Can an abnormal CT scan be predicted from common symptoms after mild head injury in children?

Correlation of clinical features with neuroimaging in children with mild head injury

Objectives

Mild head injury is defined as a pediatric Glasgow Coma Scale (GCS) score of 13-15 at admission following head trauma. There are no clear indications for neuroimaging in such children. The aim of our study was to analyze the correlation of symptoms commonly encountered following mild head injury with any abnormality on the computed tomography (CT) scan.

Materials and Methods

This is a retrospective and observational study done in a tertiary care hospital. Records of all the children fulfilling the inclusion criteria were retrieved. Demographic details such as age, gender, and type of injury (hit by a blunt object, fall from height, and road traffic accident), symptoms such as presence and number of episodes of vomiting, presence and duration of loss of consciousness (LOC), presence of drowsiness, headache, giddiness, seizures, focal deficits and the GCS score, and CT scan findings were noted in a predesigned proforma. A CT scan with any of the following abnormalities such as skull fracture, cerebral edema, intracranial bleed (epidural hematoma, subdural hematoma, intracerebral hematoma, and subarachnoid hemorrhage), and cerebral contusion was considered as abnormal. Any neurosurgical intervention done was also noted.

Results

A total of 134 children in the age group of 1 month to 18 years with mild head injury were included in this study. The median (interquartile range) age of the children was 5 (2, 8) years, with majority being males. Road traffic accidents (34.3%) were the most common cause of injury, followed by fall from lesser than 3 feet height (31.3%). The most common symptoms were vomiting (43.6%), scalp/facial abrasions (37.2%), and LOC (31.9%). CT scan was abnormal in 53.7% of the cases, with skull fracture (35.1%) being the most common finding, followed by cerebral edema (13.4%). Among all the symptoms, ear/nosebleed or cerebrospinal fluid (CSF) otorrhea/rhinorrhea had a statistically significant association with a positive CT scan with P = 0.05 and an odds ratio of 1.4 (95% confidence interval, 1-1.9).

Conclusion

Children with mild head injury presenting with clinical features such as bleeding from the ear or nose and CSF otorrhea/rhinorrhea are more likely to have an abnormal CT scan. Hence, such children require close neurological observation and prompt intervention if necessary. However, abnormality on CT scan cannot be reliably ruled out based on the symptoms alone.

Homotopic region connectivity during concussion recovery: A longitudinal fMRI study

OBJECTIVES

To (i) investigate alterations in homotopic functional connectivity (hfc) in concussed patients relative to healthy controls (HC) and to (ii) interrogate whether hfc in concussed patients normalized during the recovery process. The relationship between symptom recovery and change in hfc was assessed using post-hoc analyses.

METHODS

This study included 15 concussed patients (mean age = 39.1, SD = 10.1; sex: 13 females, 2 males) and 15 HC (mean age = 39.1, SD = 11.7; sex: 13 females, 2 males). Hfc patterns were interrogated using resting-state magnetic resonance imaging (rs-MRI) for 29 a priori selected pain-processing regions. Concussed patients underwent imaging at two time-points; at 1-month post-concussion (mean time following concussion: 28 days, SD = 9.5) and again at 5-months post-concussion (mean time following concussion: 121 days, SD = 13). At both time-points, symptoms associated with concussion were assessed using the Sports Concussion Assessment Tool (SCAT-3).

RESULTS

Concussed patients had significantly weaker hfc in the following six regions 1-month post-concussion compared to HC: middle cingulate, posterior insula, middle occipital, spinal trigeminal nucleus, precentral and the pulvinar. There were no regions of significantly stronger hfc in concussed patients relative to HC. Longitudinally, patients showed significant symptom recovery 5-months post-concussion and had significant strengthening of hfc patterns in seven homotopic ROIs: middle cingulate, posterior insula, middle occipital, secondary somatosensory area, spinal trigeminal nucleus, precentral, and the pulvinar. Post-hoc analyses indicated a significant negative correlation between somatosensory functional connectivity strengthening and symptom severity.

