the therapeutic use of DBS for patients in VS or MCS. METHODS Fourteen of 49 patients in VS or MCS qualified for inclusion in this study and underwent DBS. Of these 14 patients, 4 were in MCS and 10 were in VS. The etiology of VS or MCS was TBI in 4 cases and hypoxic encephalopathy due to cardiac arrest in 10. The selection criteria for DBS, evaluating the status of the cerebral cortex and thalamocortical reticular formation, included: neurological evaluation, electrophysiological evaluation, and the results of positron emission tomography (PET) and MRI examinations. The target for DBS was the centromedian-parafascicular (CM-pf) complex. The duration of follow-up ranged from 38 to 60 months. RESULTS Two MCS patients regained consciousness and regained their ability to walk, speak fluently, and live independently. One MCS patient reached the level of consciousness, but was still in a wheelchair at the time the article was written. One VS patient (who had suffered a cerebral ischemic lesion) improved to the level of consciousness and currently responds to simple commands. Three VS patients died of respiratory infection, sepsis, or cerebrovascular insult (1 of each). The other 7 patients remained without substantial improvement of consciousness. CONCLUSIONS Spontaneous recovery from MCS/VS to the level of consciousness with no or minimal need for assistance in everyday life is very rare. Therefore, if a patient in VS or MCS fulfills the selection criteria (presence of somatosensory evoked potentials from upper extremities, motor and brainstem auditory evoked potentials, with cerebral glucose metabolism affected not more than the level of hypometabolism, which is judged using PET), DBS could be a treatment option.

Effects of percutaneous endoscopic gastrostomy on survival of patients in a persistent vegetative state after stroke.

AIMS AND OBJECTIVES: To assess the effect of percutaneous endoscopic gastrostomy on short- and long-term survival of patients in a persistent vegetative state after stroke and determine the relevant prognostic factors. BACKGROUND: Stroke may lead to a persistent vegetative state, and the effect of percutaneous endoscopic gastrostomy on survival of stroke patients in a persistent vegetative state remains unclear. DESIGN: Prospective study. METHODS: A total of 97 stroke patients in a persistent vegetative state hospitalised from January 2009 to December 2011 at the Second Hospital, University of South China, were assessed in this study. Percutaneous endoscopic gastrostomy was performed in 55 patients, and mean follow-up time was 18 months. Survival rate and risk factors were analysed. RESULTS: Median survival in the 55 percutaneous endoscopic gastrostomy-treated patients was 17·6 months, higher compared with 8·2 months obtained for the remaining 42 patients without percutaneous endoscopic gastrostomy treatment. Univariate analyses revealed that age, hospitalisation time, percutaneous endoscopic gastrostomy treatment status, family financial situation, family care, pulmonary infection and nutrition were significantly associated with survival. Multivariate analysis indicated that older age, no gastrostomy, poor family care, pulmonary infection and poor nutritional status were independent risk factors affecting survival. Indeed, percutaneous endoscopic gastrostomy significantly improved the nutritional status and decreased pulmonary infection rate in patients with persistent vegetative state after stroke. Interestingly, median survival time was 20·3 months in patients with no or one independent risk factors of poor prognosis (n = 38), longer compared with 8·7 months found for patients with two or more independent risk factors (n = 59). CONCLUSION: Percutaneous endoscopic gastrostomy significantly improves long-term survival of stroke patients in a persistent vegetative state and is associated with improved nutritional status and decreased pulmonary infection. RELEVANCE TO CLINICAL PRACTICE: Percutaneous endoscopic gastrostomy is a promising option for the management of stroke patients in a persistent vegetative state.

Predicting long-term neurological outcomes after severe traumatic brain injury requiring decompressive craniectomy: A comparison of the CRASH and IMPACT prognostic models.

