# Marshall CT — Original Marshall CT classification of traumatic brain injury

> Time-stamped six-category traumatic-brain-injury descriptor using visible CT pathology, basal cisterns, midline shift, a greater-than-25-cm3 high- or mixed-density lesion boundary and whether a lesion was surgically evacuated. Categories are nonordinal; V is treatment-defined, and Marshall alone neither captures the complete injury nor predicts an individual outcome or chooses surgery.

**Situação:** vigente · **Órgão:** Encéfalo · **Órgão emissor:** Traumatic Coma Data Bank · **Versão:** 1991 original six-category system; 2024 neuroprognostication and 2025 NINDS imaging boundaries · **Ano:** 1991

> ⚠️ Uma versão mais nova pode existir (em revisão).

## Procedência e vigência
- Família: léxico
- Tipo de lógica: flat
- Modalidade: CT
- Fonte primária: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14
- Última verificação: 2026-07-24
- Última checagem: 2026-08-12

## Lógica de decisão
Use the exact continuous measurements and a named timepoint. Category V is treatment-defined, the six labels are nonordinal, and the API must return the full lesion phenotype and uncertainty rather than treating Marshall as prognosis or management.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| I | Diffuse injury I | Marshall diffuse injury I: no intracranial traumatic pathology is visible on the time-stamped CT. This means CT-negative within the classification, not absence of clinical traumatic brain injury. | Do not discharge, stop observation or withhold further assessment from class I alone. Management follows mechanism, symptoms, serial neurologic examination, anticoagulant status and validated imaging/observation rules; CT can miss small or nonhemorrhagic traumatic axonal or microvascular injuries. | Class I has the lowest visible CT injury burden in the Marshall framework, but a normal CT does not establish benign clinical course or exclude persistent symptoms and MRI-visible injury. The current neuroprognostication guideline does not support Marshall as a reliable standalone long-term mortality forecast. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category I; Mac Donald et al. 2025, DOI 10.1089/neu.2025.0079, PMC12409119, CT and MRI sensitivity limits; Muehlschlegel et al. 2024, PMC10959796, standalone prognostication boundary. | ✓ |
| II | Diffuse injury II | Marshall diffuse injury II: traumatic pathology is visible, basal cisterns remain present, midline shift is 0-5 mm inclusive, and no high- or mixed-density intracranial lesion is greater than 25 cm3. Bone fragments and foreign bodies may be present within this branch. | Class II is not an observation or nonoperative instruction. Report every lesion and integrate neurologic trajectory, lesion type, size, antithrombotic use, ICP and serial imaging; urgent trauma or neurosurgical assessment can be required despite the numeral. | Class II historically carries less mass-effect morphology than III or IV, but Marshall labels are not a calibrated ordinal risk scale and the category omits several prognostically relevant lesion types. Do not attach a single cohort mortality percentage to an individual patient. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category II; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, construction and comparative prognostic limitations; Muehlschlegel et al. 2024, PMC10959796. | ✓ |
| III | Diffuse injury III (swelling) | Marshall diffuse injury III (swelling): basal cisterns are compressed or absent, midline shift remains 0-5 mm inclusive, and no high- or mixed-density lesion is greater than 25 cm3. Exactly 5 mm remains in this branch when the other criteria are met. | Cisternal compression or absence is an urgent mass-effect feature, but class III does not specify an intervention. Escalate according to examination, pupils, ICP, lesion phenotype, systemic insults and neurosurgical/neurocritical assessment; never generate decompression or monitoring from the Roman numeral alone. | Cisternal compression is associated with more severe injury, yet class III is a population-level morphology category rather than an individual probability. Current guidance requires multivariable clinical context and explicit uncertainty for long-term counseling. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category III; Mac Donald et al. 2025, PMC12409119, cistern compression within granular imaging characterization; Muehlschlegel et al. 2024, PMC10959796, prognostication recommendations. | ✓ |
| IV | Diffuse injury IV (shift) | Marshall diffuse injury IV (shift): midline shift is greater than 5 mm and no high- or mixed-density lesion is greater than 25 cm3. If a greater-than-25-cm3 high/mixed lesion remains un-evacuated, classify VI instead; exactly 5 mm is not IV. | Greater-than-5-mm shift is an emergency imaging feature requiring immediate clinical and neurosurgical integration, but Marshall IV is not itself an operation order. Lesion-specific criteria, neurologic deterioration, pupils, ICP and serial change govern management. | Class IV can have worse outcomes than the treatment-defined class V, demonstrating that Marshall is nonordinal. It must not be used alone for long-term mortality prediction, withdrawal-of-support decisions or a ceiling of recovery. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category IV and >5-mm boundary; Thelin et al. 2017, PMC5542385, nonordinal behavior and modern performance; Muehlschlegel et al. 2024, PMC10959796, prognosis boundary. | ✓ |
| V | Evacuated mass lesion | Marshall mass lesion V: any intracranial traumatic lesion has been surgically evacuated by the stated classification timepoint. This is a treatment-defined state and can only be assigned with known operative status; preoperative volume does not define V. | Class V records that evacuation occurred; it neither recommends surgery prospectively nor proves adequacy, success or completion of care. Continue lesion-specific postoperative, ICP, examination and serial-imaging management according to the clinical course. | Because class V depends on treatment selection, it is not a pure imaging-severity category and is confounded by who underwent surgery. Do not rank it mechanically above IV or below VI, or use it as an individual outcome forecast. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, evacuated mass-lesion category; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, subsequent surgical-status and nonordinal limitations; current Brain Trauma Foundation surgical guideline for separate lesion-specific care. | ✓ |
| VI | Non-evacuated mass lesion | Marshall mass lesion VI: a high- or mixed-density intracranial lesion is greater than 25 cm3 and has not been surgically evacuated at the stated timepoint. Exactly 25 cm3 is not greater than 25 and does not enter VI solely by volume. | Class VI documents current non-evacuated status; it does not mean surgery is contraindicated, futile or permanently withheld. Urgent decisions use lesion type, location, continuous volume, shift, cisterns, GCS, pupils, deterioration, ICP, comorbidity and lesion-specific surgical guidance. | A large non-evacuated lesion indicates substantial injury burden, but VI remains a treatment- and threshold-defined category, not a deterministic mortality or functional-outcome prediction. Counsel only from a multivariable, time-aware assessment with substantial uncertainty. | Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, non-evacuated >25-cm3 category; Muehlschlegel et al. 2024, DOI 10.1007/s12028-023-01902-2, PMC10959796, prognostication boundary; Brain Trauma Foundation surgical guideline, distinct EDH, SDH and parenchymal-lesion thresholds. | ✓ |

