Isolated Subarachnoid Hemorrhage in Mild Traumatic Brain Injury: Is a Repeat CT Scan Necessary?

BackgroundAlthough 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.MethodsThis 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.ResultsThere 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.DiscussionOpen 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 evidenceIII.

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Evaluating mild traumatic brain injury management at a regional emergency department

Injury Prevention ◽

10.1136/injuryprev-2018-042865 ◽

2018 ◽

Vol 24 (5) ◽

pp. 390-394

Author(s):

Ashlee Maree Brown ◽

Dara M Twomey ◽

Anna Wong Shee

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

Mild Traumatic Brain Injury ◽

Best Practice ◽

Medical Service ◽

Regional Health ◽

Diagnosis Codes ◽

Retrospective Audit ◽

Concussive Injury

BackgroundEmergency departments (EDs) are usually the first point of contact, and often the only medical service available, for patients with mild traumatic brain injury (mTBI) in rural and regional areas. Clinical practice guidelines (CPGs) have been created to ensure best practice management of mTBI in EDs. Adherence to mTBI CPGs has rarely been evaluated in rural and regional areas.AimThe aim of this paper was to assess a regional health service’s adherence to their mTBI CPG.MethodsThis was a 12-month retrospective audit of 1280 ED records of patients ≥16 years presenting with mTBI to a regional Australian ED. Case selection used the Victorian Admitted Episodes Dataset codes for suspected head injury: principal diagnosis codes (S00-T98), concussive injury recorded in diagnosis codes (S06.00-S06.05) and unintentional external cause code (V00-X59). The data were collected to determine 4-hour observation rates, CT scan rates, safe discharge and appropriate referral documentation.ResultsFewer people received a CT scan than qualified (n=245, 65.3%), only 45% had 4-hour observations recorded, safe discharge was documented in 74.1% of cases and 33% received educational resources.Discussion/conclusionSeveral key elements for the management of mTBI were under-recorded, particularly 4-hour observations, safe discharge and education. Acquired brain injury clinic referrals were received in overwhelmingly fewer cases than had a CT scan (n=19, 6.3%). Overall, this study suggests that the regional health service does not currently fully adhere to the CPG and that the referral services are potentially underutilised.

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Patients with mild traumatic brain injury: Immediate and long-term outcome compared to intra-cranial injuries on CT scan

Brain Injury ◽

10.1080/02699050600832569 ◽

2006 ◽

Vol 20 (11) ◽

pp. 1131-1137 ◽

Cited By ~ 31

Author(s):

Charlotte Sadowski-Cron ◽

Jörg Schneider ◽

Pascal Senn ◽

Bogdan P. Radanov ◽

Pietro Ballinari ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

Mild Traumatic Brain Injury ◽

Term Outcome ◽

Long Term Outcome

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Admission Variables Associated with a Favorable Outcome after Mild Traumatic Brain Injury

The American Surgeon ◽

10.1177/000313481608201008 ◽

2016 ◽

Vol 82 (10) ◽

pp. 898-902 ◽

Cited By ~ 4

Author(s):

Alexander C. Schwed ◽

Monica M. Boggs ◽

Drew Watanabe ◽

David S. Plurad ◽

Brant A. Putnam ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Mild Traumatic Brain Injury ◽

Univariate Analysis ◽

Vital Signs ◽

Multivariate Regression Analysis ◽

Favorable Outcome ◽

Imaging Results ◽

Admission Variables

Consensus is lacking for ideal management of mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH). Patients are often monitored in the intensive care unit (ICU) without additional interventions. We sought to identify admission variables associated with a favorable outcome (ICU admission for 24 hours, no neurosurgical interventions, no complications or mortality) to divert these patients to a non-ICU setting in the future. We reviewed all patients with mTBI [Glasgow Coma Scale (GCS) = 13–15] and concomitant ICH between July 1, 2012, and June 30, 2015. Variables collected included demographics, vital signs, neurologic examination, imaging results, ICU course, mortality, and disposition. Of 201 patients, 78 (39%) had a favorable outcome. On univariate analysis, these patients were younger, more often had an isolated subarachnoid hemorrhage, and were more likely to have a GCS of 15 at admission. On multivariate regression analysis, after controlling for admission blood pressure, time to CT scan, and Marshall Score, age <55, GCS of 15 on arrival to the ICU, and isolated subarachnoid hemorrhage remained independent predictors of a favorable outcome. Patients meeting these criteria after mTBI with ICH likely do not require ICU-level care.

