Moderate traumatic brain injury: analysis of epidemiological variables
Article Sidebar
Main Article Content
Abstract
Objective: To describe the epidemiology of moderate traumatic brain injury (TBI) and identify risk factors predictive of unfavorable functional outcomes.
Design/Setting: Multicenter retrospective observational study conducted in two neurocritical care units in Spain and Argentina.
Patients: A total of 392 patients with moderate TBI (GCS 9–13) admitted during the first half of 2023, with follow-up at 6 months.
Variables: Clinical, radiological, and outcome variables were analyzed, including GCS and motor subscore after adequate resuscitation, pupillary reactivity, CT findings classified by the Marshall scale, early neurological deterioration, and the need for neurosurgical intervention or orotracheal intubation (OTI). Functional outcome was assessed using the Glasgow Outcome Scale Extended (GOSe) at hospital discharge and at 6 months.
Results: Within the first 24 hours, 32.6% of patients experienced early neurological deterioration and 22.5% required urgent surgery. At discharge, 34.4% had an unfavorable GOSe outcome, which decreased to 21.2% at 6 months. Notably, 16.5% of patients with GCS 13 also had poor functional outcomes. Multivariate analysis identified early OTI (OR 4.72; 95% CI: 2.72–8.21; p<0.0001) and early neurological worsening (OR 1.66; 95% CI: 1.00–2.74; p=0.04) as independent predictors of unfavorable outcomes. No significant differences were found based on hemorrhage type.
Discussion: A substantial proportion of patients with moderate TBI develop severe complications, justifying ICU admission and close monitoring. Initial GCS should be interpreted with caution due to potential confounders (sedation, substances). Lower mortality and higher surgical rates compared to other series may reflect referral to specialized centers. Study limitations require cautious interpretation and highlight the need for prospective validation and improved prognostic models.
Conclusion: Moderate TBI is associated with high morbidity. Early identification of risk factors such as OTI and neurological instability is essential for guiding management. Prospective studies are needed to confirm these findings and refine outcome prediction.
Article Details
Section
This work is licensed under a Creative Commons Attribution 4.0 International License.
The magazine does not retain the reproduction rights (copyright) so the authors can republish their works with the sole mention of the original publication source.
How to Cite
References
Rimel RW, Giordani B, Barth JT, Jane JA. Moderate head injury: completing the clinical spectrum of brain trauma. Neurosurgery. 1982;11(3):344-351.
Stein SC, Spettell C, Young G, Ross SE. Delayed and progressive brain injury in closed-head trauma: radiological demonstration. Neurosurgery. 1993;32(1):25-31.
Servadei F, Teasdale G, Merry G. Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma. 2001;18(7):657-664.
Frattalone AR, Ling GS. Moderate and severe traumatic brain injury: pathophysiology and management. Neurosurg Clin N Am. 2013;24(3):309-319. https://doi.org/10.1016/j.nec.2013.03.006
Hukkelhoven CW, Steyerberg EW, Habbema JD, Maas AI. Admission of patients with severe and moderate traumatic brain injury to specialized ICU facilities: a search for triage criteria. Intensive Care Med. 2005;31(6):799-806.
Andriessen TM, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, et al. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma. 2011;28(10):2019-2031. https://doi.org/10.1089/neu.2011.2034
Benzer A, Mitterschiffthaler G, Marosi M, Luef G, Pühringer F, De La Renotiere K, et al. Prediction of non-survival after trauma: Innsbruck Coma Scale. Lancet. 1991;338(8773):977-978. https://doi.org/10.1016/0140-6736(91)91840-q
Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008;7(8):728-741. https://doi.org/10.1016/S1474-4422(08)70164-9
Association for the Advancement of Automotive Medicine. Abbreviated Injury Scale (AIS). Chicago, USA: AAAM. Retrieved March 27, 2023, from https://www.aaam.org/abbreviated-injury-scale-ais/
Baker SP, O'Neill B, Haddon W, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-196. https://doi.org/10.1097/00005373-197403000-00001
Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care Med. 1981;9(9):672-676. https://doi.org/10.1097/00003246-198109000-00015
Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW, et al. The major trauma outcome study: establishing national norms for trauma care. J Trauma. 1990;30(11):1356-1365.
Marshall LF, Marshall SB, Klauber MR, Van Berkum Clark M, Eisenberg H, Jane JA, et al. A new classification of head injury based on computerized tomography. J Neurosurg. 1991;75(Suppl):S14-20.
Morris GF, Juul N, Marshall SB, Benedict B, Marshall LF. Neurological deterioration as a potential alternative endpoint in human clinical trials of experimental pharmacological agents for treatment of severe traumatic brain injuries. Neurosurgery. 1998;43(6):1369-1374.
Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6-15. https://doi.org/10.1227/NEU.0000000000001432
Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1(7905):480-484.
Balestreri M, Czosnyka M, Chatfield DA, Steiner LA, Schmidt EA, Smielewski P, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. 2004;75(1):161-162.
Servadei F, Antonelli V, Mastrilli A, Cultrera F, Giuffrida M, Staffa G. Integration of image transmission into a protocol for head injury management: a preliminary report. Br J Neurosurg. 2002;16(1):36-42.
Giner J, Mesa Galán L, Yus Teruel S, Guallar Espallargas MC, Pérez López C, Isla Guerrero A, et al. Traumatic brain injury in the new millennium: new population and new management. Neurologia. 2022;37(5):383-389. https://doi.org/10.1016/j.nrleng.2019.03.024
Murray GD, Teasdale GM, Braakman R, Cohadon F, Dearden M, Iannotti F, et al. The European Brain Injury Consortium survey of head injuries. Acta Neurochir (Wien). 1999;141(3):223-236.
Pentland B, Hutton LS, Jones PA. Late mortality after head injury. J Neurol Neurosurg Psychiatry. 2005;76(3):395-400.
Vitaz TW, Jenks J, Raque GH, Shields CB. Outcome following moderate traumatic brain injury. Surg Neurol. 2003;60(4):285-291.
Muehlschlegel S, Rajajee V, Wartenberg KE, et al. Guidelines for neuroprognostication in critically ill adults with moderate–severe traumatic brain injury. Neurocrit Care. 2024;40:448-476. https://doi.org/10.1007/s12028-023-01902-2