Subscribe to RSS
DOI: 10.1055/s-0043-1768671
Glasgow coma scale pupil score (GCS-P) and the hospital mortality in severe traumatic brain injury: analysis of 1,066 Brazilian patients
Escala de coma de Glasgow com resposta pupilar (ECG-P) e mortalidade hospitalar em traumatismo cranioencefálico grave: análise de 1.066 pacientes brasileirosAbstract
Background Pupil reactivity and the Glasgow Coma Scale (GCS) score are the most clinically relevant information to predict the survival of traumatic brain injury (TBI) patients.
Objective We evaluated the accuracy of the GCS-Pupil score (GCS-P) as a prognostic index to predict hospital mortality in Brazilian patients with severe TBI and compare it with a model combining GCS and pupil response with additional clinical and radiological prognostic factors.
Methods Data from 1,066 patients with severe TBI from 5 prospective studies were analyzed. We determined the association between hospital mortality and the combination of GCS, pupil reactivity, age, glucose levels, cranial computed tomography (CT), or the GCS-P score by multivariate binary logistic regression.
Results Eighty-five percent (n = 908) of patients were men. The mean age was 35 years old, and the overall hospital mortality was 32.8%. The area under the receiver operating characteristic curve (AUROC) was 0.73 (0.70–0.77) for the model using the GCS-P score and 0.80 (0.77–0.83) for the model including clinical and radiological variables. The GCS-P score showed similar accuracy in predicting the mortality reported for the patients with severe TBI derived from the International Mission for Prognosis and Clinical Trials in TBI (IMPACT) and the Corticosteroid Randomization After Significant Head Injury (CRASH) studies.
Conclusion Our results support the external validation of the GCS-P to predict hospital mortality following a severe TBI. The predictive value of the GCS-P for long-term mortality, functional, and neuropsychiatric outcomes in Brazilian patients with mild, moderate, and severe TBI deserves further investigation.
Resumo
Antecedentes A reatividade pupilar e o escore da Escala de Coma de Glasgow (ECG) representam as informações clínicas mais relevantes para predizer a sobrevivência de pacientes com traumatismo cranioencefálico (TCE).
Objetivo Avaliar a acurácia da ECG com resposta pupilar (ECG-P) como índice prognóstico para predizer mortalidade hospitalar em pacientes brasileiros acometidos por TCE grave e compará-lo com um modelo combinando ECG e resposta pupilar com fatores prognósticos radiológicos.
Métodos Foram analisados dados de 1.066 pacientes com TCE grave de 5 estudos prospectivos. Foi determinada a associação entre mortalidade hospitalar e a combinação de ECG, reatividade pupilar, idade, níveis glicêmicos, tomografia computadorizada (TC) de crânio ou o escore ECG-P por regressão logística binária multivariada.
Resultados Oitenta e cinco por cento (n = 908) dos pacientes eram homens. A média de idade foi de 35 anos e a mortalidade hospitalar geral foi de 32,8%. A AUROC (em português, Curva Característica de Operação do Receptor) foi de 0,73 (0,70–0,77) para o modelo utilizando o escore ECG-P e de 0,80 (0,77–0,83) para o modelo incluindo variáveis clínicas e radiológicas. O escore ECG-P mostrou acurácia semelhante na previsão da mortalidade relatada para pacientes com TCE grave derivados dos estudos International Mission for Prognosis and Clinical Trials in TBI (IMPACT, na sigla em inglês) e Corticosteroid Randomization After Significant Head Injury (CRASH, na sigla em inglês).
Conclusão Nossos resultados apoiam a validação externa da ECG-P para prever a mortalidade hospitalar após um TCE grave. O valor preditivo da ECG-P para mortalidade a longo prazo, resultados funcionais e neuropsiquiátricos em pacientes brasileiros com TCE leve, moderado e grave precisam ser investigados.
Palavras-chave
Escala de Coma de Glasgow - Pupila - Lesões Encefálicas Traumáticas - Prognóstico - MortalidadeAuthors' Contributions:
MMB, KL, EK, FDP, AJG, RW: contributed to the design and implementation of the research; MMB, RW: carried out the analysis of the results; MMB, ETM, FZA, HDV, NBDR, HMM: contributed to data collection; MMB, RW: wrote the manuscript.
