Diagnosis and management of minor head injury: a regional multicenter approach in Italy

Classification and management of mild head trauma

Mild head trauma had been defined in patients with direct impact or deceleration effect admitted with a Glasgow Coma Scale score of 13-15. It is one of the most frequent causes of morbidity in emergency medicine. Although common, several controversies persist about its clinical management. In this paper, we describe the Brazilian guidelines for mild head trauma, based on a critical review of the relevant literature.

A more detailed classification of mild head injury in adults and treatment guidelines

OBJECTIVE

The purpose of this study was to analyze risk factors that are associated with intracranial lesion, and to propose criteria for classification of mild head injury (MHI), and appropriate treatment guidelines.

METHODS

The study was based on 898 patients who were admitted to our hospital with Glasgow Coma Scale (GCS) score of 13 to 15 between 2003 and 2007. The patients' initial computerized tomography (CT) findings were reviewed and clinical findings that were associated with intracranial lesions were analyzed.

RESULTS

GCS score, loss of consciousness (LOC), age and skull fracture were identified as independent risk factors for intracranial lesions. Based on the data analysed in this study, MHI patients were divided into four subgroups : very low risk MHI patients are those with a GCS score of 15 and without a history of LOC or headache; low risk MHI patients have a GCS score of 15 and with LOC and/or headache; medium risk MHI patients are those with a GCS score of 15 and with a skull fracture, neurological deficits or with one or more of the risk factors; high risk MHI patients are those with a GCS score of 15 with abnormal CT findings and GCS score of 14 and 13.

CONCLUSION

A more detailed classification of MHI based on brain CT scan findings and clinical risk factors can potentially improve patient diagnosis. In light of our findings, high risk MHI patients should be admitted and treated in same manner as those with moderate head injury.

CT and MR imaging of acute cranial trauma

A wide variety of imaging findings can be seen in the setting of acute head trauma. The purpose of this manuscript is to review the major computed tomography and magnetic resonance imaging findings of various types of traumatic head injuries with the intent of providing the reader with a means to diagnose these lesions quickly and accurately.

Indications for CT Scanning in Mild Traumatic Brain Injury: A Cost-Effectiveness Study

BACKGROUND

There is considerable uncertainty about the indications for cranial computed tomography (CT) scanning in patient with minor traumatic brain injury (TBI). This analysis involves an evidence-based comparison of several strategies for selecting patients for CT with regard to effectiveness and cost.

METHODS

We performed a structured literature review of mild traumatic brain injury and constructed a cost-effectiveness model. The model estimated the impact of missed intracranial lesions on longevity, quality of life and costs. Using a 20-year-old patient for primary analysis, we compared the following strategies to screen for the need to perform a CT scan: observation in the emergency department or hospital floor, skull radiography, Selective CT based on the presence of additional risk factors and scanning all.

RESULTS

Outcome measures for each strategy included average years of life, quality of life and costs. Selective CT and the CT All policy performed significantly better than the alternatives with respect to outcome. They were also less expensive in terms of total direct health care costs, although the differences did not reach statistical significance. The model yielded similar, but smaller, differences between the selective imaging and other strategies when run for older patients.

CONCLUSIONS

Although the incidence of intracranial lesions, especially those that require surgery, is low in mild TBI, the consequences of delayed diagnosis are forbidding. Adverse outcome of an intracranial hematoma is so costly that it more than balances the expense of CT scans. In our cost-effectiveness model, the liberal use of CT scanning in mild TBI appears justified.

The value of cranial computed tomography in high-risk, mildly head-injured patients

BACKGROUND

The purpose of this article was to assess if high-risk, mildly head-injured patients with normal CT scan present an outcome similar to the group with "low-risk MHI."

METHODS

A total of 379 hospital charts of inpatients with Glasgow Coma Scale scores of 13, 14, and 15 were reviewed. Information regarding age, fGCS, trauma mechanism, cranial CT scan findings, hospital course, and follow-up using the GOS were obtained from all patients.

RESULTS

Patients were separated in 3 groups: fGCS 13 (46 patients), fGCS 14 (138 patients), and fGCS 15 (195 patients). The groups with different scores on fGCS did not differ regarding CT scan abnormalities, surgical treatment, or outcome. Patients were also separated in 2 groups based on CT scan findings: 266 patients had CT interpreted as abnormal and 113 had CT interpreted as normal. The 2 groups differed statistically regarding surgical treatment and scores on GOS (P < .05). There was no statistically significant difference between the 2 groups regarding sex, trauma mechanism, fGCS, or age.

CONCLUSIONS

Our findings support the idea that a normal cranial CT scan in patients with fGCS scores of 13 or higher ascertain a low-risk MHI outcome and, therefore, such patients must be included in this category of traumatic brain injury. On the other hand, patients with cranial CT scan abnormalities should be included in the group with moderate head injury.

