Use Of Computed Tomography In Patients Research Articles

Exploratory analysis of glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 in management of patients with mild neurological symptoms undergoing head computed tomography scan at the emergency department: a pilot study from a Croatian tertiary hospital.

Diagnostic accuracy of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1) in identification of intracranial abnormalities detected by computed tomography (CT) in mild traumatic brain injury (mTBI), and in patients with mild neurological symptoms not caused by head trauma but suspected with a neurological disorder, was examined. GFAP and UCH-L1 were determined using the chemiluminescence immunoassays on the Alinity i analyzer (Abbott Laboratories). Significantly higher GFAP (median 53.8 vs 25.7 ng/L, P < .001) and UCH-L1 (median 350.9 vs 153.9 ng/L, P < .001) were found in mTBI compared to non-head trauma patients. In mTBI diagnostic sensitivity (Se) and specificity (Sp) for the combination of GFAP and UCH-L1 were 100% and 30.9%, respectively, with area under the curve (AUC) 0.655. GFAP alone yielded Se 85.7%, Sp 41.8%, and AUC 0.638, while UCH-L1 yielded Se 57.1%, Sp 56.4%, and AUC 0.568. In non-head trauma patients, the combination of GFAP and UCH-L1 showed Se 100%, Sp 87.9%, and AUC 0.939, while GFAP alone demonstrated Se 100%, Sp 90.9%, and AUC 0.955. If these results are reproduced on a larger sample, GFAP and UCH-L1 may reduce CT use in patients with mild neurological symptoms after systemic causes exclusion and neurologist's evaluation.

Determinants of low-value imaging for patients with low-to-intermediate risk microscopic hematuria.

27 Background: In the US, two million people are referred to urologists for the evaluation of microscopic hematuria (MH). MH guidelines were revised in 2020 by the American Urological Association, recommending that only patients at high risk for malignancy based on age, smoking history, or urinalysis receive computed tomography (CT) imaging. We found in previous studies that providers continued to use CT for patients with low-to-intermediate risk, representing low-value care. To understand reasons for continued CT use for patients with low-to-intermediate risk MH, we assessed determinants of low-value care in a concurrent mixed-method study. Methods: We stratified patients with a urology consultation within 180 days of a urinalysis documented in one academic medical center’s electronic health record between 1/1/15 and 7/1/21 into high-, intermediate-, and low-risk categories and validated risk designation in a chart review of a 5% subsample. We defined low-value care as CT for patients with low-to-intermediate-risk MH. To assess determinants of low-value MH care, we conducted semi-structured interviews with primary, urology, and gynecology providers (n = 7) identified through our professional networks. Results: Six hundred nineteen patients were referred to urology for MH. 58.6% were high-risk, 33.6% intermediate-risk, 4.4% low-risk, and 3.4% were undefined. 15.9% of intermediate-risk (n = 33) and 11.1% of low-risk (n = 3) patients received CT. Of the 14 patients referred to urology post-guideline change, none with low-to-intermediate-risk received CT. Interviews demonstrated substantial variation in approaches to MH evaluation. Urologists were largely aware of the revised guideline but noted inappropriate evaluation before referral, unnecessary referrals, and inefficiency in evaluation following referral. Lacking accessible data for risk stratification, other providers’ approaches were varied but driven by a common goal of ruling out renal malignancy, based on medical school training and institutional norms. Conclusions: Low-value care was limited but persistent and may be driven by a lack of resources to support risk-stratified MH evaluation, including accessible risk stratification data and clear guidelines for appropriate evaluation. This is consistent with a lack of practical guidance for implementing MH evaluation guidelines. In future studies, we will develop strategies to facilitate risk-stratified MH evaluation in practice.

Appropriateness of Emergency CT Utilization During the Initial Peak of the COVID-19 Pandemic.

Appropriateness of Emergency CT Utilization During the Initial Peak of the COVID-19 Pandemic.

