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Gil-Jardiné C, Payen JF, Bernard R, Bobbia X, Bouzat P, Catoire P, Chauvin A, Claessens YE, Douay B, Dubucs X, Galanaud D, Gauss T, Gauvrit JY, Geeraerts T, Glize B, Goddet S, Godier A, Le Borgne P, Rousseau G, Sapin V, Velly L, Viglino D, Vigue B, Cuvillon P, Frasca D, Claret PG. Management of patients suffering from mild traumatic brain injury 2023. Anaesth Crit Care Pain Med 2023; 42:101260. [PMID: 37285919 DOI: 10.1016/j.accpm.2023.101260] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To develop a multidisciplinary French reference that addresses initial pre- and in-hospital management of a mild traumatic brain injury patient. DESIGN A panel of 22 experts was formed on request from the French Society of Emergency Medicine (SFMU) and the French Society of Anaesthesiology and Critical Care Medicine (SFAR). A policy of declaration and monitoring of links of interest was applied and respected throughout the process of producing the guidelines. Similarly, no funding was received from any company marketing a health product (drug or medical device). The expert panel had to respect and follow the Grade® (Grading of Recommendations Assessment, Development and Evaluation) methodology to evaluate the quality of the evidence on which the recommendations were based. Given the impossibility of obtaining a high level of evidence for most of the recommendations, it was decided to adopt a "Recommendations for Professional Practice" (RPP) format, rather than a Formalized Expert Recommendation (FER) format, and to formulate the recommendations using the terminology of the SFMU and SFAR Guidelines. METHODS Three fields were defined: 1) pre-hospital assessment, 2) emergency room management, and 3) emergency room discharge modalities. The group assessed 11 questions related to mild traumatic brain injury. Each question was formulated using a PICO (Patients Intervention Comparison Outcome) format. RESULTS The experts' synthesis work and the application of the GRADE® method resulted in the formulation of 14 recommendations. After two rounds of rating, strong agreement was obtained for all recommendations. For one question, no recommendation could be made. CONCLUSION There was strong agreement among the experts on important, transdisciplinary recommendations, the purpose of which is to improve management practices for patients with mild head injury.
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Affiliation(s)
- Cédric Gil-Jardiné
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin, Service des Urgences-Adultes, Population Health, INSERM U1219, équipe aHeAD, Université de Bordeaux, Bordeaux, France.
| | - Jean-François Payen
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Rémy Bernard
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Xavier Bobbia
- Montpellier University, UR UM 103 (IMAGINE), Department of Emergency Medicine, CHU Montpellier, Montpellier, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Pierre Catoire
- Emergency Consultant, Academic Clinical Fellow (Pitié-Salpétrière University, General Emergency Department, Paris) - Tactical Ultrasound Course for Ukraine (TUSC-UA) Course Director - Mehad, France
| | - Anthony Chauvin
- Service d'Accueil des Urgences/SMUR, CHU Lariboisière, Université de Paris - Inserm U942 MASCOT, Université de Paris, Paris, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse Grace, Avenue Pasteur, MC-98002, Monaco
| | - Bénédicte Douay
- SMUR/Service des Urgences, Hôpital Beaujon, AP-HP Nord, Clichy, France
| | - Xavier Dubucs
- Emergency Departement, Centre Hospitalo-Universitaire de Toulouse, Place du Docteur Baylac, 31300 Toulouse, France
| | - Damien Galanaud
- Service de Neuroradiologie, GH Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Jean-Yves Gauvrit
- Service de Neuroradiologie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Thomas Geeraerts
- Pole Anesthesie Réanimation et INSERM Tonic, CHU de Toulouse et Universite Toulouse 3, Toulouse, France
| | - Bertrand Glize
- PMR Department, CHU de Bordeaux, ACTIVE Team, BPH INSERM U1219, University of Bordeaux, France
| | - Sybille Goddet
- Samu-21, CHU de Dijon, SAU-Smur, CH du Creusot, Dijon, France
| | - Anne Godier
- Université Paris Cité, APHP, Hôpital Européen Georges Pompidou, Service d'anesthésie Réanimation and Inserm UMRS_1140, Paris, France
| | - Pierrick Le Borgne
- Emergency Department, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France - INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médecine, Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg Cedex, France
| | | | - Vincent Sapin
- Service de Biochimie et de Génétique Moléculaire, Centre de Biologie, CHU de Clermont-Ferrand, France
| | - Lionel Velly
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Damien Viglino
- University Grenoble-Alpes, Emergency Department, CHU Grenoble-Alpes, Grenoble, France - HP2 Laboratory INSERM U1300, Grenoble, France
| | - Bernard Vigue
- Département d'Anesthésie Réanimation, Hôpital Universitaire de Bicêtre, Le Kremlin Bicêtre, France
| | - Philippe Cuvillon
- EA 2992 IMAGINE, Prévention et Prise en Charge de la Défaillance Circulatoire des Patients en état de Choc, Anaesthesiology Department, CHU Nîmes, University Montpellier, 30000 Nîmes, France
| | - Denis Frasca
- Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France, Service d'Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France, INSERM U1246, Methods in Patients-Centered Outcomes and Health Research - SPHERE, Nantes, France
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Coffeng SM, Foks KA, van den Brand CL, Jellema K, Dippel DWJ, Jacobs B, van der Naalt J. Evaluation of Clinical Characteristics and CT Decision Rules in Elderly Patients with Minor Head Injury: A Prospective Multicenter Cohort Study. J Clin Med 2023; 12:jcm12030982. [PMID: 36769631 PMCID: PMC9917997 DOI: 10.3390/jcm12030982] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/10/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Age is variably described as a minor or major risk factor for traumatic intracranial lesions after head injury. However, at present, no specific CT decision rule is available for elderly patients with minor head injury (MHI). The aims of this prospective multicenter cohort study were to assess the performance of existing CT decision rules for elderly MHI patients and to compare the clinical and CT characteristics of elderly patients with the younger MHI population. Thirty-day mortality between two age groups (cutoff ≥ 60 years), along with clinical and CT characteristics, was evaluated with four CT decision rules: the National Institute for Health and Care Excellence (NICE) guideline, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and the CT Head Injury Patients (CHIP) rule. Of the 5517 MHI patients included, 2310 were aged ≥ 60 years. Elderly patients experienced loss of consciousness (17% vs. 32%) and posttraumatic amnesia (23% vs. 31%) less often, but intracranial lesions (13% vs. 10%), neurological deterioration (1.8% vs. 0.2%), and 30-day mortality (2.0% vs. 0.1%) were more frequent than in younger patients (all p < 0.001). Elderly patients with age as their only risk factor showed intracranial lesions in 5% (NOC and CHIP) to 8% (CCHR and NICE) of cases. The sensitivity of decision rules in the elderly patients was 60% (CCHR) to 97% (NOC) when age was excluded as a risk factor. Current risk factors considered when evaluating elderly patients show lower sensitivity to identify intracranial abnormalities, despite more frequent intracranial lesions. Until age-specific CT decision rules are developed, it is advisable to scan every elderly patient with an MHI.
