Prospective Evaluation of the Value of Repeat Cranial Computed Tomography in Patients With Minimal Head Injury and an I

1. Prospective Evaluation of the Value of Repeat CranialComputed Tomography in Patients With Minimal Head Injuryand an Intracranial Bleed Ziad C. Sifri, MD, Adena T. Homnick, MPAS,The Journal of TRAUMA, October 2006

2. Background • Clearly beneficial in patients with a deteriorating neurologic status, it is of questionable value in patients with a normal neurologic examination.

3. 80% of head-injured patients are classified as mild. • Minimal head injury (MHI) is defined as a loss of consciousness and/or retrograde amnesia with a GCS>12 at arrival. • Current standard care of patients the with a MHI: rapidly undergo a cranial CT scan. • 15% have an intracranial bleed (ICB);1–3% requires an immediate neurosurgical intervention.

4. Patients with a MHI and an ICB are routinely admitted for close neurologic observation in a monitored setting. A repeat cranial CT scan is almost uniformly obtained within 24 hours of admission to follow for progression of the ICB and evaluate the need for any neurosurgical intervention. • Many studies have recently challenged the notion that the routine and non-selective use of serial cranial CT scan is necessary for every patient even in the absence of neurologic changes.

5. A recent retrospective study at our own institution : • 202 adult patients with a MHI, we have shown that repeat cranial CT scan in patients with a normal or improving neurologic examination has little value. • Goal of this study was to prospectively evaluate,with close and full cooperation of the neurosurgical team, the utility of serial cranial CT scans in adult patients with a MHI.

6. Patients and Methods

7. Inclusion criteria: • >17 y/o • from 2002.07~2003.07 • Patients with a MHI and an ICB on the initial cranial head CT were selected. • ICB included • intracerebral hematoma (IPH) or contusion, subdural hematoma (SDH), • subarachnoid hematoma (SAH) • epidural hematoma (EDH).

8. Exclusion criteria: • Prior brain surgery or cerebral pathology (acquired or congenital) or with a chronic neurologic condition (such as Parkinson or Alzheimer disease, etc.) as well as those with a spinal cord injury (acute or chronic) were excluded. • History of coagulopathy or anticoagulant use were also excluded. Coagulopathy was defined as a history of bleeding or clotting disorder or current treatment with warfarin. • Underwent an immediate or planned neurosurgical intervention after their initial cranial head CT, or never had a second cranial CT scan

9. Serial neurologic examinations were performed every 2 to 4 hours for the first 24 hours until the repeat cranial CT scan was performed. • Abnormal NE : • any patient with a GCS <15 with neurologic deficits (gross motor or sensory deficits) or symptoms of TBI (persistent vomiting, severe headaches or perseveration). • After repeat CT: • Record any change in management (an admission or transfer to an intensive care unit for more frequent neurologic monitoring or administration of medication to decrease intracranial pressure ) and neurosurgical intervention (craniotomy or placement of an ICP monitor). • Out come measure: • in-hospital mortality, hospital length of stay (LOS), functional outcome as measured by the Glasgow Outcome Scale (GOS) score, and discharge disposition.

10. Results

11. The mean time from arrival to the initial CT scan was 1.4 hours • The most common ICB detected was an IPH/contusion

12. 1 (1%)death: not attributable to the TBI. The patient, an 86-year-old man, died of respiratory failure. • The overall GOS score was considered favorable (GOS score 3)

13. 31 (24%) patients had an abnormal neurologic examination at the time of the repeat cranial CT. • 5 (16%) deaths in this group. • prompted a neurosurgical intervention (craniotomy) in 2 (6%) patients. • Worse repeat CT : (p<0.0001) • 12(13%) in normal NE group • 14(45%) in abnormal NE group • Repeat CT: 14 hours

14. Association between neurologic examination and changes of findings on the repeat CT for patients with a MHI (OR=5.28, CI [2.08 –13.4], p =0.002 ) • NPV of a normal neurologic examination at the time of the repeat cranial CT was 100% in predicting the lack of need for neurosurgical intervention or change in management. • PPV of an abnormal neurologic examination in predicting the need for neurosurgical intervention was only 6%(2/31),whereas the PPV of a worsening second CT scan was 8%(2/26) in predicting the need for a neurosurgical intervention.

