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Heinonen A, Rauhala M, Isokuortti H, Raj R, Kataja A, Nikula M, Öhman J, Iverson GL, Luoto T. Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography. Acta Neurochir (Wien) 2024; 166:144. [PMID: 38514587 PMCID: PMC10957655 DOI: 10.1007/s00701-024-06040-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT). METHODS A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%). RESULTS Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma. CONCLUSION The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.
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Affiliation(s)
- Aaro Heinonen
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.
| | - Minna Rauhala
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Harri Isokuortti
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anneli Kataja
- Department of Radiology, Medical Imaging Centre, Tampere University Hospital, Tampere, Finland
| | - Milaja Nikula
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Juha Öhman
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and the Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, MA, USA
| | - Teemu Luoto
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
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Elias J, Sutherland E, Kennedy E. Concussion Management in Older People: A Scoping Review. J Head Trauma Rehabil 2024:00001199-990000000-00133. [PMID: 38453625 DOI: 10.1097/htr.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To map existing literature about concussion management in older people, identifying and analyzing gaps in our understanding. CONTEXT Concussion injuries affect older people, yet little guidance is available about how to approach concussion management with older people. Research does not always include older populations, and it is unclear to what extent standard concussion management is appropriate for older people. DESIGN Scoping review. METHOD A structured literature search was conducted using 4 databases to identify existing literature relating to concussion management in older people. Studies that assessed outcomes relating to the management of concussion/mild traumatic brain injury in those 65 years or older were included and mapped according to the main themes addressed. RESULTS The search yielded a total of 18 articles. Three themes related to early management (use of anticoagulants n = 6, intracranial lesions n = 3, and service delivery for older people n = 5), and 1 theme related to general management (cognitive issues n = 4). A lack of articles exploring general management in older people was observed. CONCLUSION Existing literature indicates that specific management strategies are needed for older people with concussion, especially in early management. This review highlights that good evidence is available about early management and this is reflected in some guidelines, yet little evidence about general management is available and this gap is not acknowledged in guidelines. Distinct approaches to early management in older people are clearly recommended to mitigate the risk of poor outcomes. In contrast, general concussion management for older people is poorly understood, with older people poorly represented in research. A better understanding is needed because-as observed in early management-older people have distinct characteristics that may render standard management approaches unsuitable.
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Affiliation(s)
- Josh Elias
- Author Affiliations: Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand (Mr Elias and Dr Kennedy); and Department of Physiology, University of Otago, Dunedin, New Zealand (Ms Sutherland)
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Martínez-Rivas JJ, Rodríguez-Lucas F, Planells G, Corrales D, Cocho D. Risk of cerebral hemorrhage in mild traumatic brain injury and antithrombotic treatment. Rev Clin Esp 2023; 223:604-609. [PMID: 37898355 DOI: 10.1016/j.rceng.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/21/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION The observation time in mild traumatic brain injury (mTBI) is controversial. Our aim was to assess the risk of neurological complications in mTBI with and without antithrombotic treatment. METHOD We retrospectively evaluated patients with mTBI seen in the emergency room for 3 years. We considered MTBI those with Glasgow ≥13 at admission. A cranial CT was performed in all cases with ≥1 risk factor at admission and at 24 h in those with neurological impairment or initial pathological cranial CT. Complications in the following 3 months were retrospectively reviewed. RESULTS We evaluated 907 patients with a mean age of 73 ± 19 years. Ninety-one percent presented risk factors, with 60% on antithrombotic treatment. We detected 11% of initial brain hemorrhage, 0.4% at 24 h, and no cases at 3 months. Antithrombotic treatment was not associated with an increased risk of brain hemorrhage (9.9% with vs 11.9% without treatment, p = 0.3). 39% of the hemorrhages presented neurological symptoms (18% post-traumatic amnesia, 12% headache, 8% vomiting, 1% seizures), with 78.4% having mild symptoms. Of the 4 hemorrhages detected at 24 h, 3 were asymptomatic and one case that worsened the initial headache. No asymptomatic patient without lesion on initial clinical cranial CT presented at 24 h. CONCLUSIONS Our study suggests that patients with asymptomatic mTBI, without a lesion on the initial cranial CT, would not require the observation period or CT control regardless of antithrombotic treatment or INR level.
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Affiliation(s)
- J J Martínez-Rivas
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain.
| | - F Rodríguez-Lucas
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain
| | - G Planells
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain
| | - D Corrales
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain
| | - D Cocho
- Servicio de Neurología, Hospital General de Granollers, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain
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Bhaumik D, Bhaumik SS, Thaker AA, Timpone VM, Bills CB, Patten L, Pattee J, Chow D, Sugrue LP, Callen AL. Ordering Characteristics Predictive of Noncontrast CT Head Positivity in the Emergency Department. Acad Radiol 2023; 30:492-498. [PMID: 35654657 DOI: 10.1016/j.acra.2022.05.001] [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: 01/19/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE AND OBJECTIVES Recent decades have seen a steady increase in noncontrast head CT utilization in the emergency department with a concurrent rise in the practice of physician assistants (PAs) and nurse practitioners (NPs). The goal of this study was to identify ordering and patient characteristics predictive of positive noncontrast head CTs in the ED. We hypothesized NP/PAs would have lower positivity rates compared to physicians, suggestive of relative overutilization. MATERIALS AND METHODS We retrospectively identified ED patients who underwent noncontrast head CTs at a single institution: a nonlevel 1 trauma center, during a 7-year period, recording examination positivity, ordering provider training/experience, and multiple additional ordering/patient attributes. Exam positivity was defined as any intracranial abnormality necessitating a change in acute management, such as acute hemorrhage, hydrocephalus, herniation, or worsening prior findings. RESULTS 6624 patients met inclusion criteria. 4.6% (280/6107) of physician exams were positive while 3.7% (19/517) of NP/PA exams were positive; however, differences were not significant. Increasing provider experience was not associated with positivity. Attributes with increased positivity were patient age (p < 0.001), daytime exam (p < 0.05), and indications regarding malignancy (p < 0.001) or focal neurologic deficit (p = 0.001). Attributes with decreased positivity were indications of trauma (p < 0.001) or vertigo/dizziness (p < 0.05). CONCLUSION We found no significant difference in rates of exam positivity between physicians and NP/PAs, even accounting for years of experience. This suggests increasing utilization of head CTs in the ED is not due to the increasing presence of NP/PAs, and may be reflective of general practice trends and clear diagnostic algorithms leading to head CT.
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Affiliation(s)
- Debayan Bhaumik
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Smitha S Bhaumik
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ashesh A Thaker
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Vincent M Timpone
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Luke Patten
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jack Pattee
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Chow
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Leo P Sugrue
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Andrew L Callen
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA.
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Evaluating the Outcome of an Unnecessary Request for CT Scan in Be'sat Hospital of Hamadan. Radiol Res Pract 2023; 2023:3709015. [PMID: 36874208 PMCID: PMC9977522 DOI: 10.1155/2023/3709015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/24/2023] Open
Abstract
Aim This study aimed to investigate the frequency of unnecessary tests requested in Be'sat Hospital in Hamadan. Materials and Methods This descriptive research was conducted in order to investigate the frequency of unnecessary requests for CT scan and radiography of patients referring to the imaging department of Be'sat Hospital in Hamadan in a 4- to 6-month period. Patient information, including gender, age, type of CT scan test, the reason for requesting the test, the expertise of the requesting physician, and the result of the radiologist's report on each test, was extracted and collected. Results A total of 1000 CT scans were evaluated. The mean age of these patients was about 36 years and most of them were men. The highest and lowest percentages of unnecessary cases were related to CT scans of the brain (42.3%) and facial bones (2.3%), respectively. The most and the least unnecessary CT scans based on the reason given for the request were related to multiple physical trauma (30.7%) and chronic kidney disease (1.5%), respectively. Conclusion In all tests, over 74% of the reports were unnecessary and less than 26% were necessary. Therefore, it is necessary to reduce unnecessary requests to reduce the radiation dose of patients. Also, the knowledge of doctors should be increased in the field of appropriate evaluation of CT scan tests based on clinical guidelines.
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Hawley C, Sakr M, Scapinello S, Bjorndalen H. Head injury among older adults and their clinical management: one year of emergency department attendances at a UK trauma center. Brain Inj 2022; 36:868-875. [PMID: 35770937 DOI: 10.1080/02699052.2022.2077989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Primary: describe characteristics of adults aged ≥65 attending the Emergency Department (ED) at one major trauma center. Secondary: examine co-morbidities and complications; identify use of anticoagulant/antiplatelet medication among older adults presenting with Head Injury (HI); assess clinical management against UK guidelines. METHODS All ED admissions were screened prospectively to identify HI using case notes, hospital records and Trauma Audit Research Network data. Data were collected on demographics, cause and severity of injury, co-morbidities, anticoagulation/antiplatelet use, diagnostic imaging and discharge outcomes. RESULTS Over 12 months, 697 patients aged ≥65 years attended the ED for HI, representing over a quarter of adult ED attendances for HI. Mean age was 78.5 years (range 65-106), 395 (56.7%) were female. Most HIs were mild (93.5%) and 86% caused by falls. Three-quarters were discharged without hospital admission. Most had a preexisting medical condition andtaking medications prior to HI. Of these 116 were taking anticoagulants/antiplatelets but only 37 (31.9%) received a head CT scan. Half the patients were given a written HI information sheet at ED discharge. CONCLUSIONS Care of HI in older adults is challenging due to comorbidities. Practising evidence-based clinical management and following guidelines is important, but strict adherence is not common practice.
