Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

STUDY OBJECTIVE

Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses.

CONCLUSIONS

We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization

INTRODUCTION

The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization.

METHODS

Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared.

RESULTS

A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01).

CONCLUSION

The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Value of Repeat CT Brain in Mild Traumatic Brain Injury Patients with High Risk of Intracerebral Hemorrhage Progression

Patients with mild traumatic brain injury (MTBI) with intracerebral hemorrhage (ICH), particularly those at higher risk of having ICH progression, are typically prescribed a second head Computer Tomography (CT) scan to monitor the disease development. This study aimed to evaluate the role of a repeat head CT in MTBI patients at a higher risk of ICH progression by comparing the intervention rate between patients with and without ICH progression.

METHODS

192 patients with MTBI and ICH were treated between November 2019 to December 2020 at a single level II trauma center. The Glasgow Coma Scale (GCS) was used to classify MTBI, and initial head CT was performed according to the Canadian CT head rule. Patients with a higher risk of ICH progression, including the elderly (≥65 years old), patients on antiplatelets or anticoagulants, or patients with an initial head CT that revealed EDH, contusional bleeding, or SDH > 5 mm, and multiple ICH underwent a repeat head CT within 12 to 24 h later. Data regarding types of intervention, length of stay in the hospital, and outcome were collected. The risk of further neurological deterioration and readmission rates were compared between these two groups. All patients were followed up in the clinic after one month or contacted via phone if they did not return.

RESULTS

189 patients underwent scheduled repeated head CT, 18% had radiological intracranial bleed progression, and 82% had no changes. There were no statistically significant differences in terms of intervention rate, risk of neurological deterioration in the future, or readmission between them.

CONCLUSION

Repeat head CT in mild TBI patients with no neurological deterioration is not recommended, even in patients with a higher risk of ICH progression.

Evaluation of Sequential Head Computed Tomography in Traumatic Brain Injuries

Background: The grading of the severity of head trauma plays a vital role in acute patient management and planning a case-appropriate follow-up protocol. Few studies have been published regarding the Rotterdam scoring. In this study, we have established a correlation between the Rotterdam scores, need for sequential CTs, and the cumulative radiation dose. This correlation has helped develop a preliminary protocol that can be followed for patients hence bringing about better planned and efficient patient care.

Materials and methods: From August 2014 to December 2020, 88 cases of traumatic head injury on whom a minimum of one sequential CT was performed, with no surgical intervention, were included and studied. Sequential head CTs of each patient were evaluated by skilled radiologists with a minimum experience of five years, all of whom were blinded to the findings of the initial and previous head CT findings. The serial head CTs were evaluated for the Rotterdam CT score (RCTS). 

Results: Among the patients with extradural hemorrhage (EDH), only 28.6% (8) progressed over successive CTs and 75.5% (34) of patients with subdural hemorrhage (SDH) showed significant progression over sequential CTs. Maximum number of serial CTs were obtained for cases presenting with a score of 3 (34 cases) with about three of them requiring up to a total of three CTs. However, no significant change in findings was noted on serial CTs. On the contrary, significant disease progression was noted in patients with baseline scores of 4 (76.9%) and 5 (100%), with statistical significance obtained on further analysis (P = 0.001).

Conclusions: We are of the opinion that there is no additional role of sequential CT for the cases with Rotterdam score of 1 or 2 in the initial CT unless there is clinical evidence of deterioration. Rotterdam score 3 needs sequential CT after 24 hours and Rotterdam scores 4 and 5 need sequential CT after 12 hours if surgical intervention is delayed. The Rotterdam score may help predict any further need for a second CT, hence decreasing the unwanted radiation exposure.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

A Multicenter Validation of the Modified Brain Injury Guidelines (mBIG): Are They Safe and Effective?

BACKGROUND

The modified Brain Injury Guidelines (mBIG) are an algorithm for treating patients with traumatic brain injury (TBI) and intracranial hemorrhage (ICH) by which selected patients do not require a repeat head CT, a neurosurgery consult, or even an admission. The mBIG refined the original Brain Injury Guidelines (BIG) to improve safety and reproducibility. The purpose of this study is to assess safety and resource utilization with mBIG implementation.

METHODS

The mBIG were implemented at three level 1 trauma centers in 8/2017. A multicenter retrospective review of prospectively collected data was performed on adult mBIG 1 and 2 patients. The post mBIG implementation period (8/2017-2/2021) was compared to a previous BIG retrospective evaluation (1/2014-12/2016).

