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

Global traumatic brain injury intracranial pressure: from monitoring to surgical decision

Traumatic brain injury (TBI) is a significant global public health issue, heavily impacting human health, especially in low-and middle-income areas. Despite numerous guidelines and consensus statements, TBI fatality rates remain high. The pathogenesis of severe TBI is closely linked to rising intracranial pressure (ICP). Elevated intracranial pressure can lead to cerebral herniation, resulting in respiratory and circulatory collapse, and ultimately, death. Managing intracranial pressure (ICP) is crucial in neuro-intensive care. Timely diagnosis and precise treatment of elevated ICP are essential. ICP monitoring provides real-time insights into a patient's condition, offering invaluable guidance for comprehensive management. ICP monitoring and standardization can effectively reduce secondary nerve damage, lowering morbidity and mortality rates. Accurately assessing and using true ICP values to manage TBI patients still depends on doctors' clinical experience. This review discusses: (a) Epidemiological disparities of traumatic brain injuries across countries with different income levels worldwide; (b) The significance and function of ICP monitoring; (c) Current status and challenges of ICP monitoring; (d) The impact of decompressive craniectomy on reducing intracranial pressure; and (e) Management of TBI in diverse income countries. We suggest a thorough evaluation of ICP monitoring, head CT findings, and GCS scores before deciding on decompressive craniectomy. Personalized treatment should be emphasized to assess the need for surgical decompression in TBI patients, offering crucial insights for clinical decision-making.

Whole-brain traumatic controlled cortical impact to the left frontal lobe: Magnetic resonance image-based texture analysis

This research assesses the capability of texture analysis (TA) derived from high-resolution (HR) T2-weighted magnetic resonance imaging to identify primary sequelae following 1-5 hours of controlled cortical impact mild or severe traumatic brain injury (TBI) to the left frontal cortex (focal impact) and secondary (diffuse) sequelae in the right frontal cortex, bilateral corpus callosum, and hippocampus in rats. The TA technique comprised first-order (histogram-based) and second-order statistics (including gray-level co-occurrence matrix, gray-level run length matrix, and neighborhood gray-level difference matrix). Edema in the left frontal impact region developed within 1 hour and continued throughout the 5-hour assessments. The TA features from HR images confirmed the focal injury. There was no significant difference among radiomics features between the left and right corpus callosum or hippocampus from 1 to 5 hours following a mild or severe impact. The adjacent corpus callosum region and the distal hippocampus region (s), showed no diffuse injury 1-5 hours after mild or severe TBI. These results suggest that combining HR images with TA may enhance detection of early primary and secondary sequelae following TBI.

The use of head computerized tomography in patients with GCS 15 following trauma: Less is more

INTRODUCTION

Computerized tomography (CT) imaging is a standard part of traumatic brain injury (TBI) evaluation but not all patients require it after mild head injury. Given the increasing incidence of TBI in the United States, there is an urgent need to better characterize CT head imaging utilization in evaluating trauma patients, especially patients at low risk of requiring intervention, such as those presenting with a normal GCS.

METHODS

We analyzed the 2017-2019 National Trauma Databank using ICD-10 codes to identify patients who received a head CT. We used Abbreviated Injury Scale (AIS) scores to identify patients with a moderate to severe head injury defined as an AIS severity ≥ 3. Procedural TBI management was defined as having an intracranial monitor or operative decompression. We used a modified Poisson modeling to identify risk factors for a moderate/severe TBI and risk factors for undergoing procedural management among patients with head CT and GCS 15.

RESULTS

Of 2,850,036 patients, 1,502,039 (52.7%) had a head CT. Among patients who had a head CT, 1,078,093 patients (74.9%) had a GCS 15 on arrival. Of this group, only 16.6% (n = 176,431) had a moderate/severe head injury. For those with moderate/severe head injury, 6.0% (n = 10,544/176,431) of patients underwent procedural head injury management. Risk factors for undergoing procedural head injury management included: isolated head injury (RR 2.43, 95% CI 2.34, 2.53), male sex (RR 1.73, 95% CI 1.67, 1.80), age > 50 years (RR 1.39 95% CI 1.32, 1.47), falls (RR 1.28, 95% CI 1.22, 1.35), and the use of anti-coagulation (RR 1.16, 95% CI 1.11, 1.21).

CONCLUSION

Few patients had moderate/severe head injury when presenting with a GCS 15. However, patients ≥ 50 years, men, and those who suffered falls were at higher risk. Anti-coagulation use was not associated with moderate/severe head injury but did increase the risk of procedural TBI management. Given the cost and associated radiation, reducing CT utilization for younger patients while using a more liberal head CT strategy for high-risk patients may provide substantial patient value.

Rate of Intracranial Hemorrhage After Minor Head Injury

Introduction: Computed tomography scans of the head (CTH) are an important component of the initial patient evaluation after blunt head trauma in select patients. Here we review findings of CTH performed for mild traumatic brain injury (TBI) at a Level I trauma center over a two-year period. We subsequently discuss the role and limitations of published clinical decision rules aiming to decrease unnecessary CTH in mild TBI patients.

Methods: We reviewed all Emergency Department CTH obtained after blunt head trauma between 2010 and 2011. Patient demographics and radiology report texts were collected. Reports were cross-referenced with our institutional trauma database to obtain initial Glasgow Coma Scale (GCS). Mild TBI was defined by an initial GCS 13-15 with or without loss of consciousness or post-traumatic amnesia.

Results: There were 5,634 mild TBI patients evaluated with CTH. A total of 477 scans (8.5%) were positive for intracranial hemorrhage. Of these, 188 (39.4%) showed more than one type of intracranial hemorrhage. The most common findings were subdural hematomas (262, 4.7% of scans), traumatic subarachnoid hemorrhages (252, 4.5% of scans), and cerebral contusions/intraparenchymal hematomas (212, 3.8% of scans). Older age (p<0.001) and male gender (p<0.001) were associated with positive CTH.

Conclusions: The rate of positive CTH in mild TBI patients in our population falls within a historical range. The clinical and medicolegal implications of missed intracranial hemorrhage have remained important factors limiting the implementation of clinical decision rules in screening mild TBI patients for CTH.

Application of NICE or SNC guidelines may reduce the need for computerized tomographies in patients with mild traumatic brain injury: a retrospective chart review and theoretical application of five guidelines

BACKGROUND

Traumatic brain injuries continue to be a significant cause of mortality and morbidity worldwide. Most traumatic brain injuries are classified as mild, with a low but not negligible risk of intracranial hemorrhage. To help physicians decide which patients might benefit from a computerized tomography (CT) of the head to rule out intracranial hemorrhage, several clinical decision rules have been developed and proven effective in reducing the amount of negative CTs, but they have not been compared against one another in the same cohort as to which one demonstrates the best performance.

METHODS

This study involved a retrospective review of the medical records of patients seeking care between January 1 and December 31, 2017 at Helsingborg Hospital, Sweden after head trauma. The Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), the National Emergency X-Radiography Utilization Study II (NEXUS II), the National Institute of Health and Care Excellence (NICE) guideline and the Scandinavian Neurotrauma Committee (SNC) guideline were analyzed. A theoretical model for each guideline was constructed and applied to the cohort to yield a theoretical CT-rate for each guideline. Performance parameters were calculated and compared.