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Affiliation(s)
- Carol Hawley
- Honorary Research Fellow, Division of Mental Health and Wellbeing, Warwick Medical School, Coventry, UK
| | - Magdy Sakr
- Consultant in Emergency Medicine, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Sarah Scapinello
- Psychiatrist, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Harald Bjorndalen
- Specialist Registrar in Anaesthesiology, Drammen Hospital, Drammen, Norway
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Lagares A, Castaño-Leon AM, Richard M, Tsitsopoulos PP, Morales J, Mihai P, Pavlov V, Mejan O, de la Cruz J, Payen JF. Variability in the indication of brain CT scan after mild traumatic brain injury. A transnational survey. Eur J Trauma Emerg Surg 2022; 49:1189-1198. [PMID: 35178583 DOI: 10.1007/s00068-022-01902-5] [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: 11/13/2021] [Accepted: 01/30/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Clinical guidelines have been developed to standardize the management of mild traumatic brain injury (mTBI) in the emergency room, in particular the indication of brain CT scan and the use of blood biomarkers. The objective of this study was to determine the degree of adherence to guidelines in the management of these patients across four countries of Southern Europe. METHODS An electronic survey including structural and general management of mTBI patients and six clinical vignettes was conducted. In-charge physicians from France, Spain, Greece and Portugal were contacted by telephone and email. Differences among countries were searched using an unconditional approach test on contingency tables. RESULTS One hundred and eighty eight physicians from 131 Hospitals (78 Spain, 36 France, 12 Greece and 5 Portugal) completed the questionnaire. There were differences regarding the in-charge specialist across these countries. There was variability in the use of guidelines and their adherence. Spain was the country with the least guideline adherence. There was a global agreement in ordering a brain CT for patients receiving anticoagulation or platelet inhibitors, and for patients with seizures, altered consciousness, neurological deficit, clinical signs of skull fracture or signs of facial fracture. Aging was not an indication for CT in French centres. Loss of consciousness and posttraumatic amnesia were considered as indications for CT more frequently in Spain than in France. These findings were in line with the data from the 6 clinical vignettes. The estimated use of CT reached around 50% of mTBI cases. The use of S100B is restricted to five French centres. CONCLUSIONS There were large variations in the guideline adherence, especially in the situations considered to order brain CT after mTBI.
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Affiliation(s)
- Alfonso Lagares
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación imas12, Madrid, Spain.
- Department of Surgery, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
| | - Ana María Castaño-Leon
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación imas12, Madrid, Spain
| | - Marion Richard
- Department of Anesthesia and Intensive Care, University Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Institut Des Neurosicences, INSERM, U1216, Grenoble, France
| | - Parmenion Philip Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Julian Morales
- Servicio de Urgencias, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Podaru Mihai
- Servicio de Urgencias, Hospital Universitario del Tajo, Aranjuez, Spain
| | - Vladislav Pavlov
- bioMérieux, Medical Affairs, Chemin de LÓrme, Marcy-L´Étoile, France
| | - Odile Mejan
- bioMérieux, Clinical Unit, Chemin de lÓrme, Marcy l´Étoile, France
| | - Javier de la Cruz
- Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, SAMID, Madrid, Spain
| | - Jean François Payen
- Department of Anesthesia and Intensive Care, University Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Institut Des Neurosicences, INSERM, U1216, Grenoble, France
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Magnusson BM, Isaksson E, Koskinen LOD. A prospective observational cohort study of traumatic brain injury in the northern region of Sweden. Brain Inj 2022; 36:191-198. [DOI: 10.1080/02699052.2022.2034952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Beatrice M. Magnusson
- Department of Surgery and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Sweden
| | - Emil Isaksson
- Department of Surgery and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Sweden
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Teeratakulpisarn P, Angkasith P, Wannakul T, Tanmit P, Prasertcharoensuk S, Thanapaisal C, Wongkonkitsin N, Kitkhuandee A, Sukeepaisarnjaroen W, Phuttharak W, Sawanyawisuth K. What are the strongest indicators of intracerebral hemorrhage in mild traumatic brain injury? Trauma Surg Acute Care Open 2021; 6:e000717. [PMID: 34423133 PMCID: PMC8340271 DOI: 10.1136/tsaco-2021-000717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/19/2021] [Indexed: 11/03/2022] Open
Abstract
Background Although there are eight factors known to indicate a high risk of intracranial hemorrhage (ICH) in mild traumatic brain injury (TBI), identification of the strongest of these factors may optimize the utility of brain CT in clinical practice. This study aimed to evaluate the predictors of ICH based on baseline characteristics/mode of injury, indications for brain CT, and a combination of both to determine the strongest indicator. Methods This was a descriptive, retrospective, analytical study. The inclusion criteria were diagnosis of mild TBI, high risk of ICH, and having undergone a CT scan of the brain. The outcome of the study was any type of ICH. Stepwise logistic regression analysis was used to find the strongest predictors according to three models: (1) injury pattern and baseline characteristics, (2) indications for CT scan of the brain, and (3) a combination of models 1 and 2. Results There were 100 patients determined to be at risk of ICH based on indications for CT of the brain in patients with acute head injury. Of these, 24 (24.00%) had ICH. Model 1 found that injury due to motor vehicle crash was a significant predictor of ICH, with an adjusted OR (95% CI) of 11.53 (3.05 to 43.58). Models 2 and 3 showed Glasgow Coma Scale (GCS) score of 13 to 14 after 2 hours of observation and open skull or base of skull fracture to be independent predictors, with adjusted OR (95% CI) of 11.77 (1.32 to 104.96) and 5.88 (1.08 to 31.99) according to model 2. Discussion Open skull or base of skull fracture and GCS score of 13 to 14 after 2 hours of observation were the two strongest predictors of ICH in mild TBI. Level of evidence III.
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Affiliation(s)
- Panu Teeratakulpisarn
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Phati Angkasith
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Thanakorn Wannakul
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Parichat Tanmit
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Chaiyut Thanapaisal
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Amnat Kitkhuandee
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Warinthorn Phuttharak
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2021; 29:123. [PMID: 34425865 PMCID: PMC8381571 DOI: 10.1186/s13049-021-00936-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background The scientific evidence regarding the risk of delayed intracranial bleeding (DB) after mild traumatic brain injury (MTBI) in patients administered an antiplatelet agent (APA) is scant and incomplete. In addition, no consensus exists on the utility of a routine repeated head computed tomography (CT) scan in these patients. Objective The aim of this study was to evaluate the risk of DB after MTBI in patients administered an APA. Methods A systematic review and meta-analysis of prospective and retrospective observational studies enrolling adult patients with MTBI administered an APA and who had a second CT scan performed or a clinical follow-up to detect any DB after a first negative head CT scan were conducted. The primary outcome was the risk of DB in MTBI patients administered an APA. The secondary outcome was the risk of clinically relevant DB (defined as any DB leading to neurosurgical intervention or death). Results Sixteen studies comprising 2930 patients were included in this meta-analysis. The pooled absolute risk for DB was 0.77% (95% CI 0.23–1.52%), ranging from 0 to 4%, with substantial heterogeneity (I2 = 61%). The pooled incidence of clinically relevant DB was 0.18%. The subgroup of patients on dual antiplatelet therapy (DAPT) had an increased DB risk, compared to the acetylsalicylic acid (ASA)-only patients (2.64% vs. 0.22%; p = 0.04). Conclusion Our systematic review showed a very low risk of DB in MTBI patients on antiplatelet therapy. We believe that such a low rate of DB could not justify routine repeated CT scans in MTBI patients administered a single APA. We speculate that in the case of clinically stable patients, a repeated head CT scan could be useful for select high-risk patients and for patients on DAPT before discharge. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00936-9.
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Marincowitz C, Gravesteijn B, Sheldon T, Steyerberg E, Lecky F. Performance of the Hull Salford Cambridge Decision Rule (HSC DR) for early discharge of patients with findings on CT scan of the brain: a CENTER-TBI validation study. Emerg Med J 2021; 39:213-219. [PMID: 34315761 DOI: 10.1136/emermed-2020-210975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 07/06/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require neurosurgical intervention, while many guidelines recommend routine admission of all patients. We aim to validate the Hull Salford Cambridge Decision Rule (HSC DR) and the Brain Injury Guidelines (BIG) criteria to select low-risk patients for discharge from the emergency department. METHOD A cohort from 18 countries of Glasgow Coma Scale 13-15 patients with injuries on CT imaging was identified from the multicentre Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Study (conducted from 2014 to 2017) for secondary analysis. A composite outcome measure encompassing need for ongoing hospital admission was used, including seizure activity, death, intubation, neurosurgical intervention and neurological deterioration. We assessed the performance of our previously derived prognostic model, the HSC DR and the BIG criteria at predicting deterioration in this validation cohort. RESULTS Among 1047 patients meeting the inclusion criteria, 267 (26%) deteriorated. Our prognostic model achieved a C-statistic of 0.81 (95% CI: 0.78 to 0.84). The HSC DR achieved a sensitivity of 100% (95% CI: 97% to 100%) and specificity of only 4.7% (95% CI: 3.3% to 6.5%) for deterioration. Using the BIG criteria for discharge from the ED achieved a higher specificity (13.3%, 95% CI: 10.9% to 16.1%) and lower sensitivity (94.6%, 95% CI: 90.5% to 97%), with 12/105 patients recommended for discharge subsequently deteriorating, compared with 0/34 with the HSC DR. CONCLUSION Our decision rule would have allowed 3.5% of patients to be discharged, none of whom would have deteriorated. Use of the BIG criteria may select patients for discharge who have too high a risk of subsequent deterioration to be used clinically. Further validation and implementation studies are required to support use in clinical practice.
