Clinical examination for outcome prediction in nontraumatic coma
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Published on: February 6, 2021
David M Greer1, Jingyun Yang, Patricia D Scripko
1Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. david.greer@yale.edu
Objectives:
Determine the utility of the neurologic examination in comatose patients from nontraumatic causes in the modern era.
Design:
Prospective observational study.
Setting:
Single academic medical center.
Patients:
Data from 500 patients in nontraumatic coma collected sequentially from 2000 to 2007 in the emergency department and neuroscience, medical, and cardiac intensive care units.
Interventions:
None.
Measurements And Main Results:
Clinical data were collected on days 0, 1, 3, and 7. Outcome was assessed at 6 months; good outcome was determined at two levels by modified Rankin Scale, ≤3 as independence and ≤4 as moderate but not severe disability. A classification and regression tree analysis was performed to determine prognostic variables, creating predictive algorithms of good vs. poor outcome for each day. Patients with coma attributable to subarachnoid hemorrhage (4/80; 5%) or global hypoxic-ischemic injury (20/202, 10%) were more likely to achieve good outcomes. The pupillary reflex was an important determinant, regardless of day or modified Rankin Scale cut point (mean odds ratio 12.51, range [6.01, 22.56] for modified Rankin Scale ≤3; mean odds ratio 19.26, range [5.38, 42.26] for modified Rankin Scale ≤4). A less robust effect was seen for oculocephalic reflexes (mean odds ratio 62.61, range [2.24, 177] for modified Rankin Scale ≤3; mean odds ratio 34.13, range [4.95, 89.93] for modified Rankin Scale ≤4). The motor response was selected as a predictor of outcome only on day 0 (odds ratio 2.35, 95% confidence interval 0.64-5.74 for modified Rankin Scale ≤3; odds ratio 2.1, 95% confidence interval 0.81-4.24 for modified Rankin Scale score ≤4). Age was not associated with outcome.
Conclusions:
The clinical neurologic examination remains central to determining prognosis in nontraumatic coma. Additional clinical and diagnostic variables may also aid in outcome prediction for specific disease states.