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Affiliation(s)
- Sophie M. Coffeng
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
- Correspondence:
| | - Kelly A. Foks
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Crispijn L. van den Brand
- Department of Emergency Medicine, Erasmus MC University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, 2512 VA The Hague, The Netherlands
| | - Diederik W. J. Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
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H Hopman J, A L Santing J, A Foks K, J Verheul R, M van der Linden C, L van den Brand C, Jellema K. Biomarker S100B in plasma a screening tool for mild traumatic brain injury in an emergency department. Brain Inj 2023; 37:47-53. [PMID: 36397287 DOI: 10.1080/02699052.2022.2145360] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A computerized tomography (CT) scan is an effective test for detecting traumatic intracranial findings after mild traumatic brain injury (mTBI). However, a head CT is costly, and can only be performed in a hospital. OBJECTIVE To determine if the addition of plasma S100B to clinical guidelines could lead to a more selective scanning strategy without compromising safety. METHODS We conducted a single center prospective cohort study at the emergency department. Patients (≥16 years) who received head CT and had a blood draw were included. The primary outcome was the accuracy of plasma S100B to predict the presence of any traumatic intracranial lesion on head CT. RESULTS We included 495 patients, out of the 74 patients who had traumatic intracranial lesions, 5 patients had a plasma S100B level below the cutoff value of 0.105 ug/L. For the detection of traumatic intracranial injury, S100B had a sensitivity of 0.932 , a specificity of 0.157, a negative predictive value of 0.930, and a positive predictive value of 0.163. CONCLUSIONS Among patients undergoing guideline-based CT scan for mTBI, the use of S100B, would results in a further decrease (14.8%) of CT scans but at a cost of missed injury, without clinical consequence, on CT.
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Affiliation(s)
- Joëlla H Hopman
- Department of Emergency Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Kelly A Foks
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rolf J Verheul
- Department of Clinical Chemistry and Laboratory Medicine, Haaglanden Medical Center, The Hague
| | | | | | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
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van den Brand CL, Foks KA, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MG, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Dippel DW, Jellema K. Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series. Injury 2022; 53:2979-2987. [PMID: 35831208 DOI: 10.1016/j.injury.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI). METHODS The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic. RESULTS Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%). CONCLUSIONS Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.
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Affiliation(s)
- Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands; Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Myriam Gm Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Centre for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Eef Reijners
- formerly Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Meriam Braaksma
- Department of Neurology, Bravis Hospital, PO Box 999, 4624 VT Bergen op Zoom, the Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
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Farris CW, Baghdanian A, Takahashi C, Sung EK, Sakai O, Patel M, Burley H, Rai A, Brahmbhatt T, Adran D, Kim H, Ravilla A, Mian AZ. Implementation of Institutional Triaging Algorithms Decreases Head and Neck MDCT Use in Blunt Trauma. Radiology 2021; 298:622-629. [PMID: 33434109 DOI: 10.1148/radiol.2021201878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Multidetector CT (MDCT) enables rapid and accurate diagnosis of head and neck (HN) injuries in patients with blunt trauma (BT). However, MDCT is overused, and appropriate selection of patients for imaging could improve workflow. Purpose To investigate the effect of implementing clinical triaging algorithms on use of MDCT in the HN in patients who have sustained BT. Materials and Methods In this retrospective study, patients aged 15 years or older with BT admitted between October 28, 2007, and December 31, 2013, were included. Patients were divided into pre- and postalgorithm groups. The institutional trauma registry and picture archiving and communication system reports were reviewed to determine which patients underwent MDCT of the head, MDCT of the cervical spine (CS), and MDCT angiography of the HN at admission and whether these examinations yielded positive results. Injury Severity Score, Acute Physiology and Chronic Health Evaluation II score (only those patients in the intensive care unit), length of hospital stay (LOS), length of intensive care unit stay (ICULOS), and mortality were obtained from the trauma registry. Results A total of 8999 patients (mean age, 45 years ± 20 [standard deviation]; age range, 15-101 years; 6027 male) were included in this study. A lower percentage of the postalgorithm group versus the prealgorithm group underwent MDCT of the head (55.8% [2774 of 4969 patients]; 95% CI: 54.4, 57.2 vs 64.2% [2589 of 4030 patients]; 95% CI: 62.8, 65.7; P < .001) and CS (49.4% [2452 of 4969 patients]; 95% CI: 48.0, 50.7 vs 60.5% [2438 of 4030 patients]; 95% CI: 59.0, 62.0; P < .001) but not MDCT angiography of the HN (9.7% [480 of 4969 patients]; 95% CI: 8.9, 10.5 vs 9.8% [393 of 4030 patients]; 95% CI: 8.9, 10.7; P > .99). Pre- versus postalgorithm groups did not differ in LOS (mean, 4.8 days ± 7.1 vs 4.5 days ± 7.1, respectively; P = .42), ICULOS (mean, 4.6 days ± 6.6 vs 4.8 days ± 6.7, respectively; P > .99), or mortality (2.9% [118 of 4030 patients]; 95% CI: 2.5, 3.5; vs 2.8% [141 of 4969 patients]; 95% CI: 2.4, 3.3; respectively; P > .99). Conclusion Implementation of a clinical triaging algorithm resulted in decreased use of multidetector CT of the head and cervical spine in patients who experienced blunt trauma, without increased adverse outcomes. © RSNA, 2021 See also the editorial by Munera and Martin in this issue.
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Affiliation(s)
- Chad W Farris
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Arthur Baghdanian
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Courtney Takahashi
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Edward K Sung
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Osamu Sakai
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Mrugesh Patel
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Hannah Burley
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Aayushi Rai
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Tejal Brahmbhatt
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Daniel Adran
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Hyunjoong Kim
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Anoop Ravilla
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Asim Z Mian
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
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Effect of the implementation of a new guideline for minor head injury on computed tomography-ratio and hospitalizations in the Netherlands. Eur J Emerg Med 2020; 27:441-446. [PMID: 32433335 DOI: 10.1097/mej.0000000000000714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A new nationwide guideline for minor head injury was introduced in the Netherlands in 2010. The effect on computed tomography (CT) ratio and hospital admission ratio after introduction of the guideline is unknown. The aim was to reduce these numbers as part of cost-effective health care. Therefore, we assessed the effect on these variables after introduction of the guideline. METHODS We used an interrupted time-series study design. Data selection was done 3 years before (2007-2009) and several years after (2012, 2014, 2015) introduction of the guideline. RESULTS Data collection was performed for 3880 patients. Introduction of the new guideline was associated with an increase in CT ratio from 24.6% before to 55% after introduction (P < 0.001). This increase is the result of both the new guideline and a secular trend. Besides this, hospital admissions increased from 14.7 to 23.4% (P < 0.001) during the study period. This increase was less clearly associated with the new guideline. After introduction of the guideline there was no significant difference in (intra)cranial traumatic findings (2.6% vs. 3.4%; P = 0.13) and neurosurgical interventions (0.1% vs. 0.2%; P = 0.50). CONCLUSION Between 2007 and 2015, a marked increase in CT ratio and hospital admissions has been observed. The increase in CT ratio seems to be caused both by the new guideline and by a secular trend to perform more CT scans. Adaptations to the guideline should be considered to improve patient care and cost-effectiveness in patients with minor head injury.