RESULTS

One thousand three hundred fifty-three patients were included; 825 (61%) CTs were performed, and 70 (5.2%) cases of intracranial hemorrhage were found. The CCHR and the NOC were applicable to a minority of the patients, while the NEXUS II, the NICE, and the SNC guidelines were applicable to the entire cohort. A theoretical application of the NICE and the SNC guidelines would have reduced the number of CT scans by 17 and 9% (P = < 0.0001), respectively, without missing patients with intracranial hemorrhages requiring neurosurgical intervention.

CONCLUSION

A broad application of either NICE or the SNC guidelines could potentially reduce the number of CT scans in patients suffering from mTBI in a Scandinavian setting, while the other guidelines seemed to increase the CT frequency. The sensitivity for intracranial hemorrhage was lower than in previous studies for all guidelines, but no fatality or need for neurosurgical intervention was missed by any guideline when they were applicable.

Clinical predictors of abnormal head computed tomography scan in patients who are conscious after head injury

Background:

Indication of a head computed tomography (CT) scan in a patient who remains conscious after head injury is controversial. We aimed to determine the clinical features that are most likely to be associated with abnormal CT scan in patients with a history of head injury, and who are conscious at the time of presentation to casualty.

Materials and Methods:

This is a prospective observation study of patients presented to casualty with history of head injury, and who were conscious, i.e., Glasgow Coma Scale (GCS) 15 at the time of evaluation. All patients underwent head CT scan. The CT scan was reported as abnormal if it showed any pathology ascribed to trauma. The following variables were used: age, gender, mode of injury (road traffic accident, fall, assault, and others), duration since injury, and history of transient loss of consciousness, headache, vomiting, ear/nose bleeding, and seizures. Logistic regression analysis was used to identify the clinical features that predicted an abnormal CT scan.

Results:

During the observation period, a total of 1629 patients with head injury were evaluated, out of which 453 were in GCS 15. Abnormal CT scan was present in 195 (43%) patients. Among all the variables, the following were found significantly associated with abnormal CT scan: duration since injury (>12 h) P < 0.001; vomiting odds, ratio (OR) 1.89 (1.23, 2.80), P < 0.001; and presence of any symptom, OR 2.36 (1.52, 3.71), P < 0.001.

Conclusion:

A patient with GCS 15 presenting after 12 hours of injury with vomiting or combination of symptoms has a significant risk of abnormal head CT scan.

Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury

Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.

Economic evaluation of the NET intervention versus guideline dissemination for management of mild head injury in hospital emergency departments

BACKGROUND

Evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available, and yet, clinical practice remains inconsistent with the guidelines. The Neurotrauma Evidence Translation (NET) intervention was developed to increase the uptake of guideline recommendations and improve the management of minor head injury in Australian emergency departments (EDs). However, the adoption of this type of intervention typically entails an upfront investment that may or may not be fully offset by improvements in clinical practice, health outcomes and/or reductions in health service utilisation. The present study estimates the cost and cost-effectiveness of the NET intervention, as compared to the passive dissemination of the guideline, to evaluate whether any improvements in clinical practice or health outcomes due to the NET intervention can be obtained at an acceptable cost.

METHODS AND FINDINGS

Study setting: The NET cluster randomised controlled trial [ACTRN12612001286831].

STUDY SAMPLE

Seventeen EDs were randomised to the control condition and 14 to the intervention. One thousand nine hundred forty-three patients were included in the analysis of clinical practice outcomes (NET sample). A total of 343 patients from 14 control and 10 intervention EDs participated in follow-up interviews and were included in the analysis of patient-reported health outcomes (NET-Plus sample).

OUTCOME MEASURES

Appropriate post-traumatic amnesia (PTA) screening in the ED (primary outcome). Secondary clinical practice outcomes: provision of written information on discharge (INFO) and safe discharge (defined as CT scan appropriately provided plus PTA plus INFO). Secondary patient-reported, post-discharge health outcomes: anxiety (Hospital Anxiety and Depression Scale), post-concussive symptoms (Rivermead), and preference-based health-related quality of life (SF6D).

METHODS

Trial-based economic evaluations from a health sector perspective, with time horizons set to coincide with the final follow-up for the NET sample (2 months post-intervention) and to 1-month post-discharge for the NET-Plus sample.

RESULTS

Intervention and control groups were not significantly different in health service utilisation received in the ED/inpatient ward following the initial mTBI presentation (adjusted mean difference $23.86 per patient; 95%CI - $106, $153; p = 0.719) or over the longer follow-up in the NET-plus sample (adjusted mean difference $341.78 per patient; 95%CI - $58, $742; p = 0.094). Savings from lower health service utilisation are therefore unlikely to offset the significantly higher upfront cost of the intervention (mean difference $138.20 per patient; 95%CI $135, $141; p < 0.000). Estimates of the net effect of the intervention on total cost (intervention cost net of health service utilisation) suggest that the intervention entails significantly higher costs than the control condition (adjusted mean difference $169.89 per patient; 95%CI $43, $297, p = 0.009). This effect is larger in absolute magnitude over the longer follow-up in the NET-plus sample (adjusted mean difference $505.06; 95%CI $96, $915; p = 0.016), mostly due to additional health service utilisation. For the primary outcome, the NET intervention is more costly and more effective than passive dissemination; entailing an additional cost of $1246 per additional patient appropriately screened for PTA ($169.89/0.1363; Fieller's 95%CI $525, $2055). For NET to be considered cost-effective with 95% confidence, decision-makers would need to be willing to trade one quality-adjusted life year (QALY) for 25 additional patients appropriately screened for PTA. While these results reflect our best estimate of cost-effectiveness given the data, it is possible that a NET intervention that has been scaled and streamlined ready for wider roll-out may be more or less cost-effective than the NET intervention as delivered in the trial.

CONCLUSIONS

While the NET intervention does improve the management of mTBI in the ED, it also entails a significant increase in cost and-as delivered in the trial-is unlikely to be cost-effective at currently accepted funding thresholds. There may be a scope for a scaled-up and streamlined NET intervention to achieve a better balance between costs and outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612001286831 , date registered 12 December 2012.

The Role of Oxidative Status in Initial Evaluation of Paediatric Patients with Graded Traumatic Brain Injury

Introduction

The purposes of this study were (a) to investigate the oxidative and antioxidative status in paediatric patients with varying severity of traumatic brain injury (TBI) during the early post-traumatic period; (b) to correlate injury severity with the oxidative and antioxidative status of patients; and (c) to identify early predictors of outcome in patients with TBI.

Methods

Fifty-two consecutive paediatric patients with isolated TBI and 31 age- and sex-matched healthy controls were enrolled. Patients were divided into two groups based on their Glasgow Coma Scale (GCS) scores recorded upon admission to the emergency department within the first 24 hours after injury. Twenty-three patients with moderate to severe TBI and 29 patients with mild TBI (GCS scores of >13) were included. The primary outcome variable was hospital mortality. Plasma total oxidant status (TOS), total antioxidant status (TAS), and the oxidative stress index (OSI) were assessed as predictors of early oxidative changes in serum using a novel automated measurement method.

Results

Compared to patients with mild TBI, TOS and OSI values were markedly elevated in patients with moderate to severe TBI. However, TAS levels did not show significant changes in either group of patients. Both GCS scores and Revised Trauma Scores were negatively correlated with the TOS and OSI, but neither was significantly correlated with the TAS. The TOS and OSI were significantly higher in non-survivors than in survivors. However, there was no significant difference in TAS levels between survivors and non-survivors.

