Evaluation of novel computerized tomography scoring systems in human traumatic brain injury: An observational, multicenter study

Abstract

BackgroundTraumatic brain injury (TBI) is a major contributor to morbidity and mortality. Computerized tomography (CT) scanning of the brain is essential for diagnostic screening of intracranial injuries in need of neurosurgical intervention, but may also provide information concerning patient prognosis and enable baseline risk stratification in clinical trials. Novel CT scoring systems have been developed to improve current prognostic models, including the Stockholm and Helsinki CT scores, but so far have not been extensively validated. The primary aim of this study was to evaluate the Stockholm and Helsinki CT scores for predicting functional outcome, in comparison with the Rotterdam CT score and Marshall CT classification. The secondary aims were to assess which individual components of the CT scores best predict outcome and what additional prognostic value the CT scoring systems contribute to a clinical prognostic model.Methods and findingsTBI patients requiring neuro-intensive care and not included in the initial creation of the Stockholm and Helsinki CT scoring systems were retrospectively included from prospectively collected data at the Karolinska University Hospital (n = 720 from 1 January 2005 to 31 December 2014) and Helsinki University Hospital (n = 395 from 1 January 2013 to 31 December 2014), totaling 1,115 patients. The Marshall CT classification and the Rotterdam, Stockholm, and Helsinki CT scores were assessed using the admission CT scans. Known outcome predictors at admission were acquired (age, pupil responsiveness, admission Glasgow Coma Scale, glucose level, and hemoglobin level) and used in univariate, and multivariable, regression models to predict long-term functional outcome (dichotomizations of the Glasgow Outcome Scale [GOS]). In total, 478 patients (43%) had an unfavorable outcome (GOS 1–3). In the combined cohort, overall prognostic performance was more accurate for the Stockholm CT score (Nagelkerke’s pseudo-R2 range 0.24–0.28) and the Helsinki CT score (0.18–0.22) than for the Rotterdam CT score (0.13–0.15) and Marshall CT classification (0.03–0.05). Moreover, the Stockholm and Helsinki CT scores added the most independent prognostic value in the presence of other known clinical outcome predictors in TBI (6% and 4%, respectively). The aggregate traumatic subarachnoid hemorrhage (tSAH) component of the Stockholm CT score was the strongest predictor of unfavorable outcome. The main limitations were the retrospective nature of the study, missing patient information, and the varying follow-up time between the centers.ConclusionsThe Stockholm and Helsinki CT scores provide more information on the damage sustained, and give a more accurate outcome prediction, than earlier classification systems. The strong independent predictive value of tSAH may reflect an underrated component of TBI pathophysiology. A change to these newer CT scoring systems may be warranted.

Marshall and Rotterdam Computed Tomography scores in predicting early deaths after brain trauma

“…Its accuracy has been evaluated in various studies and AUCs (in the range of 0.76-0.68) have been reported with the same pseudo-R2 11 , 12 . The Marshall Classification was based on the Traditional Coma Data Bank (TCDB) from 1987 to 1984, in which 746 patients with severe traumatic traumatic brain injury (GCS 3-8) compared with other classification systems that had the lowest pseudo- variance, adding it to the checklist for patients with traumatic brain injury in admission time does not provide any additional independent information to doctors 13 . Deepika et al (2015) in a study compared the predictive power of mortality from TBI in both Marshall and Rotterdam scoring methods, the mean grade based on the Marshall Classification and Rotterdam classifications in died patients was significantly higher than that of the live patients 14 , which is in agreement with our study.…”

“…Similarly, Thelin et al, Showed that the accuracy of Marshall CT classification was less than the classification of Rotterdam in examining the outcomes of patients with traumatic brain injury. Thelin and colleagues have been selected unfavorable outcomes to compare them with the tools, which suggest the possibility of using the Rotterdam system to evaluate morbidity, in addition to mortality 13 . In spite of the high accuracy of the Marshall and Rotterdam classification systems, especially the Rotterdam classification system, Maas et al (2005) in a study using CT scan results of over 2500 patients with blunt trauma, has concluded that by adding some variables to these scoring systems, their performance can be improved 7 .…”

“…The results of this study indicated a lower accuracy of the Marshall Classification System in predicting mortality, it is worth noting that this evaluation system has fundamental constraints, one of which is the worse prognosis of Grade IV than Grade V and VI. Another limitation of this classification system is the lack of attention to subarachnoid hemorrhage and the lack of consideration for the difference between epidural hematoma and subdural hematoma 13 . As previously mentioned, no additional independent information is provided to doctors 13 , if the Marshall Assessment System be added to the assessment checklist of patients with traumatic brain injury.…”

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

“…42 A range of CT findings have been shown individually to relate to prognosis in head injury. 29,41,42,51 These have been combined in a variety of ways in different approaches to classification and scoring, and there is no consensus about a uniform system. 21,26 We were clear that for practical impact our approach needed to have clinical face value, to use a very limited number of categories to produce charts with distinctly different patterns, and to be as simple and easy to apply as possible.…”

“…To take account of these differences in recording, and in accord with their prognostic value, CT data were abstracted from the CRASH and IMPACT databases and categorized according to the presence or absence of 3 abnormalities: 1) an intracranial hematoma (evacuated or not), 2) absent cisterns, and 3) SAH. 41,51…”