Pathological computed tomography features associated with adverse outcomes after mild traumatic brain injury: a TRACK-TBI study with external validation in CENTER-TBI

Research output: Contribution to journalArticlepeer-review


  • TRACK-TBI Investigators for the CENTER-TBI Investigators
  • Florence Noel
  • Amber Nolan
  • Eva Palacios
  • Daniel Perl
  • Miri Rabinowitz
  • Jonathan Rosand
  • Angelle Sander
  • Gabriella Satris
  • David Schnyer
  • Seth Seabury
  • Arthur Toga
  • Alex Valadka
  • Mary Vassar
  • Ross Zafonte
  • Tony Belli

Colleges, School and Institutes

External organisations

  • University of California
  • University of California, Irvine
  • Technical Research and Development
  • Spaulding Rehabilitation Hospital
  • Baylor College of Medicine
  • Medical College of Wisconsin
  • University of California, San Diego
  • Washington State University
  • Drexel University
  • University of Pittsburgh
  • Antwerp University Hospital and University of Antwerp
  • University of Cincinnati
  • Massachusetts General Hospital
  • Ohio State University
  • University of Southern California
  • Massachusetts General Hospital for Children
  • Virginia Commonwealth University
  • TIRR Memorial Hermann Hospital
  • Miami University
  • UT Southwestern Medical Center, USA.
  • Purdue University
  • University of California
  • Uniformed Services University
  • University of Texas at Austin
  • Harvard Medical School
  • Erasmus Medical Center
  • Vanderbilt University
  • Lehigh University
  • University of Maryland


Importance: A head computed tomography (CT) with positive results for acute intracranial hemorrhage is the gold-standard diagnostic biomarker for acute traumatic brain injury (TBI). In moderate to severe TBI (Glasgow Coma Scale [GCS] scores 3-12), some CT features have been shown to be associated with outcomes. In mild TBI (mTBI; GCS scores 13-15), distribution and co-occurrence of pathological CT features and their prognostic importance are not well understood.

Objective: To identify pathological CT features associated with adverse outcomes after mTBI.

Design, Setting, and Participants: The longitudinal, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study enrolled patients with TBI, including those 17 years and older with GCS scores of 13 to 15 who presented to emergency departments at 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018, and underwent head CT imaging within 24 hours of TBI. Evaluations of CT imaging used TBI Common Data Elements. Glasgow Outcome Scale-Extended (GOSE) scores were assessed at 2 weeks and 3, 6, and 12 months postinjury. External validation of results was performed via the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Data analyses were completed from February 2020 to February 2021.

Exposures: Acute nonpenetrating head trauma.

Main Outcomes and Measures: Frequency, co-occurrence, and clustering of CT features; incomplete recovery (GOSE scores <8 vs 8); and an unfavorable outcome (GOSE scores <5 vs ≥5) at 2 weeks and 3, 6, and 12 months.

Results: In 1935 patients with mTBI (mean [SD] age, 41.5 [17.6] years; 1286 men [66.5%]) in the TRACK-TBI cohort and 2594 patients with mTBI (mean [SD] age, 51.8 [20.3] years; 1658 men [63.9%]) in an external validation cohort, hierarchical cluster analysis identified 3 major clusters of CT features: contusion, subarachnoid hemorrhage, and/or subdural hematoma; intraventricular and/or petechial hemorrhage; and epidural hematoma. Contusion, subarachnoid hemorrhage, and/or subdural hematoma features were associated with incomplete recovery (odds ratios [ORs] for GOSE scores <8 at 1 year: TRACK-TBI, 1.80 [95% CI, 1.39-2.33]; CENTER-TBI, 2.73 [95% CI, 2.18-3.41]) and greater degrees of unfavorable outcomes (ORs for GOSE scores <5 at 1 year: TRACK-TBI, 3.23 [95% CI, 1.59-6.58]; CENTER-TBI, 1.68 [95% CI, 1.13-2.49]) out to 12 months after injury, but epidural hematoma was not. Intraventricular and/or petechial hemorrhage was associated with greater degrees of unfavorable outcomes up to 12 months after injury (eg, OR for GOSE scores <5 at 1 year in TRACK-TBI: 3.47 [95% CI, 1.66-7.26]). Some CT features were more strongly associated with outcomes than previously validated variables (eg, ORs for GOSE scores <5 at 1 year in TRACK-TBI: neuropsychiatric history, 1.43 [95% CI .98-2.10] vs contusion, subarachnoid hemorrhage, and/or subdural hematoma, 3.23 [95% CI 1.59-6.58]). Findings were externally validated in 2594 patients with mTBI enrolled in the CENTER-TBI study.

Conclusions and Relevance: In this study, pathological CT features carried different prognostic implications after mTBI to 1 year postinjury. Some patterns of injury were associated with worse outcomes than others. These results support that patients with mTBI and these CT features need TBI-specific education and systematic follow-up.


Original languageEnglish
JournalJAMA Neurology
Early online date19 Jul 2021
Publication statusE-pub ahead of print - 19 Jul 2021