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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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