CONCLUSION

At 1-month post-concussion, patients had significantly weaker hfc in a number of pain-processing regions relative to HC. However, over a period of 5-months, region-pair connectivity showed significant recovery and normalization. Those patients with more successful symptom recovery at 5-months post-concussion had more functional somatosensory strengthening, suggesting an association between functional strengthening and post-concussion symptom recovery.

Computed Tomography Profile and its Utilization in Head Injury Patients in Emergency Department: A Prospective Observational Study

Context

Based on Glasgow Coma Scale (GCS), head injury can be classified as minor (GCS 13-15), moderate (GCS 9-12), and severe (GCS 3-8). There is a lot of controversy in the use of computed tomography (CT) in head injury patients.

Aims

This study was intended to estimate the rate of CT positivity in head injury patients and to define the criteria for doing CT in head injury patients.

Settings and Design

This was a prospective observational study in the emergency department (ED) over a 12-month period. Subjects and.

Methods

Study involved all head injury patients attending ED. Risk factors studied were a loss of consciousness (LOC), vomiting, seizures, ear bleed, nosebleed, external injuries, and alcohol intoxication.

Statistical Analysis Used

Comparison of CT positivity with the patient's demographics and clinical characteristics was carried out using Chi-square.

Results

A total of 1782 patients were included in this study. Overall CT positivity was 50.9%. In minor head injury (MHI), CT positivity rate was 38%. The study showed significant association of CT positivity with five variables: LOC >5 min, vomiting, seizures, ear bleed, and nosebleed.

Conclusions

From the study, we recommend following: CT is indicated in all patients with moderate and severe head injury (GCS ≤12). Low threshold for taking CT is advisable in elderly and alcohol-intoxicated patients. In MHI, CT is indicated if any one of the following risk factors are present: LOC >5 min, history of vomiting, history of seizures, history of ear bleed, and history of nosebleed.

Through the looking glass: early non-invasive imaging in TBI predicts the need for interventions

Background

Early diagnosis and treatment of traumatic brain injury (TBI) lead to better outcomes. It is difficult to predict which patients benefit from specialised centres, leading to over triage or delay in definitive care. We propose that a non-invasive test comprising optic nerve sheath ultrasound, transcranial Doppler and quantitative papillary reactivity is feasible, correlates with CT findings and may allow for accurate early identification of TBI.

Methods

A 1-year, prospective observation study evaluated a low-risk, non-invasive method of assessing brain injury. Patients underwent a non-invasive neurological examination for trauma, including the above assessments. Data from the three examinations were collected within 6 hours of injury and at 24 hours, and were analysed. Demographics, haemodynamic data, imaging results and short-term outcomes/interventions were recorded.

Results

Trauma patients over the age of 18 years, with a Glascow coma scale (GCS) of <12 or CT evidence of TBI, and intubated were included (N=100). These were divided into +CT (n=49) and −CT groups (n=51) according to the Marshall CT classification of TBI. The +CT group was older, with worse GCS and higher lactate (p=0.008, p=0.001 and p=0.01) but were otherwise well matched. The +CT group included all TBI types, with 96% of the patients having more than one type of TBI. Pulsatility index and neurologic pupillary index were predictive of a +CT (p=0.04, p=0.02). Area under the receiver-operating curve for the logistic regression model for the prediction of positive radiographic findings was r=0.718. Finally, we suggest a preliminary scoring heuristic for predicting a positive radiological finding in a patient with TBI.

Conclusions

The proposed examination is a feasible, non-invasive tool that may have clinical utility in the early prediction of TBI. If validated, it may improve trauma triage for the brain-injured patient. Further studies are warranted to validate this model.

Scandinavian guidelines for initial management of minor and moderate head trauma in children

BACKGROUND

The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.

METHODS

General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.

RESULTS

The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.

CONCLUSIONS

We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.