Outcome Prediction in Patients of Traumatic Brain Injury Based on Midline Shift on CT Scan of Brain

Abstract

Background Clinicians treating patients with head injury often take decisions based on their assessment of prognosis. Assessment of prognosis could help communication with a patient and the family. One of the most widely used clinical tools for such prediction is the Glasgow coma scale (GCS); however, the tool has a limitation with regard to its use in patients who are under sedation, are intubated, or under the influence of alcohol or psychoactive drugs. CT scan findings such as status of basal cistern, midline shift, associated traumatic subarachnoid hemorrhage (SAH), and intraventricular hemorrhage are useful indicators in predicting outcome and also considered as valid options for prognostication of the patients with traumatic brain injury (TBI), especially in emergency setting. Materials and Methods 108 patients of head injury were assessed at admission with clinical examination, history, and CT scan of brain. CT findings were classified according to type of lesion and midline shift correlated to GCS score at admission. All the subjects in this study were managed with an identical treatment protocol. Outcome of these patients were assessed on GCS score at discharge. Result Among patients with severe GCS, 51% had midline shift. The degree of midline shift in CT head was a statistically significant determinant of outcome (p = 0.023). Seventeen out of 48 patients (35.4%) with midline shift had poor outcome as compared with 8 out of 60 patients (13.3%) with no midline shift. Conclusion In patients with TBI, the degree of midline shift on CT scan was significantly related to the severity of head injury and resulted in poor clinical outcome.

Midline Shift as a Predictor of Outcome in Head Trauma Patients managed Conservatively

“…15 In another study by Palekar SG et al, the male: female ratio was 4:1 with males more commonly being affected by head trauma. 16 Similarly in our study males were more commonly affected with male to female ratio of 2.6:1.…”

“…25 In a study by Palekar et al, the abnormal pupillary response came out to be statistically significant in relation to outcome. 16 In our study, patients having satisfactory outcomes, 68 (64.8%) patients had equally reacting pupils, while only 37 (35.2%) patients had abnormal pupillary reactivities. This association was shown to be statistically significant in our study (p-value = 0.046).…”

“…17 The reason for this might lie in the fact that old aged patients already have different comorbidities apart from the already injured brain, this in addition to senile changes like decreased elasticity and atrophic changes in the brain parenchyma can cause increased mortality in the elderly group. 16 However, Fabbri et al found no evidence that age was significantly related to the prognosis of the patients with head trauma. 18 Slewa-Younan et al, stated that the severity of TBI in males was greater than that of females.…”

“…Lower admission GCS scores are associated with worse outcomes. 16 According to a study by Selladurai et al, more than 95% of patients are likely to suffer a worse outcome if their score is 4 or lower in comparison to individuals with a score of 8 or more. 22 According to a study by Chiewvit et al, out of 46 patients with a GCS of 15, 2 cases (13.3%) and 33 patients with a GCS of 13 -14, 1 case (3.0%), respectively, had poor outcomes, while out of 136 patients with a GCS score of 12, 46 cases (33.8%) had poor outcomes.…”

“…8 However, its use is limited in patients who are under the influence of sedation, psychoactive drugs, or alcohol, or are intubated. 16 Classifying TBI according to morphology based on radiological findings is an alternative in such patients. Computed tomography (CT) continues to be the gold standard for diagnosing, treating, and determining the prognosis of traumatic brain injury despite recent advancements in imaging techniques.…”