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Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39461.643438.25 (Published 21 February 2008) Cite this as: BMJ 2008;336:425
  1. MRC CRASH Trial Collaborators
  1. 1London School of Hygiene and Tropical Medicine, London WC1B 3DP
  1. Correspondence to: P A Perel Pablo.perel{at}lshtm.ac.uk
  • Accepted 5 December 2007

Abstract

Objective To develop and validate practical prognostic models for death at 14 days and for death or severe disability six months after traumatic brain injury.

Design Multivariable logistic regression to select variables that were independently associated with two patient outcomes. Two models designed: “basic” model (demographic and clinical variables only) and “CT” model (basic model plus results of computed tomography). The models were subsequently developed for high and low-middle income countries separately.

Setting Medical Research Council (MRC) CRASH Trial.

Subjects 10 008 patients with traumatic brain injury. Models externally validated in a cohort of 8509.

Results The basic model included four predictors: age, Glasgow coma scale, pupil reactivity, and the presence of major extracranial injury. The CT model also included the presence of petechial haemorrhages, obliteration of the third ventricle or basal cisterns, subarachnoid bleeding, midline shift, and non-evacuated haematoma. In the derivation sample the models showed excellent discrimination (C statistic above 0.80). The models showed good calibration graphically. The Hosmer-Lemeshow test also indicated good calibration, except for the CT model in low-middle income countries. External validation for unfavourable outcome at six months in high income countries showed that basic and CT models had good discrimination (C statistic 0.77 for both models) but poorer calibration.

Conclusion Simple prognostic models can be used to obtain valid predictions of relevant outcomes in patients with traumatic brain injury.

Footnotes

  • CRASH trial collaborators by country (number of patients randomised)

  • Albania (41 patients): Fatos Olldashi (national coordinator), Itan Muzha (Central Military University Hospital National Trauma Centre, 35); Nikolin Filipi ( University Hospital “Mother Teresa” Tirana, 6).

  • Argentina (359 patients): Roberto Lede, Pablo Copertari, Carolina Traverso, Alejandro Copertari (IAMBE—national and regional coordinators for southern Latin America); Enrique Alfredo Vergara, Carolina Montenegro, Roberto Ruiz de Huidobro, Pantaleón Saladino (Hospital San Bernardo, 106); Karina Surt, José Cialzeta, Silvio Lazzeri (Hospital Escuela Jose de San Martin, 52); Gustavo Piñero, Fabiana Ciccioli (Hospital Municipal “Dr Leonidas Lucero,” 37); Walter Videtta, María Fernanda Barboza (Hospital Dr Ramón Carrillo, 35); Silvana Svampa, Victor Sciuto (Hospital Castro Rendon, 28); Gustavo Domeniconi, Marcelo Bustamante (Hospital Zonal General De Agudos “Heroes de Malvinas,” 27); Maximiliano Waschbusch (Policlinico Sofia T de Santamarina. 20); María Paula Gullo (Hospital Municipal Dr Hector J D’Agnillo, 17); Daniel Alberto Drago (Hospital Nacional Profesor Alejandro Posadas, 11); Juan Carlos Arjona Linares (Hospital Español de Mendoza, 10); Luis Camputaro (Hospital Italiano, 10); Gustavo Tróccoli (Hospital “Dr José Penna,” 5); Hernán Galimberti (Hospital Aleman, 1).

  • Australia (13 patients): Mandy Tallott (Gold Coast Hospital, 13).

  • Austria (21 patients): Christian Eybner, Walter Buchinger (Waldviertelklinikum Standort Horn, 17); Sylvia Fitzal (Wilhelminenspital der Stadt Wien, 4).

  • Belgium (403 patients): Guy Mazairac (national coordinator), Véronique Oleffe, Thierry Grollinger, Philippe Delvaux, Laurent Carlier (Centre Hospitalier Regional de Namur, 356); Veronique Braet (AZ Klina Hospital, 34); Jean-Marie Jacques (Hospital of Jolimont, 11); Danielle de Knoop (Clinique Saint-Luc, 2).

