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. 2024 Aug 1;7(8):e2427772.
doi: 10.1001/jamanetworkopen.2024.27772.

Automated Measurement of Cerebral Hemorrhagic Contusions and Outcomes After Traumatic Brain Injury in the TRACK-TBI Study

Samuel B Snider  1   2 , Nancy R Temkin  3   4 , Xiaoying Sun  5 , Jacob L Stubbs  6 , Quinn J Rademaker  1 , Amy J Markowitz  7 , Eric S Rosenthal  2   8 , Ramon Diaz-Arrastia  9 , Michael D Fox  2   10   11   12 , Geoffrey T Manley  7   13 , Sonia Jain  5 , Brian L Edlow  2   12   14 ; TRACK-TBI Investigators
Affiliations

Automated Measurement of Cerebral Hemorrhagic Contusions and Outcomes After Traumatic Brain Injury in the TRACK-TBI Study

Samuel B Snider et al. JAMA Netw Open. .

Abstract

Importance: Because withdrawal of life-sustaining therapy based on perceived poor prognosis is the most common cause of death after moderate or severe traumatic brain injury (TBI), the accuracy of clinical prognoses is directly associated with mortality. Although the location of brain injury is known to be important for determining recovery potential after TBI, the best available prognostic models, such as the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) score, do not currently incorporate brain injury location.

Objective: To test whether automated measurement of cerebral hemorrhagic contusion size and location is associated with improved prognostic performance of the IMPACT score.

Design, setting, and participants: This prognostic cohort study was performed in 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018. Adult participants aged 17 years or older from the US-based Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study with moderate or severe TBI (Glasgow Coma Scale score 3-12) and contusions detected on brain computed tomography (CT) scans were included. The data analysis was performed between January 2023 and February 2024.

Exposures: Labeled contusions detected on CT scans using Brain Lesion Analysis and Segmentation Tool for Computed Tomography (BLAST-CT), a validated artificial intelligence algorithm.

Main outcome and measure: The primary outcome was a Glasgow Outcome Scale-Extended (GOSE) score of 4 or less at 6 months after injury. Whether frontal or temporal lobe contusion volumes improved the performance of the IMPACT score was tested using logistic regression and area under the receiver operating characteristic curve comparisons. Sparse canonical correlation analysis was used to generate a disability heat map to visualize the strongest brainwide associations with outcomes.

Results: The cohort included 291 patients with moderate or severe TBI and contusions (mean [SD] age, 42 [18] years; 221 [76%] male; median [IQR] emergency department arrival Glasgow Coma Scale score, 5 [3-10]). Only temporal contusion volumes improved the discrimination of the IMPACT score (area under the receiver operating characteristic curve, 0.86 vs 0.84; P = .03). The data-derived disability heat map of contusion locations showed that the strongest association with unfavorable outcomes was within the bilateral temporal and medial frontal lobes.

Conclusions and relevance: These findings suggest that CT-based automated contusion measurement may be an immediately translatable strategy for improving TBI prognostic models.

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Conflict of interest statement

Conflict of Interest Disclosures: Ms Markowitz reported receiving grants from the US Department of Defense and National Institute of Neurological Disorders and Stroke (NINDS) during the conduct of the study. Dr Manley reported receiving grants from the US Department of Defense, Medical Technology Enterprise Consortium, NINDS, and the National Football League outside the submitted work.

Figures

Figure 1.
Figure 1.. Regional Distribution of Contusions
Contusions were registered to a common template and summed at each voxel. The color represents the proportion of the total Transforming Research and Clinical Knowledge in TBI cohort (N = 417) with a contusion at each voxel.
Figure 2.
Figure 2.. Temporal Contusion Volumes and Probability of Unfavorable Outcome Across IMPACT Quartiles
GOSE 1-4 indicates Glasgow Outcome Scale-Extended, with scores of 1 to 4 indicating unfavorable outcomes at 6 months; IMPACT, International Mission for Prognosis and Analysis of Clinical Trials in TBI.
Figure 3.
Figure 3.. Disability Heat Map
Heat maps were generated using 2 different outcomes: Glasgow Outcome Scale–Extended (GOSE) score of 4 or less at 6 months (A) and using the GOSE score as a continuous measure (B). Sparse canonical correlation analysis was used to identify the strongest independent voxelwise associations between the presence of a contusion and outcomes in the total International Mission for Prognosis and Analysis of Clinical Trials in TBI cohort (N = 417). The color indicates each voxel’s weight, a normalized value representing the strength of the association between the presence of a contusion and an unfavorable outcome. The redder the color, the greater the likelihood of an unfavorable outcome. The size of each cluster of colors indicates the range of brain areas that a contusion can hit to influence the outcome. The resulting maps were registered to a high-resolution Montreal Neurological Institute template for visualization.
See this image and copyright information in PMC

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