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Outcome Prediction in Moderate and Severe Traumatic Brain Injury: A Focus on Computed Tomography Variables

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Abstract

Background

With this study we aimed to design validated outcome prediction models in moderate and severe traumatic brain injury (TBI) using demographic, clinical, and radiological parameters.

Methods

Seven hundred consecutive moderate or severe TBI patients were included in this observational prospective cohort study. After inclusion, clinical data were collected, initial head computed tomography (CT) scans were rated, and at 6 months outcome was determined using the extended Glasgow Outcome Scale. Multivariate binary logistic regression analysis was applied to evaluate the association between potential predictors and three different outcome endpoints. The prognostic models that resulted were externally validated in a national Dutch TBI cohort.

Results

In line with previous literature we identified age, pupil responses, Glasgow Coma Scale score and the occurrence of a hypotensive episode post-injury as predictors. Furthermore, several CT characteristics were associated with outcome; the aspect of the ambient cisterns being the most powerful. After external validation using Receiver Operating Characteristic (ROC) analysis our prediction models demonstrated adequate discriminative values, quantified by the area under the ROC curve, of 0.86 for death versus survival and 0.83 for unfavorable versus favorable outcome. Discriminative power was less for unfavorable outcome in survivors: 0.69.

Conclusions

Outcome prediction in moderate and severe TBI might be improved using the models that were designed in this study. However, conventional demographic, clinical and CT variables proved insufficient to predict disability in surviving patients. The information that can be derived from our prediction rules is important for the selection and stratification of patients recruited into clinical TBI trials.

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References

  1. Maas AI, Marmarou A, Murray GD, Teasdale SG, Steyerberg EW. Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. J Neurotrauma. 2007;24:232–8.

    Article  PubMed  Google Scholar 

  2. Perel P, Arango M, Clayton T, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336:425–9.

    Article  PubMed  Google Scholar 

  3. Hukkelhoven CW, Rampen AJ, Maas AI, et al. Some prognostic models for traumatic brain injury were not valid 1. J Clin Epidemiol. 2006;59:132–43.

    Article  PubMed  Google Scholar 

  4. Perel P, Edwards P, Wentz R, Roberts I. Systematic review of prognostic models in traumatic brain injury. BMC Med Inform Decis Mak. 2006;6:38.

    Article  PubMed  Google Scholar 

  5. Mushkudiani NA, Hukkelhoven CW, Hernandez AV, et al. A systematic review finds methodological improvements necessary for prognostic models in determining traumatic brain injury outcomes. J Clin Epidemiol. 2008;61:331–43.

    Article  PubMed  Google Scholar 

  6. Wyatt JC, Altman DG. Prognostic models: clinically useful or quickly forgotten? BMJ. 1995;311:1539–41.

    Article  Google Scholar 

  7. Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5:e165.

    Article  PubMed  Google Scholar 

  8. Cremer OL, Moons KG, van Dijk GW, van Dijk BP, Kalkman CJ. Prognosis following severe head injury: development and validation of a model for prediction of death, disability, and functional recovery. J Trauma. 2006;61:1484–91.

    Article  PubMed  Google Scholar 

  9. Murray GD, Butcher I, McHugh GS, et al. Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:329–37.

    Article  PubMed  Google Scholar 

  10. Mattioli C, Beretta L, Gerevini S, et al. Traumatic subarachnoid hemorrhage on the computerized tomography scan obtained at admission: a multicenter assessment of the accuracy of diagnosis and the potential impact on patient outcome. J Neurosurg. 2003;98:37–42.

    Article  PubMed  Google Scholar 

  11. Hukkelhoven CW, Steyerberg EW, Habbema JD, et al. Predicting outcome after traumatic brain injury: development and validation of a prognostic score based on admission characteristics. J Neurotrauma. 2005;22:1025–39.

    Article  PubMed  Google Scholar 

  12. Maas AI, Steyerberg EW, Butcher I, et al. Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:303–14.

    Article  PubMed  Google Scholar 

  13. Wardlaw JM, Easton VJ, Statham P. Which CT features help predict outcome after head injury? J Neurol Neurosurg Psychiatry. 2002;72:188–92.

    Article  PubMed  CAS  Google Scholar 

  14. Signorini DF, Andrews PJ, Jones PA, Wardlaw JM, Miller JD. Predicting survival using simple clinical variables: a case study in traumatic brain injury. J Neurol Neurosurg Psychiatry. 1999;66:20–5.