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Affiliation(s)
- Carl Marincowitz
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR). Emergency Department, Salford Royal Hospital, University of Sheffield and Salford Royal Hospital, Sheffield, UK
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Leitner L, El-Shabrawi JH, Bratschitsch G, Eibinger N, Klim S, Leithner A, Puchwein P. Risk adapted diagnostics and hospitalization following mild traumatic brain injury. Arch Orthop Trauma Surg 2021; 141:619-627. [PMID: 32705384 PMCID: PMC7966191 DOI: 10.1007/s00402-020-03545-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/15/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) remains a leading cause of hospital admission and mortality, intracranial hemorrhage (ICH) presents a severe complication. Low complication tolerance in developed countries and risk uncertainty, often cause excessive observation, diagnostics and hospitalization, considered unnecessary and expensive. Risk factors predicting ICH, progression and death in patients hospitalized with mild TBI have not been identified yet. METHODS Mild TBI cases indicated for cranial computer tomography (CT) and hospitalization, according to international guidelines, at our Level I Trauma Center between 2008 and 2018 were retrospectively included. Multivariate logistic regression was performed for ICH, progression and mortality predictors. RESULTS 1788 mild TBI adults (female: 44.3%; age at trauma: 58.0 ± 22.7), were included. Skull fracture was diagnosed in 13.8%, ICH in 46.9%, ICH progression in 10.6%. In patients < 35 years with mild TBI, chronic alcohol consumption (p = 0.004) and skull fracture (p < 0.001) were significant ICH risk factors, whilst in patients between 35 and 65 years, chronic alcohol consumption (p < 0.001) and skull fracture (p < 0.001) revealed as significant ICH predictors. In patients with mild TBI > 65 years, age (p = 0.009), anticoagulation (p = 0.007) and neurocranial fracture (p < 0.001) were significant, independent risk factors for ICH, whilst increased age (p = 0.01) was a risk factor for mortality following ICH in mild TBI. Late-onset ICH only occurred in mild TBI cases with at least two of these risk factors: age > 65, anticoagulation, neurocranial fracture. Overall hospitalization could have been reduced by 15.8% via newly identified low-risk cases. CONCLUSIONS Age, skull fracture and chronic alcohol abuse require vigilant observation. Repeated CT in initially ICH negative cases should only be considered in newly identified high-risk patients. Non-ICH cases aged < 65 years do not gain safety from observation or hospitalization. Recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics.
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Affiliation(s)
- Lukas Leitner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Jasmin Helena El-Shabrawi
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Gerhard Bratschitsch
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Nicolas Eibinger
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Sebastian Klim
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Paul Puchwein
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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Bonney PA, Briggs A, Briggs RG, Jarvis CA, Attenello F, Giannotta SL. Rate of Intracranial Hemorrhage After Minor Head Injury. Cureus 2020; 12:e10653. [PMID: 33133823 PMCID: PMC7586355 DOI: 10.7759/cureus.10653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Computed tomography scans of the head (CTH) are an important component of the initial patient evaluation after blunt head trauma in select patients. Here we review findings of CTH performed for mild traumatic brain injury (TBI) at a Level I trauma center over a two-year period. We subsequently discuss the role and limitations of published clinical decision rules aiming to decrease unnecessary CTH in mild TBI patients. Methods: We reviewed all Emergency Department CTH obtained after blunt head trauma between 2010 and 2011. Patient demographics and radiology report texts were collected. Reports were cross-referenced with our institutional trauma database to obtain initial Glasgow Coma Scale (GCS). Mild TBI was defined by an initial GCS 13-15 with or without loss of consciousness or post-traumatic amnesia. Results: There were 5,634 mild TBI patients evaluated with CTH. A total of 477 scans (8.5%) were positive for intracranial hemorrhage. Of these, 188 (39.4%) showed more than one type of intracranial hemorrhage. The most common findings were subdural hematomas (262, 4.7% of scans), traumatic subarachnoid hemorrhages (252, 4.5% of scans), and cerebral contusions/intraparenchymal hematomas (212, 3.8% of scans). Older age (p<0.001) and male gender (p<0.001) were associated with positive CTH. Conclusions: The rate of positive CTH in mild TBI patients in our population falls within a historical range. The clinical and medicolegal implications of missed intracranial hemorrhage have remained important factors limiting the implementation of clinical decision rules in screening mild TBI patients for CTH.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Norman, USA.,Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Amy Briggs
- Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Robert G Briggs
- Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Casey A Jarvis
- Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Frank Attenello
- Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Steven L Giannotta
- Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, USA
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14
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Vaniyapong T, Phinyo P, Patumanond J, Ratanalert S, Limpastan K. Development of clinical decision rules for traumatic intracranial injuries in patients with mild traumatic brain injury in a developing country. PLoS One 2020; 15:e0239082. [PMID: 32946468 PMCID: PMC7500687 DOI: 10.1371/journal.pone.0239082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/28/2020] [Indexed: 11/20/2022] Open
Abstract
Background The majority of clinical decision rules for prediction of intracranial injury in patients with mild traumatic brain injury (TBI) were developed from high-income countries. The application of these rules in low or middle-income countries, where the primary mechanism of injury was traffic accidents, is questionable. Methods We developed two practical decision rules from a secondary analysis of a multicenter, prospective cohort of 1,164 patients with mild TBI who visited the emergency departments from 2013 to 2016. The clinical endpoints were the presence of any intracranial injury on CT scans and the requirement of neurosurgical interventions within seven days of onset. Results Thirteen predictors were included in both models, which were age ≥60 years, dangerous mechanism of injury, diffuse headache, vomiting >2 episodes, loss of consciousness, posttraumatic amnesia, posttraumatic seizure, history of anticoagulant use, presence of neurological deficits, significant wound at the scalp, signs of skull base fracture, palpable stepping at the skull, and GCS <15 at 2 hours. For the model-based score, the area under the receiver operating characteristic curve (AuROC) was 0.85 (95%CI 0.82, 0.87) for positive CT results and 0.87 (95%CI 0.83, 0.91) for requirement of neurosurgical intervention. For the clinical-based score, the AuROC for positive CT results and requirement of neurosurgical intervention was 0.82 (95%CI 0.79, 0.85) and 0.84 (95%CI 0.80, 0.88), respectively. Conclusions The models delivered good calibration and excellent discrimination both in the development and internal validation cohort. These rules can be used as assisting tools in risk stratification of patients with mild TBI to be sent for CT scans or admitted for clinical observation.
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Affiliation(s)
- Tanat Vaniyapong
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- * E-mail:
| | - Jayanton Patumanond
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Kriengsak Limpastan
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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15
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Dixon J, Comstock G, Whitfield J, Richards D, Burkholder TW, Leifer N, Mould-Millman NK, Calvello Hynes EJ. Emergency department management of traumatic brain injuries: A resource tiered review. Afr J Emerg Med 2020; 10:159-166. [PMID: 32923328 PMCID: PMC7474234 DOI: 10.1016/j.afjem.2020.05.006] [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] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/20/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma. Objectives Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework. Methods A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings. Key recommendations Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.
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16
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Khalifa M, Magrabi F, Gallego Luxan B. Evaluating the Impact of the Grading and Assessment of Predictive Tools Framework on Clinicians and Health Care Professionals' Decisions in Selecting Clinical Predictive Tools: Randomized Controlled Trial. J Med Internet Res 2020; 22:e15770. [PMID: 32673228 PMCID: PMC7381257 DOI: 10.2196/15770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 03/05/2020] [Accepted: 05/14/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND While selecting predictive tools for implementation in clinical practice or for recommendation in clinical guidelines, clinicians and health care professionals are challenged with an overwhelming number of tools. Many of these tools have never been implemented or evaluated for comparative effectiveness. To overcome this challenge, the authors developed and validated an evidence-based framework for grading and assessment of predictive tools (the GRASP framework). This framework was based on the critical appraisal of the published evidence on such tools. OBJECTIVE The aim of the study was to examine the impact of using the GRASP framework on clinicians' and health care professionals' decisions in selecting clinical predictive tools. METHODS A controlled experiment was conducted through a web-based survey. Participants were randomized to either review the derivation publications, such as studies describing the development of the predictive tools, on common traumatic brain injury predictive tools (control group) or to review an evidence-based summary, where each tool had been graded and assessed using the GRASP framework (intervention group). Participants in both groups were asked to select the best tool based on the greatest validation or implementation. A wide group of international clinicians and health care professionals were invited to participate in the survey. Task completion time, rate of correct decisions, rate of objective versus subjective decisions, and level of decisional conflict were measured. RESULTS We received a total of 194 valid responses. In comparison with not using GRASP, using the framework significantly increased correct decisions by 64%, from 53.7% to 88.1% (88.1/53.7=1.64; t193=8.53; P<.001); increased objective decision making by 32%, from 62% (3.11/5) to 82% (4.10/5; t189=9.24; P<.001); decreased subjective decision making based on guessing by 20%, from 49% (2.48/5) to 39% (1.98/5; t188=-5.47; P<.001); and decreased prior knowledge or experience by 8%, from 71% (3.55/5) to 65% (3.27/5; t187=-2.99; P=.003). Using GRASP significantly decreased decisional conflict and increased the confidence and satisfaction of participants with their decisions by 11%, from 71% (3.55/5) to 79% (3.96/5; t188=4.27; P<.001), and by 13%, from 70% (3.54/5) to 79% (3.99/5; t188=4.89; P<.001), respectively. Using GRASP decreased the task completion time, on the 90th percentile, by 52%, from 12.4 to 6.4 min (t193=-0.87; P=.38). The average System Usability Scale of the GRASP framework was very good: 72.5% and 88% (108/122) of the participants found the GRASP useful. CONCLUSIONS Using GRASP has positively supported and significantly improved evidence-based decision making. It has increased the accuracy and efficiency of selecting predictive tools. GRASP is not meant to be prescriptive; it represents a high-level approach and an effective, evidence-based, and comprehensive yet simple and feasible method to evaluate, compare, and select clinical predictive tools.
