40

Practical Guidelines for Prognostication After Traumatic Brain Injury

Sunil Kothari and Craig DiTommaso

INTRODUCTION

•   Families report that they rarely receive the prognostic information they desire after traumatic brain injuries (TBI) [1–3].

•   Subjective estimates of prognosis based solely on a clinician’s personal experience vary widely and are far less accurate than evidence-based prognoses derived from well-designed studies [4,5].

•   Recently published, evidence-based guidelines on prognosis after severe TBI are summarized in this chapter. Additional details about the methodology used are available elsewhere [6].

•   These guidelines are designed to facilitate prognostication in individual patients by using readily available information (predictor variables) to predict the likelihood of long-term outcomes.

EVIDENCE-BASED GUIDELINES: BACKGROUND

•   The guidelines are meant for adults with severe TBI. Information on both mild TBI as well as pediatric TBI is found in Chapters 8 and 59 respectively.

•   The primary outcomes include classification according to the Glasgow Outcome Scale (GOS), independent living, and vocational reentry, all assessed at 6 months or later.

•   The GOS is the most widely used measure of outcome after TBI; the guidelines assume a basic familiarity with its main categories (Table 40.1).

•   The primary predictor variables include age, initial Glasgow Coma Scale (GCS) score, duration of coma (as measured by the time to follow commands), early neuroimaging (both computed tomography [CT] and magnetic resonance imaging [MRI]), and duration of posttraumatic amnesia (PTA).

TABLE 40.1    Glasgow Outcome Scale

•   Several of the predictor variables have threshold values, which are values above or below which a particular outcome is especially unlikely. For example:

        If PTA lasts more than 3 months, a person is very unlikely to achieve a “good recovery” on the GOS.

        If PTA lasts less than 2 months, a person is very unlikely to be severely disabled as defined by the GOS.

•   Clinicians can use these threshold values as milestones in a patient’s recovery. For instance, as the length of a patient’s PTA extends beyond 3 months, rehabilitation clinicians can counsel family members about realistic expectations for the future. On the other hand, if 2 months have not yet elapsed since the injury, clinicians can give hope to families, even if the patient is still in PTA.

•   Although they are well supported by research, these threshold values are not absolute; there is a degree of clinical and statistical uncertainty in their use. In particular, the upper limit of the confidence interval averaged approximately 10%. This means that approximately 10% of individuals will prove to be exceptions to the guidelines.

EVIDENCE-BASED GUIDELINES: RESULTS

•   The results of the studies reviewed are summarized in Table 40.2. The final guidelines are presented in Table 40.3.

TABLE 40.2    Summary of Findings From Studies of Nonpenetrating TBI

Related posts:

Selected Somatic Disorders Associated With Mild Traumatic Brain Injury: Fatigue, Dizziness and Balance Impairment, and Whiplash Injury Heterotopic Ossification Resources for Traumatic Brain Injury Survivors and Caregivers Posttraumatic Headache Posttraumatic Seizures Recognizing Manifestations of Posttraumatic Stress Disorder in Patients With Traumatic Brain Injury

Stay updated, free articles. Join our Telegram channel

Join