RESUMEN
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.
Asunto(s)
Traumatismos Craneocerebrales/diagnóstico por imagen , Neuroimagen , Tomografía Computarizada por Rayos X , Adulto , Traumatismos Craneocerebrales/complicaciones , Traumatismos Craneocerebrales/terapia , Femenino , Escala de Consecuencias de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/terapia , Tiempo de Internación , Masculino , Estudios Retrospectivos , Centros Traumatológicos/estadística & datos numéricos , Resultado del TratamientoRESUMEN
INTRODUCTION: Patients with mild traumatic brain injury (MTBI) and intracranial haemorrhage (ICH) are hospitalized and monitored for progression of injury. The timeframe for ICH progression is unknown, and so the optimal duration and location of observation are generally discretionary. The goal of this study was to examine the temporal course of injury progression and establish a timeframe for when haemorrhage ceases. METHODS: We performed a retrospective review of all adult patients (age ≥ 18) with MTBI (GCS ≥ 13) and ICH admitted to a level 1 trauma centre over a consecutive 36 month period, who underwent a minimum of 2 cranial CT scans (HCT) within 48 h from ED presentation prior to any neurosurgical intervention (NSI). Patients with a history of NSI or nontraumatic cerebral lesions were excluded. Data collected include demographics and the number, timing and findings of serial HCT scans. RESULTS: A total of 341 patients met inclusion criteria. The timing for cessation of bleeding could not be confirmed in 37 patients (11 had NSI after 2nd HCT, 1 died of coagulopathy prior to NSI and 25 had no repeat HCT that could confirm the cessation of bleeding). Of the remaining 304 ICH, 96% stopped progressing by 24h and 99% by 48 h. The remaining 1% stopped by 72 h. Of all 341 ICH, 236 (69%) showed no progression after initial HCT, indicating that haemorrhage had stopped by that time (1.2h (SD ± 1.1h) from admission). None required a NSI. CONCLUSION: Almost all ICH in MTBI stop progressing within the first 24h post injury, supporting a 24-h observational period. In fact, over 3/4s of ICH has stopped by the time of the initial HCT (<2h from arrival). This suggests that early repeat HCT may identify those ICH no longer progressing, and possibly avoid unnecessary admission and prolonged observation in those patients not requiring admission for post-TBI symptom management. Prospective data are needed to evaluate this proposed paradigm change in the management of MTBI.
Asunto(s)
Lesiones Encefálicas/diagnóstico por imagen , Hemorragias Intracraneales/diagnóstico por imagen , Tiempo de Internación/estadística & datos numéricos , Tomografía Computarizada por Rayos X , Adulto , Anciano , Lesiones Encefálicas/fisiopatología , Progresión de la Enfermedad , Femenino , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Centros Traumatológicos , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Lesiones Encefálicas/diagnóstico por imagen , Lesiones Encefálicas/cirugía , Examen Neurológico/métodos , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Adulto , Anciano , Lesiones Encefálicas/mortalidad , Femenino , Estudios de Seguimiento , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/métodos , Valor Predictivo de las Pruebas , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Centros Traumatológicos , Resultado del TratamientoRESUMEN
BACKGROUND: Historically, thoracolumbar spine transverse process fractures (TVPFx) found on "plain films" of the spine were occasionally associated with occult, mechanically significant vertebral fractures. Thus, "log-roll precautions" have been used pending formal spine evaluation and further imaging. As integrated helical computed tomography (CT) scans of the torso have become routine screening tools in high-energy trauma, TVPFx have been diagnosed with far greater frequency. Yet, where no associated spine injuries are found initially, such isolated TVPFx appear to be benign. METHODS: We retrospectively reviewed the diagnosis and management of TVPFx in a large Level I trauma center in the period between 2002 and 2005. Of 314 patients with TVPFx who survived more than 48 hours, 17% had fractures of the weight-bearing columns of the thoracolumbar spine noted on the same CT scan and were excluded from study. The management and outcome of the remaining "isolated" TVPFx were assessed by review of trauma registry and charted data. RESULTS: The 248 patients included sustained 2.3 +/- 1.5 (SD) TVPFx. They spent 29 hours +/- 32 hours on log-roll precautions while being evaluated by spine consultants and "cleared" before initiating physical therapy. Despite this prolonged immobilization and substantial further investigation, none of the patients with TVPFx judged to be isolated on the basis of screening truncal CT scan proved to have a missed injury of a major vertebral element on further study. CONCLUSIONS: Isolated thoracolumbar TVPFx are found frequently when helical CT scan is used to screen the torso after high-energy injury. TVPFx are usually multiple. They can be markers for visceral injuries, and in this study, 17% were associated with "significant" fractures. TVPFx require careful pain management and benefit by early mobilization. Yet, where no other vertebral fracture is seen on an adequate screening CT scan, investigation may reasonably end. Further imaging and consultations with spine services waste scarce resources, and lead to prolonged log-roll precautions, which delay mobilization and are potentially deleterious to overall patient care.
Asunto(s)
Fracturas de la Columna Vertebral/diagnóstico por imagen , Vértebras Torácicas/lesiones , Centros Traumatológicos/estadística & datos numéricos , Heridas no Penetrantes/diagnóstico por imagen , Adulto , Femenino , Humanos , Masculino , Modalidades de Fisioterapia , Radiografía Abdominal , Sistema de Registros , Estudios Retrospectivos , Sensibilidad y Especificidad , Fracturas de la Columna Vertebral/terapia , Vértebras Torácicas/diagnóstico por imagen , Tomografía Computarizada EspiralRESUMEN
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.
Asunto(s)
Hemorragia Intracraneal Traumática/diagnóstico por imagen , Heridas no Penetrantes/diagnóstico por imagen , Adolescente , Adulto , Traumatismos Craneocerebrales/clasificación , Traumatismos Craneocerebrales/complicaciones , Traumatismos Craneocerebrales/diagnóstico por imagen , Femenino , Escala de Coma de Glasgow , Humanos , Hemorragia Intracraneal Traumática/clasificación , Hemorragia Intracraneal Traumática/complicaciones , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Heridas no Penetrantes/clasificación , Heridas no Penetrantes/complicacionesRESUMEN
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.
Asunto(s)
Causas de Muerte , Traumatismos Penetrantes de la Cabeza/epidemiología , Traumatismos Penetrantes de la Cabeza/cirugía , Procedimientos Neuroquirúrgicos/métodos , Heridas por Arma de Fuego/complicaciones , Adolescente , Adulto , Distribución por Edad , Anciano , Análisis de Varianza , Estudios de Cohortes , Enfermedad Crítica , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Escala de Coma de Glasgow , Traumatismos Penetrantes de la Cabeza/etiología , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Modelos Logísticos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/mortalidad , New Jersey/epidemiología , Valor Predictivo de las Pruebas , Probabilidad , Estudios Retrospectivos , Medición de Riesgo , Distribución por Sexo , Estadísticas no Paramétricas , Análisis de Supervivencia , ViolenciaRESUMEN
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.