Abstract
Purpose of the article:
The Rotterdam Scoring System (RSS) attempts to prognosticate early mortality and early functional outcome in patients with traumatic brain injury (TBI) based on non-contrast head computed tomography (CT) imaging findings. The purpose of this study is to identify the relationship between RSS scores and long-term outcomes in patients with severe TBI
Methods:
Consecutively treated patients with severe TBI enrolled between 2008 and 2011, in the prospective, observational, Brain Trauma Research Center database were included. The Glasgow Outcome Scale (GOS) was used to measure long-term functional outcomes at 3-, 6-, 12-, and 24-months. GOS scores were categorized into favorable (GOS = 4-5) and unfavorable (GOS = 1-3) outcomes. RSS scores were calculated at the time of image acquisition.
Results:
Of the eighty-nine patients included, 74 (83.4%) were male, 81 (91.0%) were Caucasian, and the mean age of the cohort was 41.9 ± 18.5 years old. Patients with an RSS score of 3 and lower were more likely to have a favorable outcome with increased survival rates than patients with RSS scores greater than 3.
Conclusion:
The RSS score determined on the head CT scan acquired at admission in a cohort of patients with severe TBI correlated with long-term survival and functional outcomes up to two years following injury.
Keywords: Functional Outcomes, Glasgow Outcome Scale, Head Injury, Rotterdam Scoring
Introduction
Traumatic brain injury (TBI) is one of the leading causes of death and neurological disability in the world, affecting an estimated 69 million individuals every year.1 With an estimated mortality rate of 20-40%, severe TBI presents the worst prognosis.2,3 Further, less than half of all survivors with an initial Glasgow Coma Scale (GCS) score of 3-5 achieve a favorable outcome, defined by a Glasgow Outcome Scale (GOS) score of 4 or 5.2,3 However, in more recent literature, favorable outcome has been defined as Extended Glascow Outcome Scale (GOS-E) score of greater than or equal to 4 or 5.4,5 While GCS is an essential clinical examination tool, it may be confounded in practice as patients with TBI are often inebriated, intubated, medicated and/or have distracting injuries. In these patients, a non-contrast computed tomography (CT) scan of the head is one of the earliest objective measures to assess severity and aid prognostication. Currently, there are multiple scoring systems for prognostication, including the Rotterdam, Marshall, IMPACT, and CRASH scores.5,6
The Rotterdam Scoring System (RSS) was developed to prognosticate patients with TBI based on CT imaging findings.7 The specific CT findings of interest are summarized in Table 1.4 Compared to previous CT scoring systems,8 RSS scores are easily derived and have demonstrated improved interobserver reliability.9 A number of studies have shown RSS scores to be predictive of early outcomes up to 6 months following injury in patients with TBI.9-18 However, using RSS scores to predict long-term outcomes has not been extensively investigated. In this study, we hypothesize that lower RSS scores correlate with survival and a more favorable long-term neurological outcome.
Table 1.
The Rotterdam Scoring System criteria summarized. One point is added to the aggregate to produce a range of scores from 1-6.
| Predictor | Score |
|---|---|
| Basal cisterns | |
| Normal | 0 |
| Compressed | 1 |
| Absent | 2 |
| Midline Shift | |
| No shift or shift ≤ 5mm | 0 |
| Shift > 5mm | 1 |
| Epidural Mass Lesion | |
| Present | 0 |
| Absent | 1 |
| Intraventricular blood or subarachnoid hemorrhage | |
| Absent | 0 |
| Present | 1 |
| Sum Score | +1 |
Methods
Data Collection
Consecutively treated patients with severe TBI between 2008 and 2011 were enrolled in the prospective, longitudinal Brain Trauma Research Center (BTRC) database under an IRB approved study. Patient proxies provided assent prior to the patient being enrolled in the study. All patients included in the database underwent multimodal neuromonitoring consisting of external ventricular drain (EVD) placement for drainage and intracranial pressure (ICP) monitoring, ICP bolt placement for ICP monitoring, and brain tissue oxygenation monitoring. All patients were treated with a standardized severe TBI management protocol. Eligible patients with severe TBI aged 17-80 years old were included. Severe TBI was defined as a first, post-resuscitation GCS score of less than or equal to 8 without following commands. Patients were included if they had 3-month outcome data and RSS scores. Patients were excluded if their three-month RSS scores or outcome data were not recorded. Additionally, as the focus of this study was on long term outcomes, patients with unsurvivable injury or death within 24 hours were excluded.