Is there any role for computed tomography imaging in anticipating the functional status in adults late after total cavopulmonary connection? A retrospective evaluation.

The Fontan procedure is performed in patients with congenital heart diseases and abnormal anatomy of the heart, which preclude intracardiac repair involving a separation of the systemic and pulmonary circulations. The role of computed tomography (CT) in assessing patients' clinical status after the total cavopulmonary connection (TCPC) procedure is not well defined. To determine a potential role and diagnostic capability of CT in the functional assessment of adults with the TCPC. Data obtained from 18 patients (10 women; mean [SD] age, 27.9 [6.3] years) with the TCPC were analyzed retrospectively. All patients underwent biochemical evaluation, cardiopulmonary exercise test, transthoracic echocardiography, and CT. Upon CT examination, the dimensions of the left and right pulmonary arteries, superior and inferior venae cavae, all pulmonary veins, and extracardiac conduits were measured. The measurements acquired by CT were correlated with the results of transthoracic echocardiography, cardiopulmonary exercise test, and biochemical analysis. The mean (SD) time after the TCPC was 18.5 (6.5) years. The area and circumference of the inferior vena cava significantly correlated with age (r = 0.503, P <0.05). A significant positive correlation was found between the area and circumference of a conduit and the predicted maximal oxygen uptake (r = 0.664, P <0.01). The area (β = 0.746, R2 = 0.556, P <0.01) and the circumference (β = 0.757, R2 = 0.572, P <0.01) of a conduit were considered significant predictors in estimating the value of maximal oxygen uptake. Our study showed an association between the dimensions of an extracardiac conduit and patient functional status, time elapsed since the procedure, and age of adults who underwent the TCPC in childhood. These findings support a more extensive use of CT in patients with TCPC, complemented by the measurements of the superior and inferior venae cavae and the conduit.

Effectiveness of peer pressure on computed tomography use for dizziness/vertigo patients.

Dizziness/vertigo is a common complaint in the emergency department (ED). We aimed to evaluate the effect of peer pressure on decision making in emergency physicians (EPs) to use computed tomography (CT) for patients with dizziness/vertigo.We conducted a before-and-after retrospective case review of patients who visited the ED with dizziness/vertigo. EPs were categorized into 3 groups according to seniority (in years of experience: >12, 7–12, and <7). The rate of CT use for EPs, patient number, and CT use were e-mailed monthly to update the EP team on the benchmark rate and shape of the behavior.Among the 1657 (preintervention) and 1508 (postintervention) patients with dizziness/vertigo, 320 (19.3%) and 230 (15.3%), respectively, underwent brain CT. A decrease in the rate of CT use was observed in the postintervention group (odds ratio [OR] = 0.743, 95% confidence interval [CI] = 0.615–0.897), especially in junior EPs (years of experience, <7; OR = 0.667, 95% CI: 0.474–0.933) and younger patients (age, <60) (OR = 0.625, 95% CI: 0.453–0.857).The intervention strategy created peer pressure through e-mail reminders and decreased the rate of CT use for patients with isolated dizziness/vertigo, especially in junior EPs and younger patients.

Utilization of head CT during injury visits to United States emergency departments: 2012–2015

IntroductionStudies have shown increasing utilization of head computed tomography (CT) imaging of emergency department (ED) patients presenting with an injury-related visit. Multiple initiatives, including the Choosing Wisely™ campaign and evidence-based clinical decision support based on validated decision rules, have targeted head CT use in patients with injuries. Therefore, we investigated national trends in the use of head CT during injury-related ED visits from 2012 to 2015. MethodsThis was a secondary analysis of data from the annual United States (U.S.) National Hospital Ambulatory Medical Care Survey from 2012 to 2015. The study population was defined as injury-related ED visits, and we sought to determine the percentage in which a head CT was ordered and, secondarily, to determine both the diagnostic yield of clinically significant intracranial findings and hospital characteristics associated with increased head CT utilization. ResultsBetween 2012 and 2015, 12.25% (95% confidence interval [CI] 11.48–13.02%) of injury-related visits received at least one head CT. Overall head CT utilization showed an increased trend during the study period (2012: 11.7%, 2015: 13.23%, p = 0.09), but the results were not statistically significant. The diagnostic yield of head CT for a significant intracranial injury over the period of four years was 7.4% (9.68% in 2012 vs. 7.67% in 2015, p = 0.23). ConclusionsHead CT use along with diagnostic yield has remained stable from 2012 to 2015 among patients presenting to the ED for an injury-related visit.

