Actualización en el manejo de la hipertensión intracraneal tras un traumatismo craneoencefálico / Update in management of intracraneial hypertensión after traumatic brain injury

El traumatismo craneoencefálico es una entidad heterogénea y dinámica cuya característica común, cualquiera que sea su etiología, es la disminución de la perfusión cerebral en las horas siguientes al impacto. Dado que las lesiones cerebrales por hipoxia,pueden producirse en momentos variables tras el traumatismo, la monitorización de la hipoxia, la disfunción metabólica, la hipertensión intracraneal y la actividad comicial deben detectarse de forma precoz para evitar secuelas. La neuromonitorización va a permitir detectar esas posibles anomalías que pueda comprometer el adecuado aporte de oxígeno y sustrato metabólico a las células cerebrales. A pesar de que, en los últimos años, se han incrementado las herramientas de medición de oximetría cerebral, en nuestro país su uso sigue siendo todavía muy limitado y la monitorización se basa, fundamentalmente, en la observación de la presión intracraneal y la presión de perfusión cerebral, insuficiente para garantizar una adecuada oxigenación cerebral. El objetivo de esta revisión pretende integrar la fisiopatología del traumatismo craneoencefálico con las distintas técnicas de neuromonitorización, proporcionando así un manejo actualizado y más individualizado que mejore el pronóstico del enfermo neurocrítico. (AU)

Trauma brain injury is a heterogeneous and dynamic entity characterized, whatever its etiology, by a decrease in cerebral perfusion the first hours after the impact. Brain injury due to hypoxia can occur after trauma, so monitoring brain hypoxia, metabolic dysfunction, intracranial hypertension and seizure activity must be detected early to prevent brain sequelae. Neuromonitoring will detect those anomalies that could compromise the adequate oxygen supply and substrates of cerebral metabolism. Despite cerebral oximetry monitoring has increased in recent years, unfortunately very limited in our country, neuromonitoring is often based on intracranial pressure and cerebral perfusion pressure, insufficient to measure cerebral oxygenation. The objective of this review is to integrate the pathophysiology of trauma brain injury with the different neuromonitoring techniques to provide an updated and more individualized management that improves the prognosis of neurocritical patients. (AU)

Traumatic brain injury in the elderly with high Glasgow coma scale and low injury severity scores: Factors influencing outcomes.

BACKGROUND: Current trauma activation guidelines do not clearly address age as a risk factor when leveling trauma patients. Glasgow coma scale (GCS) and mode of injury play a major role in leveling trauma patients. We studied the above relationship in our elderly patients presenting with traumatic head injury. METHODS: This study was a retrospective analysis of patients who presented to the emergency department with traumatic brain injuries. We classified the 270 patients into two groups. Group A was 64 years and younger, and group B was 65 years and older. Their GCS, ISS, age, sex, comorbidities, and anticoagulant use were abstracted. The primary outcome was mortality and length of stay. The groups were compared using an independent student's t-test and Chi-square analysis. The Cox regression analysis was used to analyze differences in the outcome while adjusting for the above factors. RESULTS: There were 140 patients in group A, and 130 patients in group B who presented to the ED with a GCS of 14-15 and an ISS of below 15. The mean ISS significantly differed between group A (6.2 ± 6.8) vs (7.9 ± 3.2) in group B (p < 0.0001). The most common diagnosis in group A was concussion (57.3%), while in group B was subdural and subarachnoid hemorrhage (55%). In group B, 13.8% presented as a level one or level two trauma activation. The mean hospital and intensive care stay for group A was 2.1 (±1.9) days and 0.9 (±1.32) days, respectively, versus 4.2 (±3.04) days and 2.4 (±2.02 days) for the elderly group B. Mortality in group A was zero and in group B was 3.8%. Cox regression analysis showed age as an independent predictor of death as well as length of stay. CONCLUSION: Elderly traumatic brain injury patients presenting to the ED with minor trauma and high GCS should be triaged at a higher level in most cases.

Usability of the Level of the S100B Protein, the Gosling Pulsatility Index, and the Jugular Venous Oxygen Saturation for the Prediction of Mortality and Morbidity in Patients with Severe Traumatic Brain Injury.