Conclusion

Paediatric patients with isolated TBI are exposed to extensive oxidative stress, which varies with injury severity.

Incidence of combined cranial and cervical spine injuries in patients with blunt minor trauma: are combined CT examinations of the head and cervical spine justified?

Background The use of computed tomography (CT) scans of the head and cervical spine has markedly increased in patients with blunt minor trauma. The actual likelihood of a combined injury of head and cervical spine following a minor trauma is estimated to be low. Purpose To determine the incidence of such combined injuries in patients with a blunt minor trauma in order to estimate the need to derive improved diagnostic guidelines. Material and Methods A total of 1854 patients were retrospectively analyzed. All cases presented to the emergency department and in all patients combined CT scans of head and cervical spine were conducted. For the following analysis, only 1342 cases with assured blunt minor trauma were included. Data acquisition covered age, sex, and presence of a head injury as well as presence of a cervical spine injury or both. Results Of the 1342 cases, 46.9% were men. The mean age was 65.6 years. CT scans detected a head injury in 116 patients; of these, 70 cases showed an intracranial hemorrhage, 11 cases a skull fracture, and 35 cases an intracranial hemorrhage as well as a skull fracture. An injury of the cervical spine could be detected in 40 patients. A combined injury of the head and cervical spine could be found in one patient. Conclusion The paradigm of the coincidence of cranial and cervical spine injuries should be revised in patients with blunt minor trauma. Valid imaging decision algorithms are strongly needed to clinically detect high-risk patients in order to save limited resources.

Post-traumatic headache in patients with minimal traumatic intracranial hemorrhage after traumatic brain injury: a retrospective matched case-control study

BACKGROUND

No evidence is available on the risks of neurologically asymptomatic minimal traumatic intracranial hemorrhage (mTIH) in patients with traumatic brain injury (TBI) for post-traumatic headache (PTH). The purpose of this study was to investigate whether mTIH in patients with TBI was associated with PTH and to evaluate its risk factors.

METHODS

Between September 2009 and December 2014, 1484 patients with TBI were treated at our institution, 57 of whom had mTIH after TBI and were include in this study. We performed propensity score matching to establish a control group among the 823 patients with TBI treated during the same period. Patients with TBI rated their headaches prospectively using a numeric rating scale (NRS). We compared NRS scores between mTIH group (n = 57) and non-mTIH group (n = 57) and evaluated risk factors of moderate-to-severe PTH (NRS ≥ 4) at the 12-month follow-up.

RESULTS

Moderate-to-severe PTH was reported by 21.9% of patients (29.8% in mTIH group and 14.0% in non-mTIH group B, p = 0.012) at the 12-month follow-up. The mean NRS was higher in mTIH group than in non-mTIH group throughout the follow-up period (95% confidence interval [CI], 0.11 to 1.14; p < 0.05, ANCOVA). Logistic regression analysis showed that post-traumatic seizure (odds ratio, 1.520; 95% CI, 1.128-6.785; p = 0.047) and mTIH (odds ratio, 2.194; 95% CI, 1.285-8.475; p = 0.039) were independently associated with moderate-to-severe PTH at the 12-month follow-up.

CONCLUSIONS

Moderate-to-severe PTH can be expected after TBI in patients with mTIH and post-traumatic seizure. PTH occurs more frequently in patients with mTIH than in those without mTIH.

The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy

INTRODUCTION

Increasing active longevity has created an increasing surge of elderly trauma patients. The majority of these patients suffer blunt trauma and many are taking antithrombotic agents. The literature is mixed regarding the utility of routine repeat head CT in patients taking antithrombotic medications with a GCS of 15 and initial negative head CT. We hypothesized that scheduled delayed CT head 12 h after admission (D-CTH) in elderly blunt trauma victims would not identify clinically significant new hemorrhages or change management.

METHODS

A retrospective chart review using our institutional trauma registry of patients ≥65 years sustaining blunt head injuries from 2010 to 2012 was performed. By hospital protocol, all such patients on antithrombotic therapy receive a routine D-CTH. All of these patients were included. Demographics, injuries, medications, laboratory values, LOS, mental status, and management were analyzed.

RESULTS

Of the 234 patients meeting inclusion criteria, 8 initially were identified as having D-ICH. Upon further review, five patients had the same findings on both initial and delayed CT scans and one patient was determined to actually have had a hemorrhage stroke. Ultimately, only two patients (0.85%, 95% CI 0.1-3.1%) had new ICH discovered on D-CTH. None of the patients on warfarin demonstrated any new injury on D-CTH (95% CI ≤ 4.6%). Only one patient taking aspirin as a sole agent had a delayed injury on D-CTH (1.1%, 95% CI 0-4.2%). The remaining patient was taking a combination of aspirin and clopidogrel representing 2.2% of 45 patients on combination therapy (95% CI 0.1-11.8%). Only two patients taking a direct thrombin inhibitor (dabigatran) met inclusion criteria and neither endured a bleed (95% CI ≤ 77.6%). Further analysis revealed no cases with clinical changes or surgical intervention for new ICH on delayed imaging. No inference could be made to predict which patients would suffer D-ICH.

CONCLUSIONS

D-CTH in elderly trauma patients taking antithrombotic agents shows no statistically significant or clinical benefit for diagnosing delayed intracranial hemorrhage after minor head injury. In those with delayed imaging showing new ICH, management was not significantly altered. Not enough data were available to predict which patients would develop D-ICH, even if asymptomatic.

Does distracting pain justify performing brain computed tomography in multiple traumas with mild head injury?

Traumatic brain injury (TBI) is a significant health concern classified as mild, moderate, and severe. Although the indications to perform brain computed tomography (CT) are clear in moderate and severe cases, there still exists controversy in mild TBI (mTBI). We designed the study to evaluate the significance of distracting pain in patients with mTBI. The study population included patients with mild traumatic brain injury (GCS ≥13). Moderate and high risk factors including age <18 months or ≥60 years, moderate to severe or progressive headache, ≥2 episodes of vomiting, loss of consciousness (LOC), post-traumatic amnesia, seizure or prior antiepileptic use, alcohol intoxication, previous neurosurgical procedures, uncontrolled hypertension, anticoagulant use, presence of focal neurologic deficits, deformities in craniofacial region, and penetrating injuries were excluded. The patients were then grouped based on presence (DP+) or absence (DP-) of another organ fracture with severe pain (based on VAS). The primary outcome was any abnormal findings on brain CT scans; 330 patients were enrolled (184 DP+ and 146 DP-). Overall, two DP+ and one DP- patients had mild cerebral edema in brain CT (p > 0.99). No patients had any neurologic symptoms or signs in follow-up. Our results show that in the absence of any other risk factors, distracting pain from other organs (limbs, pelvis, and non-cervical spine) cannot be regarded as a brain CT indication in patients with mild TBI, as it is never associated with significant intracranial lesions.

Minimizing Radiation Exposure in Evaluation of Pediatric Head Trauma: Use of Rapid MR Imaging

BACKGROUND AND PURPOSE

With >473,000 annual emergency department visits for children with traumatic brain injuries in the United States, the risk of ionizing radiation exposure during CT examinations is a real concern. The purpose of this study was to assess the validity of rapid MR imaging to replace CT in the follow-up imaging of patients with head trauma.