Physician Risk Tolerance and Head Computed Tomography Use for Patients with Isolated Headaches

BackgroundHeadaches are one of the most common afflictions in adults and reasons for emergency department (ED) visits. ObjectiveWe sought to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with headaches in the ED. MethodsWe performed a retrospective study of patients with nontraumatic isolated headaches in the ED and then administered two instruments (Risk-Taking subscale [RTS] of the Jackson Personality Index and a Malpractice Fear Scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT scans. Outcomes were head CT use during ED evaluation and hospital admission. A hierarchical logistic regression was used to determine the effect of risk scales on head CT use. ResultsOf the 1328 patients with headaches, 521 (39.2%) received brain CTs and 83 (6.9%) were admitted; 33 (2.5%) patients received a final diagnosis that the central nervous system was the origin of the disease. Among the 17 emergency physicians (EPs), the median of the MFS and RTS was 23 (interquartile range [IQR] 19–25) and 21 (IQR 20–23), respectively. EPs who were relatively risk-averse and those who possessed a higher level of malpractice fear were not more likely to order brain CTs for patients with isolated headaches. ConclusionsIndividual EP risk tolerance, as measured by RTS, and malpractice concerns, measured by MFS, were not predictive of CT use in patients with isolated headaches.

Understanding Overuse of Computed Tomography for Minor Head Injury in the Emergency Department: A Triangulated Qualitative Study.

Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury. This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT. Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury.

Childhood exposure to ionizing radiation from computed tomography imaging in Nova Scotia

Examining radiation dose in the paediatric population is particularly important due to the vulnerability of paediatric patients (increased radiosensitive tissues and postexposure life-years) and risk for future radiogenic malignancy. To evaluate trends in paediatric computed tomography (CT) use and ionizing radiation exposure using population-based data from Nova Scotia. A retrospective, population-based cohort study of CT use in patients <20 years of age, from January 1, 2004 to December 31, 2011, was performed in Nova Scotia. CT examination data were retrieved from a provincial imaging repository. Trends in CT use were described, and both annual and cumulative effective dose exposures were calculated. In total, 29,452 CT events, involving up to 22,867 individuals were retrieved. Overall annual paediatric CT examination rates remained static (range 17.4 to 18.8 per 1000 per year). However, use in children <10 years of age decreased by >50% (P<0.001); this was counterbalanced by a steady increase among 15- to 19-year-olds (P<0.0001). Overall, 15.4% of scanned patients underwent ≥2 examinations, of which 58 patients (1.6%) exceeded 50 mSv of exposure. Despite a static rate in CT imaging among the entire cohort, children <15 years of age and, particularly, those <10 years of age displayed marked reductions in CT use. This may reflect increased awareness of campaigns emphasizing judicious CT use, revised clinical practice guidelines and increased availability of alternative modalities. A small subgroup demonstrated high-dose exposure (>50 mSv), and rates in individuals >15 years of age steadily increased, suggesting further exposure reduction efforts are necessary.

Emergency Department Visits and Head Computed Tomography Utilization for Concussion Patients From 2006 to 2011.

