Pathological Computed Tomography Features Associated With Adverse Outcomes After Mild Traumatic Brain Injury
Authors: Esther L. Yuh, Sonia Jain, Xiaoying Sun, Dana Pisică, Mark H. Harris, Sabrina R. Taylor, Amy J. Markowitz, Pratik Mukherjee, Jan Verheyden, Joseph T. Giacino, Harvey S. Levin, Michael McCrea, Murray B. Stein, Nancy R. Temkin, Ramon Diaz-Arrastia, Claudia S. Robertson, Hester F. Lingsma, David O. Okonkwo, Andrew I.R. Maas, Geoffrey T. Manley, Krisztina Amrein, Nada Andelic, Lasse Andreassen, Audny Anke, Anna Antoni, Gérard Audibert, Philippe Azouvi, Maria Luisa Azzolini, Ronald Bartels, Pál Barzó, Romuald Beauvais, Ronny Beer, Bo-Michael Bellander, Antonio Belli, Habib Benal, Maurizio Berardino, Luigi Beretta, Morten Blaabjerg, Peter Bragge, Alexandra Brazinova, Vibeke Brinck, Joanne Brooker, Camilla Brorsson, Andras Buki, Monika Bullinger, Manuel Cabeleira, Alessio Caccioppola, Emiliana Calappi , Maria Rosa Calvi, Peter Cameron, Guillermo Carbayo Lozano, Marco Carbonara, Ana M. Castaño‑León, Simona Cavallo, Giorgio Chevallard, Arturo Chieregato, Giuseppe Citerio, Hans Clusmann, Mark Coburn, Jonathan Coles, Jamie D. Cooper, Marta Correia, Amra Čović, Nicola Curry, Endre Czeiter, Marek Czosnyka, Claire Dahyot‑Fizelier, Paul Dark, Helen Dawes, Véronique De Keyser, Vincent Degos, Francesco Della Corte, Hugo den Boogert, Bart Depreitere, Đula Đilvesi, Abhishek Dixit, Emma Donoghue, Jens Dreier, Guy‑Loup  Dulière, Ari Ercole, Patrick Esser, Erzsébet Ezer, Martin  Fabricius, Valery L.  Feigin, Kelly  Foks, Shirin  Frisvold, Alex Furmanov, Pablo  Gagliardo, Damien  Galanaud, Dashiell Gantner, Guoyi  Gao, Pradeep George, Alexandre  Ghuysen, Lelde Giga, Ben Glocker, Jagoš Golubovic, Pedro A.  Gomez, Johannes Gratz, Benjamin Gravesteijn, Francesca Grossi, Russell L.  Gruen, Deepak Gupta, Juanita A.  Haagsma, Iain  Haitsma, Raimund Helbok, Eirik  Helseth, Lindsay Horton, Jilske Huijben, Peter J.  Hutchinson, Bram Jacobs, Stefan Jankowski, Mike Jarrett, Ji‑yao  Jiang, Faye Johnson, Kelly  Jones, Mladen Karan, Cecilia Kerlund, Angelos G.  Kolias, Erwin  Kompanje, Daniel  Kondziella, Evgenios Kornaropoulos, Lars‑Owe  Koskinen, Noémi  Kovács, Ana Kowark, Alfonso  Lagares, Linda  Lanyon, Steven Laureys, Fiona Lecky, Didier Ledoux, Rolf  Lefering, Valerie Legrand, Aurelie Lejeune, Leon Levi, Roger Lightfoot, Marc Maegele, Marek Majdan, Alex Manara, Costanza Martino, Hugues Maréchal, Julia Mattern, Catherine McMahon, Béla Melegh, David Menon, Tomas Menovsky, Ana Mikolic, Benoit Misset, Visakh Muraleedharan, Lynnette Murray, Ancuta Negru, David Nelson, Virginia Newcombe, Daan Nieboer, József Nyirádi, Otesile Olubukola, Matej Oresic, Fabrizio Ortolano, Aarno Palotie, Paul M.  Parizel, Jean‑François  Payen, Natascha Perera, Vincent Perlbarg, Paolo Persona, Wilco Peul, Anna Piippo-Karjalainen, Matti  Pirinen, Horia Ples, Suzanne  Polinder, Inigo Pomposo, Jussi P. Posti, Louis  Puybasset, Andreea Radoi, Arminas  Ragauskas, Rahul  Raj, Malinka Rambadagalla, Jonathan Rhode, Sylvia Richardson, Sophie Richter, Samuli Ripatti, Saulius Rocka, Cecilie Roe, Olav  Roise, Jeffrey V. Rosenfeld, Christina  Rosenlund, Guy  Rosenthal, Rolf Rossaint, Sandra Rossi, Daniel Rueckert, Martin  Rusnák, Juan Sahuquillo, Oliver Sakowitz, Renan Sanchez‑Porras, Janos Sandor, Nadine Schäfer, Silke Schmidt, Herbert Schoechl, Guus Schoonman, Rico Frederik  Schou, Elisabeth  Schwendenwein, Charlie Sewalt, Toril  Skandsen, Peter Smielewski, Abayomi  Sorinola, Emmanuel  Stamatakis, Simon Stanworth, Robert  Stevens, William  Stewart, Ewout W.  Steyerberg, Nino Stocchetti, Nina Sundström, Riikka Takala, Viktória Tamás, Tomas Tamosuitis, Mark Steven  Taylor, Braden  Te Ao, Olli Tenovuo, Alice Theadom, Matt Thomas, Dick  Tibboel, Marjolein Timmers, Christos  Tolias, Tony Trapani, Cristina Maria  Tudora, Andreas Unterberg, Peter Vajkoczy, Shirley Vallance, Egils  Valeinis, Zoltán Vámos, Luc van den Hauwe, Mathieu van der Jagt, Joukje van der Naalt, Gregory Van der Steen, Jeroen T.J.M. van Dijck, Thomas A. van Essen, Wim  Van Hecke, Caroline van Heugten, Dominique  Van Praag, Thijs  Vande Vyvere, Roel P. J. van Wijk, Alessia Vargiolu van Wijk, Emmanuel  Vega, Kimberley Velt, Anne Vik, Rimantas Vilcinis, Victor Volovici, Nicole von Steinbüchel, Daphne Voormolen, Petar  Vulekovic, Kevin K.W. Wang, Eveline