1
|
Zibetti M, Di Resta C, Banfi G, Tomaiuolo R. Value-Based Health Care Implementation: The Case Study of mTBI Biomarkers. J Pers Med 2024; 14:634. [PMID: 38929855 PMCID: PMC11204511 DOI: 10.3390/jpm14060634] [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: 05/15/2024] [Revised: 06/09/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Traumatic brain injury is a significant global health issue, affecting approximately 69 million people annually. Early diagnosis is crucial for effective management, and biomarkers provide a promising approach to identifying traumatic brain injury in various settings. This study investigates the perceived usefulness of biomarker testing in two distinct contexts: emergency departments and sports settings. Comprehensive interviews were conducted among healthcare professionals in emergency departments and sports-related medical staff. The interviews assessed their perceptions of the diagnostic accuracy, practicality, and overall value of traumatic brain injury biomarker testing. The findings indicate that the perceived usefulness of biomarker testing is high among professionals in both settings. However, significant differences emerged in the perceived barriers to implementation, with emergency department staff citing logistical issues and sports professionals expressing cost concerns. Addressing identified barriers could enhance the adoption and effectiveness of these tests, ultimately improving patient outcomes. Future research should focus on optimizing testing protocols and reducing implementation challenges. This study aims to evaluate the implementation of mild traumatic brain injury biomarkers within the framework of value-based health care, focusing on diagnostic accuracy and patient outcomes.
Collapse
Affiliation(s)
- Martina Zibetti
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Chiara Di Resta
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Giuseppe Banfi
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- IRCCS Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
| | - Rossella Tomaiuolo
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- IRCCS Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
| |
Collapse
|
2
|
Tomaiuolo R, Zibetti M, Di Resta C, Banfi G. Challenges of the Effectiveness of Traumatic Brain Injuries Biomarkers in the Sports-Related Context. J Clin Med 2023; 12:jcm12072563. [PMID: 37048647 PMCID: PMC10095236 DOI: 10.3390/jcm12072563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Traumatic brain injury affects 69 million people every year. One of the main limitations in managing TBI patients is the lack of univocal diagnostic criteria, including the absence of standardized assessment methods and guidelines. Computerized axial tomography is the first-choice examination, despite the limited prevalence of positivity; moreover, its performance is undesirable due to the risk of radiological exposure, prolonged stay in emergency departments, inefficient use of resources, high cost, and complexity. Furthermore, immediacy and accuracy in diagnosis and management of TBIs are critically unmet medical needs. Especially in the context of sports-associated TBI, there is a strong need for prognostic indicators to help diagnose and identify at-risk subjects to avoid their returning to play while the brain is still highly vulnerable. Fluid biomarkers may emerge as new prognostic indicators to develop more accurate prediction models, improving risk stratification and clinical decision making. This review describes the current understanding of the cellular sources, temporal profile, and potential utility of leading and emerging blood-based protein biomarkers of TBI; its focus is on biomarkers that could improve the management of mild TBI cases and can be measured readily and directly in the field, as in the case of sports-related contexts.
Collapse
Affiliation(s)
- Rossella Tomaiuolo
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Martina Zibetti
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Chiara Di Resta
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- Correspondence:
| | - Giuseppe Banfi
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- IRCCS Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
| |
Collapse
|
3
|
Anestis DM, Monioudis PM, Foroglou NG, Tsonidis CA, Tsitsopoulos PP. Clinimetric study and review of the Reaction Level Scale. Acta Neurol Scand 2022; 145:706-720. [PMID: 35243607 DOI: 10.1111/ane.13604] [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: 12/07/2021] [Revised: 02/06/2022] [Accepted: 02/15/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although the Reaction Level Scale (RLS) is still used for the assessment of the level of consciousness in distinct centers, its clinical characteristics and significance have been incompletely researched. In the current study, the clinimetric properties, the prognostic value, and the impact of the raters' background on the application of the RLS, in comparison with the Glasgow Coma Scale (GCS), are investigated. MATERIALS AND METHODS A systematic review on the available clinical evidence for the RLS was first carried out. Next, the RLS was translated into Greek, and patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with both RLS and GCS, by four raters (two consultants, one resident, and one nurse) within one hour. Interrater reliability, construct validity, and predictive value (mortality and poor outcome, at discharge and at 6 months) were evaluated. RESULTS Literature review retrieved 9 clinimetric studies related to the RLS, most of low quality, indicating that the scale has not been thoroughly studied. Both versions of the RLS (original and modified) showed high interrater reliability (κw >0.80 for all pairs of raters), construct validity (Spearman's p > .90 for all raters), and prognostic value (areas under the curve >0.85 for all raters and outcomes). However, except for broader patients' coverage, it failed to show any advantage over the GCS. CONCLUSIONS The RLS has not succeeded in showing any advantage over the GCS in terms of reliability and validity. Available evidence cannot justify its use in clinical practice as a substitute to the widely applied GCS.