Concussion is the most common type of mild traumatic brain injury for which patients present to the emergency department (ED). It is critical to understand the contemporary epidemiology of concussion and rates of head computed tomography (CT) use in head-injured patients to inform education of evidence-based clinical practice guidelines to emergency medicine providers. This was a cross-sectional analysis of the Nationwide Emergency Department Sample (NEDS) for years 2006 to 2011, representing a stratified probability sample of all U.S. hospital-based EDs. Patients of all ages with concussion diagnoses were included, and those with intracranial hemorrhages or prolonged loss of consciousness were excluded. Descriptive and bivariate statistics were summarized for patient demographics, injury mechanism, Injury Severity Scores (ISS), and concussion incidence rates, based on U.S. Census Bureau population estimates. There were 756,214,762 (weighted) ED visits in the NEDS between 2006 and 2011, of which 0.5% received diagnoses of concussion. The national incidence rate of concussion visits increased 22.6% from 195 visits per 100,000 person-years in 2006 to 239 visits per 100,000 person-years in 2011. The incidence of concussion visits increased by 28.1% from 2006 to 2011 overall (580,573 to 743,994) and within all age group categories. The rate of head CT use in patients diagnosed with concussion increased 35.7% (range = 34.5% to 46.8%) for the entire group from 2006 to 2011 (p < 0.0001). The injury severity of patients' injuries decreased over time (66.4% ISS < 5 in 2006 and 75% in 2011; p < 0.0001), while the proportion of discharged patients increased over time (78.1% in 2006 and 86.6% in 2011; p < 0.0001). ED visits for concussions have increased over time, with a corresponding increase in head CT utilization despite a decrease in injury severity. Increased visits may be due to more concussion awareness and recognition of subtle injuries. Evidence-based clinical practice guidelines for neuroimaging in head-injured patients and management of concussion should be reinforced to emergency medicine providers.

Computed tomography in multiple trauma patients: technical aspects, work flow, and dose reduction

Patients with severe, life-threatening trauma require a fast and accurate clinical and imaging diagnostic workup during the first phase of trauma management. Early whole-body computed tomography has clearly been proven to be the current standard of care of these patients. A similar imaging quality can be achieved in the multiple trauma setting compared with routine imaging especially using rapid, latest generation computed tomography (CT) scanners. This article encompasses a detailed view on the use of CT in patients with life-threatening trauma. A special focus is placed on radiological procedures in trauma units and on the methods for CT workup in routine cases and in challenging situations. Another focus discusses the potential of dose reduction of CT scans in multiple trauma as well as the examination of children with severe trauma. Various studies have demonstrated that early whole-body CT positively correlates with low morbidity and mortality and is clearly superior to the use of other imaging modalities. Optimal trauma unit management means a close cooperation between trauma surgeons, anesthesiologists and radiologists, whereby the radiologist is responsible for a rapid and accurate radiological workup and the rapid communication of imaging findings. However, even in the trauma setting, aspects of patient radiation doses should be kept in mind.

Predictors of Significant CT Findings in Patients with Ulcerative Colitis Who Present to the Emergency Department

