Latest news with #GlasgowComaScale
Medscape
21-05-2025
- Health
- Medscape
Beyond the Glasgow Coma Scale: New TBI Framework Proposed
After more than half a century, assessment of acute traumatic brain injury (TBI) is getting a makeover. A newly proposed framework expands assessment of acute TBI beyond the Glasgow Coma Scale (GCS) to include biomarkers, CT and MRI scans, and 'modifiers' such as other medical conditions and how the injury occurred. 'Multiple factors prompted this initiative. First was a growing consensus among clinicians, researchers, and patients alike around the need for an improved system for the characterization of TBI,' co-senior author Michael McCrea, PhD, co-director of the Center for Neurotrauma Research at the Medical College of Wisconsin in Milwaukee, told Medscape Medical News . 'Second, was the recognition that a multidimensional framework could better guide individualized treatments that give TBI patients the best chance of survival, recovery, and return to life function.' 'Finally, this movement is now enabled by decades of progress in translational research that informed the components of a multidimensional framework for classification of TBI,' he added. The proposed framework was published online on May 20 in The Lancet Neurology . Beyond Level of Consciousness Since 1974, the clinical TBI severity has been classified according to the GCS sum score as mild, moderate, or severe, based largely on a patient's level of consciousness. Given its limitations, in 2022, the US National Institute of Neurological Disorders and Stroke (NINDS) launched an international initiative to develop a multidimensional classification system for acute TBI. The so-called 'CBI-M framework' is made up of four pillars — clinical, biomarker, imaging, and modifiers — and was developed by TBI experts, implementation scientists, people with lived experience, and partners from 14 countries. The clinical pillar retains the full GCS total score as a central element of assessment, measuring consciousness along with pupil reactivity as an indication of brain function. The framework recommends including the scale's responses to eye, verbal, and motor commands or stimuli, as well as the presence of amnesia and symptoms such as headache, dizziness, and sensitivity to noise. The clinical pillar 'should be assessed as first priority in all patients. Research has shown that the elements of this pillar are highly predictive of injury severity and patient outcome,' co-senior author Andrew Maas, MD, PhD, emeritus professor of neurosurgery, University of Antwerp, Antwerp, Belgium, said in a news release. Other Critical Clues to Recovery The second pillar uses blood-based biomarkers to provide objective indicators of tissue damage. Measurement of one or more of the following three biomarkers is recommended in the first 24 hours after injury: Glial fibrillary acidic protein, ubiquitin C-terminal hydrolase L1, or S100 calcium-binding protein B. The working group noted that this recommendation was based on the diagnostic and prognostic utility of these biomarkers demonstrated in acute care settings. Low levels of each of the three biomarkers accurately indicate a very low risk for traumatic intracranial injury on head CT scans and can be used to rule out the need for CT imaging. The third pillar of the CBI-M framework is neuroimaging, which offers a 'great source' of information about the type and extent of brain injury, the authors reported. This pillar focuses on CT, the most widely used imaging modality within the first 24 h of injury, but recognizes that MRI is more sensitive than CT and can provide additional information while acknowledging certain practicalities around its use in the acute phase. The final pillar in the CBI-M framework is 'modifiers,' which includes assessment of injury-related factors (how the injury happened) and patient- and society-related factors (such as medications, healthcare access, prior TBI, substance abuse, and living circumstances). 'This pillar summarizes the factors that research tells us need to be considered when we interpret a patient's clinical, blood biomarker, and neuroimaging exams,' co-first author Kristen Dams-O'Connor, PhD, professor in the Department of Rehabilitation and Human Performance and Department of Neurology, and director of the Brain Injury Research Center at the Icahn School of Medicine at Mount Sinai in New York City, said in the release. 'One example is a patient with underlying cognitive impairment who may require acute monitoring for risk of clinical deterioration, regardless of findings on the initial clinical exam,' she said. Testing and Validation The proposed framework is being phased in at trauma centers on a trial basis. It will be refined and validated before it is fully implemented. The authors of a linked Comment in The Lancet Neurology , led by Junfeng Feng, MD, Shanghai Institute of Head Trauma in Shanghai, China , offer several cautionary notes on the proposed CBI-M framework for acute TBI assessment. The new assessment model is a 'substantial advancement' in integrating the characterization of acute TBI but is 'not yet ideal,' they wrote. In their view, the biomarker pillar is limited in that testing for biomarkers requires time, their specificity for the diagnosis of TBI is not high, and the use of biomarkers is minimal in low-income and middle-income countries. 'Similar to the biomarker pillar, the modifier pillar — an individual's biopsychosocial characteristics — can be valuable for predicting outcomes in patients with TBI but has minimal effect on decision-making, particularly during the acute phase of TBI,' Feng and co-authors said. 'Another deficiency of the CBI-M framework is that it cannot quantitatively or semiquantitatively assess the condition of patients with TBI yet,' they pointed out. 'To gain recognition and application in countries around the world, the CBI-M framework requires improvement and practical testing through global multicenter, large-scale, prospective cohort studies,' Feng and colleagues cautioned. Another concern the Comment authors have is that the CBI-M framework does not consider intracranial pressure monitoring, which 'should be conducted in specific patients, if possible, and be eventually incorporated into the CBI-M framework for characterization of acute TBI,' they wrote. Asked why intracranial pressure monitoring was not included in the framework, McCrea said that 'while intracranial pressure monitoring is an important element of care for patients in the intensive care unit after TBI, the aim of this movement was to develop a multidimensional framework for characterization of acute TBI across the full spectrum of injury severity and all care settings.'
