Abstract
Background
Traumatic brainstem injury has yet to be incorporated into widely used imaging classification systems for traumatic brain injury (TBI), and questions remain regarding prognostic implications for this TBI subgroup. To address this, retrospective data on patients from the multicenter prospective Transforming Research and Clinical Knowledge in TBI study were studied.
Methods
Patients with brainstem and cerebrum injury (BSI+) were matched by age, sex, and admission Glasgow Coma Scale (GCS) score to patients with cerebrum injuries only. All patients had an interpretable head computed tomography (CT) scan from the first 48 hours after injury and a 6-month Glasgow Outcome Scale Extended (GOSE) score. CT scans were reviewed for brainstem lesions and, when present, characterized by location, size, and type (traumatic axonal injury, contusion, or Duret hemorrhage). Clinical, demographic, and outcome data were then compared between the two groups.
Results
Mann–Whitney U-tests showed no significant difference in 6-month GOSE scores in patients with BSI+ (mean 2.7) compared with patients with similar but only cerebrum injuries (mean 3.9), although there is a trend (p = 0.10). However, subclassification by brainstem lesion type, traumatic axonal injury (mean 4.0) versus Duret hemorrhage or contusion (mean 1.4), did identify a proportion of BSI+ with significantly less favorable outcome (p = 0.002). The incorporation of brainstem lesion type (traumatic axonal injury vs. contusion/Duret), along with GCS into a multivariate logistic regression model of favorable outcome (GOSE score 4–8) did show a significant contribution to the prognostication of this brainstem injury subgroup (odds ratio 0.08, 95% confidence interval 0.00–0.67, p = 0.01).
Conclusions
These findings suggest two groups of patients with brainstem injuries may exist with divergent recovery potential after TBI. These data support the notion that newer CT imaging classification systems may augment traditional clinical measures, such as GCS in identifying those patients with TBI and brainstem injuries that stand a higher chance of favorable outcome.
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Change history
30 September 2021
A Correction to this paper has been published: https://doi.org/10.1007/s12028-021-01356-4
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Acknowledgments
We would like to thank the patients and their families for their participation and support of the TRACK-TBI study. Funding for the original TRACK-TBI study was awarded to GTM by the National Institutes of Health.
Funding
Funding was provided by National Institute of Neurological Disorders and Stroke (Grant No. U01NS086090) and U.S. Department of Defense (Grant No. W81XWH-14-2-0176).
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JRW contributed to the study design, analysis, drafting of the manuscript, critical revisions, and final approval of the published work. ENB contributed to conception, intellectual content, and final approval of the published work. AF contributed to conception, intellectual content, and final approval of the published work. CY contributed to conception, intellectual content, and final approval of the published work. NRT reports contributed to study design, analysis, interpretation of the data, drafting of the manuscript, critical revisions, and final approval of the published work. JTG contributed to study design, intellectual content, and final approval of the published work. DOO contributed to study design, intellectual content, and final approval of the published work. GTM reports contributed to study design, intellectual content, and final approval of the published work. JB contributed to analysis, revising the manuscript, and final approval of the published work. SD contributed to interpretation of the data, drafting of the manuscript, critical revisions, and final approval of the published work. AJM contributed to interpretation of the data, drafting of the manuscript, critical revisions, and final approval of the published work. ELY contributed to data acquisition, interpretation of the data, intellectual content, and final approval of the published work. PM contributed to data acquisition, interpretation of the data, intellectual content, and final approval of the published work. CLMD contributed to the study design, analysis, drafting of the manuscript, critical revisions, and final approval of the published work.
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Dr. Williams reports Grants from Neurosurgery Research and Education Foundation Fellowship, Grants from Adler Giersch Law Firm Endowed Fund for Traumatic Brain Injury Research, outside the submitted work. Mr. Nieblas-Bedolla has nothing to disclose. Dr. Feroze has nothing to disclose. Dr. Young has nothing to disclose. Dr. Temkin reports Grants from US Federal Government, during the conduct of the study. Dr. Giacino reports other funding from University of California at San Francisco, during the conduct of the study. Dr. Okonkwo has nothing to disclose. Dr. Manley reports Grants from United States Department of Defense, and a contract from United States Department of Defense/MTEC, Grants from NIH-NINDS, other from United States Department of Energy, other from One Mind, and other from NeuroTruama Sciences LLC, during the conduct of the study; other from National Football League Scientific Advisory Board, outside the submitted work. Mr. Barber has nothing to disclose. Dr. Durfy has nothing to disclose. Ms. Markowitz reports Grants and contracts from US Department of Defense/MTEC, and salary support from United States Department of Energy and One Mind during the conduct of the study. Dr. Yuh reports Grant support through NIH, DoD during the conduct of the study. Dr. Mukherjee reports Grants from NIH, DoD, outside the submitted work; In addition, Dr. Mukherjee has a patent US PTO Serial No. 15/782,005 pending to University of California Regents, and a patent PCT/US No. 20/42811 pending to University of California Regents. Dr. Mac Donald reports Grants from National Institute of Neurological Disorders, Grants from Department of Defense, outside the submitted work.