The high frequency of traumatic brain injury imposes severe economic stress on health and insurance services. The objective of this study was to analyze the association between the serum S100B protein, the Gosling pulsatility index (PI), and the level of oxygen saturation at the tip of the internal jugular vein (SjVO2%) in patients diagnosed with severe TBI. The severity of TBI was assessed by a GCS score ≤ 8 stratified by Glasgow outcome scale (GOS) measured on the day of discharge from the hospital. Two groups were included: GOS < 4 (unfavorable group (UG)) and GOS ≥ 4 (favorable group (UG)). S100B levels were higher in the UG than in the FG. PI levels in the UG were also substantially higher than in the FG. There were similar levels of SjVO2 in the two groups. This study confirmed that serum S100B levels were higher in patients with unfavorable outcomes than in those with favorable outcomes. Moreover, a clear demarcation in PI between unfavorable and FGs was observed. This report shows that mortality and morbidity rates in patients with traumatic brain injury can be assessed within the first 4 days of hospitalization using the S100B protein, PI values, and SjVO2.

Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury: A 6-Month Prospective Cohort Study.

OBJECTIVE: To analyze fatigue after mild traumatic brain injury (TBI) with latent class growth analysis (LCGA) to determine distinct recovery trajectories and investigate influencing factors, including emotional distress and coping styles. DESIGN: An observational cohort study design with validated questionnaires assessing fatigue, anxiety, depression, posttraumatic stress, and coping at 2 weeks and 3 and 6 months postinjury. SETTING: Three level 1 trauma centers. PARTICIPANTS: Patients with mild TBI (N=456). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Fatigue was measured with the fatigue severity subscale of the Checklist Individual Strength, including 8 items (sum score, 8-56). Subsequently, 3 clinical categories were created: high (score, 40-56), moderate (score, 26-38), and low (score, 8-25). RESULTS: From the entire mild TBI group, 4 patient clusters with distinct patterns for fatigue, emotional distress, and coping styles were found with LCGA. Clusters 1 and 2 showed favorable recovery from fatigue over time, with low emotional distress and the predominant use of active coping in cluster 1 (30%) and low emotional distress and decreasing passive coping in cluster 2 (25%). Clusters 3 and 4 showed unfavorable recovery, with persistent high fatigue and increasing passive coping together with low emotional distress in cluster 3 (27%) and high emotional distress in cluster 4 (18%). Patients with adverse trajectories were more often women and more often experiencing sleep disturbances and pain. CONCLUSIONS: The prognosis for recovery from posttraumatic fatigue is favorable for 55% of mild TBI patients. Patients at risk for chronic fatigue can be signaled in the acute phase postinjury based on the presence of high fatigue, high passive coping, and, for a subgroup of patients, high emotional distress. LCGA proved to be a highly valuable and multipurpose statistical method to map distinct courses of disease-related processes over time.

Factors Associated With Functional Impairment After Pediatric Injury.

Importance: Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown. Objective: To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers. Design, Setting, and Participants: This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020. Exposure: At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5). Main Outcomes and Measures: New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites. Results: This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge. Conclusions and Relevance: In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.

Post-traumatic headache attributed to traumatic brain injury: classification, clinical characteristics, and treatment.

Post-traumatic headache is a common sequela of traumatic brain injury and is classified as a secondary headache disorder. In the past 10 years, considerable progress has been made to better understand the clinical features of this disorder, generating momentum to identify effective therapies. Post-traumatic headache is increasingly being recognised as a heterogeneous headache disorder, with patients often classified into subphenotypes that might be more responsive to specific therapies. Such considerations are not accounted for in three iterations of diagnostic criteria published by the International Headache Society. The scarcity of evidence-based approaches has left clinicians to choose therapies on the basis of the primary headache phenotype (eg, migraine and tension-type headache) and that are most compatible with the clinical picture. A concerted effort is needed to address these shortcomings and should include large prospective cohort studies as well as randomised controlled trials. This approach, in turn, will result in better disease characterisation and availability of evidence-based treatment options.

Phenotyping the Spectrum of Traumatic Brain Injury: A Review and Pathway to Standardization.

It is widely appreciated that the spectrum of traumatic brain injury (TBI), mild through severe, contains distinct clinical presentations, variably referred to as subtypes, phenotypes, and/or clinical profiles. As part of the Brain Trauma Blueprint TBI State of the Science, we review the current literature on TBI phenotyping with an emphasis on unsupervised methodological approaches, and describe five phenotypes that appear similar across reports. However, we also find the literature contains divergent analysis strategies, inclusion criteria, findings, and use of terms. Further, whereas some studies delineate phenotypes within a specific severity of TBI, others derive phenotypes across the full spectrum of severity. Together, these facts confound direct synthesis of the findings. To overcome this, we introduce PhenoBench, a freely available code repository for the standardization and evaluation of raw phenotyping data. With this review and toolset, we provide a pathway toward robust, data-driven phenotypes that can capture the heterogeneity of TBI, enabling reproducible insights and targeted care.

