| TBI types and severity |
Study design, sample size |
Author, publication year, study location |
Key findings in relation to TBI definition |
Recommended outcome measures or criteria for TBI (in addition to a credible mechanism of injury and, or evidence of head trauma) |
Key sources cited for recommendations |
| Blast-related TBI |
Narrative review |
Rosenfeld et al., 2013, international [25] |
Discusses definition, diagnosis, and pathophysiology of blast-related TBI |
TBI type
None recommended |
Various |
| Concussion |
Narrative review |
Almasi and Wilson, 2012, USA [24] |
Discusses diagnosis and management of concussion |
None recommended |
McCrory et al., 2008 [37] |
| Concussion |
Consensus |
McCrory et al., 2012, international [23] |
Discusses definition of concussion, risk stratification, and management. |
TBI type
Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. |
Previous consensus statements by the same committee |
| Mild head injury |
Systematic review (n=42) |
Servadei et al., 2001 [18] |
Recommends acute management based on calculations of risks of developing an ICH requiring surgical evacuation |
TBI severity
GCS 14-15 defines mild head injury
Low risk: GCS 15 and no LOC, amnesia, vomiting, or diffuse headache (risk <0.1:100)
Medium risk: GCS 15 and ≥1 of LOC, amnesia, vomiting, or diffuse headache (risk 1-3:100)
High risk: GCS 14; GCS 15 and skull fracture, and/or neurological deficits (risk 6-10:100); or GCS 15 with risk factors of coagulopathy, drug or alcohol consumption, previous neurosurgical procedures, pre-trauma epilepsy, age >60 years.
|
Various |
| Mild TBI |
Systematic review (n=313) |
Carroll et al., 2004, Canada [3] |
62% of studies used GCS for case definition. No agreed GCS. Recommends a revised definition for mild TBI. |
Lowest threshold for TBI/TBI severity
Operational definition for mild TBI includes:
1 of
confusion or disorientation;
LOC (≤30min);
PTA (<24h);
transient neurological abnormalities (focal signs, seizures, or intracranial lesion not requiring surgery);
GCS 13-15 at ≥30 min (not from other causes)
|
ACRM, 1993 [11] and CDC, 2003 [38] |
| Mild TBI |
Narrative review |
de Kruijk et al., 2001, the Netherlands [39] |
Mild TBI definition lacks uniformity in the literature. Clear case definition for mild TBI is needed. |
None recommended |
Various |
| Mild TBI |
Systematic review |
Rees, 2003, Canada [15] |
Minimum criteria in adults for clinical diagnosis of TBI |
Lowest threshold for TBI
Minimum criteria for diffuse mild TBI:
[A] Obligatory criteria
A credible mechanism of injury
Craniofacial impact
[B] Major criteria
Amnesia for blow
Disordered awareness, not necessarily LOC
Finite PTA
|
Wrightson and Gronwall, 1999 [40] |
| Mild TBI |
Clinical study (n=76) |
Ruff and Jurica, 1999, USA [19] |
Proposes a new classification system for mild TBI based on the diagnostic criteria by ACRM and DSM-IV for concussion |
TBI severity
Classification for mild TBI
[Type I] Altered state or transient LOC; PTA 1-60 seconds; ≥1 neurological symptoms
[Type II] Definite LOC unknown – 5 min duration; ≥1 neurological symptoms
[Type III] LOC 5-30 min; PTA >12 h; ≥1 neurological symptoms |
ACRM, 1993 [11]
and
DSM-IV [41] |
| Mild TBI |
Clinical study (n=125) |
Tellier et al., 2009, Canada [42] |
Symptoms or CT results did not differ between subgroups (GCS 15 cf. GCS 13-14). PTA duration is a better predictor of outcomes. |
None recommended |
Various |
| TBI with GCS 13 |
Metanalysis (n=1,047) |
Stein, 2001, USA [20] |
Intracranial lesions on CT (33.8%) and emergency surgery (10.8%) in GCS 13 are comparable to GCS 9-12, and should be treated as moderate TBI. |
TBI severity