MATERIALS AND METHODS

A retrospective review of 103 pediatric patients who underwent initial head CT and subsequent follow-up rapid MR imaging between January 2010 and July 2013 was performed. Patients had minor head injuries (Glasgow Coma Scale, >13) that required imaging. Initial head CT was performed, with follow-up rapid MR imaging completed within 48 hours. A board-certified neuroradiologist, blinded to patient information and scan parameters, then independently interpreted the randomized cases.

RESULTS

There was almost perfect agreement in the ability to detect extra-axial hemorrhage on rapid MR imaging and CT (κ = 0.84, P < .001). Evaluation of hemorrhagic contusion/intraparenchymal hemorrhage demonstrated a moderate level of agreement between MR imaging and CT (κ = 0.61, P < .001). The ability of MR imaging to detect a skull fracture also showed a substantial level of agreement with CT (κ = 0.71, P < .001). Detection of diffuse axonal injury demonstrated a slight level of agreement between MR imaging and CT (κ = 0.154, P = .04). However, the overall predictive agreement for the detection of an axonal injury was 91%.

CONCLUSIONS

Rapid MR imaging is a valid technique for detecting traumatic cranial injuries and an adequate examination for follow-up imaging in lieu of repeat CT.

Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality

BACKGROUND

Economic evaluations provide a unique opportunity to identify the optimal strategies for the diagnosis and management of traumatic brain injury (TBI), for which uncertainty is common and the economic burden is substantial.

OBJECTIVE

The objective of this study was to systematically review and examine the quality of contemporary economic evaluations in the diagnosis and management of TBI.

METHODS

Two reviewers independently searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, Health Technology Assessment Database, EconLit, and the Tufts CEA Registry for comparative economic evaluations published from 2000 onward (last updated on August 30, 2013). Data on methods, results, and quality were abstracted in duplicate. The results were summarized quantitatively and qualitatively.

RESULTS

Of 3539 citations, 24 economic evaluations met our inclusion criteria. Nine were cost-utility, five were cost-effectiveness, three were cost-minimization, and seven were cost-consequences analyses. Only six studies were of high quality. Current evidence from high-quality studies suggests the economic attractiveness of the following strategies: a low medical threshold for computed tomography (CT) scanning of asymptomatic infants with possible inflicted TBI, selective CT scanning of adults with mild TBI as per the Canadian CT Head Rule, management of severe TBI according to the Brain Trauma Foundation guidelines, management of TBI in dedicated neurocritical care units, and early transfer of patients with TBI with nonsurgical lesions to neuroscience centers.

CONCLUSIONS

Threshold-guided CT scanning, adherence to Brain Trauma Foundation guidelines, and care for patients with TBI, including those with nonsurgical lesions, in specialized settings appear to be economically attractive strategies.

[Mild head injury in children and adults: Diagnostic challenges in the emergency department]

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

[Mild head injury in children and adults. Diagnostic challenges in the emergency department]

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

Unnecessary head computed tomography scans: a level 1 trauma teaching experience

The Canadian CT Head Rule attempts to standardize the practice of obtaining head computed tomography (CT) scans in patients with minor head injury. Previous research indicates 10 to 35 per cent of CT scans performed do not meet these guidelines. The purpose of this study was to review our use of CT scans in the evaluation of mild traumatic brain injury and to identify 1) unnecessary head CT scans (UHCT); 2) variables associated with UHCT; and 3) associated costs. Using a trauma registry, inclusion criteria were age older than 18 years, Glasgow Coma Scale of 15, and at least one head CT scan. UHCTs were those without head injury, loss of consciousness, amnesia, or neurologic complaint. The proportion of patients meeting the criteria for UHCT was 24.2 per cent. Univariate analyses revealed ages 41 to 64 years, drug use, vehicular injury, and surgery within 24 hours were associated with UHCT (all P < 0.05). UHCTs were associated with higher Injury Severity Scores (P = 0.008), ventilator days, and length of stay (all P < 0.05). An average cost of $1,413 per CT equals $149,778 in extra costs. This study suggests that current practices at our Level I trauma center result in UHCT. Further investigation into best practices would benefit our center by reducing costs and providing quality patient care.

Utility of surveillance imaging after minor blunt head trauma

OBJECT

Nonoperative blunt head trauma is a common reason for admission in a pediatric hospital. Adverse events, such as growing skull fracture, are rare, and the incidence of such morbidity is not known. As a result, optimal follow-up care is not clear.

METHODS

Patients admitted after minor blunt head trauma between May 1, 2009, and April 30, 2013, were identified at a single institution. Demographic, socioeconomic, and clinical characteristics were retrieved from administrative and outpatient databases. Clinical events within the 180-day period following discharge were reviewed and analyzed. These events included emergency department (ED) visits, need for surgical procedures, clinic visits, and surveillance imaging utilization. Associations among these clinical events and potential contributing factors were analyzed using appropriate statistical methods.

RESULTS

There were 937 admissions for minor blunt head trauma in the 4-year period. Patients who required surgical interventions during the index admission were excluded. The average age of the admitted patients was 5.53 years, and the average length of stay was 1.7 days; 15.7% of patients were admitted for concussion symptoms with negative imaging findings, and 26.4% of patients suffered a skull fracture without intracranial injury. Patients presented with subdural, subarachnoid, or intraventricular hemorrhage in 11.6%, 9.19%, and 0.53% of cases, respectively. After discharge, 672 patients returned for at least 1 follow-up clinic visit (71.7%), and surveillance imaging was obtained at the time of the visit in 343 instances. The number of adverse events was small and consisted of 34 ED visits and 3 surgeries. Some of the ED visits could have been prevented with better discharge instructions, but none of the surgery was preventable. Furthermore, the pattern of postinjury surveillance imaging utilization correlated with physician identity but not with injury severity. Because the number of adverse events was small, surveillance imaging could not be shown to positively influence outcomes.

CONCLUSIONS

Adverse events after nonoperative mild traumatic injury are rare. The routine use of postinjury surveillance imaging remains controversial, but these data suggest that such imaging does not effectively identify those who require operative intervention.

Implementing evidence-based recommended practices for the management of patients with mild traumatic brain injuries in Australian emergency care departments: study protocol for a cluster randomised controlled trial

Background

Mild head injuries commonly present to emergency departments. The challenges facing clinicians in emergency departments include identifying which patients have traumatic brain injury, and which patients can safely be sent home. Traumatic brain injuries may exist with subtle symptoms or signs, but can still lead to adverse outcomes. Despite the existence of several high quality clinical practice guidelines, internationally and in Australia, research shows inconsistent implementation of these recommendations. The aim of this trial is to test the effectiveness of a targeted, theory- and evidence-informed implementation intervention to increase the uptake of three key clinical recommendations regarding the emergency department management of adult patients (18 years of age or older) who present following mild head injuries (concussion), compared with passive dissemination of these recommendations. The primary objective is to establish whether the intervention is effective in increasing the percentage of patients for which appropriate post-traumatic amnesia screening is performed.

