Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

[Assessment of the Doppler cerebral blood flow measurement in infants with perinatal trauma]. / Ocena dopplerowska przeplywu mózgowego u niemowlat z istotnym urazem okoloporodowym.

BACKGROUND: Birth trauma may lead in infants to developmental delay, cerebral palsy, epilepsy and complications with increasing risk of the death. Several complications are of vascular origin. The aim of the study was the assessment of the transcranial Doppler-sonographic (TCD) measurement of cerebral blood flow in infants with perinatal CNS pathology. MATERIAL AND METHODS: 14 infants, 9 females and 5 males, within 12 premature infants, with the CNS perinatal pathology were examined. In children during the neonatal period respiratory distress syndrome, sepsis, apnoe and seizures were also observed. Neuroimaging was performed in each neonate and TCD measurement as well, in 1-7 month of age. Pulsatility index (PI) and resistive index (RI) in anterior cerebral artery (ACA) and in middle cerebral artery (MCA) were established. RESULTS: In 10 children neuroradiologic examination revealed pathological changes: intraventricular hemorrhage, subdural hematoma, subarachnoid hemorrhage, porencephalic cyst of parietal lobes, agenesis of corpus callosum or lateral ventricles dilatation. In 7 children of this group blood flow changes were registered and in 3 of them (21%) the blood flow was normal. The most severe decrease of blood flow in ACA and MCA associated with decreased PI and RI were detected in a case after subdural hematoma operation, prior to death. In other 4 children with normal brain imaging but abnormal neurological examination, cerebral blood flow was disturbed. In three of them blood flow velocity in ACA was decrease with PI increase and in other one blood flow velocity in MCA was increased. CONCLUSIONS: 1. In 79% of the infants with CNS perinatal pathology transcranial Doppler identified blood flow changes. 2. The further research is necessary for the confirmation that a significant decrease of blood flow velocities and indexes in such cases is a poor prognostic factor.

Utility of neurosurgical consultation for mild traumatic brain injury.

Trauma patients presenting with a Glasgow Coma Scale (GCS) score of 14-15 are considered to have mild traumatic brain injury (TBI) with overall good neurologic outcomes. Current practice consists of initial stabilization, followed by a head CT, and neurosurgical consultation. Aside from serial neurologic examinations, patients with a GCS of 15 rarely require neurosurgical intervention. In this study, we examined the added value of neurosurgical consultation in the care of patients after TBI with a GCS of 15. We retrospectively reviewed the medical records of patients presenting after blunt trauma with an abnormal head CT and GCS of 15 between January 2004 and January 2005. Patients with a normal head CT and <48 hours hospital stay were excluded. Data included demographics, mechanisms of injury, Injury Severity Score, the radiologists' dictated interpretations of the head CT, and neurosurgical interventions. Fifty-six patients met the inclusion criteria. The mean age was 41+/-2.3 years, and the mean Injury Severity Scores was 10.2 +/-0.6. Mechanisms of injury included 64 per cent motor vehicle crash, 16 per cent motorcycle crash, 13 per cent fall, and 7 per cent all-terrain vehicle crash. The initial CT scans showed 43 per cent parenchymal contusions, 38 per cent subarachnoid hemorrhage, 14 per cent subdural hematomas, and 5 per cent epidural hematomas. All patients received a routine follow-up head CT, and 16 per cent showed changes (five improved and four were worse compared with initial CT scans). None of these patients received a neurosurgical intervention, and two were transferred to a rehabilitation service. In this era of limited resources, trauma patients who present with a GCS score of 15 after mild TBI can be safely managed without neurosurgical consultation, even in the presence of an abnormal head CT scan.

Assessment of intraaxial and extraaxial brain lesions with digitized computed tomographic images versus film: ROC analysis.

RATIONALE AND OBJECTIVES: The authors evaluated the diagnostic accuracy of viewing computed tomographic (CT) scans as film versus soft-copy images at a workstation. METHODS: Receiver operating characteristic analysis of the interpretation of 202 CT scans (103 were normal, 99 were abnormal) by five neuroradiologists was performed. Abnormal images contained high- or low-attenuation intraaxial lesions or extraaxial fluid (subdural, subarachnoid, or epidural hemorrhage). Hard copies were read on a standard light box, and digital images were examined at a 1,024 x 1,250 workstation. Lesion location and type and confidence ratings were recorded on a worksheet. RESULTS: There were no statistically significant differences in diagnostic accuracy between the two display modes. Reader performance was slightly better with the workstation in the assessment of low-attenuation lesions. CONCLUSION: Diagnostic accuracy is similar for CT scans displayed at a workstation and those displayed as hard copy in the assessment of subtle intra- and extraaxial brain lesions.

Computerized tomography in the assessment of brain shifts in acute subdural hematoma.

