Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.

1. TBI: when to stop and when to
give time
Nicholas Little

2. “No head injury is
so serious that it
should be
despaired of nor
so trivial that it
can be ignored.”

3. Today, physicians’ estimates of prognosis
are still often unduly optimistic,
unnecessarily pessimistic, or inappropriately
ambiguous.

4. Adults age 65 and older are at greatest risk for being hospitalized and
dying from a TBI, most likely from a fall. In every age group, serious TBI
rates are higher for men than for women. Men are more likely to be
hospitalized and are nearly three times more likely to die from a TBI than
women.
The problem

5. Outcome
Severe head injury
AANS
● Just under ⅓ good outcome
(mild disability)
● ⅙ each moderate and severe
disability
● I/3 die
● Vegetative <10%

6. Outcome
Moderate Head Injury
60%good recovery
25% moderate disability
5-10% severe disability
7-10% death/PVS

7. Severe TBI
Among participants in a vegetative state at 2 weeks, 62
of 79 (78%) regained consciousness and 14 of 56 with
available data (25%) regained orientation by 12 months
JAMA - TRACK 2021.

8. What do we want?
1. Advance directive
a. Health professionals and family members
must follow a valid directive. They cannot
override it.
2. God
3. Empathy
4. Relatives
5. Resources

9. Factors clinical
1. On site
a. GCS
b. BP/BSL/Other Injury
c. Absent pupillary response
d. Older age (40)

10. Factors imaging
1. Scan appearance CT/MRI
a. Role of MRI?
b. CT
Basal cisterns
Traumatic SAH
Marshall Vs Rotterdam
Classification
● basal cisterns
○ 0: normal
○ 1: compressed
○ 2: absent
● midline shift
○ 0: no shift or <= 5 mm
○ 1: shift > 5 mm
● epidural mass lesion
○ 0: present
○ 1: absent
● intraventricular blood or traumatic SAH
○ 0: absent
○ 1: present

11. Apples and oranges

12. Kothari
● Favorable outcome (GOS 4-5) likely when
the time to follow commands is less than 2
weeks after injury, and the duration of post-
traumatic amnesia is less than 2 months.
● Poor outcome (GOS <4) is likely when the
patient is > 65 years old, the time to follow
commands is longer than 1 month, or the
duration of post-traumatic amnesia is greater
than 3 months.
● Notably, 10% of patients will not have the
outcome predicted by the guidelines above.

13. ICP- High is bad
?Treatment is good
Metabolic manipulation
BP Manipulation
Surgical intervention
Craniectomy
Prolonged ventilation

14. Should I stay or should I go
Signposts
Opportunity
Is moderate and severe disability acceptable and
to whom?
Hippocrates again- “Do No Harm”
Patient
Family
Society

15. What is our job and when
“Go for Broke”
Prevent death and Maximize outcome
“Balanced”
Probability based decisions

16. CRASH predictor

17. CRASH baby

18. Take Home
Good faith discussions with Colleagues and family
Avoid both oppositional behaviour and groupthink
Beware the empathy trap
Sometimes you don’t know
Exceptions don’t make good laws