  • Brazil (119 patients): Luiz Nasi (national coordinator), Humberto Kukhuyn Choi, Mara Schmitt (Hospital de Pronto Socorro de Porto Alegre, 113); André Gentil (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, 5); Flavio Nacul (Clínica São Vicente, 1).

  • Chile (3 patients): Pedro Bedoya Barrios (Hospital Regional Copiapo, 3).

  • China (87 patients): Chen Xinkang, Lin Shao Hua, Huang Han Tian (Zhongshan City People’s Hospital, 79); Cai Xiaodong (Sheng Zheng Second People’s Hospital, 8).

  • Colombia (832 patients): Wilson Gualteros, Alvaro Ardila Otero (Hospital Universitario San Jorge, 216); Miguel Arango (national coordinator, regional coordinator for northern Latin America and Caribbean), Juan Ciro, Hector Jaramillo (Gloria GarciaClinica Las Americas, 199); Ignacio Gonzalez, Carolina Gomez (Hospital General de Medellin, 119); Arturo Arias, Marco Fonseca, Carlos Mora (Hospital Erasmo Meoz, 90); Edgar Giovanni Luna Cabrera, José Luis Betancurth, Porfirio Muñoz (Hospital Departamental de Nariño, 51); Jesus Alberto Quiñónez, Maria Esther Gonzalez Castillo (Hospital San Andres, 37); Orlando Lopez (Hospital Federico Lleras, 31); Rafael Perez Yepes, Diana Leon Cuellar, Gerson Paez (Hospital El Tunal, 24); Hernán Delgado Chaves, Pablo Emilio Ordoñez (Hospital Civil de Ipiales, 21); Ricardo Plata, Martha Pineda (Hospital Universitario del Valle, 15); Libardo Enrique Pulido (Hospital Regional de Duitama, 12); John Sergio Velez Jaramillo (Hospital Timothy Britton, 12); Carlos Rebolledo (Organización Clinica General del Norte, 5).

  • Costa Rica (20 patients): Oscar Palma (Hospital México, 20).

  • Cuba (404 patients): Caridad Soler (national coordinator); Irene Pastrana, Raul Falero (Hospital Abel Santamaria Cuadrado, 77); Mario Domínguez Perera, Agustín Arocha García, Raydel Oliva (Hospital Universitario “Arnaldo Milián Castro,” 55); Hubiel López Delgado (Hospital Provincial Docente “Manuel Ascunce Domenech,” 43); Aida Madrazo Carnero, Boris Leyva López (Hospital VI Lenin, 42); Angel Lacerda Gallardo, Amarilys Ortega Morales (Hospital General de Morón, 40); Humberto Lezcano (Hospital General Universitario “Carlos Manuel de Cèspedes,” 38); Marcos Iraola Ferrer (Hospital Universitario “Dr Gustavo Aldereguia Lima,” 37); Irene Zamalea Bess, Gladys Rivas Canino (Hospital Miguel Enriquez, 36); Ernesto Miguel Piferrer Ruiz (Hospital Clínico-Quirúrgico Docente “Saturnino Lora,” 32); Orlando Garcia Cruz (Centro de Investigaciones Médico-Quirúrgicas, 4).

  • Czech Republic (961 patients): Petr Svoboda (national coordinator), Ilona Kantorová, Jiřĺ Ochmann, Peter Scheer, Ladislav Kozumplík, Jitka Maršová (Research Institute for Special Surgery and Trauma, 852); Karel Edelmann (Masaryk Hospital, 41); Ivan Chytra, Roman Bosman (Charles University Hospital, Plzen, 35); Hana Andrejsová (University Hospital Hradec Kralove, 15); Jan Pachl (Hospital Kralovske Vinohgrady, 9); Jan Bürger (Hospital Pribram, 7); Filip Kramar (Univerzity Karlovy Neurochirurgicka Klinika, 2).

  • Ecuador (258 patients): Mario Izurieta Ulloa (national coordinator), Luis Gonzalez, Alberto Daccach, Antonio Ortega, Stenio Cevallos (Hospital Luis Vernaza, 202); Boris Zurita Cueva (Hospital de la Policia Guayaquil, 16); Marcelo Ochoa (Hospital Jose Carrasco Arteaga, 11); Jaime Velásquez Tapia (Hospital Naval, 11); Jimmy Hurtado (Clínica Central, 8); Miguel Chung Sang Wong (Hospital Militar de Guayaquil, 5); Roberto Santos (Hospital Regional del IESS “Dr Teodoro Maldonado Carbo,” 5).