Purpose: The use of abdominopelvic computed tomography (CT) plays an important role in the diagnosis and management of patients with inflammatory bowel disease (IBD), and its use in the emergency department (ED) has increased the last decade. A previous study demonstrated that the use of CT in the ED in patients with Crohn's disease detected significant findings in one-third of patients. We sought to assess the use of CT in patients with ulcerative colitis (UC) in the ED. Methods: We identified 92 cases of patients with UC who presented to the ED between January, 2010 and December, 2011 and underwent abdominal and/or pelvic CT. We reviewed the medical records of these visits to determine the prevalence of significant CT findings, defined as those that required urgent or emergent clinical intervention. We then assessed for potential predictors of significant CT findings. We analyzed the significance of these factors through single and multiple logistic regression. Results: A total of 92 ED visits were reviewed. Fifty-two percent were female, 79% Caucasian, and the median age was 50 years. Significant findings were seen in 44.6% (41/92) of cases. 10% (9/92) of patients had significant UC-related findings, including perforation, abscess, large bowel obstruction, and malignancy. In 34.7% (32/92) of patients, CT scans identified significant non-UC findings; the most common were small bowel obstruction (7, 21.9%), appendicitis (3, 9.38%), and diverticulitis (3, 9.38%). 55.4% (51/92) of patients had no significant CT findings, which were either UC-related inflammation (31, 33.7%) or no acute process (20, 21.7%). Predictors of significant findings on CT were a chief complaint of nausea and vomiting (odds ratio [OR] 5.31 [1.73-16.28]), history of abdominal surgery (OR 4.43 [1.79-10.95]), and no UC medications at presentation (OR 3.79 [1.59-9.03]). Predictors of non-significant findings were chief complaints of rectal bleeding (OR 20.29 [4.42-93.04]) or diarrhea (OR 7.69 [2.75-21.49]), and a 5-aminosalicylic acid medication (OR 2.98 [1.21-7.33]). On multivariate analysis, the predictors of significant findings that remained statistically significant were rectal bleeding (aOR 0.05 [0.1-0.28]), nausea and vomiting (aOR 4.25 [1.1-16.28]), and no UC medications (aOR 4.38 [1.52-12.62]) at the time of presentation. Conclusion: Less than half of patients with ulcerative colitis who present to the emergency department and undergo CT have significant findings on imaging. Understanding predictors of significant findings could alter management, and may help to minimize cost and radiation exposure in patients with UC.

Clinical Practice Guidelines for Pediatric Appendicitis Evaluation Can Decrease Computed Tomography Utilization While Maintaining Diagnostic Accuracy

The objective of this study was to compare usage of computed tomography (CT) scan for evaluation of appendicitis in a children's hospital emergency department before and after implementation of a clinical practice guideline focused on early surgical consultation before obtaining advanced imaging. A multidisciplinary team met to create a pathway to formalize the evaluation of pediatric patients with abdominal pain. Computed tomography scan utilization rates were studied before and after pathway implementation. Among patients who had appendectomy in the year before implementation (n = 70), 90% had CT scans, 6.9% had ultrasound, and 5.7% had no imaging. The negative appendectomy rate before implementation was 5.7%. In patients undergoing appendectomy in the postimplementation cohort (n = 96), 48% underwent CT, 39.6% underwent ultrasound, and 15.6% had no imaging. The negative appendectomy rate was 5.2%. We demonstrated a 41% decrease in CT use for patients undergoing appendectomy at our institution without an increase in the negative appendectomy rate or missed appendectomy. The results were even more striking when comparing the rate of CT scan use in the subset of patients undergoing appendectomy without imaging from an outside hospital. In these patients, CT scan utilization decreased from 82% to 20%, a 76% reduction in CT use in our facility after protocol implementation. Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.

Blunt Head Trauma in Children in a Community Health Care Setting: Outcomes and Variables Associated with the Use of Computed Tomography

To evaluate the incidence of clinically important traumatic brain injury (ciTBI) in children presenting to a community hospital setting and identified factors associated with computed tomography (CT) use. Retrospective cohort study of consecutive children presenting with blunt head trauma to a community emergency department or clinic over 12 months. Logistic regression models were used to compare differences in characteristics between patients who received and did not receive CT scans. Of 1007 patients, 62% male, age 14 days-18 years (270 <2 years, 737 ≥2 years), 189 (18%) had CT scans, 2 (0.2%) showed evidence of ciTBI on CT, 13 (1.3%) hospitalized, and none required neurosurgical intervention or died. Factors associated with CT use in patients ≥2 years: history of vomiting (OR 4.08, 95% CI 2.08-7.99, P < .001), change in behavior (OR 2.83, 95% CI 1.63-4.91, P < .001), headache (OR 3.4, 95% CI 1.87-6.16, P < .001), loss of consciousness (OR 2.83, 95% CI 1.38-5.8, P = .004), and abnormal neurologic examination (OR 26.18, 95% CI 2.26-303.05, P = .009). Patients were more likely to receive CT scans in community emergency departments than clinics (OR 7.04, 95% CI 2.40-20.65, P = .002). Patients in our community hospital setting are at low risk of ciTBI. The clinical indicators used to determine the need for CT in patients with more significant mechanisms of injury to pediatric or academic centers may not apply to this group. Future studies are required to determine which clinical indications are significant in this setting.

