Changes in the gray and white matter of patients with ischemic-edematous insults after traumatic brain injury

Hakseung Kim, Tak Kim, Eun Suk Song, Byung C. Yoon, Young Hun Choi, Keewon Kim, Dong Joo Kim

Research output: Contribution to journalArticlepeer-review

5 Citations (Scopus)


OBJECTIVE Gray matter (GM) and white matter (WM) are vulnerable to ischemic-edematous insults after traumatic brain injury (TBI). The extent of secondary insult after brain injury is quantifiable using quantitative CT analysis. One conventional quantitative CT measure, the gray-white matter ratio (GWR), and a more recently proposed densitometric analysis are used to assess the extent of these insults. However, the prognostic capacity of the GWR in patients with TBI has not yet been validated. This study aims to test the prognostic value of the GWR and evaluate the alternative parameters derived from the densitometric analysis acquired during the acute phase of TBI. In addition, the prognostic ability of the conventional TBI prognostic models (i.e., IMPACT [International Mission for Prognosis and Analysis of Clinical Trials in TBI] and CRASH [Corticosteroid Randomisation After Significant Head Injury] models) were compared to that of the quantitative CT measures. METHODS Three hundred patients with TBI of varying ages (92 pediatric, 94 adult, and 114 geriatric patients) and admitted between 2008 and 2013 were included in this retrospective cohort study. The normality of the density of the deep GM and whole WM was evaluated as the proportion of CT pixels with Hounsfield unit values of 31–35 for GM and 26–30 for WM on CT images of the entire supratentorial brain. The outcome was evaluated using the Glasgow Outcome Scale (GOS) at discharge (GOS score ≤ 3, n = 100). RESULTS Lower proportions of normal densities in the deep GM and whole WM indicated worse outcomes. The proportion of normal WM exhibited a significant prognostic capacity (area under the curve [AUC] = 0.844). The association between the outcome and the normality of the WM density was significant in adult (AUC = 0.792), pediatric (AUC = 0.814), and geriatric (AUC = 0.885) patients. In pediatric patients, the normality of the overall density and the density of the GM were indicative of the outcome (AUC = 0.751). The average GWR was not associated with the outcome (AUC = 0.511). IMPACT and CRASH models showed adequate and reliable performance in the pediatric and geriatric groups but not in the adult group. The highest overall predictive performance was achieved by the densitometry-augmented IMPACT model (AUC = 0.881). CONCLUSIONS Both deep GM and WM are susceptible to ischemic-edematous insults during the early phase of TBI. The extent of the secondary injury was better evaluated by analyzing the normality of the deep GM and WM rather than by calculating the GWR.

Original languageEnglish
Pages (from-to)1243-1253
Number of pages11
JournalJournal of Neurosurgery
Issue number4
Publication statusPublished - 2019 Oct

Bibliographical note

Funding Information:
This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health & Welfare, Republic of Korea (grant no. HI17C1790) and by the Ministry of Science and ICT, Korea, under the Information Technology Research Center support program (IITP-2017-2016-0-00464) supervised by the Institute for Information & Communications Technology Promotion and supported by a Korea University grant.

Publisher Copyright:
©AANS 2019.


  • Computed tomography
  • Densitometry
  • Gray matter
  • Traumatic brain injury
  • White matter

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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