RESULTS

There were 764 patients in the two study periods. No differences were identified in demographics, ISS, or admission GCS. Fewer CT scans (2 [1,2] vs 2 [2,3], p < 0.0001) and neurosurgery consults (61.9% vs 95.9%, p < 0.0001) were obtained post mBIG implementation. Hospital (2 [1,4] vs 2 [2,4], p = 0.013) and ICU (0 [0,1] vs 1 [1,2], p < 0.0001) length of stay were shorter after mBIG implementation. No difference was seen in the rate of clinical or radiographic progression, neurosurgery operations, or mortality between the two groups.After mBIG implementation, 8 patients (1.6%) worsened clinically. Six patients that clinically progressed were discharged with GCS 15 without needing neurosurgery intervention. One patient had clinical and radiographic decompensation and required craniotomy. Another patient worsened clinically and radiographically, but due to metastatic cancer, elected to pursue comfort measures and died.

CONCLUSION

This prospective validation shows the mBIG are safe, pragmatic, and can dramatically improve resource utilization when implemented.

LEVEL OF EVIDENCE

II, Therapeutic.

Role of Routine Repeat Head CT for Pediatric Patients under 2 Years Old with Mild-to-moderate Traumatic Brain Injury

Repeat head computed tomography (RHCT) is common and routine for pediatric traumatic brain injury (TBI) patients. In mild (Glasgow Coma Scale; GCS 13–15) to moderate (GCS 9–12) TBI, recent studies have shown that RHCT without clinical deterioration does not alter management. However, the effectiveness of routine RHCT for pediatric TBI patients under 2 years has not been investigated. This study aims to investigate whether routine RHCT changes management in mild-to-moderate TBI patients under 2 years. We performed a retrospective review at the emergency department of the National Center for Child Health and Development between January 2015 and December 2019. Mild-to-moderate TBI patients under 2 years with an acute intracranial injury on initial head CT scan and receiving follow-up CT scans were included. Mechanism, severity of TBI, indication for RHCT, and their findings were listed. Study outcome was intervention based on the findings of RHCT. Intervention was defined as intubation, ICP monitor placement, or neurosurgery. We identified 50 patients who met inclusion criteria and most patients (48/50) had mild TBI. The most common mechanism was ‘fall’ (68%). Almost all RHCT was routine and the overall incidence of radiographic progression on RHCT was 12%. RHCT without clinical deterioration did not lead to intervention, although one patient with moderate TBI required intervention due to radiographic progression with clinical symptoms. Our study showed that routine RHCT without clinical deterioration for mild TBI patients under 2 years may not alter clinical management. We suggest that RHCT be considered when there is clinical deterioration such as decrease in GCS.

Step up to the Brain Injury Guidelines league: Adoption of Brain Injury Guidelines at a Level III trauma center, A pilot study

Introduction

The Brain Injury Guidelines (BIG) direct surgeons to implement risk-stratified treatment plans for patients with traumatic brain injury (TBI). BIG categorize patients into one of three severity categories, from lowest to highest risk (BIG 1, BIG 2, and BIG 3). BIG empowers physicians to implement standardized treatment plans that limit unnecessary hospitalizations, repeat imaging, and neurosurgical consultation. These guidelines have been studied in Level I trauma centers, but their clinical application has never been studied in a Level III trauma center. In this pilot study, we sought to determine if the BIG can be implemented in a regional trauma center where patients with less severe brain injuries are locally evaluated and treated.

Methods

All TBI patients at a Level III trauma center were stratified using the BIG criteria, where BIG 1 and BIG 2 patients were managed locally and BIG 3 patients were transferred to a Level I trauma center. We conducted a retrospective review using the local trauma database and electronic medical records over a 1-year period when BIG were first protocolized. The primary endpoint included deaths, complications, readmissions, and length of stay.

Results

There were 6 (12.2%) BIG 1, 5 (10.2%) BIG 2, and 38 (77.6%) BIG 3 patients evaluated at the Level III trauma center. All BIG 1 and BIG 2 patients remained at the Level III trauma center, and 33 of the 38 BIG 3 patients were transferred. There were no complications, readmissions, or unexpected transfers within the BIG 1 or BIG 2 patient cohorts.

