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.

Measurement of recovery after traumatic brain injury: a cognitive-neuropsychological comparison of the WAIS-R with the cognitive assessment system (CAS) in a single case of atypical language lateralization.

A 20-year-old preferentially left-handed male suffered an extensive right, focal, medial, prefrontal hematoma and contusion with associated swelling, and an initially undetected progressive loss of consciousness following trauma to the forehead. Performance on the Cognitive Assessment System (CAS) at 1 and 6 months after traumatic brain injury was compared with performance on the WAIS-R at 6 months post-injury. The patient demonstrated significant residualized impairment on selected subtests of the CAS at 6 months post-injury (all ps < 0.05). The patient was also significantly impaired on the Information, Vocabulary, Arithmetic and Comprehension verbal subtests of the WAIS-R. The magnitude of these WAIS-R subtest discrepancies occurred with a low base rate (< 1%) in the WAIS-R standardization sample. In addition there was a significant VIQ versus PIQ discrepancy favouring PIQ of a magnitude occurring in less than 5% of the WAIS-R standardization sample. These findings could not be explained on the basis of any prior learning disability, poor educational opportunities, medication use, response bias, confabulation, or low level of general ability. The low scores on the verbal subtests of the WAIS-R in conjunction with the impairment on the CAS subtests are highly suggestive of lasting frontal-executive dysfunction in this patient. Incidental findings of persisting anomia, impaired processing of proverbs, acalculia, and fluctuating verbal attention, as well as impaired retrieval of verbal information in the context of intact PIQ and superior constructional praxis suggest some degree of bilateral representation of linguistic functions. The differential assessment of cognitive domains by these two instruments as well as theoretical concordance in the pattern of results is also addressed.

Contrast ultrasonographic assessment of cerebral perfusion in patients undergoing decompressive craniectomy for traumatic brain injury.

OBJECT: The aims of this study were to determine whether contrast-enhanced ultrasonography (CEU) could be used for noninvasive evaluation of cerebral perfusion in patients with traumatic brain injury (TBI) and to assess the effect of decompressive surgery on cerebral perfusion as measured by CEU. METHODS: Contrast-enhanced ultrasonography with intravenous administration of a microbubble contrast agent was performed in six patients with TBI undergoing decompressive craniectomy. Contrast-enhanced ultrasonography was performed through a bur hole before craniectomy and through the calvarial defect immediately after craniectomy and on postoperative Days 1 and 2. For the latter two studies, patients were placed in the recumbent position and at a 35 degrees incline to investigate changes in perfusion produced by modulation of intracranial pressure (ICP). Cerebral microvascular blood flow increased by almost threefold immediately after craniectomy, from a mean of 7.5 +/- 6.9 (standard deviation [SD]) to 20.9 +/- 11.6 (p < 0.05), and further improved on postoperative Day 1 (mean 37.1 +/- 13.9 [SD], p < 0.05, compared with postcraniectomy microvascular blood flow) without subsequent change on Day 2. The change in microvascular perfusion correlated inversely with the initial ICP (p < 0.01), indicating less recovery of flow when preoperative ICP was markedly elevated. On postoperative Days 1 and 2, head-of-bed elevation produced an increase in microvascular perfusion on CEU (mean 37 +/- 11 compared with 51 +/- 20, p < 0.05) and a small decrease in ICP (mean 16 +/- 5 mm Hg compared with 12 +/- 4 mm Hg, p < 0.05). In patients with parenchymal hematoma, CEU provided spatial information on perfusion abnormalities in the hemorrhagic core and surrounding tissues. CONCLUSIONS: Contrast-enhanced ultrasonography has potential for the intraoperative and bedside assessment of cerebral perfusion in patients with TBI. The technique may be appropriate for evaluating responses to therapies aimed at preventing secondary ischemia and for assessing regional perfusion abnormalities.

Assessment and management of the head-injured patient.

Head injury is one of the most important causes of serious morbidity and mortality in young adults. Each year in Britain, there are approximately 5000 deaths from serious head injuries. Appropriate multidisciplinary assessment and management of systemic and intracranial pathology can significantly improve the outcome.