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

Bulletin of Emergency and Trauma ◽

10.29252/beat-070310 ◽

2019 ◽

Vol 7 (3) ◽

pp. 269-277

Author(s):

Roghieh Molaei-Langroudi ◽

Ahmad Alizadeh ◽

Ehsan Kazemnejad-Leili ◽

Vahid Monsef-Kasmaie ◽

Seyed-Younes Moshirian

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

Mild Traumatic Brain Injury ◽

Clinical Criteria ◽

Brain Ct ◽

Diagnostic Probe ◽

Brain Ct Scan

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P048: Current practices of management for mild traumatic brain injuries with intracranial hemorrhage

CJEM ◽

10.1017/cem.2019.239 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S80

Author(s):

É. Fortier ◽

V. Paquet ◽

M. Émond ◽

J. Chauny ◽

S. Hegg ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

Mild Traumatic Brain Injury ◽

Intracranial Hemorrhage ◽

Management Practices ◽

Brain Injuries ◽

Quebec City ◽

Historical Cohort ◽

Public Sector Health

Introduction: The radiological and clinical follow-up of patients with a mild traumatic brain injury (mTBI) and an intracranial hemorrhage (ICH) is often heterogeneous, as there is no official guideline for CT scan control. Furthermore, public sector health expenditure has increased significantly as the number of MRI and CT scan almost doubled in Canada in the last decade. Therefore, the main objective of this study was to describe the current management practices of mTBI patients with intracranial hemorrhage at two level-1 trauma centers. Methods: Design: An historical cohort was created at the CHU de Québec – Hôpital de l'Enfant-Jésus (Québec City) and Hôpital du Sacré-Coeur (Montréal). Consecutive medical records were reviewed from the end of 2017 backwards until sample saturation using a standardized checklist. Participants: mTBI patients aged ⩾16 with an ICH were included. Measures: The main and secondary outcomes were the presence of a control CT scan and neurosurgical consultation/admission. Analyses: Univariate descriptive analyses were performed. Inter-observer measures were calculated. Results: Two hundred seventy-four patients were included, of which 51.1% (n = 140) came from a transfer. Mean age was 60.8 and 68.9% (n = 188) were men. Repeat CT scan was performed in 73.6% (n = 201) of our patients as 12.5% showed a clinical deterioration. The following factors might have influenced clinician decision to proceed to a repeat scan: anticoagulation (association of 87.1% with scanning; n = 27), antiplatelet (84.1%; 58), GCS of 13 (94.1%; 16), GCS of 14 (75%; 72) and GCS of 15 (70.2%; 111). 93.0% (n = 254) of patients had a neurosurgical consultation and only 6.7% (17) underwent a neurosurgical intervention. Conclusion: The management of mild traumatic brain injury with hemorrhage uses a lot of resources that might be disproportionate with regards to risks. Further research to identify predictive factors of deterioration is needed.

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P17 Evaluation of new orleans criteria for cranial CT scan in mild traumatic brain injury at an emergency trauma unit of a developing country

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.95 ◽

2019 ◽

Vol 90 (3) ◽

pp. e30.2-e30

Author(s):

AS Yusuf ◽

MR Mahmud ◽

NK Dalhat ◽

AI Olayiwola ◽

JD Alfin ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

New Orleans ◽

Developing Country ◽

Mild Traumatic Brain Injury ◽

Compliance Rate ◽

Mild Tbi ◽

Cranial Ct ◽

Ct Findings

ObjectivesTo assess compliance to New Orleans Criteria for cranial CT scan and its predictive value for intracranial pathology in mild TBI.DesignA retrospective review.SubjectsAll patients with mild traumatic brain injury presenting at the emergency unit of a National Trauma Centre of a Developing Country over 24 months.MethodsPatients information were retrieved from medical record and entered into SPSS spreadsheet. The New Orleans Criteria (NOC) was used to determine indications for brain CT scan. Compliance to the criteria was determined. The CT scan findings were evaluated in all patients that had scan and the findings were compared between those met NOC and those who did not.ResultsOne-hundred and eighteen patients were studied. Majority were males 92 (82%) with mean age of 27 year. Most injuries (66.9%) resulted from road traffic crashes. Among 65 (55.1%) patients who met NOC only 41 (63.1%) had CT scan while 25 (47.2%) patients who did not had CT giving a compliance rate of 58.5%. Twenty three (56.1%) patients who met NOC had abnormal CT compared to 9 (36%) patients that did not. The most common abnormal CT findings in both groups were skull vault fractures (9 for NOC group and 2 for non NOC group) only two patients had surgical intervention and both met NOC criteria.ConclusionsThe compliance for NOC guideline was below average in our Centre. NOC guideline is useful in predicting abnormal CT findings. There is a need for continuous education of emergency physicians to ensure optimal CT scan utilisation in mild TBI.