San Francisco Chronicle
21-05-2025
- Health
- San Francisco Chronicle
UCSF team's method for assessing brain injuries could transform concussion care
A team of neurologists led by UCSF scientists has developed a new scale for assessing damage caused by brain trauma that could overhaul the field of concussion medicine and help doctors better treat patients with both the least and most severe injuries, including those who are comatose and considered near-death. Health providers have been using the Glasgow Coma Scale to assess brain injuries for more than 50 years. The tool assigns patients a score based on their physical presentation, including how alert they are, whether they can speak clearly and how they respond to pain, and that score determines if their injury is mild, moderate or severe. But experts in neurology have long said that it is a blunt instrument for assessing complex injuries. The new tool, described in a paper published Tuesday in the journal Lancet Neurology, uses the Glasgow Coma Scale along with other descriptors — including head scans, blood tests and the patient's own background — to quickly produce a more nuanced and, neurologists say, accurate analysis of a brain injury. 'Mild, moderate and severe doesn't work for any disease,' said Dr. Geoff Manley, chief of neurosurgery at San Francisco General Hospital and lead author of the new paper. 'We need to characterize these patients better. Our hope is that changing the framework of how we describe these patients can hopefully change the culture.' Worldwide, head injuries are among the most common causes of disability and death. Nearly 50 million people sustain a brain injury each year, and in the United States about 70,000 people die annually from head wounds. And increasingly, concussions and other so-called minor head injuries are understood to be potentially disastrous for some people. Such injuries have become the hallmark of modern warfare, and are of mounting concern in sports like football and soccer. The new framework will provide 'more granularity and allow us to have more thoughtful conversations with our patients,' said Dr. Cathra Halabi, director of UCSF's neurorecovery clinic. 'We're in a very exciting time where there's a confluence of pretty rapid advances in neuroscience and rapid advances in technology,' Halabi said. 'And we're now at a point where we can leverage that and focus on our patients and what is going to serve them best.' The Glasgow Coma Scale lumps patients broadly into mild, moderate and severe categories, with 'mild' fitting those who are able to talk normally and understand where they are and what's going on, and 'severe' including those who are comatose or otherwise nonresponsive. But those categories don't capture the complexity of injury, especially at the mild and severe ends of the spectrum. In fact, some patients with so-called minor head wounds suffer debilitating symptoms months after their injuries, including difficulty concentrating, chronic headaches, insomnia, and depression and anxiety. Meanwhile, some coma patients considered near-death based on the Glasgow Coma Scale — including people whose families were advised to remove them from life support — are able to make a near-full recovery. 'These terms weren't doing patients any favors,' said Manley, who has experience treating both the least and most severe cases, including the 2002 case of a San Francisco police officer who fully recovered from an injury that had him in a coma. 'We were quite nihilistic' about the severe cases, Manley said, but anecdotal experience and, later, research studies found that some of those patients weren't as bad off as they appeared and could recover — if not completely, then enough to have some independence. At the same time, 'we didn't pay much attention to these people with mild traumatic brain injury,' Manley said. 'I was following up with people in the emergency department who were like, 'You said I was stable but it's been three months and I'm not back at work.'' The new scale, called the CBI-M framework, takes clinical, blood biomarker and imaging results into account, along with modifiers such as the patient's mental health, pre-existing conditions, housing status and other social determinants of health. The framework will still rely on the Glasgow Coma Scale — that's the clinical element of CBI-M — but the other factors should give a more robust sense of how injured patients are and their prognosis. For example, a patient who hit his head in a car accident may show up in the emergency room fairly alert and with a high score on the Glasgow Coma Scale, suggesting a mild brain injury. If that coma