Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study

Demographics and clinical characteristics of acute traumatic brain injury patients in the different Neuroimaging Radiological Interpretation System (NIRIS) categories

PURPOSE

To characterize the demographics, clinical and imaging findings, and outcomes of traumatic brain injury (TBI) patients in each of NeuroImaging Radiological Interpretation System (NIRIS) categories.

MATERIAL AND METHODS

We considered all consecutive patients transported to Stanford Hospital's emergency department by ambulance or helicopter between November 2015 and April 2017. We retained adult patients (> 18 years old) for whom a trauma alert was triggered and who underwent a non-contrast head computer tomography (CT) because of suspected TBI. We reviewed the non-contrast CT scans in these patients for the NIH TBI common data elements (CDEs). We recorded, then assessed differences in terms of demographics, clinical characteristics, imaging CDEs, and outcomes in patients from the different NIRIS categories.

RESULTS

In all, 1152 patients were included in this study. Patients with NIRIS 0 imaging findings were significantly younger than patients in other NIRIS categories (P<0.001). Motor vehicle accidents and falls from height were the most common mechanisms of injury across NIRIS categories. GCS scores decreased with increasing NIRIS category imaging findings and were significantly lower in patients with NIRIS 4 imaging findings (P<0.001). Significant differences in NIRIS categories were observed for all imaging CDEs (P<0.001), in agreement with the definition of the different NIRIS categories. Mortality increased progressively with increasing NIRIS severity.

CONCLUSIONS

TBI patients in different NIRIS categories have different clinical characteristics, hospital courses and outcomes. This natural history assessment of patients from different NIRIS categories could thus serve as a reference standard for future TBI clinical trials.

The Evolving Concept of Damage Control in Neurotrauma: Application of Military Protocols in Civilian Settings with Limited Resources

OBJECTIVE

The aim of the present review was to describe the evolution of the damage control concept in neurotrauma, including the surgical technique and medical postoperative care, from the lessons learned from civilian and military neurosurgeons who have applied the concept regularly in practice at military hospitals and civilian institutions in areas with limited resources.

METHODS

The present narrative review was based on the experience of a group of neurosurgeons who participated in the development of the concept from their practice working in military theaters and low-resources settings with an important burden of blunt and penetrating cranial neurotrauma.

RESULTS

Damage control surgery in neurotrauma has been described as a sequential therapeutic strategy that supports physiological restoration before anatomical repair in patients with critical injuries. The application of the concept has evolved since the early definitions in 1998. Current strategies have been supported by military neurosurgery experience, and the concept has been applied in civilian settings with limited resources.

CONCLUSION

Damage control in neurotrauma is a therapeutic option for severe traumatic brain injury management in austere environments. To apply the concept while using an appropriate approach, lessons must be learned from experienced neurosurgeons who use this technique regularly.

Global Outcome Trajectories up to 10 Years After Moderate to Severe Traumatic Brain Injury

Aims: Based on important predictors, global functional outcome after traumatic brain injury (TBI) may vary significantly over time. This study sought to: (1) describe changes in the Glasgow Outcome Scale-Extended (GOSE) score in survivors of moderate to severe TBI, (2) examine longitudinal GOSE trajectories up to 10 years after injury, and (3) investigate predictors of these trajectories based on socio-demographic and injury characteristics. Methods: Socio-demographic and injury characteristics of 97 TBI survivors aged 16-55 years were recorded at baseline. GOSE was used as a measure of TBI-related global outcome and assessed at 1-, 2-, 5-, and 10-year follow-ups. Hierarchical linear models were used to examine global outcomes over time and whether those outcomes could be predicted by: time, time^*time, sex, age, partner relationship status, education, employment pre-injury, occupation, cause of injury, acute Glasgow Coma Scale score, length of post-traumatic amnesia (PTA), CT findings, and Injury Severity Score (ISS), as well as the interactions between each of the significant predictors and time^*time. Results: Between 5- and 10-year follow-ups, 37% had deteriorated, 7% had improved, and 56% showed no change in global outcome. Better GOSE trajectories were predicted by male gender (p = 0.013), younger age (p = 0.012), employment at admission (p = 0.012), white collar occupation (p = 0.014), and shorter PTA length (p = 0.001). The time^*time^*occupation type interaction effect (p = 0.001) identified different trajectory slopes between survivors in white and blue collar occupations. The time^*time^*PTA interaction effect (p = 0.023) identified a more marked increase and subsequent decrease in functional level among survivors with longer PTA duration. Conclusion: A larger proportion of survivors experienced deterioration in GOSE scores over time, supporting the concept of TBI as a chronic health condition. Younger age, pre-injury employment, and shorter PTA duration are important prognostic factors for better long-term global outcomes, supporting the existing literature, whereas male gender and white collar occupation are vaguer as prognostic factors. This information suggests that more intensive and tailored rehabilitation programs may be required to counteract a negative global outcome development in survivors with predicted worse outcome and to meet their long-term changing needs.

Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series

BACKGROUND

Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on.

METHODS

This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed.

RESULTS

At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5.

CONCLUSIONS

The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.

Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection

Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.

Predictive utility of an adapted Marshall head CT classification scheme after traumatic brain injury

OBJECTIVE

To study the predictive relationship among persons with traumatic brain injury (TBI) between an objective indicator of injury severity (the adapted Marshall computed tomography [CT] classification scheme) and clinical indicators of injury severity in the acute phase, functional outcomes at inpatient rehabilitation discharge, and functional and participation outcomes at 1 year after injury, including death.

PARTICIPANTS

The sample involved 4895 individuals who received inpatient rehabilitation following acute hospitalization for TBI and were enrolled in the Traumatic Brain Injury Model Systems National Database between 1989 and 2014.

DESIGN

Head CT variables for each person were fit into adapted Marshall CT classification categories I through IV.

MAIN MEASURES

Prediction models were developed to determine the amount of variability explained by the CT classification categories compared with commonly used predictors, including a clinical indicator of injury severity.

RESULTS

The adapted Marshall classification categories aided only in the prediction of craniotomy or craniectomy during acute hospitalization, otherwise making no meaningful contribution to variance in the multivariable models predicting outcomes at any time point after injury.

CONCLUSION

Results suggest that head CT findings classified in this manner do not inform clinical discussions related to functional prognosis or rehabilitation planning after TBI.

ABBREVIATIONS

CT: computed tomography; DRS: disability rating scale; EGOS: extended Glasgow outcome scale; FIM: functional independence measure; NDB: National Data Base; PTA: posttraumatic amnesia; RLOS: rehabilitation length of stay; SPOS: semipartial omega squared statistic; TBI: traumatic brain injury; TBIMS: Traumatic Brain Injury Model Systems.

