Polytrauma Is Associated with Increased Three- and Six-Month Disability after Traumatic Brain Injury: A TRACK-TBI Pilot Study.

John K Yue,Hansen Deng,J Russell Huie,Adam R Ferguson,Pratik Mukherjee,Esther L Yuh,Mary J Vassar,Alex B Valadka,Ethan A Winkler,Amy J Markowitz,David O Okonkwo,Young M Lee,Geoffrey T Manley,David M Schnyer,Ava M Puccio,Hester F Lingsma,Cecilia L Dalle Ore ,Sabrina R Taylor ,Gabriela Satris

doi:10.1089/neur.2020.0004

Abstract

Polytrauma and traumatic brain injury (TBI) frequently co-occur and outcomes are routinely measured by the Glasgow Outcome Scale-Extended (GOSE). Polytrauma may confound GOSE measurement of TBI-specific outcomes. Adult patients with TBI from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study had presented to a Level 1 trauma center after injury, received head computed tomography (CT) within 24 h, and completed the GOSE at 3 months and 6 months post-injury. Polytrauma was defined as an Abbreviated Injury Score (AIS) ≥3 in any extracranial region.Univariate regressions were performed using known GOSE clinical cutoffs. Multi-variable regressions were performed for the 3- and 6-month GOSE, controlling for known demographic and injury predictors. Of 361 subjects (age 44.9 ± 18.9 years, 69.8% male), 69 (19.1%) suffered polytrauma. By Glasgow Coma Scale (GCS) assessment, 80.1% had mild, 5.8% moderate, and 14.1% severe TBI. On univariate logistic regression, polytrauma was associated with increased odds of moderate disability or worse (GOSE ≤6; 3 month odds ratio [OR] = 2.57 [95% confidence interval (CI): 1.50-4.41; 6 month OR = 1.70 [95% CI: 1.01-2.88]) and death/severe disability (GOSE ≤4; 3 month OR = 3.80 [95% CI: 2.03-7.11]; 6 month OR = 3.33 [95% CI: 1.71-6.46]). Compared with patients with isolated TBI, more polytrauma patients experienced a decline in GOSE from 3 to 6 months (37.7 vs. 24.7%), and fewer improved (11.6 vs. 22.6%). Polytrauma was associated with greater univariate ordinal odds for poorer GOSE (3 month OR = 2.79 [95% CI: 1.73-4.49]; 6 month OR = 1.73 [95% CI: 1.07-2.79]), which was conserved on multi-variable ordinal regression (3 month OR = 3.05 [95% CI: 1.76-5.26]; 6 month OR = 2.04 [95% CI: 1.18-3.42]). Patients with TBI with polytrauma are at greater risk for 3- and 6-month disability compared with those with isolated TBI. Methodological improvements in assessing TBI-specific disability, versus disability attributable to all systemic injuries, will generate better TBI outcomes assessment tools.

Highlights

Traumatic brain injury (TBI) remains a significant cause of injury-related morbidity and mortality, with an annual incidence of more than 2.5 million cases in the United States and more than 50 million cases worldwide.[1,2] Multi-system trauma is common in the setting of TBI, with reported incidences of up to 70% across large population-based cohorts.[3,4] In the trauma literature concurrent TBI is linked to poorer prognoses;[5,6] the impact of polytrauma on TBI outcomes remains understudied, especially in the civilian population
We present univariate and multi-variable outcomes associated with polytrauma versus isolated TBI, and discuss implications and solutions on TBI outcome assessment in the setting of polytrauma
Our findings suggest a less favorable trajectory over time for patients who present with polytrauma, with worse initial Glasgow Coma Scale (GCS) and worse Glasgow Outcome ScaleExtended (GOSE) at both 3 and 6 months

Summary

Introduction

Traumatic brain injury (TBI) remains a significant cause of injury-related morbidity and mortality, with an annual incidence of more than 2.5 million cases in the United States and more than 50 million cases worldwide.[1,2] Multi-system trauma is common in the setting of TBI, with reported incidences of up to 70% across large population-based cohorts.[3,4] In the trauma literature concurrent TBI is linked to poorer prognoses;[5,6] the impact of polytrauma on TBI outcomes remains understudied, especially in the civilian population. Proper outcome assessment tools are critical for capturing divergence in outcomes attributable to polytrauma after TBI. There are no validated tools for evaluating the impact of extracranial injuries on TBI outcomes. For nearly 4 decades, the Glasgow Outcome ScaleExtended (GOSE) has remained the measure of choice for standard outcome assessment after TBI.[7,8,9] The GOSE is a global disability measure that does not differentiate between disability from injury to the brain versus disability from extracranial injuries. The GOSE has been the principal measure accepted by the U.S Food and Drug Administration for primary outcomes[10] and overall functional outcomes in TBI clinical trials.[8]

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