Developing an Index of Medical Conditions Associated with Outcomes after Moderate-to-Severe Traumatic Brain Injury.

Medical conditions co-occurring with traumatic brain injury (TBI) are associated with outcomes, and comorbidity indices such as Charlson and Elixhauser are used in TBI research, but they are not TBI specific. The purpose of this research was to develop an index or indices of medical conditions, identified in acute care after moderate to severe TBI, that are associated with outcomes at rehabilitation discharge. Using the TBI Model Systems National Database, the International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes of 8988 participants were converted to Healthcare Cost and Utilization Project (HCUP) diagnostic categories. Poisson regression models were built predicting Disability Rating Scale and Functional Independence Measure Cognitive and Motor subscale scores from HCUP categories after controlling for demographic and injury characteristics. Unweighted, weighted, and anchored indices based on the outcome models predicted 7.5-14.3% of the variance in the observed outcomes. When the indices were applied to a new validation sample of 1613 cases, however, only 2.6-6.6% of the observed outcomes were predicted. Therefore, no models or indices were recommended for future use, but several study findings are highlighted suggesting the importance and the potential for future research in this area.

Anestesia para el paciente con traumatismo encéfalocraneano / Anesthesia for the Traumatic Brain Injury Patient

Traumatic brain injury (TBI) is the leading cause of death and disability for children and young adults. The Glasgow Coma Scale allows to classify TBI as mild, moderate and severe. Imaging studies show the heterogeneity of the diagnosis. Primary injury is caused by mechanical impact. Secondary injury contributes significantly to prognosis by exacerbating hypoperfusion and intracranial hypertension. Even in the absence of extracranial lesions, many patients with severe TBI present significant organ dysfunction, which transforms TBI into a multisystemic pathology. Most relevant systems compromised include cardiovascular, autonomic, respiratory and coagulation. The main aims of anesthetic management are: early decompression together with prevention, early detection, and management of determinants of secondary injury. To date, there are no techniques or drugs showing a significant impact on the outcome of TBI patients. On the other hand, maintaining good hemodynamic stability, adequate oxygenation and normocarbia all contribute to a better outcome.

El trauma encéfalocraneano (TEC) es la causa más importante de muerte y discapacidad de niños y adultos jóvenes. La escala de Glasgow permite clasificarlo en leve, moderado y severo. La imagenología da cuenta de la heterogeneidad del diagnóstico. La injuria primaria es la causada por el impacto mecánico. La injuria secundaria contribuye significativamente al pronóstico al exacerbar la hipoperfusión y la hipertensión endocraneana. Aun en ausencia de lesiones extracraneales, gran parte de los pacientes con TEC severo presenta disfunción orgánica significativa, lo que lo transforma en una patología multisistémica. Destacan el compromiso cardiovascular, autonómico, respiratorio y trastornos de la coagulación, entre otros. Los objetivos del manejo anestésico son: la descompresión precoz junto con la prevención, detección temprana y manejo de factores determinantes de injuria secundaria. No existe evidencia respecto de técnicas ni fármacos que hayan demostrado un impacto significativo en el manejo del TEC, más bien, impacta positivamente el mantener la estabilidad hemodinámica, una adecuada oxigenación y normocarbia.

Classification of Non-Severe Traumatic Brain Injury from Resting-State EEG Signal Using LSTM Network with ECOC-SVM.

Traumatic brain injury (TBI) is one of the common injuries when the human head receives an impact due to an accident or fall and is one of the most frequently submitted insurance claims. However, it is often always misused when individuals attempt an insurance fraud claim by providing false medical conditions. Therefore, there is a need for an instant brain condition classification system. This study presents a novel classification architecture that can classify non-severe TBI patients and healthy subjects employing resting-state electroencephalogram (EEG) as the input, solving the immobility issue of the computed tomography (CT) scan and magnetic resonance imaging (MRI). The proposed architecture makes use of long short term memory (LSTM) and error-correcting output coding support vector machine (ECOC-SVM) to perform multiclass classification. The pre-processed EEG time series are supplied to the network by each time step, where important information from the previous time step will be remembered by the LSTM cell. Activations from the LSTM cell is used to train an ECOC-SVM. The temporal advantages of the EEG were amplified and able to achieve a classification accuracy of 100%. The proposed method was compared to existing works in the literature, and it is shown that the proposed method is superior in terms of classification accuracy, sensitivity, specificity, and precision.