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Kavi T, Abdelhady A, DeChiara J, Lubas E, Abdelhady K, Daci R, San Roman J, Patel UK. Association of Patterns of Mild Traumatic Brain Injury with Neurologic Deterioration: Experience at a Level I Trauma Center. Cureus 2019; 11:e5677. [PMID: 31723486 PMCID: PMC6825415 DOI: 10.7759/cureus.5677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/17/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION There are about 2.5 million emergency room visits for traumatic brain injury (TBI) every year and 75%-95% of all TBI patients have mild TBI. Previous studies have suggested that a large proportion of mild TBI patients can be treated in a non-aggressive manner, but they have not differentiated mild TBI as per radiological patterns to help in the selection of these patients. Our study aimed to identify different patterns of mild TBI to determine if certain injuries make patients more prone to neurologic worsening than others, and thus require more intensive monitoring. We also studied the factors associated with neurologic deterioration. METHODS We conducted a retrospective study using an institutional trauma database to identify TBI patients between the years of 2015 and 2016 with admission Glasgow Coma Score (GCS) of 13 to 15, through chart review by the investigators. Radiological and neurological worsening was determined through computed tomography (CT) scan results, GCS scores, and the requirement for neurosurgical intervention. We identified the prevalence of demographic characteristics, radiological patterns, and risk factors. We studied neurologic deterioration (decline in GCS to less than 13 at 48 hours or earlier after admission) and surgical intervention among patients with different radiological patterns of TBI. We further studied the cohort of isolated subdural hematoma (SDH) patients requiring surgery to evaluate the associated risk factors. RESULTS Out of 374 patients with mild TBI (mean age was 63 years), 59% were male, 77% were Caucasian, the median GCS was 15, majority of patients had isolated SDH (45%), and mixed pattern of hemorrhage (39%); the use of antiplatelet (33%) was the most commonly identified risk factors. Overall 7% of patients were found to have neurologic deterioration (GCS to less than 13) and 9% required surgical intervention at 48 hours or earlier after admission. The most common pattern of TBI requiring surgical intervention was isolated SDH (85%). Among the cohort of patients with isolated SDH, 17% required surgical intervention and 69% of those isolated SDH patients requiring surgery had neurologic deterioration. The most common risk factor in isolated SDH patients requiring surgery was antiplatelet use (34%), anticoagulant use (20%), alcohol abuse (17%), severe renal failure (17%), and thrombocytopenia (7%). Mean size of SDH in patients requiring surgery was 1.6 cm with 0.8 cm of midline shift. CONCLUSION This study identified the pattern of mild TBI associated with neurological worsening at our Level I Trauma Center. Among patients with mild TBI, SDH patients seem to be at highest risk for deterioration and requirement for surgery. If these results can be externally validated through a multi-center study, these patients could be selectively identified for aggressive monitoring in the intensive care unit (ICU) and repeat CT scans.
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Affiliation(s)
- Tapan Kavi
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Ahmed Abdelhady
- Neurology, Cooper Medical School of Rowan University, Camden, USA
| | - James DeChiara
- Neurology, Cooper Medical School of Rowan University, Camden, USA
| | - Emily Lubas
- Neurology, Cooper Medical School of Rowan University, Camden, USA
| | - Khodeja Abdelhady
- Internal Medicine, Washington University of Health and Science, San Pedro, BLZ
| | - Rrita Daci
- Neurosurgery, University of Massachusetts, Worcester, USA
| | | | - Urvish K Patel
- Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
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Davey K, Saul T, Russel G, Wassermann J, Quaas J. Application of the Canadian Computed Tomography Head Rule to Patients With Minimal Head Injury. Ann Emerg Med 2018; 72:342-350. [PMID: 29753518 DOI: 10.1016/j.annemergmed.2018.03.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 03/09/2018] [Accepted: 03/23/2018] [Indexed: 10/16/2022]
Abstract
STUDY OBJECTIVE Two clinical decision rules, the Canadian CT Head Rule and the New Orleans Criteria, set the standard to guide clinicians in determining which patients with minor head trauma need computed tomography (CT) imaging. Both rules were derived with patients with minor head injury who had had a loss of consciousness or witnessed disorientation. No evidence exists for evaluating patients and need for CT imaging with minimal head injury; that is, patients who had a head injury but no loss of consciousness or disorientation and therefore would have been excluded from the Canadian CT Head Rule and New Orleans Criteria trials. We evaluate the Canadian CT Head Rule in patients with head injury without loss of consciousness or witnessed disorientation (minimal head injury). METHODS We studied a prospective convenience sample of patients with minimal head injury who received head CTs as part of their evaluations in the emergency department (ED). Participants were enrolled after head CT was ordered, but before the physician received the imaging results. Physicians were surveyed on their clinical reasoning for ordering imaging in this low-risk cohort of patients. Physicians surveyed consisted of ED attending physicians and senior-level emergency medicine residents. Final patient disposition was recorded when it became available. Patients with positive CT findings had their medical records reviewed for specific disposition, admission length of stay, ICU stay, and any operative or procedural interventions. RESULTS Two hundred forty patients with minimal head injury were enrolled. Five patients (2.1%) had head CTs that were positive for intracranial hemorrhage. All instances of intracranial hemorrhage occurred in patients who were at high or moderate risk by the Canadian CT Head Rule (2 high risk [age], 3 moderate risk [mechanism]). No patient with intracranial hemorrhage went to the ICU or underwent any intervention; the average hospital length of stay was 1.25 days. The Canadian CT Head Rule was 100% sensitive (95% confidence interval 40% to 100%) and 29% specific (95% confidence interval 23% to 35%) for the presence of intracranial hemorrhage. Physicians listed their own reassurance (24.6%), patient reassurance (24.2%), patient expectation (14.6%), and reduction of legal liability (11.7%) as the rationale for ordering head CT in patients with minimal head injury. Shared decisionmaking was used in 51% of cases. CONCLUSION Risk of intracranial hemorrhage in patients with minimal head injury was very low, and even in patients found to have an intracranial hemorrhage, none had any serious adverse outcome (eg, death, intubation, prolonged hospitalization, surgical procedure). The Canadian CT Head Rule was 100% sensitive in this small cohort of patients with minimal head injury. Among our study cohort, which specifically included only patients who had CT scanning, applying the Canadian CT Head Rule may have reduced the need for CT, potentially saving costs and resources. However, because many patients with minimal head injury who present to the ED may not have CTs, it is unclear what effect the broad application of this rule would have on overall CT use. Providers' rationale for obtaining CT was multifactorial. These represent barriers that may need to be overcome before physicians are comfortable changing CT ordering patterns in this group of head injury patients.
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Affiliation(s)
- Kevin Davey
- Department of Emergency Medicine, George Washington University, Washington, DC.
| | - Turandot Saul
- Department of Emergency Medicine, Mount Sinai St. Luke's Hospital, Mount Sinai Roosevelt Hospital, New York, NY
| | - Geoffrey Russel
- Department of Emergency Medicine, Mount Sinai St. Luke's Hospital, Mount Sinai Roosevelt Hospital, New York, NY
| | - Jonathan Wassermann
- Department of Emergency Medicine, Mount Sinai St. Luke's Hospital, Mount Sinai Roosevelt Hospital, New York, NY
| | - Joshua Quaas
- Department of Emergency Medicine, Mount Sinai St. Luke's Hospital, Mount Sinai Roosevelt Hospital, New York, NY
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9
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Foks KA, van den Brand CL, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MGM, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Jellema K, Dippel DWJ. External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands. BMJ 2018; 362:k3527. [PMID: 30143521 PMCID: PMC6108278 DOI: 10.1136/bmj.k3527] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To externally validate four commonly used rules in computed tomography (CT) for minor head injury. DESIGN Prospective, multicentre cohort study. SETTING Three university and six non-university hospitals in the Netherlands. PARTICIPANTS Consecutive adult patients aged 16 years and over who presented with minor head injury at the emergency department with a Glasgow coma scale score of 13-15 between March 2015 and December 2016. MAIN OUTCOME MEASURES The primary outcome was any intracranial traumatic finding on CT; the secondary outcome was a potential neurosurgical lesion on CT, which was defined as an intracranial traumatic finding on CT that could lead to a neurosurgical intervention or death. The sensitivity, specificity, and clinical usefulness (defined as net proportional benefit, a weighted sum of true positive classifications) of the four CT decision rules. The rules included the CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and National Institute for Health and Care Excellence (NICE) guideline for head injury. RESULTS For the primary analysis, only six centres that included patients with and without CT were selected. Of 4557 eligible patients who presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for performing CT scanning: the NOC rule was preferable at a low threshold, the NICE rule was preferable at a higher threshold, whereas the CHIP rule was preferable for an intermediate threshold. CONCLUSIONS Application of the CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT scanning among patients with minor head injury, resulting in many unnecessary CT scans and some missed intracranial traumatic findings. Until an existing decision rule has been updated, any of the four rules can be used for patients presenting minor head injuries at the emergency department. Use of the CHIP rule is recommended because it leads to a substantial reduction in CT scans while missing few potential neurosurgical lesions.
