Elsevier

Resuscitation

Volume 80, Issue 3, March 2009, Pages 341-345
Resuscitation

Clinical paper
Predicting outcome after severe traumatic brain injury using the serum S100B biomarker: Results using a single (24 h) time-point

https://doi.org/10.1016/j.resuscitation.2008.11.021Get rights and content

Abstract

Background and objectives

In recent years, biochemical markers have been employed to predict the outcome of patients with traumatic brain injury (TBI). In mild TBI, S100B has shown the most promise as a marker of outcome. The objective of this study in patients with severe TBI was to: show the range of serum S100B levels during the acute phase after trauma: determine if S100B has potential to discriminate favourable from unfavourable outcome in patients with similar brain injury severity scores and to establish an S100B ‘cut-off’ predictive for death.

Methods

All patients with severe TBI, admitted to this neurointensive care unit within 24 h of injury were eligible for inclusion in the study. One serum blood sample was obtained from each patient at the 24 h post-injury time-point. S100B levels were measured using enzyme-linked immunosorbent assay. Injuries were coded using an internationally recognised injury severity scoring system (ISS). Three-month follow-up was undertaken with outcome assessed using the Glasgow outcome score (GOS).

Results

One hundred patients were recruited. Serum S100B levels ranged from 0.08 to 12.62 μg L−1 S100B levels were significantly higher in patients with a GOS of 1 (death) 2 and 3 (unfavourable outcome) compared with those with GOS 4 and 5 (good recovery). In this study a cut-off point of 0.53 μg L−1 has sensitivity of >80% and specificity of 60% to predict unfavourable outcome and 49% to predict death.

Conclusion

In 100 patients studied with similar brain injury severity scores, serum S100B measured at the 24-h time-point after injury is significantly associated with outcome but a cut-off 0.53 μg L−1 does not have good prognostic performance.

Introduction

The severity of brain injury can be assessed in a variety of ways. For the paramedic and clinician the best empirical assessment of injury is the degree of impaired cerebral function. Here assessment of conscious level using the internationally recognised Glasgow Coma Scale (GCS)1 aids triage, prognosis and family counselling. Subsequent assessments of head and other body injuries can be made using anatomical scoring systems such as the abbreviated injury scale (AIS)2 and for multiple injuries the injury severity score (ISS).2 Physiological scoring systems can also be used using the revised trauma score (RTS)3 and the four elements composing the TRISS methodology (trauma score and injury severity score).4 These scoring and survival probability systems are particularly valuable in epidemiological studies for assessment of outcome with respect to severity of injury.

In recent years quantitative biochemical markers have been employed to diagnose a variety of diseases, e.g. creatinine for renal failure,5 troponin for myocardial infarction6 and lipase for pancreatitis.7 Of the calmodulin/troponin C superfamily of calcium binding proteins,8 S100B has shown promise as a biochemical marker of outcome after mild head injury.9 S100B has high specificity for nervous tissue although it is recognised that non-nervous tissues such as fat and muscle also release protein S100B.10 Increased levels of S100B are associated with a poor neurophysiological outcome.11, 12 Consequently, S100B has been proposed as a diagnostic and prognostic tool in mild head injury. It has also been used to aid decision making about the need for CT scanning in the Emergency Department (ED).13, 9 For patients with severe head injury, S100B has proved more reliable in predicting outcome compared with other markers such as neuron specific enolase.14, 15 However, as blood samples have been taken at many different time-points after injury in the various published studies, it remains uncertain as to the time-point at which the blood sample should be taken where S100B levels best reflect the severity of brain damage.

In a recent series of investigations from this Centre, the majority of patients with severe TBI admitted to the intensive care unit for medical management of their head injury had the same AIS score for the head (AIS 5) despite considerable differences in outcome when assessed using conventional outcome scores 3 months after brain damage.16, 17 To improve our ability to discriminate survivors of severe TBI (AIS4, AIS5) from non-survivors, the aim of this study was to: show the range of serum S100B levels after severe TBI; determine if S100B has potential to discriminate favourable from unfavourable outcome in TBI patients with the same AIS scores and to establish an S100B level cut-off predictive for death.

Section snippets

Methods

Research ethics approval was obtained before the study commenced. Patients aged ≥16 years with severe head trauma admitted to the intensive care unit (ICU) of this large University teaching hospital within 24 h of injury were eligible for recruitment to the study. Late referrals to ICU (admission ≥24 h after injury) were excluded.

Patients were admitted either as direct referrals from the ED or as tertiary referrals from ED of other hospitals within the Greater Manchester region. All the patients

Results

One hundred patients (81 male and 19 female) aged 16–86 years (median 31) years with TBI were recruited to the study over a period of 25 months (Table 2). All patients had sustained severe brain trauma. With the exception of two patients only, all injuries to the head scored 4 or 5 (median 5) on the AIS scale corresponding with severe brain damage (Table 2). In 53 patients (53%) brain injury was the only significant trauma. The remaining 47 patients (47%) had additional injuries to the body

Discussion

In this cohort of 100 patients with severe traumatic brain injury admitted to the intensive care unit of our institution, serum S100B levels measured at the 24 h time-point ranged from 0.08 to 12.62 μg L−1. Serum levels were significantly higher in those patients who, 3 months after injury, had an unfavourable outcome compared with those who had made a good recovery. The patients who died also had significantly higher S100B concentrations than the survivors. Although there is no significant

Conflict of interest

None declarable.

Acknowledgements

We thank Mrs. Laura White for assistance with AIS coding of injuries and Mr. Omar Bouamra for help with statistics. We would like to thank the nurses and doctors of the intensive care unit for their help and co-operation with the collection of blood samples.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.11.021.

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