  • Egypt (775 patients): Hussein Khamis (national coordinator), Abdul Hamid Abaza, Abdalla Fekry, Salah El Kordy, Tarek Shawky (Mataria Teaching Hospital, 364); Hesham El-Sayed (national coordinator), Nabil Khalil, Nader Negm, Salem Fisal (Suez Canal University, 180); Mamdouh Alamin, Hany Shokry (Aswan Teaching Hospital, 160); Ahmed Yahia Elhusseny, Atif Radwan, Magdi Rashid (Zagazig University Hospital, 71).

  • Georgia (56 patients): Tamar Gogichaisvili (national coordinator), George Ingorokva, Nikoloz Gongadze (Neurosurgery Department of Tbilisi State Medical University, 55); Alexander Otarashvili (Tbilisi 4th Hospital, 1).

  • Germany (27 patients): Waltraud Kleist (Ernst Moritz Arndt University, 14); Mathias Kalkum (Kreiskrankenhaus Tirschenreuth, 8); Peter Ulrich (Klinikum Offenbach, 5).

  • Ghana (7 patients): Nii Andrews (Narh-Bita Hospital, 7).

  • Greece (20 patients): George Nakos (University Hospital of Ioannina, 8); Antonios Karavelis (University General Hospital of Larissa, 5); George Archontakis (Chania General Hospital “St George,” 4); Pavlos Myrianthefs (KAT Hospital of Athens, 3).

  • India (973 patients): Yadram Yadav, Sharda Yadav, R Khatri, Arvind Baghel (NSCB Medical College, 177); Mazhar Husain (national coordinator for north India), Deepak Jha (King George Medical College, 105); Wu Hoong Chhang, Manohar Dhandhania, Choden Fonning (North Bengal Neuro Research Centre, 65); S N Iyengar, Sanjay Gupta (G R Medical College, 51); R R Ravi, K S Bopiah, Ajay Herur (Medical Trust Hospital Kochi, 51); N K Venkataramana (national coordinator for south India), A Satish (Manipal Hospital, 50); K Bhavadasan, Raymond Morris, Ramesh S (Medical College Hospital Trivandrum, 50); A Satish (Abhaya Hospital, 42); Yashbir Dewan, Yashpal Singh (Christian Medical College, 36); Rajesh Bhagchandani, Sanjana Bhagchandani (Apex Hospital Bhopal, 32); Vijaya Ushanath Sethurayar (Meenakshi Mission Hospital and Research Centre, 32); Sojan Ipe, G Sreekumar (MOSC Medical College Hospital, 32); Manas Panigrahi, Agasti Reddy (Nizam’s Institute of Medical Sciences, 28); Varinder Khosla, Sunil Gupta (Postgraduate Institute of Medical Education and Research, 28); Haroon Pillay, Nisha Thomas (Baby Memorial Hospital, 25); Krishnamurthy Sridhar, Bobby Jose (V H S Hospital, 22); Nadakkavvkakan Kurian (Jubilee Mission Hospital, 20); Shanti Praharaj, Shibu Pillai (National Institute of Mental Health and Neurosciences, 17); Ramana (Care Hospital (16); Sanjay Gupta, Smita Gupta (Sri Sai Hospital, 16); Dilip Kiyawat (Hirabi Cowasji Jehangir Medical Research Institute, 15); Kishor Maheshwari (Maheshwari Orthopaedic Hospital, 13); Dilip Panikar (Amrita Institute of Medical Sciences, 11); Jayant Chawla (Hartej Maternity and Nursing Home, 7); Satyanarayana Shenoy, Annaswamy Raja (Kasturba Medical College and Hospital, 7); Yeshomati Rupayana (Choitram Hospital and Research Centre, 6); Suryanarayan Reddy (Gowri Gopal Superspeciality Hospital, 6); Nelanuthala Mohan (Apex Hospital Visakhapatnam, 3); Shailesh Kelkar (Central India Institute of Medical Sciences, 3); Yadram Yadav (Marble City Hospital and Research Centre, 3); Jayant Chawla (Government Medical College Amritsar, 1); Mukesh Johri (Johri Hospital, 1); Yadram Yadav (National Hospital Jabalpur, 1).

