- Email: [email protected]
Glasgow coma scale versus computed tomography in prognostication
Accepted Manuscript Glasgow coma prognostication
scale
versus
computed
tomography
in
Oscar M.P. Jolobe PII: DOI: Reference:
S0735-6757(17)30485-0 doi: 10.1016/j.ajem.2017.06.033 YAJEM 56761
To appear in: Received date: Revised date: Accepted date:
28 April 2017 ###REVISEDDATE### 21 June 2017
Please cite this article as: Oscar M.P. Jolobe , Glasgow coma scale versus computed tomography in prognostication, (2017), doi: 10.1016/j.ajem.2017.06.033
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT title page
RI
Oscar M P Jolobe MB., ChB
PT
Glasgow coma scale versus computed tomography in prognostication
SC
Manchester Medical Society Simon Building
NU
Brunswick street
Manchester M13 9PL
MA
Corresponding author Oscar M P Jolobe
PT E
1 Clothorn Road
D
Flat 6 Souchay Court
CE
Manchester M20 6BR
[email protected]
AC
telephone 44 161 900 6887
ACCEPTED MANUSCRIPT
Glasgow Coma Scale versus computed tomography in prognostication Oscar M P Jolobe
SC
RI
PT
Manchester Medical Society
NU
Glasgow coma Scale versus computed tomography in prognostication The observation that 23% of 240 patients of mean age 42 experienced adverse
MA
outcomes in spite of Glasgow Coma Scale (GCS) of 15[1] calls for re-evaluation of the role of the Glasgow Coma Scale(GCS) in characterising the severity of
D
head injury and the prognosis of patients with head injury. This re-evaluation
PT E
is especially relevant to the elderly, given the fact that age affects the relationship between the GCS score and the severity of anatomic traumatic
CE
brain injury[2]. The consequence of the latter observation is that, for each
AC
grade of severity of anatomic brain injury elderly patients(aged 65 or more) have significantly(p < 0.01) better GCS scores than their younger counterparts(aged 18-64)[2]. Even among 75 nonagenarians who subsequently underwent neurosurgical intervention for chronic subdural haematoma, 94.6% presented with a GCS of 13-15[3]. The limitations of the GCS in evaluating the severity of head injury are compounded by the suboptimal interrator reliability of the GCS between emergency medicine physicians when
ACCEPTED MANUSCRIPT adult patients with altered levels of consciousness are assessed[4]. In the latter study , which enrolled 116 patients, only 55% to 74% of paired measures were identical, and 6% to 17% of them were 2 or more points apart[4]. Furthermore mild traumatic brain injury defined by GCS is not necessarily mild, given the
PT
findings in a retrospective cohort study of 876 patients(mean age 54) with traumatic brain injury who had a GCS score of 13-15 on presentation. In that
RI
study 47 patients subsequently required neurosurgical intervention(NSI)[5]. In
SC
yet another retrospective study, among 200 hospitalised patients with head
NU
trauma(including 63 aged > 30), 41% of those with GCS 15 had abnormalities on CCT. Of those with GCS equal to 15, 27% underwent NSI[6]. In view of these
MA
limitations the alternative strategy is to grade severity of head injury according to cranial computed tomography(CCT) criteria and also to use CCT criteria for
D
long term prognosis both in patients who undergo NSI and in those who are
PT E
deemed to be unsuitable for NSI. In a retrospective study which analysed 620 patients aged 45 or more(mean age 72.8) with traumatic head injury(TBI) a
CE
cranial computed tomography scoring tool(CCTST) was devised which
AC
compared CCTST with the GCS for prognostication not only in patients who underwent NSI but also in those who were managed conservatively. The tool had 8 CCT items, namely, subdural haematoma, epidural haematoma, subarachnoid haemorrhage, intraventricular haemorrhage, cerebral contusion/intraparenchymal haemorrhage, skull fracture, brain oedema, and midline shift, over and above external(skin/face trauma). In that study there were 310 head injury patients who underwent neurosurgical
ACCEPTED MANUSCRIPT intervention(NSI), and these were age-matched with 310 head injury controls with comparable injury severity score who did not undergo neurosurgical intervention. In the combined NSI and non-NSI group, CCTST and GCS generated an adjusted odds ratio(AOR) of 1.158(95% Confidence Interval 1.019
PT
to 1.335) and 1.046(95% CI 1.046 to 1.002 to 1.093), respectively, on multivariate analysis of in hospital morbidity. Also in the combined NSI and
RI
non-NSI group CCST and GCS generated an AOR of 1.31(95% CI 1.09 to 1.58)
SC
and 1.14(1.07 to 1.22), respectively, on multivariate analysis of in hospital
NU
mortality[7].
