Trauma craneal leve en adultos. Revisión de la literatura

Variability in the indication of brain CT scan after mild traumatic brain injury. A transnational survey

PURPOSE

Clinical guidelines have been developed to standardize the management of mild traumatic brain injury (mTBI) in the emergency room, in particular the indication of brain CT scan and the use of blood biomarkers. The objective of this study was to determine the degree of adherence to guidelines in the management of these patients across four countries of Southern Europe.

METHODS

An electronic survey including structural and general management of mTBI patients and six clinical vignettes was conducted. In-charge physicians from France, Spain, Greece and Portugal were contacted by telephone and email. Differences among countries were searched using an unconditional approach test on contingency tables.

RESULTS

One hundred and eighty eight physicians from 131 Hospitals (78 Spain, 36 France, 12 Greece and 5 Portugal) completed the questionnaire. There were differences regarding the in-charge specialist across these countries. There was variability in the use of guidelines and their adherence. Spain was the country with the least guideline adherence. There was a global agreement in ordering a brain CT for patients receiving anticoagulation or platelet inhibitors, and for patients with seizures, altered consciousness, neurological deficit, clinical signs of skull fracture or signs of facial fracture. Aging was not an indication for CT in French centres. Loss of consciousness and posttraumatic amnesia were considered as indications for CT more frequently in Spain than in France. These findings were in line with the data from the 6 clinical vignettes. The estimated use of CT reached around 50% of mTBI cases. The use of S100B is restricted to five French centres.

CONCLUSIONS

There were large variations in the guideline adherence, especially in the situations considered to order brain CT after mTBI.

Evaluation of the yield of 24-h close observation in patients with mild traumatic brain injury on anticoagulation therapy: a retrospective multicenter study and meta-analysis

BACKGROUND/AIMS

Patients with mild traumatic brain injury (mTBI) on anticoagulants have an increased risk of intracranial hemorrhage (ICH). However, consensus is lacking on whether to admit them after normal initial cranial CT. We evaluated the yield of 24-h neurological observation.

METHODS

Retrospective multicenter study including adult patients admitted over a 5-year period with mTBI on anticoagulation [therapeutic dose heparin, direct oral anticoagulant, or vitamin K antagonist (VKA) with international normalized ratio (INR) ≥ 1.7] and reportedly normal cranial CT obtained within 24 h after trauma. Primary endpoint was symptomatic ICH within 24 h of injury. Literature on delayed ICH in patients with mTBI and anticoagulation use was reviewed.

RESULTS

Of 17.643 mTBI patients, 905 met the inclusion criteria (median age 82 years). 97% used VKA (median INR 2.9). None developed delayed ICH within 24 h. Nine patients deteriorated neurologically due to ICH, four within 24 h (0.4%, 95% CI 0.1-1.2) and five on day 2, 18, 22, 36 and 52, respectively. In six patients, including all four that developed symptoms within 24 h, ICH was found upon reevaluation of initial imaging. The meta-analysis comprised of 9 studies with data from 2885 patients. The estimated pooled proportion of symptomatic delayed ICH or delayed diagnosis of ICH within 24 h was 0.2% (95% CI 0.0-0.5).

CONCLUSIONS

Delayed (diagnosis of) ICH within 24 h is very rare in mTBI patients on anticoagulants after reportedly normal initial CT. Routine hospitalization of these patients seems unwarranted when the initial cranial CT is scrupulously evaluated.

The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury

BACKGROUND

Since 1999, the Italian guidelines have been used at our department for the management of patients with mild head injury (MHI). According to these guidelines, a computed tomography (CT) scan should be obtained in all patients with coagulopathy and these should routinely undergo strict observation during the first 24 hours after injury; in addition they should have a control CT scan before discharge. With the increased use of anticoagulant therapy in the elderly population, admitting patients in such treatment with a MHI to the emergency rooms has become very common. The aim of our study was to evaluate the need of performing a control CT scan in patients on anticoagulation treatment who showed neither intracranial pathology on the first CT-scan nor neurologic worsening during the observation period.

METHODS

We prospectively analyzed the course of all patients on anticoagulation treatment consecutively admitted to our unit between October 2005 and December 2006 who suffered from a MHI and showed a normal initial CT scan. All patients underwent strict observation during the first 24 hours after admission and had a control CT scan performed before discharge.

RESULTS

One hundred thirty-seven patients were included in this study. Only two patients (1.4%) showed hemorrhagic changes. However, neither of them developed concomitant neurologic worsening nor needed admitting or surgery.

CONCLUSION

According with our data, patients on anticoagulation treatment suffering from MHI could be managed with strict neurologic observation without routinely performing a control CT scan that can be reserved for the rare patients showing new clinical symptoms.