### Citações por categoria
- **I**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category I; Mac Donald et al. 2025, DOI 10.1089/neu.2025.0079, PMC12409119, CT and MRI sensitivity limits; Muehlschlegel et al. 2024, PMC10959796, standalone prognostication boundary.
- **II**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category II; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, construction and comparative prognostic limitations; Muehlschlegel et al. 2024, PMC10959796.
- **III**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category III; Mac Donald et al. 2025, PMC12409119, cistern compression within granular imaging characterization; Muehlschlegel et al. 2024, PMC10959796, prognostication recommendations.
- **IV**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, original category IV and >5-mm boundary; Thelin et al. 2017, PMC5542385, nonordinal behavior and modern performance; Muehlschlegel et al. 2024, PMC10959796, prognosis boundary.
- **V**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, evacuated mass-lesion category; Thelin et al. 2017, DOI 10.1371/journal.pmed.1002368, PMC5542385, subsequent surgical-status and nonordinal limitations; current Brain Trauma Foundation surgical guideline for separate lesion-specific care.
- **VI**: Marshall LF, Marshall SB, Klauber MR, et al.. A new classification of head injury based on computerized tomography (1991) — https://doi.org/10.3171/sup.1991.75.1s.0s14 · Marshall et al. 1991, DOI 10.3171/sup.1991.75.1s.0s14, non-evacuated >25-cm3 category; Muehlschlegel et al. 2024, DOI 10.1007/s12028-023-01902-2, PMC10959796, prognostication boundary; Brain Trauma Foundation surgical guideline, distinct EDH, SDH and parenchymal-lesion thresholds.

## Referências cruzadas
- _fronteira compartilhada_ → [Rotterdam CT — Rotterdam CT score for traumatic brain injury](https://radcommons.laudos.ai/systems/rotterdam-ct.md) — Both summarize acute traumatic-brain-injury CT findings, but Marshall is a nonordinal six-category system with a treatment-defined evacuated-lesion class; Rotterdam is an additive prognostic score that separately encodes cisterns, shift, epidural lesion and traumatic SAH/IVH. Never convert by matching numerals.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 2026-07-26 | revised | Monitored source changed (version_regex). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-07-09 | revised | The NINDS TBI Imaging Working Group recommended granular lesion characterization integrated with clinical, biomarker and modifier context. Marshall remains a legacy companion classification rather than the complete injury phenotype. | confirmed |
| 2024-01-01 | revised | The Neurocritical Care Society neuroprognostication guideline concluded that Marshall should not be treated as a reliable standalone long-term mortality predictor. This is a use boundary, not a revision of the six categories. | confirmed |
| 1991-01-01 | published | Marshall and the Traumatic Coma Data Bank group published the six-category CT classification using visible pathology, cisterns, shift, lesion volume and evacuation status. | confirmed |


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> Conteúdo de referência reescrito. Confira a publicação primária vigente. Não é dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

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