scale is the only tool used — which is often the case — that patient may be sent home within hours. But a blood test may show high biomarker levels, suggesting a more serious injury, which would then prompt doctors to do a brain scan, which could show a blood clot or bleeding. In addition, the patient may have substance abuse issues that may interfere with recovery and should be taken into consideration. So that patient may stay overnight, or be referred to another clinic for follow-up care. On the other end of the spectrum, a comatose patient with a very low Glasgow Coma Scale, suggesting a very poor prognosis, but who also has low biomarker levels, no alarming signs on a brain scan and no modifying issues that could impede recovery may wake up and do well. 'The old way of categorizing brain injury was a very blunt, crude way,' said Dr. Anthony DiGiorgio, a UCSF neurosurgeon who was not involved in the Lancet paper. 'This tool makes us able to hedge on one side or the other and help manage expectations. It's a lot easier for me to figure out how to triage a patient.' The new tool also should be applied to research into head injuries, which has been frustratingly slow and stilted, Manley said. There are no drugs specifically to treat head injuries, and neurologists say that's at least in part because scientists have struggled to stratify patients in a way that makes testing effective. The 'mild,' 'moderate' and 'severe' head injury clusters that scientists have used to study therapies aren't very homogenous, as demonstrated by biomarker results, head scans and practical outcomes. Drugs to treat mild injury may have failed, for example, because 'mild' includes a broad array of symptoms and manifestations — maybe those drugs worked on some people with mild injury but not others. 'We've had numerous unsuccessful drug trials, and I think a large part of that is because of the heterogenous nature of brain injury,' DiGiorgio said. 'Maybe down the line we can get some useful clinical trials out of this framework.' Rolling out the new brain injury tool will likely take 10 years at least, Manley and others said. San Francisco General Hospital already uses aspects of the new tool, including taking patients' background into consideration when evaluating head injuries. And Manley said the tool already is being used in some clinical trials. Sean Sanford, 43, has firsthand experience on both ends of the brain injury spectrum, including a prolonged recovery from what seemed like a mild skateboarding accident eight years ago. He was just 20 for the first injury, which occurred in a car accident in his hometown of Grass Valley (Nevada County). He was in a coma for weeks, and his outlook was grim; his family was told he might not wake up. But he managed to fully recover. The second injury was 15 years later, when Sanford was skating with some friends in Glen Park. He hit his head on a ledge and knocked himself out. He came around after a few seconds, but his friends took him to the emergency room when he was behaving oddly and couldn't seem to remember where he was or what he was doing. At San Francisco General Hospital, he was told it was probably a minor head injury, but doctors decided to do a brain scan just in case — Sanford was rushed into surgery when the scan showed a skull fracture and bleeding. His friends and wife were told that if he 'had gone home and gone to sleep, he wouldn't have woken up,' Sanford recalled. The recovery from that injury has been rougher than the first time around, for reasons that aren't entirely clear. Sanford developed a seizure disorder and is on medication for that now. He had to take time off college, though he's since graduated and is working toward his master's degree in creative writing. 'The insomnia is still a thing. And I get anxiety,' Sanford said of the lingering symptoms. He struggles with short-term memory and concentration. 'Sometimes I feel like the subjects in my brain are just like a pinball bouncing around.' But he's also grateful both for the care he got and for the awareness of the nature of his injury. He said it would be incredibly frustrating to deal with the ongoing symptoms if he'd been told his was a 'mild' injury and left on his own. But he's had follow-up care, including therapy to manage his anxiety, and his family and friends too have been supportive. 'One of the big things they told me that I have to keep reminding myself is it's going to be a long road to recovery,' Sanford said. 'Don't get discouraged. Don't feel like you're broken. But it will be years, if not decades, before you even feel normal again, and you might never feel normal again.'
