The application of North American CT scan criteria to an Australian population with minor head injury

Evaluation of Clinical Criteria for Performing Brain CT-Scan in Patients with Mild Traumatic Brain Injury; A New Diagnostic Probe

OBJECTIVE

To investigate the risk factors that can be proper indications for performing brain computerized tomography (CT)-scan in patients with mild and moderate traumatic brain injury (TBI) in order to avoid unnecessary exposure to radiation, saving on costs as well as time wasted in emergency wards.

METHODS

Data of patients with mild traumatic brain injury (TBI) referring to Emergency Department with age ≥2 years and primary GCS of 13-15 were examined including focal neurological deficit, anisocoria, skull fracture, multiple trauma, superior injury of clavicle, decreased consciousness, and amnesia. Brain CT-scan was performed in all the patients. Kappa Coefficient was used to determine the ratio of agreement of the CT indications (+ and ⎼) and multiple logistic regression to determine the relative odds of positive CTs.

RESULTS

Overall we included 610 patients. One-hundred and one patients (16.5%) had positive and 509 (83.5%) had negative CT findings. Of positive CTs, the highest percentage was dedicated to high-energy mechanism of trauma. High-energy trauma mechanism (OR=1.056, 95% CI, OR, 1.03-1.04, P<0.001), superior injury of clavicle (OR=1.07, 95% CI, OR, 1.03-1.1, P<0.001) and moderate to severe headache (OR=1.04, 95% CI, OR, 1.02-1.05, P<0.001) were positive predictors of CT findings. The combined mean of positive symptoms equaled 0.29 ± 0.64 in negative CTs, but 5.13 ± 2.4 in positive CTs, showing a significant difference. (P<0.001).

CONCLUSION

Abnormal positive brain CT in victims with mild TBI is predictable if one or several risk factors are taken into account such as moderate to severe headache, decreased consciousness, skull fracture, high-energy trauma mechanism, superior injury of clavicle and GCS of 13-14. The more the symptoms, the more likely the positive CT results would be.

Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury

OBJECTIVE

The detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI.

METHODS

This retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients.

RESULTS

A total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06-8.34; P < 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08-9.23; P < 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01-1.04; P = 0.002) were independent risk factors for concomitant intracranial injury.

CONCLUSIONS

Emergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age.

Computed tomography of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?

INTRODUCTION

This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability to the Singapore adult population with minor head injury.

METHODS

We conducted a retrospective study over six months of consecutive patients who presented to the adult emergency department (ED) with minor head injury. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR was assessed by comparing the recommendations for head computed tomography (CT) to its actual usage.

RESULTS

In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). 249 (71.3%) patients underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. According to the CCHR, head CT was recommended for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) was associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2-36.3) and absence of headache (OR 10.8, 95% CI 1.3-87.4).

CONCLUSION

Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians' practices and patients' preferences may be carried out to evaluate reasons for noncompliance.

Risk factors indicating the need for cranial CT scans in elderly patients with head trauma: an Austrian trial and comparison with the Canadian CT Head Rule

OBJECT

This study presents newly defined risk factors for detecting clinically important brain injury requiring neurosurgical intervention and intensive care, and compares it with the Canadian CT Head Rule (CCHR).

METHODS

This prospective cohort study was conducted in a single Austrian Level-I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department with witnessed loss of consciousness, disorientation, or amnesia, and a Glasgow Coma Scale (GCS) score of 13-15. The studied population consisted of a large number of elderly patients living in Vienna. The aim of the study was to investigate risk factors that help to predict the need for immediate cranial CT in patients with mild head trauma.

RESULTS

Among the 12,786 enrolled patients, 1307 received a cranial CT scan. Four hundred eighty-nine patients (37.4%) with a mean age of 63.9 ± 22.8 years had evidence of an acute traumatic intracranial lesion on CT. Three patients (< 0.1%) were admitted to the intensive care unit for neurological observation and received oropharyngeal intubation. Seventeen patients (0.1%) underwent neurosurgical intervention. In 818 patients (62.6%), no evidence of an acute trauma-related lesion was found on CT. Data analysis showed that the presence of at least 1 of the following factors can predict the necessity of cranial CT: amnesia, GCS score, age > 65 years, loss of consciousness, nausea or vomiting, hypocoagulation, dementia or a history of ischemic stroke, anisocoria, skull fracture, and development of a focal neurological deficit. Patients requiring neurosurgical intervention were detected with a sensitivity of 90% and a specificity of 67% by using the authors' analysis. In contrast, the use of the CCHR in these patients detected the need for neurosurgical intervention with a sensitivity of only 80% and a specificity of 72%.

CONCLUSIONS

The use of the suggested parameters proved to be superior in the detection of high-risk patients who sustained a mild head trauma compared with the CCHR rules. Further validation of these results in a multicenter setting is needed. Clinical trial registration no.: NCT00451789 ( ClinicalTrials.gov .).

The usefulness of brain magnetic resonance imaging with mild head injury and the negative findings of brain computed tomography

Objective

To investigate the cases of intracranial abnormal brain MRI findings even in the negative brain CT scan after mild head injury.

