Prognosis Following Severe Head Injury: Development and Validation of a Model for Prediction of Death, Disability, and Functional Recovery

Cremer, Olaf L.; Moons, Karel G.M.; Dijk, Gert W van; Balen, Peter van; Kalkman, Cor J.

doi:10.1097/01.ta.0000195981.63776.ba

Cited by 59 publications

(37 citation statements)

References 34 publications

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“…40 However, few studies perform this type of validation. 10,12,16,36,37,39,42 As in those publications, we found a worse discriminative ability in the validation set, although our model performed better than other recently published studies (0.88).…”

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confidence: 53%

“…40 The systematic reviews of prognostic models for TBIs that have been published in the past 20 years have generated criticism regarding their clinical or methodological validities; 15,33 only a few studies have been subjected to extensive internal and external validations. 2,10,16,36,37,39,42 Few studies have analyzed the characteristics of patients who succumbed to early death after a TBI. 2,[6][7][8] The first aim of this study was to derive a prognostic model for early death (within 48 hours) to be used within the first 6 hours after a severe TBI and to externally validate this model.…”

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confidence: 99%

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Validation of a prognostic score for early mortality in severe head injury cases

Gómez¹,

De-la-Cruz

Lora

et al. 2014

JNS

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Object Traumatic brain injury (TBI) represents a large health and economic burden. Because of the inability of previous randomized controlled trials (RCTs) on TBI to demonstrate the expected benefit of reducing unfavorable outcomes, the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in TBI) and CRASH (Corticosteroid Randomisation After Significant Head Injury) studies provided new methods for performing prognostic studies of TBI. This study aimed to develop and externally validate a prognostic model for early death (within 48 hours). The secondary aim was to identify patients who were more likely to succumb to an early death to limit their inclusion in RCTs and to improve the efficiency of RCTs. Methods The derivation cohort was recruited at 1 center, Hospital 12 de Octubre, Madrid (1990–2003, 925 patients). The validation cohort was recruited in 2004–2006 from 7 study centers (374 patients). The eligible patients had suffered closed severe TBIs. The study outcome was early death (within 48 hours post-TBI). The predictors were selected using logistic regression modeling with bootstrapping techniques, and a penalized reduction was used. A risk score was developed based on the regression coefficients of the variables included in the final model. Results In the validation set, the final model showed a predictive ability of 50% (Nagelkerke R2), with an area under the receiver operating characteristic curve of 89% and an acceptable calibration (goodness-of-fit test, p = 0.32). The final model included 7 variables, and it was used to develop a risk score with a range from 0 to 20 points. Age provided 0, 1, 2, or 3 points depending on the age group; motor score provided 0 points, 2 (untestable), or 3 (no response); pupillary reactivity, 0, 2 (1 pupil reacted), or 6 (no pupil reacted); shock, 0 (no) or 2 (yes); subarachnoid hemorrhage, 0 or 1 (severe deposit); cisternal status, 0 or 3 (compressed/absent); and epidural hematoma, 0 (yes) or 2 (no). Based on the risk of early death estimated with the model, 4 risk of early death groups were established: low risk, sum score 0–3 (< 1% predicted mortality); moderate risk, sum score 4–8 (predicted mortality between 1% and 10%); high risk, sum score 9–12 (probability of early death between 10% and 50%); and very high risk, sum score 13–20 (early mortality probability > 50%). This score could be used for selecting patients for clinical studies. For example, if patients with very high risk scores were excluded from our study sample, the patients included (eligibility score < 13) would represent 80% of the original sample and only 23% of the patients who died early. Conclusions The combination of Glasgow Coma Scale score, CT scanning results, and secondary insult data into a prognostic score improved the prediction of early death and the classification of TBI patients.

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confidence: 99%

Validation of a prognostic score for early mortality in severe head injury cases

Gómez¹,

De-la-Cruz

Lora

et al. 2014

JNS

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“…Merging outcome categories, only to facilitate data analysis, is a waste of valuable information. As an alternative, it has been proposed to use more sophisticated analysis tools, such as ordinal logistic regression models, or differentiate the point of dichotomization of the outcome according to the patient's baseline risk [48][49][50].…”

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confidence: 99%

Does ICP monitoring make a difference in neurocritical care?

Cremer

2008

European Journal of Anaesthesiology

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Raised intracranial pressure and low cerebral perfusion pressure are associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these variables. However, there are no randomized controlled trials that have demonstrated the effectiveness of intracranial pressure-guided care in severely head-injured patients. Observational studies of such therapy have yielded inconsistent results, ranging from decreased mortality to no effect or increased morbidity or mortality. A recent cohort study supports the notion that the possible benefits of intracranial pressure monitoring after traumatic brain injury are small - if present - and would exceed a number needed for the treatment of 16. Furthermore, intracranial pressure monitoring and aggressive management of intracranial pressure and cerebral perfusion pressure have been associated with increased lengths of stay in the neurocritical care unit, conceivable costs and possibly an increased rate of complications. Against this background, there is sufficient clinical equipoise to warrant an adequately powered randomized controlled trial to compare intracranial pressure-guided care with supportive critical care without intracranial pressure monitoring in patients with severe traumatic brain injury. However, the realization of such a trial is likely to be problematic for a number of reasons, not least of which the firmly held biases of many clinicians.

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“…Age is also related to outcome following TBI, with older patients having poorer outcomes, and predictive models of TBI outcome often include age, health variables, injury characteristics, and GCS (Cremer et al, 2006;Rovlias and Kotsou, 2004;Temkin, 1995). Age-related activation increases and reduced functional asymmetry during fMRI with cognitive tasks have been reported in prefrontal areas (Cabeza, 2002) and in other brain regions, such as the parietal lobes (Nielson et al, 2002).…”

Section: Introductionmentioning

confidence: 99%

Effects of Severity of Traumatic Brain Injury and Brain Reserve on Cognitive-Control Related Brain Activation

Scheibel

Newsome

Troyanskaya

et al. 2009

Journal of Neurotrauma

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Functional magnetic resonance imaging (fMRI) has revealed more extensive cognitive-control related brain activation following traumatic brain injury (TBI), but little is known about how activation varies with TBI severity. Thirty patients with moderate to severe TBI and 10 with orthopedic injury (OI) underwent fMRI at 3 months postinjury using a stimulus response compatibility task. Regression analyses indicated that lower total Glasgow Coma Scale (GCS) and GCS verbal component scores were associated with higher levels of brain activation. Brain-injured patients were also divided into three groups based upon their total GCS score (3-4, 5-8, or 9-15), and patients with a total GCS score of 8 or less produced increased, diffuse activation that included structures thought to mediate visual attention and cognitive control. The cingulate gyrus and thalamus were among the areas showing greatest increases, and this is consistent with vulnerability of these midline structures in severe, diffuse TBI. Better task performance was associated with higher activation, and there were differences in the over-activation pattern that varied with TBI severity, including greater reliance upon left-lateralized brain structures in patients with the most severe injuries. These findings suggest that over-activation is at least partially effective for improving performance and may be compensatory.

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Prognosis Following Severe Head Injury: Development and Validation of a Model for Prediction of Death, Disability, and Functional Recovery

Cited by 59 publications

References 34 publications

Validation of a prognostic score for early mortality in severe head injury cases

Validation of a prognostic score for early mortality in severe head injury cases

Does ICP monitoring make a difference in neurocritical care?

Effects of Severity of Traumatic Brain Injury and Brain Reserve on Cognitive-Control Related Brain Activation

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