Methods/design

The design of this study is a cluster randomised trial. We aim to include 34 Australian 24-hour emergency departments, which will be randomised to an intervention or control group. Control group departments will receive a copy of the most recent Australian evidence-based clinical practice guideline on the acute management of patients with mild head injuries. The intervention group will receive an implementation intervention based on an analysis of influencing factors, which include local stakeholder meetings, identification of nursing and medical opinion leaders in each site, a train-the-trainer day and standardised education and interactive workshops delivered by the opinion leaders during a 3 month period of time. Clinical practice outcomes will be collected retrospectively from medical records by independent chart auditors over the 2 month period following intervention delivery (patient level outcomes). In consenting hospitals, eligible patients will be recruited for a follow-up telephone interview conducted by trained researchers. A cost-effectiveness analysis and process evaluation using mixed-methods will be conducted. Sample size calculations are based on including 30 patients on average per department. Outcome assessors will be blinded to group allocation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12612001286831 (date registered 12 December 2012).

Neuroimaging after mild traumatic brain injury: review and meta-analysis

This paper broadly reviews the study of mild traumatic brain injury (mTBI), across the spectrum of neuroimaging modalities. Among the range of imaging methods, however, magnetic resonance imaging (MRI) is unique in its applicability to studying both structure and function. Thus we additionally performed meta-analyses of MRI results to examine 1) the issue of anatomical variability and consistency for functional MRI (fMRI) findings, 2) the analogous issue of anatomical consistency for white-matter findings, and 3) the importance of accounting for the time post injury in diffusion weighted imaging reports. As we discuss, the human neuroimaging literature consists of both small and large studies spanning acute to chronic time points that have examined both structural and functional changes with mTBI, using virtually every available medical imaging modality. Two key commonalities have been used across the majority of imaging studies. The first is the comparison between mTBI and control populations. The second is the attempt to link imaging results with neuropsychological assessments. Our fMRI meta-analysis demonstrates a frontal vulnerability to mTBI, demonstrated by decreased signal in prefrontal cortex compared to controls. This vulnerability is further highlighted by examining the frequency of reported mTBI white matter anisotropy, in which we show a strong anterior-to-posterior gradient (with anterior regions being more frequently reported in mTBI). Our final DTI meta-analysis examines a debated topic arising from inconsistent anisotropy findings across studies. Our results support the hypothesis that acute mTBI is associated with elevated anisotropy values and chronic mTBI complaints are correlated with depressed anisotropy. Thus, this review and set of meta-analyses demonstrate several important points about the ongoing use of neuroimaging to understand the functional and structural changes that occur throughout the time course of mTBI recovery. Based on the complexity of mTBI, however, much more work in this area is required to characterize injury mechanisms and recovery factors and to achieve clinically-relevant capabilities for diagnosis.

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mTBI neuroimaging literature review and meta-analyses of fMRI and DTI.

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fMRI meta-analysis revealed differences between mTBI and controls in 13 regions.

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mTBI anisotropy findings are statistically more frequently reported in anterior regions.

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Anisotropy is elevated in acute mTBI, but depressed in chronic mTBI.

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We hypothesize a statistical interaction between anisotropy, cognitive score, and time.

Using decision analysis to assess comparative clinical efficacy of surgical treatment of unstable ankle fractures

BACKGROUND/OBJECTIVES

The development of a robust treatment algorithm for ankle fractures based on well-established stability criteria has been shown to be prognostic with respect to treatment and outcomes. In parallel with the development of improved understanding of the biomechanical rationale of ankle fracture treatment has been an increased emphasis on assessing the effectiveness of medical and surgical interventions. The purpose of this study was to investigate the use of using decision analysis in the assessment of the cost effectiveness of operative treatment of ankle fractures based on the existing clinical data in the literature.

METHODS

Using the data obtained from a previous structured review of the ankle fracture literature, decision analysis trees were constructed using standard software. The decision nodes for the trees were based on ankle fracture stability criteria previously published. The outcomes were assessed by calculated Quality-Adjusted Life Years (QALYs) assigned to achieving normal ankle function, developing posttraumatic arthritis, or sustaining a postoperative infection. Sensitivity analysis was undertaken by varying the patient's age, incidence of arthritis, and incidence or infection.

RESULTS

Decision analysis trees captured the essential aspects of clinical decision making in ankle fracture treatment in a clinically useful manner. In general, stable fractures yielded better outcomes with nonoperative treatment, whereas unstable fractures had better outcomes with surgery. These were consistent results over a wide range of postoperative infection rates. Varying the age of the patient did not qualitatively change the results. Between the ages of 30 and 80 years, surgery yielded higher expected QALYs than nonoperative care for unstable fractures, and generated lower QALYs than nonoperative care for stable fractures. Using local cost estimates for operative and nonoperative treatment, the incremental cost of surgery for unstable fractures was less than $40,000 per QALY (the usual cutoff for the determination of cost effectiveness) for patients aged up to 90 years.

DISCUSSION/CONCLUSIONS

Decision analysis is a useful methodology in developing treatment guidelines. Numerous previous studies have indicated superior clinical outcomes when unstable ankle fractures underwent operative reduction and stabilization. What has been lacking was an examination of the cost effectiveness of such an approach, particularly in older patients who have fewer expected years of life. In light of the evidence for satisfactory outcomes for surgery of severe ankle fractures in older people, the justification for operative intervention is an obvious question that can be asked in the current increasingly cost-conscious environment. Using a decision-tree decision analysis structured around the stability-based ankle fracture classification system, in conjunction with a relatively simple cost effectiveness analysis, this study was able to demonstrate that surgical treatment of unstable ankle fractures in elderly patients is in fact cost effective.

SIGNIFICANCE

The clinical implication of the present analysis is that these existing treatment protocols for ankle fracture treatment are also cost effective when quality of life outcome measures are taken into account.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Acute assessment of brain injuries in ground-level falls

OBJECTIVE

The purpose of this study was to characterize traumatic brain injuries (TBI) sustained in ground-level falls (GLFs). The focus was on factors associated with acute computed tomographic (CT) findings.

METHODS

The sample included 575 subjects examined and treated at the Tampere University Hospital emergency department (ED). Retrospective data collection consisted of subject- and injury-related data and clinical information from the emergency department. All CT scans were analyzed and systematically coded.

RESULTS

Ground-level falls were the mechanism of injury in 48.3% (n = 278) of the subjects. In the GLF group, independent risk factors for acute traumatic CT findings were long-term alcohol abuse, older age, being found on the ground, and left temporoparietal and occipital location of direct head impact. There were no significant differences in the incidence of any intracranial traumatic lesion type between those with GLFs and other causes of TBI. None of the classic clinical TBI severity markers studied were associated with acute traumatic CT findings in patients with GLFs.

CONCLUSIONS

Older age and long-term alcohol abuse increase the likelihood of acute intracranial CT abnormalities. The pattern of intracranial traumatic CT findings does not differ from other causes of TBI. Clinical signs and indices of TBI severity did not predict traumatic CT findings.

The cost-effectiveness of diagnostic management strategies for adults with minor head injury

STUDY OBJECTIVE

To estimate the cost-effectiveness of diagnostic management strategies for adults with minor head injury.

METHODS

A mathematical model was constructed to evaluate the incremental costs and effectiveness (Quality Adjusted Life years Gained, QALYs) of ten diagnostic management strategies for adults with minor head injuries. Secondary analyses were undertaken to determine the cost-effectiveness of hospital admission compared to discharge home and to explore the cost-effectiveness of strategies when no responsible adult was available to observe the patient after discharge.

