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Supercourse 2001-2002 Abel Murgio, M.D.

Supercourse 2001-2002 Abel Murgio, M.D. “Is the CT Scan important at the 24 Hours in Children with Mild Traumatic Brain Injury? International Multicentre Study” Authors : ° Murgio A.,*Mutluer S., **Fong D., #Hotz G., ^Di Rocco C., ^^Herrera EJ., ^^Viano JC.

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Supercourse 2001-2002 Abel Murgio, M.D.

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  1. Supercourse 2001-2002 Abel Murgio, M.D.

  2. “Is the CT Scan important at the 24 Hours in Children with Mild Traumatic Brain Injury? International Multicentre Study” Authors:°Murgio A.,*MutluerS., **Fong D., #Hotz G., ^Di Rocco C., ^^Herrera EJ., ^^Viano JC. ºI.S.H.I.P. Group Argentina ,*Turkey; **China; #USA; ^Italy; ^^Argentina;

  3. Definition of Mild TBI • Traditionally: “as those with a history of acute injury, a GCS score of 13 to 15, and no focal neurologic deficits”... • “May or may not associated with a brief LOC that lasts a few seconds to no longer than 30 minutes”...(HIISIGroup) • No abnormal Imaging findings and no focal neurologic findings are present on initial clinical evaluation... • Neurologically intact with a GCS of 13 to 15... • Confusion with Amnesia for the event of trauma, include amnesia for events immediately before or after the accident (time: minutes to a few hours not more than 24 hs).Dec.1998

  4. Objectives Theprincipalideaofthisstudy was to evaluate–usinganinternationaland multicentrepopulation- therelationships betweenseverity of injury, risk factor andimagingfindingsbyattending physicians.

  5. I.S.H.I.P. group Countries 1996-98 1999-2001 Phase I 5 countries Phase II 22 countries Web Site: www.iship-international.org

  6. Methods Multicentreprospective,randomized, studyofchildrenwhoseriallypresentedto EmergencyDepartmentwithTraumaticBrain Injury. PhaseI:1996-98 with4,690Patients; Phase II:1999-01 with4,770Patients. Neurological Evaluations: GCS and PGCS Follow-up: GOS

  7. International Advisory Board Statistical evaluation P.Patrick (Virginia University); G. Zitnay (CEO IBIA) G.Teasdale (Glasgow-UK), M.Choux (Marseille France) C. Di Rocco and F.Servadei (Italy)

  8. Results 7pat. operated 3 pat. operated P= n.s.

  9. Severity of TBI by GCS or PGCS PHASE II:4,6770Pat. PHASE I : 4,690Pat. 3.0% 1.0% 96.0% 96.4

  10. Relationships:Age and Sex Sex Age distribution 38.2 40 % 60 61.8 P=n.s. p=n.s.

  11. Results: Mechanism of TBI Phase I 9,460 Pat.Phase II Mechanism Percentage Valor p • Fall: 71.7 70.6 n.s. • < 1 mt.: 50 59.0 n.s. • 1-2 mts.: 20 32.6 n.s. • >2 mts.: 8.0 8.0 n.s. • Even surface: 22 0.4 0.001 • *Road Acc.:17.0 16.8n.s. • p= n.s.

  12. LOC:Loss of Consciousness Phase II: 4,770 Pat. Phase I: 4,690 Pat. 4.0 1.7 24.0 18.8 P= n.s.

  13. Symptoms PhaseI N. 4690 Pat. 10.4% 2.3% 11.4% 23.6% 1.9% 19.1% 33.6%

  14. Symptoms Phase II N. 4770 Pat. s m o t p m y S

  15. Results: Imaging P = n.s.

  16. Results: Imaging P=n.s. P < 0.0001

  17. Results: CT Scan Phase I 85.5% 5% 9.4% 236 674 CT [ 35% ] N. 4690 Patients

  18. Results: CT Scan Phase II 28.5% 2,528 CT scan (53%) 721 47% 1807 2,242 71.4% Total: 4,770 Patients /15 months – Entry rate: 318 Pat/month Nb: the percentage was calculated of the total patients included.