Central versus Local Radiological Reading of Acute Computed Tomography Characteristics in Multi-Center Traumatic Brain Injury Research

Observer variability in local radiological reading is a major concern in large-scale multi-center traumatic brain injury (TBI) studies. A central review process has been advocated to minimize this variability. The aim of this study is to compare central with local reading of TBI imaging datasets and to investigate the added value of central review. A total of 2050 admission computed tomography (CT) scans from subjects enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study were analyzed for seven main CT characteristics. Kappa statistics were used to calculate agreement between central and local evaluations and a center-specific analysis was performed. The McNemar test was used to detect whether discordances were significant. Central interobserver and intra-observer agreement was calculated in a subset of patients. Good agreement was found between central and local assessment for the presence or absence of structural pathology (CT+, CT-, κ = 0.73) and most CT characteristics (κ = 0.62 to 0.71), except for traumatic axonal injury lesions (κ = 0.37). Despite good kappa values, discordances were significant in four of seven CT characteristics (i.e., midline shift, contusion, traumatic subarachnoid hemorrhage, and cisternal compression; p = 0.0005). Central reviewers showed substantial to excellent interobserver and intra-observer agreement (κ = 0.73 to κ = 0.96), contrasted by considerable variability in local radiological reading. Compared with local evaluation, a central review process offers a more consistent radiological reading of acute CT characteristics in TBI. It generates reliable, reproducible data and should be recommended for use in multi-center TBI studies.

Final outcome trends in severe traumatic brain injury: a 25-year analysis of single center data

BACKGROUND

Evidence from the last 25 years indicates a modest reduction of mortality after severe traumatic head injury (sTBI). This study evaluates the variation over time of the whole Glasgow Outcome Scale (GOS) throughout those years.

METHODS

The study is an observational cohort study of adults (≥ 15 years old) with closed sTBI (GCS ≤ 8) who were admitted within 48 h after injury. The final outcome was the 1-year GOS, which was divided as follows: (1) dead/vegetative, (2) severely disabled (dependent patients), and (3) good/moderate recovery (independent patients). Patients were treated uniformly according to international protocols in a dedicated ICU. We considered patient characteristics that were previously identified as important predictors and could be determined easily and reliably. The admission years were divided into three intervals (1987-1995, 1996-2004, and 2005-2012), and the following individual CT characteristics were noted: the presence of traumatic subarachnoid or intraventricular hemorrhage (tSAH, IVH), midline shift, cisternal status, and the volume of mass lesions (A × B × C/2). Ordinal logistic regression was performed to estimate associations between predictors and outcomes. The patients' estimated propensity scores were included as an independent variable in the ordinal logistic regression model (TWANG R package).

FINDINGS

The variables associated with the outcome were age, pupils, motor score, deterioration, shock, hypoxia, cistern status, IVH, tSAH, and epidural volume. When adjusting for those variables and the propensity score, we found a reduction in mortality from 55% (1987-1995) to 38% (2005-2012), but we discovered an increase in dependent patients from 10 to 21% and just a modest increase in independent patients of 6%.

CONCLUSIONS

This study covers 25 years of management of sTBI in a single neurosurgical center. The prognostic factors are similar to those in the literature. The improvement in mortality does not translate to better quality of life.

Risk factors predicting prognosis and outcome of elderly patients with isolated traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI), particularly in the elderly patient population, is known to be the single largest cause of death and disability worldwide. The purpose of this retrospective study was to evaluate clinical factors predicting poor outcome with special emphasis on the impact of respiratory failure (RF) on mortality in elderly patients with isolated severe TBI.

METHODS

All elderly patients (age ≥ 65 years) with isolated severe head injury, admitted to this level I trauma center, during a period of 18 years (from January 1992 to December 2010) were identified from the trauma registry. The medical records were reviewed for demographics, mechanism of injury (MOI), GCS score at admission, RF, pupillary light reflex (LR), CT findings (subdural hematoma, subarachnoid hematoma, edema, midline-shift), and whether there was conservative treatment or surgical intervention and the Glasgow Outcome Score (GOS) at hospital discharge. Stepwise logistic regression analysis was used to identify risk factors for a poor prognosis and outcome.

RESULTS

The following variables influenced the mortality: respiratory failure, pupillary response, and the injury severity score (ISS). A significant increased risk of death was also found for patients with a midline shift of over 15 mm.

CONCLUSIONS

The present study predicts a strong correlation between respiratory failure, pathological pupillary response, a higher ISS, and substantial midline shift with poor outcomes in elderly patients sustaining an isolated severe TBI.

TRIAL REGISTRATION

Clinical trials: ID: NCT02386865 . Registered 12 March 2015-retrospectively registered.

Modified Revised Trauma-Marshall score as a proposed tool in predicting the outcome of moderate and severe traumatic brain injury

Background

Traumatic brain injury (TBI) is a common healthcare problem related to disability. An easy-to-use trauma scoring system informs physicians about the severity of trauma and helps to decide the course of management. The purpose of this study is to use the combination of both physiological and anatomical assessment tools that predict the outcome and develop a new modified prognostic scoring system in TBIs.

Patients and methods

A total of 181 subjects admitted to the emergency department (ED) of Sanglah General Hospital were documented for both Marshall CT scan classification score (MCTC) and Revised Trauma Score (RTS) upon admission. Glasgow Outcome Scale (GOS) was then documented at six months after brain injury. A new Modified Revised Trauma–Marshall score (m-RTS) was developed using statistical analytic methods.

Results

The total sample enrolled for this study was 181 patients. The mean RTS upon admission was 10.2±1.2. Of the 181 subjects, 110 (60.8%) were found to have favorable GOS (GOS score >3). Best Youden’s index results were obtained with any of the RTS of ≤10 with area under receiver operating characteristic (ROC) curve of 0.2542 and with risk ratio of 2.9 (95% CI=1.98−4.28; P=0.001); and Marshall score ≤2 with area under ROC curve of 0.2249 with risk ratio of 3.9 (95% CI=2.52−5.89; P=0.001). The RTS–Marshall combination has higher sensitivity with risk ratio of 4.5 (CI 95%=2.55−8.0; P=0.001) for screening tools of unfavorable outcome. The Pearson’s correlation between RTS and Marshall classification is 0.464 (P<0.001).

Conclusion

Combination of physiological and anatomical score improves the prognostic of outcome in moderate and severe TBI patients, formulated in this accurate, simple, applicable and reliable m-RTS prognostic score model.

Prognostication of chronic disorders of consciousness using brain functional networks and clinical characteristics

Disorders of consciousness are a heterogeneous mixture of different diseases or injuries. Although some indicators and models have been proposed for prognostication, any single method when used alone carries a high risk of false prediction. This study aimed to develop a multidomain prognostic model that combines resting state functional MRI with three clinical characteristics to predict one year-outcomes at the single-subject level. The model discriminated between patients who would later recover consciousness and those who would not with an accuracy of around 88% on three datasets from two medical centers. It was also able to identify the prognostic importance of different predictors, including brain functions and clinical characteristics. To our knowledge, this is the first reported implementation of a multidomain prognostic model that is based on resting state functional MRI and clinical characteristics in chronic disorders of consciousness, which we suggest is accurate, robust, and interpretable.

Disorders of Consciousness in China

With the development of modern international medicine, the subject of disorders of consciousness (DOCs) has begun to be raised in mainland China. Much progress has been made to date in several specialties related to the management of chronic DOC patients in China. In this article, we briefly review the present status of DOC studies in China, specifically concerning diagnosis, prognosis, therapy, and rehabilitation. The development of DOC-related scientific organizations and activities in China are introduced. Some weaknesses that need improvement are also noted. The current program provides a good foundation for future development.