BACKGROUND: Predicting long-term neurological outcomes after severe traumatic brain (TBI) is important, but which prognostic model in the context of decompressive craniectomy has the best performance remains uncertain. METHODS: This prospective observational cohort study included all patients who had severe TBI requiring decompressive craniectomy between 2004 and 2014, in the two neurosurgical centres in Perth, Western Australia. Severe disability, vegetative state, or death were defined as unfavourable neurological outcomes. Area under the receiver-operating-characteristic curve (AUROC) and slope and intercept of the calibration curve were used to assess discrimination and calibration of the CRASH (Corticosteroid-Randomisation-After-Significant-Head injury) and IMPACT (International-Mission-For-Prognosis-And-Clinical-Trial) models, respectively. RESULTS: Of the 319 patients included in the study, 119 (37%) had unfavourable neurological outcomes at 18-month after decompressive craniectomy for severe TBI. Both CRASH (AUROC 0.86, 95% confidence interval 0.81-0.90) and IMPACT full-model (AUROC 0.85, 95% CI 0.80-0.89) were similar in discriminating between favourable and unfavourable neurological outcome at 18-month after surgery (p=0.690 for the difference in AUROC derived from the two models). Although both models tended to over-predict the risks of long-term unfavourable outcome, the IMPACT model had a slightly better calibration than the CRASH model (intercept of the calibration curve=-4.1 vs. -5.7, and log likelihoods -159 vs. -360, respectively), especially when the predicted risks of unfavourable outcome were <80%. CONCLUSIONS: Both CRASH and IMPACT prognostic models were good in discriminating between favourable and unfavourable long-term neurological outcome for patients with severe TBI requiring decompressive craniectomy, but the calibration of the IMPACT full-model was better than the CRASH model.

Efficacy of progesterone for moderate to severe traumatic brain injury: a meta-analysis of randomized clinical trials.

Progesterone has been shown to have neuroprotective effects in multiple animal models of brain injury, whereas the efficacy and safety in patients with traumatic brain injury (TBI) remains contentious. Here, a total of seven randomized controlled trials (RCTs) with 2492 participants were included to perform this meta-analysis. Compared with placebo, there was no significant decrease to be found in the rate of death or vegetative state for patients with acute TBI (RR = 0.88, 95%CI = 0.70, 1.09, p = 0.24). Furthermore, progesterone was not associated with good recovery in comparison with placebo (RR = 1.00, 95%CI = 0.88, 1.14, p = 0.95). Together, our study suggested that progesterone did not improve outcomes over placebo in the treatment of acute TBI.

The etiology and outcome of non-traumatic coma in critical care: a systematic review.

BACKGROUND: Non-traumatic coma (NTC) is a serious condition requiring swift medical or surgical decision making upon arrival at the emergency department. Knowledge of the most frequent etiologies of NTC and associated mortality might improve the management of these patients. Here, we present the results of a systematic literature search on the etiologies and prognosis of NTC. METHODS: Two reviewers independently performed a systematic literature search in the Pubmed, Embase and Cochrane databases with subsequent reference and citation checking. Inclusion criteria were retrospective or prospective observational studies on NTC, which reported on etiologies and prognostic information of patients admitted to the emergency department or intensive care unit. RESULTS: Eventually, 14 studies with enough data on NTC, were selected for this systematic literature review. The most common causes of NTC were stroke (6-54%), post-anoxic coma (3-42%), poisoning (<1-39%) and metabolic causes (1-29%). NTC was also often caused by infections, especially in African studies affecting 10-51% of patients. The NTC mortality rate ranged from 25 to 87% and the mortality rate continued to increase long after the event had occurred. Also, 5-25% of patients remained moderately-severely disabled or in permanent vegetative state. The mortality was highest for stroke (60-95%) and post-anoxic coma (54-89%) and lowest for poisoning (0-39%) and epilepsy (0-10%). CONCLUSION: NTC represents a challenge to the emergency and the critical care physicians with an important mortality and moderate-severe disability rate. Even though, included studies were very heterogeneous, the most common causes of NTC are stroke, post anoxic, poisoning and various metabolic etiologies. The best outcome is achieved for patients with poisoning and epilepsy, while the worst outcome was seen in patients with stroke and post-anoxic coma. Adequate knowledge of the most common causes of NTC and prioritizing the causes by mortality ensures a swift and adequate work-up in diagnosis of NTC and may improve outcome.