  • Indonesia (238 patients): Nyoman Golden (national coordinator), Sri Maliawan (Sanglah General Hospital, 222); Achmad Fauzi, Umar Farouk (Sidoarjo General Hospital, 14).

  • Iran (233 patients): Esmaeel Fakharian, Amir Aramesh (Naghavi University Hospital, 110); Maasoumeh Eghtedari, Farhad Ahmadzadeh, Alireza Gholami (Fatemeh Zahra Hospital, 85); Maasoumeh Eghtedari, Farhad Ahmadzadeh (Social Security Hospital, 38).

  • Ireland (113 patients): Patrick Plunkett, Catherine Redican, Geraldine McMahon (St James’s Hospital, 113).

  • Italy (9 patients): Maria Giuseppina Annetta (Università Cattolica del Sacro Cuore, 4); Homère Mouchaty (Università di Firenze, 3); Eros Bruzzone (Ospedale San Martino, 2).

  • Ivory Coast (3 patients): Béatrice Harding (CHU de Cocody, 3).

  • Kenya (2 patients): Mahmood Qureshi (Aga Khan Hospital, 2).

  • Malaysia (176 patients): Zamzuri Idris, Jafri Abdullah NC, Ghazaime Ghazali, Abdul Rahman Izaini Ghani (Hospital University Science Malaysia, 162); Fadzli Cheah (Ipoh Specialist Hospital, 14).

  • Mexico (17 patients): Alfredo Cabrera (national coordinator); José Luis Mejía González (Hospital General Regional No 1, 12); José Luis Mejía González (Hospital General de Queretaro, 4); Jorge Loría-Castellanos (Hospital General Regional No 25, 1).

  • New Zealand (43 patients): Suzanne Jackson, Robyn Hutchinson (Dunedin Hospital, 43).

  • Nigeria (180 patients): Edward Komolafe (national coordinator), Augustine Adeolu, Morenikeji Komolafe (Obafemi Awolowo University Teaching Hospitals, 77); Olusanya Adeyemi-Doro, Femi Bankole (Lagos University Teaching Hospital, 43); Bello Shehu, Victoria Danlami (Usmanu Danfodiyo University Teaching Hospital, 36); Olugbenga Odebode (University of Ilorin Teaching Hospital, 15); Kehinde Oluwadiya (Lautech Teaching Hospital, 7); Ahmed Sanni (Lagos State University Teaching Hospital, 1); Herb Giebel (Seventh Day Adventist Hospital, 1); Sushil Kumar (St Stephen’s Hospital, 1).

  • Pakistan (17 patients): Rashid Jooma (Jinnah Postgraduate Medical Centre, 17).

  • Panama (7 patients): Jose Edmundo Mezquita (Complejo Hospitalario M A Guerrero, 7).

  • Paraguay (10 patients): Carlos Ortiz Ovelar (Instituto de Prevision Social, 10).

  • Peru (8 patients): Marco Gonzales Portillo (Hospital Nacional “Dos de Mayo,” 6); Diana Rodriguez (national coordinator) (Hospital Nacional Arzobispo Loayza, 2).

  • Romania (319 patients): Laura Balica (national coordinator), Bogdan Oprita, Mircea Sklerniacof, Luiza Steflea, Laura Bandut (Spitalul Clinic de Urgenötùa Bucuresö ti, 282); Adam Danil, Remus Iliescu (Sfantum Pantelimon Hospital, 28); Jean Ciurea (Prof Dr D Bagdasar Clinical Emergency Hospital, 9).

  • Saudi Arabia (32 patients): Abdelazeem El-Dawlatly, Sherif Alwatidy (King Khalid University Hospital, 24); Walid Al-Yafi, Megahid El-Dawlatly (King Khalid National Guard Hospital, 8).

