- Department of Neurosurgery, Emory University, 1365 Clifton Road NE, Building B Suite 2200
- Department of Biostatistics and Bioinformatics, Emory University, Rollins School of Public Health, 1518 Clifton Road NE Atlanta, GA 30322
- Department of Neurosurgical Surgery, University of California at San Francisco, 505 Parnassus Ave., Room 779 M San Francisco, CA 94143-0112
Eric A. Sribnick
Department of Neurosurgical Surgery, University of California at San Francisco, 505 Parnassus Ave., Room 779 M San Francisco, CA 94143-0112
DOI:10.4103/2152-7806.148541Copyright: © 2015 Sribnick EA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Sribnick EA, Hanfelt JJ, Dhall SS. A clinical scale to communicate surgical urgency for traumatic brain injury: A preliminary study. Surg Neurol Int 05-Jan-2015;6:1
How to cite this URL: Sribnick EA, Hanfelt JJ, Dhall SS. A clinical scale to communicate surgical urgency for traumatic brain injury: A preliminary study. Surg Neurol Int 05-Jan-2015;6:1. Available from: http://sni.wpengine.com/surgicalint_articles/a-clinical-scale-to-communicate-surgical-urgency-for-traumatic-brain-injury-a-preliminary-study/
Background:While the Glasgow Coma Scale (GCS) provides a tool for evaluating traumatic brain injury (TBI) patients, there is no widely used scale that provides guidance for surgical management. This study introduces a scoring system that physicians potentially could use to determine and communicate the need for surgical decompression in TBI patients. The proposed system is designed to be both comprehensive and easy to use.
Methods:The Surgical Intervention for Traumatic Injury (SITI) scale uses radiographic and clinical findings. Patients were graded based on their GCS: GCS >12 received 0 points, GCS 9-12 received 1 point, and GCS 10 mm received 4 points. The presence of temporal pathology added 1 point, and epidural hematoma (EDH) ≥10 mm added 2 points. Retrospective analysis of 48 patients was then performed using the SITI scale.
Results:Of the 48 patients reviewed, 24 patients underwent craniotomy and the other 24 were treated non-operatively. The mean SITI score was 5.7 (range 3-10) for operative patients and 2.5 (range 1-4) for non-operative patients.
Conclusions:The proposed SITI scale is designed to be a simple, objective system for assisting in communication between clinical services and for suggesting the need for surgical decompression for TBI. Based upon our initial review, a SITI score of 3 or less correlated with non-operative management and a score of 5 or greater correlated with operative management. Given the results of this study, we believe that further development and research of the SITI scale are warranted.
Keywords: Computed tomography, emergency medicine, Glasgow Coma Scale, neurosurgery, traumatic brain injury
This year, 2014, marks the 40th anniversary of the Glasgow coma scale (GCS),[
However, it is rather astonishing that thus far no other reliable scale has been developed aiming to go one step further: At providing a suitable management guideline when encountering such injuries. There is hence a persistent lack of any established standardized assessment tool that allows care providers to communicate the likelihood of the need of any surgical intervention. This could be of considerable importance, for instance, when transferring a TBI patient from a smaller receiving institution to a specialized tertiary care facility or trauma level 1 center and it is especially valuable to have such a scale available for the nonneurosurgical provider.
The current paper by Sribnick and colleagues is therefore a long overdue attempt to introduce a clinically meaningful scoring system (SITI), an acronym for surgical intervention for traumatic head injury. The author's goal is that “physicians could use such a scale to determine and communicate the need for surgical decompression in TBI patients”. The proposed SITI system is designed to be both comprehensive and easy to use, especially for nonneurosurgeons. To this end, the current SITI scale uses basic radiographic aspects obtained by standard computed tomography (CT)-scanning (the existence and degree of midline shift; the presence of temporal pathology or an epidural hematoma) and principal clinical findings (the admission GCS and the possible presence of a dilated pupil), all of which in isolation have proven to be of clinical relevance.