Support:
The present work was supported by the PRONEX Program (NENASC Project, process 56802/2010) and by the PPSUS Program (TO 201302248) of FAPESC-CNPq-MS, Santa Catarina, Brazil.
Publication History
Received: 22 November 2022
Accepted: 15 January 2023
Article published online:
31 May 2023
© 2023. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)
Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil
-
References
- 1 Davanzo JR, Sieg EP, Timmons SD. Management of traumatic brain injury. Surg Clin North Am 2017; 97 (06) 1237-1253 DOI: 10.1016/j.suc.2017.08.001.
- 2 World Health Organization. . Neurological disorders: Public health challenges [Internet]. Geneva; 2006. Available from: https://www.who.int/publications/i/item/9789241563369
- 3 Majdan M, Plancikova D, Brazinova A. et al. Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. Lancet Public Health 2016; 1 (02) e76-e83 DOI: 10.1016/S2468-2667(16)30017-2.
- 4 Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002-2006 [Internet]. Atlanta; 2010. Available from: www.cdc.gov/TraumaticBrainInjury
- 5 Maas AIR, Menon DK, Adelson PD. et al; InTBIR Participants and Investigators. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16 (12) 987-1048 DOI: 10.1016/S1474-4422(17)30371-X.
- 6 James SL, Bannick MS, Montjoy-Venning WC. et al; GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019; 18 (01) 56-87 DOI: 10.1016/S1474-4422(18)30415-0.
- 7 Areas FZ, Schwarzbold ML, Diaz AP. et al. Predictors of hospital mortality and the related burden of disease in severe traumatic brain injury: A prospective multicentric study in Brazil. Front Neurol 2019; 10: 432 DOI: 10.3389/fneur.2019.00432.
- 8 Langlois JA, Sattin RW. Traumatic brain injury in the United States: research and programs of the Centers for Disease Control and Prevention (CDC). J Head Trauma Rehabil 2005; 20 (03) 187-188 DOI: 10.1097/00001199-200505000-00001.
- 9 Roozenbeek B, Maas AIR, Menon DK. Changing patterns in the epidemiology of traumatic brain injury. Nat Rev Neurol 2013; 9 (04) 231-236 DOI: 10.1038/nrneurol.2013.22.
- 10 Junior JR, Welling LC, Schafranski M. et al. Prognostic model for patients with traumatic brain injuries and abnormal computed tomography scans. J Clin Neurosci 2017; 42: 122-128 DOI: 10.1016/j.jocn.2017.03.012.
- 11 Steyerberg EW, Mushkudiani N, Perel P. et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 2008; 5 (08) e165 , discussion e165 DOI: 10.1371/journal.pmed.0050165.
- 12 Perel P, Edwards P, Wentz R, Roberts I. Systematic review of prognostic models in traumatic brain injury. BMC Med Inform Decis Mak 2006; 6: 38 DOI: 10.1186/1472-6947-6-38.
- 13 Mushkudiani NA, Hukkelhoven CWPM, Hernández AV. et al. A systematic review finds methodological improvements necessary for prognostic models in determining traumatic brain injury outcomes. J Clin Epidemiol 2008; 61 (04) 331-343 DOI: 10.1016/j.jclinepi.2007.06.011.
- 14 Perel P, Arango M, Clayton T. et al; MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 2008; 336 (7641): 425-429 DOI: 10.1136/bmj.39461.643438.25.
- 15 Brennan PM, Murray GD, Teasdale GM. Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. J Neurosurg 2018; 128 (06) 1612-1620 DOI: 10.3171/2017.12.JNS172780.
- 16 Steyerberg EW, Moons KGM, van der Windt DA. et al; PROGRESS Group. Prognosis Research Strategy (PROGRESS) 3: prognostic model research. PLoS Med 2013; 10 (02) e1001381 DOI: 10.1371/journal.pmed.1001381.