Simplifying the use of prognostic information in traumatic brain injury. Part 2: Graphical presentation of probabilities

OBJECTIVE Clinical features such as those included in the Glasgow Coma Scale (GCS) score, pupil reactivity, and patient age, as well as CT findings, have clear established relationships with patient outcomes due to neurotrauma. Nevertheless, predictions made from combining these features in probabilistic models have not found a role in clinical practice. In this study, the authors aimed to develop a method of displaying probabilities graphically that would be simple and easy to use, thus improving the usefulness of prognostic information in neurotrauma. This work builds on a companion paper describing the GCS-Pupils score (GCS-P) as a tool for assessing the clinical severity of neurotrauma. METHODS Information about early GCS score, pupil response, patient age, CT findings, late outcome according to the Glasgow Outcome Scale, and mortality were obtained at the individual adult patient level from the CRASH (Corticosteroid Randomisation After Significant Head Injury; n = 9045) and IMPACT (International Mission for Prognosis and Clinical Trials in TBI; n = 6855) databases. These data were combined into a pooled data set for the main analysis. Logistic regression was first used to model the combined association between the GCS-P and patient age and outcome, following which CT findings were added to the models. The proportion of variability in outcomes "explained" by each model was assessed using Nagelkerke's R². RESULTS The authors observed that patient age and GCS-P have an additive effect on outcome. The probability of mortality 6 months after neurotrauma is greater with increasing age, and for all age groups the probability of death is greater with decreasing GCS-P. Conversely, the probability of favorable recovery becomes lower with increasing age and lessens with decreasing GCS-P. The effect of combining the GCS-P with patient age was substantially more informative than the GCS-P, age, GCS score, or pupil reactivity alone. Two-dimensional charts were produced displaying outcome probabilities, as percentages, for 5-year increments in age between 15 and 85 years, and for GCS-Ps ranging from 1 to 15; it is readily seen that the movement toward combinations at the top right of the charts reflects a decreasing likelihood of mortality and an increasing likelihood of favorable outcome. Analysis of CT findings showed that differences in outcome are very similar between patients with or without a hematoma, absent cisterns, or subarachnoid hemorrhage. Taken in combination, there is a gradation in risk that aligns with increasing numbers of any of these abnormalities. This information provides added value over age and GCS-P alone, supporting a simple extension of the earlier prognostic charts by stratifying the original charts in the following 3 CT groupings: none, only 1, and 2 or more CT abnormalities. CONCLUSIONS The important prognostic features in neurotrauma can be brought together to display graphically their combined effects on risks of death or on prospects for independent recovery. This approach can support decision making and improve communication of risk among health care professionals, patients, and their relatives. These charts will not replace clinical judgment, but they will reduce the risk of influences from biases.

Cranioplasty After Severe Traumatic Brain Injury: Effects of Trauma and Patient Recovery on Cranioplasty Outcome

Background

In patients with severe traumatic brain injury (sTBI) treated with decompressive craniectomy (DC), factors affecting the success of later cranioplasty are poorly known.

Objective

We sought to investigate if injury- and treatment-related factors, and state of recovery could predict the risk of major complications in cranioplasty requiring implant removal, and how these complications affect the outcome.

Methods

A retrospective cohort of 40 patients with DC following sTBI and subsequent cranioplasty was studied. Non-injury-related factors were compared with a reference population of 115 patients with DC due to other conditions.

Results

Outcome assessed 1 day before cranioplasty did not predict major complications leading to implant removal. Successful cranioplasty was associated with better outcome, whereas a major complication attenuates patient recovery: in patients with favorable outcome assessed 1 year after cranioplasty, major complication rate was 7%, while in patients with unfavorable outcome the rate was 42% (p = 0.003). Of patients with traumatic subarachnoid hemorrhage (tSAH) on admission imaging 30% developed a major complication, while none of patients without tSAH had a major complication (p = 0.014). Other imaging findings, age, admission Glasgow Coma Scale, extracranial injuries, length of stay at intensive care unit, cranioplasty materials, and timing of cranioplasty were not associated with major complications.

Conclusion

A successful cranioplasty after sTBI and DC predicts favorable outcome 1 year after cranioplasty, while stage of recovery before cranioplasty does not predict cranioplasty success or failure. tSAH on admission imaging is a major risk factor for a major complication leading to implant removal.

The Optimal Operative Timing of Traumatic Intracranial Acute Subdural Hematoma Correlated with Outcome

Objective

Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH.

Materials and Methods

The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups.

Results

The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome.

Conclusions

The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.

Clinical characteristics and prognosis of traumatic head injury following road traffic accidents admitted in ICU "analysis of 694 cases"

BACKGROUND

The aim of the present study is to analyze the clinical and epidemiological characteristics of Traumatic Brain Injury (TBI) following Road Traffic Accidents (RTAs). Moreover, we aim to evaluate the outcome of the TBI victims referred to our medico-surgical Intensive Care Unit (ICU), and to define predictive factors associated with poor prognosis.

METHODS

A retrospective study over a 4-year period (2009 to 2012) of 694 patients with head injuries, incurred during road traffic accidents, admitted to the Intensive Care Unit (ICU) of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological, and radiological data were recorded on admission and during the ICU stay.

RESULTS

There were 592 males (85.3%), and 102 female patients. The mean age was at 31.8 ± 17.8 years (range 1-91). The mechanism of the accident was detailed in 666 patients (96%). The majority of the victims were motorcycle riders and/or passengers (40.5%), followed by pedestrians (29.1%). Extra-cranial pathology was present in 452 patients (65%). A total of 677 patients (97.6%) required intubation, mechanical ventilation, and sedation. Mean ICU stay was 16 ± 17.4 days. A total of 187 patients (26.9%) died during their hospital stay. The GOS performed within a mean delay of 6 months after hospital discharge was as follows: 198 deaths (28.5%), 13 vegetative state (1.9%), and 349 (50.3%) good recovery and/or moderate disability. A multivariate analysis showed that the factors which correlated with a poor prognosis (mortality and severe disability) were: age > 38 years, Glasgow coma scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic).

CONCLUSION

In Tunisia, traumatic brain injury due to RTAs is a frequent cause of ICU admission, especially among young adults, and is associated with high mortality and morbidity rates. The majority of the victims were motorcycle riders and/or passengers and pedestrians. The factors associated with a poor outcome were: age > 38 years, Glasgow Coma Scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic). As a consequence, prevention is highly warranted.

Increased risk of subdural hematoma in patients with liver cirrhosis

BACKGROUND

Subdural hematoma (SDH) is associated with a high mortality rate. The risk of SDH in cirrhotic patients has not been well studied.

AIM

The aim of the study was to examine the risk of SDH in cirrhotic patients.

DESIGN

A retrospective study from a universal insurance claims database of Taiwan.

METHODS

A cohort of 9455 liver cirrhotic patients from 2000 to 2011 and an age-and sex-matched control cohort of 35992 subjects without cirrhosis were identified. The severity of liver cirrhosis was classified into uncomplicated and complicated according to presence of complications or not. The incidence and hazard ratio of SDH were measured by the end of 2011.

RESULTS

The mean follow-up years were 4.34 ± 3.45 years in the cirrhosis cohort and 6.36 ± 3.28 years in the non-cirrhosis cohort. The incidence of SDH was 2.73-fold higher in the cirrhosis cohort than in the control cohort (29.3 vs. 10.9 per 10 000 person-years), with an adjusted hazard ratio of 2.73 (95% CI = 2.19-3.42), 2.42 (95% CI = 1.89-3.08), and 5.07 (95% CI = 3.38-7.60) in the all liver cirrhosis, the uncomplicated liver cirrhosis, and the complicated liver cirrhosis patients compared to the control cohort. The adjusted hazard ratios were 2.65 (95% CI = 2.06-3.41) for traumatic SDH and 3.09 (95% CI 1.91-5.02) for non-traumatic SDH in liver cirrhosis patients, compared to the controls.