The concordance of optic nerve sheath diameter measurements with the clinical course in children with traumatic head injury.

BACKGROUND: Intracranial pressure (ICP) monitoring is of profound importance concerning prognosis and treatment among children with traumatic brain injury (TBI). Measurements of the optic nerve sheath diameter (ONSD) are one of the methods recommended for ICP monitoring. In this study, we aimed to evaluate the correlation of ONSD change in brain computed tomography (CT) with pediatric Glasgow Coma Score (pGCS) in the follow-up of pediatric cases with TBI, and also to evaluate the usability of the ONSD, which is the indicator of ICP. METHODS: The data of 921 pediatric patients who were admitted to the emergency department with head injury between January 2016 and January 2018 were retrospectively evaluated in this study. Age, gender, trauma type, brain CT finding, pGCS, type of intracranial hemorrhage (ICH), and isolated skull fracture (ISF) were investigated. The patients were evaluated in three groups based on CT findings: (i) patients with parenchymal brain injury, (ii) patients with ISF, and (iii) patients with normal brain CT results. The measurements of ONSD were performed using CT. Whether the ONSD measurement results of the patients were compatible with the clinical data was investigated. RESULTS: The median age of the patients was 36 months (interquartile range [IQR] = 64) and 64.2% were male. The ONSD values and pGCSs of the patients with parenchymal injury were found to be significantly higher than patients with ISF and normal brain CT findings (p<0.05). The pGCSs showed a significant negative correlation with the first and second measurement results of ONSD (p<0.05). In groups undergoing control brain CT, ONSD levels in the second brain CT were found to be significantly high (p<0.05). CONCLUSION: In the clinical follow-up, ONSD measurements are reliable and significant parameters when evaluated with brain CT findings and pGCSs. We think that repeated ONSD measurements will be useful in determining possible adverse effects of secondary injury, as well as in determining the severity of the trauma during admission.

Facial emotion recognition in adult with traumatic brain injury: A protocol for systematic review and meta-analysis.

BACKGROUND: Traumatic brain injury (TBI) refers to head injuries that disrupt normal function of the brain. TBI commonly lead to a wide range of potential psychosocial functional deficits. Although psychosocial function after TBI is influenced by many factors, more and more evidence shows that social cognitive skills are critical contributors. Facial emotion recognition, one of the higher-level skills of social cognition, is the ability to perceive and recognize emotional states of others based on their facial expressions. Numerous studies have assessed facial emotion recognition performance in adult patients with TBI. However, there have been inconsistent findings. The aim of this study is to conduct a meta-analysis to characterize facial emotion recognition in adult patients with TBI. METHODS: A systematic literature search will be performed for eligible studies published up to March 19, 2020 in three international databases (PubMed, Web of Science and Embase). The work such as article retrieval, screening, quality evaluation, data collection will be conducted by two independent researchers. Meta-analysis will be conducted using Stata 15.0 software. RESULTS: This meta-analysis will provide a high-quality synthesis from existing evidence for facial emotion recognition in adult patients with TBI, and analyze the facial emotion recognition performance in different aspects (i.e., recognition of negative emotions or positive emotions or any specific basic emotion). CONCLUSIONS: This meta-analysis will provide evidence of facial emotion recognition performance in adult patients with TBI. INPLASY REGISTRATION NUMBER: INPLASY202050109.

Two latent classes of diagnostic and treatment procedures among traumatic brain injury inpatients.

