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AZ ÉLETTUDOMÁNYI- KLINIKAI FELSŐOKTATÁS GYAKORLATORIENTÁLT ÉS HALLGATÓBARÁT
KORSZERŰSÍTÉSE A VIDÉKI KÉPZŐHELYEK NEMZETKÖZI VERSENYKÉPESSÉGÉNEK ERŐSÍTÉSÉRE
TÁMOP-4.1.1.C-13/1/KONV-2014-0001
Andras Buki M.D., Ph.D.,D.Sc.Department of Neurosurgery, Medical Faculty of Pecs University, Pecs, Hungary, H-7624
Clinical Evaluation and Prognosis
of Traumatic Brain Injury
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• Clinical evaluation is still the most important independent predictor of outcome
• Focused neurological examination
• Other prognostic factors
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Focused neurological
examination
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Post-resuscitation GCS
• Systolic blood pressure is over 90mmHg
• SatO2 is over 90%
• Mind the conditions with unreliable pulse
oxymetry reading!
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Standardisation of pain stimuli
Best response of best arm
Courtesy of Prof. Andrew Maas
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59/451 (13%) non surgical cases:
mistakenly severe
Courtesy of Prof. Andrew Maas
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Trade-off
Clinical observation
Deep sedation for
ICP control
Ventilation, etc.
Sedation and myorelaxants for
airways and ventilation
Courtesy of Prof. Andrew Maas
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PRIMARY BRAIN INJURY
SECONDARY BRAIN INJURY
ASSOCIATED CNS INJURYassociated C-spine (CO-II) injurytandem injury
ASSOCIATED INJURYmultiple/polytraumaassociated multiorgan injury/failure (MOF)
General classification
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Advanced Trauma Life Support®-ATLS ®
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The gold standard upon
radiological evaluation …• (Forget skull Xrays!!!!!!!!!!!!!!!!!!!!!!!!)
• …is CT
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• NOOOO SKULL X RAYSSS!!!
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Outcome prediction: why do we bother with?
• support early clinical decision-making
• inform the relatives
• facilitate comparison of outcomes (patient series, results over time)
• audit of care
• provide endpoint and facilitate the selection of target population in RCTs
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Building Blocks for prognosisCharacteristics of the individual
Admission Clinical Course Early Endpoints
Outcome
Biological constitution- genotype
________________Demographic factors- age- race
________________Socioeconomic status and education
________________Medical History
Injury details
- type (closed, penetrating etc.)- cause
_________________Clinical severity
- intracranial (GCS/pupils)
- extracranial(AIS/ISS)
_________________Second insults
- systemic (hypoxia, hypotension, hypothermia)
- intracranial (neuroworsening, seizures)
_________________CT characteristics
_________________Biomarkers/lab values
Biological response to injury- metabolomics
_______________Change in adm.parameters- clin. severity- change in CT
- biomarkers, lab values
_______________‘New’ predictorsSecond insult
Clinical Monitoring (ICP, brain tissue PO2, evoked potentials)
Early mortality(day 14)
_______________Neuroworsening
_______________ICP control
_______________Neuro-imaging
Mortality
______________GOS (E)
______________HRQoL
______________Neuro-imaging
______________Neuro-psychological assessment
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Factors contributing to outcome -AGE
• studies identified age as the strongest independent predictive factor
• Cut off for survival: 50y
• Cut off for good outcome 30y
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Factors contributing to outcome -GCS
• clinical utility of the GCS is limited by the application of therapeutic guidelines based on sedation
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Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT; Workshop Scientific Team and Advisory Panel Members. Classification of traumatic brain injury for targeted therapies. J Neurotrauma. 2008;25(7):719-38.
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The gold standard upon
radiological evaluation …• (Forget skull Xrays!!!!!!!!!!!!!!!!!!!!!!!!)
• …is CT
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Marshall CT classification
Category Definition
Diffuse Injury I./No visible pathology/
No visible pathology seen on CT scan
Diffuse Injury II. Cisterns are present with midline shift 0-5 mm
and/or:
lesion densities present
no high- or mixed-density lesion > 25 cc may
include bone fragments and foreign bodies
Diffuse Injury III./Swelling/
Cisterns compressed or absent with midline shift
0-5 mm, no high- or mixed-density lesion > 25 cc
Diffuse Injury IV./Shift/
Midline shift > 5 mm, no high- or mixed-density
lesion > 25 cc
Evacuated mass lesion Any lesion surgically evacuated
Nonevacuated mass lesion High- or mixed-density lesion > 25 cc, not
surgically evacuated
Based on: J Neurosurg. 1991 Nov;75(5S):S14 – S20
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Rotterdam CT Score Basal cysterns
• Normal 0
• Compressed 1
• Absent 2
Midline shift
• No shift or shift ≤ 5mm 0
• Shift > 5mm 1
Epidural mass lesion
• Present 0
• Absent 1
Intraventricular blood or tSAH
• Absent 0
• Present 1
• Add plus 1 to make the grading numerically consistent with the grading ofthe motor score of the GCS and with the Marshall CT classification.
• Based on: Maas et al.: Neurosurgery 57:1173-1182, 2005
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Factors contributing to outcome –CT, MR
• CT misses diffuse lesions,
• predictive value of diffuse lesions identified on CT is relatively low
• MR: problems with:– Availability
– Cost efficiency
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• The significance of MRI-only lesions is not
yet established
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Factors contributing to outcome – Monitoring
• Multiparametric ICU monitoring primarily reflects
secondary insults;
• initial results do not necessarily harbour
predicitve value
• Conflicting data on the significance of Pbr02-
monitoring
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Classic models of risk prediction at critical care
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IMPACT (International Mission for Prognosis
And Clinical Trial Design)
Outcome calculator
• core prognostic model: based on three
clinical predictors: age, motor component
of Glasgow coma score (GCS), and
pupillary reactivity
• extended model: core + secondary insults
and CT characteristics
• laboratory model: also includes
haemoglobin and glucose
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CRASH
• Corticosteroid Randomisation After
Significant Head Injury trial
MRC CRASH Trial Collaborators, Perel P, Arango M,
Clayton T, Edwards P, et al. (2008) Predicting outcome
after traumatic brain injury: Practical prognostic models
based on large cohort of international patients. BMJ 336:
425-429.
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0%
20%
40%
60%
80%
100%
0% 20% 40% 60% 80% 100%
probability of unfavorable outcome, IMPACT CORE model
observ
ed m
ort
alit
y
Probability of unfavorable outcome: IMPACT-calculator
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• Concerns: – Statistics: decision tree analysis vs.
Logistic regression analysis– Content: limitations due to initial data-
collection: • Lack of :
– data on coagulopathy– Rotterdam score– detailed data on surgery– some physiological parameters
• Work is needed to establish the accuracy of these models prospectively in patients not enrolled in clinical trials.
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What measures should help?
• Coagulopathy
• Rotterdam score
• Biomarkers
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2,289
0,930 0,850 0,946
6.955*
2,173
0,01,02,03,04,05,06,07,08,0
OR
Patients with SDH above 60
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4,1051.160* 0,788 0,435
55.513*
23.846*
0,05,0
10,015,020,025,030,035,040,045,050,055,060,0
OR
Patients with SDH below 60
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0,171 0,188
0,2640,289
0,3100,355
0,429 0,428
0,501
0
0,1
0,2
0,3
0,4
0,5
0,6R2
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Take home message…
• Outcome prediction is important:– Continuous validation and revision of
institutional protocols
• Outcome calculators provide useful information, but fine tuning by expert opinion is important–and vica versa.
• Outcome calculators should take into consideration additional issues primarily biomarkers