Collapse
Affiliation(s)
- Dimitrios M. Anestis
- Department of Neurosurgery Hippokration General Hospital Aristotle University School of Medicine Thessaloniki Greece
| | - Panagiotis M. Monioudis
- Department of Neurosurgery Hippokration General Hospital Aristotle University School of Medicine Thessaloniki Greece
| | - Nikolaos G. Foroglou
- Department of Neurosurgery AHEPA University Hospital Aristotle University School of Medicine Thessaloniki Greece
| | - Christos A. Tsonidis
- Department of Neurosurgery Hippokration General Hospital Aristotle University School of Medicine Thessaloniki Greece
| | - Parmenion P. Tsitsopoulos
- Department of Neurosurgery Hippokration General Hospital Aristotle University School of Medicine Thessaloniki Greece
| |
Collapse
|
4
|
The diagnostic value of the neurological examination in coma of unknown etiology. J Neurol 2021; 268:3826-3834. [PMID: 33796895 PMCID: PMC8463407 DOI: 10.1007/s00415-021-10527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 11/20/2022]
Abstract
Background Identifying the cause of non-traumatic coma in the emergency department is challenging. The clinical neurological examination is the most readily available tool to detect focal neurological deficits as indicators for cerebral causes of coma. Previously proposed clinical pathways have granted the interpretation of clinical findings a pivotal role in the diagnostic work-up. We aimed to identify the actual diagnostic reliability of the neurological examination with regard to identifying acute brain damage.
Methods Eight hundred and fifty-three patients with coma of unknown etiology (CUE) were examined neurologically in the emergency department following a predefined routine. Coma-explaining pathologies were identified retrospectively and grouped into primary brain pathology with proof of acute brain damage and other causes without proof of acute structural pathology. Sensitivity, specificity and percentage of correct predictions of different examination protocols were calculated using contingency tables and binary logistic regression models. Results The full neurological examination was 74% sensitive and 60% specific to detect acute structural brain damage underlying CUE. Sensitivity and specificity were higher in non-sedated patients (87/61%) compared to sedated patients (64%/59%). A shortened four-item examination protocol focusing on pupils, gaze and pyramidal tract signs was only slightly less sensitive (67%) and more specific (65%).
Conclusions Due to limited diagnostic reliability of the physical examination, the absence of focal neurological signs in acutely comatose patients should not defer from a complete work-up including brain imaging. In an emergency, a concise neurological examination should thus serve as one part of a multimodal diagnostic approach to CUE.
Collapse
|
5
|
Ayaz H, Izzetoglu M, Izzetoglu K, Onaral B, Ben Dor B. Early diagnosis of traumatic intracranial hematomas. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:1-10. [PMID: 30719879 PMCID: PMC6992895 DOI: 10.1117/1.jbo.24.5.051411] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 01/03/2019] [Indexed: 05/07/2023]
Abstract
Timing of the intervention for intracranial hematomas is critical for its success, specifically since expansion of the hemorrhage can result in debilitating and sometimes fatal outcomes. Led by Britton Chance, we and an extended team from University of Pennsylvania, Baylor and Drexel universities developed a handheld brain hematoma detector for early triage and diagnosis of head trauma victims. After obtaining de novo Food and Drug Administration clearance, over 200 systems are deployed in all Marine battalion aid stations around the world. Infrascanner, a handheld brain hematoma detection system, is based on the differential near-infrared light absorption of the injured versus the noninjured part of brain. About 12 independent studies have been conducted in the USA, Canada, Spain, Italy, the Netherlands, Germany, Russia, Poland, Afghanistan, India, China, and Turkey. Here, we outline the background and design of the device as well as clinical studies with a total of 1293 patients and 203 hematomas. Infrascanner demonstrates high sensitivity (adults: 92.5% and children: 93%) and specificity (adults: 82.9% and children: 86.5%) in detecting intracranial hematomas >3.5 mL in volume and <2.5 cm from the surface of the brain. Infrascanner is a clinically effective screening solution for head trauma patients in prehospital settings where timely triage is critical.
Collapse
Affiliation(s)
- Hasan Ayaz
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, Department of Family and Community Health, Philadelphia, Pennsylvania, United States
- Children’s Hospital of Philadelphia, Center for Injury Research and Prevention, Philadelphia, Pennsylvania, United States
- Address all correspondence to Hasan Ayaz, E-mail:
| | - Meltem Izzetoglu
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania, United States
- Villanova University, Electrical and Computer Engineering, Villanova, Pennsylvania, United States
| | - Kurtulus Izzetoglu
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania, United States
| | - Banu Onaral
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania, United States
| | - Baruch Ben Dor
- Infrascan Inc., Philadelphia, Pennsylvania, United States
| |
Collapse
|
6
|
Prasad GL. Minor Head Injuries in Infants: Recommendations for Computed Tomography Imaging. World Neurosurg 2017; 103:942-943. [PMID: 28672717 DOI: 10.1016/j.wneu.2017.02.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 11/19/2022]
Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal University, Manipal, India.
| |
Collapse
|
7
|
|
8
|
Stevens MC, Lovejoy D, Kim J, Oakes H, Kureshi I, Witt ST. Multiple resting state network functional connectivity abnormalities in mild traumatic brain injury. Brain Imaging Behav 2012; 6:293-318. [PMID: 22555821 DOI: 10.1007/s11682-012-9157-4] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Several reports show that traumatic brain injury (TBI) results in abnormalities in the coordinated activation among brain regions. Because most previous studies examined moderate/severe TBI, the extensiveness of functional connectivity abnormalities and their relationship to postconcussive complaints or white matter microstructural damage are unclear in mild TBI. This study characterized widespread injury effects on multiple integrated neural networks typically observed during a task-unconstrained "resting state" in mild TBI patients. Whole brain functional connectivity for twelve separate networks was identified using independent component analysis (ICA) of fMRI data collected from thirty mild TBI patients mostly free of macroscopic intracerebral injury and thirty demographically-matched healthy control participants. Voxelwise group comparisons found abnormal mild TBI functional connectivity in every brain network identified by ICA, including visual processing, motor, limbic, and numerous circuits believed to underlie executive cognition. Abnormalities not only included functional connectivity deficits, but also enhancements possibly reflecting compensatory neural processes. Postconcussive symptom severity was linked to abnormal regional connectivity within nearly every brain network identified, particularly anterior cingulate. A recently developed multivariate technique that identifies links between whole brain profiles of functional and anatomical connectivity identified several novel mild TBI abnormalities, and represents a potentially important new tool in the study of the complex neurobiological sequelae of TBI.
