Abnormal Head Computed Tomography Scans Research Articles

Neurotrauma Care Delivery in a Limited Resource Setting—Lessons Learned From Referral and Patient Flow in a Tertiary Care Center

With the increasing population, motorization, and road traffic accidents, neurotrauma has been increasing in India. Inadequate triage and underusage of locally available resources at all healthcare levels has led to nonuniform neurotrauma care delivery. We present our experience at a tertiary care hospital. We evaluated the referral pattern of mild traumatic brain injury (mTBI) cases to enable adequate care to patients with moderate and severely injured TBI. All patients with head injury (n= 3891) referred to the emergency department of our institution during a 4-month period were evaluated. The demographic characteristics, ambulance usage, and time management during in-hospital patient flow were evaluated using the Lean Six Sigma approach. We have also provided solutions for optimal usage of available resources. Patients with mTBI comprised 77% of head injury referrals. Of all the patients referred from peripheral hospitals, 48% had normal head computed tomography (CT) scan findings. The CT waiting and lead (arrival-to-discharge) times were 35 ± 44 minutes and 114 minutes, respectively. No clinical to radiological correlation was found between the head CT scan findings and a decision to refer a patient to our institute. Only 10% of the patients with abnormal head CT scans (41%) required neurosurgical intervention. The mean duration from CT imaging to the initiation of surgery was 192.7 ± 172.1 minutes. Most of the patients with mTBI were referred to a tertiary care center, leading to secondary overtriage and overburdening of the existing resources at a specialized care hospital, possibly owing to ineffective triage at the primary and secondary healthcare centers. This would limit the adequate management of moderate to severe TBI cases in such a hospital.

Kryteria kliniczne kwalifikacji dziecka z lekkim urazem głowy do badania tomografii komputerowej ocenione w materiale własnym

ABSTRAKTWstęp: Celem pracy było ustalenie klinicznych wskazań do wykonania tomografii komputerowej głowy bez kontrastu (TKGbK) u dzieci z lekkim urazem głowy (LUG).Materiały i metody: Retrospektywnej analizie poddano dokumentację 1615 dzieci leczonych w latach 2010–2015 z powodu urazów głowy. Do grupy badanej zakwalifikowano 162 pacjentów z LUG w różnym wieku, u których wykonano TKGbK. Lekki uraz głowy zdefiniowano w oparciu o wytyczne Scandinavian Neurotrauma Committee. Stan świadomości dziecka oceniano za pomocą skali Glasgow (GCS), przeznaczonej zarówno dla osób dorosłych, jak i dzieci. Analizie poddano wiek i płeć dziecka w chwili urazu, mechanizm urazu, odchylenia stwierdzone w badaniu przedmiotowym i w badaniu tomografii komputerowej głowy. Na podstawie analizy statystycznej ustalono kryteria kliniczne wysokiego ryzyka zmian pourazowych w badaniu TKGbK dla dzieci z LUG.Wyniki: Średni wiek pacjenta w dniu urazu wynosił 9 lat i 10 miesięcy. Przeważali chłopcy, którzy stanowili 60% analizowanego materiału (98/162). Najczęstszym mechanizmem urazu był upadek z wysokości notowany w 25% i wypadek komunikacyjny w 22% przypadków. U 149 (92%) dzieci oceniono stan świadomości po urazie na 15 pkt GCS. Najczęściej notowanym wskazaniem do wykonania TKGbK był ból głowy (50%) i utrata przytomności (39%). Analiza dokumentacji dotyczącej TKGbK wykazała złamanie czaszki/obrażenie wenątrzczaszkowe u 50 (31%) dzieci. U 7 (4%) dzieci stwierdzono istotne zmiany w badaniu TKGbK, co było wskazaniem do leczenia neurochirurgicznego. Sugestie płynące z analizy danych dotyczących zmian stwierdzonych w badaniu TKGbK wskazują na wysokie prawdopodobieństwo zmian pourazowych u dzieci, które doznały urazu głowy w wypadku komunikacyjnym i miały wymioty pourazowe, a także w grupie pacjentów z klinicznymi objawami złamania czaszki.Wnioski: Uraz głowy doznany w wypadku komunikacyjnym, wymioty oraz kliniczne objawy złamania twarzoczaszki/podstawy czaszki wydają się istotnym wskazaniem do wykonania TKGbK u dzieci z LUG.

