"Don't lose hope early": Hemorrhagic diffuse axonal injury on head CT is not associated with poor outcome in moderate-severe TBI patients.

Background: Diffuse axonal injury (DAI) on MRI has been associated with poor functional outcome after moderate-severe traumatic brain injury (msTBI). Yet, DAI assessment with highly-sensitive MRI-techniques is unfeasible in the acute trauma setting, and CT remains the key diagnostic modality despite its lower sensitivity. We sought to determine whether CT-defined-hemorrhagic-DAI (hDAI) is associated with discharge and favorable 3-and 12-month functional outcome (Glasgow Outcome Score >=4) after msTBI. Methods: We analyzed 361 msTBI patients from the single-center longitudinal OPTIMISM-study collected over six years (11/2009-11/2015) with prospective outcome assessments at 3- and 12-months. Patients with microhemorrhages on CT were designated "CT-hDAI-positive" and those without as "CT-hDAI-negative". For secondary analyses "CT-hDAI-positive" was stratified into two phenotypes according to presence ("associated") versus absence ("predominant") of concomitant large acute traumatic lesions to determine whether presence vs. absence of additional focal mass lesions portends a different prognosis. Results: Seventy patients (19%) were CT-hDAI-positive (n=36 predominant; n=34 associated hDAI). In univariate analyses, CT-hDAI-positive status was associated with discharge survival (p=0.004) and favorable outcome at 3-months (p=0.003) and 12-months (p=0.005). After multivariable adjustment, CT-hDAI-positivity was no longer associated with discharge survival and functional outcome (all p>0.05). Stratified by hDAI phenotype, predominant hDAI patients had worse trauma severity, longer ICU stays, and more systemic medical complications. Predominant hDAI, but not associated hDAI, was an independent predictor of discharge survival (adjusted OR 24.7; 95% CI 3.2-192.6; p=0.002) and favorable 12-month outcome (adjusted OR 4.7; 95% CI 1.5-15.2; p=0.01). Sensitivity analyses using Cox-regression confirmed this finding for 1-year survival (adjusted HR 5.6; 95% CI 1.3-23; p=0.048). Conclusion: CT-defined-hDAI was not an independent predictor of unfavorable short- and long-term outcomes and should not be used for acute prognostication in msTBI patients. Predominant hDAI patients had good clinical outcomes when supported to ICU discharge and beyond. Level of Evidence: Level III; prognostic study. (C) 2017 Lippincott Williams & Wilkins, Inc.

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