Conclusion

The BIG criteria can be successfully implemented in a Level III trauma center. A collaborative transfer agreement with a Level I trauma center reduces unnecessary transfers without negatively affecting patient care. The BIG criteria should be considered for well-developed regional trauma systems.

ACR Appropriateness Criteria® Head Trauma: 2021 Update

Head trauma (ie, head injury) is a significant public health concern and is a leading cause of morbidity and mortality in children and young adults. Neuroimaging plays an important role in the management of head and brain injury, which can be separated into acute (0-7 days), subacute (<3 months), then chronic (>3 months) phases. Over 75% of acute head trauma is classified as mild, of which over 75% have a normal Glasgow Coma Scale score of 15, therefore clinical practice guidelines universally recommend selective CT scanning in this patient population, which is often based on clinical decision rules. While CT is considered the first-line imaging modality for suspected intracranial injury, MRI is useful when there are persistent neurologic deficits that remain unexplained after CT, especially in the subacute or chronic phase. Regardless of time frame, head trauma with suspected vascular injury or suspected cerebrospinal fluid leak should also be evaluated with CT angiography or thin-section CT imaging of the skull base, respectively. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Assessing the efficacy of mild traumatic brain injury management

OBJECTIVE

Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI.

METHODS

Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included.

RESULTS

Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion.

CONCLUSION

Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

Low-Value Clinical Practices in Adult Traumatic Brain Injury: An Umbrella Review

Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias.

The “Headstrike” Protocol: A Retrospective Review of a Single Trauma Center's Operational Change in the Management of Anticoagulated Ground-Level Falls

Anticoagulated older adults suffering ground-level falls are a specialty trauma population at risk for intracranial hemorrhage (ICH). Delays in diagnosis or initiation of anticoagulation reversal can lead to increased morbidity/mortality. A novel “Headstrike” protocol was implemented to improve the treatment efficacy and disposition of these patients. The study objective was to determine effectiveness of the “Headstrike” protocol in providing these patients with timely treatment and disposition, while maintaining positive outcomes. A trauma performance improvement database was queried for all “Headstrike” activations for a 12-month period after implementation. Demographics, patient care, and health data were collected. Descriptive statistics were used for cohort analysis. Five hundred fifteen patients were activated as a “Headstrike” during the study period. Thirty eight patients were diagnosed with ICH (7.4%), 35 of whom were identified on initial imaging. Anticoagulation reversal was ordered for 84.6 per cent of these patients. Of the patients with negative initial CT, only three patients (0.8%) were found to have a delayed ICH on routine follow-up imaging. No anticoagulant/antiplatelet agent was associated with a significantly higher risk of ICH. Implementation of the “Headstrike” protocol resulted in trauma service line resources being used more efficiently, while ensuring high-quality, expeditious care to this population.

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Routine repeat head CT may not be necessary for patients with mild TBI

Background

Routine repeat cranial CT (RHCT) is standard of care for CT-verified traumatic brain injury (TBI). Despite mixed evidence, those with mild TBI are subject to radiation and expense from serial CT scans. Thus, we investigated the necessity and utility of RHCT for patients with mild TBI. We hypothesized that repeat head CT in these patients would not alter patient care or outcomes.

Methods

We retrospectively studied patients suffering from mild TBI (Glasgow Coma Scale (GCS) score 13–15) and treated at the R Adams Cowley Shock Trauma Center from November 2014 through January 2015. The primary outcome was the need for surgical intervention. Outcomes were compared using paired Student’s t-test, and stratified by injury on initial CT, GCS change, demographics, and presenting vital signs (mean ± SD).

Results

Eighty-five patients met inclusion criteria with an average initial GCS score=14.6±0.57. Our center sees about 2800 patients with TBI per year, or about 230 per month. This includes patients with concussions. This sample represents about 30% of patients with TBI seen during the study period. Ten patients required operation (four based on initial CT and others for worsening GCS, headaches, large unresolving injury). There was progression of injury on repeat CT scan in only two patients that required operation, and this accompanied clinical deterioration. The mean brain Abbreviated Injury Scale (AIS) score was 4.8±0.3 for surgical patients on initial CT scan compared with 3.4±0.6 (P<0.001) for non-surgical patients. Initial CT subdural hematoma size was 1.1±0.6 cm for surgical patients compared with 0.49±0.3 cm (P=0.05) for non-surgical patients. There was no significant difference between intervention groups in terms of other intracranial injuries, demographics, vital signs, or change in GCS. Overall, 75 patients that did not require surgical intervention received RHCT. At $340 per CT, $51 000 was spent on unnecessary imaging ($367 000/year, extrapolated).