  19. Age Group - Type of lesion CT scan Phase II 229/721 Cts (31.8%) ICI 35.4% 40.6% 24.0% A: Extradural Haematoma;B: Contusion/Haemorr. Intrap.; C: Subdural Haemorr./Subarachnoid

  20. Intracranial Injury by CT Scanning 170/236 Cts (72.0%) 229/721 Cts (31.8%) n. a b c a b c Abnormal CT Scan: “focuses only on acute changes to the contents of the cranial vault with an special interest Neurosurgical aspects, example: Contusion, Extradural Haematoma, Subaracnoid Haemorrhage, Intraparenchymatous Haemorrhage, Subdural” Abnormal CT Scan: “focuses only on acute changes to the contents of the cranial vault with an special interest Neurosurgical aspects, example: Contusion, Extradural Haematoma, Subaracnoid Haemorrhage, Intraparenchymatous Haemorrhage, Subdural”

  21. Pattern of Lesions TBI and CTs 589 101 20 11 217 16 3 ( N. 721 CTs + ) ( N. 236 CTs + ) Phase II Phase I 1-81.7% 2-14.0% 3-2.8% 1-91.9%; 2-6.8%; 3-1.3% 4-1.5%

  22. Neurosurgical Intervention: patients description Phase II Phase I 31.4% 130 Patients 81 Patients 56% 26.9% 25.4% MildsTBI 59/81 (72.9%) MildsTBI 130 (100%) 27.3% 16.4% 7 Pat. Died GCS < 11 16.7% 3 Pat. Died

  23. Outcome at 3 Months 91% 99.8% 5= 99% 5= 99.6% *Method of evaluation: phone or face to face

  24. Follow-up: Phase II GOS 3 MONTHS 6 MONTHS 4,760 patients (99.8%) 43 patients (0.9%) 5: 99.6% (4,745 Pat.) 5: 94.1% ( 40 pat.) 4: 0.3% (14 pat.) 4: 2.9% ( 2 pat.) 3: 0.04% ( 2 pat.) 1: 0.04% (2 pat.) 1: 2.9% (1 pat.) *GOS: 5Goodrecovery ; 4Moderatelydisabled; 3Severelydisabled 2Vegetativestate; 1Death

  25. a-Conclusion • Advantage of the multicentre study is that allows us a glimpse of practice in varied setting and makes it possible to compare these experiences with our own; • We suggest that some of the beliefs that govern us in decision-making need review, i.e. “older and familiar technologies” (X-rays) to determine the need for a more complex evaluation, including CT;

  26. b-Conclusion • The physical and neurological examination are inadequate “predictors” of ICI; • The CT Scan is “more sensitive”; • Liberal use of CT scans in children under 6 years of age and younger with TBI is because they “may present without symptoms”;

  27. c-Conclusion • Until more definitive information is available, clinicians should be liberal in their use of CT so that early identification of significant ICI can be obtained and appropriate management of the injuries initiated.

  28. International Society of Pediatric Neurosurgery : I.S.P.N. • “The critical issue will be to have guidelines that, when used would identify all patients who need surgery, with as few negative scans to achieve this.” • “Should we now try to use the data to create guidelines and then validate them…”

  29. Past - Present & Future 1996 Mar del Plata (Argentina) 1996-98 X-rays-Epidemiology 5 countries 1999-2001 Role X-rays-CTscan 22 countries *Columella Award: ICRAN’96 *Nomination: (CDC-IBIA) EH Cristopherson Award: AAP 2000 2002-2003 CTscan - Mild TBI 26 countries Contribution: *Neurosurgical Sciences’99 *Child’s Nerv System’00-01 *Brain Injury Sources’00 *Book: Brain Injury’01-02 Markers Brain Damage-CTscan? Neuropsychology Tests?

  30. Centers of the I.S.H.I.P. group UK Sweden Russia India Hong Kong Taiwan Singapore Indonesia 22 United States Canada Uruguay Chile Brazil Argentina Spain France Italy Israel Germany Turkey Poland Arabia

  31. d-Conclusion • We think that is necessary to make an accurate evaluation of each patient with Mild TBI under 12 years of age and considerer order a CT scan into 24 hours to identify ICI and guarantee a good out come .

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