RESULTS

The apparent optimal strategy was based on the high and medium risk Canadian CT Head Rule (CCHRhm), although the costs and outcomes associated with each strategy were broadly similar. Hospital admission for patients with non-neurosurgical injury on CT dominated discharge home, whilst hospital admission for clinically normal patients with a normal CT was not cost-effective compared to discharge home with or without a responsible adult at £39 and £2.5 million per QALY, respectively. A selective CT strategy with discharge home if the CT scan was normal remained optimal compared to not investigating or CT scanning all patients when there was no responsible adult available to observe them after discharge.

CONCLUSION

Our economic analysis confirms that the recent extension of access to CT scanning for minor head injury is appropriate. Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost-saving. The cost of CT scanning is very small compared to the estimated cost of caring for patients with brain injury worsened by delayed treatment. It is recommended therefore that all hospitals receiving patients with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence based guidelines. Provisionally the CCHRhm decision rule appears to be the best strategy although there is considerable uncertainty around the optimal decision rule. However, the CCHRhm rule appears to be the most widely validated and it therefore seems appropriate to conclude that the CCHRhm rule has the best evidence to support its use.

Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study

STUDY OBJECTIVE

The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury.

METHODS

This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value.

RESULTS

We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15.

CONCLUSION

For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Whole body imaging in the diagnosis of blunt trauma, ionizing radiation hazards and residual risk

Ever since the introduction of radiographic imaging, its utility in identifying injuries has been well documented and was incorporated in the workup of injured patients during advanced trauma life support algorithms [American College of Surgeons, 8th ed. Chicago, 2008]. More recently, computerized tomography (CT) has been shown to be more sensitive than radiography in the diagnosis of injury. Due to the increased use of CT scanning, concerns were raised regarding the associated exposure to ionizing radiation [N Engl J Med 357:2277-2284, 2007]. During the last several years, a significant amount of research has been published on this topic, most of it being incorporated in the BEIR VII Phase 2 report, published by the National Research Council of the National Academies [National Academy of Sciences, Washington DC, 2006]. The current review will analyze the scientific basis for the concerns over the ionizing radiation associated with the use of CT scanning and will examine the accuracy of the typical advanced trauma life support work-up for diagnosis of injuries.

Is aggressive treatment of traumatic brain injury cost-effective?

OBJECT

The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective.

METHODS

A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with "routine care," in which Brain Trauma Foundation guidelines are not followed. A "comfort care" category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age.

RESULTS

For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds.

CONCLUSIONS

When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.

Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center

OBJECTIVES

This study compared the clinical performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) for detecting any traumatic intracranial lesion on computed tomography (CT) in patients with a Glasgow Coma Scale (GCS) score of 15. Also assessed were ability to detect patients with "clinically important" brain injury and patients requiring neurosurgical intervention. Additionally, the performance of the CCHR was assessed in a larger cohort of those presenting with GCS of 13 to 15.

METHODS

This prospective cohort study was conducted in a U.S. Level I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department (ED) with witnessed loss of consciousness, disorientation or amnesia, and GCS 13 to 15. The rules were compared in the group of patients with GCS 15. The primary outcome was prediction of "any traumatic intracranial injury" on CT. Secondary outcomes included "clinically important brain injury" on CT and need for neurosurgical intervention.

RESULTS

Among the 431 enrolled patients, 314 patients (73%) had a GCS of 15, and 22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT. There were 11 of 314 (3.5%) who had "clinically important" brain injury, and 3 of 314 (1.0%) required neurosurgical intervention. The NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%), but the CCHR was more specific for detecting any traumatic intracranial lesion on CT, with a specificity of 36.3% (95% CI = 31% to 42%) versus 10.2% (95% CI = 7% to 14%) for NOC. For "clinically important" brain lesions, the CCHR and the NOC had similar sensitivity (both 100%; 95% CI = 68% to 100%), but the specificity was 35% (95% CI = 30% to 41%) for CCHR and 9.9% (95% CI = 7% to 14%) for NOC. When the rules were compared for predicting need for neurosurgical intervention, the sensitivity was equivalent at 100% (95% CI = 31% to 100%) but the CCHR had a higher specificity at 80.7% (95% CI = 76% to 85%) versus 9.6% (95% CI = 7% to 14%) for NOC. Among all 431 patients with a GCS score 13 to 15, the CCHR had sensitivities of 100% (95% CI = 84% to 100%) for 27 patients with clinically important brain injury and 100% (95% CI = 46% to 100%) for five patients requiring neurosurgical intervention.

CONCLUSIONS

In a U.S. sample of mildly head-injured patients, the CCHR and the NOC had equivalently high sensitivities for detecting any traumatic intracranial lesion on CT, clinically important brain injury, and neurosurgical intervention, but the CCHR was more specific. A larger cohort will be needed to validate these findings.

Transcranial Doppler to screen on admission patients with mild to moderate traumatic brain injury

BACKGROUND

Detecting patients at risk for secondary neurological deterioration (SND) after mild to moderate traumatic brain injury is challenging.

OBJECTIVE

To assess the diagnostic accuracy of transcranial Doppler (TCD) on admission in screening these patients.

METHODS

This prospective, observational cohort study enrolled 98 traumatic brain injury patients with an initial Glasgow Coma Scale score of 9 to 15 whose initial computed tomography (CT) scan showed either absent or mild lesions according to the Trauma Coma Data Bank (TCDB) classification, ie, TCDB I and TCDB II, respectively. TCD measurements of the 2 middle cerebral arteries were obtained on admission under stable conditions in all patients. Neurological outcome was reassessed on day 7.

RESULTS

Of the 98 patients, 21 showed SND, ie, a decrease of ≥ 2 points from the initial Glasgow Coma Scale or requiring any treatment for neurological deterioration. Diastolic cerebral blood flow velocities and pulsatility index measurements were different between patients with SND and patients with no SND. Using receiver-operating characteristic analysis, we found the best threshold limits to be 25 cm/s (sensitivity, 92%; specificity, 76%; area under curve, 0.93) for diastolic cerebral blood flow velocity and 1.25 (sensitivity, 90%; specificity, 91%; area under curve, 0.95) for pulsatility index. According to a recursive-partitioning analysis, TCDB classification and TCD measurements were the most discriminative among variables to detect patients at risk for SND.

CONCLUSION

In patients with no severe brain lesions on CT after mild to moderate traumatic brain injury, TCD on admission, in complement with brain CT scan, could accurately screen patients at risk for SND.

Long-term cognitive and emotional consequences of mild traumatic brain injury

BACKGROUND

The objective of this study was to investigate long-term cognitive and emotional sequelae of mild traumatic brain injury (mTBI), as previous research has remained inconclusive with respect to their prevalence and extent.

METHOD

Thirty-three individuals who had sustained mTBI on average 6 years prior to the study and 33 healthy control subjects were matched according to age, gender and education. Structural brain damage at time of testing was excluded by magnetic resonance imaging (MRI). A comprehensive neuropsychological test battery was conducted to assess learning, recall, working memory, attention and executive function. Psychiatric symptoms were assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Beck Depression Inventory (BDI). Possible negative response bias was ruled out by implementing the Word Memory Test (WMT).

RESULTS

The mTBI individuals had significant impairments in all cognitive domains compared to the healthy control subjects. Effect sizes of cognitive deficits were medium to large, and could not be accounted for by self-perceived deficits, depression, compensation claims or negative response bias. BDI scores were significantly higher in the patient group, and three patients fulfilled DSM-IV criteria for a mild episode of major depression.

