1) The document compares the predictability of the Marshall and Rotterdam grading systems for determining mortality after traumatic brain injury based on CT scans. 2) It finds that both systems have good accuracy in predicting early mortality, with the Marshall system having an AUC of 0.707 and the Rotterdam system having an AUC of 0.681. 3) While previous studies have reported the superiority of the Rotterdam system, this study found that both systems perform similarly in predicting mortality.

1. वक्रतुण्ड महाकाय सुययकोटि समप्रभ
निर्वयघ्िंकुरु मे देव सवयकायेषु सवयदा

2. Comparison of Predictability of Marshall
and Rotterdam Grading System in
Determining Mortality after
Traumatic Brain Injury
Dhaval Shukla
Department of Neurosurgery
NIMHANS, Bangalore

3. 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.

4. Marshall (TCDB) Classification
Marshall, et al. JNS 1991.

5. 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.

6. 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

7. 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.

8. 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.

9. Hematoma Types and Mortality
• EDH: 7-12.5%
• SDH: 40-60%
• Contusions: 16 to 72%
Bullock, et al. JNT 2000.

10. Extent of Cisterns Compression and
Unfavorable Outcome
90
80
70
60
50
40
30
20
10
0
Open Cisterns Compressed Cisterns Absent Cisterns
Study 1 Study 2 Study 3
Bullock, et al. JNT 2000.

11. Marshall Grading and Unfavorable
Outcome
100
90
80
70
60
50
40
30
20
10
0
Diffuse Injury I Diffuse Injury II Diffuse Injury III Diffuse Injury IV Evacuated Mass Non-Evacuated
Mass
Marshall, et al. JNS 1991.

12. Rotterdam Grading of CT Scan
70
60
50
40
30
20
10
0
1 2 3 4 5 6
Mass, et al. Neurosurgery 2005.

13. Objective of Our Study
• To validate Rotterdam CT grading for
determining early mortality
• Compare predictability of Rotterdam with
Marshall

14. Methods
Subjects
• Patients with clinically moderate and severe TBI
Set up
• Casualty
Raters
• Senior Resident
• Consultant
Outcome
• 14 day mortality
Servadei, et al. Neurosurgery 2002.
MRC CRASH Trial Collaborators. BMJ 2008.
Roozenbeek, et al. J Neurotrauma 2012.

15. 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=0.003
p=0.41

16. Results
50
40
30
20
10
0
1 2 3 4 5 6
Marshall Rotterdam
Spearman's rho = 0.682

17. Discrimination of Marshall and
Rotterdam CT scan Scores
ROC Curve
0.00 .25 .50 .75 1.00
1 - Specificity
Diagonal segments are produced by ties.
Sensitivity
1.00
.75
.50
.25
0.00
Source of the Curve
Ref erence Line
ROTTERDA
MARSHALL
Marshall AUC: 0.707 (0.572 - 0.842)
Rotterdam AUC: 0.681 (0.527 – 0.835)

18. 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.

19. श्री गणेशाय िमः