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We further confirm adherence to ethical guidelines and investigated whether we needed institutional review board approval, but as this was a retrospective analysis of deidentified patient data, it was deemed “nonhuman subjects” and was not required to have formal institutional review board approval.
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This article is related to the Commentary available at https://doi.org/10.1007/s12028-021-01264-7.
TRACK-TBI Investigators are listed at the end of the article.
This article was updated to correct Esther L. Yuh’s name.
Appendix: TRACK-TBI Investigators
Appendix: TRACK-TBI Investigators
Opeolu Adeoye, MD, University of Cincinnati; Neeraj Badjatia, MD, University of Maryland; Kim Boase, University of Washington; Yelena Bodien, PhD, Massachusetts General Hospital; M. Ross Bullock, MD PhD, University of Miami; Randall Chesnut, MD, University of Washington; John D. Corrigan, PhD, ABPP, Ohio State University; Karen Crawford, University of Southern California; Ramon Diaz-Arrastia, MD PhD, University of Pennsylvania; Sureyya Dikmen, PhD, University of Washington; Ann-Christine Duhaime, MD, MassGeneral Hospital for Children; Richard Ellenbogen, MD, University of Washington; V Ramana Feeser, MD, Virginia Commonwealth University; Adam R. Ferguson, PhD, University of California, San Francisco; Brandon Foreman, MD, University of Cincinnati; Raquel Gardner, University of California, San Francisco; Etienne Gaudette, PhD, University of Southern California; Dana Goldman, PhD, University of Southern California; Luis Gonzalez, TIRR Memorial Hermann; Shankar Gopinath, MD, Baylor College of Medicine; Rao Gullapalli, PhD, University of Maryland; J Claude Hemphill, MD, University of California, San Francisco; Gillian Hotz, PhD, University of Miami; Sonia Jain, PhD, University of California, San Diego; C. Dirk Keene, MD PhD, University of Washington; Frederick K. Korley, MD, PhD, University of Michigan; Joel Kramer, PsyD, University of California, San Francisco; Natalie Kreitzer, MD, University of Cincinnati; Harvey Levin, MD, Baylor College of Medicine; Chris Lindsell, PhD, Vanderbilt University; Joan Machamer, MA, University of Washington; Christopher Madden, MD, UT Southwestern; Alastair Martin, PhD, University of California, San Francisco; Thomas McAllister, MD, Indiana University; Michael McCrea, PhD, Medical College of Wisconsin; Randall Merchant, PhD, Virginia Commonwealth University; Lindsay Nelson, PhD, Medical College of Wisconsin; Laura B. Ngwenya, MD, PhD, University of Cincinnati; Florence Noel, PhD, Baylor College of Medicine; Amber Nolan, MD PhD, University of California, San Francisco; Eva Palacios, PhD, University of California, San Francisco; Daniel Perl, MD, Uniformed Services University; Ava Puccio, PhD, University of Pittsburgh; Miri Rabinowitz, PhD, University of Pittsburgh; Claudia Robertson, MD, Baylor College of Medicine; Jonathan Rosand, MD, MSc, Massachusetts General Hospital; Angelle Sander, PhD, Baylor College of Medicine; Gabriella Satris, University of California, San Francisco; David Schnyer, PhD, UT Austin; Seth Seabury, PhD, University of Southern California; Murray Stein, MD MPH, University of California, San Diego; Sabrina Taylor, PhD, University of California, San Francisco; Arthur Toga, PhD, University of Southern California; Alex Valadka, MD, Virginia Commonwealth University; Mary Vassar, RN MS, University of California, San Francisco; Paul Vespa, MD, University of California, Los Angeles; Kevin Wang, PhD, University of Florida; John K. Yue, MD, University of California, San Francisco; Ross Zafonte, Harvard Medical School.
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Williams, J.R., Nieblas-Bedolla, E., Feroze, A. et al. Prognostic Value of Hemorrhagic Brainstem Injury on Early Computed Tomography: A TRACK-TBI Study. Neurocrit Care 35, 335–346 (2021). https://doi.org/10.1007/s12028-021-01263-8
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DOI: https://doi.org/10.1007/s12028-021-01263-8