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Affiliation(s)
- Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Myriam G M Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Centre for Health Decision Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Eef Reijners
- Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Meriam Braaksma
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
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Hassan S, Alarhayema AQ, Cohn SM, Wiersch JC, Price MR. Natural History of Isolated Skull Fractures in Children. Cureus 2018; 10:e3078. [PMID: 30280073 PMCID: PMC6167063 DOI: 10.7759/cureus.3078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Head injury is the most common cause of neurologic disability and mortality in children. We had hypothesized that in children with isolated skull fractures (SFs) and a normal neurological examination on presentation, the risk of neurosurgical intervention is very low. We retrospectively reviewed the medical records of all children aged six to sixteen years presenting to our Level 1 trauma center with traumatic brain injuries between January 1, 2006 and December 31, 2014. We also analyzed the National Trauma Data Bank (NTDB) research data set for the years 2012-2014 using the same metrics. During this study period, our center admitted 575 children with skull fractures, 197 of which were isolated (no associated intracranial lesions (ICLs)). Of the 197 patients with isolated SFs, 155 had a normal neurological examination at presentation. In these patients, there were no fatalities and only three (1.9%) required surgery, all for the elevation of the depressed skull fracture. Analyzing the NTDB yielded similar results. In 5,194 children with isolated SFs and a normal neurological examination on presentation, there were no fatalities and 249 (4.8%) required neurosurgical intervention, almost all involving craniotomy/craniectomy and/or elevation of the SF segments. In conclusion, children with non-depressed isolated skull fractures and a normal Glasgow coma scale (GCS) at the time of initial presentation are at extremely low risk of death or needing neurosurgical intervention.
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Affiliation(s)
- Saif Hassan
- Surgery, St. Luke's the Woodlands Hospital, Woodland, USA
| | | | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
| | | | - Mitchell R Price
- Pediatric Surgery, Northwell Health at Staten Island University Hospital, Staten Island, USA
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11
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Development of Delayed Posttraumatic Acute Subdural Hematoma. World Neurosurg 2018; 117:353-356. [PMID: 29959076 DOI: 10.1016/j.wneu.2018.06.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prior studies have shown that most patients with mild traumatic brain injury or negative computed tomography (CT) scans of the head rarely decline or require neurosurgical interventions. One common reason for a delayed decline is an intracranial hemorrhage that presents within 24-48 hours. This is typically seen in elderly patients and/or patients on antiplatelet or anticoagulation agents. We describe a case of a delayed subdural hemorrhage presenting in a young adult not on any antiplatelet or anticoagulation therapy. CASE DESCRIPTION A 19-year-old male presented to the emergency department after being involved in a motor vehicle accident. He had a Glasgow Coma Scale of 15, and an initial CT was negative for any intracranial hemorrhage or pathology, so he was then admitted to the intensive care unit for further care. The patient received 1 dose of aspirin 325 mg the following day for treatment of blunt cerebrovascular injury. Six hours later he reported a severe headache and had an episode of emesis with a subsequent rapid neurologic decline. Repeat CT showed an acute right subdural hematoma, and he underwent an emergent right decompressive hemicraniectomy. CONCLUSIONS In rare cases, patients with negative initial head CT scans neurologically deteriorate as a result of a delayed acute subdural hematoma. We present an unusual case of a young patient on no medications with no CT findings of an intracranial injury who neurologically declined due to a delayed acute subdural hematoma.
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12
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Seabury SA, Gaudette É, Goldman DP, Markowitz AJ, Brooks J, McCrea MA, Okonkwo DO, Manley GT. Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study. JAMA Netw Open 2018; 1:e180210. [PMID: 30646055 PMCID: PMC6324305 DOI: 10.1001/jamanetworkopen.2018.0210] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Mild traumatic brain injury (mTBI) affects millions of Americans each year. Lack of consistent clinical practice raises concern that many patients with mTBI may not receive adequate follow-up care. OBJECTIVE To characterize the provision of follow-up care to patients with mTBI during the first 3 months after injury. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data on patients with mTBI enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study between February 26, 2014, and August 25, 2016. We examined site-specific variations in follow-up care, the types of clinicians seen by patients receiving follow-up care, and patient and injury characteristics associated with a higher likelihood of receiving follow-up care. The TRACK-TBI study is a prospective, multicenter, longitudinal observational study of patients with TBI presenting to the emergency department of 1 of 11 level I US trauma centers. Study data included patients with head trauma who underwent a computed tomography (CT) scan within 24 hours of injury, had a Glasgow Coma Scale score of 13 to 15, were aged 17 years or older, and completed follow-up care surveys at 2 weeks and 3 months after injury (N = 831). MAIN OUTCOMES AND MEASURES Follow-up care was defined as hospitals providing TBI educational material at discharge, hospitals calling patients to follow up, and patients seeing a physician or other medical practitioner within 3 months after the injury. Unfavorable outcomes were assessed with the Rivermead Post Concussion Symptoms Questionnaire. RESULTS Of 831 patients (289 [35%] female; 483 [58%] non-Hispanic white; mean [SD] age, 40.3 [16.9] years), less than half self-reported receiving TBI educational material at discharge (353 patients [42%]) or seeing a physician or other health care practitioner within 3 months after injury (367 patients [44%]). Follow-up care varied by study site; adjusting for patient characteristics, the provision of educational material varied from 19% to 72% across sites. Of 236 patients with a positive finding on a CT scan, 92 (39%) had not seen a medical practitioner 3 months after the injury. Adjusting for injury severity and demographics, patient admission to the hospital ward or intensive care unit, patient income, and insurance status were not associated with the probability of seeing a medical practitioner. Among the patients with 3 or more moderate to severe postconcussive symptoms, only 145 of 279 (52%) reported having seen a medical practitioner by 3 months. CONCLUSIONS AND RELEVANCE There are gaps in follow-up care for patients with mTBI after hospital discharge, even those with a positive finding on CT or who continue to experience postconcussive symptoms.
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Affiliation(s)
- Seth A. Seabury
- Department of Ophthalmology and Leonard D. Schaeffer Center for Health Policy and Economics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Étienne Gaudette
- Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles
| | - Dana P. Goldman
- Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles
- Leonard D. Schaeffer Center for Health Policy and Economics, Price School of Public Policy, University of Southern California, Los Angeles
| | | | - Jordan Brooks
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
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Anada RP, Wong KT, Jayapalan JJ, Hashim OH, Ganesan D. Panel of serum protein biomarkers to grade the severity of traumatic brain injury. Electrophoresis 2018; 39:2308-2315. [PMID: 29570807 DOI: 10.1002/elps.201700407] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/11/2018] [Accepted: 03/12/2018] [Indexed: 12/22/2022]
Abstract
The Glasgow Coma Scale (GCS), which classifies patients into mild, moderate or severe traumatic brain injury (TBI), is a system used to prioritize treatment and prognosticate the severity of head injury. In this study, sera of patients with various stages of TBI, as well as control subjects, were analyzed to screen for proteins that may be used to complement the GCS system. By subjecting pooled serum samples to iTRAQ analysis for quantitative comparison of protein abundance, and attesting their altered levels using ELISA, we have detected increased levels of serum amyloid A, C-reactive protein, leucine-rich alpha-2-glycoprotein, lipopolysaccharide-binding protein, fibronectin, vitronectin and alpha-1-antichymotrypsin in patients across all strata of TBI relative to the controls. However, kininogen was decreased only in moderate and severe TBI, whereas apolipoprotein E and zinc-alpha-2-glycoprotein were only increased in severe TBI. Hence, we propose a panel of serum biomarkers, which if analyzed within 24 h of the injury, can be used to diagnose patients with TBI into mild, moderate or severe stratification objectively, thus complementing the traditional GCS.