The Journal
07-05-2025
- The Journal
Paediatrician tells trial that baby suffered brain bleeding and fractured collar bone
A PAEDIATRICIAN HAS told the trial of a man charged with seriously assaulting his five-month-old daughter that when the child was admitted to hospital doctors found she had suffered bruising to her face, chest, abdomen and right buttock, a fractured collar bone, blood on the surface of the brain and tearing of its connective fibres. The 31-year-old accused is on trial at Cork Circuit Criminal Court, having pleaded not guilty to three charges. The man, who can't be named to protect the identity of the child, previously entered a not guilty plea to a charge of causing serious harm to his five month old daughter on 4 January 2021. He also pleaded not guilty to a charge of assault causing harm to his daughter on dates between 25 November and 15 December 2020 and with wilfully assaulting or ill-treating the child in a manner likely to cause unnecessary suffering to the child's health or seriously affect the child's wellbeing. Dr Rosina McGovern, who is a consultant paediatrician at Cork University Hospital, said that when the child was brought to hospital on the evening of 4 January 2021 she was 'lethargic' and 'drowsy.' Her parents told medical staff that their young daughter had been vomiting and wasn't tolerating fluids. It was noted that she 'poor head control' and was 'very quiet.' In addition to bruising an X ray indicated that the baby had sustained a fractured collar bone which was 'healing.' The child had bleeding in the eyes. McGovern said an MRI showed that the young girl had blood on the surface of her brain and tearing of the fibres of the brain. She said that the parents didn't give an explanation for the injuries the child had sustained. McGovern told Judge Dermot Sheehan and the jury that children under the age of six months rarely suffer from bruising arising out of their lack of mobility. The child was found to have 'no underlying medical condition' to explain her injuries. According to the doctor, the fracture of the collar bone on such a young child was also 'unusual' given her young age. Blood was found on the spine of the child from the top of the neck to the lower back. Advertisement McGovern said that the child spent from 4 January to 18 January 2021 in hospital. The court heard that that on 5 January 2021 the child was found to have a score of nine out of fifteen on the Glasgow Coma Scale. The scale is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. Under cross examination by defence barrister Ray Boland, SC, McGovern said that a score of nine means that a patient is 'quite impaired in terms of a brain injury. She told the jury that a score of less than 8 generally involves the placing of a patient in intensive care. It was her belief, the court heard, that the child had sustained 'serious harm.' Prosecution barrister Jane Hyland SC said that in Irish law serious harm is defined as an injury that creates a substantial risk of death, or causes serious disfigurement or substantial loss or impairment of mobility of the body or function of a bodily member or organ. Meanwhile, the jury also heard evidence from crèche workers who said that they noticed that the child had bruising on her cheek and forehead. One crèche worker said that she rang her manager and on her advice she documented what she had spotted and took photographs of the injuries. She said that she noticed the bruising on the 15 December 2020 when the child was dropped off wearing a festive elf outfit. She stated that she felt the bruising was 'unusual' in such a young child. She gave evidence that when she raised the matter with the mother of the child she said that it was 'nothing.' No explanation was furnished for the bruising with the crèche worker saying that the mother 'brushed it off.' Another worker present that day said that they noticed a bruise on both the left and right cheek of the child. She said that there no accident or incident in the crèche involving the child as it would have been documented. The case will continue tomorrow in front of a jury of seven women and five men.
Irish Daily Mirror
07-05-2025
- Health
- Irish Daily Mirror
Five month old baby had blood on the brain & fractured collar bone, court hears
A paediatrician has told the trial of a man charged with seriously assaulting his five month old daughter that when the child was admitted to hospital doctors found she had suffered bruising to her face, chest, abdomen and right buttock, a fractured collar bone, blood on the surface of the brain and tearing of its connective fibres. The 31 year-old accused is on trial at Cork Circuit Criminal Court having pleaded not guilty to three charges. The man, who can't be named to protect the identity of the child, previously entered a not guilty plea to a charge of causing serious harm to his five month old daughter on January 4, 2021. He also pleaded not guilty to a charge of assault causing harm to his daughter on dates between November 25 and December 15, 2020 and with wilfully assaulting or ill-treating the child in a manner likely to cause unnecessary suffering to the child's health or seriously affect the child's wellbeing. Dr Rosina McGovern, who is a consultant paediatrician at Cork University Hospital, said that when the child was brought to hospital on the evening of January 4, 2021 she was 'lethargic' and 'drowsy.' Her parents told medical staff that their young daughter had been vomiting and wasn't tolerating fluids. It was noted that she had 'poor head control' and was 'very quiet.' In addition to bruising an X-ray indicated that the baby had sustained a fractured collar bone which was 'healing.' The child had bleeding in the eyes. Dr McGovern said an MRI showed that the young girl had blood on the surface of her brain and tearing of the fibres of the brain. She said that the parents didn't give an explanation for the injuries the child had sustained. Dr McGovern told Judge Dermot Sheehan and the jury that children under the age of six months rarely suffer from bruising arising out of their lack of mobility. The child was found to have 'no underlying medical condition' to explain her injuries. Dr McGovern stated that the fracture of the collar bone on such a young child was also 'unusual' given her young age. Blood was found on the spine of the child from the top of the neck to the lower back. She said that the child spent from January 4 to January 18, 2021 in hospital. The court heard that that on January 5, 2021 the child was found to have a score of nine out of fifteen on the Glasgow Coma Scale. The scale is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. Under cross examination by defence barrister Ray Boland, SC, Dr Govern said that a score of nine means that a patient is 'quite impaired in terms of a brain injury. She told the jury that a score of less than eight generally involves the placing of a patient in intensive care. Dr McGovern said that it was her belief that the child had sustained 'serious harm.' Prosecution barrister Jane Hyland SC said that in Irish law serious harm is defined as an injury that creates a substantial risk of death, or causes serious disfigurement or substantial loss or impairment of mobility of the body or function of a bodily member or organ. Meanwhile, the jury also heard evidence from crèche workers who said that they noticed that the child had bruising on her cheek and forehead. One crèche worker said that she rang her manager and on her advice she documented what she had spotted and took photographs of the injuries. She said that she noticed the bruising on December 15, 2020 when the child was dropped off wearing a festive elf outfit. She stated that she felt the bruising was 'unusual' in such a young child. She gave evidence that when she raised the matter with the mother of the child she said that it was "nothing". No explanation was furnished for the bruising with the crèche worker saying that the mother 'brushed it off.' Another worker present that day said that they noticed a bruise on both the left and right cheek of the child. She said that there no accident or incident in the crèche involving the child as it would have been documented. The case will continue on Thursday in front of a jury of seven women and five men. Subscribe to our newsletter for the latest news from the Irish Mirror direct to your inbox: Sign up here.