Image Classification
All patients underwent non-contrast head CT scans immediately after resuscitation and stabilization in the emergency department. Individual features of the CT scan were interpreted by a board-certified radiologist at the time of collection and scored according to the Rotterdam CT classification by a neurosurgical attending. These features included traumatic subarachnoid blood or intraventricular blood, epidural mass lesion, midline shift, and the status of the basal cisterns (Table 1). CT scans were interpreted and RSS scores were calculated at the time of CT acquisition.
Outcome Measures
The five-point Glasgow Outcome Scale (GOS) (Table 2) was used to measure long-term functional outcomes at 3-, 6-, 12-, and 24-months via in-person or telephone interviews by trained, qualified neuropsychological technicians.19 GOS scores were dichotomized into favorable (GOS = 4-5) and unfavorable (GOS = 1-3) outcomes.
Table 2.
Glasgow Outcome Scale (GOS) score description
| Score | Description |
|---|---|
| 1 | Dead |
| 2 | Persistent vegetative state with inability to interact with the environment |
| 3 | Severe disability with inability to live independently but able to follow commands |
| 4 | Moderate disability with the ability to live independently but unable to return to work or school |
| 5 | Mild or no disability with the ability to return to work or school |
Statistical Analysis
Data were presented as mean ± SD for continuous variables and N (%) for categorical variables. In the analysis, RSS score was treated as a categorical measure, and its associations with GOS outcome (favorable vs. unfavorable) and with mortality were assessed by Fisher’s exact tests. Post-hoc pairwise comparisons of RSS with outcomes were carried out for all possible pairs of RSS scores, and Bonferroni correction was applied to control for multiple comparisons. Finally, Kaplan-Meier curves for time to death and time to favorable outcome were constructed for each individual RSS score, and log-rank test was used to compare the survival distributions across the groups. Censored data occur when the survival time is incomplete or unknown for some groups in on the Kaplan-Meier curves. This can happen if there is loss of follow-up or the outcome was not experienced within the study period. The censored data points were indicated appropriately on the curves. Patients with an RSS score of 1 and 2 were grouped together. Analyses were conducted using SAS v9.4 (SAS Institute, Cary, NC).
Results
Of 168 eligible patients, a total of 89 patients met the inclusion criteria. The remaining 79 were excluded due to loss of follow-up. Of the 89 included patients, 74 (83.4%) were male and the mean age of the cohort was 41.9 ± 18.5 years old. The cohort consisted of 81 (91.0%) Caucasian patients, 7 (7.9%) African-American patients, and 1 (1.1%) Asian patient. There was a wide distribution of initial post-resuscitation GCS scores as 21 (23.6%) patients had a GCS score of 3, 8 (8.9%) had a GCS score of 4, 10 (11.2%) had a GCS score of 5, 13 (14.6%) had a GCS score of 6, 33 (37.1%) had a GCS score of 7, and 4 (4.5%) patients had a GCS score of 8. Similarly, RSS scores in our cohort showed a wide distribution with 3 (3.4%) patients with an RSS score of 1, 10 (11.2%) with an RSS score of 2, 33 (37.1%) with an RSS score of 3, 19 (21.3%) with an RSS score of 4, 14 (15.7%) with an RSS score of 5, and 10 (11.2%) with an RSS score of 6. Interestingly, all patients with an RSS score of 1, 5, and 6 (with the exception of 1 patient), had an unfavorable outcome. These findings are summarized in Table 3 and the consort diagram of selection is visualized in Figure 1.
Table 3.
