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Better neurotrauma classification system, more common data elements needed
Precision medicine, more education can make it easier to classify neurotrauma patients, surgeons said.
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The most workable classification system now used with neurotrauma patients has inherent problems, but according to two surgeons, it can be improved upon by better stratification of the patient’s main symptoms and problems and better physician education.
However, despite work underway worldwide to standardize the neurotrauma classification process, finding a better system to classify neurotrauma patients remains controversial, they said.
According to neurosurgeon Stephen B. Lewis, MD, MBBS, PhD, of Perth, Australia, combining information about the type of injury that the patient sustained with their current symptoms and other common data elements including standardized imaging studies and new diagnostic methods, such as proteomics, may help improve treatments and outcomes for patients.
Stephen B. Lewis
During an AONeuro webinar held on Dec. 5, 2013, Lewis and Christian W. Matula, MD, PhD, professor of neurosurgery in the Neurosurgical Department at Medical University of Vienna, Austria, discussed the strengths and weaknesses of the three current forms of classification by injury mechanism, pathology and the Glasgow Coma Scale (GCS), a clinical severity score.
Matula was doubtful about how well neurosurgeons can ultimately analyze outcomes if they are basically unable to classify what happened to the patient.
“A lot of people around the world are focusing their interest on classification of traumatic brain injury (TBI), especially for target therapies. Is there a way to make it better? Can we make it better? Yes we can,” he said.
Classification of the pathology
Lewis reviewed the three general or standard methods now used to classify a neurotrauma patient and said, “We hope to show you that we can do better.”
Christian W. Matula
He discussed the classification methods that take the actual mechanism of injury – blunt and penetrating forms of trauma, into account.
“A more recent addition to that has been the blast injury,” Lewis said.
Specific pathology also can be classified with the existing clinical severity grading system.
“That is probably the most common form of a workable classification system that we use, but it has a lot of inherent problems,” Lewis said, referring to the three-tier GCS, which is subjective and gives patients a possible total of 15 points.
“[It] is probably the mainstay of our classification system,” he said. “Using this clinical scoring system we can now start to stratify the impact of a head injury into mild, moderate or severe.”
The TBI guidelines also help define the workup and treatment after the GCS is determined, according to Lewis.
Imaging, specific tests
The use of similar types of MRI and CT imaging, similar types of blood tests, including those with proteomic analysis of chemicals, and a good assessment of how patients do with the treatment they receive are among strategies that Lewis said should be part of any new classification paradigm in neurotrauma.
An initiative in this area, including work by the group at UCSF headed by Professor Geoff Manley, is underway, which involves pilot studies and the application of specific diagnostic tools and markers.
“The whole essence of this was to develop a prospective, multivariable TBI database so that the investigators could start to build up a better taxonomy of disease and understand TBI a lot better,” Lewis said.
Publications to date on this topic have identified key areas that are part of this new, novel approach to neurotrauma classification, with specific MRI among them, he noted.
“Certainly imaging is going to play a bigger … role in our development of a classification system,” because it will help physicians determine if and when intracranial pressure monitoring is needed, for example, Lewis said.
Bedside testing
The role of proteomics in treating neurotrauma patients is expected to expand into a bedside tool or test for TBI “that can directly and accurately say whether or not we should go on and do imaging,” he said.
According to Lewis, many of these techniques are still in the pilot phase, although their use is expected to feed vital information into the new database and provide better insights into this problem.
Matula mentioned published research by Turkish investigators that highlights the problem of inter-rater variability with the current neurotrauma classification.
“There are just a third of people who are classifying in an appropriate way,” he said of the study findings, which showed a possible difference of more than 7 points between clinical severity ratings for the same patient.
This study highlighted the need for training and improved knowledge to solve this classification problem, he said. “There is a clear lack of operation rules and GCS training in TBI study.”
Matula continued, “The take-home message is that improving your diagnostic instrument seems to be the most effect way in reducing the problem of inter-rater variability in classifying TBI patients and above all, training…and education.” – by Susan M. Rapp
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For more information:
Christian W. Matula, MD, PhD, can be reached at Neurosurgical Department, Medical University of Vienna, General Hospital, Waehringerguertel 18-20, 1090 Vienna, Austria; email: christian.matula@meduniwien.ac.at.
Disclosures: Lewis and Matula have no relevant financial disclosures.