Pneumonia in patients with severe head injury: incidence, risk factors, and outcomes.

OBJECT: The reported incidence of hospital-acquired bacterial pneumonia in critically ill trauma patients varies from as low as 4% to as high as 87%, with fatality rates varying from 6% to 59%. Clinical studies have identified the risk factors for pneumonia. The authors undertook this retrospective study to evaluate the incidence, risk factors, and outcomes of hospital-acquired bacterial pneumonia in a group of patients with severe head injuries. METHODS: This was a retrospective review of consecutive adult patients admitted to the neurosurgical ICU in the authors' hospital because of severe head injury (Glasgow Coma Scale scores ≤ 8) between January 2008 and December 2010. RESULTS: During the study period, 290 patients were admitted to the neurosurgical ICU. Multivariate Cox regression analysis showed that age (HR 1.01, 95% CI 1.001-1.02), nasogastric tube insertion (HR 4.56, 95% CI 1.11-18.64), and hemiplegia or hemiparesis (HR 3.79, 95% CI 2.01-7.17) were significantly associated with the development of pneumonia. CONCLUSIONS: The authors identified 3 risk factors (age, nasogastric tube insertion, and hemiplegia or hemiparesis) associated with the development of pneumonia in patients with severe head injury. This finding constituted the basis for developing a simple screening tool that can be used to assess the risk of occurrence of pneumonia in such patients.

Evidence of a non-progressive course of alternating hemiplegia of childhood: study of a large cohort of children and adults.

Alternating hemiplegia of childhood is a neurological disorder characterized by episodes of hemiplegia, various non-epileptic paroxysmal events and global neurological impairment. Characterization of the evolution and outcome into adulthood has not been sufficiently investigated. The goal of this study was to elucidate the natural history of alternating hemiplegia within a large cohort of 157 patients, as part of the European Network for Research on Alternating Hemiplegia project. A questionnaire was formulated to determine the severity of both paroxysmal and global neurological impairment and address progression of the disorder by allocating data to specific age epochs up to and over 24 years of age. Patients in early age groups were consistently present in subsequent later age groups and for each patient, data were collected for each corresponding age epoch. The study was based on predominantly retrospective and, for a period of 2 years, prospective data. At inclusion, patients were aged from 9 months to 52 years. The median age at diagnosis was 20 months. All patients experienced hemiplegic attacks; 86.5% reported episodes of bilateral weakness, 88% dystonic attacks, 53% epileptic seizures, 72% developed chorea and/or dystonia and 92% mental retardation. When data over the course of the illness were examined for the whole cohort, the severity of symptoms did not appear to change, with the exception of abnormal ocular movements and hypotonia that regressed, but did not disappear into adulthood (from 86 to 36% and 76 to 36%, respectively). No statistically significant correlation between a history of severe paroxysmal hemiplegic/dystonic episodes and a worse neurological outcome was identified. Seven patients died, some of whom experienced severe plegic attacks or epileptic seizures at the time of death. History of severe plegic/dystonic attacks was not found to be an aggravating factor for deceased patients. Our results provide evidence that the natural history of alternating hemiplegia is highly variable and unpredictable for individual patients. However, we did not find evidence to support a steadily progressive and degenerative course of the disorder when patients were analysed as a group. For a minority of patients, a risk of sudden death was associated with more severe neurological impairment. The European Network for Research on Alternating Hemiplegia Registry, validated by our study, includes all major neurological signs and symptoms of alternating hemiplegia and may thus be used as a precedent for the progressive inclusion and follow-up of patients as well as a reference for genetic studies and treatment trials.

Outcome three years after motor stroke.