To characterize latent classes of diagnostic and/or treatment procedures among hospitalized U.S. adults, 18-64 years, with primary diagnosis of TBI from 2004-2014 Nationwide Inpatient Samples, latent class analysis (LCA) was applied to 10 procedure groups and differences between latent classes on injury, patient, hospital and healthcare utilization outcome characteristics were modeled using multivariable regression. Using 266,586 eligible records, LCA resulted in two classes of hospitalizations, namely, class I (n = 217,988) (mostly non-surgical) and class II (n = 48,598) (mostly surgical). Whereas orthopedic procedures were equally likely among latent classes, skin-related, physical medicine and rehabilitation procedures as well as behavioral health procedures were more likely among class I, and other types of procedures were more likely among class II. Class II patients were more likely to have moderate-to-severe TBI, to be admitted on weekends, to urban, medium-to-large hospitals in Midwestern, Southern or Western regions, and less likely to be > 30 years, female or non-White. Class II patients were also less likely to be discharged home and necessitated longer hospital stays and greater hospitalization charges. Surgery appears to distinguish two classes of hospitalized patients with TBI with divergent healthcare needs, informing the planning of healthcare services in this target population.

Latent Class Analysis to Classify Injury Severity in Pediatric Traumatic Brain Injury.

Heterogeneity of injury severity among children with traumatic brain injury (TBI) classified by the Glasgow Coma Scale (GCS) makes comparisons across research cohorts, enrollment in clinical trials, and clinical predictions of outcomes difficult. The present study uses latent class analysis (LCA) to distinguish severity subgroups from a prospective cohort of 433 children 2.5-15 years of age with TBI who were recruited from two level 1 pediatric trauma centers. Indicator variables available within 48 h post-injury including emergency department (ED) GCS, hospital motor GCS, Abbreviated Injury Score (AIS), Rotterdam Score, hypotension in the ED, and pre-hospital loss of consciousness, intubation, seizures, and sedation were evaluated to define subgroups. To understand whether latent class subgroups were predictive of clinically meaningful outcomes, the Pediatric Injury Functional Outcome Scale (PIFOS) at 6 and 12 months, and the Behavior Rating Inventory of Executive Function at 12 months, were compared across subgroups. Then, outcomes were examined by GCS (primary) and AIS (secondary) classification alone to assess whether LCA provided improved outcome prediction. LCA identified four distinct increasing severity subgroups (1-4). Unlike GCS classification, mean outcome differences on PIFOS at 6 months showed decreasing function across classes. PIFOS differences relative to the lowest latent class (LC1) were: LC2 2.27 (0.83, 3.72), LC3 3.99 (1.88, 6.10), and LC4 11.2 (7.04, 15.4). Differences in 12 month outcomes were seen between the most and least severely injured groups. Differences in outcomes in relation to AIS were restricted to the most and less severely injured at both time points. This study distinguished four latent classes that are clinically meaningful, distinguished a more homogenous severe injury group, and separated children by 6-month functional outcomes better than GCS alone. Systematic reporting of these variables would allow comparisons across research cohorts, potentially improve clinical predictions, and increase sensitivity to treatment effects in clinical trials.

Association of clinically important traumatic brain injury and Glasgow Coma Scale scores in children with head injury.

OBJECTIVE: Head injury (HI) is a common presentation to emergency departments (EDs). The risk of clinically important traumatic brain injury (ciTBI) is low. We describe the relationship between Glasgow Coma Scale (GCS) scores at presentation and risk of ciTBI. METHODS: Planned secondary analysis of a prospective observational study of children<18 years who presented with HIs of any severity at 10 Australian/New Zealand centres. We reviewed all cases of ciTBI, with ORs (Odds Ratio) and their 95% CIs (Confidence Interval) calculated for risk of ciTBI based on GCS score. We used receiver operating characteristic (ROC) curves to determine the ability of total GCS score to discriminate ciTBI, mortality and need for neurosurgery. RESULTS: Of 20 137 evaluable patients with HI, 280 (1.3%) sustained a ciTBI. 82 (29.3%) patients underwent neurosurgery and 13 (4.6%) died. The odds of ciTBI increased steadily with falling GCS. Compared with GCS 15, odds of ciTBI was 17.5 (95% CI 12.4 to 24.6) times higher for GCS 14, and 484.5 (95% CI 289.8 to 809.7) times higher for GCS 3. The area under the ROC curve for the association between GCS and ciTBI was 0.79 (95% CI 0.77 to 0.82), for GCS and mortality 0.91 (95% CI 0.82 to 0.99) and for GCS and neurosurgery 0.88 (95% CI 0.83 to 0.92). CONCLUSIONS: Outside clinical decision rules, decreasing levels of GCS are an important indicator for increasing risk of ciTBI, neurosurgery and death. The level of GCS should drive clinician decision-making in terms of urgency of neurosurgical consultation and possible transfer to a higher level of care.