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Affiliation(s)
- Mohamed Khalifa
- Centre for Health Informatics, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Farah Magrabi
- Centre for Health Informatics, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Blanca Gallego Luxan
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
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Orlando A, Rubin B, Panchal R, Tanner A, Hudson J, Harken K, Madayag R, Berg G, Bar-Or D. In Patients Over 50 Years, Increased Age Is Associated With Decreased Odds of Documented Loss of Consciousness After a Concussion. Front Neurol 2020; 11:39. [PMID: 32082248 PMCID: PMC7005230 DOI: 10.3389/fneur.2020.00039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 01/10/2020] [Indexed: 12/28/2022] Open
Abstract
Background: Advanced aged adults have the highest rate of traumatic brain injury (TBI) related hospital admissions, compared to younger age groups. Data were published in 2014 indicating differential injury and neurological responses to a TBI by age categories. In a recent article examining patients with mTBI and isolated subdural hematoma, it was found that older patients had a decreased risk of documented loss of consciousness (LOC). The primary objective was to determine the extent to which the odds of documented LOC changes with increasing age in a population of older adults suffering an isolated concussion and uncomplicated mTBI. Methods: This was a retrospective study utilizing 6 years (2010–2015) of National Trauma Data Bank data. This study included patients with (1) diagnosis of concussion; (2) positive or negative loss of consciousness; (3) loss of consciousness durations no longer than 59 min or undefined; (4) age ≥50 years; (5) had a “fall” mechanism of injury; and (6) a valid emergency department Glasgow coma scale 13–15. We excluded patients (1) with any intracranial hemorrhage or intracranial injury of other and unspecified nature; (2) skull fracture; (3) an injury severity scale score >17; (4) a concussion with “unspecified” LOC (ICD-9: 850.9). Results: There were 7,466 patients included in the study; the median (IQR) age was 70 (60–80) years. The risk of documented LOC was 71% (n = 5,319). An 80-year-old had 72% decreased odds of having a documented LOC, compared to a 50-year-old (OR = 0.28, 99.5%CI [0.23–0.34], P < 0.001). This association held when controlling for multiple demographic, comorbid, and clinical variables, and in sensitivity analyses. Conclusion: These nationwide data suggest that in patients aged ≥50 years, a significant inverse association exists between age and odds of documented LOC after sustaining a fall-related concussion. Additional studies are needed to validate these findings and to investigate the triad of age, documented LOC, and intracranial hemorrhage. Clinical diagnostic criteria relying on LOC might be at risk of being modified by the association between increasing age and decreasing odds of LOC.
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Affiliation(s)
- Alessandro Orlando
- Department of Trauma Research, Swedish Medical Center, Englewood, CO, United States.,Department of Trauma Research, Penrose Hospital, Colorado Springs, CO, United States.,Department of Trauma Research, Medical City Plano, Plano, TX, United States.,Department of Trauma Research, St. Anthony Hospital, Lakewood, CO, United States.,Department of Trauma Research, Research Medical Center, Kansas City, MO, United States.,Department of Trauma Research, Wesley Medical Center, Wichita, KS, United States
| | - Benjamin Rubin
- Department of Neurosurgery, Swedish Medical Center, Englewood, CO, United States
| | - Ripul Panchal
- Department of Neurosurgery, Medical City Plano, Plano, TX, United States
| | - Allen Tanner
- Department of Trauma Services, Penrose Hospital, Colorado Springs, CO, United States
| | - John Hudson
- Department of Neurosurgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Kyle Harken
- Department of Trauma Services, Research Medical Center, Kansas City, MO, United States
| | - Robert Madayag
- Department of Trauma Services, St. Anthony Hospital, Lakewood, CO, United States
| | - Gina Berg
- Department of Trauma Research, Wesley Medical Center, Wichita, KS, United States
| | - David Bar-Or
- Department of Trauma Research, Swedish Medical Center, Englewood, CO, United States.,Department of Trauma Research, Penrose Hospital, Colorado Springs, CO, United States.,Department of Trauma Research, Medical City Plano, Plano, TX, United States.,Department of Trauma Research, St. Anthony Hospital, Lakewood, CO, United States.,Department of Trauma Research, Research Medical Center, Kansas City, MO, United States.,Department of Trauma Research, Wesley Medical Center, Wichita, KS, United States
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18
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Relevance of emergency head CT scan for fall in the elderly person. J Neuroradiol 2020; 47:54-58. [DOI: 10.1016/j.neurad.2019.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/08/2019] [Accepted: 03/08/2019] [Indexed: 11/23/2022]
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19
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Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy. J Clin Med 2019; 8:jcm8111780. [PMID: 31731421 PMCID: PMC6912196 DOI: 10.3390/jcm8111780] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/09/2019] [Accepted: 10/23/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Delayed intracranial hemorrhage can occur up to several weeks after head trauma and was reported more frequently in patients with antithrombotic therapy. Due to the risk of delayed intracranial hemorrhage, some hospitals follow extensive observation and cranial computed tomography (CT) protocols for patients with head trauma, while others discharge asymptomatic patients after negative CT. Methods: We retrospectively analyzed data on patients with head trauma and antithrombotic therapy without pathologies on their initial CT. During the observation period, we followed a protocol of routine repeat CT before discharge for patients using vitamin K antagonists, clopidogrel or direct oral anticoagulants. Results: 793 patients fulfilled the inclusion criteria. Acetylsalicylic acid (ASA) was the most common antithrombotic therapy (46.4%), followed by vitamin K antagonists (VKA) (32.2%) and Clopidogrel (10.8%). We observed 11 delayed hemorrhages (1.2%) in total. The group of 390 patients receiving routine repeat CT showed nine delayed hemorrhages (2.3%). VKA were used in 6 of these 11 patients. One patient needed an urgent decompressive craniectomy while the other patients were discharged after an extended observation period. The patient requiring surgical intervention due to delayed hemorrhage showed neurological deterioration during the observation period. Conclusions: Routine repeat CT scans without neurological deterioration are not necessary if patients are observed in a clinical setting. Patients using ASA as single antithrombotic therapy do not require in-hospital observation after a negative CT scan.
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20
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Isokuortti H, Iverson GL, Silverberg ND, Kataja A, Brander A, Öhman J, Luoto TM. Characterizing the type and location of intracranial abnormalities in mild traumatic brain injury. J Neurosurg 2019; 129:1588-1597. [PMID: 29328003 DOI: 10.3171/2017.7.jns17615] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/06/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVEThe incidence of intracranial abnormalities after mild traumatic brain injury (TBI) varies widely across studies. This study describes the characteristics of intracranial abnormalities (acute/preexisting) in a large representative sample of head-injured patients who underwent CT imaging in an emergency department.METHODSCT scans were systematically analyzed/coded in the TBI Common Data Elements framework. Logistic regression modeling was used to quantify risk factors for traumatic intracranial abnormalities in patients with mild TBIs. This cohort included all patients who were treated at the emergency department of the Tampere University Hospital (between 2010 and 2012) and who had undergone head CT imaging after suffering a suspected TBI (n = 3023), including 2766 with mild TBI and a reference group with moderate to severe TBI.RESULTSThe most common traumatic lesions seen on CT scans obtained in patients with mild TBIs and those with moderate to severe TBIs were subdural hematomas, subarachnoid hemorrhages, and contusions. Every sixth patient (16.1%) with mild TBI had an intracranial lesion compared with 5 of 6 patients (85.6%) in the group with moderate to severe TBI. The distribution of different types of acute traumatic lesions was similar among mild and moderate/severe TBI groups. Preexisting brain lesions were a more common CT finding among patients with mild TBIs than those with moderate to severe TBIs. Having a past traumatic lesion was associated with increased risk for an acute traumatic lesion but neurodegenerative and ischemic lesions were not. A lower Glasgow Coma Scale score, male sex, older age, falls, and chronic alcohol abuse were associated with higher risk of acute intracranial lesion in patients with mild TBI.CONCLUSIONSThese findings underscore the heterogeneity of neuropathology associated with the mild TBI classification. Preexisting brain lesions are common in patients with mild TBI, and the incidence of preexisting lesions increases with age. Acute traumatic lesions are fairly common in patients with mild TBI; every sixth patient had a positive CT scan. Older adults (especially men) who fall represent a susceptible group for acute CT-positive TBI.