There are few well-designed descriptive studies that focus exclusively on the long-term outcomes of patients after motor stroke. This study reports mortality rates and describes the psychological and functional outcomes 3 years after motor stroke. A description of the variables during acute care and at 3 months that best explain function 3 years after motor stroke is also provided. Home visits were made to 30 patients and another 19 were interviewed by phone. The four instruments used to measure the outcomes were the Center for Epidemiological Studies Depression Scale (CES-D), the Neurobehavioral Cognitive Status Examination (COGNISTAT), the Mini-Mental State Examination (MMSE), and the Functional Independence Measure (FIM). Eleven of the 60 patients contacted had died by the 3-year follow up. The main outcome measures were 3-month FIM of 117.07 (+/- 12.53) and 3-year outcomes for CES-D (6.70 [+/- 7.29]), COGNISTAT (69.67 [+/- 15.62]), MMSE (27.53 +/- 2.74]), and FIM (114.57 +/- 19.00]). A number of multiple regression models were examined; in the best model, the FIM at 3 months accounted for 46% of the variance in function 3 years following the stroke. It is important for rehabilitation nurses to know that the mortality rate was low, psychological outcome was improved, and function was stable 3 years after a motor stroke.

Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization.

UNLABELLED: OBJECTIVE, PATIENTS, AND METHODS: A severe case of cerebral air embolism after unintentional central venous catheter disconnection was the impetus for a systematic literature review (1975-1998) of the clinical features of 26 patients (including our patient) with cerebral air embolism resulting from central venous catheter complications. RESULTS: The jugular vein had been punctured in eight patients and the subclavian vein, in 12 patients. Embolism occurred in four patients during insertion, in 14 patients during unintentional disconnection, and in eight patients after removal and other procedures. The total mortality rate was 23%. Two types of neurologic manifestations may be distinguished: group A (n = 14) presented with encephalopathic features leading to a high mortality rate (36%); and group B (n = 12) presented with focal cerebral lesions resulting in hemiparesis or hemianopia affecting mostly the right hemisphere, with a mortality rate as high as 8%. In 75% of patients, an early computed tomography indicated air bubbles, proving cerebral air embolism. Hyperbaric oxygen therapy was performed in only three patients (12%). A cardiac defect, such as a patent foramen ovale was considered the route of right to left shunting in 6 of 15 patients (40%). More often, a pulmonary shunt was assumed (9 of 15 patients; 60%). For the remainder, data were not available. CONCLUSION: When caring for critically ill patients needing central venous catheterization, nursing staff and physicians should be aware of this potentially lethal complication.

The association of visual field deficits and visuo-spatial neglect in acute right-hemisphere stroke patients.

BACKGROUND: Visuo-spatial neglect (VSN) after stroke is associated with a poor prognosis for rehabilitation. The co-existence of a visual field deficit (VFD) with VSN may be associated with impaired visuo-spatial functioning and thereby poor functional outcome. OBJECTIVE: To determine whether the presence of a VFD (i) exacerbates VSN and (ii) influences recovery of VSN. METHODS: A prospective study of consecutive acute (<7 days), right-hemisphere stroke patients who were able to undergo detailed assessment of visuo-spatial functioning and visual fields. Clinical assessment and a standardized neuropsychological test was administered by one observer, followed by independent assessment of visual fields by a second observer. Patients were followed up for 12 weeks with 4-weekly re-assessments. RESULTS: 44 consecutive patients (23 women) with a first in a lifetime, acute hemisphere stroke were recruited. Twenty had VSN and VFD, seven VSN only, one VFD only and 17 had normal visual fields and no neglect. The finding of a VFD was significantly associated with the presence of VSN (P<0.0001). Patients with both VFD and VSN had a significantly lower score on the behavioural inattention test. One month post-stroke, this difference was no longer significant. Recovery of VSN and VFD was maximal in the first month, however VSN recovery continued for up to 12 weeks. Patients with VSN and a VFD on admission had a greater mortality at 1 and 3 months. CONCLUSION: The presence of a VFD does appear to exacerbate neglect in the acute stroke patient; this effect is no longer seen after 1 month. Recovery of VSN continues independent of a VFD. Patients with neglect and a VFD have an increased mortality, probably because of greater neurological impairment.

Hemispherectomy for intractable seizures in children: a report of 58 cases.