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Affiliation(s)
- Raj Poovindran Anada
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kum Thong Wong
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jaime Jacqueline Jayapalan
- University of Malaya Centre for Proteomics Research, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Onn Haji Hashim
- University of Malaya Centre for Proteomics Research, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Dharmendra Ganesan
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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14
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Thaler HW, Jung-Schmidsfeld J, Pienaar S. [Mild head injuries in the elderly]. Z Gerontol Geriatr 2017; 50:451-459. [PMID: 28660534 DOI: 10.1007/s00391-017-1274-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 11/29/2022]
Abstract
In the elderly, particularly those over 80 years old, head injuries often occur as a result of falls. The majority suffer from mild head injury. After clarification of the initial symptoms in these patients, the main aim is to recognize or exclude intracranial injuries (bleeding). Demonstration of intracranial bleeding is possible with cranial computed tomography (CCT), which in contrast to magnetic resonance imaging (MRI) can be quickly carried out in most cases; however, most patients with mild head injury show no intracranial bleeding. The performance of CCT and the often necessary hospital admission place a severe physical and psychological burden on the elderly. The plasma parameter S100B, combined with the clinical findings, is a valuable instrument for decision making in the management of elderly patients with mild head injury.
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Affiliation(s)
- Heinrich W Thaler
- AUVA-Unfallkrankenhaus Wien-Meidling, Kundratstr. 37, 1120, Wien, Österreich.
| | | | - Simon Pienaar
- AUVA-Unfallkrankenhaus Wien-Meidling, Kundratstr. 37, 1120, Wien, Österreich
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15
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Mata-Mbemba D, Mugikura S, Nakagawa A, Murata T, Kato Y, Tatewaki Y, Takase K, Kushimoto S, Tominaga T, Takahashi S. Canadian CT head rule and New Orleans Criteria in mild traumatic brain injury: comparison at a tertiary referral hospital in Japan. SPRINGERPLUS 2016; 5:176. [PMID: 27026873 PMCID: PMC4766169 DOI: 10.1186/s40064-016-1781-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/12/2016] [Indexed: 11/10/2022]
Abstract
We compared Canadian computed tomography (CT) head rule (CCHR) and New Orleans Criteria (NOC) in predicting important CT findings in patients with mild traumatic brain injury (TBI). We included 142 consecutive patients with mild TBI [Glasgow coma scale (GCS) 13-15] who showed at least one of the risk factors stated in the CCHR or the NOC. We introduced two scores: a Canadian from the CCHR and a New Orleans from the NOC. A patient's score represented a sum of the number of positive items. We examined the relationship between scores or items and the presence of important CT findings. Only the Canadian was significantly associated with important CT findings in multivariate analyses and showed higher area under the receiver operating characteristic curve (AUC) either in all 142 patients (GCS 13-15: P = 0.0130; AUC = 0.69) or in the 67 with a GCS = 15 (P = 0.0128, AUC = 0.73). Of items, ">60 years" or "≥65 years" included in either guideline was the strongest predictor of important CT finding, followed by "GCS < 15 after 2 h" included only in the CCHR. In a tertiary referral hospital in Japan, CCHR had higher performance than the NOC in predicting important CT findings.
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Affiliation(s)
- Daddy Mata-Mbemba
- Department of Diagnostic Radiology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan ; Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Shunji Mugikura
- Department of Diagnostic Radiology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Atsuhiro Nakagawa
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Takaki Murata
- Department of Diagnostic Radiology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Yumiko Kato
- Department of Diagnostic Radiology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Yasuko Tatewaki
- Department of Diagnostic Radiology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Shoki Takahashi
- Department of Diagnostic Radiology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
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Isokuortti H, Luoto TM, Kataja A, Brander A, Siironen J, Liimatainen S, Iverson GL, Ylinen A, Ohman J. Necessity of monitoring after negative head CT in acute head injury. Injury 2014; 45:1340-4. [PMID: 24810669 DOI: 10.1016/j.injury.2014.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 04/04/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT). MATERIALS AND METHODS This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010-July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n=2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication. RESULTS The majority (n=1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n=27) of these patients returned to ED within 72h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%. CONCLUSION In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.
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Affiliation(s)
- Harri Isokuortti
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland.
| | - Teemu M Luoto
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Anneli Kataja
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Antti Brander
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Suvi Liimatainen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School & Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, MA, USA
| | - Aarne Ylinen
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland; Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Ohman
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
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Ratcliff JJ, Adeoye O, Lindsell CJ, Hart KW, Pancioli A, McMullan JT, Yue JK, Nishijima DK, Gordon WA, Valadka AB, Okonkwo DO, Lingsma HF, Maas AIR, Manley GT. ED disposition of the Glasgow Coma Scale 13 to 15 traumatic brain injury patient: analysis of the Transforming Research and Clinical Knowledge in TBI study. Am J Emerg Med 2014; 32:844-50. [PMID: 24857248 DOI: 10.1016/j.ajem.2014.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/04/2014] [Accepted: 04/05/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Mild traumatic brain injury (mTBI) patients are frequently admitted to high levels of care despite limited evidence suggesting benefit. Such decisions may contribute to the significant cost of caring for mTBI patients. Understanding the factors that drive disposition decision making and how disposition is associated with outcomes is necessary for developing an evidence-base supporting disposition decisions. We evaluated factors associated with emergency department triage of mTBI patients to 1 of 3 levels of care: home, inpatient floor, or intensive care unit (ICU). METHODS This multicenter, prospective, cohort study included patients with isolated head trauma, a cranial computed tomography as part of routine care, and a Glasgow Coma Scale (GCS) score of 13 to 15. Data analysis was performed using multinomial logistic regression. RESULTS Of the 304 patients included, 167 (55%) were discharged home, 76 (25%) were admitted to the inpatient floor, and 61 (20%) were admitted to the ICU. In the multivariable model, admission to the ICU, compared with floor admission, varied by study site, odds ratio (OR) 0.18 (95% confidence interval [CI], 0.06-0.57); antiplatelet/anticoagulation therapy, OR 7.46 (95% CI, 1.79-31.13); skull fracture, OR 7.60 (95% CI, 2.44-23.73); and lower GCS, OR 2.36 (95% CI, 1.05-5.30). No difference in outcome was observed between the 3 levels of care. CONCLUSION Clinical characteristics and local practice patterns contribute to mTBI disposition decisions. Level of care was not associated with outcomes. Intracranial hemorrhage, GCS 13 to 14, skull fracture, and current antiplatelet/anticoagulant therapy influenced disposition decisions.
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Affiliation(s)
- Jonathan J Ratcliff
- Emergency Medicine and Neurocritical Care, University of Cincinnati, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769.
| | - Opeolu Adeoye
- Emergency Medicine and Neurosurgery, University of Cincinnati, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769.
| | - Christopher J Lindsell
- Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769.
| | - Kimberly W Hart
- Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769.
| | - Arthur Pancioli
- Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769.
| | - Jason T McMullan
- Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769.
| | - John K Yue
- Neurological Surgery, University of California, San Francisco, 1001 Potrero Ave, Building 1 Room 101, San Francisco, CA 94110.
| | - Daniel K Nishijima
- Emergency Medicine, University of California, Davis, 4150 V St, Suite 2100, Sacramento, CA 95817.
| | - Wayne A Gordon
- Rehabilitation Medicine, Mount Sinai School of Medicine, 1425 Madison Ave, Box 1240, New York, NY 10029.
| | - Alex B Valadka
- Seton Brain and Spine Institute, 1400 North IH 35, Suite 300, Austin, TX.
| | - David O Okonkwo
- Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St Suite B-400, Pittsburgh, PA 15213.
| | | | - Andrew I R Maas
- Neurosurgery, Antwerp University Hospital, University of Antwerp, Wilrijkstraat, Edegem, Belgium 102650.
| | - Geoffrey T Manley
- Emergency Medicine, University of California, Davis, 4150 V St, Suite 2100, Sacramento, CA 95817.
