J Neurol Surg A Cent Eur Neurosurg 2015; 76(06): 456-465
DOI: 10.1055/s-0035-1551826
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Clinical, Radiologic, and Legal Significance of “Extensor Response” in Posttraumatic Coma

Raimund Firsching
1   Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Klinik für Neurochirurgie, Magdeburg, Germany
,
Dieter Woischneck
2   Klinikum Landshut, Klinik für Neurochirurgie, Landshut, Germany
,
Alexander Langejürgen
1   Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Klinik für Neurochirurgie, Magdeburg, Germany
,
Andreas Parreidt
1   Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Klinik für Neurochirurgie, Magdeburg, Germany
,
Imre Bondar
1   Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Klinik für Neurochirurgie, Magdeburg, Germany
,
Martin Skalej
3   Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Institut für Neuroradiologie, Magdeburg, Germany
,
Friedrich Röhl
4   Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Institut für Biometrie und Medizinische Informatik, Magdeburg, Germany
,
Benjamin Voellger
1   Otto-von-Guericke-Universität Magdeburg, Universitätsklinikum, Klinik für Neurochirurgie, Magdeburg, Germany
5   Universitätsklinikum Marburg, Klinik für Neurochirurgie, Marburg, Germany
› Author Affiliations
Further Information

Publication History

04 August 2014

06 February 2015

Publication Date:
27 July 2015 (online)

Abstract

Objective The timely detection of neurologic deterioration can be critical for the survival of a neurosurgical patient following head injury. Because little reliable evidence is available on the prognostic value of the clinical sign “extensor response” in comatose posttraumatic patients, we investigated the correlation of this clinical sign with outcome and with early radiologic findings from magnetic resonance imaging (MRI).

Methods This retrospective analysis of prospectively obtained data included 157 patients who had remained in a coma for a minimum of 24 hours after traumatic brain injury. All patients received a 1.5-T MRI within 10 days (median: 2 days) of the injury. The correlations between clinical findings 12 and 24 hours after the injury—in particular, extensor response and pupillary function, MRI findings, and outcome after 1 year—were investigated. Statistical analysis included contingency tables, Fisher exact test, odds ratios (ORs) with confidence intervals (CIs), and weighted κ values.

Results There were 48 patients with extensor response within the first 24 hours after the injury. Patients with extensor response (World Federation of Neurosurgical Societies coma grade III) statistically were significantly more likely to harbor MRI lesions in the brainstem when compared with patients in a coma who had no further deficiencies (coma grade I; p = 0.0004 by Fisher exact test, OR 10.8 with 95% CI, 2.7–42.5) and patients with unilateral loss of pupil function (coma grade II; p = 0.0187, OR 2.8 with 95% CI, 1.2–6.5). The correlation of brainstem lesions as found by MRI and outcome according to the Glasgow Outcome Scale after 1 year was also highly significant (p ≤ 0.016).

Conclusion The correlation of extensor response and loss of pupil function with an unfavorable outcome and with brainstem lesions revealed by MRI is highly significant. Their sudden onset may be associated with the sudden onset of brainstem dysfunction and should therefore be regarded as one of the most fundamental warning signs in the clinical monitoring of comatose patients.

 
  • References

  • 1 Chesnut RM, Temkin N, Carney N , et al; Global Neurotrauma Research Group. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012; 367 (26) 2471-2481
  • 2 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872) 81-84
  • 3 Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 1976; 34 (1–4) 45-55
  • 4 Firsching R, Woischneck D, Diedrich M , et al. Early magnetic resonance imaging of brainstem lesions after severe head injury. J Neurosurg 1998; 89 (5) 707-712
  • 5 Firsching R, Woischneck D, Klein S, Reissberg S, Döhring W, Peters B. Classification of severe head injury based on magnetic resonance imaging. Acta Neurochir (Wien) 2001; 143 (3) 263-271
  • 6 Brihaye J, Frowein RA, Lindgren S , et al. Report on the meeting of the WFNS Neuro-Traumatology Committee. Brussels. I. Coma scaling. Acta Neurochir (Wien) 1978; 40: 181-186
  • 7 Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975; 1 (7905) 480-484
  • 8 Frowein RA. Classification of coma. Acta Neurochir (Wien) 1976; 34 (1-4) 5-10
  • 9 Frowein RA, auf der Haar K, Terhaag D. Assessment of coma reliability of prognosis. Neurosurg Rev 1980; 3 (1) 67-74
  • 10 Sherrington CS. Decerebrate rigidity, and reflex coordination of movements. J Physiol 1898; 22 (4) 319-332
  • 11 Andrews PJ. Predicting recovery. J Neurosurg 2003; 98: 442
  • 12 Fernandez R, Firsching R, Lobato R , et al. Guidelines for treatment of head injury in adults. Opinions of a group of neurosurgeons. Zentralbl Neurochir 1997; 58 (2) 72-74
  • 13 Leitlinie der Deutschen Gesellschaft für Neurochirurgie (DGNC). Schädel-Hirn-Trauma im Erwachsenenalter. Available at: http://www.awmf.org/leitlinien/detail/ll/008-001.html . Accessed May 2, 2015
  • 14 Andrews PJ, Sleeman DH, Statham PF , et al. Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg 2002; 97 (2) 326-336
  • 15 Balestreri M, Czosnyka M, Chatfield DA , et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry 2004; 75 (1) 161-162
  • 16 Moskopp D, Stähle C, Wassmann H. Problems of the Glasgow Coma Scale with early intubated patients. Neurosurg Rev 1995; 18 (4) 253-257
  • 17 Starmark JE, Holmgren E, Stålhammar D. Current reporting of responsiveness in acute cerebral disorders. A survey of the neurosurgical literature. J Neurosurg 1988; 69 (5) 692-698
  • 18 Firsching R, Roehl FW, Woischneck DH, John N, Skalej M. The predictive value of ICP as compared to magnetic resonance imaging in comatose patients after head injury. Acta Neurochir Suppl (Wien) 2008; 102: 237-240
  • 19 Firsching RJ, Voellger B. Evidence-based indications for ICP recording after head injury. A review. Cent Eur Neurosurg 2010; 71 (3) 134-137
  • 20 Miller JD, Becker DP, Ward JD, Sullivan HG, Adams WE, Rosner MJ. Significance of intracranial hypertension in severe head injury. J Neurosurg 1977; 47 (4) 503-516
  • 21 Lazaridis C, DeSantis SM, Smielewski P , et al. Patient-specific thresholds of intracranial pressure in severe traumatic brain injury. J Neurosurg 2014; 120 (4) 893-900