Utility of repeat head computed tomography in patients with an abnormal neurologic examination after minimal head injury.

BACKGROUND: Previous studies proposed that repeat head computed tomography (RHCT) is of no value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). The goal of our study was to investigate the value of RHCT in patients with MHI with an abnormal NE. METHODS: A retrospective chart review of adult patients presenting to a Level I trauma center from July 2002 to December 2006 with MHI was performed. Demographics, injury severity, and HCT findings were collected. Patients with an abnormal NE at the time of RHCT were divided into three subgroups: acute deterioration NE (AD-NE), persistently abnormal NE (PA-NE), and unknown NE (U-NE). Changes in the management and outcomes after RHCT were compared. RESULTS: One hundred seven patients had a MHI with an abnormal NE. Of those, seven (6.5%) had a change in management after RHCT. At the time of RHCT, 68 patients (63%) had a PA-NE, 21 AD-NE, and 18 U-NE. Six patients (29%) with AD-NE, 1 patient (6%) with an U-NE, and no patients with PA-NE required changes in management after RHCT. Compared with a RHCT, NE had higher positive and negative predictive values in determining the need for management changes. CONCLUSIONS: Of all patients with MHI with an abnormal NE at the time of RHCT, 63% had a PA-NE. Although a RHCT is beneficial to patients with an acutely deteriorating or U-NE, it appears to be of little value in patients with a PA-NE. Compared with RHCT, serial NE may be a stronger predictor for the need for intervention in patients with MHI.

Civilian craniocerebral gunshot wounds: an update in predicting outcomes.

Given the high mortality in patients sustaining intracranial injury secondary to gunshot wounds (GSWs), predictors to identify patients at increased risk of death are needed to assist clinicians early in determining optimal treatment. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients, which do not allow for adequate prediction of mortality. A retrospective chart review of 298 patients who sustained GSWs to the head between 1992 and 2003 was conducted at a level 1 trauma center. Demographics, bullet trajectory, admitting Glasgow Coma Scale (GCS), head Abbreviated Injury Score (AIS), as well as admission blood pressure and respiratory rate were evaluated. Univariate testing followed by multivariate logistic regression was performed to identify independent predictors of death. In-hospital mortality for patients with intracranial injury secondary to GSW was 51 per cent. A GCS <5 on admission and a high Injury Severity Score (ISS >25) was associated with mortality as compared with survivors (P < 0.05). Of those patients presenting with a GCS of 3, there were seven survivors to discharge. Logistic regression identified the following variables as predictors of death: respiratory arrest on admission, hypotension on admission, transhemispheric and transventricular GSW. Identification of those patients at the highest risk of death secondary to a craniocerebral GSW allows clinicians to better predict outcome and prognosis. This is not only important in determining treatment algorithms for physicians but also for appropriate counseling of family members to educate them with regard to patients' outcomes.

Value of repeat cranial computed axial tomography scanning in patients with minimal head injury.

BACKGROUND: Patients with minimal head injury (MHI) and a cranial computed axial tomography (CAT) scan positive for the presence of intracranial injury routinely undergo a repeat CAT scan within 24 hours after injury. The value of this repeat cranial CAT scan is unclear in those patients who are neurologically normal or improving. METHODS: A retrospective analysis of all adult patients admitted to a level-1 trauma center with MHI and a positive cranial CAT scan during a 32-month period was performed. The need for neurosurgical intervention after repeat CAT scan in patients with a persistently normal or improved neurological examination was recorded. RESULTS: One hundred fifty-one patients had a persistently normal or improved neurological examination, but none of these patients required neurosurgical intervention after the repeat cranial CAT scan. CONCLUSIONS: A persistently normal or improving neurological examination in a patient with MHI appears to exclude the need for neurosurgical intervention and thus a repeat cranial CAT scan.

Neurologic outcome of minimal head injury patients managed with or without a routine repeat head computed tomography.