Fifty-eight children who underwent anatomical, functional, or modified anatomical hemispherectomy for intractable seizures from 1986 to 1995 were evaluated for seizure control, motor function, and complications. Age at surgery ranged from 0.3 to 17.3 years (median 2.8 years). Twenty-seven anatomical, 27 functional, and 4 modified anatomical hemispherectomies were performed. Seizure control and motor function in the 50 patients with more than 1 year follow-up revealed a 90% or better reduction in seizure frequency in 44/50 (88%) overall: 19/22 (86%) anatomical, 23/26 (89%) functional, and 2/2 modified anatomical. Motor function of the preoperatively hemiparetic extremities was improved or unchanged postoperatively in 38/50 (76%) of the patients. Complications included one intraoperative death, one late death from shunt obstruction managed elsewhere, late postoperative seizure breakthrough requiring reoperation and further disconnection in 5/27 functional hemispherectomy patients, mild cerebrospinal fluid infections in 3/27 anatomical hemispherectomy patients, and hydrocephalus requiring shunting in 3/27 functional hemispherectomy patients. A review of the literature and comparison of techniques is presented.

Life expectancy of mentally retarded hemiplegics.

Sixty-four mentally retarded people with hemiplegia (35 females and 29 males), first recorded in 1963, were re-examined 30 years later for life expectancy. Detailed physical and mental states, lengths of hospital stays and other information were noted. Recent advances in diagnosis and prognosis of hemiplegics were included. The results of the study indicate that, with special provisions available, people with hemiplegia have the prospect of reaching pensionable age and beyond: the oldest female is 85 and the oldest male 76 years of age.

Outcome in patients who require a gastrostomy after stroke.

Dysphagia is common after a stroke and is associated with a poor outcome in terms of survival or functional recovery. Percutaneous gastrostomy (PG) provides reliable and safe nutrition for patients with neurological dysphagia in the short term but little is known about the the subsequent outcome in stroke patients. We reviewed the medical records of all stroke patients who had required a PG in four West Yorkshire hospitals over a 30-month period. All patients alive at the time of the study were contacted and functional status was recorded. Forty-one stroke patients had undergone PG and 37 records were obtained. There were 24 men and 13 women with a mean age of 74 years. Thirty-three patients had had a hemiplegia while four patients presented acutely with dysphagia but no hemiplegia (all had cerebral infarcts on CT scan). The timing of PG varied with a median time from stroke of 26 days (range 12-131). Complications include five chest infections ( < 1 week after PG), three local infections, two tubes pulled out and one perforation. Three patients died in the first 5 days after the PG. Thirty-one of the 37 patients had died at the time of the assessment, 21 during the original hospital admission. The median survival from the time of PG was 53 days (range 2-528) with only 12 patients surviving for more than 3 months. Six patients were alive at the time of the study and all but one were severely disabled (mean modified Barthel Index seven). There is no consensus about patients selection or timing of PG and our data should lead to more careful consideration of the risks and benefits of the procedure in stroke patients.

[Rehabilitation of over 60-year-old stroke patients]. / Die Rehabilitation des über 60jährigen Schlaganfallpatienten.

The rehabilitation processus in over 60-year-old patients is documented. History, clinical findings and progress of rehabilitation in 289 patients were evaluated. A pre- and post-comparison and a subgroup formation on the basis of rehabilitation success and finally the evaluation of possible predicting factors for the rehabilitation success are presented. "Successful rehabilitation" was defined, based on the clinical outcome, and judged by the responsible physician. This decision was subjected to thorough analysis. The outcome was judged to be 'very successful' in 18.3%, 'successful' in 51.2% and 'not successful' in only 30.5%. The costs per case were 16,000 DM. Highly significant relationships could be found between the expression 'successful rehabilitation', the discharge lacation, the stage of care at the time of discharge, the Barthel index and the in-house hemiplegic status at discharge. The following conditions resulted as highly significant predictors: stage of car, general condition, the numeric value of the Barthel index, presence of incontinence and presence of a psychoorganic syndrome. Age, sex and number of strokes revealed no relationship to the rehabilitation success in this work. In spite of multiple morbidity and in spite of mobility restrictions and prolonged reconvalescence time, the geriatric rehabilitation carried out in a trained team is successful.