Computed tomography (CT) was used to characterize brain shifts in 30 adult patients (mean age 51.9 years) with fatal supratentorial acute subdural hematomes (ASH) who were admitted within 3 hours of the head trauma. The Glasgow Coma Scale (GCS) score, hematoma width, and midline shift were tabulated. The width of the cistern surrounding the brainstem (CSBS) and the distance from the floor of the fourth ventricle to the posterior clinoid process (IVv-PC) were measured. Opening (+) or disappearance (-) of the suprasellar cistern (SC) was determined using axial CT. The data were compared with those in agematched controls (n = 26) using the Wilcoxon and Kruskal-Wallis tests. The hematomas in the SC(-) group (n = 22, mean GCS score: 3.8 +/- 1.0) were wider (p = 0.02) than those in the SC(+) group (n = 8, mean GCS score: 4.7 +/- 1.5). The CSBS in the SC(+) group was significantly smaller than that in the controls (p < 0.01). In the SC(-) group the CSBS was smaller and the IVv-PC was significantly larger than those in the controls (IVv-PC; p < 0.01) and the SC(+) group (IVv-PC; p < 0.05). In the evolution of brainstem shifts in ASH, when the SC is open the predominant vector is in the direction of the skull base, while when the SC is not observed, an axial vector shifts the brainstem.

Computer tomographic assessment of the pre- and postoperative ventricle width in patients with traumatic intracranial haematomas.

The cellular integrity of the brain tissue is not only disturbed by space occupying traumatic intracranial haematomas but also by traumatic brain tissue damage and the accompanying oedema. Due to the insufficiency of visual inspection, methods for an objective quantification of the ventride width are required. A number of techniques have been used for evaluation of the CSF-space after cerebral trauma. In the present study changes of the ventricle size have been evaluated by using planimetric measurements of CT scans. In 222 patients with traumatic intracranial haematomas significant changes in the ventricle width could be demonstrated when the data were analysed by Wilcoxon signed rank test for pair differences. Comparison of the initial cranial computed tomography (CT) with a CT 14 days later revealed a significant dilatation of the ventricle width in all age groups in the second measurement. When patients were divided into groups with or without signs and symptoms of brainstem alteration after trauma, patients with symptoms of brainstem alteration exhibited a significantly greater ventricle width as compared to patients without such symptoms and signs.

Detection of intracranial tumors, subarachnoid hemorrhages, and subdural hematomas in primary care patients: a report from ASPN, Part 2.

BACKGROUND: The initial diagnosis of intracranial tumor, subarachnoid hemorrhage (SAH), and subdural hematoma (SDH) can be difficult. This study was undertaken to determine the incidence and presenting signs and symptoms of these disorders in primary care settings, and to determine whether a more aggressive investigative strategy for patients with headache is justifiable. METHODS: Weekly return cards and a chart audit were used to collect data over a 19-month period on every patient who had a new diagnosis of intracranial tumor, SAH, or SDH. Age and sex reports were collected annually. RESULTS: Twenty-five new tumors, 17 SAHs, and 8 SDHs were reported in 58 practices (a rate of 12/100,000 patients per year). Only one half of these patients had headaches, and no abnormalities were found on neurological examination of many. Diagnosis was delayed in only four patients with headache caused by a brain tumor and in three patients with SAHs. Diagnosis was delayed in two of the latter because of false-negative CT scans. CONCLUSIONS: Although clinical findings and CT scans are not reliable indicators, clinicians are able to detect the majority of these rare conditions without undue delay by selecting a small subset of patients for further investigation. More extensive use of CT scans appears to be a weak strategy to improve detection of these serious disorders, as increased use would lead to increased health care costs and unintended adverse effects, and provide little benefit.

Emergency skull radiography: the effect of restrictive criteria on skull radiography and CT use.

A prospective study was performed to determine the effect of restrictive criteria on the use of emergency skull radiography and computed tomography (CT) of the head. Emergency skull radiography required the completion of a special requisition form. Emergency CT of the head was done at the request of senior consultants and was available on a full-time basis. Over 1 year, 2,758 skull studies were performed, a decrease of 39.1% when compared with the year before restrictive criteria were instituted, during which 4,587 skull examinations were done. In the same period, the number of emergency CT scans of the head increased by 45.7%, from 471 in the control year to 686 in the experimental year. With the use of restrictive criteria, a net savings of +164,000 was achieved. Our results suggest that the use of restrictive criteria is a cost-effective means of limiting skull radiography when CT of the head is readily available.

Impact of computed tomography on subdural hematoma. A population study.

The Mayo Clinic (Rochester, Minn) medical record linkage and indexing system was used to examine the impact of computed tomography (CT) on the diagnostic investigation, management, and outcome of all cases of subdural hematoma (SDH) that occurred in Olmsted County, Minnesota, from 1965 through 1980. Comparisons were made between an eight-year period prior to the introduction of CT (1965 through 1972) and a similar period after CT became available in this community (1973 through 1980). The advent of CT did not change the treatment, course of the disease, or prognosis of SDH. However, the introduction of CT had a marked effect on the pattern of neurological investigations carried out. This resulted in a 15% reduction in the cost of diagnosing SDH in this community, while the overall cost of health care in the United States rose by 87% during the same period.