Demographic Information
| Variable | |
|---|---|
| Age (mean ± SD) | 41.9 ± 18.5 |
| Gender | |
| Male | 74 (83.4%) |
| Female | 15 (16.6%) |
| Glasgow Coma Scale (GCS) scores | |
| 3 | 21 (23.6%) |
| 4 | 8 (8.9%) |
| 5 | 10 (11.2%) |
| 6 | 13 (14.6%) |
| 7 | 33 (37.1%) |
| 8 | 4 (4.5%) |
| Rotterdam CT Scale scores | |
| 1 | 3 (3.4%) |
| 2 | 10 (11.2%) |
| 3 | 33 (37.1%) |
| 4 | 19 (21.3%) |
| 5 | 14 (15.7%) |
| 6 | 10 (11.2%) |
| 3-month Glasgow Outcome Scale score | |
| 1 – Death | 40 (51.2%) |
| 2 – Persistent Vegetative State | 3 (3.8%) |
| 3 – Severe Disability | 24 (30.8%) |
| 4 – Moderate Disability | 10 (12.8%) |
| 5 – Mild or No Disability | 1 (1.3%) |
| 6-month Glasgow Outcome Scale score | |
| 1 – Death | 40 (51.9%) |
| 2 – Persistent Vegetative State | 1 (1.3%) |
| 3 – Severe Disability | 22 (28.6%) |
| 4 – Moderate Disability | 8 (10.4%) |
| 5 – Mild or No Disability | 6 (7.8%) |
| 12-month Glasgow Outcome Scale score | |
| 1 – Death | 41 (54.7%) |
| 2 – Persistent Vegetative State | 0 (0.0%) |
| 3 – Severe Disability | 8 (10.7%) |
| 4 – Moderate Disability | 13 (17.3%) |
| 5 – Mild or No Disability | 13 (17.3%) |
| 24-month Glasgow Outcome Scale score | |
| 1 – Death | 41 (63.1%) |
| 2 – Persistent Vegetative State | 0 (0.0%) |
| 3 – Severe Disability | 10 (15.4%) |
| 4 – Moderate Disability | 7 (10.8%) |
| 5 – Mild or No Disability | 7 (10.8%) |
Figure 1.
Selection criteria/consort diagram of patients included in this study.
Following statistical analysis, we found lower RSS scores correlated significantly with favorable outcomes (GOS 4-5) at 3-months (p=0.0100), 6-months (p=0.0003), 12-months (p=0.0002), and 24-months (p=0.0004). At 6-month follow up, patients with an RSS score of 2 were more likely to have a favorable outcome (77.8%) when compared to patients with an RSS score of 3 (17.9% favorable outcome, p=0.030), an RSS score of 4 (6.3% favorable outcome, p=0.008) or an RSS score of 5 (p=0.003). Beyond 6-months, an RSS score of 2 was significantly correlated with a favorable outcome compared to RSS scores of 4 (p=0.032 at 12-months) and 5 (p=0.003 at 12-months, p=0.027 at 24-months).
Similarly, we found a significant correlation between lower RSS scores and survival at 3-months (p<0.0001), 6-months (p<0.0001), 12-months (p<0.0001), and 24-months (p=0.004). Following post-hoc analysis, there was a stronger correlation between an RSS of 2 and survival within 2 years after the TBI than RSS scores of 4 (p=0.024 at 3-months, p=0.042 at 6-months, p=0.042 at 12-months), 5 (p<0.0001 at 3-months, p<0.0001 at 6-months, p<0.0001 at 12-months), and 6 (p=0.047 at 3-months, p=0.035 at 6-months, p=0.006 at 12-months). An RSS score of 3 was more strongly associated with survival within a year than an RSS score of 5 (p=0.027 at 3-months, 0.029 at 6-months) only. There were no significant post-hoc analyses at the 24-month time point. The outcomes of patients based on their RSS scores at each time point are illustrated in Figure 2 with the p-values for survival and GOS represented in Table 4.
Figure 2.
