Early Mortality Predictor of Severe Traumatic Brain Injury: A Single Center Study of Prognostic Variables Based On Admission Characteristics

Early mortality predictor of severe traumatic brain injury:
A single center study of prognostic variables based on admission

characteristics
Mardjono Tjahjadi, Muhammad Z. Arifin, Arwinder Singh Gill*, Ahmad Faried
Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, JL. Pasteur No. 38, Bandung 40161, West Java, Indonesia.
1
ABSTRACT
•Objectives: Traumatic brain injury (TBI) is one of the leading cause
of death in many developing countries. To develop a predictor model
– identify high death risk of severely head-injured patients in an early
priod in order to plan an effective and efficient treatment strategy.
•Methods: Retrospective cross-sectional study with subjects of severe

TBI patients from 1st of January to 31st December 2010. These models –
then analyzed using multiple logistic regression.
2
Introduction
•Traumatic brain injury (TBI) constitutes a critical public health and socioeconomic problem
throught the world. It is the leading cause of mortality and disability among young individuals in
many countries.
•In Indonesia, incidence of severe TBI is between 6 and 12% of all traumatic brain injuries with
mortality rate ranging between 25 and 37%.
•Trauma data from our emergency department revealed 5.274 cases of trauma admission in which
2342 (44.4%) had a reported head injury.
•Mild head injury  68.9 %
•Moderate head injury  20.96%
•Severe head injury 10.1%
•Post TBI prognosis still remain a challenge to this day. Study of putative predictors are an active
area of TBI research at present, and these studies are long-held concepts in the field that still
remains really challenging.
•Our aim is simple, to develop a simple prognostic tool based on clinical and radiological
characteristics to determine early mortality in severe TBI patients.
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CLINICAL MATERIALS and METHODS
• PATIENT POPULATION AND METHOD
• This cross-sectional restropective study consists of 61 patients diagnosed with
severe TBI (GCS < 9) treated in neurointensive care unit between 1st January and
31st December 2010.
Below 14 years of age

Multiple trauma patient with AIS ≥ 3
GCS 3 and dilated pupils after resuscitation Excluded
Admission > 8 h after injury
Sign of aspiration pneumonia
Without CT-Scan
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• PATIENT POPULATION AND METHOD
• Information about injury severity was obtained from medical records and
from data specifically collected for the purpose of the study.
Cause and Nature of Injury
Age of Patient
Gender
GCS Score after Resuscitation
Best Motor Response
Physical Findings (Blood Pressure, Heart Rate, Rectal Temperature)
Result Of Computerized Tomography Scans
Management of these patients
Patients were grouped into two groups

1.Survived
2.Unsurvived
5
Within 1 week period after admission
• STATISTICAL ANALYSIS
• Processed on a personal computer by using available statistic software
• Compared using chi square test with p value ≤ 0.05
• Only significant prognostic factors were then summarized into a scoring system using multiple
regression test based on the odds ratio of each variable.
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RESULTS
• 65.5% mortality rate in 61 patients with severe traumatic brain injury after
one week in hospital.
• Mean arterial pressure (MAP > 97.17 mmHg)
• Motor Response (≥ 4)
• Abnormalities on CT findings (compresed basal cistern, presence of
intradural lesion, midline shift) to be statistically significant. ( p ≤ 0.05 )
• Multiple logistic regression test and found that basal cistern to be the most
dominant predictor with value of 2.860 followed by motoric response with
value of 2.448
• Basal Cistern, motor response  major risk factor (sensitivity 92.50%)
• Presence of intradural lesion, MAP and Midline Shift  minor risk factor
10
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DISCUSSION
• Prognosis is an essential element of medicine, and estimation of
prognosis is a frequent component of clinical decision making.
• Therapeutic and diagnostic actions were aimed to improve prognosis.
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Sex and Age
• Some investigations reprted better outcomes below the age – of 40 -50
years.
• Despite the fact that age is a significant factor in predicting mortality,
we did not find this factor having correlation in our study.
13
GCS and Motor Response
• Since its first development in 1974, GCS has become the most
frequently used classification of TBI severity.
• In patients with more severe injuries, the motor component of the GCS
has the greatest predictive values because eye and verbal responses are
commonly absent in these patients.
• We found that a motoric score > 4 showed a more favorable outcome.
14
Blood Pressure, Heart Rate, Temperature,
and Respiration Rate
• Hypotension is one of the few variable that respond to medical
manipulation.
• According to Brain Trauma Guidelines, Class I Evidence shows that
blood pressure (Systolic blood pressure < 90 mmHg), especially in
combination with hypoxia, is an indicator of unfavourable outcome.
Decrease in blood pressure, MAP and core temperature will cause
brain cells ischemia resulting in secondary effect.
• With MAP cut off point of 97.17 mmHg, there is a favourable
outcome in the survivor group of our study.
15
Head CT scan findings
• Prognostic CT findings include: primary CT Abnormalities within the
first 12 h of TBI, compresed basal cistern at the level of midbrain,
presence of SAH and midline shift.
• Presence of SAH or intradural lesion and compression of basal cistern
are one of the most important criteria in predicting mortality of head
injured patients.
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Head CT scan findings
• In this study we found compression of basal cistern to be the most
dominant variable in determining mortality.
• Midline shift and other CT parameters were third in correlation
strength.
• The largest amount of prognostic information was contained in a core
set of two predictors:
• Basal cistern compression
• Poor motoric score
18
Conclusions
• Mortality of severe TBI patients are significantly shown in patients
with poor motoric response and compression of basal cisterns.
• These variable may be useful for providing realistic information to the
relatives on expectations of outcome, for quantifying and classifying
the severity of brain injury especially for the attending physcians in
the emergency department
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Early mortality predictor of severe traumatic brain injury:

A single center study of prognostic variables based on admission

Mardjono Tjahjadi, Muhammad Z. Arifin, Arwinder Singh Gill*, Ahmad Faried

•Methods: Retrospective cross-sectional study with subjects of severe

Below 14 years of age

Patients were grouped into two groups

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