Individuals classified as having mild traumatic brain injury (mTBI) showing certain patterns of injury on CT appear to be at risk for incomplete recovery and/or adverse outcomes, according to a report published online on July 19 in JAMA Neurology.
Specifically, patients with Glasgow Coma Scale scores of 13 to 15 showing contusion, subarachnoid hemorrhage (SAH), and/or subdural hematoma (SDH) features are more likely to have incomplete recovery (defined as a Glasgow Outcome Scale–Extended (GOSE) score of less than 8) and unfavorable outcome (defined as a GOSE score of less than 5) one year after injury. Those with intraventricular and/or petechial hemorrhage appear more likely to have unfavorable outcomes up to 12 months after injury.
“An imaging biomarker can be used to identify patients with GCS scores of 13 to 15 who are likely to have bad outcomes and should be followed closely," said lead author Geoffrey Manley, MD, PhD, chief of neurosurgery at Zuckerberg San Francisco General Hospital and professor and vice chairman of neurological surgery at the University of California, San Francisco. “All of the imaging phenotypes we looked at with the exception of epidural hematomas are associated with bad outcomes."
In an interview with Neurology Today, Dr. Manley stressed that the study results suggest more generally that there is a large cohort of individuals classified as having mTBI who should be receiving better follow-up care and education about TBI. “The GCS was meant to describe patients individually, but the habit that clinicians have fallen into of classifying patients as mild, moderate or severe biases against those patients with 'mild' TBI in terms of how we take care of them and their struggles with disability," he said.
Dr. Manley and colleagues analyzed CT findings and outcomes on a subset of 1,935 patients enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study with GCS scores of 13 to 15; they presented to emergency departments at 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018.
A positive CT result was defined as the presence of any acute intracranial abnormality on the first head CT after admission. GOSE scores were assessed at two-, three-, six-weeks post-injury and then again at 12 months. CT findings and outcomes were validated externally using results from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study.
Overall, 715 of 1935 individuals (37 percent) in this analytic cohort had a positive CT result for acute intracranial pathology. The most common pattern was isolated SAH. Other common patterns were combined SAH, SDH, and contusion; isolated SDH; and combined SAH and SDH.
Three trends emerged from the analysis of CT phenotypes. Subdural hematoma and contusion often co-occurred and were associated with both incomplete recovery and more severe impairment up to 12 months after injury. Intraventricular and/or petechial hemorrhage co-occurred and were associated with more severe impairment up to 12 months after injury. And epidural hematoma was associated with incomplete recovery at some points but not with more severe impairment.
Disclosures: Dr. Manley reports grants from NINDS to TRACK-TBI, the US Department of Defense for the Traumatic Brain Injury Endpoints Development Initiative, funding for stipends for patients in TRACK-TBI and support to clinical sites from One Mind, support for TRACK-TBI data curation efforts from NeuroTrauma Sciences LLC, support for a precision medicine collaboration from US Department of Energy, grants from US Department of Defense for TRACK-TBI precision medicine, a contract from the US Department of Defense to the Medical Technology Enterprise Consortium TRACK-TBI Network, and a grant from the National Football League to the TRACK-TBI LONG study (which will extend TRACK-TBI's current one-year follow-up for three additional years) during the conduct of the study.
Link Up for More Information:
Yuh EL, Jain S, Sun X, et al. Pathological computed tomography features associated with adverse outcomes after mild traumatic brain injury: A TRACK-TBI Study with external validation in CENTER-TBI. JAMA Neurol 2021; Epub 2021 Jul 19.
Seabury SA, Gaudette E, Goldman DP, et al, for the TRACK-TBI Investigators. Assessment of follow-up care after emergency department presentation for mild traumatic brain injury and concussion: Results from the TRACK-TBI study. JAMA Netw Open 2018;1(1):e18