Collapse
Affiliation(s)
- Michael C Stevens
- Olin Neuropsychiatry Research Center, The Institute of Living/Hartford Hospital, CT, USA.
| | | | | | | | | | | |
Collapse
|
9
|
Levy ML, Kasasbeh AS, Baird LC, Amene C, Skeen J, Marshall L. Concussions in soccer: a current understanding. World Neurosurg 2011; 78:535-44. [PMID: 22120567 DOI: 10.1016/j.wneu.2011.10.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 09/14/2011] [Accepted: 10/20/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a significant public health problem in the United States, with approximately 1.5-2 million TBIs occurring each year. However, it is believed that these figures underestimate the true toll of TBI. Soccer is the most popular sport in the world and has a following of millions in the United States. Soccer is a sport not traditionally identified as high-risk for concussions, yet several studies have shown that concussion rates in soccer are comparable to, and often exceed those of, other contact sports. As many as 22% of all soccer injuries are concussions. METHODS Soccer is a sport not traditionally identified as high risk for concussions, yet several studies have shown that concussion rates in soccer are comparable to, and often exceed those of, other contact sports. As many as 22% of all soccer injuries are concussions. Head injury during soccer is usually the result of either "direct contact" or contact with the ball while "heading" the ball. Relationships between the number of headers sustained in a single season and the degree of cognitive impairment (attention and visual/verbal memory) have been demonstrated. It is also likely that multiple concussions may cause cumulative neuropsychologic impairment in soccer players. RESULTS Although our understanding of risk factors for sports-related concussions is far from complete, there is great potential for prevention in sports-related concussions. Several measures must be taken to avert the development of concussions in soccer and, when they take place, reduce their effects. These include the development and testing of effective equipment during play, the maintenance of regulatory standards for all such equipment, educating young athletes on the safe and appropriate techniques used during play, and strict adherence to the rules of competition. CONCLUSIONS In spite of such preventive measures, concussions in soccer will continue to occur. Considering the frequency of concussions in soccer, the serious sequelae of these concussions, and because almost half of concussed soccer players were noncompliant with recommended American Academy of Neurology return-to-play guidelines, further measures must be taken to protect players, in addition to understanding those criteria that result in removing an injured player from competition and the steps by which to safely return an athlete to competition after injury.
Collapse
Affiliation(s)
- Michael L Levy
- Division of Pediatric Neurosurgery Rady Children's Hospital of San Diego, San Diego, CA, USA.
| | | | | | | | | | | |
Collapse
|
10
|
Andrade AF, Paiva WS, Soares MS, De Amorim RL, Tavares WM, Teixeira MJ. Classification and management of mild head trauma. Int J Gen Med 2011; 4:175-9. [PMID: 21475628 PMCID: PMC3068877 DOI: 10.2147/ijgm.s13464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Indexed: 11/23/2022] Open
Abstract
Mild head trauma had been defined in patients with direct impact or deceleration effect admitted with a Glasgow Coma Scale score of 13-15. It is one of the most frequent causes of morbidity in emergency medicine. Although common, several controversies persist about its clinical management. In this paper, we describe the Brazilian guidelines for mild head trauma, based on a critical review of the relevant literature.