Is aphasia an additional prognostic factor in ischemic stroke with regard to the severity of hemiparesis in the subacute stage?

The outcome of 122 patients with ischemic stroke in the left carotid territory (ascertained by CT) was investigated using mailed questionnaires after a mean follow-up time of 60.7 months (SD 20.5 months). Patients who had had cerebrovascular accidents others than TIA prior to the stroke were not included in the study. The relationship between the degree of aphasia in the postacute stage and the long-term outcome was evaluated with regard to the severity of motor deficits. With respect to survival, recurrent stroke, single activities of daily living such as dressing, personal hygiene, walking, feeding, bowel management and overall self-care status, the outcome of patients was not dependent on the severity of aphasia. Aphasia did also not serve as a prognostic factor in returning to work after left hemispheric cerebral infarction. Our results indicate that in presence of motor deficits the severity of aphasia in the subacute stage does not additionally influence the long-term outcome after left hemispheric cerebral infarction.

Factors influencing survival and need for institutionalization following stroke: the Framingham Study.

The distinction between factors that influence survival after stroke and those that increase the likelihood of institutionalization is an important health issue. Estimates of survival and frequency of institutionalization after stroke vary widely, depending on the patient population. A precise picture of variability of outcome from stroke may be obtained from a prospective epidemiologic study. This report uses the Framingham Study population sample of 5,184 men and women, aged 30 to 62 at entry in 1948, who were free of cardiovascular disease. All completed strokes that occurred between 1971 and 1981 were evaluated. Of the 213 patients with completed strokes, 154 survived more than 30 days. Multivariate logistic regression analysis indicated that acute survival was negatively influenced by stroke type, severity of neurologic impairment, and age. For those who survived at least 30 days, independent living was determined by social factors as much as by severity of disability. Being married protected men but not women from institutionalization. Older women, married or not, with moderate to severe residual impairment and minimal education, were at highest risk of institutionalization. In acute stroke, medical factors dominated rates of survival. However, in those who survived, family and social factors had an equal impact in determining final outcome from stroke.

Long-term survival after stroke.

A total of 162 patients referred for rehabilitation were followed-up for two years. Using the t test and the chi-square test, 15 variables distinguishing the 107 survivors from the 55 who died were identified. Multiple regression analysis identified three factors that gave a predictive equation which correctly identified 92% of the two-year survivors and 48% of those dying in that time. These factors were the severity of the stroke (represented by the patient's walking ability), the presence of pre-existing cardiovascular disease (indicated by a history of myocardial infarction), and the patient's age. Pre-stroke motivation or fitness may also influence long-term survival. The technique of using multiple regression analysis allows a clearer separation of the important prognostic factors than the more usual comparative statistical methods.

The post-stroke hemiplegic patient. II. Incidence, mortality, and vocational return in Göteborg, Sweden with a review of the literature.

A review of recent literature on incidence, mortality and prevalence of stroke with special emphasis on hemiplegia is given. A combined retrospective/prospective study of first stroke with hemiplegia before age 66 shows identical age-specific incidence 1965/66 and five years later 1970/71. The mortality rates are also nearly identical during one year after stroke. Half-survival time is 6 years. 32% of all 6-year survivors and 41% of those who had only one stroke return to a vocation. Return to work is correlated to degree of motor handicap and probably also to age. In the Swedish population of 8 million, each year about 2,300 individuals, still in their vocationally active years, fall victim to first stroke with hemiplegia. Of these, more than 1,000 will survive more than 6 years, but only about 300--400 of these can under the present circumstances be actively re-employed. It is felt that more active vocational measures would be beneficial for both handicapped individuals and society.