Glasgow Outcome Scale (GOS) scores of patients over time by individual Rotterdam score values. A) includes GOS scores for all patients with an initial Rotterdam score of 1; B) includes GOS scores for all patients with an initial Rotterdam score of 2; C) includes GOS scores for all patients with an initial Rotterdam score of 3; D) includes GOS scores for all patients with an initial Rotterdam score of 4; E) includes GOS scores for all patients with an initial Rotterdam score of 5; F) includes GOS scores for all patients with an initial Rotterdam score of 6.
Table 4.
Significant Post-Hoc Analyses
| 3-Month Glasgow Outcome Scale | |
| Overall Lower Rotterdam Score vs. Higher | 0.010 |
| 6-Month Glasgow Outcome Scale | |
| Overall Lower Rotterdam Score vs. Higher | 0.0003 |
| Rotterdam Score 2 vs. 3 | 0.030 |
| Rotterdam Score 2 vs. 4 | 0.008 |
| Rotterdam Score 2 vs. 5 | 0.003 |
| 12-Month Glasgow Outcome Scale | |
| Overall Lower Rotterdam Score vs. Higher | 0.0002 |
| Rotterdam Score 2 vs. 4 | 0.032 |
| Rotterdam Score 2 vs. 5 | 0.003 |
| 24-Month Glasgow Outcome Scale | |
| Overall Lower Rotterdam Score vs. Higher | 0.0004 |
| Rotterdam Score 2 vs. 5 | 0.027 |
| 3-Month Survival | |
| Overall Lower Rotterdam Score vs. Higher | <0.0001 |
| Rotterdam Score 2 vs. 4 | 0.024 |
| Rotterdam Score 2 vs. 5 | <0.0001 |
| Rotterdam Score 2 vs. 6 | 0.047 |
| Rotterdam Score 3 vs. 5 | 0.027 |
| 6-Month Survival | |
| Overall Lower Rotterdam Score vs. Higher | <0.0001 |
| Rotterdam Score 2 vs. 4 | 0.042 |
| Rotterdam Score 2 vs. 5 | <0.0001 |
| Rotterdam Score 2 vs. 6 | 0.035 |
| Rotterdam Score 3 vs. 5 | 0.029 |
| 12-Month Survival | |
| Overall Lower Rotterdam Score vs. Higher | <0.0001 |
| Rotterdam Score 2 vs. 4 | 0.042 |
| Rotterdam Score 2 vs. 5 | <0.0001 |
| Rotterdam Score 2 vs. 6 | 0.006 |
| 24-Month Survival | |
| Overall Lower Rotterdam Score vs. Higher | 0.004 |
Finally, there was a step-wise relationship, of which a lower RSS score was significantly correlated with survival (p<0.0001) and a favorable outcome (p<0.0001) at 24-months when compared directly to the next highest RSS score (Figure 3A and C). Dichotomizing RSS scores of 1-3 and 4-6 revealed a statistically significant difference in survival and rate of favorable outcome between the two groups at 24-months. Specifically, 74% of patients with an RSS score of 1-3 were still alive at 24-months following the TBI compared to 23% of patients with an RSS score of 4-6 (p<0.0001). Similarly, 52% of patients with an RSS score of 1-3 reached a favorable outcome by 24-months following the TBI compared to only 11% of patients with an RSS score of 4-6 (p<0.0001). Kaplan-Meier curves visually represent these differences in survival rates and time to favorable outcome (Figure 3).
Figure 3.
Kaplan-Meier curves for survival and time to a favorable outcome by individual Rotterdam scores as well as dichotomized Rotterdam scores. A) Kaplan-Meier curve for survival by individual Rotterdam scores. B) Kaplan-Meier curve for survival by dichotomized Rotterdam scores, 1-3 and 4-6. C) Kaplan-Meier curve for time to a favorable outcome by individual Rotterdam scores and D) Kaplan-Meier curve for time to a favorable outcome by dichotomized Rotterdam scores, 1-3 and 4-6. Censored data are labelled on the curve with tick marks.