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Affiliation(s)
| | - Grant L Iverson
- 2Department of Physical Medicine and Rehabilitation, Harvard Medical School.,6Spaulding Rehabilitation Hospital.,7Sports Concussion Program, MassGeneral Hospital for Children; and.,8Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts
| | - Noah D Silverberg
- 2Department of Physical Medicine and Rehabilitation, Harvard Medical School.,3Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia; and.,8Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts.,9GF Strong Rehab Centre, Vancouver, British Columbia, Canada
| | - Anneli Kataja
- 4Medical Imaging Centre, Department of Radiology, and
| | - Antti Brander
- 4Medical Imaging Centre, Department of Radiology, and
| | - Juha Öhman
- 5Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Teemu M Luoto
- 5Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
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21
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Karr JE, Iverson GL, Berghem K, Kotilainen AK, Terry DP, Luoto TM. Complicated mild traumatic brain injury in older adults: Post-concussion symptoms and functional outcome at one week post injury. Brain Inj 2019; 34:26-33. [DOI: 10.1080/02699052.2019.1669825] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Justin E. Karr
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Spaulding Rehabilitation Hospital, Boston, MA, USA
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, USA
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Spaulding Rehabilitation Hospital, Boston, MA, USA
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, USA
- Spaulding Research Institute, Boston, MA, USA
| | - Ksenia Berghem
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | | | - Douglas P. Terry
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Spaulding Rehabilitation Hospital, Boston, MA, USA
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, USA
| | - Teemu M. Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
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22
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Sert ET, Mutlu H, Kokulu K. The effectiveness of clinical risk factors on determining delayed traumatic intracranial pathology in the treatment of mild head trauma. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919869510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background:Currently, a large burden of hospital admissions is related to minor head trauma and its related imaging studies. One of the challenging issues for emergency physicians is head computed tomography scan.Objective:The aim of this study was to determine whether there are clinical risk factors that may reveal the intracranial pathology occurring after discharge in adult patients who underwent computerized tomography because of mild/minor head traumas. We aimed to evaluate the prevalence of abnormal computerized tomography in these patients.Methods:Between January 2013 and December 2017 medical records and imaging findings of patients over 18 years of age who had undergone computerized tomography examination in the emergency department of our hospital were evaluated retrospectively. Patients were divided into groups according to age, sex, symptoms and physical examination findings. The relationship between these findings and abnormal computerized tomography findings was evaluated statistically.Results:A total of 619 patients who were admitted to the emergency department for the second time because of the same head trauma and underwent control head computerized tomography were included in the study. Abnormal head computerized tomography findings were found in 7.6% (47) of the patients. Clinical risk factors; Glasgow Coma Scale score, vomiting, loss of consciousness, dangerous trauma mechanism and anticoagulant drug use were significantly correlated with the presence of pathology on head CT( p<0.05).Conclusion:Patients who are readmitted to the emergency department due to worsening symptoms after the injury and who undergo control head computerized tomography have the risk of traumatic brain injury as much as those who are admitted for the first time. A very early computerized tomography may cause to miss an evolving bleeding. The presence of one or more of the identified risk factors will help clinicians to decide which patient requires computerized tomography.
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Affiliation(s)
- Ekrem Taha Sert
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Hüseyin Mutlu
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Kamil Kokulu
- Department of Emergency Medicine, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
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23
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Foks KA, Dijkland SA, Lingsma HF, Polinder S, van den Brand CL, Jellema K, Jacobs B, van der Naalt J, Sir Ö, Jie KE, Schoonman GG, Hunink MG, Steyerberg EW, Dippel DW, Gaakeer MI, Schutte CE, Visee HF, den Boogert H, Reijners E, Braaksma M, de Jong E, Patka P. Risk of Intracranial Complications in Minor Head Injury: The Role of Loss of Consciousness and Post-Traumatic Amnesia in a Multi-Center Observational Study. J Neurotrauma 2019; 36:2377-2384. [DOI: 10.1089/neu.2018.6354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kelly A. Foks
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Simone A. Dijkland
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Crispijn L. van den Brand
- Department of Emergency Medicine, Haaglanden Medical Center, the Hague, the Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kim E. Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Guus G. Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, the Netherlands
| | - Myriam G.M. Hunink
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Diederik W.J. Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands
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How effective are the computerized tomography imaging prompts in the emergency department?”. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/jcm.596718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Su YS, Schuster JM, Smith DH, Stein SC. Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury. J Neurotrauma 2019; 36:2083-2091. [PMID: 30547708 DOI: 10.1089/neu.2018.6020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.
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Affiliation(s)
- YouRong Sophie Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas H Smith
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: an Austrian interdisciplinary consensus statement. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:62. [PMID: 30795779 PMCID: PMC6387521 DOI: 10.1186/s13054-019-2352-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/10/2019] [Indexed: 12/11/2022]
Abstract
There is a high degree of uncertainty regarding optimum care of patients with potential or known intake of oral anticoagulants and traumatic brain injury (TBI). Anticoagulation therapy aggravates the risk of intracerebral hemorrhage but, on the other hand, patients take anticoagulants because of an underlying prothrombotic risk, and this could be increased following trauma. Treatment decisions must be taken with due consideration of both these risks. An interdisciplinary group of Austrian experts was convened to develop recommendations for best clinical practice. The aim was to provide pragmatic, clear, and easy-to-follow clinical guidance for coagulation management in adult patients with TBI and potential or known intake of platelet inhibitors, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. Diagnosis, coagulation testing, and reversal of anticoagulation were considered as key steps upon presentation. Post-trauma management (prophylaxis for thromboembolism and resumption of long-term anticoagulation therapy) was also explored. The lack of robust evidence on which to base treatment recommendations highlights the need for randomized controlled trials in this setting.
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Lee HJ, Kim YJ, Seo DW, Sohn CH, Ryoo SM, Ahn S, Lee YS, Kim WY, Lim KS. Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury. Injury 2018; 49:963-968. [PMID: 29503015 DOI: 10.1016/j.injury.2018.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/07/2018] [Accepted: 02/24/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI. METHODS This retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients. RESULTS A total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06-8.34; P < 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08-9.23; P < 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01-1.04; P = 0.002) were independent risk factors for concomitant intracranial injury. CONCLUSIONS Emergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age.
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Affiliation(s)
- Hyung-Joo Lee
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Dong-Woo Seo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Shin Ahn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Yoon-Seon Lee
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Kyoung Soo Lim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
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Yuksen C, Sittichanbuncha Y, Patumanond J, Muengtaweepongsa S, Sawanyawisuth K. Clinical predictive score of intracranial hemorrhage in mild traumatic brain injury. Ther Clin Risk Manag 2018; 14:213-218. [PMID: 29440905 PMCID: PMC5798541 DOI: 10.2147/tcrm.s147079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Mild traumatic brain injury (TBI) is a common condition at the Emergency Medicine Department. Head computer tomography (CT) scans in mild TBI patients must be properly justified in order to avoid unnecessary exposure to X-rays and to reduce the hospital/transfer costs. This study aimed to evaluate which clinical factors are associated with intracranial hemorrhage in Asian population and to develop a user-friendly predictive model. Methods The study was conducted retrospectively at the Emergency Medicine Department in Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand. The study period was between September 2013 and August 2016. The inclusion criteria were age >15 years and having received a head CT scan after presenting with mild TBI. Those patients with mild TBI and no symptoms/deterioration after 24 h of clinical observation were excluded. The predictive model and prediction score for intracranial hemorrhage was developed by multivariate logistic regression analysis. Results During the study period, there were 708 patients who met the study criteria. Of those, 100 patients (14.12%) had positive head CT scan results. There were seven independent factors that were predictive of intracranial hemorrhage. The clinical risk scores to predict intracranial hemorrhage are developed with an accuracy of 92%. The score of >3 had the likelihood of intracranial hemorrhage by 1.47 times. Conclusion Clinical predictive score of >3 was associated with intracranial hemorrhage in mild TBI.
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Affiliation(s)
- Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok
| | - Yuwares Sittichanbuncha
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok
| | - Jayanton Patumanond
- Clinical Epidemiology Unit and Clinical Research Center, Faculty of Medicine, Thammasat University, Pathum Thani
| | | | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen.,Sleep Apnea Research Group, Research Center in Back, Neck, Other Joint Pain and Human Performance (BNOJPH), and Research and Training Center for Enhancing Quality of Life of Working Age People, Khon Kaen University, Khon Kaen, Thailand
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Hsiao KY, Li WC, Chang CH, Lin MHC, Yang JT, Wang PC, Chen KH. An Evaluation of the ACEP Guideline for Mild Head Injuries in Taiwan. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791702400204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Traumatic brain injury (TBI) is an important issue in the emergency department. In the United States, the American College of Emergency Physicians (ACEP) published clinical guideline to select patients with mild head injuries for head computed tomography (CT) scans in 2008. The aim of this study was to identify the possible benefits of compliance with these guidelines for mild head injury patients in Taiwan. Method This was a secondary analysis on our previous study published for association of hypertension and head injuries. In our previous study, we collected data about 1290 patients with head injuries who received brain CT scans in the emergency department from September 2012 to August 2013 for a study regarding the association between head injury and hypertension. In present study, we subjected this data to further analysis to try to validate the ACEP clinical policy for mild head injuries. Results Of these 1,290 patients, 154 were found to have brain haemorrhage on the initial brain CT scan, and 5 were in need of neurosurgical intervention. A total of 859 patients met the ACEP guideline criteria, and 117 of these had brain haemorrhages. The sensitivity and specificity of the ACEP guideline to predict brain haemorrhage were 75.97% (95% confidence interval [CI], 68.44% to 82.48%) and 34.68% (95% CI, 31.91% to 37.53%), respectively. In predicting neurosurgical intervention, the sensitivity and specificity of the guideline were 100% (95% CI, 47.82% to 100%) and 33.54% (95% CI, 30.96% to 36.2%), respectively. Conclusion Although adoption of the ACEP clinical policy may reduce the number of brain CT scans in mild head injury patients who may need neurosurgical interventions, it is not a good selection tool in Taiwan.
