Role of computed tomography scores and findings to predict early death in patients with traumatic brain injury: A reappraisal in a major tertiary care hospital in Nepal

Abstract

Background:Glasgow Coma Scale has been a long sought model to classify patients with head injury. However, the major limitation of the score is its assessment in the patients who are either sedated or under the influence of drugs or intubated for airway protection. The rational approach for prognostication of such patients is the utility of scoring system based on the morphological criteria based on radiological imaging. Among the current armamentarium, a scoring system based on computed tomography (CT) imaging holds the greatest promise in conquering our conquest for the same.Methods:We included a total of 634 consecutive neurosurgical trauma patients in this series, who presented with mild-to-severe traumatic brain injury (TBI) from January 2013 to April 2014 at a tertiary care center in rural Nepal. All pertinent medical records (including all available imaging studies) were reviewed by the neurosurgical consultant and the radiologist on call. Patients’ worst CT image scores and their outcome at 30 days were assessed and recorded. We then assessed their independent performance in predicting the mortality and also tried to seek the individual variables that had significant interplay for determining the same.Results:Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute TBI with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift, and status of the peri-mesencephalic cisterns.Conclusion:We demonstrated in this cohort that though the Marshall score has the high predictive power to determine the mortality, better discrimination could be sought through the application of the Rotterdam score that encompasses various individual CT parameters. We thereby recommend the use of such comprehensive prognostic model so as to augment our predictive power for properly dichotomizing the prognosis of the patients with TBI. In the future, it will therefore be important to develop prognostic models that are applicable for the majority of patients in the world they live in, and not just a privileged few who can use resources not necessarily representative of their societal environment.

Predictive Factors of Brain Death in Acute Neurocritical Patients Identified as Potential Organ Donors

“…We are furthermore able to show that cisterna ambiens and brain herniation (include midline shift) had a significant impact on the outcome of these patients. In a cohort study, Munakomi S, et al clearly show that status of the cisterns, presence of midline shift and traumatic SAH on CT scan had a significant impact on the outcome of these patients [12]. The midline shift is the direct signs of brain herniation, own the same meaning with brain herniation used in our study.…”

“…The severity of acute neurocritical patients remains a subjective notion and is currently based on the clinicians' experience taking into account all the clinical and radiological signs, which could predict a life-threatening condition for the patient [12]. A diagnosis of BD requires a massive brain or brain stem injury.…”

“…The fundamental knowledge that the brain stem loses function is needed to understand the neurology of brain death, typically progressing from a hemispheric lesion to a brain stem lesion [10]. Multiple independent risk factors predicting the outcome of patients with TBI (traumatic brain injury) have been identified; the most widely accepted ones being age, GCS score, pupil size and reactivity, motor response to pain and CT scan findings, but those risk factors have not yet been identified as predictors of BD after spontaneous respiration arrest in acute neurocritical patient [1,10,12]. Based on this, we designed a prospective observational study to screen predictive factors for brain death.…”

“…Current studies show absence of intracranial pathologies certainly adds up the odds for better outcome. Moreover, the role of individual characteristics within the model such as status of the cisterns, midline shift (MLS), subarachnoid hemorrhage (SAH), and mass lesions were associated with the outcome of the patients have already been detailed and verified [12]. Previous studies have verified the role of CT scores in predicting the mortality of patients following TBI [10,13].…”

“…A scoring system based on CT imaging holds the greatest promise [12]. Current studies show absence of intracranial pathologies certainly adds up the odds for better outcome.…”