In conclusion, at the very least, CCTST is marginally superior to the GCS in
MA
predicting in patient morbidity and in patient mortality in the presence of TBI, and this is irrespective of NSI status[6]. What we now need is a prospective
D
study to evaluate the utility of CCTST in predicting long term functional
PT E
outcomes exclusively in elderly patients with TBI, given the increasing incidence of chronic subdural in people aged >65[8], and the recognition that
CE
as many as 15 out of 225 patients of mean age 81 who are on oral
AC
anticoagulants may experience intracranial haemorrhage even after minor head trauma[9]. Using CCTST criteria[7] a comparison between NSI patients and those managed conservatively might also prove more reliable than GCS criteria[10] for defining which head injury patients should best be managed conservatively. Acknowledgment I have no funding and no conflict of interest
ACCEPTED MANUSCRIPT References [1]Kreitzer N., Hart K., Lindsell CJ., Betham B., Gozal Y., Andaluz NO et al Factors associated with adverse outcomes in patients with traumatic intracranial haemorrhage and Glasgow coma Scale of 15
PT
American Journal of Emergency Medicine 2017 doi.org/10.1016/j.ajem.2017.01.051
RI
[2]Salottolo K., Levy AS., Slone DS., Mains CW., Bar-Or D
SC
The effect of age on Glasgow Coma Scale Score in patients with traumatic brain
JAMA Surg 2014;149(7): 727-734
NU
injury
MA
[3]Bartek J., Sjavik K., Stahl F., Kristiansson H., Solheim O., Gulati S., Sagberg LM et al
D
Surgery for chronic subdural hematoma in nonagenarians: A Scandinavian
PT E
population-based multicentre study Acta Neurol Scand DOI:10.1111/ane.12764
CE
[4]Gill MR., Reiley DG., Green SM
AC
Interrater reliability of Glasgow Coma Scale scores in the emergency department
Ann Emerg Med 2004;43:215-223 [5]Joseph B., Pandit V., Aziz H., Kulvatunyou N., Zangbar B., Green DJ et al Mild traumatic brain injury defined by Glasgow Coma Scale: Is it really mild? Brain Injury DOI:10.3109/02699052.2014.945959 [6]Nayebaghayee H., Afsharian T
ACCEPTED MANUSCRIPT Correlation between Glasgow Coma Scale and brain compute tomographyscan findings in head trauma patients Asian Journal of Neurosurgery 2016;11:46-49 [7]Stawicki SP., Woida TR., Nuschke JD., Mubang R., Cipolla J., Hoff WS et al
PT
Prognostication of traumatic brain injury in older trauma patients: A novel risk assessment tool based on initial CT findings
RI
Int J Crit Inj Sci 2017;7:23-31
SC
[8]Adhiyaman V., Chattopadhyay I., Irshad F., Curran D., Abraham S
NU
Increasing incidence of chronic subdural haematoma in the elderly QJM 2017 Jan 9.pii:hcw231.doi:1093/qjmed/hcw231[Epub ahead of print]
MA
[9]Riccardi A., Spinola B., Minuto P., Ghinatti M., Guiddo G., Malerba M et al Intracranial complications after minor head trauma injury(MHI) in patients
D
taking vitamin K antagonists(VKA) or direct acting oral anticoagulanys(DOACs)
PT E
American Journal of Emergency Medicine 2017;doi/10.1016/j.ajem.2017.03.072
CE
[10]Maurice-Williams RS
AC
Head injuries in the elderly British journal of Neurosurgery 1999;13:5-8
scale
versus
computed
tomography
in
Oscar M.P. Jolobe PII: DOI: Reference:
S0735-6757(17)30485-0 doi: 10.1016/j.ajem.2017.06.033 YAJEM 56761
To appear in: Received date: Revised date: Accepted date:
28 April 2017 ###REVISEDDATE### 21 June 2017
Please cite this article as: Oscar M.P. Jolobe , Glasgow coma scale versus computed tomography in prognostication, (2017), doi: 10.1016/j.ajem.2017.06.033
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT title page
RI
Oscar M P Jolobe MB., ChB
PT
Glasgow coma scale versus computed tomography in prognostication
SC
Manchester Medical Society Simon Building
NU
Brunswick street
Manchester M13 9PL
MA
Corresponding author Oscar M P Jolobe
PT E