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Affiliation(s)
- KY Hsiao
- Chang Gung Memorial Hospital, Department of Emergency Medicine; and Chang Gung University of Science and Technology, Department of Nursing, Chiayi, Taiwan
| | - WC Li
- Chang Gung Memorial Hospital, Department of Occupation Medicine, Taipei, Taiwan
| | - CH Chang
- Chang Gung University of Science and Technology, College of Nursing &the Chronic Diseases and Health Promotion Research Center, Chiayi Campus, Chiayi, Taiwan
| | - MHC Lin
- Chang Gung Memorial Hospital, Department of Neurosurgery, Chiayi, Taiwan
| | - JT Yang
- Chang Gung Memorial Hospital, Department of Neurosurgery, Chiayi; and Chang Gung University, College of Medicine, Tao-Yuan, Taiwan
| | - PC Wang
- Chang Gung Memorial Hospital, Department of Cardiology, Chiayi, Taiwan
| | - KH Chen
- Chang Gung University, College of Medicine, Tao-Yuan; and Chang Gung Memorial Hospital, Department of Physical Medicine and Rehabilitation, Chiayi, Taiwan
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Fung HS, Chiu JLF, Shu SJ, Chan MK, Lai AKH, Wong WK, Chan SCH. A Man with Head Injury. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790801500208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Head injury is common and can be associated with significant morbidity and mortality. We report a 71-year-old man with typical imaging findings of depressed skull fracture on plain film and computed tomography with images in multi-planar reformat and 3-dimensional volume rendering technique, followed by a brief review of the literature.
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Ibañez Pérez De La Blanca MA, Fernández Mondéjar E, Gómez Jimènez FJ, Alonso Morales JM, Lombardo MDQ, Viso Rodriguez JL. Risk factors for intracranial lesions and mortality in older patients with mild traumatic brain injuries. Brain Inj 2017; 32:99-104. [PMID: 29156999 DOI: 10.1080/02699052.2017.1382716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PRIMARY OBJECTIVE To identify risk factors for intracerebral lesion (ICL) in older adults with mild traumatic brain injury (MTBI) and evaluate the influence of comorbidities on outcomes. RESEARCH DESIGN Prospective cohort study. METHODS AND PROCEDURES Information was gathered on clinical history/examination, cranial computed tomography, admission Glasgow Coma Scale (GCS) score, analytical and coagulation findings, and mortality at 1 week post-discharge. Bivariate and multivariate logistic regression analyses were performed, calculating odds ratios for ICL with 95% confidence interval. P < 0.05 was considered significant. MAIN OUTCOMES AND RESULTS Data were analyzed on 504 patients with mean±SD age of 79.37 ± 8.06 years. Multivariate analysis showed that traffic accident, GCS score of 14/15, transient consciousness loss, nausea, and receipt of antiplatelets were predictors of ICL, while SRRI and/or benzodiazepine intake was a protective factor. A score was assigned to patients by rounding OR values, and a score ≥1 indicated moderate/high risk of ICL. CONCLUSIONS MTBI management should be distinct in over-60 year-olds, who may not present typical symptoms, with frequent comorbidities. Knowledge of risk factors for post-MTBI ICL, associated with higher mortality, is important to support clinical decision-making. Further research is warranted to verify our novel finding that benzodiazepines and/or SSRI inhibitors may act as neuroprotectors.
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Clinical Factors Predictive for Intracranial Hemorrhage in Mild Head Injury. Neurol Res Int 2017; 2017:5385613. [PMID: 29359046 PMCID: PMC5735672 DOI: 10.1155/2017/5385613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 10/30/2017] [Accepted: 11/05/2017] [Indexed: 11/18/2022] Open
Abstract
Patients with mild head injuries, a GCS of 13-15, are at risk for intracranial hemorrhage. Clinical decision is needed to weigh between risks of intracranial hemorrhage and costs of the CT scan of the brain particularly those who are equivocal. This study aimed to find predictors for intracranial hemorrhage in patients with mild head injuries with a moderate risk of intracranial hemorrhage. We defined moderate risk of mild head injury as a GCS score of 13-15 accompanied by at least one symptom such as headache, vomiting, or amnesia or with alcohol intoxication. There were 153 patients who met the study criteria. Eighteen of the patients (11.76%) had intracranial hemorrhage. There were four independent factors associated with intracranial hemorrhage: history of hypertension, headache, loss of consciousness, and baseline GCS. The sensitivity for the presence of intracranial hemorrhage was 100% with the cutoff point for the GCS of 13. In conclusion, the independent factors associated with intracranial hemorrhage in patients with mild head injury who were determined to be at moderate risk for the condition included history of hypertension, headache, loss of consciousness, and baseline GCS score.
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Intracranial Pathology (CT+) in Emergency Department Patients With High GCS and High Standard Assessment of Concussion (SAC) Scores. J Head Trauma Rehabil 2017; 33:E61-E66. [PMID: 29084105 DOI: 10.1097/htr.0000000000000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate that a subpopulation of patients with mild/moderate traumatic brain injury (TBI) had intracranial pathology despite having a Glasgow Coma Scale (GCS) score of 15 and a Standardized Assessment of Concussion (SAC) score of 25 or higher. SETTING A network of 11 US emergency departments (ED) enrolling patients in a multisite study of TBI. PARTICIPANTS Men and women between the ages of 18 and 85 years admitted to a participating ED having sustained a closed head injury within the prior 72 hours and a GCS score of 13 to 15 at the time of enrollment. DESIGN Prospective observational study. MAIN MEASURES GCS, SAC, computed tomography (CT) positive or negative for intracranial pathology, Marshall scoring of CT scans. RESULTS Of 191 patients with intracranial pathology (CT+) and having a SAC score recorded, 24% (46/191) had a SAC score in the normal range (≥25) as well as a GCS score of 15. All causes of CT+ brain injury were present in both SAC groups. CONCLUSION A normal GCS score and a SAC score do not exclude the possibility of significant intracranial injury.
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Borade A, Kempegowda H, Maniar HH, De Giacomo A, Tornetta P, Bramlett K, Marcantonio AJ, Marchand LS, Kubiak EN, Ip WH, Kellam JF, Bender JS, Meinberg EG, Kee J, Renard R, Suk M, Horwitz DS. External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures. Injury 2017; 48:1594-1596. [PMID: 28502379 DOI: 10.1016/j.injury.2017.04.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/17/2017] [Accepted: 04/25/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. PATIENTS AND METHODS Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. RESULTS In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative. CONCLUSION With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.
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Affiliation(s)
- Amrut Borade
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Harish Kempegowda
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Hemil H Maniar
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Anthony De Giacomo
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - Kasey Bramlett
- Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Andrew J Marcantonio
- Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Lucas S Marchand
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Erik N Kubiak
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - William H Ip
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - James F Kellam
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jay S Bender
- SFGH/UCSF Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Eric G Meinberg
- SFGH/UCSF Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - James Kee
- Department of Orthopaedic Surgery, University Arkansas of Medical Sciences, Little Rock, AR, USA
| | - Regis Renard
- Department of Orthopaedic Surgery, University Arkansas of Medical Sciences, Little Rock, AR, USA
| | - Michael Suk
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Daniel S Horwitz
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA.
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Hack D, Huff JS, Curley K, Naunheim R, Ghosh Dastidar S, Prichep LS. Increased prognostic accuracy of TBI when a brain electrical activity biomarker is added to loss of consciousness (LOC). Am J Emerg Med 2017; 35:949-952. [DOI: 10.1016/j.ajem.2017.01.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 10/20/2022] Open
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Stippler M, Liu J, Motiei-Langroudi R, Voronovich Z, Yonas H, Davis RB. Complicated Mild Traumatic Brain Injury and the Need for Imaging Surveillance. World Neurosurg 2017; 105:265-269. [PMID: 28502689 DOI: 10.1016/j.wneu.2017.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the need for repeat head computed tomography (CT) in patients with complicated mild traumatic brain injury (TBI) determined nonoperative after the first head CT. METHODS A total of 380 patients with mild TBI and a positive head CT not needing surgery were included. Changes between first and second head CT were categorized as decreased, increased, or stable. RESULTS Three patients required neurosurgical intervention (0.8%) after the second CT. There were no significant differences in demographics including age, gender, alcohol consumption, anticoagulation status, time between first and second CT, Glasgow Coma Scale score at admission and discharge, and incidence of subarachnoid hemorrhage, epidural hematoma, contusion, or skull fractures between the operated and nonoperated groups. All patients in the operated group had subdural hematoma compared with 40.8% in the nonoperated group (P = 0.07). All operated patients showed symptoms of neurologic worsening after initial head CT, compared with 2.7% in the nonoperated group (P < 0.001). Moreover, patients who showed neurologic worsening were more likely to show increased intracranial bleeding on repeat head CT, whereas patients who did not show neurologic worsening were more likely to show decreased or stable intracranial bleeding (P = 0.04). CONCLUSIONS Routine repeat head CT in patients with complicated mild TBI is very low yield to predict need for delayed surgical intervention. Instead, serial neurologic examination and observation over the first 8 hours after the injury is recommended. A second CT scan should be obtained only in patients who have neurologic worsening.