CONCLUSIONS

Primarily, well-recovered individuals who had sustained a minor trauma more than half a decade ago continue to have long-term cognitive and emotional sequelae relevant for everyday social and professional life. mTBI may lead to a lasting disruption of neurofunctional circuits not detectable by standard structural MRI and needs to be taken seriously in clinical and forensic evaluations.

Comparison of clinical performance of cranial computed tomography rules in patients with minor head injury: a multicenter prospective study

OBJECTIVES

The objective was to compare the predictive performance of three previously derived cranial computed tomography (CT) rules, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and National Emergency X-Ray Utilization Study (NEXUS)-II, for detecting clinically important traumatic brain injury (TBI) and the need for neurosurgical intervention in patients with blunt head trauma.

METHODS

This was a prospective, multicenter, observational cohort study of patients with blunt head trauma from June 2008 to May 2009. The historical and physical examination components of the CCHR, NOC, and NEXUS-II were documented on a data collection form and the performance of each of the three rules was compared. Patient eligibility for each specific rule was defined exactly as previously described for each specific rule. To compare the three decision rules in terms of sensitivity and specificity, an intersection cohort satisfying inclusion criteria of all three decision rules was derived. The primary outcome was clinically important TBI, and the secondary outcome was neurosurgical intervention. The sensitivity and specificity of each rule were calculated with 95% confidence intervals (95% CIs). We also calculated the potential reduction rate in cranial CT scan utilization realized by theoretical implementation of these rules.

RESULTS

A total of 7,131 patients were prospectively enrolled, including 692 (9.7%) with clinical TBI. Among the enrolled population, patients eligible for CCHR, NOC, and NEXUS-II totaled 696, 677, and 2,951, respectively. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 112 of 144 (79.2%, 95% CI = 70.8% to 86.0%) and 228 of 552 (41.3%, 95% CI = 37.3% to 45.5%); NOC, 91 of 99 (91.9%, 95% CI = 84.7% to 96.5%) and 125 of 558 (22.4%, 95% CI = 19.0% to 26.1%); and NEXUS-II, 511 of 576 (88.7%, 95% CI = 85.8% to 91.2%) and 1,104 of 2,375 (46.5%, 95% CI = 44.5% to 48.5%). The sensitivity and specificity for neurosurgical intervention were as follows: CCHR, 100% (95% CI = 59.0% to 100.0%) and 38.3% (95% CI = 34.5% to 41.9%); NOC, 100% (95% CI = 54.1% to 100.0%) and 20.4% (95% CI = 17.4% to 23.7%); and NEXUS-II, 95.1% (95% CI = 90.1% to 98.0%) and 41.4% (95% CI = 39.5% to 43.2%). Among the enrolled population, intersection patients of CCHR, NOC, and NEXUS-II totaled 588. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 73 of 98 (74.5%, 95% CI = 64.7% to 82.8%) and 201 of 490 (41.0%, 95% CI = 36.6% to 45.5%); NOC, 89 of 98 (90.8%, 95% CI = 83.3% to 95.7%) and 112 of 490 (22.9%, 95% CI = 19.2% to 26.8%); and NEXUS-II, 82 of 98 (83.7%, 95% CI = 74.8% to 90.4%) and 172 of 490 (35.1%, 95% CI = 30.9% to 39.5%). The potential reduction in emergency CT scans by using these decision rules would have been higher with the NEXUS-II rule (39.6%, 95% CI = 37.8% to 41.4%) than with the CCHR rule (27.0%, 95% CI = 23.7% to 30.3%) or NOC rule (20.2%, 95% CI = 17.2% to 23.3%).

CONCLUSIONS

For clinically important TBI, the three cranial CT decision rules had much lower sensitivities in this population than the original published studies, while the specificities were comparable to those studies. The sensitivities for neurosurgical intervention, however, were comparable to the original studies. The NEXUS-II rule showed the highest reduction rate for CT scans compared to other rules, but failed to identify all undergoing neurosurgical intervention for their original inclusion cohort.

Challenges of surgical trauma emergency admission

INTRODUCTION

Trauma still remains as one of the leading causes for mortality in Western civilization. The early clinical management of severely injured patients leads to structural and organizational challenges involving different specialties.

EMERGENCY DEPARTMENT

Trauma team leaders have to coordinate diagnostic and therapeutic steps in cooperation with different involved specialties. Furthermore, they have to make decisions based on contrary department-depending assessments. In addition, several special injuries commonly found in multiple traumatized patients require special attention.

RECENT DEVELOPMENT

Actually, structural changes in generating trauma networks are to be mentioned. Trauma networks suggest to improve patients survival in close cooperation between hospitals with different structural and personal capabilities. Close communication networks are required to guarantee transportation to an adequate trauma center.

Role of Neuroprotein S-100B in the Diagnostic of Pediatric Mild Brain Injury

Traumatic brain injury is one of the leading causes of death and disability in children and adolescents. Patients with moderate or severe lesions can be readily recognized clinically, require immediate radiologic diagnostics by computed tomography (CT) or magnetic resonance imaging (MRI), admission to intensive care units, and, in some cases, will go on to require neurosurgical intervention. Patients with mild traumatic brain injuries (MTBIs) are diagnostically challenging. Often, the event is unobserved and head injury can only be suspected. Clinical symptoms are unreliable and clinical findings from neurological examination have to be interpreted with care. As a small percentage of MTBI patients progress to have a life-threatening intracranial hemorrhage, the recognition of this group of patients and their judicious and timely management is, therefore, an important goal. Subjecting every MTBI patient to a cranial CT scanning results in high costs and unnecessary exposure to ionizing radiation. Admitting all MTBI patients for observation and performing CTs only in case of clinical deterioration is costly and a substantial drain on resources, not to mention the radiation exposure and a source of stress for the majority of patients. Current European guidelines for diagnostics and therapy in MTBI patients are only partially applicable to the pediatric population. This article reviews the clinical problem, treatment options and guidelines, as well as diagnostic tools, with special focus on neuroprotein S-100B in pediatric and adolescent patients with MTBIs.

PET Imaging for Traumatic Brain Injury

Traumatic brain injury represents a substantial public health problem for which clinicians have limited treatment avenues. Traditional FDG-positron emission tomography (PET) brain imaging has provided unique insights into this disease including prognostic information. With the advent and implementation of novel tracers as well as improvement in instrumentation, molecular brain imaging using PET can further illustrate traumatic brain injury pathophysiology and point to novel treatment strategies.

Low plasma D-dimer concentration predicts the absence of traumatic brain injury in children

BACKGROUND

Head Computerized Tomography (CT) has significant risks, especially in children. To reduce this burden, we sought to develop a biomarker panel that predicts the absence of traumatic brain injury (TBI) on head CT.

METHODS

We conducted a prospective cohort observational study followed by validation in a retrospective cohort at a regional pediatric trauma center. The prospective cohort included 57 consecutive children evaluated for TBI in the emergency department between September 2007 and March 2008. At the time of initial evaluation, blood was obtained to measure electrolytes, coagulation markers, complete blood count, and plasma levels of s100beta, D-dimer, and matrix metalloproteinase-9. We conducted routine statistical analysis to determine which predicted TBI on head CT. The independent retrospective cohort included 57 consecutive patients evaluated for the same indication.