Discussion
Lower RSS scores on admission head CT scan significantly correlated with survival and improved functional outcome in patients with severe TBI up to two years following injury. Patients with an initial RSS score of 2 often achieved a favorable functional outcome after 6-months when compared to patients with initial RSS scores of 3 or greater. For prediction of mortality, patients with an initial RSS score of 2 were more likely to survive up to a year following the TBI compared to patients with RSS scores of 4 or greater. Finally, we found a significant difference in survival and functional outcome in patients with an RSS score of 3 or less compared to patients with an RSS score of 4 or greater. Unexpectedly, all patients with an RSS score of 1 had unfavorable outcomes (Figure 2). However, this finding is limited by the cohort sample size, with patients with an RSS of 1 being only three individuals. Additionally, although these CT scans were scored low, a subsequent MRI was not performed due to the limited standards of the time. Moreover, it is possible that these early CT scans did not reflect severe occult injuries which may compound an unfavorable outcome. For instance, one patient was thrown 25 feet while riding his motorcycle and may have suffered diffuse axonal injury as a result, which may not have been readily apparent on imaging.
In 2005, Maas et al. first introduced the RSS as a prognostication tool for mortality in patients with moderate and severe TBI.7 Since then, numerous studies have externally validated the RSS as an effective prognosticator of mortality in various populations, including children,15 patients with TBI who undergo decompressive hemicraniectomy,10-12 and different global populations.9,16,18,20 Of these previous studies, three described the relationship between RSS and in-hospital mortality,15,16,20 whereas individual studies investigated mortality up to 2-weeks,18 3-months,11 and 6-months9 following discharge. Huang et al. had a follow-up period of 42-months; however, they only included patients with TBI who underwent decompressive craniectomy.12 Our results largely corroborate these earlier studies by demonstrating a correlation between lower RSS scores and increased 3- and 6-month survival, while also expanding on their findings by showing a correlation between lower initial RSS scores and survival at two years in a population of patients with severe TBI followed longitudinally.
Specific to our population with severe TBI and prediction of neurological outcome, we found that lower RSS scores are associated with favorable long-term functional outcomes. This finding has been previously defined in the literature. Siahaan et al. reported a relationship between higher RSS scores and 30-day GOS scores in non-surgical patients with moderate and severe TBI.21 Further, both Fujimoto et al. and Huang et al. studied populations of patients with TBI that underwent decompressive craniectomy and found higher preoperative RSS scores to be significantly associated with unfavorable outcomes (GOS scores 1-3) at 3 months and 42 months.11,12 Finally, Flint et al. indirectly described this relationship between RSS scores and functional outcome. They found that higher RSS scores are associated with expanded hemorrhagic contusion volume and expanded hemorrhagic contusion volumes greater than 20 cm3 to be predictive of unfavorable 6-month GOS scores.10
We also identified that an RSS score of 3 or less is significantly associated with a favorable outcome and increased survival rate compared to RSS scores greater than 3. This result is further supported by Talari et al. who described a sensitivity and specificity of 84.2% and 96.4%, respectively, when they used a cut-off RSS value of 4 to predict 14-day mortality.18 While further investigation may be necessary to corroborate these results, clinicians should be aware that patients with an RSS score of 3 or less are highly likely to achieve a favorable functional outcome with long-term follow-up.
Another interesting finding from this study includes the relative stabilization of outcomes at the 12-month timepoint. The number of patients with a favorable outcome peaks at this time point for all patients with the exception of those with an RSS score of 2. Similarly, there was only 1 additional patient who did not survive at the 24-month time-point compared to the 12-month time-point.