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18
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Traumi cranioencefalici. Neurologia 2014. [DOI: 10.1016/s1634-7072(14)67225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Schoonman GG, Bakker DP, Jellema K. Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: education instead of hospitalization. Eur J Neurol 2014; 21:1021-5. [DOI: 10.1111/ene.12429] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/24/2014] [Indexed: 11/28/2022]
Affiliation(s)
- G. G. Schoonman
- Department of Neurology; St Elisabeth Hospital; Tilburg The Netherlands
- Department of Neurology; Medisch Centrum Haaglanden; The Hague The Netherlands
| | - D. P. Bakker
- Department of Neurology; Medisch Centrum Haaglanden; The Hague The Netherlands
| | - K. Jellema
- Department of Neurology; Medisch Centrum Haaglanden; The Hague The Netherlands
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20
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Undén J, Ingebrigtsen T, Romner B. Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update. BMC Med 2013; 11:50. [PMID: 23432764 PMCID: PMC3621842 DOI: 10.1186/1741-7015-11-50] [Citation(s) in RCA: 255] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 02/25/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines for initial management of these injuries. Since then, considerable new evidence has emerged. METHODS General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Systematic evidence-based review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, based upon relevant clinical questions with respect to patient-important outcomes, including Quality Assessment of Diagnostic Accuracy Studies (QUADAS) and Centre of Evidence Based Medicine (CEBM) quality ratings. Based upon the results, GRADE recommendations, guidelines and discharge instructions were drafted. A modified Delphi approach was used for consensus and relevant clinical stakeholders were consulted. CONCLUSIONS We present the updated SNC guidelines for initial management of minimal, mild and moderate head injury in adults including criteria for computed tomography (CT) scan selection, admission and discharge with suggestions for monitoring routines and discharge advice for patients. The guidelines are designed to primarily detect neurosurgical intervention with traumatic CT findings as a secondary goal. For elements lacking good evidence, such as in-hospital monitoring, routines were largely based on consensus. We suggest external validation of the guidelines before widespread clinical use is recommended.
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Affiliation(s)
- Johan Undén
- Department of Intensive Care and Perioperative Medicine, Institute for Clinical Sciences, Södra Förstadsgatan 101, 20502 Malmö, Sweden.
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21
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Evaluation and management of mild traumatic brain injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2013; 73:S307-14. [PMID: 23114486 DOI: 10.1097/ta.0b013e3182701885] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time. METHODS The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined. RESULTS A total of 112 articles were reviewed and used to construct a series of recommendations. CONCLUSION The previous recommendation that brain computed tomographic (CT) should be performed on patients that present acutely with suspected brain trauma remains unchanged. A number of additional recommendations were added. Standardized criteria that may be used to determine which patients receive a brain CT in resource-limited environments are described. Patients with an MTBI and negative brain CT result may be discharged from the emergency department if they have no other injuries or issues requiring admission. Patients taking warfarin who present with an MTBI should have their international normalized ratio (INR) level determined, and those with supratherapeutic INR values should be admitted for observation. Deficits in cognition and memory usually resolve within 1 month but may persist for longer periods in 20% to 40% of cases. Routine use of magnetic resonance imaging, positron emission tomography, nuclear magnetic resonance, or biochemical markers for the clinical management of MTBI is not supported at the present time.
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22
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Holmes MW, Goodacre S, Stevenson MD, Pandor A, Pickering A. The cost-effectiveness of diagnostic management strategies for adults with minor head injury. Injury 2012; 43:1423-31. [PMID: 21835403 DOI: 10.1016/j.injury.2011.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 07/18/2011] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- M W Holmes
- School of Health and Related Research, The University of Sheffield, United Kingdom.
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23
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Vos PE, Alekseenko Y, Battistin L, Ehler E, Gerstenbrand F, Muresanu DF, Potapov A, Stepan CA, Traubner P, Vecsei L, von Wild K. Mild traumatic brain injury. Eur J Neurol 2012; 19:191-8. [PMID: 22260187 DOI: 10.1111/j.1468-1331.2011.03581.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Traumatic Brain Injury (TBI) is among the most frequent neurological disorders. Of all TBIs 90% are considered mild with an annual incidence of 100–300/100.000. Intracranial complications of Mild Traumatic Brain Injury (MTBI) are infrequent (10%), requiring neurosurgical intervention in a minority of cases (1%), but potentially life-threatening (case fatality rate 0,1%). Hence, a true health management problem exists because of the need to exclude the small chance of a life threatening complication in large numbers of individual patients. The 2002 EFNS guidelines used a best evidence approach based on the literature until 2001 to guide initial management with respect to indications for CT, hospital admission, observation and follow up of MTBI patients. This updated EFNS guideline version for initial management inMTBI proposes a more selectively strategy for CT when major (dangerous mechanism, GCS<15, 2 points deterioration on the GCS, clinical signs of (basal) skull fracture, vomiting, anticoagulation therapy, post traumatic seizure) or minor (age, loss of consciousness, persistent anterograde amnesia, focal deficit, skull contusion, deterioration on the GCS) risk factors are present based on published decision rules with a high level of evidence. In addition clinical decision rules for CT now exist for children as well. Since 2001 recommendations, although with a lower level of evidence, have been published for clinical in hospital observation to prevent and treat other potential threads to the patient including behavioral disturbances (amnesia, confusion and agitation) and infection.
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Affiliation(s)
- P E Vos
- Radboud University Nijmegen Medical Centre, The Netherlands.
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24
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Agius S, Ansari S, Zrinzo A. Pattern of head injuries in Malta (EU): a small Mediterranean island. Br J Neurosurg 2011; 26:212-5. [DOI: 10.3109/02688697.2011.609920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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25
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Diagnosis of Concussion: The Role of Imaging Now and in the Future. Phys Med Rehabil Clin N Am 2011; 22:635-52, viii. [DOI: 10.1016/j.pmr.2011.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Internationale und nationale Leitlinien für die Indikation zur Bildgebung bei Verdacht auf leichtes Schädel-Hirn-Trauma. Notf Rett Med 2011. [DOI: 10.1007/s10049-011-1422-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
The definition of a mild traumatic brain injury (TBI) has come under close scrutiny and is changing as a result of refined diagnostic testing. Although up to 15% of patients with a mild TBI will have an acute intracranial lesion identified on head computed tomography (CT), less than 1% of these patients will have a lesion requiring a neurosurgical intervention. Evidence-based guideline methodology has assisted in generating recommendations to facilitate clinical decision making; however, no set of guidelines is 100% sensitive and specific. Evidence supports the safety of discharging patients with mild TBI who have a negative CT. However, though patients with a negative CT are at almost no risk of deteriorating from a neurosurgical lesion, a key intervention is to provide these patients at discharge from the emergency department with counseling regarding postconcussive symptoms, when to return to work, school, or sports, and when to seek additional medical care.
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Affiliation(s)
- Andy S Jagoda
- Department of Emergency Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1620, New York, NY 10029, USA.