GCS 13 (in addition to 9-12) is moderate TBI. |
Various |
| Severe TBI |
Pre-course survey of anaesthetists in 2005 (n=843) |
Chieregato et al., 2010, Italy [8] |
40% believed that classification of TBI severity would be improved by adding pupil reactivity to light, and CT findings, to GCS scores. |
TBI severity
Severe TBI definition should incorporate:
GCS;
Pupil reactivity to light; and
CT findings
|
Saatman et al., 2008 [12] |
| Severe TBI with coma for ≥24h |
Prospective clinical study (n=102) |
Firsching et al., 2001, Germany [21] |
Diagnostic groups of lesions based on MRI are predictive of mortality, coma duration, and GOS. |
TBI severity
Grades based on MRI:
[I] Supratentorial lesion only
[II] Unilateral lesion of brain stem at any level
[III] Bilateral lesion of mesencephalon
[IV] Bilateral pontine lesion |
Various |
| Severe TBI (AIS head≥3) |
Retrospective analysis of registry (n=8,746) |
Grote et al., 2011, Germany [22] |
GCS ≤ 8 in patients with multiple injuries (ISS >16) has a low sensitivity (56.1%) for severe TBI compared with AIS |
TBI severity
Recommend defining severe TBI as AIS head≥3 in multiple injuries |
Various |
| All severity TBI |
Narrative review |
DeCuypere and Klimo Jr, 2012, USA [17] |
TBI is graded based on GCS. Duration of LOC and PTA are indices of severity of TBI. |
TBI severity
Defines GCS of:
13-15 as mild TBI
9-12 as moderate TBI
3-8 as severe TBI
|
Bullock et al., 2007 [43] |
| All severity TBI |
Analysis of epidemiological dataset (n=1,501) |
Malec et al., 2007, USA [16] |
Despite missing information, the Mayo Classification System for TBI Severity allowed classification of TBI |
Lowest threshold for TBI/TBI severity
[a] Classify as Moderate-Severe (Definite) TBI if ≥1 of:
Death; LOC ≥ 30 min; PTA ≥ 24h; worst GCS in 24h <13; ICH; SDH; EDH; cerebral contusion; haemorrhagic contusion; dura penetrated; SAH; or brain stem injury;
and if none of the above apply,
[b] Classify as Mild (Probable) TBI if ≥1 of:
LOC momentary to <30min; PTA momentary to <24h; or depressed, basilar or linear skull fracture;
and if none of the above apply,
[c] Classify as Symptomatic (Possible) TBI if ≥1 of:
Blurred vision; confusion; dazed; dizziness; focal neurological symptoms; headache; or nausea.
|
ACRM, 1993 [11] and Rimel et al., 1982 [44] |
| All severity TBI |
Consensus |
Menon et al., 2010, international [5] |
TBI defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force. |
Lowest threshold for TBI/TBI severity/TBI type
[a] Alteration in brain function:
Any period of LOC
Any duration of PTA
Neurologic deficits
Any alteration in mental state
[b] Or other evidence of brain pathology:
Visual,
Neuroradiologic, or
Laboratory confirmation of damage to the brain
[c] Caused by an external force
Head being struck/striking an object
Acceleration/deceleration without direct external trauma
Penetrating foreign body
Forces from blasts/explosion, or
Other force yet to be defined
|
ACRM, 1993 [11]
and
VA/DoD, 2009 [45] |
| All severity TBI |
Narrative review |
Nolan, 2005, USA [26] |
Discusses diagnosis and management of TBI |
TBI type
Mechanism of injury
Blunt, penetrating or blast
Types of injury
Focal: contusions, EDH, SDH, SAH, ICH
Diffuse: cerebral concussion, DAI
|
Brain Trauma Foundation, 2000 |
| All severity TBI |
Consensus |
Saatman et al., 2008 [12] |
Multidimensional classification system incorporating pathoanatomical and severity indices will improve TBI clinical trial design |
TBI type
None recommended |
Various |
| All severity TBI |
Narrative review |
Van Baalen et al., 2003, the Netherlands [4] |
Initial severity can be based on CT or clinical condition |
TBI severity
None recommended |
Various |
