A proposed novel traumatic brain injury classification system – an overview and inter-rater reliability validation on behalf of the Society of British Neurological Surgeons

Abstract

Introduction The measurement of traumatic brain injury (TBI) ‘severity’ has traditionally been based on the earliest Glasgow Coma Score (GCS) recorded, however, the underlying parenchymal pathology is highly heterogonous. This heterogeneity renders prediction of outcome on an individual patient level inaccurate and makes comparison between patients both in clinical practice and research difficult. The complexity of this heterogeneity has resulted in generic all encompassing ‘traumatic brain injury protocols’. Early management and studies of neuro-protectants are often done irrespective of TBI type, yet it may well be that a specific treatment may be beneficial in a subset of TBI pathologies. Methods A simple CT-based classification system rating the recognised types of blunt TBI (extradural, subdural, subarachnoid haemorrhage, contusions/intracerebral haematoma and diffuse axonal injury) as mild (1), moderate (2) or severe (3) is proposed. Hypoxic brain injury, a common secondary injury following TBI, is also included. Scores can be combined to reflect concomitant types of TBI and predominant location of injury is also recorded. To assess interrater reliability, 50 patient CT images were assessed by 5 independent clinicians of varying experience. Interrater reliability was calculated using overall agreement through Cronbach’s alpha including confidence intervals for intra-class coefficients. Results Interrater reliability scores showed strong agreement for same score and same injury for TBIs with blood on CT and Cronbach’s alpha co-efficient (range 0.87–0.93) demonstrated excellent correlation between raters. Cronbach’s alpha was not affected when individual raters were removed. Conclusions The proposed simple CT classification system has good inter-rater reliability and hence potentially could enable better individual prognostication and targeted treatments to be compared while also accounting for multiple intracranial injury types. Further studies are proposed and underway.