TBI Prognostication and Outcomes

Topic Progress:

Outcomes

Measuring the effects of TBI on an individual, their family and society as a whole is difficult.

Clinical trials need to do this to test efficacy of interventions on outcomes.

Commonly used outcome measures include the Glasgow Outcome Score (1975) and the Extended Glasgow Outcome Score GOSE (1981)

Even the 8 levels in the GOSE are relatively crude assessments.

Sometimes outcomes are divided further into “favourable” and “unfavourable” which as you can imagine is even cruder.

These also don’t take a patient’s opinion as to their outcome into account and there is increasing recognition that patient-reported outcome measures such as the Quality of Life after Brain Injury (Qolibri) should be used.

Current Outcomes from TBI at a single Trauma Centre (n=403)

PROGNOSTICATION

“Prognostication in TBI is notoriously difficult”

Areas assess in prognostication are:

CLINICAL FACTORS

Age (>40 years, worse with increasing age)

Severity based on initial GCS post-resuscitation

Hypotension (SBP < 90 mmHg) – major predictive factor

Hypoxia (Sats < 90%) – major predictive factor

Pupil size and reaction to light (i.e fixed and dilated is bad!)

ICP

Type of intracranial haemorrhage (worst to least, subdural -> extradural -> SAH)

Co-morbidities

Resources available e.g. Low-to-middle income countries have worse outcomes

RADIOLOGICAL FACTORS

CT Brain

  • Obliteration of 3rd ventricle/basal cisterns
  • Midline shift
  • Petechial haemorrhages
  • Subarachnoid haemorrhage
  • Unevacuated haematoma
  • Brainstem injury

MRI Brain

Areas if damaged which are associated with worse prognosis:

  • Brainstem lesions (any region of brainstem REF)
  • Splenium of corpus callosum REF
  • Diffuse axonal injury REF

MARSHALL CT GRADING

> Commonly used CT grading system, used in many clinical trials
> Prognostic to an extent

Main problem is most patients are either 2 or 6, so not very discriminatory

Diffuse injury I  (no visible pathology)

  • no visible intracranial pathology

Diffuse injury II

  • midline shift of 0 to 5 mm
  • basal cisterns remain visible
  • no high or mixed density lesions >25 cm3

Diffuse injury III (swelling)

  • midline shift of 0 to 5 mm
  • basal cisterns compressed or completely effaced
  • no high or mixed density lesions >25 cm3

Diffuse injury IV (shift)

  • midline shift >5 mm
  • no high or mixed density lesions >25 cm3

Evacuated mass lesion V

  • any lesion evacuated surgically

Non-evacuated mass lesion VI

  • high or mixed density lesions >25 cm3
  • not surgically evacuated

ROTTERDAM CT GRADING

> Another more recent CT grading system, being used more now
> Prognostic
> Better than Marshall in many ways

The Score

Basal cisterns

  • 0: normal
  • 1: compressed
  • 2: absent

Midline shift

  • 0: no shift or <= 5 mm
  • 1: shift > 5 mm

Epidural mass lesion

  • 0: present
  • 1: absent

Intraventricular blood or traumatic SAH

  • 0: absent
  • 1: present

Interpretation

In adults the mortality at six months increases with the score:

  1. 0%
  2. 7%
  3. 16%
  4. 26%
  5. 53%
  6. 61%

REF

BIOMARKERS

Not routinely used clinically at present

The most studied biomarkers of TBI severity are:

  • S100-B protein in blood (note – not CNS specific)
  • Glial fibrillary acidic protein (GFAP)
  • Neuron-specific enolase (NSE) in blood or CSF (Present in red blood cells, elevated with hemolysis)
  • UCH-L1

S100-B has been used in mild TBI to stratify who should get a CTB REF
S100-B, GFAP, and UCH-L1 together have been used in prognostication

CALCULATORS

Two outcome calculators exist, based on large data sets.

They are not designed to tell you exactly what will happen to your patient!

They just give a broad overview of prognosis.

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