1 Clothorn Road
D
Flat 6 Souchay Court
CE
Manchester M20 6BR
[email protected]
AC
telephone 44 161 900 6887
ACCEPTED MANUSCRIPT
Glasgow Coma Scale versus computed tomography in prognostication Oscar M P Jolobe
SC
RI
PT
Manchester Medical Society
NU
Glasgow coma Scale versus computed tomography in prognostication The observation that 23% of 240 patients of mean age 42 experienced adverse
MA
outcomes in spite of Glasgow Coma Scale (GCS) of 15[1] calls for re-evaluation of the role of the Glasgow Coma Scale(GCS) in characterising the severity of
D
head injury and the prognosis of patients with head injury. This re-evaluation
PT E
is especially relevant to the elderly, given the fact that age affects the relationship between the GCS score and the severity of anatomic traumatic
CE
brain injury[2]. The consequence of the latter observation is that, for each
AC
grade of severity of anatomic brain injury elderly patients(aged 65 or more) have significantly(p < 0.01) better GCS scores than their younger counterparts(aged 18-64)[2]. Even among 75 nonagenarians who subsequently underwent neurosurgical intervention for chronic subdural haematoma, 94.6% presented with a GCS of 13-15[3]. The limitations of the GCS in evaluating the severity of head injury are compounded by the suboptimal interrator reliability of the GCS between emergency medicine physicians when
ACCEPTED MANUSCRIPT adult patients with altered levels of consciousness are assessed[4]. In the latter study , which enrolled 116 patients, only 55% to 74% of paired measures were identical, and 6% to 17% of them were 2 or more points apart[4]. Furthermore mild traumatic brain injury defined by GCS is not necessarily mild, given the
PT
findings in a retrospective cohort study of 876 patients(mean age 54) with traumatic brain injury who had a GCS score of 13-15 on presentation. In that
RI
study 47 patients subsequently required neurosurgical intervention(NSI)[5]. In
SC
yet another retrospective study, among 200 hospitalised patients with head
NU
trauma(including 63 aged > 30), 41% of those with GCS 15 had abnormalities on CCT. Of those with GCS equal to 15, 27% underwent NSI[6]. In view of these
MA
limitations the alternative strategy is to grade severity of head injury according to cranial computed tomography(CCT) criteria and also to use CCT criteria for
D
long term prognosis both in patients who undergo NSI and in those who are
PT E
deemed to be unsuitable for NSI. In a retrospective study which analysed 620 patients aged 45 or more(mean age 72.8) with traumatic head injury(TBI) a
CE
cranial computed tomography scoring tool(CCTST) was devised which
AC
compared CCTST with the GCS for prognostication not only in patients who underwent NSI but also in those who were managed conservatively. The tool had 8 CCT items, namely, subdural haematoma, epidural haematoma, subarachnoid haemorrhage, intraventricular haemorrhage, cerebral contusion/intraparenchymal haemorrhage, skull fracture, brain oedema, and midline shift, over and above external(skin/face trauma). In that study there were 310 head injury patients who underwent neurosurgical
ACCEPTED MANUSCRIPT intervention(NSI), and these were age-matched with 310 head injury controls with comparable injury severity score who did not undergo neurosurgical intervention. In the combined NSI and non-NSI group, CCTST and GCS generated an adjusted odds ratio(AOR) of 1.158(95% Confidence Interval 1.019
PT
to 1.335) and 1.046(95% CI 1.046 to 1.002 to 1.093), respectively, on multivariate analysis of in hospital morbidity. Also in the combined NSI and
RI
non-NSI group CCST and GCS generated an AOR of 1.31(95% CI 1.09 to 1.58)
SC
and 1.14(1.07 to 1.22), respectively, on multivariate analysis of in hospital
NU
mortality[7].