CONCLUSIONS

This study demonstrates that patients with cirrhosis are at higher risk of both traumatic and non-traumatic SDH than individuals without cirrhosis. The risk increases further in patients with complicated liver cirrhosis.

β-Blocker after severe traumatic brain injury is associated with better long-term functional outcome: a matched case control study

PURPOSE

Severe traumatic brain injury (TBI) is the predominant cause of death and disability following trauma. Several studies have observed improved survival in TBI patients exposed to β-blockers, however, the effect on functional outcome is poorly documented.

METHODS

Adult patients with severe TBI (head AIS ≥ 3) were identified from a prospectively collected TBI database over a 5-year period. Patients with neurosurgical ICU length of stay <48 h and those dying within 48 h of admission were excluded. Patients exposed to β-blockers ≤ 48 h after admission and who continued with treatment until discharge constituted β-blocked cases and were matched to non β-blocked controls using propensity score matching. The outcome of interest was Glasgow Outcome Scores (GOS), as a measure of functional outcome up to 12 months after injury. GOS ≤ 3 was considered a poor outcome. Bivariate analysis was deployed to determine differences between groups. Odds ratio and 95% CI were used to assess the effect of β-blockers on GOS.

RESULTS

362 patients met the inclusion criteria with 21% receiving β-blockers during admission. After propensity matching, 76 matched pairs were available for analysis. There were no statistical differences in any variables included in the analysis. Mean hospital length of stay was shorter in the β-blocked cases (18.0 vs. 26.8 days, p < 0.01). The risk of poor long-term functional outcome was more than doubled in non-β-blocked controls (OR 2.44, 95% CI 1.01-6.03, p = 0.03).

CONCLUSION

Exposure to β-blockers in patients with severe TBI appears to improve functional outcome. Further prospective randomized trials are warranted.

Regional brain morphometry in patients with traumatic brain injury based on acute- and chronic-phase magnetic resonance imaging

Traumatic brain injury (TBI) is caused by a sudden external force and can be very heterogeneous in its manifestation. In this work, we analyse T1-weighted magnetic resonance (MR) brain images that were prospectively acquired from patients who sustained mild to severe TBI. We investigate the potential of a recently proposed automatic segmentation method to support the outcome prediction of TBI. Specifically, we extract meaningful cross-sectional and longitudinal measurements from acute- and chronic-phase MR images. We calculate regional volume and asymmetry features at the acute/subacute stage of the injury (median: 19 days after injury), to predict the disability outcome of 67 patients at the chronic disease stage (median: 229 days after injury). Our results indicate that small structural volumes in the acute stage (e.g. of the hippocampus, accumbens, amygdala) can be strong predictors for unfavourable disease outcome. Further, group differences in atrophy are investigated. We find that patients with unfavourable outcome show increased atrophy. Among patients with severe disability outcome we observed a significantly higher mean reduction of cerebral white matter (3.1%) as compared to patients with low disability outcome (0.7%).

Revisiting Grade 3 Diffuse Axonal Injury: Not All Brainstem Microbleeds are Prognostically Equal

BACKGROUND

Recovery of functional independence is possible in patients with brainstem traumatic axonal injury (TAI), also referred to as "grade 3 diffuse axonal injury," but acute prognostic biomarkers are lacking. We hypothesized that the extent of dorsal brainstem TAI measured by burden of traumatic microbleeds (TMBs) correlates with 1-year functional outcome more strongly than does ventral brainstem, corpus callosal, or global brain TMB burden. Further, we hypothesized that TMBs within brainstem nuclei of the ascending arousal network (AAN) correlate with 1-year outcome.

METHODS

Using a prospective outcome database of patients treated for moderate-to-severe traumatic brain injury at an inpatient rehabilitation hospital, we retrospectively identified 39 patients who underwent acute gradient-recalled echo (GRE) magnetic resonance imaging (MRI). TMBs were counted on the acute GRE scans globally and in the dorsal brainstem, ventral brainstem, and corpus callosum. TMBs were also mapped onto an atlas of AAN nuclei. The primary outcome was the disability rating scale (DRS) score at 1 year post-injury. Associations between regional TMBs, AAN TMB volume, and 1-year DRS score were assessed by calculating Spearman rank correlation coefficients.

RESULTS

Mean ± SD number of TMBs was: dorsal brainstem = 0.7 ± 1.4, ventral brainstem = 0.2 ± 0.6, corpus callosum = 1.8 ± 2.8, and global = 14.4 ± 12.5. The mean ± SD TMB volume within AAN nuclei was 6.1 ± 18.7 mm3. Increased dorsal brainstem TMBs and larger AAN TMB volume correlated with worse 1-year outcomes (R = 0.37, p = 0.02, and R = 0.36, p = 0.02, respectively). Global, callosal, and ventral brainstem TMBs did not correlate with outcomes.

CONCLUSIONS

These findings suggest that dorsal brainstem TAI, especially involving AAN nuclei, may have greater prognostic utility than the total number of lesions in the brain or brainstem.

Severe traumatic brain injury: targeted management in the intensive care unit

Severe traumatic brain injury (TBI) is currently managed in the intensive care unit with a combined medical-surgical approach. Treatment aims to prevent additional brain damage and to optimise conditions for brain recovery. TBI is typically considered and treated as one pathological entity, although in fact it is a syndrome comprising a range of lesions that can require different therapies and physiological goals. Owing to advances in monitoring and imaging, there is now the potential to identify specific mechanisms of brain damage and to better target treatment to individuals or subsets of patients. Targeted treatment is especially relevant for elderly people-who now represent an increasing proportion of patients with TBI-as preinjury comorbidities and their therapies demand tailored management strategies. Progress in monitoring and in understanding pathophysiological mechanisms of TBI could change current management in the intensive care unit, enabling targeted interventions that could ultimately improve outcomes.

Formulation of a Three-Tier Cisternal Grade as a Predictor of In-Hospital Outcome from a Prospective Study of Patients with Traumatic Intracranial Hematoma

OBJECTIVE

Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score.

METHODS

Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome.

RESULTS

Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels.

CONCLUSIONS

The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.

A Novel Triage Tool: Optic Nerve Sheath Diameter in Traumatic Brain Injury and its Correlation to Rotterdam Computed Tomography (CT) Scoring

Background

Optic nerve sheath diameter (ONSD) evaluated in CT imaging as well as Rotterdam CT Score (RCTS) are proven independent predictors of outcome in patients with traumatic brain injury (TBI). To date, no study has correlated ONSD on admission CT scan with RCTS.

Material/Methods

Retrospective cohort study comprised of consecutive patients undergoing CT imaging for traumatic brain injury recruited between January and October 2015. Bilateral ONSD was measured 3 mm behind the eyeball in axial and sagittal planes and mean value was calculated. RCTS was assessed on the same CT images, bias was eliminated by blinding RCTS to ONSD measurement.

Results

150 patients were included; mean age in the group was 42.94±16.7 years. ONSD in mild TBI, RCTS 2 and 3 were 3.3 mm (SD 0.39 mm) and 4.1 mm (0.047 mm), respectively. Mean ONSD in moderate and severe TBI (RCTS score 4 and above) was 4.83 mm and above, SD 0.4 mm. Mean ONSD correlated with occurrence of diffuse cerebral oedema, presence of subdural and extradural hematoma; however in isolation there was no statistical significance.