Imaging of maxillofacial trauma: Evolutions and emerging revolutions

The aim of diagnostic imaging for maxillofacial trauma is to provide additional information that can positively influence medical or surgical patient management. Current advances in diagnostic imaging have come from the confluence of 3 driving forces: (1) the demand from clinicians to enhance and expand their diagnostic abilities; (2) the development of new theoretical concepts by basic scientists; and (3) the application of concepts by engineers and manufacturers to provide increasingly sophisticated imaging capabilities. The role of imaging within the health care environment is, however, also buffeted by the complex, sometimes competing, interactions of external social, political, economic, and technological pressures at the national, regional, and local levels. The purposes of this review are to provide a perspective on current imaging modalities used for maxillofacial trauma and to provide an insight into the influences, both technologic and external, on future developments and applications.

A meta-analysis of variables that predict significant intracranial injury in minor head trauma

BACKGROUND

Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury.

AIMS

To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population.

METHODS

The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected.

OUTCOME VARIABLE

CT presence or absence of ICH.

RESULTS

Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to 22 420. Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0).

CONCLUSIONS

There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups.

Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study

OBJECT

The aims of this study were to analyze the relevance of risk factors in mild head injury (MHI) by studying the possibility of establishing prediction models based on these factors and to evaluate the reliability of the clinical guidelines proposed for the management of MHI.

METHODS

A series of 1101 patients with MHI were prospectively enrolled in this study. In all cases clinical data were collected and a computerized tomography (CT) scan was obtained. The relationship between clinical findings and the presence of intracranial lesions was studied to establish prediction models based on logistic regression and recursive partitioning analysis. Recently proposed guidelines and recommendations for the treatment of MHI were selected, calculating their diagnostic efficiency when applying each of them to our series. The incidence of acute intracranial lesions was 7.5% (83 patients). A Glasgow Coma Scale score of 14, loss of consciousness, vomiting, headache, signs of basilar skull fracture, neurological deficit, coagulopathies, hydrocephalus treated with shunt insertion, associated extracranial lesions, and patient age greater than 65 years were identified as independent risk factors. Prediction models built on clinical variables were able to indicate patients with clinically important lesions, but failed to achieve 100% sensitivity in the detection of all patients with CT scans positive for intracranial lesions within reasonable specificity limits.

CONCLUSIONS

Clinical variables are insufficient to predict all cases of intracranial lesions following MHI, although they can be used to detect patients with relevant injuries. Avoiding systematic CT scan indication implies a rate of misdiagnosis that should be known and assumed when planning treatment in these patients by using guidelines based on clinical parameters.

[Minor head injury management in Spain: a multicenter national survey]

INTRODUCTION AND OBJECTIVES

Despite of the high incidence of minor head injury, there is still controversy and disparity of criteria regarding its management. The lack of consensual protocols and clinical guidelines can lead to deficiencies in the attention to these patients and to inadequate use of resources. The objective of this study has been to describe the present situation of the management of this entity in the neurosurgical departments of the Spanish public hospitals, and to compare it with other European countries.

MATERIAL AND METHODS

A 57-item questionnaire regarding different aspects of minor head injury was designed and distributed to the 66 neurosurgical departments of the Spanish National Health System between December 1999 and February 2000.

RESULTS

A 83.3% of responses were obtained. More than 92,000 patients per year are assisted at the Spanish third-level hospitals (general hospitals) after suffering a minor head injury. In-hospital on duty neurosurgeons are not available in 49.1% of the Spanish neurosurgical departments. Only in 7.3% of the centres the neurosurgeon is the first physician that assists these patients. However, in 52.7% of the hospitals neurosurgical evaluation is required if the patient refers transient loss of consciousness. A GCS score of 13 is still included in the group of minor head injuries in 29.1% of the centres. Although 89.1% of the surveyed neurosurgical departments considered as satisfactory the attention they provide to these patients, 85.5% think that it would be convenient to elaborate clinical guidelines. Cranial x-ray is considered a useful diagnostic tool by only 38.2% of the centres, however, 89.1% of them still use it as a routine. CT-scan is systematically indicated in all patients after suffering a mild head trauma only in 5.5% of the centres, although it is completely available in 74.5% of them. The study of economical costs shows that choosing cranial CT as screening tool in these patients would mean a 40.6% reduction in costs compared to a management based on x-ray plus in-hospital observation.

CONCLUSIONS

This study shows the inter-hospital variability of minor head injury management in Spain. Clinical guidelines are considered as positive and necessary. Although the Spanish situation is similar to that in other European countries, following the tendency toward a broader cranial CT utilisation, would improve diagnosis profitability and economical efficiency. The results of this study may contribute to the creation of consensual protocols and clinical guidelines in our country that help in daily practice decision-making optimising assistance quality.

The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation)

Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated 1 million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale score of 13 to 15. Although most patients with minor head injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived. [Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A, for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.]

