Our next speaker is Ross Puffer, who will be talking about CT evidence of brainstem hemorrhage does not lead to worsened long-term outcomes in severe traumatic brain injury. So, I'm Ross Puffer. I'm a resident at Mayo. I want to present a project I worked with Dr. Okonkwo on out at Pittsburgh just looking at CT evidence of brainstem hemorrhage and outcomes in TBI. No financial relationships. So, traumatic brainstem hemorrhage really should be classified as primary versus secondary. Primary traumatic brainstem hemorrhage being a hemorrhage that occurs at the time of injury. So, vascular damage happens immediately after the impact from the TBI compared to the sort of classic secondary Duret hemorrhage that everybody hears about. So, Dr. Duret, a famous neurologist, originally described in 1878, and this is his drawing traumatic hemorrhage, including the brainstem. But he was really talking about shearing forces of the small perforating vessels off the basilar artery with downward herniation and increased ICP. So, very different mechanisms that I think are often brought together too commonly. So, a lot of residents I know will look at a CT scan and see a hemorrhage in the brainstem and say that's a Duret hemorrhage and that carries a very bad prognosis. And that starts to seep into your decision making perhaps or at least thinking about outcomes. But there are some reports of very remarkable recovery after Duret hemorrhage or brainstem hemorrhage. This one's out of San Francisco. It's a 24-year-old woman who is in a high-speed motor vehicle collision. She had a right-sided epidural hematoma that was decompressed. In the post-op setting, she had evidence of a brainstem hemorrhage that was confirmed on MRI, a pretty substantial hemorrhage. This is her at follow-up. She initially came in with a GCS of six with the absence of several brainstem reflexes. And here she's standing and flexing both upper extremities. So, pretty good outcome. So, the objectives of this study were to evaluate the outcomes in TBI patients with and without evidence of brainstem hemorrhage. Only severe TBI and only looking at the admission CT scan to really get at that idea of you see evidence of hemorrhage in the brainstem on admission and compare those outcomes to patients without hemorrhage. So, we used the BTRC database at Pittsburgh, which is a prospectively maintained trauma database that I retrospectively reviewed between 91 and 2007. I only looked for severe TBI subjects within admission CT and any evidence of hyperdensity in the brainstem that was consistent with hemorrhage was considered CT positive. So, the outcome was by Glasgow outcome scale and determined at final follow-up listed. This wasn't the extended scale and that's just based on time frame for when the patients were involved in this study. But the groups were compared using the mean GOS at final follow-up. I'll talk about it a little bit at the end that comes into play I believe for the results here. So, just under 700 cases of severe TBI during that time frame and just about 500 had CT and follow-up data to be included. Average age was just under 40 and 75% of the subjects were male. The mean admission GCS for the entire group was 5.3. And the final follow-up was generally speaking a year or two years for the majority of the cohort. So, looking at the comparison between the two groups, there was no difference in age, gender, or admission GCS, no significant difference. But you can see the hemorrhage group was 4.9 versus no hemorrhage 5.3 for admission GCS. So, the overall numbers in the cohorts of 28 subjects with hemorrhage versus 466 without. So, the results here, the GOS at the final follow-up which is an average of 17 months, subjects with hemorrhage in the brain stem had a GOS of 2.2 versus no hemorrhage 2.7. The P value there is 0.1 which is, of course, not significant but suggests perhaps a trend. And here's a table of the GOS itself. Now, I think this gets into a little bit of the issue with the study, you know, the patients are not doing well. We're in between persistent vegetative state and severely disabled. But the extended scale adds more categories that might provide meaningful data. Nonetheless, I thought that these numbers were fairly low and that perhaps patients that died during the hospitalization were bringing those numbers down. So, when those patients were removed, the group with hemorrhage had a GOS average of 3.1 at final follow-up versus no hemorrhage of 3.5 and that was, there was no significant difference. So, in thinking about this, there's a trend towards improved GOS in those without hemorrhage but it's not significant. And a fair number of these patients ultimately die, 50% in the hemorrhage group and 42% in the no hemorrhage group. But when those patients were removed, there was no significant difference at final follow-up. Again though, the mean GOS remained about 3 which is a severe disability. But that gets at to the limitations of the study. So, the GOS itself is an outcome measure. There might be a difference in those groups when the extended scale if it were to be applied. So, 3.5 mean GOS might correlate with a 4 on the extended scale which would be upper severe disability and someone who could spend up to 8 hours a day at home unsupervised compared to lower severe disability which needs more intensive care. So, that's a limitation. I think something that could provide a next step for this type of study. Another limitation would be outcomes measured between 1991 and 2007, 25 years ago. A lot of practice variations and things may change over time. And the last thing, not all patients had follow-up up to 2 years. So, the recovery trajectory may show a difference. I'd be interested in looking at subjects at final follow-up. What's the difference in their recovery to get to their final GOS level? So, to put this together in take-home points, evidence of traumatic brain stem hemorrhage on admission CT scan does not preclude a functional recovery. Again, I hear a lot of fellow residents, they see the CT scan on admission, evidence of brain stem hemorrhage and they think that's it. But in reality, that doesn't necessarily preclude a good recovery or a functional recovery. But up to 50% of these patients may end up dying. The survivors end up with a similar GOS at final follow-up. And then lastly, it's limited by the GOS as a primary outcome measure as well as improvements in care of TBI patients from 1991 to the present. Thank you. Yes, please. I've done a comparative study of my life comparing MRI, CT, in all of those patients within a few days of the interview. And we always had an initial CT scan when the patient was admitted. And the CT MRI was done about two or three days later. And from the brain scan readings that you can see on MRI, only 10% were visible on CT. Sure, sure. Sure. Mm-hmm. And I think certainly some of the 460 patients that didn't have evidence of hemorrhage on CT, perhaps even 10% of them would have evidence on MRI, and that may be affecting the outcomes. Yes, sir. I think as far as for me this is a study that you know I thought about and opened my eyes a little bit and I think it warrants a lot more intensive look and even within the database that I used trying to parse out some of these things a little bit more but also I think the biggest factor will be using the extended scale and trying to bring this closer to to current treatment so congratulations on a very interesting project

CT evidence

brainstem hemorrhage

outcomes

traumatic brain injury

TBI patients