Comorbidities: a key issue in patients with disorders of consciousness.

The aim of this study was to identify the impact of comorbidities on outcomes of patients with vegetative state (VS) or minimally conscious state (MCS). All patients in VS or MCS consecutively admitted to two postacute care units within a 1-year period were evaluated at baseline and at 6 months through the Coma Recovery Scale-Revised Version and the Disability Rating Scale (DRS). Comorbidities were also recorded for each patient along the same period. Six-month outcomes included death, full recovery of consciousness, and functional improvement. One hundred and thirty-nine patients (88 male and 51 female; median age, 59 years) were included. Ninety-seven patients were in VS (70%) and 42 in MCS (30%). At 6 months, 33 patients were dead (24%), 39 had a full recovery of consciousness (28%), and 67 remained in VS or MCS (48%). According to DRS scores, 40% of patients (n=55) showed a functional improvement in the level of disability. One hundred and thirty patients (94%) showed at least one comorbidity. Severity of comorbidities (hazard ratio [HR]=2.8; 95% confidence interval [CI], 1.71-4.68; p<0.001) and the presence of ischemic or organic heart diseases (HR=2.6; 95% CI, 1.21-5.43; p=0.014) were the strongest predictors of death, together with increasing age (HR=1.0; 95% CI, 1.0-1.06; p=0.033). Respiratory diseases and arrhythmias without organic heart diseases were negative predictors of full recovery of consciousness (odds ratio [OR]=0.3; 95% CI, 0.12-0.7; p=0.006; OR=0.2; 95% CI, 0.07-0.43; p<0.001) and functional improvement (OR=0.4; 95% CI, 0.15-0.85, p=0.020; OR=0.2; 95% CI, 0.08-0.45; p<0.001). Our data show that comorbidities are common in these patients and some of them influence recovery of consciousness and outcomes.

Risk factors for mortality in 600 patients in vegetative and minimally conscious states.

A significant proportion of patients who survive traumatic or nontraumatic severe acquired brain injuries experiences disorders of consciousness. The vegetative state and the minimally conscious state may have different prognoses, and while some patients regain awareness, others have negative outcomes and die. The aim of this work is to identify age-related, medical and behavioural risk factors for mortality in those patients. Participants were enrolled from June 2009 to March 2012 in 107 Italian health care institutions. Univariate and multivariate Cox proportional hazard models were adopted to screen and test candidate risk factors. The study enrolled 600 subjects in vegetative and minimally conscious states for an overall mortality rate of 180.1 per 1,000 person-years. The following traits were associated with a significantly lower chance of survival: age at the acute event higher than 51 years, disease duration less than 1 year, post-anoxic aetiology, absence of visual fixation, and the presence of endocrine, nutritional, and metabolic diseases, and immunity disorders. Clinical history, behavioural assessment, and age-related factors provide important prognostic information on negative outcomes that helps clinicians and researchers to predict patients who are at higher risk of mortality. This knowledge has important clinical, managerial, and ethical implications.

Neuropathology of prolonged unresponsive wakefulness syndrome after blunt head injury: review of 100 post-mortem cases.