  • Serbia (23 patients): Ranka Krunic-Protic, Vesna Janosevic (Klinicki Centar Srbije, 23).

  • Singapore (23 patients): James Tan (national coordinator) (National Neuroscience Institute, 21); Charles Seah (Changi General Hospital, 2).

  • Slovakia (179 patients): Štefan Trenkler (national coordinator), Matuš Humenansky, Tatiana Stajančová (Reiman Hospital, 71); Ivan Schwendt, Anton Laincz (NsP Poprad, 39); Zeman Julius, Stano Maros (Nemocnica Bojnice, 25); Jozef Firment (FNsp Kosice, 12); Maria Cifraničova (NsP Trebisov, 11); Beata Sániová (Faculty Hospital in Martin, 10); Karol Kalig (NsP Ruzinov, 4); Soňa Medekova (NsP Nové Zámky, 3); Radovan Wiszt (NsP Liptovsky Mikulas, 2); NsP F D Roosevelt, 1); Ivan Mačuga (NsP Zilina, 1).

  • South Africa (366 patients): Bennie Hartzenberg (national coordinator), Grant du Plessis, Zelda Houlie (Tygerberg Academic Hospital, 307); Narendra Nathoo, Sipho Khumalo (Wentworth Hospital, 57); Ralph Tracey (Curamed Kloof Hospital, 1).

  • Spain (259 patients): Angeles Muñoz-Sánchez (national coordinator), Francisco Murillo-Cabezas NC, Juan Flores-Cordero, Dolores Rincón-Ferrari (Hospital Universitario Virgen del Rocio, 133); Martin Rubi, Lopez Caler (Hospital Torrecárdenas, 37); Maite Misis del Campo, Luisa Bordejé Laguna (Hospital Universitario Germans Trias i Pujol, 32); Juan Manuel Nava (Hospital Mútua de Terrassa, 20); Miguel Arruego Minguillón (Hospital Universitario de Girona Dr Josep Trueta, 12); Alfonso Muñoz Lopez (Hospital Carlos Haya, 10); Luis Ramos-Gómez (Hospital General de La Palma, 6); Victoria de la Torre-Prados (Hospital Universitario Virgen de la Victoria, 5); Romero Pellejero (Hospital General Yagüe, 4).

  • Sri Lanka (132 patients): Véronique Laloë (national coordinator), Bernhard Mandrella, Suganthan (Batticaloa General Hospital-Médecins Sans Frontières, 84); Sunil Perera (National Hospital of Sri Lanka, 39); Véronique Laloë, Kanapathipillai Mahendran (Point-Pedro Base Hospital, 9).

  • Switzerland (160 patients): Reto Stocker (national coordinator), Silke Ludwig (national coordinator) (University Hospital of Zurich, 133); Heinz Zimmermann (University Hospital Bern, 15); Urs Denzler (Kantonsspital Schaffhausen, 12).

  • Thailand (579 patients): Surakrant Yutthakasemsunt (national coordinator), Warawut Kittiwattanagul, Parnumas Piyavechvirat, Pojana Tapsai, Ajchara Namuang-jan (Khon Kaen Regional Hospital, 535); Upapat Chantapimpa (Chiangrai Prachanuko Hospital, 12); Chanothai Watanachai, Pusit Subsompon (Rayong Hospital, 11); Wipurat Pussanakawatin, Pensri Khunjan (Krabi Hospital, 10); Sakchai Tangchitvittaya, Somsak Nilapong (Suratthani Hospital, 8); Tanagorn Klangsang, Wibul Taechakosol (Roi Et Hospital, 2); Atirat Srinat (Lampang Hospital, 1).

  • Tunisia (63 patients): Zouheir Jerbi (national coordinator), Nebiha Borsali-Falfoul, Monia Rezgui (Hospital Habib Thameur, 63).

  • Turkey (2 patients): Nahit Cakar (Istanbul Medical Faculty, 2).

  • Uganda (43 patients): Hussein Ssenyonjo, Olive Kobusingye (Makerere Medical School, 43).

