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Meta-Analysis
. 2018 Mar 1;35(5):703-718.
doi: 10.1089/neu.2017.5259. Epub 2018 Jan 11.

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

Carl Marincowitz  1 , Fiona E Lecky  2 , William Townend  3 , Aditya Borakati  4 , Andrea Fabbri  5 , Trevor A Sheldon  6
Affiliations
Meta-Analysis

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

Carl Marincowitz et al. J Neurotrauma. .

Abstract

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Keywords: intra-cranial hemorrhage; mild traumatic brain injury; minor head injury; prognostic modeling.

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Conflict of interest statement

No competing financial interests exist.

Figures

<b>FIG. 1.</b>
FIG. 1.
PRISMA flow-diagram showing selection of studies for inclusion in the systematic review.
<b>FIG. 2.</b>
FIG. 2.
Risk for death stratified by initial Glasgow Coma Scale (GCS).
<b>FIG. 3.</b>
FIG. 3.
Meta-regression of risk for death by mean age study population (coefficient odds 1.05, 95% confidence interval [CI]: 1.00–1.12; p = 0.049).
<b>FIG. 4.</b>
FIG. 4.
Meta-regression of risk for death by mean Glasgow Coma Scale (GCS) study population (coefficient odds 0.12, 95% confidence interval [CI]: 0.02–0.86; p = 0.04).
<b>FIG. 5.</b>
FIG. 5.
Risk for neurosurgery stratified by the initial Glasgow Coma Scale (GCS) of the study population.
<b>FIG. 6.</b>
FIG. 6.
Meta-regression of risk for neurosurgery by mean Glasgow Coma Scale (GCS) study population (coefficient odds 0.71, 95% confidence interval [CI]: 0.01–0.56; p = 0.01).
<b>FIG. 7.</b>
FIG. 7.
Meta-regression of risk for neurosurgery by mean age study population (coefficient odds 1.01, 95% confidence interval [CI]: 1.02–1.11; p = 0.01).
<b>FIG. 8.</b>
FIG. 8.
Meta-regression of risk for neurosurgery by percentage of study population taking anti-coagulants (coefficient odds 1.1, 95% confidence interval [CI]: 1.01–1.19; p = 0.04).
<b>FIG. 9.</b>
FIG. 9.
Estimates of clinical deterioration stratified by the outcome measure.
<b>FIG. 10.</b>
FIG. 10.
Risk on repeat computed tomography (CT) imaging for progression of injury stratified by whether entire population selected for repeat imaging.
<b>FIG. 11.</b>
FIG. 11.
Pooled risk for neurosurgery stratified by isolated injury type identified by initial computed tomography (CT) imaging.
See this image and copyright information in PMC

References

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