J Neurotrauma. 2023 Apr 21. doi: 10.1089/neu.2022.0433. Online ahead of print.
ABSTRACT
Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Early triage and treatment after TBI have been shown to improve outcome. However, identifying patients at risk for increased intracranial pressure (ICP) via baseline computed tomography (CT) has not previously been validated in a prospective dataset. We hypothesized that acute CT findings of elevated ICP, combined with direct ICP measurement, hold prognostic value in terms of 6-month patient outcome after TBI. Data were obtained from the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (ProTECTIII) multicenter clinical trial. Baseline CT scans for 881 participants were individually reviewed by a blinded central neuroradiologist. Five signs of elevated ICP were measured (sulcal obliteration, lateral ventricle compression, 3rd ventricle compression, midline shift, and herniation). Associations between signs of increased ICP and outcomes (6-month functional outcome and mortality) were assessed. Secondary analyses of 354 patients with recorded ICP monitoring data available explored the relationships between hemorrhage phenotype/anatomic location, sustained ICP ≥ 20mmHg, and surgical intervention(s). Univariate and multivariate logistic / linear regressions were performed; p<0.05 is defined as statistically significant. Imaging characteristics associated with ICP in this cohort include sulcal obliteration (p=0.029) and third ventricular compression (p=0.039). Univariate regression analyses indicated that increasing combinations of the five defined signs of elevated ICP were associated with mortality, poor functional outcome, and time to death. There was also an increased likelihood of mortality if patients required craniotomy (OR=4.318, 95% Confidence Interval [1.330-16.030]) or hemicraniectomy (OR=2.993 [1.109-8.482]). On multivariate regression analyses, hemorrhage location was associated with mortality (posterior fossa, OR=3.208 [1.120-9.188] and basal ganglia, OR=3.079 [1.178-8.077]). Volume of hemorrhage > 30cc was also associated with increased mortality, OR=3.702 [1.575-8.956]). The proportion of patient hours with sustained ICP ≥20 mmHg, and maximum ICP ≥20 mmHg, were also directly correlated with increased mortality (OR=64.99 [7.731-635.51]; and OR=1.025 [1.004-1.047]), but not with functional outcome. Poor functional outcome was predicted by concurrent presence of all five radiographic signs of elevated ICP (OR=4.44 [1.514-14.183]) and presence of frontal lobe (OR=2.951 [1.265-7.067]), subarachnoid (OR=2.231 [1.067-4.717]), or intraventricular (OR=2.249 [1.159-4.508]) hemorrhage. Time to death was modulated by total patient days of elevated ICP ≥20 mmHg (Effect Size = 3.424 [1.500, 5.439]) in the first two weeks of hospitalization. Sulcal obliteration and third ventricular compression, radiographic signs of elevated ICP, were significantly associated with measurements of ICP ≥20mmHg. These radiographic biomarkers were significantly associated with patient outcome. There is potential utility of ICP-related imaging variables in triage and prognostication for patients following moderate-severe TBI.
PMID:37082956 | DOI:10.1089/neu.2022.0433
