Score to scan: Is there a link between Glasgow Coma Scale score and CT neuroimaging findings in trauma?

ObjectivesWe analysed magnetic resonance imaging (MRI) findings after traumatic brain injury (TBI) aiming to improve the grading of traumatic axonal injury (TAI) to better reflect the outcome.MethodsFour-hundred sixty-three patients (8–70 years) with mild (n = 158), moderate (n = 129), or severe (n = 176) TBI and early MRI were prospectively included. TAI presence, numbers, and volumes at predefined locations were registered on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging, and presence and numbers on T2*GRE/SWI. Presence and volumes of contusions were registered on FLAIR. We assessed the outcome with the Glasgow Outcome Scale Extended. Multivariable logistic and elastic-net regression analyses were performed.ResultsThe presence of TAI differed between mild (6%), moderate (70%), and severe TBI (95%). In severe TBI, bilateral TAI in mesencephalon or thalami and bilateral TAI in pons predicted worse outcomes and were defined as the worst grades (4 and 5, respectively) in the Trondheim TAI-MRI grading. The Trondheim TAI-MRI grading performed better than the standard TAI grading in severe TBI (pseudo-R2 0.19 vs. 0.16). In moderate-severe TBI, quantitative models including both FLAIR volume of TAI and contusions performed best (pseudo-R2 0.19–0.21). In patients with mild TBI or Glasgow Coma Scale (GCS) score 13, models with the volume of contusions performed best (pseudo-R2 0.25–0.26).ConclusionsWe propose the Trondheim TAI-MRI grading (grades 1–5) with bilateral TAI in mesencephalon or thalami, and bilateral TAI in pons as the worst grades. The predictive value was highest for the quantitative models including FLAIR volume of TAI and contusions (GCS score <13) or FLAIR volume of contusions (GCS score ≥ 13), which emphasise artificial intelligence as a potentially important future tool.Clinical relevance statementThe Trondheim TAI-MRI grading reflects patient outcomes better in severe TBI than today’s standard TAI grading and can be implemented after external validation. The prognostic importance of volumetric models is promising for future use of artificial intelligence technologies.Key PointsTraumatic axonal injury (TAI) is an important injury type in all TBI severities. Studies demonstrating which MRI findings that can serve as future biomarkers are highly warranted.This study proposes the most optimal MRI models for predicting patient outcome at 6 months after TBI; one updated pragmatic model and a volumetric model.The Trondheim TAI-MRI grading, in severe TBI, reflects patient outcome better than today’s standard grading of TAI and the prognostic importance of volumetric models in all severities of TBI is promising for future use of AI.

Chapter 7. Neuroimaging

Posttraumatic brain injury patients with depressive symptoms were compared with nondepressed mild and moderate traumatic brain injury (TBI) patients based on their scores on the Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ). A factor analysis demonstrated that the items of the RPCSQ loaded into three factors: mood and cognition, general somatic, and visual somatic symptom groups. Factor scores based on this model were calculated for each group and it was found that depressed subjects reported a greater severity of all three symptom groups compared to nondepressed patients. These results suggest that depression post-TBI may influence patient perception of postconcussion symptoms.

The burden of traumatic brain injury in children

Fifty-one patients with mild (n = 14), moderate (n = 10) and severe traumatic brain injury (n = 27) received early rehabilitation. Level of consciousness was evaluated using the Glasgow Coma Score. Functional level was determined using the Glasgow Outcome Score, whilst mobility was evaluated using the Mobility Scale for Acute Stroke. Activities of daily living were assessed using the Barthel Index. Following Bobath neurodevelopmental therapy, the level of consciousness was significantly improved in patients with moderate and severe traumatic brain injury, but was not greatly influenced in patients with mild traumatic brain injury. Mobility and functional level were significantly improved in patients with mild, moderate and severe traumatic brain injury. Gait recovery was more obvious in patients with mild traumatic brain injury than in patients with moderate and severe traumatic brain injury. Activities of daily living showed an improvement but this was insignificant except for patients with severe traumatic brain injury. Nevertheless, complete recovery was not acquired at discharge. Multiple regression analysis showed that gait and Glasgow Coma Scale scores can be considered predictors of functional outcomes following traumatic brain injury.