    Article  PubMed  CAS  Google Scholar 

  15. Marshall LF, Eisenberg HM, Jane JA, Luerssen TG, Marmarou A, Foulkes MA. A new classification of head injury based on computerized tomography. J Neurosurg. 1991;75:s14–20.

    Google Scholar 

  16. Maas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery. 2005;57:1173–82.

    Article  PubMed  Google Scholar 

  17. The American Association of Neurological Surgeons. The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Computed tomography scan features. J Neurotrauma. 2000;17:597–627.

    Article  Google Scholar 

  18. Nelson DW, Nystrom H, MacCallum RM, et al. Extended analysis of early computed tomography scans of traumatic brain injured patients and relations to outcome. J Neurotrauma. 2010;27:51–64.

    Article  PubMed  Google Scholar 

  19. Franschman G, Verburg N, Brens-Heldens V, et al. Effects of physician-based emergency medical service dispatch in severe traumatic brain injury on prehospital run time. Injury. 2012;43:1838–42.

    Article  PubMed  CAS  Google Scholar 

  20. American College of Surgeons. Advanced Trauma Life Support for Doctors. 6th ed. Chicago: 1997.

  21. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–96.

    Article  PubMed  CAS  Google Scholar 

  22. Jacobs B, Beems T, Stulemeijer M, et al. Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities. J Neurotrauma. 2010;27:655–68.

    Article  PubMed  Google Scholar 

  23. Jacobs B, Beems T, van der Vliet TM, Borm GF, Vos PE. The status of the fourth ventricle and ambient cisterns predict outcome in moderate and severe traumatic brain injury. J Neurotrauma. 2010;27:331–40.

    Article  PubMed  Google Scholar 

  24. Jacobs B, Beems T, van der Vliet TM, Diaz-Arrastia RR, Borm GF, Vos PE. Computed tomography and outcome in moderate and severe traumatic brain injury: hematoma volume and midline shift revisited. J Neurotrauma. 2011;28:1–12.

    Article  Google Scholar 

  25. Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma. 1998;15:573–85.

    Article  PubMed  CAS  Google Scholar 

  26. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1:480–4.

    Article  PubMed  CAS  Google Scholar 

  27. Wilson JT, Edwards P, Fiddes H, Stewart E, Teasdale GM. Reliability of postal questionnaires for the Glasgow Outcome Scale. J Neurotrauma. 2002;19:999–1005.

    Article  PubMed  CAS  Google Scholar 

  28. Andriessen T, Horn J, Franschman G, et al. Epidemiology, severity classification and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma. 2011;28:1–14.

    Article  Google Scholar 

  29. Hukkelhoven CW, Steyerberg EW, Rampen AJ, et al. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg. 2003;99:666–73.

    Article  PubMed  Google Scholar 

  30. Stulemeijer M, van der Werf SP, Jacobs B, et al. Impact of additional extracranial injuries on outcome after mild traumatic brain injury. J Neurotrauma. 2006;23:1561–9.

    Article  PubMed  Google Scholar 

  31. Young NH, Andrews PJ. Developing a prognostic model for traumatic brain injury—a missed opportunity? PLoS Med. 2008;5:e168.

    Article  PubMed  Google Scholar 

  32. Marmarou A, Lu J, Butcher I, et al. IMPACT database of traumatic brain injury: design and description. J Neurotrauma. 2007;24:239–50.

    Article  PubMed  Google Scholar 

  33. Van Beek JG, Mushkudiani NA, Steyerberg EW, et al. Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:315–28.

    Article  PubMed  Google Scholar 

  34. Lannoo E, Van Rietvelde F, Colardyn F, et al. Early predictors of mortality and morbidity after severe closed head injury. J Neurotrauma. 2000;17:403–14.

    Article  PubMed  CAS  Google Scholar 

  35. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991;100:1619–36.

    Article  PubMed  CAS  Google Scholar 

  36. Vos PE, Lamers KJ, Hendriks JC, et al. Glial and neuronal proteins in serum predict outcome after severe traumatic brain injury. Neurology. 2004;62:1303–10.

    Article  PubMed  CAS  Google Scholar 

  37. Vos PE, Jacobs B, Andriessen TM, et al. GFAP and S100B are biomarkers of traumatic brain injury: an observational cohort study. Neurology. 2010;75:1786–93.

