ReviewHead injury outcome prediction: A role for protein S-100B?
Introduction
Head injury severity affects prognosis. A prompt and full recovery should be more likely following a mild head injury, than an injury classified moderate, and, in turn, one classified as severe. Classification of head injury severity has been based on conscious level, enumerated by the Glasgow Coma Scale (GCS).35 This approach has been validated by large scale studies showing a higher risk of intracranial haematoma requiring evacuation with low GCS scores recorded at initial assessment.22, 23 This complication, however, is experienced by only 0.5% of head injured patients presenting to health care services.22, 36 It is much more likely that a patient experiences disabling symptoms without the need for surgery, although estimates of incidence vary.38, 41 The highest possible score on the Glasgow Coma Scale accounts for around 88% of head injured patients presenting to hospital.39 The reported rate of disability, up to 47%,38 implies that disabling late sequelae cannot be confined to those with impaired conscious level at initial assessment. A taxonomy of severity, and thereby prognosis, based on GCS score is therefore limited.
Identifying a high-risk group for adverse outcome after head trauma would allow after care to be targeted at those with most to gain. One approach has been to search for objective indicators of brain tissue damage, as the clinical assessment of a head injured patient can be confounded by intoxication by alcohol or street drugs.3 A comparison of the rate of scan abnormality, around 6% in unselected head injury patients11, 33 and estimates of the incidence of head injury sequelae [23–47%]38, 41 suggest that CT would not be sensitive enough for this purpose. Magnetic resonance imaging has practical and cost limitations as a first line test for the extent of brain injury after trauma. A blood test that reflects the degree of disruption to brain architecture might be such an indicator. The aim of this review is to evaluate the use of protein S-100B, the potential marker most studied thus far, for clinical use in the assessment of the head injured patient.
Section snippets
Methods
A review of published literature evaluating relations between S-100B and outcome of head injury was performed as follows:
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Medline from 1966 to December 2005 and Embase from 1980 to December 2005 were searched using the Ovid web-based interface using the following search terms: {Exp S-100$ OR S100$ OR exp biological markers OR serum markers m.p.} AND {Exp craniocerebral trauma OR head injury m.p. OR exp brain injury or brain injury m.p. or brain trauma m.p.} LIMIT {human}.
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Cochrane database.
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Results
This search yielded 18 studies. These are sub-classified into three groups to rationalise comparisons:
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Pilot studies.13, 44 (Table 1).
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“Minor” head injury studies14, 29, 15, 12, 39, 9, 30, 34, 8, 31, 32 (Table 2).
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“Severe” head injury studies46, 28, 16, 6, 21 (Table 3)
Discussion
This review identified 18 papers designed to investigate the prognostic significance of circulating S-100B concentration after head trauma. Studies were variable in conduct and findings. The studies of patients with low conscious level at presentation were more similar in design then those of the mildly injured. The Glasgow Outcome Scale has been recommended for use in this population,5 and it was performed at 6 months in 3/5 of these studies. This is the time point recommended by the scales
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