Collapse
Affiliation(s)
- Almir F Andrade
- Division of Neurosurgery, Hospital Das Clínicas University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | | | | | | | | |
Collapse
|
11
|
Seel RT, Sherer M, Whyte J, Katz DI, Giacino JT, Rosenbaum AM, Hammond FM, Kalmar K, Pape TLB, Zafonte R, Biester RC, Kaelin D, Kean J, Zasler N. Assessment Scales for Disorders of Consciousness: Evidence-Based Recommendations for Clinical Practice and Research. Arch Phys Med Rehabil 2010; 91:1795-813. [PMID: 21112421 DOI: 10.1016/j.apmr.2010.07.218] [Citation(s) in RCA: 406] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 07/16/2010] [Accepted: 07/19/2010] [Indexed: 10/18/2022]
|
12
|
De Monte VE, Geffen GM, May CR, McFarland K. Improved sensitivity of the rapid screen of mild traumatic brain injury. J Clin Exp Neuropsychol 2010; 32:28-37. [DOI: 10.1080/13803390902806519] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Veronica Eileen De Monte
- a Cognitive Psychophysiology Laboratory , University of Queensland , Brisbane, Queensland, Australia
| | - Gina Malke Geffen
- a Cognitive Psychophysiology Laboratory , University of Queensland , Brisbane, Queensland, Australia
| | - Christopher Randall May
- b Department of Emergency Medicine , Royal Brisbane Hospital , Brisbane, Queensland, Australia
| | - Ken McFarland
- c School of Psychology , University of Queensland , Brisbane, Queensland, Australia
| |
Collapse
|
13
|
Compagnone C, d'Avella D, Servadei F, Angileri FF, Brambilla G, Conti C, Cristofori L, Delfini R, Denaro L, Ducati A, Gaini SM, Stefini R, Tomei G, Tagliaferri F, Trincia G, Tomasello F. PATIENTS WITH MODERATE HEAD INJURY. Neurosurgery 2009; 64:690-6; discussion 696-7. [DOI: 10.1227/01.neu.0000340796.18738.f7] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | - Franco Servadei
- Division of Neurosurgery, Azienda Ospedaliero-Universitaria, Parma, Italy
| | | | | | - Carlo Conti
- Division of Neurosurgery, Azienda Ospedaliera Mestre, Mestre, Italy
| | | | - Roberto Delfini
- Department of Neurosurgery, University of Rome La Sapienza, Rome, Italy
| | - Luca Denaro
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | | | - Sergio M. Gaini
- Clinica Neurochirurgica, Ospedale Policlinico IRCCS, Milan, Italy
| | - Roberto Stefini
- Clinica Neurochirurgica, University of Brescia, Brescia, Italy
| | - Giustino Tomei
- Clinica Neurochirurgica, Università dell'Insubria Varese, Varese, Italy
| | | | - Giuseppe Trincia
- Division of Neurosurgery, Azienda Ospedaliera Mestre, Mestre, Italy
| | | |
Collapse
|
14
|
Metting Z, Rödiger LA, De Keyser J, van der Naalt J. Structural and functional neuroimaging in mild-to-moderate head injury. Lancet Neurol 2007; 6:699-710. [PMID: 17638611 DOI: 10.1016/s1474-4422(07)70191-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Head injury is a major cause of disability and death in adults. Significant developments in imaging techniques have contributed to the knowledge of the pathophysiology of head injury. Although extensive research is available on severe head injury, less is known about mild-to-moderate head injury despite the fact that most patients sustain this type of injury. In this review, we focus on structural and functional imaging techniques in patients with mild-to-moderate head injury. We discuss CT and MRI, including different MRI sequences, single photon emission computed tomography, perfusion-weighted MRI, perfusion CT, PET, magnetic resonance spectroscopy, functional MRI and magnetic encephalography. We outline the advantages and limitations of these various techniques in the contexts of the initial assessment and identification of brain abnormalities and the prediction of outcome.
Collapse
Affiliation(s)
- Zwany Metting
- Department of Neurology, University Medical Center Groningen, Netherlands
| | | | | | | |
Collapse
|
15
|
Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics 2006; 117:1359-71. [PMID: 16585334 DOI: 10.1542/peds.2005-0994] [Citation(s) in RCA: 234] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Athletic concussion is a growing focus of attention for pediatricians. Although numerous literature reviews and clinical guidelines are now available pertaining to athletic concussion, few have focused on the pediatric athlete in particular. Sport-related concussions occur relatively frequently in children and adolescents, and primary health care providers are often responsible for coordinating clinical management. Here we summarize the scientific literature pertinent to the care of young athletes. We examine how concussion affects younger and older athletes differently at biomechanical, pathophysiological, neurobehavioral, and contextual levels. We also discuss important issues in clinical management, including preparticipation assessment, concussion evaluation and recovery tracking, and when and how to return pediatric athletes to play sports. We also briefly cover non-sport-related interventions (eg, school support). With proper management, most children and adolescents sustaining a sport-related concussion can be expected to recover fully.
Collapse
Affiliation(s)
- Michael W Kirkwood
- Department of Physical Medicine and Rehabilitation, Children's Hospital, Denver, Colorado, USA.
| | | | | |
Collapse
|
16
|
Udgiri NR, Tewari MK, Dwarakanath S, Khandelwal N, Sharma BS. Role of computed tomography in minor head injury. INDIAN JOURNAL OF NEUROTRAUMA 2004. [DOI: 10.1016/s0973-0508(04)80007-8] [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]
|
17
|
Dunning J, Stratford-Smith P, Lecky F, Batchelor J, Hogg K, Browne J, Sharpin C, Mackway-Jones K. A Meta-Analysis of Clinical Correlates that Predict Significant Intracranial Injury in Adults with Minor Head Trauma. J Neurotrauma 2004; 21:877-85. [PMID: 15307900 DOI: 10.1089/0897715041526122] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Previous studies have resulted in conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in adults with minor head injury. We sought to perform a meta-analysis of the literature to assess the significance of these factors for the prediction of intracranial hemorrhage (ICH). The literature was searched using Medline, Embase, Experts, and the Grey literature. Reference lists of major guidelines were crosschecked. Included were control or nested case control studies of patients attending hospital with head injury that recorded clinical correlates relating to the outcome variable of presence or absence of ICH. The common relative risk ratio was calculated using the Mantel-Haenszel test with a pooled estimate. Thirty-five papers containing 83,636 patients were included in the meta-analysis after systematic review of the literature. Relative risk ratios were calculated for 23 clinical correlates from the history, the mechanism of injury, and the examination. In addition, adjusted relative risks were presented for those variables that showed significant heterogeneity across studies. Reasons for the heterogeneity are discussed. This study has determined the relative risks of 23 clinical variables that may predict the presence of an ICH in patients after minor head injury. These risks should prove invaluable to clinicians for the assessment of individual patients as well as the assessment of guidelines presented for the management of minor head injuries.
