An initial Glasgow Coma Scale score of 8 or less does not define severe brain injury

Fitzgerald, Mark; Tan, Terence; Rosenfeld, Jeffrey V.; Noonan, Michael P; Tee, Jin; Ng, Evan; Mathew, Joseph; Broderick, Shane; Kim, Yesul; Groombridge, Christopher J.; Udy, Andrew; Mitra, Biswadev

doi:10.1111/1742-6723.13937

Cited by 8 publications

(7 citation statements)

References 12 publications

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“…Total GCS has an alarming rate of VS and MCS misdiagnosis compared to Coma Recovery Scale-Revised (CRS-R), 1,62,63 and recent studies 64 have emphasized the imprecision of total GCS, especially in the range of 3-8 total GCS. 65 Our predictive models included recent GCS sub-scores as features rather than total scores, which may have enhanced the ability of the GCS-only models to predict future DoC diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Resting-State Electroencephalography for Continuous, Passive Prediction of Coma Recovery After Acute Brain Injury

Zabihi

Rubin

Ack

et al. 2022

Preprint

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Accurately predicting emergence from disorders of consciousness (DoC) after acute brain injury can profoundly influence mortality, acute management, and rehabilitation planning. While recent advances in functional neuroimaging and stimulus-based EEG offer the potential to enrich shared decision-making, their procedural sophistication and expense limit widespread availability or repeated performance. We investigated continuous EEG (cEEG) within a passive, resting-state framework to provide continuously updated predictions of DoC recovery at 24-, 48-, and 72-hour prediction horizons. To develop robust, continuous prediction models from a large population of patients with acute brain injury (ABI), we leveraged a recently described pragmatic approach transforming Glasgow Coma Scale assessment sub-score combinations into frequently assessed DoC diagnoses: coma, vegetative state, minimally conscious state with or without language, and post-injury confusional or recovered states. We retrospectively identified consecutive patients undergoing cEEG following acute traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). Models continuously predicting DoC diagnosis for multiple prediction horizons were evaluated utilizing recent clinical assessments with or without cEEG information, which comprised a comprehensive EEG feature set of 288 time, frequency, and time-frequency characteristics computed from consecutive 5-minute EEG epochs, with 6 additional features capturing each EEG feature's temporal dynamics. Features were fed into a predictive model developed with cross-validation; the ordinal DoC diagnosis was discriminated using an ensemble of XGBoost binary classifiers. For 201 ABI patients (46 TBI, 140 SAH, 15 ICH patients comprising 27,280 cEEG-hours with concomitant clinical assessments), cEEG-augmented models accurately predicted the future DoC diagnosis at 24 hours (one-vs-rest AU-ROC, 92.4%; weighted-F1 84.1%), 48 hours (one-vs-rest AU-ROC=88%, weighted-F1=80%) and 72 hours (one-vs-rest AU-ROC=86.3%, weighted-F1=76.6%). Models were robust to utilizing different ordinal cut-points for the DoC prediction target and evaluating additional models derived from specific sub-populations using a confound-isolating cross-validation framework. The most robust features across evaluation configurations included Petrosian fractal dimension, relative power of high to low (gamma-beta to delta-alpha) EEG frequency spectra, energy within the 12-35 Hz frequency band in the short-time Fourier transform domain, and wavelet entropy. The cEEG-augmented model exceeded the performance of models using preceding clinical assessments, continuously predicting future DoC diagnosis with one-vs-rest AU-ROC in the range of 84.3-92.4% while utilizing approaches to limit overfitting. The proposed continuous, resting-state cEEG prediction method represents a promising tool to predict DoC emergence in ABI patients. Enabling these methods prospectively would represent a new paradigm of continuous prognostic monitoring for predicting coma recovery and assessing treatment response.