By retrospectively assigning patients of a sizeable cohort with a numeric scoring value, the authors were able to show that low scoring patients did not undergo surgical intervention, whereas high scoring patients had a surgical intervention performed. This retrospective observation is compelling and warrants further prospective study since it could help in appropriate triage decisions, preparation of timely intervention, and allocation of resources to head trauma victims.
Needless to say, any new scoring system needs to stand the proof of time and further prospective proper evaluation and will change and develop over time. The incorporation of further physiological data and interventions will be needed[
We hope that the proposed SITI scale will initially instigate widespread use of it and thus raise attention to the need for further research in this area. May it prove its usefulness and allow the development of it or subsequent tools into a meaningful instrument to effectively communicate the needs of respective patients for better surgical planning and thereby ultimately improve outcome.
Ekkehard M. Kasper
Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA, USA
Traumatic brain injury (TBI) remains a major health concern in the United States with an estimated 1.36 million emergency room visits, 275,000 hospital admissions, and 52,000 deaths.[
While the Glasgow Coma Scale (GCS) provides a reproducible and convenient way of quickly assessing the level of consciousness in TBI patients,[
This is a retrospective study evaluating the possible utility of the SITI scale. Patient data was gathered from a TBI database of neurosurgery patients at Grady Memorial Hospital (Atlanta, GA), a Level 1 trauma center. Patients included in this study were admitted from March 2012 to October 2012. All patients were originally evaluated by the Emergency Department and found to have a TBI possibly requiring neurosurgical intervention, prompting a neurosurgical consultation. Clinical exam data was gathered from the electronic medical record and radiographic data was obtained from the picture archiving and communication system (PACS). This research was approved by the Internal Review Board at Emory University. Patient treatment (i.e. operative versus non-operative intervention) was at the discretion of the attending neurosurgeon.
The SITI scale was designed to provide a numeric score to the initial assessment that clinicians perform on TBI patients, and both physical exam findings and radiographic findings were incorporated to create the scoring system. The SITI scale was designed based on previously published surgical guidelines[
Several pathologic findings on non-contrast head computed tomography (CT) can add to the SITI score. Midline shift at the septum pellucidum was measured and given a score based on severity: 0 points for midline shift <5 mm, 2 points for midline shift measuring 5-10 mm, and 4 points for midline shift >10 mm. In addition, pathology of the temporal lobe was given 1 point, and epidural hematoma (EDH) ≥ 10 mm was given 2 points [
After obtaining the clinical exam data and radiographic data, this information was applied to the SITI scale, and the score for each patient was determined. As the authors intend to use the SITI scale as a clinical tool for initial evaluation of a trauma patient, all data used to determine the SITI score were based on the patient's initial presentation. Patients were divided based on whether they ultimately required a craniotomy, and the operative and non-operative groups were compared.
Clinical findings and the SITI scores of operative and non-operative patients were compared using Student's t-test (IBM SPSS Statistics Package Version 19.0, Armonk, NY, USA). For binary variables, Fisher's exact test was used. Multivariate analysis was also conducted using a logistic regression analysis to examine simultaneously the associations between the SITI features and the neurosurgeon's decision to operate. Statistical significance was defined as P < 0.05.