Collapse
Affiliation(s)
- Joel Dunning
- Department of Accident and Emergency Medicine, Manchester Royal Infirmary, Manchester, United Kingdom.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Ibañez J, Arikan F, Pedraza S, Sánchez E, Poca MA, Rodriguez D, Rubio E. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg 2004; 100:825-34. [PMID: 15137601 DOI: 10.3171/jns.2004.100.5.0825] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aims of this study were to analyze the relevance of risk factors in mild head injury (MHI) by studying the possibility of establishing prediction models based on these factors and to evaluate the reliability of the clinical guidelines proposed for the management of MHI. METHODS A series of 1101 patients with MHI were prospectively enrolled in this study. In all cases clinical data were collected and a computerized tomography (CT) scan was obtained. The relationship between clinical findings and the presence of intracranial lesions was studied to establish prediction models based on logistic regression and recursive partitioning analysis. Recently proposed guidelines and recommendations for the treatment of MHI were selected, calculating their diagnostic efficiency when applying each of them to our series. The incidence of acute intracranial lesions was 7.5% (83 patients). A Glasgow Coma Scale score of 14, loss of consciousness, vomiting, headache, signs of basilar skull fracture, neurological deficit, coagulopathies, hydrocephalus treated with shunt insertion, associated extracranial lesions, and patient age greater than 65 years were identified as independent risk factors. Prediction models built on clinical variables were able to indicate patients with clinically important lesions, but failed to achieve 100% sensitivity in the detection of all patients with CT scans positive for intracranial lesions within reasonable specificity limits. CONCLUSIONS Clinical variables are insufficient to predict all cases of intracranial lesions following MHI, although they can be used to detect patients with relevant injuries. Avoiding systematic CT scan indication implies a rate of misdiagnosis that should be known and assumed when planning treatment in these patients by using guidelines based on clinical parameters.
Collapse
MESH Headings
- Adolescent
- Adult
- Aged
- Brain Concussion/complications
- Brain Concussion/diagnosis
- Brain Concussion/therapy
- Cerebral Hemorrhage, Traumatic/diagnosis
- Cerebral Hemorrhage, Traumatic/etiology
- Cerebral Hemorrhage, Traumatic/therapy
- Cerebral Ventricles/pathology
- Emergency Service, Hospital
- Female
- Glasgow Coma Scale
- Head Injuries, Closed/complications
- Head Injuries, Closed/diagnosis
- Head Injuries, Closed/therapy
- Hematoma, Epidural, Cranial/diagnosis
- Hematoma, Epidural, Cranial/etiology
- Hematoma, Epidural, Cranial/therapy
- Hematoma, Subdural/diagnosis
- Hematoma, Subdural/etiology
- Hematoma, Subdural/therapy
- Humans
- Logistic Models
- Male
- Middle Aged
- Neurologic Examination
- Pneumocephalus/diagnosis
- Pneumocephalus/etiology
- Pneumocephalus/therapy
- Practice Guidelines as Topic
- Prospective Studies
- Risk Factors
- Spain
- Tomography, X-Ray Computed
Collapse
Affiliation(s)
- Javier Ibañez
- Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain.
| | | | | | | | | | | | | |
Collapse
|
19
|
Self ML, Blake AM, Whitley M, Nadalo L, Dunn E. The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries. Am J Surg 2003; 186:609-13; discussion 613-4. [PMID: 14672766 DOI: 10.1016/j.amjsurg.2003.08.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The evaluation of multitrauma patients for blunt truncal injuries remains open for debate. We sought to evaluate the role of routine computed tomography (CT) of the chest, abdomen, and pelvis as a screening tool for patients already undergoing cranial CT studies. METHODS Charts of blunt trauma patients admitted from June 2000 to June 2001 were reviewed for demographics, Glascow Coma Scale (GCS), physical and radiological findings, and length of stay. RESULTS Our study found that 38% of patients undergoing cranial CT scanning had a unexpected finding on body scans. Changes were made in 26% of the study group because results found on the adjuvant CTs. CONCLUSIONS Additional body CTs add minimal cost to the care of trauma patients but can significantly change the management. We believe it is beneficial to perform routine body CT examinations when performing cranial imaging for blunt head injury.
Collapse
Affiliation(s)
- Michael L Self
- Department of Surgery, Methodist Hospitals of Dallas, Dallas, TX, USA
| | | | | | | | | |
Collapse
|
20
|
Waseem M, Ryan MT. Head trauma discharge instructions. South Med J 2003; 96:327. [PMID: 12659380 DOI: 10.1097/01.smj.0000061510.81880.7f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
McCrea M, Kelly JP, Randolph C, Cisler R, Berger L. Immediate Neurocognitive Effects of Concussion. Neurosurgery 2002. [DOI: 10.1227/00006123-200205000-00017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
22
|
McCrea M, Kelly JP, Randolph C, Cisler R, Berger L. Immediate neurocognitive effects of concussion. Neurosurgery 2002; 50:1032-40; discussion 1040-2. [PMID: 11950406 DOI: 10.1097/00006123-200205000-00017] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2001] [Accepted: 12/14/2001] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To prospectively measure the immediate neurocognitive effects and early course of recovery from concussion and to examine the effects of loss of consciousness (LOC) and posttraumatic amnesia (PTA) on the severity of neurocognitive impairment immediately after concussion. METHODS A sports-related concussion research model was used to allow prospective immediate evaluation of concussion. A total of 2385 high school and college football players were studied. Ninety-one players (3.8%) sustained concussions during the study. A brief neurocognitive and neurological screening measure, the Standardized Assessment of Concussion, was used to assess cognitive functioning before the football season, immediately after injury, and 15 minutes, 48 hours, and 90 days after injury. RESULTS Standardized Assessment of Concussion scores immediately after concussion were significantly lower than the preseason baseline score and the noninjured population baseline mean, even for injured subjects without LOC or PTA. Subjects with LOC were most severely impaired immediately after injury, whereas those without LOC or PTA were least impaired. Significant impairment was also detected 15 minutes after injury, but all three groups returned to baseline levels of cognitive functioning within 48 hours. CONCLUSION These findings are the first to demonstrate not only that a gradient of increasing concussion severity is represented by PTA and LOC but also that measurable neurocognitive abnormalities are evident immediately after injury without PTA or LOC.