Beyond the RSS, a multitude of prognostication scoring systems exist. In their analysis comparing the RSS with others for predicting long-term Glasgow Outcome Scale (GOS), Khaki et al. identified the Stockholm CT score as the most effective, followed by the Helsinki CT score, RSS, and Marshall CT classification, albeit their investigation was confined to outcomes at one year.22 Additionally, Honeybul and Ho demonstrated that both the IMPACT and CRASH scoring systems possess commendable predictive accuracy for favorable neurological outcomes up to 18 months. Given these findings, it becomes imperative for future research to extend the comparative analysis to outcomes observed at 24 months across these principal scoring systems.23
BTRC Database and Intensive Care
All patients with severe TBI regardless of race, gender, or socioeconomic status are included within the BTRC database. Patients who present to the emergency department with an ‘unsurvivable’ injury, (i.e., GCS 3 with unreactive dilated pupils, no cough, gag, or corneal reflexes and a devastating brain injury that explains this clinical examination) are excluded from this database as no medical or surgical treatment is initiated on these patients. All other patients undergo aggressive surgical and medical management at a level 1 trauma center in an urban city with a large catchment area across Eastern Ohio, Western Pennsylvania, and West Virginia. Although the rate of surgical management for mass lesions is not documented, all operable mass lesions at our institution are treated surgically unless otherwise contraindicated (i.e., patients with diffuse coagulopathies or other such medical contraindications to surgery). All patients are cared for in a specialized neurotrauma intensive care unit (ICU) with specialized intensivists and nursing staff who routinely follow the Brain Trauma Foundation guidelines, via standing orders, for management of severe TBI. There is no difference in care administered to patients based on enrollment into the BTRC database.
Patients who had not survived beyond the first 24 hours of presentation were excluded from this database; however, patients who later (> 24 hours of admission) succumbed to brain death or whose care was withdrawn were included in this database and study population. If the family had information regarding a living will or an advanced directive, then care was withdrawn after extensive goals of care discussions between the neurosurgeon, neuro-intensivist, and family members.
Limitations and Generalizability
This study population of patients with severe TBI was predominantly male (83.4%) and Caucasian (91.0%). Although the former seems to limit the generalizability of our results, males represent a higher proportion of patients with TBI than females globally.24 The racial breakdown of our study population reflects the demographic make-up of the regional population from which the sample was drawn, but overrepresents Caucasian patients compared to the larger patient population with TBI in the United States. No patients were excluded due to race, ethnicity or gender. Racial minorities have a higher incidence of TBI and may have higher mortality rates following TBI than Caucasian counterparts.25-28 As mentioned previously, care was withdrawn for some patients. These withdrawals of care most typically occurred between 7- and 14-days after the day of presentation, and thus this patient population is likely overrepresented in our 3-month timepoint analysis group. The inclusion of patients who were discontinued from care but the absence of the data as to the rates of patients who were discontinued from care within each study group is admittedly a large limitation of this study. It is possible that patients with higher RSS scores were more likely to be discontinued from care as their injuries were perceived to be more severe than those with lower RSS scores. Finally, this study is limited by the study cohort size of 89 patients and more specifically by the fact that close to 50% of the original study population was excluded due to lack of follow-up or initial RSS score data. The latter group was not studied further and thus it is possible this group was not excluded randomly and may in fact be significantly different than the included study group. As such, additional and larger studies are warranted to support the validity of the presented results.
Conclusion
In conclusion, a cohort of patients with severe TBI were analyzed to identify the relationship between RSS scores determined from the head CT scan taken on admission and long-term morbidity and mortality. RSS scores of 3 or less correlated with a favorable functional outcome (GOS 4-5) and greater likelihood of survival at two years after severe TBI compared to RSS scores of 4 or more. The long-term prognostic value of early head CT RSS scores may allow for improved treatment and rehabilitation planning, enhanced resource allocation, and more information for patients and their families to make informed decisions.
Funding Details:
This work was supported, in part, by the National Institutes of Health (NS30318; Brain Trauma Research Center: Department of Neurosurgery, University of Pittsburgh).
Biographies
Dr. Nitin Agarwal – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
nitin.agarwal@upmc.edu
Nitin Agarwal, MD, serves as the associate program director of the UPMC/University of Pittsburgh neurological surgery residency program and co-director of the department’s Complex and Minimally Invasive Spine Deformity Fellowship. On the clinical front, he is director of the department’s Minimally Invasive Spine and Robotics Surgery program.
