Prediction of Outcome in Moderate and Severe Traumatic Brain Injury: The Value of Pragmatic Estimation of the Duration of Posttraumatic Confusional State

Objective

To explore the added value of posttraumatic confusional state (PTCS) duration for outcome prediction, in patients with moderate and severe traumatic brain injury (TBI).

Design

Neurosurgical inception cohort study with follow-up 12 months postinjury.

Setting

Regional trauma center.

Participants

Patients aged ≥16 years admitted with moderate or severe TBI (Glasgow Coma Scale score 9-13 and 3-8), who survived the acute phase. Three hundred ninety-five patients completed follow-up and had a valid PTCS duration estimation; 75% were men.

Interventions

Not applicable.

Main Outcome Measures

PTCS duration was pragmatically categorized into weekly intervals, primarily through retrospective review of medical records. In addition to PTCS duration, predictors included age, sex, the admission Glasgow Coma Scale score, pupillary dilatation, and the worst Rotterdam computed tomography score. The outcome was assessed using the Glasgow Outcome Scale–Extended (GOSE). Uni- and multivariable binary logistic regression analyses were performed to explore predictive models with and without PTCS duration. The dependent variable GOSE was dichotomized using several cutoffs: GOSE scores ≤7, ≤6, ≤5, and ≤4.

Results

The GOSE score (with lower scores indicating worse function) decreased with longer PTCS duration in patients with moderate and severe TBI. PTCS duration was a significant predictor of most outcomes and the only significant predictor in the multivariable models for severe TBI. Adding PTCS duration as a covariate improved the fit of the multivariable models, particularly in severe TBI. When PTCS lasted <28 days, a GOSE score of 1-4 was observed in only 3% of cases.

Conclusions

The strong association between PTCS duration and outcomes demonstrates the benefit of estimating PTCS in hospital and rehabilitation settings. Moreover, PTCS holds promise as a modifier of the TBI severity classification.