The Rotterdam Scoring System Can Be Used as an Independent Factor for Predicting Traumatic Brain Injury Outcomes

Objective

Predicting outcomes in patients with traumatic brain injury is critically important for making sound clinical decisions. This study aimed at determining the prognostic value of the Rotterdam scoring system to predict early death among these patients.

Materials and Methods

This study was performed prospectively on 150 patients with traumatic brain injury hospitalized in Shahid Beheshti Hospital, Kashan, Iran. Patients' demographic and clinical characteristics such as age, sex, mechanism of trauma, initial Glasgow Coma Scale score, and accompanying lesions were documented. A brain computed tomography was performed for each patient and scored by use of the Rotterdam system. Patients were monitored for 2 weeks after hospital discharge, and their outcomes were documented. Univariate and multiple logistic regression analysis and prognostic values of Rotterdam system were conducted by SPSS software.

Results

Nineteen patients (12.7%) died during the course of the study. The mean age of the dead patients was significantly greater than those who survived (P = 0.037). The sensitivity and the specificity of the Rotterdam scoring system at the cutoff score of 4 were 84.2% and 96.2%, respectively. Rotterdam score was significantly correlated with patient outcomes (P < 0.0001). Moreover, logistic regression analyses revealed that factors such as age, sex, Glasgow Coma Scale score, and Rotterdam score significantly contributed to patient outcomes.

Conclusions

Rotterdam score is an independent factor for predicting outcomes among patients with traumatic brain injury. At the cutoff score of 4, the Rotterdam system can predict outcomes among patients suffering from traumatic brain injury with acceptable sensitivity and specificity.

Introduction

Traumatic brain injury (TBI) is among the leading causes of death in the United States.¹ TBI is accountable for about 40% of all deaths induced by acute injuries in the United States and leads to about 52,000 deaths each year. Motor vehicle accidents (50%) and falls (20%–30%) are the most prevalent causes of TBI.²

The early diagnosis of TBI is critically important to make sound clinical decisions and to determine prognosis. One of the methods for such purposes is the Glasgow Coma Scale (GCS), which categorizes TBIs into mild, moderate, and severe according to the patient's level of consciousness. Use of the GCS at the time of hospital admission, however, is difficult and does not provide conclusive results because patients are intubated and/or receive narcotics. Moreover, GCS cannot differentiate among different types of intracranial injuries.³ Another diagnostic technique for assessing TBI is brain imaging by computed tomography (CT) and magnetic resonance imaging (MRI). Brain imaging significantly helps the early diagnosis and the effective treatment of life-threatening conditions in patients with TBI.⁴

Brain CT is the gold standard for assessing patients with acute TBI. Given its ability to immediately show cranial and intracranial abnormalities, CT is considered as the modality of choice for evaluating patients with acute TBI. Moreover, it is used for determining the severity of brain injuries. MRI, however, also is used widely for brain imaging. Compared with CT, MRI has greater sensitivity for detecting contusions and diffuse axonal injuries.⁵ It is associated, however, with several shortcomings, such as the inability to show skull fractures, subarachnoid hemorrhages, and hyper-acute hemorrhages, as well as a longer duration of imaging procedure. Consequently, MRI is mainly used for studying subacute and chronic TBIs.⁶

Integrating clinical examination findings with CT findings has significantly improved the ability to determine the prognosis of TBI. Performing clinical examinations on patients with TBI, however, is difficult. In addition, the accuracy of clinical examination findings greatly depends on the examiner's proficiency. Consequently, predictive models that are based solely on the findings of imaging studies, particularly CT, have been developed for resolving the shortcoming of clinical examination in this patient population.

Currently, there are 2 CT-based systems for evaluating CT findings, the Marshall Classification System (MCS) and the Rotterdam Scoring System (RSS).7, 8 The MCS, developed by Marshall et al.⁷ in 1991, was the first CT-based system for determining the prognosis of TBI. The MCS classifies CT findings into 4 grades: Grade 1, no pathologic findings; Grade 2, basal cisterns are present and midline shift is less than 5 mm; Grade 3, basal cisterns are compressed; and Grade 4, midline shift is greater than 5 mm.⁷ This system was developed primarily for predicting patient outcomes and the risk for increased intracranial pressure in patients with severe TBI. Despite its great use and applicability, the MCS has several limitations, such as failing to assess epidural hematomas and intracranial hemorrhages as well as having weak prognostic power for determining the prognosis of intracranial mass lesions.⁹

To overcome these shortcomings, in 2005 Maas et al.⁸ introduced the RSS. This system provides a better estimation of disease prognosis by using certain criteria such as basal cisterns condition, midline shift, traumatic subarachnoid or intraventricular hemorrhage, and the epidural hematoma. Rotterdam scores predict posttrauma 6-month mortality rate as follows: score 1, 5%; score 2, 7%; score 3, 16%; score 4, 26%; score 5, 53%; and score 6, 61%.⁸ Although it is not a fully validated scoring system and hence, further studies are still needed for its validation, the RSS has overcome some of the shortcoming of the MCS.¹⁰

The MCS and the RSS have been used and evaluated in several studies. For instance, Maas et al.¹¹ conducted a study to evaluate the correlation of CT findings with 6-month patient outcomes and found that CT-based classification was significantly correlated with outcomes of patients suffering from TBI. The worst outcomes were among patients with class III (brain edema) and IV (midline shift). Finally, they concluded that both independent and combined CT findings are significant predictors of outcomes in patients with TBI.¹¹ The results of another study, conducted by Mata-Mbemba et al.⁹ on 245 patients with mild-to-severe TBIs, also revealed that the predictive power of the MCS and the RSS were almost the same. Other studies also have shown that the RSS scores are significantly correlated with death and other adverse outcomes among patients with TBI3, 12, 13; however, Washington and Grubb¹⁴ conducted a retrospective study on 1101 patients with TBI and found a weak relationship between death and Rotterdam score.

Most of the previous studies that used the RSS for outcome prediction dealt mainly with long-term patient outcomes. Moreover, the results of the previous studies in this area are conflicting. In addition, to the best of our knowledge, the RSS has not been used and evaluated in our country, Iran. This study was conducted to narrow these gaps. The aim of the study was to determine the prognostic value of the RSS to predict early death among patients with TBI.