Wiegers, Guy Williams, Lindsay  Wilson, Stefan Winzeck, Stefan Wolf, Zhihui Yang, Peter  Ylén, Alexander  Younsi, Frederick A. Zeiler, Veronika Zelinkova, Agate Ziverte, Tommaso Zoerle, Opeolu Adeoye, Neeraj Badjatia, Kim Boase, Yelena Bodien, John D. Corrigan, Karen Crawford, Sureyya Dikmen, Ann-Christine Duhaime, Richard Ellenbogen, V. Ramana Feeser, Adam R. Ferguson, Brandon Foreman, Raquel Gardner, Etienne Gaudette, Luis Gonzalez, Shankar Gopinath, Rao Gullapalli, J. Claude Hemphill, Gillian Hotz, C. Dirk Keene, Joel Kramer, Natalie Kreitzer, Chris Lindsell, Joan Machamer, Christopher Madden, Alastair Martin, Thomas McAllister, Randall Merchant, Lindsay Nelson, Laura B. Ngwenya, Florence Noel, Amber Nolan, Eva Palacios, Daniel Perl, Miri Rabinowitz, Jonathan Rosand, Angelle Sander, Gabriella Satris, David Schnyer, Seth Seabury, Arthur Toga, Alex Valadka, Mary Vassar, Ross Zafonte
Journal: JAMA Neurology (2021)

<h3>Importance</h3> A head computed tomography (CT) with positive results for acute intracranial hemorrhage is the gold-standard diagnostic biomarker for acute traumatic brain injury (TBI). In moderate to severe TBI (Glasgow Coma Scale [GCS] scores 3-12), some CT features have been shown to be associated with outcomes. In mild TBI (mTBI; GCS scores 13-15), distribution and co-occurrence of pathological CT features and their prognostic importance are not well understood. <h3>Objective</h3> To identify pathological CT features associated with adverse outcomes after mTBI. <h3>Design, Setting, and Participants</h3> The longitudinal, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study enrolled patients with TBI, including those 17 years and older with GCS scores of 13 to 15 who presented to emergency departments at 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018, and underwent head CT imaging within 24 hours of TBI. Evaluations of CT imaging used TBI Common Data Elements. Glasgow Outcome Scale–Extended (GOSE) scores were assessed at 2 weeks and 3, 6, and 12 months postinjury. External validation of results was performed via the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Data analyses were completed from February 2020 to February 2021. <h3>Exposures</h3> Acute nonpenetrating head trauma. <h3>Main Outcomes and Measures</h3> Frequency, co-occurrence, and clustering of CT features; incomplete recovery (GOSE scores &lt;8 vs 8); and an unfavorable outcome (GOSE scores &lt;5 vs ≥5) at 2 weeks and 3, 6, and 12 months. <h3>Results</h3> In 1935 patients with mTBI (mean [SD] age, 41.5 [17.6] years; 1286 men [66.5%]) in the TRACK-TBI cohort and 2594 patients with mTBI (mean [SD] age, 51.8 [20.3] years; 1658 men [63.9%]) in an external validation cohort, hierarchical cluster analysis identified 3 major clusters of CT features: contusion, subarachnoid hemorrhage, and/or subdural hematoma; intraventricular and/or petechial hemorrhage; and epidural hematoma. Contusion, subarachnoid hemorrhage, and/or subdural hematoma features were associated with incomplete recovery (odds ratios [ORs] for GOSE scores &lt;8 at 1 year: TRACK-TBI, 1.80 [95% CI, 1.39-2.33]; CENTER-TBI, 2.73 [95% CI, 2.18-3.41]) and greater degrees of unfavorable outcomes (ORs for GOSE scores &lt;5 at 1 year: TRACK-TBI, 3.23 [95% CI, 1.59-6.58]; CENTER-TBI, 1.68 [95% CI, 1.13-2.49]) out to 12 months after injury, but epidural hematoma was not. Intraventricular and/or petechial hemorrhage was associated with greater degrees of unfavorable outcomes up to 12 months after injury (eg, OR for GOSE scores &lt;5 at 1 year in TRACK-TBI: 3.47 [95% CI, 1.66-7.26]). Some CT features were more strongly associated with outcomes than previously validated variables (eg, ORs for GOSE scores &lt;5 at 1 year in TRACK-TBI: neuropsychiatric history, 1.43 [95% CI .98-2.10] vs contusion, subarachnoid hemorrhage, and/or subdural hematoma, 3.23 [95% CI 1.59-6.58]). Findings were externally validated in 2594 patients with mTBI enrolled in the CENTER-TBI study. <h3>Conclusions and Relevance</h3> In this study, pathological CT features carried different prognostic implications after mTBI to 1 year postinjury. Some patterns of injury were associated with worse outcomes than others. These results support that patients with mTBI and these CT features need TBI-specific education and systematic follow-up.