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In order to reduce mortality in severely injured patients, a rapid radiologic diagnosis is essential. Sonography plays a role only as a focused assessment with sonography for trauma (FAST) to clarify free intraperitoneal fluid immediately on admittance. Today, whole-body multislice helical computed tomography (CT) has become increasingly important as a diagnostic tool. Based on the results of the CT scan, patients can be referred for laparotomy or safely classified for "wait and see" treatment. Although the reduction in injury-related mortality would outweigh the risk of radiation dose, the indiscriminate use of CT for patients with minor injuries is not justified and must be avoided.

Regional Variability in the Use of CT for Patients with Suspected Mild Traumatic Brain Injury

To investigate the use of computed tomography (CT) scans in patients with suspected acute mild traumatic brain injury (mTBI) presenting to emergency departments. 850 potential mTBI cases were identified through reviews of three months of health records from nine selected emergency departments across the province of Ontario. Records for review were selected using the International Classification of Disease, 9th revision, Clinical Modification codes and Injury codes. Patients who received head CT were significantly older (p<0.01), had documented loss-of-consciousness (LOC) &/or Post-Traumatic Amnesia (PTA) (p<0.001), documented nausea (p<0.01), documented vomiting (p<0.001), abnormal neurological exam results (p<0.01), had visited an urban center (p<0.001), and/or arrived by ambulance (p<0.001). The significant predictors of CT scan prescription (in a forward stepwise logistic regression) were urban location of hospital (OR=5.14; p<0.001), LOC &/or PTA (OR=4.83; p< or =0.001), vomiting (OR=2.56; p< or =0.01), arrival by ambulance (OR=2.15; p< or =0.001), nausea (OR=1.92; p< or =0.02) and older age (OR=1.02; p< or =0.01). These data extend our knowledge regarding the use of CT during acute diagnosis and management of suspected mTBI patients. In addition to confirming previously reported risk factors of intracranial complication, geographical location of hospital and arrival mode were found to be significant predictors of CT use. The results suggest that the management patterns for acute mTBI are inconsistent. The implications of this are discussed.

Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era

To determine the association between the increasing computed tomography (CT) use for suspected pulmonary embolism (PE) on the annual rates of PE diagnosis and mortality, using time as a surrogate for CT use. New York State's (NYS) Statewide Planning and Research Cooperative System (SPARCS) database was used to determine the rate of PE diagnosis and mortality between 1 January 1994 and 31 December 2004. Risk factors for PE were investigated. Bivariate and multivariate analyses were performed to determine the relationships between variables. The study population consisted of 24,871,131 NYS patients. The number of patients with a primary diagnosis of PE nearly doubled over the study period, from 2590 in 1994 to 4920 in 2004, while total admissions remained stable. PE deaths did not vary significantly over time, from 157 in 1994 to 159 in 2004 and did not vary with the diagnoses of PE. Age-adjusted multivariate analysis did not reveal a significant association between the rates of PE diagnosis or mortality and corresponding risk factors. This study suggests that the increased use of CT in patients with suspected PE has led to an increase in the diagnosis of PE without a corresponding decline in mortality. Further evidence, using data on individual patients, is needed to determine the appropriate role of CT in evaluating patients with suspected PE.