Evaluation of the Roche® Elecsys and the Diasorin® Liaison S100 kits in the management of mild head injury in the emergency room

IntroductionThe aim of this single-center prospective study is to compare two commercially available S100ß kits (the Roche® Elecsys and the Diasorin® Liaison S100 kits) in terms of analytical and clinical performances in a population admitted in the emergency room for mild traumatic brain injury (mTBI). Material and method110 patients were enrolled from September 2014 to May 2015. Blood sample draws were performed within 3h after head trauma and the study population was split into pediatric and adult subpopulations (>18years of age). ResultsAlthough both kits correlated well, we observed a significant difference in terms of S100ß levels (P value<0.05) in both subpopulations.In the pediatric subpopulation, both kits showed elevated S100ß levels for the only patient (3.5%) who displayed abnormal findings on a CT-scan. However, we observed a poor agreement between both kits (Cohen's kappa=0.345, P value=0.077).In the adult subpopulation, a total of 10 patients (12.2%) had abnormal head computed tomography scans. Using the Roche® (cut off=0.1μg/L) and the Diasorin® (cut off=0.15μg/L) S100ß kits, brain injuries were detected with a sensitivity of 100% (95% CI: 65–100%) and 100% (95% CI: 63–100%) and a specificity of 15.28% (95% CI: 7.9–25.7%) and 24.64% (95% CI: 15–36.5) respectively. Finally, a moderate agreement was concluded between both kits (Cohen's kappa=0.569, P value=0.001). ConclusionAlthough a good correlation could be found between both kits, emergency physicians should be aware of discrepancies observed between both methods, making those immunoassays not interchangeable. Furthermore, more studies are still needed to validate cut off used according to technique and to age, especially in the population below the age of 2years.

Clinical predictors of abnormal head computed tomography scan in patients who are conscious after head injury.

Background:Indication of a head computed tomography (CT) scan in a patient who remains conscious after head injury is controversial. We aimed to determine the clinical features that are most likely to be associated with abnormal CT scan in patients with a history of head injury, and who are conscious at the time of presentation to casualty.Materials and Methods:This is a prospective observation study of patients presented to casualty with history of head injury, and who were conscious, i.e., Glasgow Coma Scale (GCS) 15 at the time of evaluation. All patients underwent head CT scan. The CT scan was reported as abnormal if it showed any pathology ascribed to trauma. The following variables were used: age, gender, mode of injury (road traffic accident, fall, assault, and others), duration since injury, and history of transient loss of consciousness, headache, vomiting, ear/nose bleeding, and seizures. Logistic regression analysis was used to identify the clinical features that predicted an abnormal CT scan.Results:During the observation period, a total of 1629 patients with head injury were evaluated, out of which 453 were in GCS 15. Abnormal CT scan was present in 195 (43%) patients. Among all the variables, the following were found significantly associated with abnormal CT scan: duration since injury (>12 h) P < 0.001; vomiting odds, ratio (OR) 1.89 (1.23, 2.80), P < 0.001; and presence of any symptom, OR 2.36 (1.52, 3.71), P < 0.001.Conclusion:A patient with GCS 15 presenting after 12 hours of injury with vomiting or combination of symptoms has a significant risk of abnormal head CT scan.