15. Discussion • Consistent with our retrospective study • none of the patients (n =151) that had a normal or improving neurologic status at the time of the repeat CT scan required a neurosurgical intervention. • Conversely, in the group of patients with an abnormal or worsening neurologic status (n =51), 5 (10%) patients required a neurosurgical intervention after the repeat cranial CT scan.

16. Brown et al.: (100 cases) • a routine repeat cranial CT scan never led to TBI-related interventions. • Kaups et al.:(462 cases) • no patients with severe blunt head injury required an intervention based on the repeat cranial CT scan alone unless other clinical findings were present (decrease in GCS score,coagulopathy, hypotension, or increased ICP). • 3 other retrospective studies: • Adult and pediatric patients

17. Concerns about significant progression of ICB without clinical manifestation leading to late neurologic deterioration or emergent neurosurgical interventions has fueled support for the need for the serial CT scan. • 12/99(12%) : worse repeat cranial CT in normal NE group but none led to a neurologic deterioration or intervention, or progressed any further

18. 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. • The combination of an abnormal neurologic examination and a worsening cranial CT scan indicates a more significant injury which deserves special consideration.

19. Limitations in this prospective nonrandomized observational study: • 1) moderately small sample size from a single institution • 2) lack of blinded and standardized cranial CT scan interpretations • 3) absence of longer term follow up.

20. Thanks for your attention~!!!

22. GOS Syllabus • Definition of Terms • 1 • DEAD • 2 • VEGETATIVE STATE Unable to interact with environment; unresponsive Patients who show no evidence of meaningful responsiveness. Patients who obey even simple commands, or who utter any words, are assigned to the better category of severe disability. Vegetative patients breathe spontaneously, have periods of spontaneous eye-opening when they may follow moving objects with their eyes, show reflex responses in their limbs (to postural or painful stimuli), and they may swallow food placed in their mouths. This non-sentient state must be distinguished from other conditions of wakeful, reduced responsiveness--such as the locked-in syndrome, akinetic mutism and total global aphasia. • 3 • SEVERE DISABILITYAble to follow commands/ unable to live independently This indicates that a patient is conscious but needs the assistance of another person for some activities of daily living every day. This may range from continuous total dependency (for feeding and washing) to the need for assistance with only one activity--such as dressing, getting out of bed or moving about the house, or going outside to a shop. Often dependency is due to a combination of physical and mental disability--because when physical disability is severe after head injury there is almost always considerable mental deficit. The patient cannot be left overnight because they would be unable to plan their meals or to deal with callers, or any domestic crisis which might arise. The severely disabled are described by the phrase "conscious but dependent." • 4 • MODERATE DISABILITYAble to live independently; unable to return to work or school These patients may be summarized as "independent but disabled," but it is perhaps the least easily described category of survivor. such a patient is able to look after himself at home, to get out and about to the shops and to travel by public transport. However, some previous activities, either at work or in social life, are now no longer possible by reason of either physical or mental deficit. Some patients in this category are able to return to certain kinds of work, even to their own job, if this happens not to involve a high level of performance in the area of their major deficit. • 5 • GOOD RECOVERYAble to return to work or school This indicates the capacity to resume normal occupational and social activities, although there may be minor physical or mental deficits. However, for various reasons, the patient may not have resumed all his previous activities, and in particular may not be working. • Glasgow Outcome Score • ScoreRatingDefinition 5 Good Recovery Resumption of normal life despite minor deficits 4 Moderate Disability Disabled but independent. Can work in sheltered setting 3 Severe Disability Conscious but disabled. Dependent for daily support 2 Persistent vegetative Minimal responsiveness 1 Death Non survival