Conclusions

Higher ONSD was observed in patients with moderate and severe TBI, correlating with admission RCTS of 4 and above. Subsequent increase in ONSD was also found with increase in RCTS. ONSD could serve as an initial triage tool in the emergency department as well as a method of determining the need for sequential CT in patients with mild TBI.

Acute brain trauma, lung injury, and pneumonia: more than just altered mental status and decreased airway protection

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Even when patients survive the initial insult, there is significant morbidity and mortality secondary to subsequent pulmonary edema, acute lung injury (ALI), and nosocomial pneumonia. Whereas the relationship between TBI and secondary pulmonary complications is recognized, little is known about the mechanistic interplay of the two phenomena. Changes in mental status secondary to acute brain injury certainly impair airway- and lung-protective mechanisms. However, clinical and translational evidence suggests that more specific neuronal and cellular mechanisms contribute to impaired systemic and lung immunity that increases the risk of TBI-mediated lung injury and infection. To better understand the cellular mechanisms of that immune impairment, we review here the current clinical data that support TBI-induced impairment of systemic and lung immunity. Furthermore, we also review the animal models that attempt to reproduce human TBI. Additionally, we examine the possible role of damage-associated molecular patterns, the chlolinergic anti-inflammatory pathway, and sex dimorphism in post-TBI ALI. In the last part of the review, we discuss current treatments and future pharmacological therapies, including fever control, tracheostomy, and corticosteroids, aimed to prevent and treat pulmonary edema, ALI, and nosocomial pneumonia after TBI.

Early Brain Edema is a Predictor of In-Hospital Mortality in Traumatic Brain Injury

BACKGROUND

Identifying patients who may progress to a poor clinical outcome will encourage earlier appropriate therapeutic interventions. Brain edema may contribute to secondary injury in traumatic brain injury (TBI) and thus, may be a useful prognostic indicator.

OBJECTIVE

We determined whether the presence of brain edema on the initial computed tomography (CT) scan of TBI patients would predict poor in-hospital outcome.

METHODS

We performed a retrospective review of all trauma patients with nonpenetrating head trauma at a Level I Trauma Center. International Classification of Diseases, Ninth Revision codes indicated the presence of brain edema and we evaluated the validity of this pragmatic assessment quantitatively in a random subset of patients. In-hospital mortality was the primary outcome variable. Univariate analysis and logistic regression identified predictors of mortality in all TBI patients and those with mild TBI.

RESULTS

Over 7200 patients were included in the study, including 6225 with mild TBI. Measurements of gray and white matter CT density verified radiological assessments of brain edema. Patients with documented brain edema had a mortality rate over 10 times that of the entire study population. With logistic regression accounting for Injury Severity Score, Glasgow Coma Scale score, other CT findings, and clinical variables, brain edema predicted an eightfold greater mortality rate in all patients (odds ratio 8.0, 95% confidence interval 4.6-14.0) and fivefold greater mortality rate for mild TBI patients (odds ratio 4.9, 95% confidence interval 2.0-11.7).

CONCLUSIONS

Brain edema is an independent prognostic variable across all categories of TBI severity. By alerting emergency physicians to patients with poor predicted clinical outcomes, this finding will drive better resource allocation, earlier intervention, and reduced patient mortality.

Commonly available CT characteristics and prediction of outcome in traumatic brain injury patients

Background: Acute Computerized Tomography (CT) characteristics are used widely and most accepted for prediction of outcome among Traumatic Brain Injury (TBI). The commonly available and simple combinations of existing and unexplored CT parameters may be more useful in prediction of outcome. The present study explores commonly available CT characteristics by possible combinations based on anatomical basics.

Methods: Abnormal CT sign was considered with any cranial lesion. Based on anatomical locations of cortical lobes, nine possibilities were made that include individual and combinations of mentioned lobes. The laterality was either right or left or bilateral. The outcome was favourable or unfavourable based on discharge Glasgow Outcome Scale (GOS). Binary logistic regression was used to predict outcome.

Results: 452 patients were recruited in the present study. There was significant risk of unfavourable outcome among patients with location of Sub Dural Haemorrhage (SDH) in Parietal + Temporal region (OR=10,p<0.001); Cerebral Contusion in Temporal region (OR=3,p=0.03), Frontal + Temporal region(OR=16,P=0.001), Frontal + Parietal + Temporal region (OR=18.7,p<0.001). Patients with four abnormal CT signs had worst outcome. Presence of SDH on right side (OR=4.5,p<0.001) and bilateral Cerebral Contusion (OR=4.5,p=0.003) was at the risk of unfavourable outcome.

Conclusion: The present study based on anatomical classification has shown that location and laterality of lesion can significantly predict TBI outcome.

Computed tomography and clinical outcome in patients with severe traumatic brain injury

OBJECTIVE

To study: (i) acute computed tomography (CT) characteristics and clinical outcome; (ii) clinical course and (iii) Corticosteroid Randomisation after Significant Head Injury acute calculator protocol (CRASH) model and clinical outcome in patients with severe traumatic brain injury (sTBI).

METHODS

Initial CT (CT_i) and CT 24 hours post-trauma (CT₂₄) were evaluated according to Marshall and Rotterdam classifications. Rancho Los Amigos Cognitive Scale-Revised (RLAS-R) and Glasgow Outcome Scale Extended (GOSE) were assessed at three months and one year post-trauma. The prognostic value of the CRASH model was evaluated.

RESULTS

Thirty-seven patients were included. Marshall CT_i and CT₂₄ were significantly correlated with RLAS-R at three months. Rotterdam CT₂₄ was significantly correlated with GOSE at three months. RLAS-R and the GOSE improved significantly from three months to one year. CRASH predicted unfavourable outcome at six months for 81% of patients with bad outcome and for 85% of patients with favourable outcome according to GOSE at one year.

CONCLUSION

Neither CT nor CRASH yielded clinically useful predictions of outcome at one year post-injury. The study showed encouragingly many instances of significant recovery in this population of sTBI. The combination of lack of reliable prognostic indicators and favourable outcomes supports the case for intensive acute management and rehabilitation as the default protocol in the cases of sTBI.

The trajectories of overall disability in the first 5 years after moderate and severe traumatic brain injury

PRIMARY OBJECTIVES

To assess longitudinal trajectories of overall disability after moderate-to-severe traumatic brain injury (TBI) and to examine whether those trajectories could be predicted by socio-demographic and injury characteristics.

METHODS

Demographics and injury characteristics of 105 individuals with moderate-to-severe TBI were extracted from medical records. At the 1-, 2-, and 5-year follow-ups, TBI-related disability was assessed by the GOSE. A hierarchical linear model (HLM) was used to examine functional outcomes up to 5 years following injury and whether those outcomes could be predicted by: time, gender, age, relationship, education, employment pre-injury, occupation, GCS, cause of injury, length of post-traumatic amnesia (PTA), CT findings and injury severity score, as well as the interactions between each of these predictors and time.

RESULTS

Higher GOSE trajectories (lower disability) were predicted by younger age at injury and shorter PTA, as well as by the interaction terms of time*PTA and time*employment. Those who had been employed at injury decreased in disability over time, while those who had been unemployed increased in disability.