Methods

During a 2-year period (January 2009-December 2010), we prospectively evaluated both brain CT and brain MRI of 180 patients with mild head injury. Patients were classified into two groups according to presence or absence of abnormal brain MRI finding even in the negative brain CT scan after mild head injury. Two neurosurgeons and one neuroradiologist validated the images from both brain CT scan and brain MRI double blindly.

Results

Intracranial injury with negative brain CT scan after mild head injury occurred in 18 patients (10.0%). Headache (51.7%) without neurologic signs was the most common symptom. Locations of intracranial lesions showing abnormal brain MRI were as follows; temporal base (n=8), frontal pole (n=5), falx cerebri (n=2), basal ganglia (n=1), tentorium (n=1), and sylvian fissure (n=1). Intracranial injury was common in patients with a loss of consciousness, symptom duration >2 weeks, or in cases of patients with linear skull fracture (p=0.00013), and also more frequent in multiple associated injury than simple one (35.7%>8.6%) (p=0.105).

Conclusion

Our investigation showed that patients with mild head injury even in the negative brain CT scan had a few cases of intracranial injury. These findings indicate that even though the brain CT does not show abnormal findings, they should be thoroughly watched in further study including brain MRI in cases of multiple injuries and when their complaints are sustained.

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.

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.

Prediction of intracranial computed tomography findings in patients with minor head injury by using logistic regression

Object

The aim of this study was to develop a decision rule for physicians in developing countries to identify patients with minor head injury who will benefit from emergency brain CT scanning.

Methods

Three hundred eighteen patients with a history of blunt head trauma and a Glasgow Coma Scale (GCS) score ≥ 13 who had presented within 12 hours of trauma underwent nonenhanced brain CT and were included in this prospective study. Computed tomography findings that necessitated neurosurgical care (either observation or intervention) were considered as positive findings. Logistic regression was used to develop the decision rule.

Results

Computed tomography scans were always normal in patients < 65 years old who did not have an obvious head wound, a raccoon sign, vomiting, memory deficit, or a decrease in their GCS score. Patients with 1 major criterion (GCS score < 14, raccoon sign, failure to remember the impact, age > 65 years, or vomiting) or 2 minor criteria (wound at the scalp or GCS score < 15) had an abnormal CT scan in 13% of the cases.

Conclusions

The decision rule developed by the authors appears to be 100% sensitive and 46% specific for positive findings on brain CT and will, in developing countries, help clarify the decision to obtain scans.

Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting

This clinical policy provides evidence-based recommendations on select issues in the management of adult patients with mild traumatic brain injury (TBI) in the acute setting. It is the result of joint efforts between the American College of Emergency Physicians and the Centers for Disease Control and Prevention and was developed by a multidisciplinary panel. The critical questions addressed in this clinical policy are: (1) Which patients with mild TBI should have a noncontrast head computed tomography (CT) scan in the emergency department (ED)? (2) Is there a role for head magnetic resonance imaging over noncontrast CT in the ED evaluation of a patient with acute mild TBI? (3) In patients with mild TBI, are brain specific serum biomarkers predictive of an acute traumatic intracranial injury? (4) Can a patient with an isolated mild TBI and a normal neurologic evaluation result be safely discharged from the ED if a noncontrast head CT scan shows no evidence of intracranial injury? Inclusion criteria for application of this clinical policy's recommendations are nonpenetrating trauma to the head, presentation to the ED within 24 hours of injury, a Glasgow Coma Scale score of 14 or 15 on initial evaluation in the ED, and aged 16 years or greater. The primary outcome measure for questions 1, 2, and 3 is the presence of an acute intracranial injury on noncontrast head CT scan; the primary outcome measure for question 4 is the occurrence of neurologic deterioration.

Head computed tomography guidelines are being followed

OBJECTIVE

Several guidelines have been developed to direct the ordering of head computed tomography (CT) for patients, but most are clinical presentation-specific. Recently, an integrated guideline for ordering emergent head CT for patients who present to the ED of Western Hospital, Footscray, Victoria, Australia, was developed in response to concerns raised regarding perceived over-utilization of head CT for ED patients. Our aim was to determine compliance with the guideline.

METHODS

This was an explicit retrospective medical record review of patients who presented to the ED of Western Hospital between 1/04/2004 and 17/6/2004 and had a head CT as part of their assessment. Clinical information for these cases was compared with guideline recommendations. Data are described by descriptive statistics.

RESULTS

Of the 231 cases that were included in the study, 65 (28.1%, 95% confidence interval 23-35%) had abnormal CT findings. Guidelines were adhered to in 217 (93.9%, 95% confidence interval 91-97%) cases. For the cases where the guidelines were not adhered to (14; [6.1%]), there was only one abnormal scan the clinical significance of which is not clear.

CONCLUSION

The study found that compliance with head CT guideline was high. This suggests that the guideline is both clinically relevant and supported by ED doctors or conversely that the guideline is concordant with existing ordering practices of the ED.

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.