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Study protocol for investigating the performance of an automated blood test measuring GFAP and UCH-L1 in a prospective observational cohort of patients with mild traumatic brain injury: European BRAINI study

BMJ Open ◽

10.1136/bmjopen-2020-043635 ◽

2021 ◽

Vol 11 (2) ◽

pp. e043635

Author(s):

Marion Richard ◽

Alfonso Lagares ◽

Victor Bondanese ◽

Javier de la Cruz ◽

Odile Mejan ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

Mild Traumatic Brain Injury ◽

Brain Lesions ◽

Ct Scans ◽

Secondary Outcome ◽

Serum Concentrations ◽

Brain Ct ◽

Automated Assay

IntroductionMild traumatic brain injury (mTBI) is a common cause of clinical consultation in the emergency department. Patients with mTBI may undergo brain CT scans based on clinical criteria. However, the proportion of patients with brain lesions on CT is very low. Two serum biomarkers, glial fibrillar acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), have been shown to discriminate patients regarding the presence or absence of brain lesions on initial CT scan when assessed within the first 12 hours after TBI. However, the current technique for measuring serum concentrations of GFAP and UCH-L1 is manual and time consuming, which may hinder its use in routine clinical practice. This study assesses the diagnostic accuracy of an automated assay for the measurement of serum GFAP and UCH-L1 in a cohort of patients with mTBI who received a CT scan as the standard of care.Methods and analysisThis is a prospective multicentre observational study of 1760 patients with mTBI recruited in France and Spain across 16 participating sites. Adult patients with an initial Glasgow Coma Scale score of 13–15 and a brain CT scan underwent blood sampling within 12 hours after TBI. The primary outcome measure is the diagnostic performance of an automated assay measuring serum concentrations of GFAP and UCH-L1 for discriminating between patients with positive and negative findings on brain CT-scans. Secondary outcome measures include the performance of these two biomarkers in predicting the neurological status and quality of life at 1 week and 3 months after the trauma.Ethics and disseminationEthics approval was obtained by the Institutional Review Board of Sud-Ouest Outre Mer III in France (Re#2019-A01525-52) and Hospital 12 de Octubre in Spain (Re#19/322). The results will be presented at scientific meetings and published in peer-reviewed publications.Trial registration numberClinicalTrials.gov: NCT04032509.

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Evaluating mild traumatic brain injury in adults: an emergency physician’s dilemma

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20204902 ◽

2020 ◽

Vol 8 (11) ◽

pp. 4050

Author(s):

Suvan K. Chowdhury ◽

Subhankar Paul ◽

Rajpratim Das ◽

Ilias Ali

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Alcohol Use ◽

Ct Scan ◽

Mild Traumatic Brain Injury ◽

Alcohol Use Disorder ◽

Multiple Logistic Regression Analysis ◽

Skull Fracture ◽

Post Traumatic ◽

Basal Skull Fracture

Background: Mild traumatic brain injury (MTBI) is a common presentation in emergency departments across the globe. A controversy about the policy of evaluating them with CT scan and hospital admission or discharge and for these patients. This study is directed towards correlation of clinical profile with CT brain findings of the patients to predict the possibility of an intracranial lesion and need for early neurosurgical intervention.Methods: This prospective observational study was carried out in the Emergency Department (ED) of a tertiary care government medical college and hospital. All patients aged more than 12 years presenting to the ED with mild traumatic brain injury (MTBI) within 24 hours of injury in whom NCCT head (trauma protocol) was done during the Study. Descriptive and analytical statistics were applied. Multiple logistic regression analysis was used to identify factors related to different outcomes.Results: 178 patients with MTBI were enrolled in the study among which intracranial injuries were found by CT scan in 28 patients (15.7%). Odds of finding intracranial injuries were highest with the presence of post-traumatic vomiting, post traumatic amnesia (PTA), pre-existing alcohol use disorder, GCS≤14, focal neurological deficit and clinical signs of basal skull fracture. 2.8% patients required urgent neurosurgical intervention.Conclusions: Presence of post-traumatic vomiting, PTA, alcohol use disorder, GCS≤14, focal neurodeficit and signs of basal skull fracture in a MTBI patient should be considered as high-risk factors for significant intracranial injuries.

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