RTÉ News
07-05-2025
- Health
- RTÉ News
Doctor tells court baby girl suffered multiple bruises
A paediatrician has told the trial of a man charged with seriously assaulting his five-month-old daughter that when the child was admitted to hospital doctors found she had suffered bruising to her face, chest, abdomen and right buttock, a fractured collar bone, blood on the surface of the brain and tearing of its connective fibres. The 31-year-old accused is on trial at Cork Circuit Criminal Court having pleaded not guilty to three charges. The man, who cannot be named to protect the identity of the child, previously entered a not guilty plea to a charge of causing serious harm to his five-month-old daughter on 4 January 2021. He also pleaded not guilty to a charge of assault causing harm to his daughter on dates between 25 November and 15 December 2020, and with wilfully assaulting or ill-treating the child in a manner likely to cause unnecessary suffering to the child's health or seriously affect the child's wellbeing. Dr Rosina McGovern, who is a consultant paediatrician at Cork University Hospital, said that when the child was brought to hospital on the evening of 4 January 2021, she was "lethargic" and "drowsy". Her parents told medical staff that their young daughter had been vomiting and was not tolerating fluids. It was noted that she "poor head control" and was "very quiet". In addition to bruising an X ray indicated that the baby had sustained a fractured collar bone which was "healing." The child had bleeding in the eyes. Dr McGovern said an MRI showed that the young girl had blood on the surface of her brain and the tearing of the fibres of the brain. She said that the parents did not give an explanation for the injuries the child had sustained. Dr McGovern told Judge Dermot Sheehan and the jury that children under the age of six months rarely suffer from bruising arising out of their lack of mobility. The child was found to have "no underlying medical condition" to explain her injuries. Dr McGovern stated that the fracture of the collar bone on such a young child was also "unusual" given her young age. Blood was found on the spine of the child from the top of the neck to the lower back. She said that the child spent from 4 January to 18 January 2021 in hospital. The court heard that that on 5 January 2021 the child was found to have a score of nine out of fifteen on the Glasgow Coma Scale. The scale is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. Under cross examination by defence barrister Ray Boland, Dr Govern said that a score of nine means that a patient is "quite impaired in terms of a brain injury". She told the jury that a score of less than eight generally involves placing a patient in intensive care. Dr McGovern said that it was her belief that the child had sustained "serious harm". Prosecution barrister Jane Hyland said that in Irish law serious harm is defined as an injury that creates a substantial risk of death or causes serious disfigurement or substantial loss or impairment of mobility of the body or function of a bodily member or organ. Meanwhile, the jury also heard evidence from crèche workers who said that they noticed that the child had bruising on her cheek and forehead. One crèche worker said that she rang her manager and on her advice, she documented what she had spotted and took photographs of the injuries. She said that she noticed the bruising on the 15 December 2020 when the child was dropped off wearing a festive elf outfit. She stated that she felt the bruising was "unusual" in such a young child. She gave evidence that when she raised the matter with the mother of the child, she said that it was "nothing". No explanation was furnished for the bruising with the crèche worker saying that the mother "brushed it off". Another worker present that day said that they noticed a bruise on both the left and right cheek of the child. She said that there was no accident or incident in the crèche involving the child as it would have been documented. The case will continue tomorrow in front of a jury of seven women and five men.