In conclusion, at the very least, CCTST is marginally superior to the GCS in
MA
predicting in patient morbidity and in patient mortality in the presence of TBI, and this is irrespective of NSI status[6]. What we now need is a prospective
D
study to evaluate the utility of CCTST in predicting long term functional
PT E
outcomes exclusively in elderly patients with TBI, given the increasing incidence of chronic subdural in people aged >65[8], and the recognition that
CE
as many as 15 out of 225 patients of mean age 81 who are on oral
AC
anticoagulants may experience intracranial haemorrhage even after minor head trauma[9]. Using CCTST criteria[7] a comparison between NSI patients and those managed conservatively might also prove more reliable than GCS criteria[10] for defining which head injury patients should best be managed conservatively. Acknowledgment I have no funding and no conflict of interest
ACCEPTED MANUSCRIPT References [1]Kreitzer N., Hart K., Lindsell CJ., Betham B., Gozal Y., Andaluz NO et al Factors associated with adverse outcomes in patients with traumatic intracranial haemorrhage and Glasgow coma Scale of 15
PT
American Journal of Emergency Medicine 2017 doi.org/10.1016/j.ajem.2017.01.051
RI
[2]Salottolo K., Levy AS., Slone DS., Mains CW., Bar-Or D
SC
The effect of age on Glasgow Coma Scale Score in patients with traumatic brain
JAMA Surg 2014;149(7): 727-734
NU
injury
MA
[3]Bartek J., Sjavik K., Stahl F., Kristiansson H., Solheim O., Gulati S., Sagberg LM et al
D
Surgery for chronic subdural hematoma in nonagenarians: A Scandinavian
PT E
population-based multicentre study Acta Neurol Scand DOI:10.1111/ane.12764
CE
[4]Gill MR., Reiley DG., Green SM
AC
Interrater reliability of Glasgow Coma Scale scores in the emergency department
Ann Emerg Med 2004;43:215-223 [5]Joseph B., Pandit V., Aziz H., Kulvatunyou N., Zangbar B., Green DJ et al Mild traumatic brain injury defined by Glasgow Coma Scale: Is it really mild? Brain Injury DOI:10.3109/02699052.2014.945959 [6]Nayebaghayee H., Afsharian T
ACCEPTED MANUSCRIPT Correlation between Glasgow Coma Scale and brain compute tomographyscan findings in head trauma patients Asian Journal of Neurosurgery 2016;11:46-49 [7]Stawicki SP., Woida TR., Nuschke JD., Mubang R., Cipolla J., Hoff WS et al
PT
Prognostication of traumatic brain injury in older trauma patients: A novel risk assessment tool based on initial CT findings
RI
Int J Crit Inj Sci 2017;7:23-31
SC
[8]Adhiyaman V., Chattopadhyay I., Irshad F., Curran D., Abraham S
NU
Increasing incidence of chronic subdural haematoma in the elderly QJM 2017 Jan 9.pii:hcw231.doi:1093/qjmed/hcw231[Epub ahead of print]
MA
[9]Riccardi A., Spinola B., Minuto P., Ghinatti M., Guiddo G., Malerba M et al Intracranial complications after minor head trauma injury(MHI) in patients
D
taking vitamin K antagonists(VKA) or direct acting oral anticoagulanys(DOACs)
PT E
American Journal of Emergency Medicine 2017;doi/10.1016/j.ajem.2017.03.072
CE
[10]Maurice-Williams RS
AC
Head injuries in the elderly British journal of Neurosurgery 1999;13:5-8