Calculation of the SITI score involved evaluation of the neurological exam and non-contrast head CT. For example, a 26-year-old female was brought to the Grady Memorial Hospital Emergency Department by Emergency Medical Services [Figure
(a-c) Representative sections of a head CT from an operative patient. A 26-year-old female who fell from a car demonstrates findings of left subdural hematoma above the level of foramen of Monro (a). At the level of foramen of Monro (b), there is 9 mm of left to right shift, as measured by displacement of the septum pellucidum. Below the level of foramen of Monro (c), subdural hematoma extends lateral to the temporal lobe. (d-f) Representative sections of a head CT from a non-operative patient. A 23-year-old female involved in a motor vehicular collision demonstrates a thin, left-sided subdural hematoma above the level of foramen of Monro (d). At the level of foramen of Monro (e), there is no midline shift of the septum pellucidum. Below the level of foramen of Monro (f), no temporal lobe pathology is noted
An example of a non-operative patient reviewed using the SITI scale is a 23-year-old female who was brought by Emergency Medical Services to Grady Memorial Hospital. She was a restrained passenger involved in a motor vehicular collision with a semi-trailer truck. On initial evaluation, she was found to have a GCS of 8T: she opened her eyes to painful stimuli, was intubated, and localized to painful stimuli bilaterally. Her pupils were equal and reactive bilaterally. Her initial head CT revealed a thin subdural hematoma over the left frontal convexity [Figure
Medical charts and imaging from 48 patients were retrospectively reviewed to determine SITI scores [
The admission GCS score of the non-operative group was 10.7, as compared to 9 in the operative group (P = 0.093). None of the patients in the non-operative group demonstrated an enlarged unilateral pupil on exam, while 25% of patients in the operative group had a unilateral enlarged pupil (P = 0.02). Patients in the non-operative group had a mean 0.25 mm of midline shift on initial head CT, while patients in the operative group had 7.4 mm of midline shift (P < 0.001). Temporal lobe pathology was noted in 62.5% of patients in the non-operative group and 67% of patients in the operative group (P = 0.73). The mean SITI score for non-operative patients was 1.75 (range 0-3; 95% confidence interval 1.39-2.11), and the mean SITI score for operative patients was 4.875 (range 2-9; 95% confidence interval 4.15-5.60). There was a significant difference noted between SITI scores of the non-operative and operative groups (P < 0.001). There was cross-over between the groups: five patients from the non-operative group were determined to have a SITI score of 3, and from the operative group, one patient had a SITI score of 2 and two patients had a score of 3.
Logistic regression analysis on factors associated with the neurosurgeon's decision to operate indicated that the odds ratios associated with each unit increase in three of the SITI components (GCS, midline shift, and epidural hematoma) were approximately equal, suggesting a correlation between a higher score on the SITI scale and need for surgery [
This retrospective analysis of prior TBI patients with application of the SITI scale demonstrates a statistically significant difference in the SITI score between the operative group and the non-operative group. Because this study was retrospective, the presented data cannot validate this scale for use, but instead suggest that a higher SITI score may correlate with a patient's need for surgical intervention. While a neurosurgeon's discretion is the final arbiter regarding surgery for TBI, retrospective application of the SITI scoring system suggests that patients with a SITI score of 0-1 correlate with non-operative treatment and patients with a SITI score of 4 or above correlate with a need for operative intervention. Cross-over between the groups was seen with SITI scores of 2 or 3.
Application of the proposed SITI scoring system should not be difficult as the clinical findings (GCS and pupillary light reaction) are examined in all TBI patients. The radiographic findings (midline shift, temporal pathology, presence of an epidural hematoma) could be quickly interpreted by a radiologist or other clinician who is familiar with head CT scans. The measurement of midline shift is easily quantified and, in other studies, has demonstrated little interobserver variability.[
A similar scale for grading surgical need in traumatic cervical spinal injury has been introduced,[
There are several limitations to this study, including the limited number of patients and the use of retrospective analysis. Future work will involve the use of a prospective study of the SITI scale in order to validate its utility as a predictive tool and will focus on refining the criteria used to determine the SITI score.
We have described a simple method for grading neurotrauma patients and their potential need for emergent craniotomy. We believe that the creation and use of a scoring system to signify a patient's clinical and radiographic findings will allow for easier communication between emergency care personnel and their neurosurgical colleagues. Given the results of this study, we believe that further research and design of the SITI scale are warranted. Future studies examining the SITI scale will likely be both prospective and multi-institutional.
Supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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