Injury outcome among helmeted and non-helmeted motorcycle riders and passengers at a tertiary care hospital in north-western Tanzania

Motorcycle helmets have been reported to reduce the risk of death and head injuries following motorcycle accidents. The aim of this descriptive prospective study was to determine the injury outcome among helmeted and non-helmeted motorcyclists and passengers at a tertiary hospital in north-western Tanzania. A total of 654 patients involved in the motorcycle accident were studied. Of these, 468 (71.6%) were motorcyclists (riders) and the remaining 186 (28.4%) were passengers. The median age of patients at presentation was 26 years. Male outnumbered females by a ratio of 4.5: 1. Helmet use was reported in 312 (47.7%) patients. Non- helmeted patients were young compared with helmeted patients and this was statistically significant (p = 0.021). The rate of helmet use was significantly higher among motorcyclists than among passengers (p = 0.004). History of alcohol consumption prior to the accident was reported in 212 (32.4%) patients. The rate of helmet use was significantly low among alcohol consumers compared with non-alcohol consumers (p = 0.011). Lack of helmet use was significantly associated with abnormal head Computed Tomography scans, admission to the Intensive care unit, severe trauma, and worse traumatic brain injury severity (p < 0.001). Helmet use was significantly associated with shorter period of hospitalization and reduced mortality rate (p < 0.001). Motorcycle helmet use is still low in this part of Tanzania and this poses a great impact on injury outcome among motorcycle injury patients. This observation calls for action to implement more widespread injury prevention and helmet safety education and advocacy.

Head CT Scan Overuse in Frequently Admitted Medical Patients

BackgroundPatients frequently admitted to medical services undergo extensive computed tomography (CT) imaging. Some of this imaging may be unnecessary, and in particular, head CT scans may be over-used in this patient population. We describe the frequency of abnormal head CT scans in patients with multiple medical hospitalizations. MethodsWe retrospectively reviewed all CT scans done in 130 patients with 7 or more admissions to medical services between January 1 and December 31, 2011 within an integrated health care system. We calculated the number of CT scans, anatomic site of imaging, and source of ordering (emergency department, inpatient floor). We scored all head CT scans on a 0-4 scale based on the severity of radiographic findings. Higher scores signified more clinically important findings. ResultsThere were 795 CT scans performed in total, with a mean of 6.7 (± SD 5.8) CT scans per patient. Abdominal/pelvis (39%), chest (30%), and head (22%) CT scans were the most frequently obtained. The mean number of head CT scans performed was 2.9 (SD ± 4.2). Inpatient floors were the major site of CT scan ordering (53.7%). Of 172 head CT scans, only 4% had clinically significant findings (scores of 3 or 4). ConclusionsPatients with frequent medical admissions are medically complex and undergo multiple CT scans in a year. The vast majority of head CT scans lack clinically significant findings and should be ordered less frequently. Interdisciplinary measures should be advocated by hospitalists, emergency departments, and radiologists to decrease unnecessary imaging in this population.

Classification Accuracy of Serum Apo A-I and S100B for the Diagnosis of Mild Traumatic Brain Injury and Prediction of Abnormal Initial Head Computed Tomography Scan

The objective of the current study was to determine the classification accuracy of serum S100B and apolipoprotein (apoA-I) for mild traumatic brain injury (mTBI) and abnormal initial head computed tomography (CT) scan, and to identify ethnic, racial, age, and sex variation in classification accuracy. We performed a prospective, multi-centered study of 787 patients with mTBI who presented to the emergency department within 6 h of injury and 467 controls who presented to the outpatient laboratory for routine blood work. Serum was analyzed for S100B and apoA-I. The outcomes were disease status (mTBI or control) and initial head CT scan. At cutoff values defined by 90% of controls, the specificity for mTBI using S100B (0.899 [95% confidence interval (CI): 0.78-0.92]) was similar to that using apoA-I (0.902 [0.87-0.93]), and the sensitivity using S100B (0.252 [0.22-0.28]) was similar to that using apoA-I (0.249 [0.22-0.28]). The area under the receiver operating characteristic curve (AUC) for the combination of S100B and apoA-I (0.738, 95% CI: 0.71, 0.77), however, was significantly higher than the AUC for S100B alone (0.709, 95% CI: 0.68, 0.74, p=0.001) and higher than the AUC for apoA-I alone (0.645, 95% CI: 0.61, 0.68, p<0.0001). The AUC for prediction of abnormal initial head CT scan using S100B was 0.694 (95%CI: 0.62, 0.77) and not significant for apoA-I. At a S100B cutoff of <0.060 μg/L, the sensitivity for abnormal head CT was 98%, and 22.9% of CT scans could have been avoided. There was significant age and race-related variation in the accuracy of S100B for the diagnosis of mTBI. The combined use of serum S100B and apoA-I maximizes classification accuracy for mTBI, but only S100B is needed to classify abnormal head CT scan. Because of significant subgroup variation in classification accuracy, age and race need to be considered when using S100B to classify subjects for mTBI.