Collapse
Affiliation(s)
- Michael McCrea
- Neuropsychology Service, Waukesha Memorial Hospital, Waukesha, Wisconsin 53188, USA.
| | | | | | | | | |
Collapse
|
23
|
Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med 2001; 38:160-9. [PMID: 11468612 DOI: 10.1067/mem.2001.116796] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated 1 million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale score of 13 to 15. Although most patients with minor head injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived. [Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A, for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.]
Collapse
Affiliation(s)
- I G Stiell
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario, Canada K1Y 4E9
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
Neurocognitive status is often considered the domain of neurologic functioning most sensitive to change following concussion, but the effects are often subtle and difficult to detect on routine clinical examination. Recent efforts have focused on the development of brief, standardized methods of mental status assessment for use by sports medicine clinicians to quantify the acute neurocognitive effects of concussion and objectively track postinjury recovery. Research has demonstrated the reliability, validity, and sensitivity of these measures in detecting concussion in athletes and providing empirical data for consideration in the context of other examination findings, neuropsychologic test data, and neuroimaging results. Standardized measures of mental status and other postconcussive symptoms are valuable tools to assist clinicians in the assessment and management of concussion, but should not be used as a replacement for medical evaluation or viewed as a stand-alone means for determining readiness to return to competition after injury.
Collapse
Affiliation(s)
- M McCrea
- Neuropsychology Service, Waukesha Memorial Hospital, Wisconsin 53188, USA.
| |
Collapse
|
25
|
Svenson JE, Spurlock CW. Insurance status and admission to hospital for head injuries: are we part of a two-tiered medical system? Am J Emerg Med 2001; 19:19-24. [PMID: 11146011 DOI: 10.1053/ajem.2001.18041] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Previous studies have shown an association between insurance status and use of resources for inpatient care. We sought to assess whether insurance status influences decisions regarding the evaluation and treatment of head injured patients in the emergency department (ED). Head injured patients were identified from ED data from 4 hospitals reporting to the Kentucky Emergency Medical Services Information System. Multiple regression analysis using admission, ED length of stay, and ED charges as outcome variables was then performed. From 216,137 ED visits there were 8,591 (4%) head injured patients identified from the database. Eliminating those with revisits, transfers to another hospital in the database, and isolated facial lacerations, there were 3,821 cases. Controlling for age, hospital, race, primary diagnosis, and indicators of severity of the injury, insurance status was significantly associated with hospital admission. Those uninsured were the least likely to be admitted (OR 0.41; 95% CI (0.31, 0.50), whereas those with public insurance had an intermediate probability (OR 0.50 95% CI (0.37, 0.68) as compared with those with private insurance. Similarly, ED charges were lower for Medicaid patients than insured patients ($880) and tended to be slightly lower for uninsured patients ($1,043) than insured patients ($1,141) (P =.001). Length of stay in the ED was shorter for publicly insured patients (179 minutes) than uninsured (186 minutes) and privately insured patients (192 minutes) (P =.001). The extent of evaluation and admission for head injured patients is associated with insurance status. This creates a dual standard of care for patients. Practitioners should work to standardize the evaluation of patients independent of paying status.
Collapse
Affiliation(s)
- J E Svenson
- Section of Emergency Medicine, University of Wisconsin, Madison, WI 53792, USA.
| | | |
Collapse
|
26
|
Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000; 343:100-5. [PMID: 10891517 DOI: 10.1056/nejm200007133430204] [Citation(s) in RCA: 660] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury who do not need to undergo CT. METHODS In the first phase of the study, we recorded clinical findings in 520 consecutive patients with minor head injury who had a normal score on the Glasgow Coma Scale and normal findings on a brief neurologic examination; the patients then underwent CT. Using recursive partitioning, we derived a set of criteria to identify all patients who had abnormalities on CT scanning. In the second phase, the sensitivity and specificity of the criteria for predicting a positive scan were evaluated in a group of 909 patients. RESULTS Of the 520 patients in the first phase, 36 (6.9 percent) had positive scans. All patients with positive CT scans had one or more of seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3 percent) had positive scans. In this group of patients, the sensitivity of the seven findings combined was 100 percent (95 percent confidence interval, 95 to 100 percent). All patients with positive CT scans had at least one of the findings. CONCLUSIONS For the evaluation of patients with minor head injury, the use of CT can be safely limited to those who have certain clinical findings.
