Prediction Of Awakening And Evaluation Of Prognosis In Long-term Unconscious Patients After Severe Traumatic Brain Injury

Background Traumatic brain injury is a prevalent problem around the world which threatens the health of mankind and seriously affects the development of social economy, which also brings a heavy burden to the patients' families. So how to establish an effective, reliable and practicable model to predict the probability of patients' awakening is an urgent issue. First, we can classify the patients according to the severity of the disease, and avoid the occurrence of risk factors; this will greatly improve the level of our medical treatment in the future. Second, it can provide accurate information concerning patients' disease, which can guide us in making decisions and is good for the allocation of medical resources. With the development of our society, more and more. attention has been paid to this field, especially in the West. However our research is just at start level, so making a predictive model is essential for our country. Objective To investigate the correlation between Magnetic Resonance Imaging (MRI) findings and awakening in long-term unconscious patients with severe traumatic brain injury (TBI)Methods MRI data were collected retrospectively in 66 patients suffering from severe TBI from January 2003 to August 2008 in the South Medical University, Zhujiang Hospital. These patients had a long-term disturbance of consciousness≥2weeks; GCS≤8 points; aged from 5 years old to 75 years old; with spontaneous breathing; without history of cardiopulmonary resuscitation, primary cerebral infarction; non-traumatic brain injury and neurological impairment. All of the patients'age, sex, injury time, data of head MRI and awakening or not awakening are completely recorded.1. Examination in the brain MRI.(1) We use the Signa advangtage 1.5T superconducting Magnetic resonance produced by the U.S. GE, conventional SE sequence, T2WI axial; slice thickness 8mm, layer of distance 10mm. Inspection time is from 1 week to 24 weeks with an average of 9 weeks after TBI.(2) Region of interests (ROI) in MRI:1) brain stem:including the pontine (ventral pontine and dorsal pontine) and the midbrain (ventral midbrain and dorsal midbrain); 2) the thalamus:including both sides of the thalamus; 3) the basal forebrain:including the gyrus rectus, the orbital gyrus, the vice olfactory cortex, the preoptic area and the anterior hypothalamus; 4) corpus callosum:including the genu, the body and the callosum; 5) cerebral cortex and subcortical:including the cerebral cortex and subcortica in various lobes of the brain.2. Criterion of Awakening:The outcome of awakening after the sixth month from injury was used as the criterion. We appraised the outcome of awakening in patients as following:At least one of the traits is apparent or easy to identify, and it must be repetitive or consistent:1) Simple commands can conducted.2) "Yes" or "No" with gesture or language can be replied.3) Words can be understood.4) Actions or emotional reactions in special environment are not caused by conditional reflexion.3. Statistical methods:All data were delt withχ2 test and Logistic regression analysis to analyze the relationship between the regions of abnormal signal in MRI and outcome of awakening by SPSS 13.0. A P< 0.05 was considered statistically significant.Results 27 patients had awaked while 39 patients remained in long-term unconsciousness at the sixth month. Unconscious group revealed a significantly higher frequency in ventral brain stem, dorsal brain stem, basal forebrain, corpus callosum and thalamus lesion than conscious group; theχ2 test was significant, P <0.05. Logistic regression analysis showed that dorsal brainstem, right thalamus and corpus callosum injuries were predictive of non-awaked. Logit (non-awaked)= 3.83×brainstem dorsal+3.47×thalamus (right)+1.73×corpus callosum-2.55. The area under the ROC curve is 0.934(95% CI 0.876-0.993).Conclusions There are close correlation between MRI findings and outcome in long-term unconscious patients after severe traumatic brain injury at the 6th month. The stem dorsal, the right thalamus and the corpus callosum lesions in patients MRI shows difficult to become awakening. Objective To investigate the magnetic resonance imaging (MRI) grading in unconscious patients after severe traumatic brain injury (TBI) considering awakening.Methods Region of interests (ROI) of MRIs were collected retrospectively in 66 patients suffering from severe TBI from January 2003 to August 2008 in the South Medical University, Zhujiang Hospital. These patients had a long-term disturbance of consciousness≥2weeks; GCS≤8 points; aged from 5 years old to 75 years old; with spontaneous breathing; without history of cardiopulmonary resuscitation, primary cerebral infarction; non-traumatic brain injury and neurological impairment.1. Standards of Brain MRI gradingOur MRI grading were classified as following according to ROI:GradeⅠ:The lesions of the hemispheres; GradeⅡ:The lesions of the thalamus and/or corpus callosum with or without lesions of gradeⅠ; GradeⅡa:The unilateral lesions of the thalamus; GradeⅡb:The corpus callosum and/or bilateral lesions of the thalamus; GradeⅢ:The lesions of the dorsolateral brainstem with or without lesions of gradeⅡ。