Effect of blood alcohol level on Glasgow Coma Scale scores following traumatic brain injury

Objective: It is a common clinical perception that alcohol intoxication systematically lowers Glasgow Coma Scale (GCS) scores when evaluating traumatic brain injury (TBI). However, the research findings in this area do not uniformly support this notion. The purpose of this study is to examine the effects of blood alcohol level (BAL) on GCS scores following TBI.Method: Participants were 475 patients (64% male) who presented to a Level 1 trauma centre following a TBI. Patients were selected if they were injured in a motor vehicle accident and had an available day-of-injury GCS, BAL and Computed Tomography (CT) brain scan.Results: Overall, acute alcohol intoxication did not significantly affect GCS scores, even in patients with BALs of 200 mg dl−1 or higher. When controlling for the effects of injury severity, acute alcohol intoxication affected GCS scores only in those patients with BALs greater than 200 mg dl−1 who also had intracranial abnormalities detected on CT scan.Conclusions: These findings suggest that GCS scores can be interpreted at face value in the vast majority of patients who are intoxicated. However, GCS scores will likely over-estimate the severity of brain injury in patients with abnormal head CT scans and BALs greater than 200 mg dl−1.

The Economic Impact of S-100B as a Pre-Head CT Screening Test on Emergency Department Management of Adult Patients with Mild Traumatic Brain Injury

Recent research suggests that serum S-100B may serve as a good pre-head computed tomography (CT) screening test because of its high sensitivity for abnormal head CT scans. The potential economic impact of using S-100B in the emergency department setting for management of adult patients with isolated mild traumatic brain injury (mTBI) has not been evaluated despite its clinical implementation in Europe. Using evidence from the literature, we constructed a decision tree to compare the average cost per patient of using S-100B as a pre-head CT screening test to the current practice of ordering CT scans based on patients' presenting symptoms without the aid of S-100B. When compared to scanning 45-77% of isolated mTBI patients based upon their presenting symptoms, using S-100B as a pre-head CT screen does not lower hospital costs ($281 versus $160), primarily due to its low specificity for abnormal head CT scans. Sensitivity analyses showed, however, that S-100B becomes cost-lowering when the proportion of mTBI patients being scanned exceeds 78%, or when final CT scan results require 96 min or more than the wait for blood test results. Generally speaking, if blood test results require less time than imaging, and if head CT scan rates for patients with isolated mTBI are relatively high, using S-100B will lower costs. Recommendations for using S-100B as a screening tool should account for setting-specific characteristics and their consequent economic impacts. Despite its high sensitivity and excellent negative predictive value, serum S-100B has low specificity and low positive predictive value, limiting its ability to reduce numbers of CT scans and hospital costs.

Utility of pretest probability to assess the risk of abnormal head computed tomography scans: Can risk stratification be used to eliminate scanning in low-risk patients?

Utility of pretest probability to assess the risk of abnormal head computed tomography scans: Can risk stratification be used to eliminate scanning in low-risk patients?