Multivariable Prognostic Analysis in Traumatic Brain Injury: Results from The IMPACT Study

Public Health Sciences, University of Edinburgh Medical School, Edinburgh, United Kingdom.
Journal of Neurotrauma (Impact Factor: 3.97). 03/2007; 24(2):329-37. DOI: 10.1089/neu.2006.0035
Source: PubMed

ABSTRACT We studied the prognostic value of a wide range of conventional and novel prognostic factors on admission after traumatic brain injury (TBI) using both univariate and multivariable analysis. The outcome measure was Glasgow Outcome Scale at 6 months after injury. Individual patient data were available on a cohort of 8686 patients drawn from eight randomized controlled trials and three observational studies. The most powerful independent prognostic variables were age, Glasgow Coma Scale (GCS) motor score, pupil response, and computerized tomography (CT) characteristics, including the Marshall CT classification and traumatic subarachnoid hemorrhage. Prothrombin time was also identified as a powerful independent prognostic factor, but it was only available for a limited number of patients coming from three of the relevant studies. Other important prognostic factors included hypotension, hypoxia, the eye and verbal components of the GCS, glucose, platelets, and hemoglobin. These results on prognostic factors will underpin future work on the IMPACT project, which is focused on the development of novel approaches to the design and analysis of clinical trials in TBI. In addition, the results provide pointers to future research, including further analysis of the prognostic value of prothrombin time, and the evaluation of the clinical impact of intervening aggressively to correct abnormalities in hemoglobin, glucose, and coagulation.

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Available from: Ewout W Steyerberg, Aug 28, 2015
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    • "of secondary insults or structural abnormalities on imaging, and laboratory abnormalities to be predictive of eventual outcome [9]. However, clinical course after TBI is often unpredictable , and most prognostic models are unable to incorporate information gleaned from the patients' treatment and recovery. "
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    ABSTRACT: In patients with severe traumatic brain injury, increased intracranial pressure (ICP) is associated with poor functional outcome or death. Hypertonic saline (HTS) is a hyperosmolar therapy commonly used to treat increased ICP; this study aimed to measure initial patient response to HTS and look for association with patient outcome. Patients >17 years old, admitted and requiring ICP monitoring between 2008-2010 at a large urban tertiary care facility were retrospectively enrolled. The first dose of hypertonic saline administered after admission for ICP >19 mmHg was recorded and correlated with vital signs recorded at the bedside. The absolute and relative change in ICP at 1 and 2 hours after HTS administration was calculated. Patients were stratified by mortality and long-term (≥6 months) functional neurological outcome. We identified 46 patients who received at least 1 dose of HTS for ICP > 19, of whom 80% were male, mean age 34.4, with a median post-resuscitation GCS score of 6. All patients showed a significant decrease in ICP one hour after HTS administration. Two hours post-administration, survivors showed a further decrease in ICP (43% reduction from baseline), while ICP began to rebound in non-survivors (17% reduction from baseline). When patients were stratified for long-term neurological outcome, results were similar, with a significant difference in groups by two hours after HTS administration. In patients treated with HTS for intracranial hypertension, those who survived or had good neurological outcome, when compared to those who died or had poor outcomes, showed a significantly larger sustained decrease in ICP two hours after administration. This suggests that even early in a patient's treatment, treatment responsiveness is associated with mortality or poor functional outcome. While this work is preliminary, it suggests that early failure to obtain a sustainable response to hyperosmolar therapy may warrant greater treatment intensity or therapy escalation.
    Injury 09/2014; 45(12). DOI:10.1016/j.injury.2014.08.041 · 2.46 Impact Factor
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    • "Many factors have been reported to influence the prognosis of TBI, including age, gender, severity of injury, co-morbidities, concomitant use of anticoagulants, secondary insults, the initial Glasgow Coma Scale (GCS) score, the motor score, pupil reactivity, the type of lesion visualized on brain computed tomography (CT) scan, changes in intracranial pressure (ICP) and blood levels of specific proteins. Two prognostic scores for TBI patients on admission have been developed on the basis of the large, prospective IMPACT and CRASH databases [4,5]. However, these scores are complex, require numerous data and are not easy to perform in the emergency unit. "
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    ABSTRACT: Introduction The aim of this study was to evaluate the prognostic value of optic nerve sheath diameter (ONSD) measured on the initial brain computed tomography (CT) scan for intensive care unit (ICU) mortality in severe traumatic brain injury (TBI) patients. Methods A prospective observational study of all severe TBI patients admitted to a neurosurgical ICU (over a 10-month period). Demographic and clinical data and brain CT scan results were recorded. ONSD for each eye was measured on the initial CT scan. The group of ICU survivors was compared to non-survivors. Glasgow Outcome Scale (GOS) was evaluated six months after ICU discharge. Results Seventy-seven patients were included (age: 43 ± 18; 81% males; mean Injury Severity Score: 35 ± 15; ICU mortality: 28.5% (n = 22)). Mean ONSD on the initial brain CT scan was 7.8 ± 0.1 mm in non-survivors vs. 6.8 ± 0.1 mm in survivors (P < 0.001). The operative value of ONSD was a good predictor of mortality (area under the curve: 0.805). An ONSD cutoff ≥ 7.3 had a sensitivity of 86.4% and a specificity of 74.6% and was independently associated with mortality in this population (adjusted odds ratio 95% confidence interval: 22.7 (3.2 to 159.6), P = 0.002). There was a relationship between initial ONSD values and six-month GOS (P = 0.03). Conclusions ONSD measured on the initial brain CT scan is independently associated with ICU mortality rate (when ≥ 7.3 mm) in severe TBI patients.
    Critical care (London, England) 03/2013; 17(2):R61. DOI:10.1186/cc12589
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    • "Several prognostic factors of a poor outcome have been proposed, such as old age, low initial Glasgow Coma Scale (GCS) score, anisocoria, hypotension, or shock.2-4 Radiological findings, such as obliteration of the third ventricle or basal cistern, midline shift, subarachnoid hemorrhage (SAH),3,4 lesion burden,5 and grade of diffuse axonal injury6 are reported as being predictive of a poor outcome. "
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    ABSTRACT: The functional outcome of traumatic brain injury (TBI) varies widely. The aim of this study was to identify the factors predicting outcome following TBI. We prospectively enrolled acute TBI patients, and assessed them clinically and radiologically using brain magnetic resonance imaging (MRI). Functional outcome was measured using the Glasgow Outcome Scale (GOS) at 3 months after TBI. A GOS score of ≤4 was regarded as an unfavorable outcome. We performed multivariate analysis to investigate the association between clinicoradiological variables and outcome. Forty-two patients completed the clinical evaluation in the acute phase and outcome measurement at 3 months. Motorcycle accident was associated with unfavorable outcome [odds ratio (OR)=38.3, p=0.022]. If the patients were the victims of the accident, they were more likely to have an unfavorable outcome (OR=21.3, p=0.037). All seven patients with a low Glasgow Coma Scale (GCS) score (i.e., ≤8) at 24 or 48 h after TBI were also found to have an unfavorable outcome. The presence of diffuse axonal injury (DAI) was a significant predicting factor of an unfavorable outcome (OR=8.48, p=0.042). Motorcycle accident, being an accident victim, and a lower GCS score at 24 hours or more after the accident were found to be unfavorable prognostic variables. DAI was the only radiologic variable predicting an unfavorable outcome. Thus, it is important to identify DAI by applying MRI in the acute phase.
    Journal of Clinical Neurology 09/2012; 8(3):224-9. DOI:10.3988/jcn.2012.8.3.224 · 1.81 Impact Factor
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