Research Reports - Early predictors of outcome after mild traumatic brain injury

Lancet Neurol. 2017 Jul;16(7):532-540. doi: 10.1016/S1474-4422(17)30117-5. Epub
2017 Jun 13.

van der Naalt J(1), Timmerman ME(2), de Koning ME(3), van der Horn HJ(3),
Scheenen ME(4), Jacobs B(3), Hageman G(5), Yilmaz T(6), Roks G(6), Spikman JM(7).

BACKGROUND: Mild traumatic brain injury (mTBI) accounts for most cases of TBI,
and many patients show incomplete long-term functional recovery. We aimed to
create a prognostic model for functional outcome by combining demographics,
injury severity, and psychological factors to identify patients at risk for
incomplete recovery at 6 months. In particular, we investigated additional
indicators of emotional distress and coping style at 2 weeks above early
predictors measured at the emergency department.
METHODS: The UPFRONT study was an observational cohort study done at the
emergency departments of three level-1 trauma centres in the Netherlands, which
included patients with mTBI, defined by a Glasgow Coma Scale score of 13-15 and
either post-traumatic amnesia lasting less than 24 h or loss of consciousness for
less than 30 min. Emergency department predictors were measured either on
admission with mTBI-comprising injury severity (GCS score, post-traumatic
amnesia, and CT abnormalities), demographics (age, gender, educational level,
pre-injury mental health, and previous brain injury), and physical conditions
(alcohol use on the day of injury, neck pain, headache, nausea, dizziness)-or at
2 weeks, when we obtained data on mood (Hospital Anxiety and Depression Scale),
emotional distress (Impact of Event Scale), coping (Utrecht Coping List), and
post-traumatic complaints. The functional outcome was recovery, assessed at 6
months after injury with the Glasgow Outcome Scale Extended (GOSE). We
dichotomised recovery into complete (GOSE=8) and incomplete (GOSE≤7) recovery. We
used logistic regression analyses to assess the predictive value of patient
information collected at the time of admission to an emergency department (eg,
demographics, injury severity) alone, and combined with predictors of outcome
collected at 2 weeks after injury (eg, emotional distress and coping).
FINDINGS: Between Jan 25, 2013, and Jan 6, 2015, data from 910 patients with mTBI
were collected 2 weeks after injury; the final date for 6-month follow-up was
July 6, 2015. Of these patients, 764 (84%) had post-traumatic complaints and 414
(45%) showed emotional distress. At 6 months after injury, outcome data were
available for 671 patients; complete recovery (GOSE=8) was observed in 373 (56%)
patients and incomplete recovery (GOSE ≤7) in 298 (44%) patients. Logistic
regression analyses identified several predictors for 6-month outcome, including
education and age, with a clear surplus value of indicators of emotional distress
and coping obtained at 2 weeks (area under the curve [AUC]=0·79, optimism 0·02;
Nagelkerke R(2)=0·32, optimism 0·05) than only emergency department predictors at
the time of admission (AUC=0·72, optimism 0·03; Nagelkerke R(2)=0·19, optimism
0·05).
INTERPRETATION: Psychological factors (ie, emotional distress and maladaptive
coping experienced early after injury) in combination with pre-injury mental
health problems, education, and age are important predictors for recovery at 6
months following mTBI. These findings provide targets for early interventions to
improve outcome in a subgroup of patients at risk of incomplete recovery from
mTBI, and warrant validation. 

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