Collapse
Affiliation(s)
- M J Haydel
- Section of Emergency Medicine, Louisiana State University Health Science Center at New Orleans, USA.
| | | | | | | | | | | |
Collapse
|
27
|
Braun M, Cordoliani YS, Dosch JC. [Head and brain injuries. Place of imaging]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:296-8. [PMID: 10836117 DOI: 10.1016/s0750-7658(99)00150-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article considers the various mechanisms of brain injury and specifies the most efficient radiologic technique for assessing patients, depending on clinical presentation. The brain injuries include either extracerebral and intracerebral lesions. The former require rapid diagnosis and therapy and the latter determine management in an intensive therapy, unit and outcome. Standard X-rays are obsolete. The CT, rapidly performed, is the most relevant imaging procedure for surgical lesions. Cortical contusions and diffuse axonal injuries are underestimated by CT and best depicted by MRI. Only late MRI has a strong correlation with neuropsychological outcome. In terms of prognosis, MRI needs to be evaluated. The indications include: a) unstable neurological status: CT; b) moderate head injury: CT may help to decide hospital admission; c) severe head injury: initial CT may be followed by MRI; d) long-term consequences: MRI. Special Indications: a) angio-MRI: suspicion of vascular lesion; b) CT with thin slices and bone window: depressed skull fracture; c) teleradiology (image transfer): to decide a patient transport from a peripheral hospital to a neurosurgical centre. In conclusion, CT remains the first-line examination to detect immediately life-threatening lesions. MRI is the examination of choice for full assessment of brain lesions.
Collapse
Affiliation(s)
- M Braun
- Service de neuroradiologie diagnostique et thérapeutique, hôpital neurologique, CHU Nancy, France
| | | | | |
Collapse
|
28
|
Gómez P, Lobato R, Lagares A, Alén J. Trauma craneal leve en adultos. Revisión de la literatura. Neurocirugia (Astur) 2000. [DOI: 10.1016/s1130-1473(00)70949-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
29
|
Tellier A, Della Malva LC, Cwinn A, Grahovac S, Morrish W, Brennan-Barnes M. Mild head injury: a misnomer. Brain Inj 1999; 13:463-75. [PMID: 10462145 DOI: 10.1080/026990599121386] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Despite controversy surrounding the concept of mild head injury (MHI), it is becoming evident that even a head trauma termed 'mild' may result in significant behavioural sequelae. The present study was an attempt at documenting structural cerebral damage, by way of computerized tomography, in a group of patients having suffered a MHI as defined by the Glasgow Coma Scale (GCS) score. A 1-year retrospective chart review identified 80 MHI patients who presented to the Emergency department of a lead hospital for trauma. Sixty-six per cent of these MHI patients were scanned. Evidence of intracranial abnormalities was obtained in 31% of the overall sample. Patients with a lower GCS score had a higher percentage of abnormal scans than those with a GCS score of either 14 or 15. The present findings suggest that a MHI can be associated with significant morbidity, and that a MHI group does not constitute a homogeneous pool of patients.
Collapse
Affiliation(s)
- A Tellier
- Department of Psychology, Ottawa Hospital, University of Ottawa, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
30
|
Cheung DS, Kharasch M. Evaluation of the patient with closed head trauma: an evidence based approach. Emerg Med Clin North Am 1999; 17:9-23, vii. [PMID: 10101338 DOI: 10.1016/s0733-8627(05)70044-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article approaches the subject of closed head trauma from the time-sensitive vantage point of the emergency physician. As the clinical scenario unfolds, he or she constantly evaluates the need for diagnostic tests as information is received from paramedics, nurses, and the history and physical examination. This article provides a synopsis and a critique of original clinical trials to aid the emergency physician in making an evidence based decision.
Collapse
Affiliation(s)
- D S Cheung
- Department of Internal Medicine, Northwestern University Medical School, Chicago, Illinois, USA
| | | |
Collapse
|
31
|
Stein SC. High-risk minor head injury. J Neurosurg 1998; 88:613-4. [PMID: 9488324 DOI: 10.3171/jns.1998.88.3.0613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
32
|
Hutchinson PJ, Kirkpatrick PJ, Addison J, Jackson S, Pickard JD. The management of minor traumatic brain injury. J Accid Emerg Med 1998; 15:84-8. [PMID: 9570046 PMCID: PMC1343030 DOI: 10.1136/emj.15.2.84] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Minor traumatic brain injury accounts for the majority of the one million head trauma attendances at A&E departments in the United Kingdom. Guidelines have been established listing criteria for skull films, admission to hospital, computed tomography, and neurosurgical consultation. These are currently undergoing revision and were the subject of a satellite symposium to the J Douglas Miller memorial meeting held in October 1996 in Edinburgh. In the East Anglia Region the current guidelines have been issued as memo-cards for A&E officers. The aim of admission is to observe for deterioration, predominantly caused by intracranial haematomas. The indicators for the development of such lesions are an impaired level of consciousness and presence of a skull fracture. Such patients should therefore undergo regular and frequent neurological observations, and be admitted for at least 12 hours. Following discharge, routine follow up should be considered to identify and treat patients with postconcussion symptoms and signs. The possible way forward for the management of these patients is adopting a greater emphasis on preventative aspects, and establishing, implementing, and auditing evidence based guidelines. Improved teaching in the form of formal induction seminars and computerised teaching aids is required, and a better understanding of the aetiology and treatment of the postconcussion syndrome.