  • UK (1391 patients): Gabrielle Lomas, David Yates, Fiona Lecky (Hope Hospital, 209); Anthony Bleetman, Alan Baldwin, Emma Jenkinson, Shiela Pantrini (Birmingham Heartlands Hospital, 123); James Stewart, Nasreen Contractor, Trudy Roberts, Jim Butler (North Manchester General Hospital, 85); Alan Pinto, Diane Lee (Royal Albert Edward Infirmary, 83); Nigel Brayley, Karly Robbshaw, Clare Dix (Colchester General Hospital, 79); Sarah Graham, Sue Pye (Whiston Hospital, 69); Marcus Green, Annie Kellins (Selly Oak Hospital, 61); Chris Moulton, Barbara Fogg (Royal Bolton Hospital, 51); Rowland Cottingham, Sam Funnell, Utham Shanker (Eastbourne District General Hospital, 50); Claire Summers, Louise Malek (Trafford General Hospital, 41); Rowland Cottingham (national coordinator), Christopher Ashcroft, Jacky Powell (Royal Sussex County Hospital, 38); Steve Moore, Stephanie Buckley (Countess of Chester Hospital, 36); Mandy Grocutt, Steve Chambers (Worthing Hospital, 34); Amanda Morrice, Helen Marshall (Medway Maritime Hospital, 29); Julia Harris, Wendy Matthews, Jane Tippet (Chelsea and Westminster Hospital, 28); Simon Mardell, Fiona MacMillan, Anita Shaw (Furness General Hospital, 27); Pramod Luthra, Gill Dixon (Royal Oldham Hospital, 26); Mohammed Ahmed, John Butler, Mike Young (Stepping Hill Hospital, 26); Sue Mason, Ian Loveday (Northern General Hospital, 25); Christine Clark, Sam Taylor (Blackburn Royal Infirmary, 23); Paul Wilson (Cheltenham General Hospital, 23); Kassim Ali, Stuart Greenwood (Fairfield General Hospital, 23); Martin White, Rosa Perez (Queen Elizabeth the Queen Mother Hospital, 21); Sam Eljamel (Ninewells Hospital and Medical School, 19); Jonathan Wasserberg, Helen Shale (Queen Elizabeth Hospital Birmingham, 18); Colin Read, John McCarron (Russell’s Hall Hospital, 18); Aaron Pennell (Princess Alexandra Hospital, 16); Gautam Ray (Princess Royal Hospital, 14); John Thurston, Emma Brown (Darent Valley Hospital, 13); Lawrence Jaffey, Michael Graves (Royal Liverpool University Hospital, 12); Richard Bailey, Nancy Loveridge (Chesterfield and North Derbyshire Royal Hospital, 10); Geraint Evans, Shirleen Hughes, Major Kafeel Ahmed (Withybush General Hospital, 10); Jeremy Richardson, Claire Gallagher (Aberdeen Royal Infirmary, 8); Titus Odedun, Karen Lees (Ormskirk and District General Hospital, 8); David Foley, Nick Payne (Queen Mary’s Hospital, 8); Alan Pennycook, Carl Griffiths (Arrowe Park Hospital, 6); David Moore, Denise Byrne (City Hospital Birmingham, 5); Sunil Dasan (St Helier Hospital, 4); Ashis Banerjee, Steve McGuinness (Whittington Hospital, 4); Claude Chikhani (Doncaster Royal Infirmary, 2); Nigel Zoltie, Ian Barlow (Leeds General Infirmary, 2); Ian Stell (Bromley Hospital, 1); William Hulse, Jacqueline Crossley (Harrogate District Hospital, 1); Laurence Watkins (Institute of Neurology, 1); Balu Dorani (Queen Elizabeth Hospital Gateshead, 1).

  • Vietnam (2 patients)—Truong Van Viet (Cho Ray Hospital, 2).

  • Contributors: The writing committee comprised Pablo Perel (Chair), Miguel Arango, Tim Clayton, Phil Edwards, Edward Komolafe, Stuart Poccock, Ian Roberts, Haleema Shakur, Ewout Steyerberg, and Surakrant Yutthakasemsunt

  • Funding: The MRC CRASH trial was funded by the UK Medical Research Council.

  • Competing interests: None declared.

  • Ethical approval: All MRC CRASH collaborators obtained local ethics or research committee approval.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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