marshall and rotterdam ct scan grading
DESCRIPTION
Head Injury CT scan, prediction of mortalityTRANSCRIPT
वक्रतुण्ड महाकाय सुय�कोटि� समप्रभनि�र्विव�घ्�ं कुरु मे देव सव�काय�षु सव�दा
Comparison of Predictability of Marshall and Rotterdam Grading System in Determining Mortality after
Traumatic Brain Injury
Dhaval ShuklaDepartment of Neurosurgery
NIMHANS, Bangalore
CT Scan in Head Injury
• CT scan necessary not only for diagnosis and management of TBI but also for prognosis
• Both individual CT scan features and classification system are important for prognosis
• Following CT features have Class I and II evidence for >70% PPV in TBI – Presence of abnormalities– CT classification– Compressed basal cisterns– Traumatic Subarachnoid Hemorrhage (tSAH)
• Basal cisternal SAH• Extensive tSAH
Chesnut, et al. J Neurotrauma 2000.
Marshall (TCDB) Classification
Marshall, et al. JNS 1991.
Limitations of Marshall (TCDB) Classification
• In the TCDB classification, the categorization of mass lesions (into “evacuated” or “non-evacuated”) depended on knowing what subsequently actually happened to the patient– Can be applied retrospectively – As patient management could vary between individual neurosurgeons
the hematoma categorization might be difficult to apply prospectively to guide management
• Does not capture the predictive information in as closely as other parameters like overall appearance of CT scan
• Not a significant independent outcome predictor in the multivariate model once clinical features are included
Wardlaw, et al. JNNP 2002.
Major Limitations of Marshall Classification
• Lack of tSAH• Basis of volume of mass lesion as 25 cc is not
clear• Does not classify type of hematoma• Does not further categorize extent of basal
cisterns compression• Cannot be used as grading system• Rotterdam CT grading overcomes limitations
Traumatic Subarachnoid Hemorrhage (tSAH)
• European Brain Injury Consortium (n=750)• 41% patients had tSAH• After adjustment for age, GCS, Motor Scores,
and admission CT findings tSAH had strong, highly statistically significant association with poor outcomes (OR, 2.49 (1.74–3.55; P<0.001)
Servadei, et al. Neurosurgery 2002.
Hematoma Volume and Surgery
• EDH > 30 cm3 should be evacuated regardless GCS
• SDH > 10 mm thick or a with midline shift > 5 mm should be evacuated regardless of the GCS
• Contusions/ Parenchymal hematomas > 50 cm3 should be treated operatively
Bullock, et al. Neurosurgery 2006.
Hematoma Types and Mortality
• EDH: 7-12.5%
• SDH: 40-60%
• Contusions: 16 to 72%
Bullock, et al. JNT 2000.
Extent of Cisterns Compression and Unfavorable Outcome
Open Cisterns Compressed Cisterns Absent Cisterns0
10
20
30
40
50
60
70
80
90
Study 1 Study 2 Study 3
Bullock, et al. JNT 2000.
Marshall Grading and Unfavorable Outcome
Diffuse Injury I Diffuse Injury II Diffuse Injury III Diffuse Injury IV Evacuated Mass Non-Evacuated Mass
0
10
20
30
40
50
60
70
80
90
100
Marshall, et al. JNS 1991.
Rotterdam Grading of CT Scan
1 2 3 4 5 60
10
20
30
40
50
60
70
Mass, et al. Neurosurgery 2005.
Objective of Our Study
• To validate Rotterdam CT grading for determining early mortality
• Compare predictability of Rotterdam with Marshall
Methods
Subjects• Patients with clinically moderate and severe TBISet up• CasualtyRaters• Senior Resident• ConsultantOutcome• 14 day mortality
Servadei, et al. Neurosurgery 2002.MRC CRASH Trial Collaborators. BMJ 2008.
Roozenbeek, et al. J Neurotrauma 2012.
Results
• 134 patients – 103 moderate– 31 severe TBI
• Mortality: 11.2%• Mean GCS: 9.60 +/- 2.32
– Alive: 10.19 +/- 1.48– Dead: 4.93 +/- 2.46
• Age: 38.1 +/- 15.7 years– Alive: 38.28 +/- 16.07– Dead: 38.53 +/- 15.22
p=0.41
p=0.003
Results
1 2 3 4 5 605
101520253035404550
Marshall RotterdamSpearman's rho = 0.682
Discrimination of Marshall and Rotterdam CT scan Scores
ROC Curve
Diagonal segment s are produced by t ies.
1 - Spec i fi c i ty
1. 00. 75. 50. 250. 00
Se
ns
itiv
ity
1. 00
. 75
. 50
. 25
0. 00
So u rc e o f the Cu rv e
Ref erence Line
ROTTERDA
MARSHALL
Marshall AUC: 0.707 (0.572 - 0.842)Rotterdam AUC: 0.681 (0.527 – 0.835)
Conclusion• Though superiority of Rotterdam scoring system have
been reported in literature, when found that both CT scan system have good accuracy in predicting early mortality
• There is still scope of improvement in CT classification by inclusion of following specific features:– Thickness and distribution of tSAH– Hemorrhagic DAI– Brainstem hematoma– Infarcts/ Black Brain
Mata-Mbemba, et al. Acad Radiol 2014.Nelson, et al. JNT 2010.
Mass, et al. Neurosurgery 2005.
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