1260 Neuroworsening in the Emergency Department: An Early and Important Indicator of Traumatic Brain Injury Severity and Neurosurgical Intervention

INTRODUCTION: Neuroworsening, commonly defined as a declining Glasgow Coma Scale motor score (GCS-M), indicates injury progression and is a component of traumatic brain injury (TBI) intensive care guidelines. The utility of assessing neuroworsening in emergency department (ED) settings requires examination. METHODS: Adult subjects from the 18-center TRACK-TBI Study (enrollment years 2014-2018) with ED arrival GCS-M=6 and ED disposition GCS-M were analyzed. Subjects received head CT <24h of TBI. Neuroworsening = ED disposition GCS-M<6. Clinical characteristics, acute plasma glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) levels, cranial surgery/intracranial pressure monitor, hospital mortality, length of stay (LOS), and 3- and 6-month functional outcomes (Glasgow Outcome Scale-Extended) were compared. Multivariable regressions were performed for procedural intervention, mortality, and unfavorable outcome (GOSE=4). Multivariable odds ratios (mOR [95%CI]) were reported. (*) denotes p<0.0001. RESULTS: In 1328 subjects, 3.1% had neuroworsening. Neuroworsening was associated with ICU admission (90.2%/30.1%*), hypoxia (17.1%/2.5%*), Marshall CT Score 3-6 (31.7%/2.8%*), subarachnoid hemorrhage (58.5%/27.0%*), subdural hematoma (51.2%/18.7%*), intracerebral contusion (41.5%/14.0%*), midline shift (24.4%/2.3%*), and downward herniation (19.5%/1.5%*). Neuroworsening subjects had higher GFAP* (median: 1400-pg/mL [IQR:864-3663] vs. 314 [82-868]) and UCH-L1* levels (459 [287-1036] vs. 170 [94-322]), procedural interventions (34.2%/2.3%*), hospital mortality (7.7%/0.9%*), LOS* (7.4-days [4.9-19.7] vs. 2.3 [1.3-4.1]), and 3- and 6-month unfavorable outcomes (23.1%/3.6%*; 23.1%/3.9%*). On multivariable regressions, neuroworsening independently predicted neurosurgical procedural interventions (mOR=9.0 [1.9-42.7]*). CONCLUSIONS: Our study confirms neuroworsening in the emergency department as an early indicator of clinical and radiological TBI severity, and a predictor of neurosurgical procedural interventions. We provide the first report on the direct relationship between ED neuroworsening and diagnostic blood-based biomarkers of TBI. Clinicians evaluating neurotrauma patients should be vigilant in detecting neuroworsening, as affected patients may benefit from immediate therapeutic interventions.