RESULTS

All patients generally met common clinical criteria (such as the CHALICE criteria 4) for head CT after trauma. Plasma levels of D-dimer were associated with TBI on head CT by univariate analysis (p < 0.001). Other markers including prothrombin time, partial thromboplastin time, and s100beta were not. D-dimer also had the strongest association in multivariate analysis (p = 0.02). This association was independent of and stronger than the baseline Glascow Coma Scale (p = 0.08). A D-dimer level cut-off of 500 pg/microl had 94% negative predictive value (p < 0.001) for brain injury on head CT. The discriminatory capacity of this D-dimer level was confirmed in the independent retrospective cohort.

CONCLUSIONS

In children who meet clinical criteria for a head CT scan after trauma, low plasma d-dimer suggests the absence of significant brain injury.

Neuroprotein s-100B -- a useful parameter in paediatric patients with mild traumatic brain injury?

AIMS

To examine the correlation of S-100B to cranial computerized tomography (CCT) scan results in children after mild traumatic brain injury (MTBI).

METHODS

One hundred and nine paediatric patients (0-18 years) with MTBI were included in this prospective single-centre study. Serum was collected within 6 h of trauma for determination of serum S-100B. The upper reference of S-100B was set to 0.16 mug/L. A CCT scan was performed in all patients and the results were correlated to the S-100B values.

RESULTS

Computerized tomography was abnormal in 36 patients showing intracerebral haemorrhages and/or skull fractures. Serum S-100B level was significantly higher in patients with a pathological condition as shown in CT scan results (p = 0.003). There were no false negative, but 42 false positive test results for S-100B. This resulted in a sensitivity of 1.00, specificity of 0.42, positive predictive value of 0.46 and negative predictive value of 1.00. An area under the receiver operating curve of 0.68 was calculated.

CONCLUSION

S-100B is a valuable tool to rule out patients with pathological CCT findings in a collective of paediatric patients with MTBI. Elevations of S-100B do not necessarily lead to a pathological finding in the CT scan, but values below the cut-off safely rule out the evidence of intracranial lesions.

The predictive brain state: timing deficiency in traumatic brain injury?

Attention and memory deficits observed in traumatic brain injury (TBI) are postulated to result from the shearing of white matter connections between the prefrontal cortex, parietal lobe, and cerebellum that are critical in the generation, maintenance, and precise timing of anticipatory neural activity. These fiber tracts are part of a neural network that generates predictions of future states and events, processes that are required for optimal performance on attention and working memory tasks. The authors discuss the role of this anticipatory neural system for understanding the varied symptoms and potential rehabilitation interventions for TBI. Preparatory neural activity normally allows the efficient integration of sensory information with goal-based representations. It is postulated that an impairment in the generation of this activity in traumatic brain injury (TBI) leads to performance variability as the brain shifts from a predictive to reactive mode. This dysfunction may constitute a fundamental defect in TBI as well as other attention disorders, causing working memory deficits, distractibility, a loss of goal-oriented behavior, and decreased awareness.

Prediction of cognitive sequelae based on abnormal computed tomography findings in children following mild traumatic brain injury

OBJECT

The aim of this study was to determine whether the presence of intracranial pathophysiology on computed tomography (CT) scans obtained within 24 hours of mild traumatic brain injury (MTBI) in children adversely affects neuropsychological outcome during the 1st year postinjury.

METHODS

A prospective longitudinal design was used to examine the neuropsychological outcomes in children (ages 5-15 years) who had been treated for MTBI, which was defined as a loss of consciousness for up to 30 minutes and a lowest Glasgow Coma Scale (GCS) score of 13-15. Exclusion criteria included any preinjury neurological disorder. Outcome assessments were performed within 2 weeks and at 3, 6, and 12 months postinjury. Outcomes were compared between patients with MTBI whose postinjury CT scans revealed complications of brain pathophysiology (32 patients, CMTBI group) and those with MTBI but without complications (48 patients, MTBI group).

RESULTS

Significant interactions confirmed that the pattern of recovery over 12 months after injury differed depending on the intracranial pathology, presence and severity of injuries to body regions other than the head, preinjury attention-deficit hyperactivity disorder (ADHD), and socioeconomic status. Children in the CMTBI group had significantly poorer episodic memory, slower cognitive processing, diminished recovery in managing cognitive interference, and poorer performance in calculating and reading than patients in the MTBI group. Among the patients with mild or no extracranial injury, visuomotor speed was slower in those in the CMTBI group; and among patients without preinjury ADHD, working memory was worse in those in the CMTBI group.

CONCLUSIONS

Neuropsychological recovery during the 1st year following MTBI is related to the presence of radiographically detectable intracranial pathology. Children with intracranial pathology on acute CT performed more poorly in several cognitive domains when compared with patients whose CT findings were normal or limited to a linear skull fracture. Depending on the presence of preinjury ADHD and concomitant extracranial injury, working memory and visuomotor speed were also diminished in patients whose CT findings revealed complications following MTBI. Computed tomography within 24 hours postinjury appears to be useful for identifying children with an elevated risk for residual neuropsychological changes.

A critical comparison of clinical decision instruments for computed tomographic scanning in mild closed traumatic brain injury in adolescents and adults

STUDY OBJECTIVE

A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having surgical, nonsurgical, or no intracranial lesions.

METHODS

We performed a secondary analysis of prospectively collected database from 7,955 patients aged 10 years or older with mild traumatic brain injury to compare sensitivity and specificity of 6 common clinical decision strategies: the Canadian CT Head Rule, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the New Orleans, the National Emergency X-Radiography Utilization Study II (NEXUS-II), the National Institute of Clinical Excellence guideline, and the Scandinavian Neurotrauma Committee guideline. Excluded from the database were patients for whom the history of trauma was unclear, the initial Glasgow Coma Scale score was less than 14, the injury was penetrating, vital signs were unstable, or who refused diagnostic tests. Patients revisiting the emergency department within 7 days were counted only once.

RESULTS

The percentage of scans that would have been required by applying each of the 6 aids were Canadian CT head rule (high risk only) 53%, Canadian (medium & high risk) 56%, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies 56%, New Orleans 69%, NEXUS-II 56%, National Institute of Clinical Excellence 71%, and the Scandinavian 50%. The 6 decision aids' sensitivities for surgical hematomas could not be distinguished statistically (P>.05). Sensitivity was 100% (95% confidence interval [CI] 96% to 100%) for NEXUS-II, 98.1% (95% CI 93% to 100%) for National Institute of Clinical Excellence, and 99.1% (95% CI 94% to 100%) for the other 4 clinical decision instruments. Sensitivity for any intracranial lesion ranged from 95.7% (95% CI 93% to 97%) (Scandinavian) to 100% (95% CI 98% to 100%) (National Institute of Clinical Excellence). In contrast, specificities varied between 30.9% (95% CI 30% to 32%) (National Institute of Clinical Excellence) and 52.9% (95% CI 52% to 54) (Scandinavian).

CONCLUSION

NEXUS-II and the Scandinavian clinical decision aids displayed the best combination of sensitivity and specificity in this patient population. However, we cannot demonstrate that the higher sensitivity of NEXUS-II for surgical hematomas is statistically significant. Therefore, choosing which of the 2 clinical decision instruments to use must be based on decisionmakers' attitudes toward risk.