Dr. Sharath Kumar Anand – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
anands2@upmc.edu
Sharath Kumar Anand, MD, joined the University of Pittsburgh Department of Neurological Surgery residency program in July 2021 after earning an MD degree from Wayne State University School of Medicine. At Wayne State, he was elected into the Alpha Omega Alpha Honor Medical Society and was awarded the Karl G. Pinckard Scholarship. Prior to medical school, he graduated from the University of Michigan in 2017 with a Bachelor of Science degree in cellular and molecular biology as well as a minor in electrical engineering and computer science.
During medical school, Dr. Anand conducted clinical neurosurgical research on topics including subarachnoid hemorrhage surgery outcomes, spine surgery and epilepsy care. He has a special interest in socioeconomic disparity research and institutional factors that affect neurosurgical outcomes.
Dr. Enyinna L. Nwachuku – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
nwachukuel@upmc.edu
Enyinna Nwachuku, MD, specializes in neurosurgery and practices with Great Lakes Neurosurgery. Dr. Nwachuku is affiliated with UPMC Hamot, UPMC Mercy and UPMC Altoona and completed his Medical Education at the University of Pittsburgh School of Medicine.
Dr. Tiffany E. Wilkins – 320 E North Ave, Pittsburgh, PA 15212
tiffelizabethwilkins@gmail.com
Dr. Tiffany Wilkins is a general surgery resident physician at Allegheny General Hospital.
Dr. Hanna Algattas – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
algattash@upmc.edu
Dr. Hanna Algattas is an Assistant Professor of Neurosurgery at the University at Buffalo Medical School who joined the UBNS team in 2023. He specializes in complex open and endoscopic treatments of skull base and pituitary disease, neuro-oncology, and minimally invasive cranial surgery. He has additional interests in neurotrauma, degenerative spine disease, traumatic brain/spinal cord injury, and concussions.
Rohit Prem Kumar – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
kumarrp@upmc.edu
Rohit Prem Kumar is a neurosurgery research fellow at the University of Pittsburgh Medical Center who is interested in pursuing a career in spine surgery. He is a medical student at Hackensack Meridian School of Medicine in Nutley, NJ, USA.
Dr. Hansen Deng – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
dengh3@upmc.edu
Hansen Deng, MD, joined the University of Pittsburgh Department of Neurological Surgery residency program in July of 2019. Dr. Deng graduated with distinction from the University of California San Francisco School of Medicine, where he was elected into the Alpha Omega Alpha Honor Medical Society. He completed his undergraduate degrees in oil-painting and biology at the University of California Berkeley, where he was elected into the Phi Beta Kappa Society.
Dr. Yue-Fang Chang – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
changy@upmc.edu
Dr. Chang has worked in a variety of areas, such as brain tumor, traumatic brain injury, health outcome, neuroimaging study, women’s health and diabetes epidemiology. She serves as the statistician in several epidemiological studies including Cardiovascular Health Study, Women’s Health Initiative and Study of Women’s Health Across the Nation. Over the years she has been involved in numerous grant preparations, providing statistical expertise in design, analysis and power/sample size calculations
Dr. Ava Puccio – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
puccam@upmc.edu
Ava M. Puccio, RN, PhD, is an associate professor with tenure in the Department of Neurological Surgery and also co-director of the Neurotrauma Clinical Trials Center in collaboration with David O. Okonkwo, MD, PhD.
Dr. David O. Okonkwo – 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213
okonkwodo@upmc.edu
David Okonkwo, MD, PhD, is professor of neurological surgery and director of the Neurotrauma Clinical Trials Center at the University of Pittsburgh. He is also director of neurotrauma and the scoliosis and spinal deformity program at UPMC Presbyterian. Dr. Okonkwo is past chair of the AANS/CNS Section on Neurotrauma and Critical Care. In addition, Dr. Okonkwo is team neurosurgeon for the Pittsburgh Steelers.
Footnotes
Disclosure of Interest
Dr. Nitin Agarwal receives royalties from Thieme Medical Publishers and Springer International Publishing.
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