BACKGROUND: Previous studies proposed that routine repeat head computed tomography (RHCT) is of little value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). As of 2003, routine RHCT in these MHI patients was ordered at the discretion of the attending physician. The goal of this study was to compare the neurologic outcomes of MHI patients with an intracranial bleed and a normal NE who were managed with or without a routine RHCT. METHODS: A retrospective chart review of adult patients with MHI presenting to a Level I trauma center from August 2003 to December 2008 was performed. Demographics, injury severity, and HCT findings were collected for patients managed with or without a routine RHCT. Outcome measures included delayed neurologic deterioration, neurosurgical interventions, Glasgow Outcome Scale, and hospital length of stay (LOS). RESULTS: A total of 321 MHI patients with an intracranial bleed had a normal NE 24 hours after presentation. There were no significant differences in demographics, arrival Glasgow Coma Scale score, or injury severity between the 142 (44%) patients managed with RHCT and the 179 (56%) managed without RHCT. No patient had a neurologic deterioration or required a neurosurgical intervention, regardless of initial management. There was no significant difference in the neurologic outcomes, mortality, or discharge dispositions between both groups. Patients managed without an RHCT had significantly shorter LOS (2.2 ± 2.3 days vs. 4.3 ± 6.0 days; p < 0.001) compared with those with RHCT. CONCLUSION: Our study is the first to compare early neurologic outcomes of MHI patients with or without a routine RHCT. Patients managed without an RHCT had similar neurologic outcomes and shorter hospital LOS. Our data suggest that initial HCT followed by serial NEs (not routine RHCT) should be the standard of care in this patient population.

A prospective evaluation of the value of repeat cranial computed tomography in patients with minimal head injury and an intracranial bleed.

BACKGROUND: Patients with minimal head injury (MHI) and intracranial bleed (ICB) detected on cranial computed tomography (CT) scan routinely undergo a repeat cranial CT within 24 hours after injury to assess for progression of intracranial injuries. While this is clearly beneficial in patients with a deteriorating neurologic status, it is of questionable value in patients with a normal neurologic examination. The goal of this study was to prospectively assess the value of a repeat cranial CT in patients with a MHI and an ICB who have a normal neurologic examination. METHODS: A prospective analysis of all adult patients admitted to a Level I trauma center after blunt trauma causing a MHI (defined as the loss of consciousness or posttraumatic amnesia with a Glasgow Coma Scale (GCS) score of greater or equal to 13) and an ICB on the initial cranial CT during a 12-month period (July 2002 through July 2003) was performed. All patients with MHI were prospectively evaluated and followed until discharge. Data collected included demographics, neurologic examination and findings on the initial and repeat cranial CT scan. Outcome data included neurologic deterioration, neurosurgical intervention, and Glasgow Outcome Scale (GOS) on discharge. RESULTS: In all, 161 consecutive patients with MHI and a positive cranial CT scan were identified. The initial cranial CT lead to a neurosurgical intervention (1 craniotomy, 4 intracranial pressure monitors) in 4% of cases. The remaining 130 patients who met inclusion criteria, underwent a repeat cranial CT scan within 24 hours postadmission. Ninety nine (76%) patients had a normal neurologic examination at the time of their repeat cranial CT. After the repeat cranial CT none required immediate neurosurgical intervention or had delayed neurologic deterioration related to their head injury. Fifteen patients underwent additional neuroradiologic studies but none showed further progression of their ICB or lead to a change in management. One patient died from non-traumatic brain injury related causes and of the remaining 26 patients, 98% had an overall favorable GOS score (> 3) on discharge. In this group of patients with MHI and ICB, the negative predictive value of a normal neurologic examination was 100%. CONCLUSIONS: Repeat cranial CT, in patients with a MHI and a normal neurologic examination, resulted in no change in management or neurosurgical intervention and is therefore not indicated. A multicenter prospective study would further validate these conclusions, reduce unnecessary CT scans, and likely improve our current standard of care in these patients.