Collapse
Affiliation(s)
- P J Hutchinson
- University Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | | | | | | | | |
Collapse
|
33
|
Lee TT, Aldana PR, Kirton OC, Green BA. Follow-up computerized tomography (CT) scans in moderate and severe head injuries: correlation with Glasgow Coma Scores (GCS), and complication rate. Acta Neurochir (Wien) 1998; 139:1042-7; discussion 1047-8. [PMID: 9442218 DOI: 10.1007/bf01411558] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The wide availability of computerized tomography (CT) scan has popularized its use in initial and follow-up evaluations of head trauma patients. Follow-up CT scans of clinically stable patients, however, may not provide additional information, but could potentially subject the patients to secondary injuries. The authors investigated the correlation between CT scans and Glasgow coma score (GCS), and complication rate during follow-up CT scans in an attempt to dissuade clinicians from obtaining unnecessary follow-up CT scans. METHODS The medical records of 180 patients with blunt head trauma were retrospectively reviewed. Only patients (117) with moderate and severe head injuries were included in the study. A total of 319 follow-up brain CT's for 94 patients were obtained. RESULTS The change in CT scans was compared to the GCS the day of the scan. These two variables were found to be positively correlated by Chi-square analysis (chi 2 = 81.2; alpha < 0.001). CPP trend was found also be correlated with CT scan evolution by the Chi-square analysis (alpha < 0.001). When patients had unchanged or improved GCS, 73.1% had improved or the same CT appearance. When patients had a worse GCS, the CT was worse in 77.9%. A 16.9% (54/319) complication rate was documented during the follow-up scans (hemodynamic instability, increased intracranial pressure, desaturation, and agitation). This rate was higher in severe head trauma (GCS 3-8) patients than in moderate head injury (GCS 9-12) patients. Hemodynamic instability was the most common complication, which comprises 42.6% (23/54) of all complications. CONCLUSION Because of the correlation between the CT scan appearance and the clinical status, as well as the detrimental effect of mobilizing critically ill patients, the authors urge the use of follow-up CT scans only in patients with clinical deterioration unexplained by ICP changes alone.
Collapse
Affiliation(s)
- T T Lee
- Department of Neurological Surgery, University of Miami, FL, USA
| | | | | | | |
Collapse
|
34
|
Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhauer MA, Greenberg GH, MacPhail I, McKnight RD, Reardon M, Verbeek R, Worthington J, Lesiuk H. Variation in ED use of computed tomography for patients with minor head injury. Ann Emerg Med 1997; 30:14-22. [PMID: 9209219 DOI: 10.1016/s0196-0644(97)70104-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE To determine the frequency of utilization, yield for brain injury, incidence of missed injury, and variation in the use of computed tomography (CT) for ED patients with minor head injury. METHODS This retrospective health records survey was conducted over a 12-month period in the EDs at seven Canadian teaching institutions. Included in this review were adult patients who sustained acute minor head injury, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale score of 13 or greater. Data were collected by research assistants who were trained to select cases and abstract data in a standardized fashion according to a resource manual. Subsequently, patient eligibility was reviewed by the study coordinator and principal investigator. RESULTS Of the 1,699 patients seen, 521 (30.7%) were referred for CT, and 418 (79.8%) of these scans were negative for any type of brain injury. Overall, 105 (6.2%) of these patients sustained acute brain injury, including 9 (.5%) with an epidural hematoma Cochran's Q test for homogeneity demonstrated significant variation between the seven centers for rate of ordering CT (P < .0001), from a low of 15.9% to a high of 70.4%. All five cases of "missed" hematoma occurred at the institutions with the highest and third highest rates of CT use. After controlling for possible differences in case severity and patient characteristics at each hospital, logistic regression analysis revealed that five of seven hospitals were significantly associated with the use of CT (respected odds ratios [OR], .4, .5, .5, 3.2, and 4.7). Three of the centers (two with the highest ordering rates) showed significant heterogeneity in the ordering of CT among their attending staff physicians, from a low of 6.5% to a high of 80.0%. CONCLUSION There was considerable variation among institutions and individual physicians in the ordering of CT for patients with minor head injury. Although emergency physicians were selective when ordering CT, the yield of radiography was very low at all hospitals. None of the cases of "missed" intracranial hematoma came from the lowest ordering institutions, indicating that patients may be managed safely with a selective approach to CT use. These findings suggest great potential for more standardized and efficient use of CT of the head, possibly through the use of a clinical decision rule.
Collapse
Affiliation(s)
- I G Stiell
- Department of Medicine, Ottawa Civic Hospital, Loeb Medical Research Institute, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Abstract
In Binder et al. (1997) a metal-analytic review revealed a small effect size attributable to a history of mild head trauma (MHT). The results suggested a weak association between MHT and persistent neuropsychological deficits. In this paper, additional outcome data are summarized and the results are discussed. On a chronic basis, 7-8% of MHT patients remain symptomatic and 14% are disabled from work. Magnetic resonance studies of acutely injured persons may show lesions that are not detected in usual clinical practice. It is likely that the effects of these lesions dissipate with time, consistent with the neuropsychological data. The association between MHT and cognitive deficits, symptoms, and disability may not be casual; data suggest that MHT patients have more psychosocial problems prior to injury than do non-injured persons. The examiner of the MHT patient with chronic complaints must consider alternative medical and psychiatric explanations and perform a differential diagnosis. The possibility of a neurological basis for sustained neuropsychological problems cannot be completely dismissed. Presently, however, there is little evidence for neurological causation of most persisting complaints.
Collapse
|