Objective Traumatic brain injury (TBI) proves to be an obstacle for Bangladeshi patients due to the lack of facilities and specialist doctors in regional sections of the country. This study aimed to record different attributes of Bangladeshi TBI patients over a year i.e., their injury characteristics, treatments received and understand their impacts on the severity of TBI. Method This cross-sectional study was carried out among 280 TBI patients treated in a tertiary care hospital in Dhaka. The physicians determined TBI's severity and prognosis as per the Glasgow Coma Scale (GCS) and Glasgow Outcome Score (GOS) respectively. Results Most TBI patients were male (76.1%) and aged between 18 and 50 years (52.2%), as in previous studies in South Asian countries. However, the prevalence of TBI due to road traffic accidents (RTAs) was much higher (67.9%) than in the earlier studies in South Asia. Additionally, more patients suffered from severe TBI (29.3%) and moderate TBI (35.7%), and a higher percentage of patients went through surgery (56.8%) compared to previous studies. A significant association of demographic (residence) and clinical characteristics (consciousness after injury, CT scan findings and treatment type) with the severity of TBI was found in bivariate analysis. It also revealed the significant dependence of clinical characteristics (TBI etiology, post-injury consciousness, treatment type and TBI severity) on TBI prognosis. Multivariate analysis showed that patients who were unconscious after TBI and with evident brain injury observed in CT scans have a substantially higher risk of having moderate or severe TBI than mild TBI. Moreover, patients with TBI due to RTAs or falls, evident brain injury in CT scans, post-surgical seizure, and moderate or severe TBI have a significantly higher risk of getting a more unfavorable TBI prognosis than moderate disability. Conclusions In this study, RTAs were found to be the major cause of TBI. Additionally, some variables were identified as possible determinants of TBI severity and prognosis among Bangladeshi patients. The correlation of these variables with TBI should be further studied with the hopes that steps will be taken to reduce TBI incidents and improve its management to reduce the overall burden.

To analyze the ability of prehospital lactate levels to predict 2-day in-hospital mortality in patients with traumatic brain injury (TBI), severe TBI (Glasgow Coma Scale (GCS) ≤ 8 points), and mild or moderate TBI (GCS ≥ 9 points). Second, 90-day mortality was also explored. This was a prospective, multicenter, emergency medical services (EMSs) delivery, ambulance-based, derivation-validation cohort study developed in 5 tertiary hospitals (Spain), from November 1, 2019, to July 31, 2022. Patients were recruited from among all phone requests for emergency assistance among adults who were later evacuated to referral hospitals with acute TBI. The exclusion criteria were minors, pregnancy, trauma patients without TBI, delayed presentations, patients were discharged in situ, participants with cardiac arrest, and unavailability to obtain a blood sample. The primary outcome was all-cause 2-day in-hospital mortality and 90-day mortality in patients with moderate or mild TBI compared with patients with severe TBI. Clinical and analytical parameters (lactate and glucose) were collected. The discriminative power (area under the receiver operating characteristic curve [AUC]) and calibration curve were calculated for 2 geographically separated cohorts. A total of 509 patients were ultimately included. The median age was 58 years (interquartile range: 43-75), and 167 patients were female (32.8%). The primary outcome occurred in 9 (2.2%) of 415 patients with moderate or mild TBI and in 42 (44.7%) of 94 patients with severe TBI. The predictive capacity of the lactate concentration was globally validated in our cohort, for which the AUC was 0.874 (95% CI 0.805-0.942) for the validation cohort. The ability of the GCS score to predict lactate concentration was greater in patients with a GCS score ≥9 points, with an AUC of 0.925 (95% CI 0.808-1.000) and a negative predictive value of 99.09 (95% CI 98.55-99.64) in the validation cohort. Our results show the benefit of using lactate in all patients with TBI, particularly in those with a GCS ≥9 points. Routine incorporation of lactate in the screening of patients with TBI could presumably reduce mortality and deterioration rates because of quicker and better identification of patients at risk.

