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Through the looking glass: early non-invasive imaging in TBI predicts the need for interventions
  1. Jacob Glaser1,
  2. Matthew Vasquez2,
  3. Cassandra Cardarelli2,
  4. Samuel Galvagno Jr3,
  5. Deborah Stein1,
  6. Sarah Murthi1,
  7. Thomas Scalea1
  1. 1Division of Trauma and Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
  2. 2Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  3. 3Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
  1. Correspondence to Dr Jacob Glaser; jacob.glaser1{at}


Background Early diagnosis and treatment of traumatic brain injury (TBI) lead to better outcomes. It is difficult to predict which patients benefit from specialised centres, leading to over triage or delay in definitive care. We propose that a non-invasive test comprising optic nerve sheath ultrasound, transcranial Doppler and quantitative papillary reactivity is feasible, correlates with CT findings and may allow for accurate early identification of TBI.

Methods A 1-year, prospective observation study evaluated a low-risk, non-invasive method of assessing brain injury. Patients underwent a non-invasive neurological examination for trauma, including the above assessments. Data from the three examinations were collected within 6 hours of injury and at 24 hours, and were analysed. Demographics, haemodynamic data, imaging results and short-term outcomes/interventions were recorded.

Results Trauma patients over the age of 18 years, with a Glascow coma scale (GCS) of <12 or CT evidence of TBI, and intubated were included (N=100). These were divided into +CT (n=49) and −CT groups (n=51) according to the Marshall CT classification of TBI. The +CT group was older, with worse GCS and higher lactate (p=0.008, p=0.001 and p=0.01) but were otherwise well matched. The +CT group included all TBI types, with 96% of the patients having more than one type of TBI. Pulsatility index and neurologic pupillary index were predictive of a +CT (p=0.04, p=0.02). Area under the receiver-operating curve for the logistic regression model for the prediction of positive radiographic findings was r=0.718. Finally, we suggest a preliminary scoring heuristic for predicting a positive radiological finding in a patient with TBI.

Conclusions The proposed examination is a feasible, non-invasive tool that may have clinical utility in the early prediction of TBI. If validated, it may improve trauma triage for the brain-injured patient. Further studies are warranted to validate this model.

  • traumatic brain injury
  • Transcranial Doppler
  • optic nerve
  • Noninvasive

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