Discussion

In an environment of increased scrutiny on healthcare expenditures, it is necessary to question dogma and eliminate unnecessary cost. Our data questions the use of routine repeat head CT scans in every patient with anatomic TBI and suggests that clinically stable patients with small injury can simply be followed clinically.

Level of evidence

Level III.

ACR Appropriateness Criteria Head Trauma

Neuroimaging plays an important role in the management of head trauma. Several guidelines have been published for identifying which patients can avoid neuroimaging. Noncontrast head CT is the most appropriate initial examination in patients with minor or mild acute closed head injury who require neuroimaging as well as patients with moderate to severe acute closed head injury. In short-term follow-up neuroimaging of acute traumatic brain injury, CT and MRI may have complementary roles. In subacute to chronic traumatic brain injury, MRI is the most appropriate initial examination, though CT may have a complementary role in select circumstances. Advanced neuroimaging techniques are areas of active research but are not considered routine clinical practice at this time. In suspected intracranial vascular injury, CT angiography or venography or MR angiography or venography is the most appropriate imaging study. In suspected posttraumatic cerebrospinal fluid leak, high-resolution noncontrast skull base CT is the most appropriate initial imaging study to identify the source, with cisternography reserved for problem solving. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Update in mild traumatic brain injury

There has been concern for many years regarding the identification of patients with mild traumatic brain injury (TBI) at high risk of developing an intracranial lesion (IL) that would require neurosurgical intervention. The small percentage of patients with these characteristics and the exceptional mortality associated with mild TBI with IL have led to the high use of resources such as computerised tomography (CT) being reconsidered. The various protocols developed for the management of mild TBI are based on the identification of risk factors for IL, which ultimately allows more selective indication or discarding both the CT application and the hospital stay for neurological monitoring. Finally, progress in the study of brain injury biomarkers with prognostic utility in different clinical categories of TBI has recently been incorporated by several clinical practice guidelines, which has allowed, together with clinical assessment, a more accurate prognostic approach for these patients to be established.

Utility of repeat head computed tomography after mild head trauma: influence on short- and long-term prognosis and health-related quality of life

The aim of this study was to investigate the utility of repeat head CT in a large population of patients with non-isolated blunt mild head trauma (MTBI), especially in the presence of intracranial injury. This is a study of a cohort of 478 non-isolated MTBI patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to December 2013. Results of initial and subsequent head CT scans, and indications for repeat head CT scan (routine vs. neurologic change) were recorded. The study population was divided into two subgroups: 28 (6 %) patients with neurological change or persistently reduced GCS (group GCS-) and 450 (94 %) patients with normal or improving GCS (group GCS+). After 6 months from the event, a telephone interview using SF12 questionnaire was conducted. Among GCS- patients, the admission CT scan showed intracranial lesions (ICI) in 16 (57 %) patients; only two patients had a TBI-related neurosurgical intervention. Among GCS+ patients, the first CT scan showed an ICI in 133 patients; in a significant proportion of patients with ICI at the first CT scan, the injury worsened (40/133, 30 %, p < 0.0001). However, no GCS+ patient had any neurosurgical intervention. We observed a significant reduction in both MCS and PCS scores after the injury compared with the previous period. The number of repeat CT scan was high in patients who presented ICI at the first CT scan; however, no patient with ICI and normal or improving GCS score needed a neurosurgical intervention.

Imaging Evaluation of Acute Traumatic Brain Injury

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Imaging plays an important role in the evaluation, diagnosis, and triage of patients with TBI. Recent studies suggest that it also helps predict patient outcomes. TBI consists of multiple pathoanatomic entities. This article reviews the current state of TBI imaging including its indications, benefits and limitations of the modalities, imaging protocols, and imaging findings for each of these pathoanatomic entities. Also briefly surveyed are advanced imaging techniques, which include several promising areas of TBI research.

Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis

BACKGROUND

Delayed intracranial hemorrhage is a potential complication of head trauma in anticoagulated patients.