Firsching MRI grading standards:GradeⅠ:Lesions of the hemisphere; GradeⅡ: Lesions in unilateral brain stem of any level with or without lesions in the supratentorial; GradeⅢ:Lesions in bilateral midbrain with or without lesions in supratentorial; GradeIV:Lesions in the bilateral pons with or without other lesions.2. Criterion of Awakening:The awakening after the sixth months from injury was used as the criterion.3. All patients were followed up 7 months to 5 years to weeks; record the classification in MRI and the awakening time.4. Statistical methods:SPSS13.0 statistical package used for statistical analysis. Both classification are separate analysed by Mann-whitney test, A P<0.05 was considered significant; two classification criteria comparison by the using the area under the ROC curve. The comparison of awakening time using two independent sample t test.Results 66 patients with severe traumatic brain injury in patients with long-term disturbance of consciousness (52 men,14 women), aged 5 years old to 75 years, mean 33 years. From a total of 66 patients,4 cases were patients with high falling injury (2 cases recovery),10 cases were Violence Contusion injuries (6 cases recovery),4 cases were falls (1 case recovery),48 cases were traffic accident (18 cases recovery). A awaking probability of our grading were:gradeⅠ88.89%, gradeⅡa 83.33%, gradeⅡb 28.57%, gradeⅢ7.14%. Our grading standards by the Mann-whitney test, Z= 5.713 (P= 0.000), Gamma correlation coefficient was-0.896 (P= 0.000). A awaking probability of the Firsching grading were:gradeⅠ61.90%, gradeⅡ65.00%, gradeⅢ0%, gradeIV6.25%; Firsching grading standards by Mann-whitney test, Z= 4.326 (P= 0.000), Gamma correlation coefficient of-0.746 (P = 0.000). We set up our grading in gradeⅡb,Ⅲas indicator of not awake at the 6th month after severe traumatic brain injury, the sensitivity was 85.71%, specificity was 87.50%, accuracy rate was 86.36%, the error rate was 13.64%. After comparing the area under the ROC curve, our grading standards with the area under the ROC curve 0.893,95% confidence interval (0.808,0.978), Firsching grading with the area under the ROC curve 0.803,95% confidence interval (0.695,0.911). GradeⅡa and GradeⅡb average awakening time was 8.00±4.10 weeks; GradeⅡb and GradeⅢaverage awakening time was 22.67±23.66 weeks. GradeⅠ,Ⅱa and gradeⅡb,Ⅲaverage awakening time by two independent sample t test, t=-1.848, P= 0.101, the difference was not statistically significant.Conclusion 1. Our MRI grading standards can predict the probability of awaking objectively and accurately, and better than the Firsching MRI grading standards.2. Our MRI grading standards showed gradeⅠandⅡa have 88.89% and 83.33% of patients awaking at 6th month; gradeⅡb andⅢprobability of awaking dropped to 28.57% and 7.14%.3. We set up our grading gradeⅡb,Ⅲas indicator of not awake at 6th month after severe traumatic brain injury, the sensitivity was 85.71%, specificity was 87.50%, accuracy rate was 86.36%, the error rate was 13.64%.4. GradeⅡa and GradeⅡb average awakening time was 8.00±4.10 weeks; GradeⅡb and GradeⅢaverage awakening time was 22.67±23.66 weeks; However, gradeⅠ,Ⅱa andⅡb,Ⅲaverage awakening time differences can not be considered significant now. Objective To investigate using the magnetic resonance imaging (MRI) grading to evaluate the prognosis in long term unconscious patients after severe traumatic brain injury.Methods Selected and analyzed 66 patients suffering from severe TBI with duration of disturbance of unconsciousness>2week. The GOS score at the 6th month after the injury were recorded. Analysis the correlation between the MRI classification and the patients' GOS score and the prognosis with GOS 5,4 as good prognosis, GOS 3,2,1 as poor prognosis.1. MRI examination and standards of Brain MRI grading:Ibid.2. Glasgow Outcome Scale (GOS) criteria:1 point:death;2 points:vegetative state:the unconscious, with a heartbeat and breathing, eyes occasionally, suck, yawn, and localized motor response;3 points:severe disability:conscious, but the cognitive, speech, body movement, severe disability,24 hours must require care;4 points:moderate disability:cognitive, behavioral, personality disorders; a mild hemiplegia, ataxia, speech difficulties and other disabilities, in everyday life, family and social activities are still capable of independent reluctantly;5 points:good recovery:able to re-enter normal social activities, and to return to work but can have a variety of new sequels.3. Statistical methods:SPSS 13.0 statistical package used for statistical analysis. Kruskal-wallis test was used to analyze the correlation between the MRI grading and the patients'GOS score; Chi-square test was used to analyze the correlation between the MRI grading and the prognosis. A P<0.05 was considered significant.Results 17 cases with good prognosis,49 patients with poor prognosis, total poor prognosis rate was 74.24%; 15 cases with good prognosis in gradeⅠandⅡa, 9 patients with poor prognosis in gradeⅠandⅡa, poor prognosis rate was 37.50% in gradeⅠandⅡa; 2 cases with good prognosis in the gradeⅡb andⅢ,40 cases with poor prognosis in the gradeⅡb andⅢ, poor prognosis rate was 95.24% in the gradeⅡb andⅢ; 8 cases died, the total mortality rate was 12.12%.1 case in the gradeⅠandⅡa died, the mortality rate was 4.17%.7 cases in the gradeⅡb and gradeⅢdied, the mortality rate was 16.67%. The MRI grading and GOS of 6 months after the injury status by Kruskal-wallis test,χ2= 30.134, P= 0.000. To made gradeⅠ,Ⅱa into a group, gradeⅡb,Ⅲinto the other group, the poor prognosis rate between two groups are statistics by Chi-square test,χ2= 30.134, P= 0.000. If the gradeⅠandⅡa are used as the indicator of good prognosis, gradeⅡb,Ⅲare used as the indicator of poor prognosis, the accuracy rate was 83.33%, error rate was 16.67%.Conclusions MRI is a clinical examination method that can be used to find the lesion and provide diagnostic information accurately in the TBI patients. The MRI grading can reflect the degree of brain injury objectively and accurately; the higher the classification, the worse prognosis. If the gradeⅠandⅡa are used as the indicator of good prognosis, gradeⅡb,Ⅲare used as the indicator of poor prognosis, the accuracy rate was 83.33%, error rate was 16.67%.