Abstract
BackgroundTraumatic brain injury (TBI) is a devastating condition with significant long-term mortality and morbidity. Despite current need for objective indicators to guide initial decision-making, few reliable acute phase prognostic factors have been identified. Early magnetic resonance imaging (MRI) has been investigated as a prognostic tool, but uncertainty remains in both its discriminative predictive value and which acute phase lesion patterns correlate with long-term outcome.MethodsWe will conduct a systematic review of observational cohort studies and randomized controlled trials of adult moderate or severe TBI patients who underwent MRI in the acute phase after trauma. A high sensitivity search strategy will be employed in MEDLINE, EMBASE, BIOSIS, and Cochrane CENTRAL to identify citations. Two reviewers will independently screen all identified references for eligibility and extract data into a standardized form. Data will be collected on study design, baseline demographics, trauma characteristics, magnetic resonance (MR) technical specifications, lesion patterns, and outcomes as related to acute MRI imaging. If meta-analysis is possible, quantitative data for each outcome will be pooled per type of lesion pattern using random effects models and expressed as Mantel-Haenszel relative risks in order to determine the prognostic value of lesions detected on acute MRI and their strength as discriminatory predictors of long-term outcome. Statistical heterogeneity will be evaluated with the I2 statistics, and risk of bias and reporting quality will be assessed with standardized scales. Subgroup analyses are planned as a function of TBI severity, MRI-timing post-TBI, MRI field strength, MRI sequence, timing of outcome assessment, and risk of bias.DiscussionWe expect significant clinical heterogeneity, as eligible studies will likely encompass different periods in evolving MRI technology in addition to significant variability of image sequence protocols and timing of acquisition between centers. Based on existing studies in TBI, we expect lesions detected in the brainstem to be of significant predictive value as MRI is particularly sensitive for imaging the brain’s posterior fossa. Our systematic review will allow clinicians to more accurately interpret MRI in the context of determining prognosis for moderate and severe TBI patients and inform researchers in this domain to improve the methodology of future studies.Systematic review registrationProspero CRD42015017074Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0184-x) contains supplementary material, which is available to authorized users.
Highlights
Traumatic brain injury (TBI) is a devastating condition with significant long-term mortality and morbidity
Determination of long-term prognosis is an important step in the acute evaluation of moderate and severe TBI patients, since a large proportion of such patients are young [1] with few or no comorbid conditions
A significant body of evidence has shown that magnetic resonance imaging (MRI) is superior to Computed tomography (CT) in detecting most types of traumatic parenchymal lesions [8, 20], only the latter is currently routine whereas use of the former remains sporadic in the acute phase
Summary
Design A team of experts including intensivists, internists, epidemiologists, and a biostatistician collaborated to develop the research question and study design of this systematic review, in accordance with the methodological guidelines delineated in the Cochrane Handbook for Systematic Reviews and Meta-Analyses [13]. By performing these assessments independently and in parallel, we seek to differentiate between methodological bias and omissions in reporting in the primary studies Summaries of these evaluations will be presented in a graphical format to offer precise recommendations for future studies in this domain and, in the case of the risk of bias assessment, to guide subgroup analysis. Where permitted by the data available, sensitivity and subgroup analyses will be undertaken to explore sources of heterogeneity and test the robustness of the results Such analyses will be performed in regard to minimal age of inclusion, severity of TBI, timing of MRI post-TBI, MRI field strength, MRI sequence, timing of outcome assessment, inter-rater reproducibility of image analysis, timing of outcome assessment, rehabilitation strategies, and study risk of bias. Visual analysis of funnel plots will be used to evaluate the presence and degree of publication bias
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