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28
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Jacobs B, Beems T, Stulemeijer M, van Vugt AB, van der Vliet TM, Borm GF, Vos PE. Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities. J Neurotrauma 2010; 27:655-68. [PMID: 20035619 DOI: 10.1089/neu.2009.1059] [Citation(s) in RCA: 159] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a common heterogeneous neurological disorder with a wide range of possible clinical outcomes. Accurate prediction of outcome is desirable for optimal treatment. This study aimed both to identify the demographic, clinical, and computed tomographic (CT) characteristics associated with unfavorable outcome at 6 months after mTBI, and to design a prediction model for application in daily practice. All consecutive mTBI patients (Glasgow Coma Scale [GCS] score: 13-15) admitted to our hospital who were age 16 or older were included during an 8-year period as part of the prospective Radboud University Brain Injury Cohort Study (RUBICS). Outcome was assessed at 6 months post-trauma using the Glasgow Outcome Scale-Extended (GOSE), dichotomized into unfavorable (GOSE score 1-6) and favorable (GOSE score 7-8) outcome groups. The predictive value of several variables was determined using multivariate binary logistic regression analysis. We included 2784 mTBI patients and found CT abnormalities in 20.7% of the 1999 patients that underwent a head CT. Age, extracranial injuries, and day-of-injury alcohol intoxication proved to be the strongest outcome predictors. The presence of facial fractures and the number of hemorrhagic contusions emerged as CT predictors. Furthermore, we showed that the predictive value of a scheme based on a modified Injury Severity Score (ISS), alcohol intoxication, and age equalled the value of one that also included CT characteristics. In fact, it exceeded one that was based on CT characteristics alone. We conclude that, although valuable for the identification of the individual mTBI patient at risk for deterioration and eventual neurosurgical intervention, CT characteristics are imperfect predictors of outcome after mTBI.
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Affiliation(s)
- Bram Jacobs
- Department of Neurology, Radboud University Nijmegen Medical Centre (RUNMC), Nijmegen, the Netherlands
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Smits M, Dippel DWJ, Nederkoorn PJ, Dekker HM, Vos PE, Kool DR, van Rijssel DA, Hofman PAM, Twijnstra A, Tanghe HLJ, Hunink MGM. Minor Head Injury: CT-based Strategies for Management—A Cost-effectiveness Analysis. Radiology 2010; 254:532-40. [DOI: 10.1148/radiol.2541081672] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ruan S, Noyes K, Bazarian JJ. The economic impact of S-100B as a pre-head CT screening test on emergency department management of adult patients with mild traumatic brain injury. J Neurotrauma 2010; 26:1655-64. [PMID: 19413465 DOI: 10.1089/neu.2009.0928] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Recent research suggests that serum S-100B may serve as a good pre-head computed tomography (CT) screening test because of its high sensitivity for abnormal head CT scans. The potential economic impact of using S-100B in the emergency department setting for management of adult patients with isolated mild traumatic brain injury (mTBI) has not been evaluated despite its clinical implementation in Europe. Using evidence from the literature, we constructed a decision tree to compare the average cost per patient of using S-100B as a pre-head CT screening test to the current practice of ordering CT scans based on patients' presenting symptoms without the aid of S-100B. When compared to scanning 45-77% of isolated mTBI patients based upon their presenting symptoms, using S-100B as a pre-head CT screen does not lower hospital costs ($281 versus $160), primarily due to its low specificity for abnormal head CT scans. Sensitivity analyses showed, however, that S-100B becomes cost-lowering when the proportion of mTBI patients being scanned exceeds 78%, or when final CT scan results require 96 min or more than the wait for blood test results. Generally speaking, if blood test results require less time than imaging, and if head CT scan rates for patients with isolated mTBI are relatively high, using S-100B will lower costs. Recommendations for using S-100B as a screening tool should account for setting-specific characteristics and their consequent economic impacts. Despite its high sensitivity and excellent negative predictive value, serum S-100B has low specificity and low positive predictive value, limiting its ability to reduce numbers of CT scans and hospital costs.
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Affiliation(s)
- Shuolun Ruan
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Lee YB, Kwon SJ. A more detailed classification of mild head injury in adults and treatment guidelines. J Korean Neurosurg Soc 2009; 46:451-8. [PMID: 20041055 DOI: 10.3340/jkns.2009.46.5.451] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 09/16/2009] [Accepted: 10/25/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to analyze risk factors that are associated with intracranial lesion, and to propose criteria for classification of mild head injury (MHI), and appropriate treatment guidelines. METHODS The study was based on 898 patients who were admitted to our hospital with Glasgow Coma Scale (GCS) score of 13 to 15 between 2003 and 2007. The patients' initial computerized tomography (CT) findings were reviewed and clinical findings that were associated with intracranial lesions were analyzed. RESULTS GCS score, loss of consciousness (LOC), age and skull fracture were identified as independent risk factors for intracranial lesions. Based on the data analysed in this study, MHI patients were divided into four subgroups : very low risk MHI patients are those with a GCS score of 15 and without a history of LOC or headache; low risk MHI patients have a GCS score of 15 and with LOC and/or headache; medium risk MHI patients are those with a GCS score of 15 and with a skull fracture, neurological deficits or with one or more of the risk factors; high risk MHI patients are those with a GCS score of 15 with abnormal CT findings and GCS score of 14 and 13. CONCLUSION A more detailed classification of MHI based on brain CT scan findings and clinical risk factors can potentially improve patient diagnosis. In light of our findings, high risk MHI patients should be admitted and treated in same manner as those with moderate head injury.
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Affiliation(s)
- Young Bae Lee
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Gyeongju, Korea
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Secondary intracranial hemorrhage after mild head injury in patients with low-dose acetylsalicylate acid prophylaxis. ACTA ACUST UNITED AC 2009; 67:521-5; discussion 525. [PMID: 19741394 DOI: 10.1097/ta.0b013e3181a7c184] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low-dose acetylsalicylate acid (LDA) therapy is accepted as a major risk factor for intracranial hemorrhages (ICH) in head injuries. Coincidentally, patient admissions that might be indicated for in hospital observation of neurologic function causes increased health care costs. In the literature, there is no evidence concerning the incidence of secondary intracranial hemorrhagic events (SIHE) in patients with LDA prophylaxis that had negative primary computed tomography (CT)-scan of the head. METHODS In this prospective study, we enrolled 100 consecutive trauma patients older than 65 years presenting in a Level I urban trauma center after a mild head injury (Glasgow Coma Scale score of 15) who had LDA prophylaxis. Patients included had a negative primary head CT-scan concerning ICH. For analysis of the incidence of SIHEs patients had routine repeat head CT (RRHCT) after 12 hours to 24 hours. RESULTS Sixty-one patients were women and 39 men. Mean age was 81 years +/- 10 years. Injury mechanism was a level fall in 84 cases and others in 16. In four patients (4%) an SIHE was detected in the RRHCT (p < 0.00001). In two patients (2%) major secondary ICH had occurred without neurologic deterioration at the time of RRHCT with fatal outcome in one patient and neurosurgical intervention in another. The remaining two patients (2%) had minor SIHE with an uneventful clinical course. CONCLUSION The incidence of SIHE has been neglected until now. The current study revealed that patients with LDA prophylaxis after mild head injury with negative primary head CT should be subjected to RRHCT within 12 hours to 24 hours to accurately identify SIHE. Alternatively to RRHCT, patients should be subjected to a prolonged in-hospital observation for at least 48 hours.
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Delayed life-threatening subdural hematoma after minor head injury in a patient with severe coagulopathy: a case report. CASES JOURNAL 2009; 2:7587. [PMID: 19918473 PMCID: PMC2769363 DOI: 10.4076/1757-1626-2-7587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Accepted: 07/21/2009] [Indexed: 11/15/2022]
Abstract
Minor head injury is a frequent cause for neurologic consultation and imaging. Most patients with minor head injury will make an uneventful recovery, but in a very small proportion of these patients life threatening intracranial complications occur. We describe a patient on oral anticoagulation therapy, and severely impaired coagulation, with normal head computed tomography on admission, who developed a subdural hematoma requiring surgery 12 hours later. Current guidelines and literature for the management of minor head injury are discussed.
