Prognosis of Diffuse Axonal Injury with Traumatic Brain Injury

BACKGROUND Determine the prognostic impact of MRI-defined DAI after TBI on functional outcomes, quality of life, and 3-year mortality. METHODS This retrospective single center cohort included adult trauma patients (age>17y) admitted from 2006-2012 with TBI. Inclusion criteria were positive head CT with brain MRI within 2 weeks of admission. Exclusion criteria included penetrating TBI or prior neurologic condition. Separate ordinal logistic models assessed DAI's prognostic value for following scores: 1)hospital-discharge Functional Independence Measure (FIM); 2)long-term Glasgow Outcome Scale-Extended (GOSE); and 3)long-term Quality of Life after Brain Injury-Overall Scale (QOLIBRI-OS). Cox proportional hazards modeling assessed DAI's prognostic value for 3-year survival. Covariates included age, sex, race, insurance status, Injury Severity Score (ISS), admission Glasgow Coma Scale Score, Marshall Head CT Class, clinical DAI on MRI (Y/N), research-level anatomic DAI Grades I-III (I:cortical, II:corpus callosum, III:brainstem), ventilator days, time to follow commands, and time to long-term follow up (for logistic models). RESULTS Eligibility criteria was met by 311 patients, who had a median age=40y (IQR:23-57), ISS=29 (IQR:22-38), ICU stay=6d (IQR:2-11), and follow-up=5y (IQR:3-6y). Clinical DAI was present on 47% of MRIs. Among 300 readable MRIs, 56% of MRIs had anatomic DAI (25% Grade I, 18% Grade II, 13% Grade III). On regression, only clinical (not anatomic) DAI was predictive of a lower FIM score (OR=2.5 [95% CI:1.28-4.76], P=0.007). Neither clinical nor anatomic DAI were related to survival, GOSE, or QOLIBRI scores. CONCLUSIONS In this longitudinal cohort, clinical evidence of DAI on MRI may only be useful for predicting short-term in-hospital functional outcome. Given no association of DAI and long-term TBI outcomes, providers should be cautious in attributing DAI to future neurologic function, quality of life, and/or survival. LEVEL OF EVIDENCE III STUDY TYPE Retrospective cohort study DISCLOSURES OF FUNDING RECEIVED FOR THIS WORK: National Institutes of Health R01GM120484 and R01HL111111 (mbp); Vanderbilt Faculty Research Scholars Program (mbp); REDCap, UL1 TR000445 from NCATS/NIH (all authors), Vanderbilt Institute for Clinical and Translational Research award (VR9296) via CTSA grant UL1TR000011 (NCRR/NCATS/NIH) CONFLICT OF INTEREST WITH ALL SOURCES OF SUPPORT: Dr. Patel has been or is supported by the Vanderbilt Institute for Clinical and Translational Research awards (VR1584, VR5351, VR12073, VR22411) via CTSA grant UL1TR000011 (NCRR/NCATS/NIH); Department of Defense, Joint Program Committee-6, Combat Casualty Care, W81XWH-16-R-0033 (subcontract); and speaker fee from Pfizer. Dr. Patel has served on the EAST Guidelines Committee, Mentoring Committee, Manuscript and Literature Review Committee, and Board of Directors. PRESENTATION AT: 1st Place in the Timothy Fabian Trauma Paper Competition for the 2017 Tennessee Chapter of the American College of Surgeons Meeting in Nashville, TN on August 5, 2017; Oral Presentation (Quickshot) at the 31st Eastern Association for the Surgery of Trauma Annual Scientific Assembly on January 9-13, 2018 in Lake Buena Vista, Florida. CORRESPONDING AUTHOR AND CONTACT INFORMATION: Mayur B. Patel MD MPH FACS, mayur.b.patel@vanderbilt.edu, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212 © 2018 Lippincott Williams & Wilkins, Inc.

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