Value of radiological diagnosis of skull fracture in the management of mild head injury: meta-analysis

OBJECTIVES

Head injury is a common event. Most patients sustain a mild head injury (MHI), and management depends on the risk of an intracranial haemorrhage (ICH). The value of a plain skull radiograph as a screening tool for ICH is controversial. The aim of this meta-analysis was to estimate and explain differences in reported sensitivity and specificity of the finding of a skull fracture for the diagnosis of ICH, in order to assess the value of the plain skull radiograph in the investigation of patients with MHI, and to estimate the prevalence of ICH in these patients.

METHOD

After a systematic literature search 20 studies were selected that reported data on the prevalence of ICH after MHI and/or data on the diagnostic value of skull fracture for the diagnosis of ICH. The mean prevalence of ICH weighted for the sample size was determined. The sensitivity and specificity of different studies were combined using a summary receiver operator characteristic curve. Correlation analysis was used to determine factors that could explain the reported differences between studies.

RESULTS

The weighted mean prevalence of ICH after MHI is 0.083. The potential for verification bias and the percentage of patients who had suffered loss of consciousness or post-traumatic amnesia were the most significant factors explaining interstudy differences in sensitivity and specificity. Based on studies wherein at least 50% of patients had a CT study of the brain, the estimated sensitivity of a radiographic finding of skull fracture for the diagnosis of ICH is 0.38 with a corresponding specificity of 0.95.

CONCLUSION

The plain skull radiograph is of little value in the initial assessment of MHI patients.

Variation in ED use of computed tomography for patients with minor head injury

STUDY OBJECTIVE

To determine the frequency of utilization, yield for brain injury, incidence of missed injury, and variation in the use of computed tomography (CT) for ED patients with minor head injury.

METHODS

This retrospective health records survey was conducted over a 12-month period in the EDs at seven Canadian teaching institutions. Included in this review were adult patients who sustained acute minor head injury, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale score of 13 or greater. Data were collected by research assistants who were trained to select cases and abstract data in a standardized fashion according to a resource manual. Subsequently, patient eligibility was reviewed by the study coordinator and principal investigator.

RESULTS

Of the 1,699 patients seen, 521 (30.7%) were referred for CT, and 418 (79.8%) of these scans were negative for any type of brain injury. Overall, 105 (6.2%) of these patients sustained acute brain injury, including 9 (.5%) with an epidural hematoma Cochran's Q test for homogeneity demonstrated significant variation between the seven centers for rate of ordering CT (P < .0001), from a low of 15.9% to a high of 70.4%. All five cases of "missed" hematoma occurred at the institutions with the highest and third highest rates of CT use. After controlling for possible differences in case severity and patient characteristics at each hospital, logistic regression analysis revealed that five of seven hospitals were significantly associated with the use of CT (respected odds ratios [OR], .4, .5, .5, 3.2, and 4.7). Three of the centers (two with the highest ordering rates) showed significant heterogeneity in the ordering of CT among their attending staff physicians, from a low of 6.5% to a high of 80.0%.

CONCLUSION

There was considerable variation among institutions and individual physicians in the ordering of CT for patients with minor head injury. Although emergency physicians were selective when ordering CT, the yield of radiography was very low at all hospitals. None of the cases of "missed" intracranial hematoma came from the lowest ordering institutions, indicating that patients may be managed safely with a selective approach to CT use. These findings suggest great potential for more standardized and efficient use of CT of the head, possibly through the use of a clinical decision rule.

Compelling evidence for discretionary brain computed tomographic imaging in those patients with mild cognitive impairment after blunt trauma

OBJECTIVE

To identify computed tomographic-detected intracranial hemorrhage (CTIH) risk factors and outcome in mild cognitive impairment (MCI) blunt trauma patients.

METHODS

In 2,587 consecutive patients, 251 (9.7%) had CTIH.

RESULTS

Analysis is on 2,252 direct transports with 163 CTIH, because transfers were different (7.2 vs. 26.3%, p < 0.0001). CTIH rates for patients age 14-60 and > 60 years were 6.3 and 15.9%, p = 0.001. In those 14-60 years (n = 2,032), CTIH (n = 128) was independently related to arrival Glasgow Coma Scale (GCS) score and cranial soft tissue injury (CSTI) (p = 0.0001). [table: see text] Craniotomy was < or = 0.6% in each group except GCS score of 13 with CSTI, 7.4%. Of those with CTIH, 98.4% survived. Of those at low risk (GCS score of 14 without CSTI and GCS score of 15), 1,504 had no CTIH. Of these, 64.4% were available for serial cognitive evaluation (noncranial injuries mandated hospitalization; tracheal intubation was not required). In those > 60 years (n = 220), CTIH (n = 35) was independently related to GCS and CSTI (p = 0.003). CTIH for GCS score of 15 without CSTI was 5.8%, but > or = 16% for others. One craniotomy was required. Of those with CTIH, 91.4% survived.

CONCLUSIONS

In mild cognitive impairment patients triaged directly to a Level I trauma center, age, arrival GCS score, and cranial soft tissue injury are risk factors for CT-detected intracranial hemorrhage. Neurologic deterioration and death are infrequent. These data strongly suggest that observation and discretionary brain CT imaging are a rational approach for blunt-injury mild cognitive impairment.