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Section: Discussionmentioning

confidence: 99%

Resting-State Electroencephalography for Continuous, Passive Prediction of Coma Recovery After Acute Brain Injury

Zabihi

Rubin

Ack

et al. 2022

Preprint

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“…We included cases of moderate to severe TBI, defined by an AIS code for the head region greater than 2 5,13,16 . We selected this criterion because of the major limitations associated with using the GCS to define TBI severity; people who have sustained a moderate or severe TBI can have high GCS scores, and a low GCS score may not be related to TBI 5,8 . We excluded cases for which key variable data (age, sex, death in hospital) were incomplete.…”

Section: Methodsmentioning

confidence: 99%

“…4 TBI varies in severity, from mild to severe, and is better classified according to brain injury pathology identified by neuroimaging (eg, Abbreviated Injury Scale [AIS] head injury code) than by using the Glasgow Coma Scale (GCS). [5][6][7][8] Moderate to severe TBI often has substantial lasting consequences for the person, their family, and their caregivers. TBI can also require considerable health care resources and have a significant socioeconomic impact.…”

mentioning

confidence: 99%

“…TBI is an injury to the brain caused by an external force, including road accidents, falls, and being struck by an object, person, or animal 4 . TBI varies in severity, from mild to severe, and is better classified according to brain injury pathology identified by neuroimaging (eg, Abbreviated Injury Scale [AIS] head injury code) than by using the Glasgow Coma Scale (GCS) 5‐8 . Moderate to severe TBI often has substantial lasting consequences for the person, their family, and their caregivers.…”

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confidence: 99%

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Hospitalisations and in‐hospital deaths following moderate to severe traumatic brain injury in Australia, 2015–20: a registry data analysis for the Australian Traumatic Brain Injury National Data (ATBIND) project

O'Reilly,

Curtis,

Mitra

et al. 2023

Medical Journal of Australia

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ObjectiveTo describe the frequency of hospitalisation and in‐hospital death following moderate to severe traumatic brain injury (TBI) in Australia, both overall and by patient demographic characteristics and the nature and severity of the injury.Design, settingCross‐sectional study; analysis of Australia New Zealand Trauma Registry data.ParticipantsPeople with moderate to severe TBI (Abbreviated Injury Score [head] greater than 2) who were admitted to or died in one of the twenty‐three major Australian trauma services that contributed data to the ATR throughout the study period, 1 July 2015 – 30 June 2020.Major outcome measuresPrimary outcome: number of hospitalisations with moderate to severe TBI; secondary outcome: number of deaths in hospital following moderate to severe TBI.ResultsDuring 2015–20, 16 350 people were hospitalised with moderate to severe TBI (mean, 3270 per year), of whom 2437 died in hospital (14.9%; mean, 487 per year). The mean age at admission was 50.5 years (standard deviation [SD], 26.1 years), and 11 644 patients were male (71.2%); the mean age of people who died in hospital was 60.4 years (SD, 25.2 years), and 1686 deaths were of male patients (69.2%). The overall number of hospitalisations did not change during 2015–20 (per year: incidence rate ratio [IRR], 1.00; 95% confidence interval [CI], 0.99–1.02) and death (IRR, 1.00; 95% CI, 0.97–1.03).ConclusionInjury prevention and trauma care interventions for people with moderate to severe TBI in Australia reduced neither the incidence of the condition nor the associated in‐hospital mortality during 2015–20. More effective care strategies are required to reduce the burden of TBI, particularly among younger men.

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“…Using the patient’s GCS to (solely) define the severity of TBI is rightly being questioned 3. So I ask: is discharging a patient the right thing to do without this important assessment step in the process?…”

mentioning

confidence: 99%

In reply: Carl Marincowitzet al, Performance of the Hull Salford Cambridge Decision Rule: the start of the traumatic brain injury (TBI) assessment and recovery journey

Henshall

2022

Emerg Med J

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An initial Glasgow Coma Scale score of 8 or less does not define severe brain injury

Cited by 8 publications

References 12 publications

Resting-State Electroencephalography for Continuous, Passive Prediction of Coma Recovery After Acute Brain Injury

Resting-State Electroencephalography for Continuous, Passive Prediction of Coma Recovery After Acute Brain Injury

Hospitalisations and in‐hospital deaths following moderate to severe traumatic brain injury in Australia, 2015–20: a registry data analysis for the Australian Traumatic Brain Injury National Data (ATBIND) project

In reply: Carl Marincowitzet al, Performance of the Hull Salford Cambridge Decision Rule: the start of the traumatic brain injury (TBI) assessment and recovery journey

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