- 17 Emami P, Czorlich P, Fritzsche FS. et al. Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study. J Neurosurg 2017; 126 (03) 760-767 DOI: 10.3171/2016.1.JNS152385.
- 18 Marmarou A, Lu J, Butcher I. et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma 2007; 24 (02) 270-280 DOI: 10.1089/neu.2006.0029.
- 19 Roberts I, Yates D, Sandercock P. et al; CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004; 364 (9442): 1321-1328 DOI: 10.1016/S0140-6736(04)17188-2.
- 20 Gullo JdaS, Bertotti MM, Silva CCP. et al. Hospital mortality of patients with severe traumatic brain injury is associated with serum PTX3 levels. Neurocrit Care 2011; 14 (02) 194-199 DOI: 10.1007/s12028-010-9462-y.
- 21 DE Souza RL, Thais ME, Cavallazzi G. et al. Side of pupillary mydriasis predicts the cognitive prognosis in patients with severe traumatic brain injury. Acta Anaesthesiol Scand 2015; 59 (03) 392-405 DOI: 10.1111/aas.12447.
- 22 Hohl A, Gullo Jda S, Silva CCP. et al. Plasma levels of oxidative stress biomarkers and hospital mortality in severe head injury: a multivariate analysis. J Crit Care 2012; 27 (05) 523.e11-523.e19 DOI: 10.1016/j.jcrc.2011.06.007.
- 23 Hohl A, Ronsoni MF, Debona R. et al. Role of hormonal levels on hospital mortality for male patients with severe traumatic brain injury. Brain Inj 2014; 28 (10) 1262-1269 DOI: 10.3109/02699052.2014.915986.
- 24 Martins ET, Linhares MN, Sousa DS. et al. Mortality in severe traumatic brain injury: a multivariated analysis of 748 Brazilian patients from Florianópolis City. J Trauma 2009; 67 (01) 85-90 DOI: 10.1097/TA.0b013e318187acee.
- 25 Marshall LF, Marshall SB, Klauber MR. et al. A new classification of head injury based on computerized tomography. J Neurosurg 1991; 75: S14-S20 DOI: 10.3171/sup.1991.75.1s.0s14.
- 26 Marshall LF, Marshall SB, Klauber MR. et al. The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 1992; 9 (Suppl. 01) S287-S292
- 27 Braakman R, Gelpke GJ, Habbema JD, Maas AI, Minderhoud JM. Systematic selection of prognostic features in patients with severe head injury. Neurosurgery 1980; 6 (04) 362-370
- 28 de Almeida CER, de Sousa Filho JL, Dourado JC, Gontijo PAM, Dellaretti MA, Costa BS. Traumatic brain injury epidemiology in Brazil. World Neurosurg 2016; 87: 540-547 DOI: 10.1016/j.wneu.2015.10.020.
- 29 Moskopp D, Stähle C, Wassmann H. Problems of the Glasgow Coma Scale with early intubated patients. Neurosurg Rev 1995; 18 (04) 253-257 DOI: 10.1007/BF00383876.
- 30 Hoffmann M, Lefering R, Rueger JM. et al; Trauma Registry of the German Society for Trauma Surgery. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg 2012; 99 (Suppl. 01) 122-130 DOI: 10.1002/bjs.7707.
- 31 Osler T, Cook A, Glance LG. et al. The differential mortality of Glasgow Coma Score in patients with and without head injury. Injury 2016; 47 (09) 1879-1885 DOI: 10.1016/j.injury.2016.04.016.
- 32 Rabelo NN, Sisnando da Costa BB, Sakaya GR, Teixeira MJ, Figueiredo EG. Letter to the Editor. Glasgow Coma Scale-Pupils Score: opening the eyes to new ways of predicting outcomes in TBI. J Neurosurg 2019; 131 (01) 326-327 DOI: 10.3171/2019.2.JNS19296.
- 33 Royston P, Moons KGM, Altman DG, Vergouwe Y. Prognosis and prognostic research: Developing a prognostic model. BMJ 2009; 338 (7707): b604 DOI: 10.1136/bmj.b604.