Posttraumatic Stress Disorder Symptoms During the First Six Months After Traumatic Brain Injury

When considering the use of the initial GCS for prognosis, the two most important problems are the reliability of the initial measurement, and its lack of precision for prediction of a good outcome if the initial GCS is low. If the initial GCS is reliably obtained and not tainted by prehospital medications or intubation, approximately 20% of the patients with the worst initial GCS will survive and 8-10% will have a functional survival (GOS 4-5).

Worldwide, 54-60 million individuals sustain traumatic brain injury (TBI) each year. This meta-analysis aimed to quantify intelligence impairments after TBI and to determine the value of age and injury severity in the prognosis of TBI. An electronic database search identified 81 relevant peer-reviewed articles encompassing 3890 patients. Full-scale IQ (FSIQ), performance IQ (PIQ) and verbal IQ (VIQ) impairments were quantified (Cohen's d) for patients with mild, moderate and severe TBI in the subacute phase of recovery and the chronic phase. Meta-regressions explored prognostic values of age and injury severity measures for intelligence impairments. The results showed that, in the subacute phase, FSIQ impairments were absent for patients with mild TBI, medium-sized for patients with moderate TBI (d = -0.61, P < 0.001) and large for patients with severe TBI (d = -1.09, P < 0.001). In the chronic phase, FSIQ impairments were small for patients with mild or moderate TBI (d = -0.37 and -0.19, P ≤ 0.008) and large for patients with severe TBI (d = -0.80, P < 0.001). Adults with mild TBI had larger PIQ and VIQ impairments in the chronic phase than children (both Q ≥ 5.21, P ≤ 0.02), whilst children with severe TBI had larger FSIQ and VIQ impairments than adults (both Q ≥ 4.40, P ≤ 0.04). Glasgow Coma Scale score, duration of loss of consciousness and post-traumatic amnesia duration moderately to strongly predicted FSIQ, PIQ and VIQ impairments (0.41 ≤ r ≤ 0.82, P ≤ 0.02), but no differences in predictive value were observed. In conclusion, TBI causes persisting intelligence impairments, where children may have better recovery from mild TBI and poorer recovery from severe TBI than adults. Injury severity measures predict intelligence impairments and do not outperform one another.

Characterisation of serum total tau following paediatric traumatic brain injury: a case-control study

Background: The most widely used methods of describing traumatic brain injury (TBI) are the Glasgow Coma Scale (GCS) and the Abbreviated Injury Scale (AIS). Recent evidence suggests that presenting GCS in older patients may be higher than that in younger patients for an equivalent anatomical severity of TBI. This study aimed to assess these observations with a propensity-score matching approach using the data from Trauma Registry System in a Level I trauma center. Methods: We included all adult patients (aged ≥20 years old) with moderate to severe TBI from 1 January 2009 to 31 December 2016. Patients were categorized into elderly (aged ≥65 years) and young adults (aged 20–64 years). The severity of TBI was defined by an AIS score in the head (AIS 3‒4 and 5 indicate moderate and severe TBI, respectively). We examined the differences in the GCS scores by age at each head AIS score. Unpaired Student’s t- and Mann–Whitney U-tests were used to analyze normally and non-normally distributed continuous data, respectively. Categorical data were compared using either the Pearson chi-square or two-sided Fisher’s exact tests. Matched patient populations were allocated in a 1:1 ratio according to the propensity scores calculated using NCSS software with the following covariates: sex, pre-existing chronic obstructive pulmonary disease, systolic blood pressure, hemoglobin, sodium, glucose, and alcohol level. Logistic regression was used to evaluate the effects of age on the GCS score in each head AIS stratum. Results: The study population included 2081 adult patients with moderate to severe TBI. These patients were categorized into elderly (n = 847) and young adults (n = 1234): each was exclusively further divided into three groups of patients with head AIS of 3, 4, or 5. In the 162 well-balanced pairs of TBI patients with head AIS of 3, the elderly demonstrated a significantly higher GCS score than the young adults (14.1 ± 2.2 vs. 13.1 ± 3.3, respectively; p = 0.002). In the 362 well-balanced pairs of TBI patients with head AIS of 4, the elderly showed a significantly higher GCS score than the young adults (13.1 ± 3.3 vs. 12.2 ± 3.8, respectively; p = 0.002). In the 89 well-balance pairs of TBI patients with head AIS of 5, no significant differences were observed for the GCS scores. Conclusions: This study demonstrated that elderly patients with moderate TBI present higher GCS score than younger patients. This study underscores the importance of determining of TBI severity in this group of elderly patients based on the GCS score alone. A lower threshold of GCS cutoff should be adopted in the management of the elderly patients with TBI.