CONCLUSION

The study results support the view that individual factors generally outweigh injury-related factors as predictors of disability after TBI, except for PTA.

Sequential changes in Rotterdam CT scores related to outcomes for patients with traumatic brain injury who undergo decompressive craniectomy

OBJECT

Rotterdam CT scoring is a CT classification system for grouping patients with traumatic brain injury (TBI) based on multiple CT characteristics. This retrospective study aimed to determine the relationship between initial or preoperative Rotterdam CT scores and TBI prognosis after decompressive craniectomy (DC).

METHODS

The authors retrospectively reviewed the medical records of all consecutive patients who underwent DC for nonpenetrating TBI in 2 hospitals from January 2006 through December 2013. Univariate and multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used to determine the relationship between initial or preoperative Rotterdam CT scores and mortality at 30 days or Glasgow Outcome Scale (GOS) scores at least 3 months after the time of injury. Unfavorable outcomes were GOS Scores 1–3 and favorable outcomes were GOS Scores 4 and 5.

RESULTS

A total of 48 cases involving patients who underwent DC for TBI were included in this study. Univariate analyses showed that initial Rotterdam CT scores were significantly associated with mortality and both initial and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes. Multivariable logistic regression analysis adjusted for established predictors of TBI outcomes showed that initial Rotterdam CT scores were significantly associated with mortality (OR 4.98, 95% CI 1.40–17.78, p = 0.01) and unfavorable outcomes (OR 3.66, 95% CI 1.29–10.39, p = 0.02) and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes (OR 15.29, 95% CI 2.50–93.53, p = 0.003). ROC curve analyses showed cutoff values for the initial Rotterdam CT score of 5.5 (area under the curve [AUC] 0.74, 95% CI 0.59–0.90, p = 0.009, sensitivity 50.0%, and specificity 88.2%) for mortality and 4.5 (AUC 0.71, 95% CI 0.56–0.86, p = 0.02, sensitivity 62.5%, and specificity 75.0%) for an unfavorable outcome and a cutoff value for the preoperative Rotterdam CT score of 4.5 (AUC 0.81, 95% CI 0.69–0.94, p < 0.001, sensitivity 90.6%, and specificity 56.2%) for an unfavorable outcome.

CONCLUSIONS

Assessment of changes in Rotterdam CT scores over time may serve as a prognostic indicator in TBI and can help determine which patients require DC.

Relationship between quality-of-life after 1-year follow-up and severity of traumatic brain injury assessed by computerized tomography

PURPOSE

This paper studies the relationship between computed tomography (CT) scan on admission, according to Marshall's tomographic classification, and quality-of-life (QoL) after 1 year in patients admitted to the Intensive Care Unit (ICU) with traumatic brain injury (TBI).

METHODS

This study used validated scales including the Glasgow Outcome Scale and the PAECC (Project for the Epidemiologic Analysis of Critical Care Patients) QoL questionnaire.

RESULTS

We enrolled 531 patients. After 1 year, 171 patients (32.2%) had died (missing data = 6.6%). Good recovery was seen in 22.7% of the patients, while 20% presented moderate disability. The PAECC score after 1 year was 9.43 ± 8.72 points (high deterioration). Patients with diffuse injury I had a mean of 5.08 points vs 7.82 in those with diffuse injury II, 11.76 in those with diffuse injury III and 19.29 in those with diffuse injury IV (p < 0.001). Multivariate analysis found that QoL after 1 year was associated with CT Marshall classification, depth of coma, age, length of stay, spinal injury and tracheostomy.

CONCLUSIONS

Patients with TBI had a high mortality rate 1 year after admission, deterioration in QoL and significant impairment of functional status, although more than 40% were normal or self-sufficient. QoL after 1 year was strongly related to cranial CT findings on admission.

Role of computed tomography scores and findings to predict early death in patients with traumatic brain injury: A reappraisal in a major tertiary care hospital in Nepal

Background:

Glasgow Coma Scale has been a long sought model to classify patients with head injury. However, the major limitation of the score is its assessment in the patients who are either sedated or under the influence of drugs or intubated for airway protection. The rational approach for prognostication of such patients is the utility of scoring system based on the morphological criteria based on radiological imaging. Among the current armamentarium, a scoring system based on computed tomography (CT) imaging holds the greatest promise in conquering our conquest for the same.

Methods:

We included a total of 634 consecutive neurosurgical trauma patients in this series, who presented with mild-to-severe traumatic brain injury (TBI) from January 2013 to April 2014 at a tertiary care center in rural Nepal. All pertinent medical records (including all available imaging studies) were reviewed by the neurosurgical consultant and the radiologist on call. Patients’ worst CT image scores and their outcome at 30 days were assessed and recorded. We then assessed their independent performance in predicting the mortality and also tried to seek the individual variables that had significant interplay for determining the same.

Results:

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute TBI with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift, and status of the peri-mesencephalic cisterns.

Conclusion:

We demonstrated in this cohort that though the Marshall score has the high predictive power to determine the mortality, better discrimination could be sought through the application of the Rotterdam score that encompasses various individual CT parameters. We thereby recommend the use of such comprehensive prognostic model so as to augment our predictive power for properly dichotomizing the prognosis of the patients with TBI. In the future, it will therefore be important to develop prognostic models that are applicable for the majority of patients in the world they live in, and not just a privileged few who can use resources not necessarily representative of their societal environment.

A comparative study between Marshall and Rotterdam CT scores in predicting early deaths in patients with traumatic brain injury in a major tertiary care hospital in Nepal

PURPOSE

CT plays a crucial role in the early assessment of patients with traumatic brain injury (TBI). Marshall and Rotterdam are the mostly used scoring systems, in which CT findings are grouped differently. We sought to determine the values of the scoring system and initial CT findings in predicting the death at hospital discharge (early death) in patients with TBI.

METHODS

There were consecutive 634 traumatic neurosurgical patients with mild-to-severe TBI admitted to the emergency department of College of Medical Sciences. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score is related to early death; compared the two scoring systems' performance in predicting early death, and identified the CT findings that are independent predictors for early death.

RESULTS

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute traumatic brain injury with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift and status of the peri-mesencephalic cisterns.

CONCLUSIONS

Marshall CT classification has strong predictive power, but greater discrimination can be obtained if the individual CT parameters underlying the CT classification are included in a prognostic model as in Rotterdam score. Consequently, for prognostic purposes, we recommend the use of individual characteristics rather than the CT classification. Performance of CT models for predicting outcome in TBI can be significantly improved by including more details of variables and by adding other variables to the models.

The Rotterdam Scoring System Can Be Used as an Independent Factor for Predicting Traumatic Brain Injury Outcomes

OBJECTIVE

Predicting outcomes in patients with traumatic brain injury is critically important for making sound clinical decisions. This study aimed at determining the prognostic value of the Rotterdam scoring system to predict early death among these patients.

MATERIALS AND METHODS

This study was performed prospectively on 150 patients with traumatic brain injury hospitalized in Shahid Beheshti Hospital, Kashan, Iran. Patients' demographic and clinical characteristics such as age, sex, mechanism of trauma, initial Glasgow Coma Scale score, and accompanying lesions were documented. A brain computed tomography was performed for each patient and scored by use of the Rotterdam system. Patients were monitored for 2 weeks after hospital discharge, and their outcomes were documented. Univariate and multiple logistic regression analysis and prognostic values of Rotterdam system were conducted by SPSS software.