OBJECTIVE

Our aim was to use a systematic review and meta-analysis to determine the risk of delayed intracranial hemorrhage 24 h after head trauma in patients who have a normal initial brain computed tomography (CT) scan but took vitamin K antagonist before injury.

METHODS

EMBASE, Medline, and Cochrane Library were searched using controlled vocabulary and keywords. Retrospective and prospective observational studies were included. Outcomes included positive CT scan 24 h post-trauma, need for surgical intervention, or death. Pooled risk was estimated with logit proportion in a random effect model with 95% confidence intervals (CIs).

RESULTS

Seven publications were identified encompassing 1,594 patients that were rescanned after a normal first head scan. For these patients, the pooled estimate of the incidence of intracranial hemorrhage on the second CT scan 24 h later was 0.60% (95% CI 0-1.2%) and the resulting risk of neurosurgical intervention or death was 0.13% (95% CI 0.02-0.45%).

CONCLUSIONS

The present study is the first published meta-analysis estimating the risk of delayed intracranial hemorrhage 24 h after head trauma in patients anticoagulated with vitamin K antagonist and normal initial CT scan. In most situations, a repeat CT scan in the emergency department 24 h later is not necessary if the first CT scan is normal. Special care may be required for patients with serious mechanism of injury, patients showing signs of neurologic deterioration, and patients presenting with excessive anticoagulation or receiving antiplatelet co-medication.

Results of delayed follow-up imaging in traumatic brain injury

OBJECT

There is a paucity of scientific evidence available about the benefits of outpatient follow-up imaging for traumatic brain injury patients. In this study, 1 year of consecutive patients at a Level 1 trauma center were analyzed to determine if there is any benefit to routinely obtaining CT of the head at the outpatient follow-up visit.

METHODS

This single-institution retrospective review was performed on all patients with a traumatic brain injury seen at a Level 1 trauma center in 2013. Demographic data, types of injuries, surgical interventions, radiographic imaging in inpatient and outpatient settings, and outcomes were assessed through a review of the institution’s trauma registry, patient charts, and imaging.

RESULTS

Five hundred twenty-five patients were seen for traumatic brain injury in 2013 at Regional One Health in Memphis, Tennessee. One hundred eighty-five patients (35%) presented for outpatient follow-up, all with CT scans of the head. Seven of these patients (4%) showed worsening of their intracranial injuries on outpatient imaging studies; however, surgical intervention was recommended for only 3 of these patients (2%). All patients requiring an intervention had neurological deterioration prior to their follow-up appointment.

CONCLUSIONS

These experiences suggest that outpatient follow-up imaging for traumatic brain injury should be done selectively, as it was not helpful for patients who did not exhibit worsening of neurological signs or symptoms. Furthermore, routine outpatient imaging results in unnecessary resource utilization and radiation exposure.

NIR light propagation in a digital head model for traumatic brain injury (TBI)

Near infrared spectroscopy (NIRS) is capable of detecting and monitoring acute changes in cerebral blood volume and oxygenation associated with traumatic brain injury (TBI). Wavelength selection, source-detector separation, optode density, and detector sensitivity are key design parameters that determine the imaging depth, chromophore separability, and, ultimately, clinical usefulness of a NIRS instrument. We present simulation results of NIR light propagation in a digital head model as it relates to the ability to detect intracranial hematomas and monitor the peri-hematomal tissue viability. These results inform NIRS instrument design specific to TBI diagnosis and monitoring.

Neuroimaging in adult penetrating brain injury: a guide for radiographers

Penetrating brain injuries (PBI) are a medical emergency, often resulting in complex damage and high mortality rates. Neuroimaging is essential to evaluate the location and extent of injuries, and to manage them accordingly. Currently, a myriad of imaging modalities are included in the diagnostic workup for adult PBI, including skull radiography, computed tomography (CT), magnetic resonance imaging (MRI) and angiography, with each modality providing their own particular benefits. This literature review explores the current modalities available for investigating PBI and aims to assist in decision making for the appropriate use of diagnostic imaging when presented with an adult PBI. Based on the current literature, the authors have developed an imaging pathway for adult penetrating brain injury that functions as both a learning tool and reference guide for radiographers and other health professionals. Currently, CT is recommended as the imaging modality of choice for the initial assessment of PBI patients, while MRI is important in the sub-acute setting where it aids prognosis prediction and rehabilitation planning, Additional follow-up imaging, such as angiography, should be dependent upon clinical findings.