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Affiliation(s)
- Martina Stippler
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jingyi Liu
- School of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rouzbeh Motiei-Langroudi
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Zoya Voronovich
- Department of Neurosurgery, University of New Mexico Health Science Center, Albuquerque, New Mexico, USA
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico Health Science Center, Albuquerque, New Mexico, USA
| | - Roger B Davis
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Sauter TC, Ziegenhorn S, Ahmad SS, Hautz WE, Ricklin ME, Leichtle AB, Fiedler GM, Haider DG, Exadaktylos AK. Age is not associated with intracranial haemorrhage in patients with mild traumatic brain injury and oral anticoagulation. J Negat Results Biomed 2016; 15:12. [PMID: 27401915 PMCID: PMC4940966 DOI: 10.1186/s12952-016-0055-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 05/17/2016] [Indexed: 11/24/2022] Open
Abstract
Background Patients admitted to emergency departments with traumatic brain injury (TBI) are commonly being treated with oral anticoagulants. In contrast to patients without anticoagulant medication, no guidelines, scores or recommendations exist for the management of mild traumatic brain injury in these patients. We therefore tested whether age as one of the high risk factors of the Canadian head CT rule is applicable to a patient population on oral anticoagulants. Methods This cross-sectional analysis included all patients with mild TBI and concomitant oral anticoagulant therapy admitted to the Emergency Department, Inselspital Bern, Switzerland, from November 2009 to October 2014 (n = 200). Using a logistic regression model, two groups of patients with mild TBI on oral anticoagulant therapy were compared — those with and those without intracranial haemorrhage. Results There was no significant difference in age between the patient groups with (n = 86) and without (n = 114) intracranial haemorrhage (p = 0.078). In univariate logistic regression, GCS (OR = 0.419 (0.258; 0.680)) and thromboembolic event as reason for anticoagulant therapy (OR = 0.486 (0.257; 0.918)) were significantly associated with intracranial haemorrhage in patients with mild TBI and anticoagulation (all p < 0.05). However, there was no association with age (p = 0.078, OR = 1.024 (0.997; 1.051)), the type of accident or additional medication with acetylsalicylic acid or clopidogrel ((both p > 0.05; 0.552 (0.139; 2.202) and 0.256 (0.029; 2.237), respectively). Conclusion Our study found no association between age and intracranial bleeding. Therefore, until further risk factors are identified, diagnostic imaging with CCT remains necessary for mild TBI patients on oral anticoagulation of all ages, especially those with therapeutic anticoagulation because of thromboembolic events.
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Affiliation(s)
- Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Stephan Ziegenhorn
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Sufian S Ahmad
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Meret E Ricklin
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Alexander Benedikt Leichtle
- Centre of Laboratory Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Georg-Martin Fiedler
- Centre of Laboratory Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Dominik G Haider
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
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Epidemiologic study in hospitalized patients with head injuries. Eur J Trauma Emerg Surg 2016; 43:467-473. [PMID: 27062402 DOI: 10.1007/s00068-016-0668-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 04/01/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of this study was to analyze epidemiologic data of patients with head injuries (HI) who were admitted to the Trauma and Emergency Surgery Department. METHODS The hospital records of 497 patients with HI who were admitted to the Trauma and Emergency Surgery Department from January 1, 2014, through 31 December, 2014, were analyzed retrospectively. RESULTS The male-to-female ratio was 2:1, and the mean age was 16.3 years. The rates of patients with mild, moderate, and severe HI were 93, 3, and 4 %, respectively. The most common cause of trauma was falls. Linear fractures were the most common radiologic diagnoses with 242 cases (49 %). Of the patients admitted to hospital, 22 % presented 4 h after the trauma had occurred. Mortality rate due to HI was 3 % (15 patients). Outcome was associated with admission Glasgow Coma Scale and presence of additional trauma. CONCLUSIONS The number of traffic accidents and assaults were considerably higher in the young adult population compared with the other age groups. Traffic accidents accounted for 46.6 % of the mortality rate. Mortality in HI patients mostly arises from preventable conditions, and the young adult population seems to be the most affected group. HI should be considered as a public health issue, and prevention of HI should be the primary goal.
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Yellinek S, Cohen A, Merkin V, Shelef I, Benifla M. Clinical significance of skull base fracture in patients after traumatic brain injury. J Clin Neurosci 2015; 25:111-5. [PMID: 26724846 DOI: 10.1016/j.jocn.2015.10.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/10/2015] [Indexed: 10/22/2022]
Abstract
About 4% of all head injuries include skull base fractures. Most of these fractures (90%) are secondary to closed head trauma; the remainder are due to penetrating trauma. We reviewed the records from January 2006 through December 2008 of all patients older than 18 years of age who arrived at Soroka Medical Center in Be'er-Sheva, Israel, with skull base fractures following a traumatic brain injury (TBI). We identified 107 patients with a mean age of 42 years at the time of TBI. Glasgow Coma score on arrival predicted the clinical outcome. We observed temporal fractures in 30% of these patients, occipital fractures in 20%, pyramidal fractures in 19%, anterior skull base fractures in 17%, and multiple fractures in 14%. Cerebrospinal fluid (CSF) leak was observed in 16 patients (15%). Of the patients experiencing CSF leaks, otorrhea occurred in 10 (62%) and rhinorrhea occurred in six (37%). Three patients required surgical intervention to repair the leak. Meningitis occurred in four patients with clinically evident CSF leak. Multiple skull base fractures are associated with poor neurological outcome. The low rate of meningitis in this patient sample implies that there is no indication to administer prophylactic antibiotics to patients with skull base fractures.
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Affiliation(s)
- Shlomi Yellinek
- Neurosurgery Department, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Avi Cohen
- Neurosurgery Department, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Vladimir Merkin
- Neurosurgery Department, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Ilan Shelef
- Neuroradiology Division, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Mony Benifla
- Neurosurgery Department, Hadassah Medical Center, Jerusalem, Israel.
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Asadollahi S, Heidari K, Taghizadeh M, Seidabadi AM, Jamshidian M, Vafaee A, Manoochehri M, Shojaee AH, Hatamabadi HR. Reducing head computed tomography after mild traumatic brain injury: Screening value of clinical findings and S100B protein levels. Brain Inj 2015; 30:172-8. [PMID: 26671496 DOI: 10.3109/02699052.2015.1091504] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PRIMARY OBJECTIVE The present prospective study was performed to investigate whether primary clinical findings and serum S100B concentrations at 3 and 6 hours post-trauma can contribute to the selection of patients for an initial computed tomography (CT) scanning. RESEARCH DESIGN AND METHODS S100B was measured in serum samples obtained at 3 and 6 hours after the injury. Adjusted odds ratios (OR) and 95% confidence interval (CI) associated with demographics and clinical predictors of positive CT scan were calculated. Sensitivity, specificity, negative and positive predictive values were also calculated for S100B levels. MAIN OUTCOMES AND RESULTS It was found that the presence of loss of consciousness (OR = 2.3; 95% CI = 1.00-4.01; p = 0.008) and post-traumatic vomiting ≥ 2 episodes (OR = 1.8; 95% CI = 1.08-3.29; p = 0.019) are factors associated with positive CT scan. In this study the best cut-off point of 0.115 µg L(-1) for 3-hour S100B has sensitivity of 94.9% (95% CI = 86.8-98.3) with specificity of 35.4% (95% CI = 25.2-47.0) to predict intracranial injury on CT scanning. The corresponding results for 6-hour S100B > 0.210 µg L(-1) were 98.7% (95% CI = 92.1-99.9) for sensitivity and 39.2% (95% CI = 28.6-50.8) for specificity. CONCLUSIONS Serum S100B measurement along with clinical evaluation of patients with mild traumatic brain injury has promising screening value to support selection of patients for CT scanning.
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Affiliation(s)
- Shadi Asadollahi
- a School of Medicine , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Kamran Heidari
- b Department of Emergency Medicine , Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Mehrdad Taghizadeh
- b Department of Emergency Medicine , Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Arash Mohammad Seidabadi
- b Department of Emergency Medicine , Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Morteza Jamshidian
- c Department of Emergency Medicine , Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Ali Vafaee
- b Department of Emergency Medicine , Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Mohammad Manoochehri
- b Department of Emergency Medicine , Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Ali Habibzade Shojaee
- a School of Medicine , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Hamid Reza Hatamabadi
- d Sina Trauma and Surgery Research Center , Tehran University of Medical Sciences , Tehran , Iran
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Maniar H, McPhillips K, Torres D, Wild J, Suk M, Horwitz DS. Clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures. Injury 2015; 46:2185-9. [PMID: 26296456 DOI: 10.1016/j.injury.2015.06.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To define the role of head computed tomography (CT) scans in the geriatric population with isolated low-energy femur fractures and describe the pertinent clinical variables which are associated with positive CT findings with the objective to decrease the number of unnecessary CT scans performed. DESIGN Retrospective review. SETTING Level I trauma centre. PATIENTS Eleven hundred ninety-two (1192) patients sustaining a femur fracture following a low-energy fall. MAIN OUTCOME MEASUREMENT Pertinent clinical variables that were associated with CTs that yielded positive findings. RESULTS Two hundred fifty patients (21%) underwent a head CT scan as part of their evaluation. Of these patients, 83% suffered proximal femur fractures, 11% shaft fractures and 6% distal fractures. The majority of the patients were evaluated by the emergency department (ED) with only 18% (44/250) being evaluated by the trauma team. Average patient age was 83 years (range 65-99 years). One hundred seventy-three patients (69%) were on some form of antiplatelet medication or anticoagulation. Of the 250 patients who underwent head CT scan, 16 (6%) patients had acute findings (haemorrhage - 15, infarct - 1), and none of the patients required neurosurgical intervention. CONCLUSION None of the patients with a traumatic injury required a neurosurgical invention after sustaining a low energy fall (0/1192). Head CT scans should have a limited role in the work-up of this patient population and should be reserved for patients with a history and physical findings that support head trauma. LEVEL OF EVIDENCE Prognostic level III. See instructions for authors for a complete description of levels of evidence.
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Affiliation(s)
- Hemil Maniar
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA(1)
| | - Kristin McPhillips
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA(1)
| | - Denise Torres
- Department of Trauma Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2168, USA(2)
| | - Jeffrey Wild
- Department of Trauma Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2168, USA(2)
| | - Michael Suk
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA(1)
| | - Daniel S Horwitz
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA(1).