The Effect of Traumatic Brain Injury (TBI) on Cognitive Performance in a Sample of Active Duty U.S. Military Service Members.

INTRODUCTION: Traumatic brain injury (TBI) is considered a signature injury from the fighting in Iraq and Afghanistan. Since the year 2000, over 370,000 U.S. active duty service members have been diagnosed with TBI. Although prior research has shown that even mild forms of TBI are associated with impaired cognitive performance, it is not clear which facets of cognition (computation, memory, reasoning, etc.) are impacted by injury. METHOD: In the present study, we compared active duty military volunteers (n = 88) with and without TBI on six measures of cognition using the Automated Neuropsychological Assessment Metric software. RESULTS: Healthy volunteers exhibited significantly faster response times on the matching-to-sample, mathematical processing, and second round of simple reaction time tasks and had higher throughput scores on the mathematical processing and the second round of the simple reaction time tasks (P < 0.05). CONCLUSION: In this population, cognitive impairments associated with TBI influenced performance requiring working memory and basic neural processing (speed/efficiency).

Interobserver Agreement for the Computed Tomography Severity Grading Scales for Acute Traumatic Brain Injury.

The purpose of this study was to determine the interobserver variability among providers of different specialties and levels of experience across five established computed tomography (CT) scoring systems for acute traumatic brain injury (TBI). One hundred cases were selected at random from a retrospective population of adult patients transported to our emergency department and subjected to a non-contrast head CT due to suspicion of TBI. Eight neuroradiologists and neurosurgeons in trainee (residents and fellows) and attending roles independently scored each non-contrast head CT scan on the Marshall, Rotterdam, Helsinki, Stockholm, and NeuroImaging Radiological Interpretation System (NIRIS) head CT scales. Interobserver variability of scale scores-overall and by specialty and level of training-was quantified using the intraclass correlation coefficient (ICC), and agreement with respect to National Institutes of Health Common Data Elements (NIH CDEs) was assessed using Cohen's kappa. All CT severity scoring systems showed high interobserver agreement as evidenced by high ICCs, ranging from 0.75-0.89. For all scoring systems, neuroradiologists (ICC range from 0.81-0.94) tended to have higher interobserver agreement than neurosurgeons (ICC range from 0.63-0.76). For all scoring systems, attendings (ICC range from 0.76-0.89) had similar interobserver agreement to trainees (ICC range from 0.73-0.89). Agreement with respect to NIH CDEs was high for ascertaining presence/absence of hemorrhage, skull fracture, and mass effect, with estimated kappa statistics of least 0.89. Acute TBI CT scoring systems demonstrate high interobserver agreement. These results provide scientific rigor for future use of these systems for the classification of acute TBI.

Trauma patients with prehospital Glasgow Coma Scale less than nine: not a homogenous group.

PURPOSE: Prehospital guidelines stratify and manage patients with Glasgow Coma Scale (GCS) less than nine and any sign of head injury as affected by severe traumatic brain injury (STBI). We hypothesized that this group of patients is so inhomogeneous that uniform treatment guidelines cannot be advocated. METHODS: Patients (2005-2012) with prehospital GCS below nine and abbreviated injury scale head and neck above two were identified from trauma registry. Patients with acute lethal injuries, isolated neck injuries, extubated within 24 h or transferred interhospitally were excluded. Patients were dichotomized based on the worst prehospital GCS (recorded before sedatives) into two groups: GCS 3-5 and GCS 6-8. These were statistically compared using univariate analysis. RESULTS: The GCS 3-5 group (99 patients) when compared with the GCS 6-8 group (49 patients) had shorter prehospital times (63 vs. 79 min; p < 0.05), more frequent episodes of both hypoxia (30.3% vs. 7.7%; p < 0.05) and hypotension (26.7% vs. 6.4%; p < 0.05), more often required craniectomy (15.1% vs. 4.0%; p = 0.05) and higher mortality (33.3% vs. 2%; p < 0.05). In the GCS 3-5 group, prehospital endotracheal intubation was attempted more often (57.5% vs. 28.6%, p < 0.05) and was more often successful (39.3% vs. 10.2%; p = 0.05). Length of stay in ICU did not differ. CONCLUSIONS: STBI patients are fundamentally different based on whether their initial GCS falls into 3-5 or 6-8 category. Recommendations from trials investigating trauma patients with GCS less than nine as one group should be translated with caution to clinical practice.