RESULTS

Nineteen patients (12.7%) died during the course of the study. The mean age of the dead patients was significantly greater than those who survived (P = 0.037). The sensitivity and the specificity of the Rotterdam scoring system at the cutoff score of 4 were 84.2% and 96.2%, respectively. Rotterdam score was significantly correlated with patient outcomes (P < 0.0001). Moreover, logistic regression analyses revealed that factors such as age, sex, Glasgow Coma Scale score, and Rotterdam score significantly contributed to patient outcomes.

CONCLUSIONS

Rotterdam score is an independent factor for predicting outcomes among patients with traumatic brain injury. At the cutoff score of 4, the Rotterdam system can predict outcomes among patients suffering from traumatic brain injury with acceptable sensitivity and specificity.

Radiological prognostication in patients with head trauma requiring decompressive craniectomy: Analysis of optic nerve sheath diameter and Rotterdam CT Scoring System

INTRODUCTION

Optic nerve sheath diameter (ONSD) measured on CT scan has been shown to predict outcomes of patients with severe traumatic brain injury. No such relation has been studied in patients undergoing decompressive craniectomy (DC). We evaluated ONSD on admission CT scan to predict outcomes of patients undergoing DC along with Rotterdam CT Score (RCTS).

MATERIALS AND METHODS

This retrospective cohort study was approved by the institutional ethics committee. All the consecutive patients undergoing DC with available images and records were included. We measured ONSD 3mm behind the eyeball and calculated RCTS. Glasgow Outcome Scale (GOS) was measured at last follow-up. We analyzed the data on SPSS v 19. Receiver operator curve analysis (ROC) was done to measure the predictive values of ONSD and RCTS for mortality and unfavorable outcomes.

RESULTS

One hundred and seventeen patients were included. Twenty patients had bilateral DC. Mean GCS at presentation was 8.5±3.5. Mean follow-up was 7.5±1.2 months. Thirty-day mortality was 19%. Mean ONSD of both eyes was 6.73±0.89mm. Area under the curve (AUC) for bilateral mean ONSD as predictor of mortality was 0.49 [95%CI: 0.36-0.62]. AUC for RCTS was as a predictor of 30-day mortality was significant, i.e. 0.67 [95%CI: 0.572-0.820]. The difference of mean ONSD was also not significantly different between survivor and non-survivors.

CONCLUSION

Admission ONSD in DC patients is high but does not predict mortality and unfavorable outcomes. RCTS has a better prognostic value for predicting mortality and unfavorable outcomes in DC patients.

Predicting outcome in traumatic brain injury: development of a novel computerized tomography classification system (Helsinki computerized tomography score)

BACKGROUND

Early computerized tomography (CT) abnormalities are important predictors of outcome after traumatic brain injury (TBI).

OBJECTIVE

To develop a novel CT scoring system (Helsinki CT score) and to compare it with the Marshall CT classification and the Rotterdam CT score in predicting long-term outcome of patients with TBI.

METHODS

Eight hundred sixty-nine consecutive TBI patients were included in this open-cohort, retrospective, single-center study. Logistic regression was used to develop the Helsinki CT score. The scores from the Marshall, Rotterdam, and Helsinki CT scoring methods were added to a clinical model based on age, motor score, and pupils to evaluate their value in predicting outcome. Internal validity was assessed by a bootstrap technique and expressed as area under the curve (AUC). Outcome was 6-month unfavorable neurological outcome and mortality.

RESULTS

Variables included in the Helsinki CT score were bleeding type and size, intraventricular hemorrhage, and suprasellar cisterns. In the present data set, the performance of the Helsinki CT score was superior to that of the Marshall CT and Rotterdam CT scores (AUC, 0.74-0.75 vs 0.63-0.70; P < .001). Addition of the Helsinki CT score modestly increased prognostic performance of the clinical model (AUC neurological outcome +0.02 [P = .002]; AUC mortality, +0.01 [P = .21]). In contrast, the Marshall and Rotterdam CT scores were of no additional predictive value to the clinical model (P > .05).

CONCLUSION

Use of the novel Helsinki CT score improved outcome prediction accuracy, and the Helsinki CT score is a feasible alternative to the Rotterdam and Marshall CT systems. External validation of the Helsinki CT score is advocated to show generalizability.

Predictors of intensive care unit length of stay and intracranial pressure in severe traumatic brain injury

OBJECTIVE

The aim of this study was to explore the relationship of intracranial pressure (ICP) with intensive care unit (ICU) length of stay in a large cohort of severe traumatic brain injury patients and identify factors associating with prolonged ICU course.

METHODS

This was a single-center database review of de-identified research data that had been prospectively collected; setting: neurosurgical ICU, Ben Taub General Hospital, Houston, TX.

RESULTS

In a cohort of 438 severe traumatic brain injury (TBI) patients, 149 (34%) had a motor Glasgow Coma Scale score of 1 to 3 on admission and 284 (65%) had 4 to 5. Intracranial pressure during the ICU course was 19.8±11.2 mm Hg. Favorable outcome was obtained in 148 (34%), and unfavorable, in 211 (48%) patients with a mortality of 28%. ICU length of stay (LOS) was 19.4±13.9 days. Joint modeling of ICP and ICU LOS was undertaken, adjusted for the International Mission for Prognosis and Analysis of Clinical Trials in TBI admission prognostic indicators. A higher ICP was not significantly associated with longer ICU LOS (P=.4). However, presence of a mass lesion on admission head computed tomography was strongly correlated with a prolonged ICU LOS (P=.0007). Diffuse injuries with basal cistern compression or midline shift were marginally associated with a longer ICU LOS (P=.053).

CONCLUSIONS

ICP, as monitored and managed according to BTF guidelines, is not associated with ICU length of stay. Patients with severe TBI and a mass lesion on admission head computed tomography were found to have prolonged ICU LOS independently of other indicators of injury severity and intracranial pressure course.

The epidemiology of vasospasm in children with moderate-to-severe traumatic brain injury

OBJECTIVE

To gain a description of the prevalence and time course of vasospasm in children suffering moderate-to-severe traumatic brain injury.

DESIGN

A prospective, observational study was performed. Children with a diagnosis of traumatic brain injury, a Glasgow Coma Score less than or equal to 12, and abnormal head imaging were enrolled. Transcranial Doppler ultrasound was performed to identify and follow vasospasm. Diagnostic criteria included flow velocity elevation more than or equal to 2 sd above age and gender normal values for the middle cerebral and basilar arteries. Additional criteria required for vasospasm diagnosis in the middle cerebral artery was a ratio of flow in the middle cerebral artery to extracranial internal carotid artery more than or equal to 3.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-nine children were included. The prevalence of middle cerebral artery vasospasm in children with moderate traumatic brain injury (Glasgow Coma Score, 9-12) was 8.5% and was 33.5% in those with severe traumatic brain injury (Glasgow Coma Score, ≤ 8). The prevalence of basilar artery vasospasm in children with moderate traumatic brain injury was 3% and with severe traumatic brain injury was 21%. Mean time to onset of vasospasm was 4 days (± 2 d) in the middle cerebral arteries and 5 days (± 2.5 d) in the basilar artery. Mean duration of vasospasm in the middle cerebral artery was 2 days (± 2 d) and 1.5 days (± 1 d) in the basilar artery. Children in whom vasospasm developed were more likely to have been involved in motor vehicle accidents, had higher Injury Severity Scores, had fever at admission, and had lower Glasgow Coma Score scores. Good neurologic outcome (Glasgow Outcome Score Extended Pediatric version of ≥ 4) at 1 month from injury was seen in 76% of those with moderate traumatic brain injury without vasospasm and in 40% of those with vasospasm. In those with severe traumatic brain injury, good neurologic outcome was seen in 29% of those children without vasospasm and in 15% of those with vasospasm.