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Sauter TC, Kreher J, Ricklin ME, Haider DG, Exadaktylos AK. Risk Factors for Intracranial Haemorrhage in Accidents Associated with the Shower or Bathtub. PLoS One 2015; 10:e0141812. [PMID: 26513749 PMCID: PMC4626205 DOI: 10.1371/journal.pone.0141812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 10/13/2015] [Indexed: 11/22/2022] Open
Abstract
Background There has been little research on bathroom accidents. It is unknown whether the shower or bathtub are connected with special dangers in different age groups or whether there are specific risk factors for adverse outcomes. Methods This cross-sectional analysis included all direct admissions to the Emergency Department at the Inselspital Bern, Switzerland from 1 January 2000 to 28 February 2014 after accidents associated with the bathtub or shower. Time, age, location, mechanism and diagnosis were assessed and special risk factors were examined. Patient groups with and without intracranial bleeding were compared with the Mann-Whitney U test.The association of risk factors with intracranial bleeding was investigated using univariate analysis with Fisher's exact test or logistic regression. The effects of different variables on cerebral bleeding were analysed by multivariate logistic regression. Results Two hundred and eighty (280) patients with accidents associated with the bathtub or shower were included in our study. Two hundred and thirty-five (235) patients suffered direct trauma by hitting an object (83.9%) and traumatic brain injury (TBI) was detected in 28 patients (10%). Eight (8) of the 27 patients with mild traumatic brain injuries (GCS 13–15), (29.6%) exhibited intracranial haemorrhage. All patients with intracranial haemorrhage were older than 48 years and needed in-hospital treatment. Patients with intracranial haemorrhage were significantly older and had higher haemoglobin levels than the control group with TBI but without intracranial bleeding (p<0.05 for both).In univariate analysis, we found that intracranial haemorrhage in patients with TBI was associated with direct trauma in general and with age (both p<0.05), but not with the mechanism of the fall, its location (shower or bathtub) or the gender of the patient. Multivariate logistic regression analysis identified only age as a risk factor for cerebral bleeding (p<0.05; OR 1.09 (CI 1.01;1.171)) Conclusion In patients with ED admissions associated with the bathtub or shower direct trauma and age are risk factors for intracranial haemorrhage. Additional effort in prevention should be considered, especially in the elderly.
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Affiliation(s)
- Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
- * E-mail:
| | - Jannes Kreher
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Meret E. Ricklin
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Dominik G. Haider
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
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Neurotrauma. Int Anesthesiol Clin 2015; 53:23-38. [PMID: 25551740 DOI: 10.1097/aia.0000000000000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Stein SC, Attiah MA. Clinical Prediction and Decision Rules in Neurosurgery. Neurosurgery 2015; 77:149-55; discussion 156. [DOI: 10.1227/neu.0000000000000818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Levin HS, Diaz-Arrastia RR. Diagnosis, prognosis, and clinical management of mild traumatic brain injury. Lancet Neurol 2015; 14:506-17. [PMID: 25801547 DOI: 10.1016/s1474-4422(15)00002-2] [Citation(s) in RCA: 315] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 10/16/2014] [Accepted: 10/17/2014] [Indexed: 12/14/2022]
Abstract
Concussion and mild traumatic brain injury (TBI) are interchangeable terms to describe a common disorder with substantial effects on public health. Advances in brain imaging, non-imaging biomarkers, and neuropathology during the past 15 years have required researchers, clinicians, and policy makers to revise their views about mild TBI as a fully reversible insult that can be repeated without consequences. These advances have led to guidelines on management of mild TBI in civilians, military personnel, and athletes, but their widespread dissemination to clinical management in emergency departments and community-based health care is still needed. The absence of unity on the definition of mild TBI, the scarcity of prospective data concerning the long-term effects of repeated mild TBI and subconcussive impacts, and the need to further develop evidence-based interventions to mitigate the long-term sequelae are areas for future research that will improve outcomes, reduce morbidity and costs, and alleviate delayed consequences that have only recently come to light.
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Affiliation(s)
- Harvey S Levin
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Departments of Physical Medicine and Rehabilitation, Neurology, Neurosurgery, Pediatrics, and Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.
| | - Ramon R Diaz-Arrastia
- Center for Neuroscience and Regenerative Medicine, Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Garbossa D, Altieri R, Specchia FMC, Agnoletti A, Pilloni G, Lanotte M, Spaziante R, Ducati A. Are acute subdural hematomas possible without head trauma? Asian J Neurosurg 2015; 9:218-22. [PMID: 25685219 PMCID: PMC4323966 DOI: 10.4103/1793-5482.146612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Acute subdural hematomas (ASDHs) are rarely reported in the literature. In general, it is due to head trauma, but if the traumatic event is very mild, it is inadequate to explain the ASDH occurrence. Risk factors for the development of spontaneous ASDH include hypertension, vascular abnormalities and deficit of coagulation. We present two cases of ASDH in patients with the coagulation deficit and review of the literature to understand the coagulation factors role and platelet role in the management of ASDHs.
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Affiliation(s)
- D Garbossa
- Department of Neurosurgery, University of Turin, Turin, Italy
| | - R Altieri
- Department of Neurosurgery, University of Turin, Turin, Italy
| | | | - A Agnoletti
- Department of Neurosurgery, University of Turin, Turin, Italy
| | - G Pilloni
- Department of Neurosurgery, University of Turin, Turin, Italy
| | - M Lanotte
- Department of Neurosurgery, University of Turin, Turin, Italy
| | - R Spaziante
- Department of Medicine, University of Salerno, Salerno, Italy
| | - A Ducati
- Department of Neurosurgery, University of Turin, Turin, Italy
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Wintermark M, Sanelli PC, Anzai Y, Tsiouris AJ, Whitlow CT, Druzgal TJ, Gean AD, Lui YW, Norbash AM, Raji C, Wright DW, Zeineh M. Imaging Evidence and Recommendations for Traumatic Brain Injury: Conventional Neuroimaging Techniques. J Am Coll Radiol 2015; 12:e1-14. [DOI: 10.1016/j.jacr.2014.10.014] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 10/14/2014] [Accepted: 10/18/2014] [Indexed: 12/14/2022]
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Indications for CT scanning in minor head injuries: a review. Neurol Neurochir Pol 2015; 49:52-7. [PMID: 25666774 DOI: 10.1016/j.pjnns.2014.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 12/29/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine indications for performing head CT following minor head injuries, which allow reducing number of imaging. MATERIALS AND METHODS Based on 15 articles dedicated to this topic, the clinical decision rules were systematically analysed. RESULTS The Canadian Computed Tomography Head Rule was found to be the most reliable instrument meeting these criteria, characterised by excellent sensitivity of 100% and fairly good specificity of 48-77%. Remaining scales, although very sensitive, showed poor ability to reduce number of "unnecessary" CT scans. Features most predictive for intracranial injuries included: disorientation, abnormal alertness, somnolentia and neurological deficits. Patients with no loss of consciousness and in normal physical condition need only clinical assessment. Indications to head CT scanning are determined by decision rules presented in the article. CONCLUSION Use of clinical decision rules may have effect on reducing number of head CT scanning performed "just in a case".
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Prichep LS, Ghosh Dastidar S, Jacquin A, Koppes W, Miller J, Radman T, O׳Neil B, Naunheim R, Huff JS. Classification algorithms for the identification of structural injury in TBI using brain electrical activity. Comput Biol Med 2014; 53:125-33. [DOI: 10.1016/j.compbiomed.2014.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/16/2014] [Accepted: 07/18/2014] [Indexed: 11/28/2022]
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Zargar Balaye Jame S, Majdzadeh R, Akbari Sari A, Rashidian A, Arab M, Rahmani H. Indications and overuse of computed tomography in minor head trauma. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e13067. [PMID: 25031853 PMCID: PMC4082513 DOI: 10.5812/ircmj.13067] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 07/29/2013] [Accepted: 08/19/2013] [Indexed: 11/23/2022]
Abstract
Background: Computed Tomography (CT) is a useful diagnostic technology, particularly in accident and emergency departments. Objectives: To identify a comprehensive list of indications for application of CT in patients with minor head trauma (MHT) and to determine appropriateness of its use on the basis of this list. Materials and Methods: A cross-sectional study was conducted in three Imaging centers in Tehran. A panel of experts developed a list of CT indications for MHT by reviewing documents. A pre-structured checklist was designed and incorporated into a structured form. Four hundred consecutive patients referring to three imaging centers for performing CT due to MHT completed the questionnaire. Results: Of 400 patients who underwent CT after MHT, 187 (46.8%) patients had Glasgow coma scale (GCS) score of 13 or 14 at two hours post-trauma and 37 (19.8%) of these patients did not have any indication of imaging. In addition, 213 (53.2%) patients had GCS score of 15 out of which 110 (51.6%) patients did not have any indication of imaging. Patients with a GCS score of 15 had a noticeably lower proportion of abnormal CT results in comparison to patients with a GCS score of 13 or 14, (odds ratio, 19.07; 95% confidence interval, 6.74-54.00; and P < 0.001). There was a statistically significant association between abnormal CT results and the presence of indications including vomiting, dangerous mechanism of injury, visible signs of trauma above the clavicles, signs of skull base fracture, and suspected skull fracture (P < 0.001). Conclusions: On average, about 37% of the patients with MHT referring to the emergency departments had no indication of CT and approximately 86.5% of CT results were normal. Improving this situation can result in a significant saving in health care costs.
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Affiliation(s)
- Sanaz Zargar Balaye Jame
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Reza Majdzadeh
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
- Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
- Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Ali Akbari Sari, Department of Health Management and Economics, and Knowledge Utilization Research Center, School of Public Health, Tehran University of Medical Sciences, Poorsina St, Tehran, IR Iran. Tel: +98-2188989129, Fax: +98-2188989129, E-mail:
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
- Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Arab
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Hojjat Rahmani
- Department of Health Care Management, School of Applied Medical Sciences, Tehran University of Medical Sciences, Tehran, IR Iran
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