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Jagoda AS, Bazarian JJ, Bruns JJ, Cantrill SV, Gean AD, Howard PK, Ghajar J, Riggio S, Wright DW, Wears RL, Bakshy A, Burgess P, Wald MM, Whitson RR. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. J Emerg Nurs 2009; 35:e5-40. [PMID: 19285163 DOI: 10.1016/j.jen.2008.12.010] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Andy S Jagoda
- Division of Injury Response, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, USA
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Abstract
Mild traumatic brain injury accounts for 1% to 2% of emergency department visits in the United States. Up to 15% of these patients will have an acute intracranial lesion identified on head computed tomography; less than 1% of mild traumatic brain injuries will require neurosurgical intervention. Clinical research over the past decade has focused on identifying the subgroup of patients with mild traumatic brain injury with acute traumatic lesions on computed tomography and specifically those at risk for harboring a potentially catastrophic lesion. This research has been used to generate evidence-based guidelines to assist in clinical decision making. There is no evidence to support the use of plain film radiographs in the evaluation of patients with mild traumatic brain injury. The utility of brain-specific biomarkers is rapidly evolving, and a growing body of evidence supports their potential role in determining the need for neuroimaging. Clinical predictors for identifying patients with abnormal computed tomography have been established and, if used, may have a significant positive impact on traumatic brain injury-related morbidity and healthcare utilization in the United States. Patients with negative computed tomography are at almost no risk of deteriorating; however, they should be counseled regarding postconcussive symptoms and should be given appropriate written instructions and referrals at discharge.
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Affiliation(s)
- John J Bruns
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting. Ann Emerg Med 2008; 52:714-48. [DOI: 10.1016/j.annemergmed.2008.08.021] [Citation(s) in RCA: 337] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Smits M, Dippel DWJ, de Haan GG, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PAM, Twijnstra A, Tanghe HLJ, Hunink MGM. Minor head injury: guidelines for the use of CT--a multicenter validation study. Radiology 2007; 245:831-8. [PMID: 17911536 DOI: 10.1148/radiol.2452061509] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively and externally validate published national and international guidelines for the indications of computed tomography (CT) in patients with a minor head injury. MATERIALS AND METHODS The study protocol was institutional review board approved. All patients implicitly consented to use of their deidentified data for research purposes. Between February 2002 and August 2004, data were collected in consecutive adult patients with blunt minor head injury (Glasgow Coma Scale score of 13-14 or 15) and a risk factor for neurocranial traumatic complications at presentation at four Dutch university hospitals. Primary outcome was any neurocranial traumatic CT finding. Secondary outcomes were clinically relevant traumatic CT findings and neurosurgical intervention. Sensitivity and specificity of each guideline for all outcomes and the number of patients needed to scan to detect one outcome (ie, the number of patients needed to undergo CT to find one patient with a neurocranial traumatic CT finding, a clinically relevant traumatic CT finding, or a CT finding that required neurosurgical intervention) were estimated. RESULTS Data were available for 3181 patients. Only the European Federation of Neurological Societies guidelines reached a sensitivity of 100% for all outcomes. Specificity was 0.0%-0.5%. The Dutch guidelines had the lowest sensitivity (76.5%) for neurosurgical interventions. The best specificities for traumatic CT findings and neurosurgical interventions were reached with the criteria proposed by the United Kingdom National Institute for Clinical Excellence (NICE) (46.1% and 43.6%, respectively), albeit at relatively low sensitivities (82.1% and 94.1%, respectively). The number of patients needed to scan ranged from six to 13 for traumatic CT findings and from 79 to 193 for neurosurgical interventions. CONCLUSION All validated guidelines demonstrated a trade-off between sensitivity and specificity. The lowest number of patients needed to scan for either of the outcomes was reached with the NICE criteria. SUPPLEMENTAL MATERIAL radiology.rsnajnls.org/cgi/content/full/2452061509/DC1 (c) RSNA, 2007.
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Affiliation(s)
- Marion Smits
- Department of Radiology, Erasmus MC-University Medical Center Rotterdam, the Netherlands
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af Geijerstam JL, Oredsson S, Britton M. Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial. BMJ 2006; 333:465. [PMID: 16895944 PMCID: PMC1557917 DOI: 10.1136/bmj.38918.669317.4f] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare immediate computed tomography during triage for admission with observation in hospital in patients with mild head injury. DESIGN Multicentre, pragmatic, non-inferiority randomised trial. SETTING 39 acute hospitals in Sweden. PARTICIPANTS 2602 patients (aged > or = 6) with mild head injury. INTERVENTIONS Immediate computed tomography or admission for observation. MAIN OUTCOME MEASURE Dichotomised extended Glasgow outcome scale (1-7 v 8). The non-inferiority margin was 5 percentage points. RESULTS At three months, 275 patients (21.4%) in the computed tomography group had not recovered completely compared with 300 (24.2%) admitted for observation. The difference was - 2.8 percentage points, non-significantly in favour of computed tomography (95% confidence interval - 6.1% to 0.6%). The worst outcomes (mortality and more severe loss of function) were similar between the groups. In the patients admitted for observation, there was a considerable delay in time to treatment in those who required surgery. None of the patients with normal findings on immediate computed tomography had complications later. Patients' satisfaction with the two strategies was similar. CONCLUSIONS The use of computed tomography in the management of patients with mild head injury is feasible and leads to similar clinical outcomes compared with observation in hospital. TRIAL REGISTRATION ISRCTN81464462.
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Affiliation(s)
- Jean-Luc af Geijerstam
- Department of Medicine, Clinical Epidemiology Unit, Karolinska University Hospital, 171 76 Stockholm, Sweden.
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de Andrade AF, de Almeida AN, Bor-Seng-Shu E, Lourenço L, Mandel M, Marino R. The value of cranial computed tomography in high-risk, mildly head-injured patients. ACTA ACUST UNITED AC 2006; 65 Suppl 1:S1:10-1:13. [PMID: 16427436 DOI: 10.1016/j.surneu.2005.11.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 11/03/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this article was to assess if high-risk, mildly head-injured patients with normal CT scan present an outcome similar to the group with "low-risk MHI." METHODS A total of 379 hospital charts of inpatients with Glasgow Coma Scale scores of 13, 14, and 15 were reviewed. Information regarding age, fGCS, trauma mechanism, cranial CT scan findings, hospital course, and follow-up using the GOS were obtained from all patients. RESULTS Patients were separated in 3 groups: fGCS 13 (46 patients), fGCS 14 (138 patients), and fGCS 15 (195 patients). The groups with different scores on fGCS did not differ regarding CT scan abnormalities, surgical treatment, or outcome. Patients were also separated in 2 groups based on CT scan findings: 266 patients had CT interpreted as abnormal and 113 had CT interpreted as normal. The 2 groups differed statistically regarding surgical treatment and scores on GOS (P < .05). There was no statistically significant difference between the 2 groups regarding sex, trauma mechanism, fGCS, or age. CONCLUSIONS Our findings support the idea that a normal cranial CT scan in patients with fGCS scores of 13 or higher ascertain a low-risk MHI outcome and, therefore, such patients must be included in this category of traumatic brain injury. On the other hand, patients with cranial CT scan abnormalities should be included in the group with moderate head injury.
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Affiliation(s)
- Almir Ferreira de Andrade
- Department of Neurology of Hospital das Clínicas of São Paulo University, Medical School, Rue Eneas Carvalho de Aguiar 255, Caixa Postal 8091, São Paulo (SP), Brazil.
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Muthukumar N. Indications and need for neuroimaging and newer developments in brain imaging in mild head injury. INDIAN JOURNAL OF NEUROTRAUMA 2005. [DOI: 10.1016/s0973-0508(05)80021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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