CONCLUSIONS

Vasospasm occurs in a sizeable number of children with moderate and severe traumatic brain injury. Children in whom vasospasm developed were more likely to have been involved in a motor vehicle accident, had higher Injury Severity Scores, had fever at admission, and had lower Glasgow Coma scores than in those whom vasospasm did not develop. Based on these findings, we recommend aggressive screening for posttraumatic vasospasm in these patients. Future studies should establish the relationship between vasospasm and long-term functional outcomes and should also evaluate potential preventative or therapeutic options for vasospasm in these children.

Acute bilateral mass-occupying lesions in non-penetrating traumatic brain injury: a retrospective study

BACKGROUND

Traumatic acute bilateral mass-occupying lesions (TABML) is a common entity in head injury, with high morbidity and mortality. Our aim in this study was to evaluate the benefits of different treatment options and the outcome predictors in patients with TABML.

METHODS

From October 2010 to November 2012, a consecutive cohort of patients aged 16-70 years with TABML were retrospectively analyzed based on the clinical and radiological characteristics. Patients with TABML were included if admitted within 24 h after injury and were excluded if they presented with infratentorial lesions, unilateral lesions within the first 24 h after injury, or penetrating head injury. According to their treatment option, patients were divided into three groups: a conservative treatment group, a unilateral surgery group, and a bilateral surgery group. Outcomes were assessed using the Glasgow Outcome Scale (GOS). Binary logistic regression analysis was applied to determine the outcome predictors.

RESULTS

Forty-seven patients (58.8%) had severe injuries (Glasgow Coma Scale score (GCS), 3-8) upon admission, and the overall mortality was 31.3% at 6 months post-injury. The mortality was 55.6% in patients who underwent conservative treatment (N = 18), 17.9% in unilateral surgery patients (N = 39), and 34.8% in the bilateral surgery group (N = 23). In the surgical group, the mortality was 53.3% (8 of 15) in those with a GCS of 3-5, which decreased steeply to 14.9% (7 of 47) of those with GCS ≥ 6. On logistic regression analysis, the absence of pupillary reactivity, disappearances of basal cisterns and conservative treatment were related to higher mortality. A lower initial GCS score was associated with an unfavorable outcome. Midline shift tended to be associated with mortality and an unfavorable outcome, although statistical analysis did not show a significant difference.

CONCLUSIONS

TABML is suggestive of severe brain injury. As conservative treatment is always associated with a poorer outcome, surgery is advocated, especially in patients with a GCS score of ≥ 6. Whereas the prognostic value of midline shift might be limited because of the counter-mass effect in TABML, the GCS score, the pupillary reactivity, and particularly, the compression of basal cisterns should be emphasized.

Validation of the revised injury severity classification score in patients with moderate-to-severe traumatic brain injury

INTRODUCTION

By analysing risk-adjusted mortality ratios, weaknesses in the process of care might be identified. Traumatic brain injury (TBI) is the main cause of death in trauma, and thus it is crucial that trauma prediction models are valid for TBI patients. Accordingly, we assessed the validity of the RISC score in TBI patients by internal and external validation analyses.

METHODS

Patients with moderate-to-severe TBI admitted to the TraumaRegister DGU® (TR-DGU) and the trauma registry of Helsinki University Hospital (TR-THEL) in 2006-2011 were included in this retrospective open cohort study. Definition of moderate-to-severe TBI was head abbreviated injury scale of 3 or higher. Subgroup analysis for patients with isolated and polytrauma TBI was performed. The performance of the RISC score was evaluated by assessing its discrimination (area under the curve, AUC) and calibration (Hosmer-Lemeshow [H-L] test).

RESULTS

Among the 9106 and 809 patients with moderate-to-severe TBI admitted to TR-DGU and TR-THEL, unadjusted mortality was 26% and 23%, respectively. Internal and external validation of the RISC score showed good discrimination (TR-DGU AUC 0.89, 95% confidence interval [CI] 0.88-0.90 and TR-THEL AUC 0.84, 95% CI 0.81-0.87), but poor calibration (p<0.001) in patients with moderate-to-severe TBI. Subgroup analysis found the discrimination only to be modest in isolated TBI (AUC 0.76) and calibration to be particularly poor in polytrauma TBI (TR-DGU H-L=4356, p<0.001; TR-THEL H-L 112, p<0.001).

CONCLUSION

The RISC score was found to be of limited predictive value in patients with moderate-to-severe TBI. A new general trauma scoring system that includes TBI specific prognostic factors is warranted.

Validation of a prognostic score for early mortality in severe head injury cases

Object

Traumatic brain injury (TBI) represents a large health and economic burden. Because of the inability of previous randomized controlled trials (RCTs) on TBI to demonstrate the expected benefit of reducing unfavorable outcomes, the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in TBI) and CRASH (Corticosteroid Randomisation After Significant Head Injury) studies provided new methods for performing prognostic studies of TBI. This study aimed to develop and externally validate a prognostic model for early death (within 48 hours). The secondary aim was to identify patients who were more likely to succumb to an early death to limit their inclusion in RCTs and to improve the efficiency of RCTs.

Methods

The derivation cohort was recruited at 1 center, Hospital 12 de Octubre, Madrid (1990–2003, 925 patients). The validation cohort was recruited in 2004–2006 from 7 study centers (374 patients). The eligible patients had suffered closed severe TBIs. The study outcome was early death (within 48 hours post-TBI). The predictors were selected using logistic regression modeling with bootstrapping techniques, and a penalized reduction was used. A risk score was developed based on the regression coefficients of the variables included in the final model.

Results

In the validation set, the final model showed a predictive ability of 50% (Nagelkerke R2), with an area under the receiver operating characteristic curve of 89% and an acceptable calibration (goodness-of-fit test, p = 0.32). The final model included 7 variables, and it was used to develop a risk score with a range from 0 to 20 points. Age provided 0, 1, 2, or 3 points depending on the age group; motor score provided 0 points, 2 (untestable), or 3 (no response); pupillary reactivity, 0, 2 (1 pupil reacted), or 6 (no pupil reacted); shock, 0 (no) or 2 (yes); subarachnoid hemorrhage, 0 or 1 (severe deposit); cisternal status, 0 or 3 (compressed/absent); and epidural hematoma, 0 (yes) or 2 (no). Based on the risk of early death estimated with the model, 4 risk of early death groups were established: low risk, sum score 0–3 (< 1% predicted mortality); moderate risk, sum score 4–8 (predicted mortality between 1% and 10%); high risk, sum score 9–12 (probability of early death between 10% and 50%); and very high risk, sum score 13–20 (early mortality probability > 50%). This score could be used for selecting patients for clinical studies. For example, if patients with very high risk scores were excluded from our study sample, the patients included (eligibility score < 13) would represent 80% of the original sample and only 23% of the patients who died early.

Conclusions

The combination of Glasgow Coma Scale score, CT scanning results, and secondary insult data into a prognostic score improved the prediction of early death and the classification of TBI patients.