Considering Glasgow Coma Scale (GCS) scores and brain CT scans in a group of children and adolescents with traumatic brain injury (TBI), the scope of this study was to identify the criteria established for the indication of emergency neurosurgical treatment in a level 1 trauma center. This was a cross-sectional study with consecutive review of medical records of children and adolescents < 17 years with TBI who were hospitalized and underwent neurosurgical treatment between January 2016 and December 2023. Two groups were formed for analysis: patients with GCS scores ≤ 8 versus patients with GCS scores > 8. Based on the GCS score and brain CT scan of each patient, the authors investigated the criteria established for the surgical indications in this group. In the period considered for the study, 376 children and adolescents with TBI were hospitalized and 31% required neurosurgical treatment. The median age was 5 years (interquartile range 1-11 years) and there was a predominance of males (68%). Home accidents predominated in 77% of children < 5 years of age, whereas road accidents predominated among those older than 5 (47%). Diffuse brain lesions on CT scans predominated in patients with GCS scores ≤ 8 when compared to the group with GCS scores > 8 (89% vs 19%; p < 0.0001). Regarding neurosurgical access, decompressive craniectomies (70%) and invasive intracranial pressure monitoring (44%) prevailed among patients with GCS scores ≤ 8, whereas craniotomies for drainage of intracranial hematomas (70%) and surgical correction of depressed skull fracture (21%) prevailed among those with GCS scores > 8. Based on the GCS scores and CT scans, the authors were able to define the criteria used for neurosurgical indications in a Brazilian level 1 trauma center. They found a high prevalence of decompressive craniectomy in patients with severe TBI in their department due to the irregular supply of disposable catheters necessary for intracranial pressure monitoring.

Elevated Levels of Serum Glial Fibrillary Acidic Protein Breakdown Products in Mild and Moderate Traumatic Brain Injury Are Associated With Intracranial Lesions and Neurosurgical Intervention

BackgroundAntiepileptic agents are recommended to prevent early post-traumatic seizures (PTS) within seven days of injury in patients with severe traumatic brain injury (TBI). These agents are not routinely recommended for patients with mild-to-moderate TBI, defined as Glasgow Coma Scale (GCS) score > 8. At St. Joseph Mercy Oakland, levetiracetam (LEV) is commonly prescribed to prevent PTS. The objective of this study was to evaluate the appropriateness of LEV use in patients with mild, moderate, and severe TBI.MethodsThis retrospective cohort study evaluated the use of LEV in adult patients admitted with TBI over a five-year period. Patients who were younger than 18 years, had a history of seizures, were transferred to a tertiary center, or succumbed to their injuries were excluded. The primary outcome was appropriateness of LEV use. Secondary outcomes included duration of LEV treatment and rate of seizures.ResultsOf the 448 patients evaluated, 36 patients were excluded. Of the 412 included patients, 403 (97.8%) had a non-severe TBI, defined as GCS score > 8. In patients with non-severe TBI, 153 (38%) received LEV and 94 (23.3%) received LEV for more than seven days. Additionally, 105 (26.1%) patients with non-severe TBI were discharged with a prescription for LEV despite not having a seizure during hospitalization. All six patients with non-severe TBI who experienced a seizure were receiving LEV.ConclusionsInappropriate use of LEV is common in patients admitted with non-severe TBI, with many patients continuing LEV post-discharge. With careful patient selection, patients with mild and moderate TBI likely do not need seizure prophylaxis with LEV. Education on appropriate indication and duration of LEV in patients with TBI is warranted.