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When Mild Is Severe – Contradictions In TBI Classification Using GCS And PTA

When Mild Is Severe – Contradictions In TBI Classification Using GCS And PTA. Olli Tenovuo Department of Neurology University of Turku Finland. Introduction.

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When Mild Is Severe – Contradictions In TBI Classification Using GCS And PTA

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  1. When Mild Is Severe – Contradictions In TBI Classification Using GCS And PTA Olli Tenovuo Department of Neurology University of Turku Finland

  2. Introduction • Glasgow ComaScale (GCS) and duration of post-traumatic amnesia (PTA) aretwobyfar the most common measures of TBI severity • The pathophysiologybehindthesemeasures is largelyunknown

  3. Introduction, continued • The relationshipbetween GCS and PTA is poorlystudied • In a series of 157 consecutivemildTBIs (GCS 13-15), 48 patients (= 30.6 %) had a PTA > 24 hrs, in 22 of these PTA wasover 7 days (= 14 %) and in 7 patients (= 4.5 %) PTA wasovertwo weeks1 1Dikmen S, Machamer J, Temkin N. Mild head injury: facts and artifacts. J Clin Exp Neuropsychol 2001;23:729-38.

  4. Purpose of the study • To study the eventual contradictions in TBI classification using the GCS and the duration of PTA • To study the eventual reasons for discordant classifications using these two measures

  5. Methods • A database of 1029 TBI patients, treated at the neurological outpatient clinic at the University of Turku, Finland during the years 1993 – 2005 • The outpatient clinic receives most TBI patients admitted to the hospital due to acute TBI + patients having suspected sequels of TBI within the region (= ½ million inhabitants)

  6. Methods • A sample of 112 TBI patients, selected in randomfrom the database • Exclusion criteria: - age < 18 or > 65 at injury - GCS or PTA not available - CT within 3 days of injury lacking • After exclusion, 95 patients formed the study group

  7. Material, demographics(n = 95) Age± SD 36.6 ± 13.1 Sex (M / F) 64 / 31 Education - elementary school 25.3 % - college 47.4 % - high school 16.8 % - ND 10.5 % Work status - employed 63.2 % - unemployed 12.6 % - student 20.0 % - other 4.2 %

  8. Material,injurycharacteristics Injurytype - traffic 60.0 % - fall 30.5 % - other 9.5 % GCS (mean± SD) 10.7 ± 4.1 PTA (mean ± SD) 10.5 ± 9.2 days

  9. Material, riskfactors EarlierTBIs - none 70.5 % - onemild 8.4 % - severalmild 5.3 % -  moderate 3.2 % - notknown 12.6 % Psychiatrichistory - none 67.4 % - yes 24.2 % - notknown 8.4 % Drug/alcoholabuse - none 67.4 % - mild 11.6 % - moderate 10.5 % - notknown 10.5 %

  10. Classification of TBI severity • GCS 3 – 8 = severe TBI • GCS 9 – 13 = moderate TBI • GCS 14 – 15 = mild TBI • PTA > 7 days = severe TBI • PTA 1 – 7 days = moderate TBI • PTA < 24 hrs = mild TBI GCS wasassessed at arrival to the hospital PTA wasassessedwith the Rivermeadmethod

  11. Results • GCS and PTA yielded discordant classification of severity in 48.9 % of patients • In 91 % of these, PTA suggested a more severe injury • A difference of two classes of severity (= mild vs. severe) was found in 12.8 % of patients

  12. Results, continued ConcordantDiscordant p Age 34.5 ± 13.0 38.5 ± 13.2 0.151 Gender 63 / 37 % 74 / 26 % 0.235 Low / higheducation 36 / 64 % 20 / 80 % 0.015* PreviousTBIs 17 % 23 % 0.867 Psychiatrichistory 27 % 26 % 0.910 Injurytype (traf / fall / o) 64 / 25 / 11 % 54 / 37 / 9 % 0.205 Abusehistory 35 % 15 % 0.076° Confoundingfactors 56 % 35 % 0.053°

  13. Discussion The results suggest that • GCS and PTA reflect different aspects of TBI, • they may give clearly discordant assessment of severity in a large portion of patients, • pre-injury or injury-related factors do not seem to explain this discordance

  14. Conclusions • There is a fairly common type of injury, where the consciousness is well preserved, but where the PTA may be long as a sign of more severe injury. • The classification of TBI severity based solely on GCS is inadequate, and probably one of the main reasons for the conflicting views of the outcome in “mild” TBIs.

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