Recovery is in the eye of the beholder How visual fixation can predict TBI patients’ outcome Caroline Arbour, RN, PhD 12th annual conference, Brain Injury Canada September 30th, 2015
Annual incidence of TBI in Quebec About 400 moderate/severe TBI are admitted in ICUs Of them, 65% will survive their injuries and return home Nord du Québec Côte-Nord Baie James Saguenay Abitibi- Lac-St-Jean Témiscamingue Québec Outaouais Estrie Montérégie Centre
The initial Glasgow score (Teasdale & Jennett, 1974) Lowest score in the first 24h post-TBI Eye opening - Spontaneous 4 and prior to intubation - To speech 3 - To pain 2 - None 1 Used to index severity of TBI Verbal response Severe - score 3-8 - Oriented 5 - Confused 4 Moderate - score 9-12 - Words (inappropriate) 3 - Sounds 2 - None 1 More or less performant for the Motor response prediction of TBI prognosis - Obey commands 6 - Localise pain 5 - Normal flexion 4 But remain widely used as it is the - Decortication 3 only marker available within 24h - Decerebration 2 - None 1
Post-traumatic amnesia - PTA (GOAT: Levin, O’Donnell & Grossman, 1979) Known as the most robust predictor of TBI prognosis However, takes several days/weeks to assess Glasgow score of ≥9 Coma Retrograde amnesia Recovery of ability to APT assessment create new memory TBI
Recovery of visual fixation post-TBI Already assessed regularly by nurses in the study setting Fixation was considered present … - If sustained 2sec - On 2 consecutive times Otherwise considered absent Published with patient’s consent
Two-phase cohort study Does recovery of visual fixation at 24h post-ICU admission can predict better than the initial Glasgow score… PTA duration? Global recovery in the months following TBI?
Markers of recovery Phase 1 – During hospitalisation PTA duration ≤ 14 days indicated good recovery > 14 days indicated poorer recovery Phase 2 – 1 to 3 years post-TBI Glasgow Outcome Scale – Extended (GOSE score) Visual attention task (in sec) Structural brain deficits (cerebellum, thalamus, PFC)
Study sample Phase 2 Unlocatable GOSE score n=89 n=92 Phase 1 Follow up Not eligible for further testing n=45 181 m/s TBI discharged alive Attention task Refused between n=32 n=15 2010-2013 MRI n=20
Comparing the sub-samples considered for GOSE testing Variables n (%) or mean (SD) Included Unlocatable Group n=92 n=89 differences Gender (Male) 71 (77%) 74 (83%) ns 34 14 35 15 Age ns 14 13 14 13 ICU stay (days) ns Initial Glasgow score 8 ± 3 7 ± 3 ns 175 162 143 127 Hrs without fixation in the ICU ns 1318 951 1071 1019 Cum. dose of Fentanyl adm. first 24h ns 1406 1271 2056 1731 Cum. dose of Propofol adm. first 24h ns CT scan findings Midline shift 10 (11%) 9 (10%) ns Compressed cisterns 21 (23%) 17 (19%) ns Subdural hemorrhage 47 (51%) 47 (53%) ns Subarachnoid hemorrhage 40 (43%) 38 (43%) ns Swelling 40 (43%) 34 (38%) ns
Comparing the sub-samples considered for attention testing Variables n (%) or mean (SD) Included Not eligible Eligible but Group refused differences n=32 n=45 n=15 Gender (Male) 21 (66%) 33 (73%) 11 (73%) ns 34 15 36 14 Age 37 ± 14 ns 16 15 14 13 ICU stay (days) 8 ± 4 ns Initial Glasgow score 9 ± 4 8 ± 3 7 ± 2 ns 184 171 182 162 Hrs without fixation in the ICU 118 ± 111 ns 1326 699 1200 979 Cum. dose of Fentanyl adm. first 24h 1825 ± 530 ns 1583 1137 1400 910 Cum. dose of Propofol adm. first 24h 900 ± 636 ns CT scan findings Midline shift 3 (9%) 4 (9%) 1 (7%) ns Compressed cisterns 9 (29%) 11 (24%) 4 (28%) ns Subdural hemorrhage 17 (54%) 24 (53%) 8 (53%) ns Subarachnoid hemorrhage 11 (33%) 19 (42%) 6 (40%) ns Swelling 13 (41%) 17 (38%) 8 (53%) ns
Phase I (N=181) Variables n (%) or mean (SD) Fixation at 24h Fixation at 24h Group PRESENT ABSENT differences n=103 n=78 Gender (Male) 76 (74%) 62 (79%) ns 34 16 35 15 Age ns 7 6 20 13 ICU stay (days) 0.000 Initial Glasgow score 8 ± 3 7 ± 3 ns 7 ± 6 352 ± 170 Hrs without fixation in the ICU 0.000 1187 1029 1392 1323 Cum. dose of Fentanyl adm. first 24h ns 1759 1443 1793 1533 Cum. dose of Propofol adm. first 24h ns 6 ± 5 23 ± 17 PTA duration (days) 0.000
ROC curve for the prediction of PTA 14days Courbe ROC pour prédiction APT < 14 jours 100 12h 36h 80 At 24h, recovery of visual fixation showed: 12 sensitivity 60 Sensibilité Sensitivity of 84% Specificity of 82% 40 20 ----- Hrs without fixation in the ICU – AUC 89% Hr sans fixation à l'USI - AUC 89% Score de Glasgow initial - AUC 67% ----- Initial Glasgow score – AUC 67% 0 0 20 40 60 80 100 100-specificity 100-Spécificité
Phase II – GOSE score (n=92) Variables B SE (B) t Sig PTA duration -0.037 0.014 -0.400 -2.592 0.015 Initial Glasgow 0.038 0.067 0.100 0.560 ns score Hrs without -0.004 0.001 -0.552 -3.238 0.003 fixation in the ICU
Phase II – Attention task (n=32) Variables B SE (B) t Sig PTA duration 1.072 0.428 0.496 2.508 0.021 Initial Glasgow 0.865 1.832 0.086 0.472 ns score Hrs without 3.623 1.490 0.441 2.431 0.023 fixation in the ICU
Post-hoc analysis What about the prediction of intra-hospital mortality? We reviewed the medical charts of all TBI patients deceased in the ICU (n=52) over a period of 12 months (Jan-Dec 2013 )… Of all patients who died during hospitalization, only one was able to fixate at 24h post-ICU admission
Conclusions This study is the first to show that: • Visual fixation recovery is a strong predictor of PTA duration • It was also found to be as performant as PTA for predicting TBI long term outcomes Visual fixation could be considered by clinicians for the estimation of TBI recovery, especially when PTA is under investigation
Acknowledgments Co-authors Andrée-Ann Baril, PhD (c) Francis Bernard, MD, FRCSC Marie-Aurélie Bruno, PhD Jean-François Giguère, MD, PhD, FRCSC Danielle Gilbert, MD Nadia Gosselin, PhD Steven Laureys, MD, PhD Gilles Lavigne, DMD, PhD
Acknowledgments We would like to thank the ICU nursing team of Sacred-Heart Hospital in Montreal Funding agencies
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