Predicting in-hospital mortality in severe traumatic brain injury patients using admission CT perfusion

Dear Editor,

We read with great interest the recent article by Shankar et al. on the use of admission CT perfusion (CTP) to diagnose in-hospital mortality in patients with severe traumatic brain injury (TBI) [1]. The study presents a compelling case for CTP as an early prognostic tool. However, we have a few questions and concerns that we believe warrant further discussion [2,3,4].

1. 1.

   The study defines non-survivable brain injury as a matched decrease in cerebral blood flow (CBF) and cerebral blood volume (CBV) in the brainstem. While this definition is clearly stated, the authors do not provide detailed information on the specific quantitative thresholds used to define "decrease" in CBF and CBV. Could the authors elaborate on how these thresholds were determined and whether any specific software or algorithms were used for CTP image analysis?

2. 2.

   The interpretation of CTP images was performed by two independent neuroradiologists, which is a strength of the study. However, the article does not report the level of agreement between the two readers. Could the authors provide data on inter-observer variability (e.g., kappa statistic) for the assessment of decreased CBF and CBV in the brainstem? This would help to further validate the reliability of the CTP findings.

3. 3.

   The study mentions that the results of CTP were not used for clinical decision-making. While this approach minimizes potential bias, it also raises questions about the clinical utility of CTP in this context. If CTP findings of non-survivable brain injury are not acted upon, what is the potential benefit of this information? Could the authors discuss the potential implications of their findings for future clinical practice and whether CTP might be used to guide treatment strategies or inform prognosis in the future?

4. 4.

   The authors acknowledge that their study focused on in-hospital mortality. It would be valuable to know if the CTP findings of non-survivable brain injury were also associated with other important outcomes, such as long-term functional status or neurological recovery. Did the authors explore any correlations between CTP results and other clinical outcomes, and are there plans to investigate these associations in future research?

5. 5.

   The study population consisted of adult patients with severe TBI. Could the authors comment on the generalizability of these findings to other populations, such as pediatric patients or patients with different types of brain injury?

Addressing these questions would provide a more comprehensive understanding of the role of CTP in predicting mortality in severe TBI patients and its potential clinical implications.

No datasets were generated or analysed during the current study.

1. Shankar J, Alcock S, Leeies M, Ayroso M, Unrau S, Park J, Blackwood B, Trivedi R, Marin R, Raja M, Sinha N, Trivedi A, Essig M, Martin D, Grierson R, Zeiler FA. Diagnosis of in-hospital mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI study). Crit Care. 2025;29(1):174.

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2. Alcock S, Batoo D, Ande SR, Grierson R, Essig M, Martin D, Trivedi A, Sinha N, Leeies M, Zeiler FA. Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study. BMJ Open. 2021;11(6): e047305.

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3. Shankar JJS, Green R, Virani K, Wong H, Eddy K, Vandorpe R. Admission perfusion CT for classifying early in-hospital mortality of patients with severe traumatic brain injury: a pilot study. Am J Roentgenol. 2020;214(4):872–6.

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4. Wintermark M, Van Melle G, Schnyder P, Revelly J-P, Porchet F, Regli L, Meuli R, Maeder P, Chioléro R. Admission perfusion CT: prognostic value in patients with severe head trauma. Radiology. 2004;232(1):211–20.

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We appreciate the Clinical Research Development Center of Imam Reza Hospital for their wise advice.

There was no external source of funding.

Authors and Affiliations

1. Department of Neurosurgery, Kermanshah University of Medical Sciences, Kermanshah, Iran

   Nila Salimi

2. Department of Neurosurgery, Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran

   Ehsan Alimohammadi

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1. Nila SalimiView author publications

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Contributions

EA and NS had the idea for this study. EA and NS participated in outlining the concept and design. EA wrote the first draft of the manuscript. Both authors revised the final manuscript and approved the manuscript.

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Correspondence to Ehsan Alimohammadi.

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The authors declare no competing interests.

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Salimi, N., Alimohammadi, E. Predicting in-hospital mortality in severe traumatic brain injury patients using admission CT perfusion. Crit Care 29, 191 (2025). https://doi.org/10.1186/s13054-025-05455-y

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• Received: 06 May 2025

• Accepted: 09 May 2025

• Published: 13 May 2025

• DOI: https://doi.org/10.1186/s13054-025-05455-y

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