    Article  PubMed  CAS  Google Scholar 

  38. Zhou W, Xu D, Peng X, Zhang Q, Jia J, Crutcher KA. Meta-analysis of APOE4 allele and outcome after traumatic brain injury. J Neurotrauma. 2008;25:279–90.

    Article  PubMed  Google Scholar 

  39. Clifton GL, Grossman RG, Makela ME, Miner ME, Handel S, Sadhu V. Neurological course and correlated computerized tomography findings after severe closed head injury. J Neurosurg. 1980;52:611–24.

    Article  PubMed  CAS  Google Scholar 

  40. Cooper PR, Maravilla K, Moody S, Clark WK. Serial computerized tomographic scanning and the prognosis of severe head injury. Neurosurgery. 1979;5:566–9.

    Article  PubMed  CAS  Google Scholar 

  41. Lobato RD, Gomez PA, Alday R, et al. Sequential computerized tomography changes and related final outcome in severe head injury patients. Acta Neurochir. 1997;139:385–91.

    Article  PubMed  CAS  Google Scholar 

  42. Narayan RK, Maas AI, Servadei F, Skolnick BE, Tillinger MN, Marshall LF. Progression of traumatic intracerebral hemorrhage: a prospective observational study. J Neurotrauma. 2008;25:629–39.

    Article  PubMed  Google Scholar 

  43. Servadei F, Murray GD, Penny K, et al. The value of the “worst” computed tomographic scan in clinical studies of moderate and severe head injury. European Brain Injury Consortium. Neurosurgery. 2000;46:70–5.

    Article  PubMed  CAS  Google Scholar 

  44. Zuercher M, Ummenhofer W, Baltussen A, Walder B. The use of Glasgow Coma Scale in injury assessment: a critical review. Brain Inj. 2009;23:371–84.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors wish to thank Ronald H.M.A. Bartels, MD, PhD of the Department of Neurosurgery, Radboud University Nijmegen Medical Centre, for critically reviewing this manuscript and his suggestions, and Robert Huiskes for the development of the prognostic calculator and the website www.tbi-prognosis.com. The POCON study is funded by the Dutch Brain Foundation (Hersenstichting - HSN-07-01). The authors express their gratitude to Dick Drost, Annemiek Coers, Annelou van der Veen, Joshua Field, Vivian de Ruijter, and Heleen Biersteker for their help with data collection. Amon Heijne is thanked for his help with the development and maintenance of the POCON database.

Conflict of interest

All authors declare no conflict of interest to disclose.

Author information

Author notes

  1. Bram Jacobs

    Present address: Department of Neurology (AB51), University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands

  2. Ton M. van der Vliet

    Present address: Department of Radiology, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands

  3. Arie B. van Vugt

    Present address: Department of Surgery, Medisch Spectrum Twente, P.O. Box 50.000, 7500 KA, Enschede, The Netherlands

Authors and Affiliations

  1. Department of Neurology (935), Radboud University Nijmegen Medical Centre (RUNMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands

    Bram Jacobs, Teuntje M. J. C. Andriessen & Pieter E. Vos

  2. Department of Neurosurgery (931), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands

    Tjemme Beems

  3. Department of Radiology, RUNMC, Nijmegen, The Netherlands

    Ton M. van der Vliet

  4. Department of Emergency Medicine, RUNMC, Nijmegen, The Netherlands

    Arie B. van Vugt

  5. Department of Intensive Care Medicine (632), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands

    Cornelia Hoedemaekers

  6. Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands

    Janneke Horn

  7. Department of Anesthesiology, VU University Medical Centre, Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands

    Gaby Franschman

  8. Department of Neurosurgery, Erasmus Medical Centre, Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands

    Ian Haitsma

  9. Department of Neurology, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands

    Joukje van der Naalt

  10. Department of Epidemiology, Biostatistics and HTA (133), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands

    George F. Borm

Authors
  1. Bram Jacobs
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  2. Tjemme Beems
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Corresponding author

Correspondence to Pieter E. Vos.

Additional information

Tjemme Beems—Deceased.

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Jacobs, B., Beems, T., van der Vliet, T.M. et al. Outcome Prediction in Moderate and Severe Traumatic Brain Injury: A Focus on Computed Tomography Variables. Neurocrit Care 19, 79–89 (2013). https://doi.org/10.1007/s12028-012-9795-9

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  • DOI: https://doi.org/10.1007/s12028-012-9795-9

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