Original ArticleDemographics and clinical characteristics of acute traumatic brain injury patients in the different Neuroimaging Radiological Interpretation System (NIRIS) categories
Graphical abstract
Introduction
An estimated 10 million people worldwide are affected every year by a new traumatic brain injury (TBI) event [1]. In the United States alone, there are more than 2.5 million emergency department (ED) visits for TBI yearly [2], [3], [4]. This number of ED visits has increased steeply over the last few decades [5], primarily as a result of increased occurrences of mild TBI and/or concussions. As a disease process rather than a single event, TBI increases long-term mortality and is associated with increased incidences of neurodegenerative and psychiatric diseases [6]. Thus, accurate and timely identification of the injury severity is paramount for mitigating associated symptoms and disease processes, and ultimately preventing poor clinical outcomes.
The Glasgow Coma Scale (GCS) is the primary clinical classification system used to assess TBI severity in patients. GCS separates TBI into three broad categories: mild (GCS scores of 13–15), moderate (9–12), and severe (< 9) [7]. However, patients with the same GCS scores were found to have quite different TBI injuries in several clinical trials, illustrating the limited ability of GCS to stratify TBI patients in terms of the pathophysiology of their injury [8]. Yet, the different pathophysiologic mechanisms of TBI are responsible for neurological deficits and the target of therapeutic interventions [9], [10]. In addition, GCS may be difficult to interpret in some trauma patients. For instance, changes in respiratory pattern or brainstem reflexes, which reflect the severity of coma, are not accounted for in the calculation of GCS [11].
Imaging classification systems were developed to improve stratification of TBI patients. The most commonly used are the Marshall score [12] and the Rotterdam score [13]. Both scoring systems are used as independent predictors of patient outcomes. However, Marshall and Rotterdam scores are meant to predict early death in patients with moderate and severe TBI [14], [15]. Recently, a new classification system, the NeuroImaging Radiological Interpretation System (NIRIS), was developed to predict TBI patient outcomes and management, including discharge from the ED, follow-up brain imaging, admission, need for intensive care unit, neurosurgical procedure (ventricular drain, burr hole, craniotomy/craniectomy, surgical drainage/evacuation of hematoma), as well as death [16].
The clinical characteristics and natural history of TBI patients in the different NIRIS categories are poorly known. The goal of this study was to close this gap in knowledge by assessing the demographics, clinical and imaging findings, and outcomes of TBI patients in each of the NIRIS categories.
Section snippets
Study population
Under the auspices of our institutional review board, all consecutive patients transported to our emergency department by ambulance or helicopter between November 2015 and April 2017 were considered for study inclusion. Included in the study were adult patients (> 18 years old) for whom a trauma alert was triggered per established criteria [17] (http://stan.md/2nw7pfD) and who underwent a non-contrast head CT because of suspicion of traumatic brain injury. Patients with the following conditions
Study population
In all, 1152 patients were included according to the study eligibility criteria as shown in the flow diagram (Fig. 1). Demographics are presented in Table 2 and Fig. 2. Patients with NIRIS 0 imaging findings were significantly younger than patients in the other NIRIS categories (P < 0.001).
Motor vehicle accidents and falls from height were the most common mechanisms of injury in all NIRIS categories, accounting for more than 60% of patients in each NIRIS category (Table 2). 60.4% of injury causes
Discussion
TBI is a major cause of mortality and disability [19]. Traffic accidents, which are a leading cause of TBI in many parts of the world, are expected to become the third largest cause of global disease burden by 2020 [20]. At least 5.3 million Americans live with TBI-related disability and face numerous challenges in their efforts to return to a full and productive life [21]. Mortality among individuals who survive a moderate-to-severe TBI has also remained constant [22].
To date, no therapeutic
Funding
Dr. Hui Chen is supported by a grant from the National Natural Science Foundations of China (Grant No. 81771273).
Disclosure of interest
The authors declare that they have no competing interest.
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