OBJECTIVES: Recently, 'unresponsive wakefulness syndrome' (UWS) was coined for challenging conditions previously termed vegetative state or apallic syndrome. MATERIALS AND METHODS: In a post-mortem series of 630 patients who sustained a blunt traumatic brain injury, 100 (59 men and 41 women, aged 5-86 years; 77% traffic accidents, 23% falls and others) showed various disorders of consciousness which were compared with neuropathology with focus on brainstem lesions. RESULTS: In the total autopsy series (n = 630), the incidence of cortical contusions, diffuse axonal injury (DAI) and intracranial haemorrhages was 41, 55 and 73%, respectively, of diencephalic, hypothalamic and hippocampal lesions 62% each, brainstem lesions 92%. Clinical prognosis was related to the location and extent of brainstem damage. Lesions in central parts of the rostral brainstem, frequently associated with extensive DAI, allowed no recovery from coma or UWS (n = 67), which occurred only with damage to the dorso-lateral brainstem tegmentum or pontine basis (n = 33). Only two of 11 patients with minimally conscious state (MCS), in addition to haemorrhages (n = 4), contusions (n = 10) and DAI (n = 7), showed small lesions in dorsolateral pontine tegmentum or diffuse pontine gliosis. CONCLUSIONS: These and other data confirm the importance of the pattern and extent of brainstem damage for the prognosis of UWS, only small peripheral lesions in pontine tegmentum allowing progressive remission.

An Italian population study on 600 persons in vegetative state and minimally conscious state.

OBJECTIVE: To describes socio-demographic and clinical features of adults and children in vegetative state (VS) and minimally conscious state (MCS). DESIGN: Observational cross-sectional study. METHODS: Demographic, aetiological and clinical data were collected, together with patients' management procedures. Mann-Whitney U-test was used for continuous variables and chi-squared test for categorical variables. RESULTS: Six hundred patients (69.7% in VS; 6% children) were enrolled. No difference regarding age at enrolment, age at acute event and disease duration was observed between VS and MCS. Disease duration was superior to 10 years for 3.3% of the whole sample and 64.3-77% of cases had a non-traumatic aetiology. Mean number of drugs per adult patient was four and decreased consistently with increased disease duration. DISCUSSION: Patients with VS and MCS were similar for age at acute event and at enrolment, both over 50 years, as well as for the frequency of non-traumatic aetiology. Disease duration was similar for both conditions and 2.6% of VS and 4.8% of MCS patients survived for more than 10 years. Finally care and treatment needs are similar and not related to diagnosis.

Life expectancy of brain impaired, chronically ventilated children.

We present a 5-year survival profile of 42 children and adolescents between 1 to 21 years of age in an immobile minimally conscious state, chronically dependent on supportive ventilation. Data were collected from a 22-bed pediatric unit dedicated to this unique population, within a 350-bed geriatric hospital, between May 2006 and May 2011. The practice of ventilating children even in minimally conscious state stems from the unique cultural, religious, and ethnic background of the population in Israel. The 5-year survival probability was 48% (52% probability of death within 5 years, 26.5% within 2 years). No significant difference was found in the survival profile of patients admitted following hypoxic accidents (20 children) and those admitted with other problems such as genetic/metabolic diseases or brain anomalies (22). The mortality rate of male patients was higher than that of female patients, but the difference was not statistically significant. No difference in 5-year mortality rates was found between children of different ethnic backgrounds.

Traumatic peritentorial subdural hematomas: a study of 32 cases.

AIM: This study aimed to investigate the clinicoradiological features in patients with traumatic peritentorial subdural hematomas (SDHs). MATERIAL AND METHODS: We retrospectively reviewed the clinical and radiological findings, management criteria, and outcomes in 32 patients with peritentorial SDHs. The outcomes were classified as favorable (good recovery or moderate disability) or poor (severe disability, vegetative state, or death). RESULTS: Of the 32 patients, 19 were male and 13 were female. The patients' ages ranged from 10-92 years (mean age, 60.9 years). Coagulopathies were observed in 23 patients. Twenty-four patients presented with associated intracranial lesions. Eighteen patients had favorable outcomes and 14 had poor outcomes. All patients were treated conservatively. The presence of coagulopathy (p = 0.024) and presence of convexity SDH (p = 0.008) correlated with the outcome. CONCLUSION: The patients with traumatic peritentorial SDHs were predominantly male and relatively elderly, and had a high incidence of coagulopathy, associated intracranial lesions (especially falx SDHs), a high rate of impact in the occipital or frontal regions, and a low incidence of skull fractures. The factors that were correlated with outcome in patients receiving conservative therapy were the presence of coagulopathy and the presence of convexity SDH.