S100B Serum Level Predicts Computed Tomography Findings After Minor Head Injury

Mild head injury (MHI) implies a risk for traumatic brain injury and even a small risk for development of an intracranial hematoma. Head computed tomography (CT) is recommended for early detection of such pathologic findings. The present multicenter study was performed to investigate whether determination of protein S100B in serum could contribute to the selection of patients for CT scanning. We included 226 patients with a history of head injury and a Glasgow Coma Scale (GCS) score of 13 to 15 at admission to hospital. Blood samples for S100B analysis and head CT were obtained within 12 hours after the injury. The diagnostic properties of S100B measurements for prediction of intracranial injury revealed by CT were tested with receiver operating characteristic (ROC) analysis and cross-table analysis at different cut-off levels. We also included analysis of S100B levels normalized to correspond to blood sampling 1 hour after the injury. CT showed intracranial injury in 21 (9.3%) patients. S100B levels were significantly (p < 0.001) elevated in patients with intracranial injury (mean, 0.36; 95% CI, 0.21-0.50 microg/L) compared with those in patients without intracranial injury (mean, 0.18; 95% CI, 0.16-0.20 microg/L). ROC curve analysis showed a significant (p = 0.001) area under the curve (0.73; 95% CI, 0.62-0.84). Cross-table analysis showed that 20 of 21 (sensitivity 0.95) patients with intracranial injury were detected at a cut-off level of 0.10 microg/L, but 141 of 205 (specificity 0.31) patients with no such injury also had a S100B level above this limit. Exclusion of cases with blood samples collected more than 3 hours after injury or normalization did not improve the diagnostic properties. Determination of serum S100B cannot replace the clinical examination or use of CT for patients with minor head injury, but adding S100B measurement to the clinical evaluation might support selection of patients for CT scanning.

Predicting Intracranial Traumatic Findings on Computed Tomography in Patients with Minor Head Injury: The CHIP Prediction Rule

Prediction rules for patients with minor head injury suggest that the use of computed tomography (CT) may be limited to certain patients at risk for intracranial complications. These rules apply only to patients with a history of loss of consciousness, which is frequently absent. To develop a prediction rule for the use of CT in patients with minor head injury, regardless of the presence or absence of a history of loss of consciousness. Prospective, observational study. 4 university hospitals in the Netherlands that participated in the CT in Head Injury Patients (CHIP) study. Consecutive adult patients with minor head injury (> or =16 years of age) with a Glasgow Coma Scale (GCS) score of 13 to 14 or with a GCS score of 15 and at least 1 risk factor. Outcomes were any intracranial traumatic CT finding and neurosurgical intervention. The authors performed logistic regression analysis by using variables from existing prediction rules and guidelines, with internal validation by using bootstrapping. 3181 patients were included (February 2002 to August 2004): 243 (7.6%) had intracranial traumatic CT findings and 17 (0.5%) underwent neurosurgical intervention. A detailed prediction rule was developed from which a simple rule was derived. Sensitivity of both rules was 100% for neurosurgical interventions, with an associated specificity of 23% to 30%. For intracranial traumatic CT findings, sensitivity and specificity were 94% to 96% and 25% to 32%, respectively. Potential CT reduction by implementing the prediction rule was 23% to 30%. Internal validation showed slight optimism for the model's performance. External validation of the prediction model will be required. The authors propose the highly sensitive CHIP prediction rule for the selective use of CT in patients with minor head injury with or without loss of consciousness.

The Canadian CT Head Rule for patients with minor head injury

There is much controversy about the use of computed tomography (CT) for patients with minor head injury. We aimed to develop a highly sensitive clinical decision rule for use of CT in patients with minor head injuries. We carried out this prospective cohort study in the emergency departments of ten large Canadian hospitals and included consecutive adults who presented with a Glasgow Coma Scale (GCS) score of 13-15 after head injury. We did standardised clinical assessments before the CT scan. The main outcome measures were need for neurological intervention and clinically important brain injury on CT. The 3121 patients had the following characteristics: mean age 38.7 years); GCS scores of 13 (3.5%), 14 (16.7%), 15 (79.8%); 8% had clinically important brain injury; and 1% required neurological intervention. We derived a CT head rule which consists of five high-risk factors (failure to reach GCS of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years) and two additional medium-risk factors (amnesia before impact >30 min and dangerous mechanism of injury). The high-risk factors were 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive (95% CI 96-99%) and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT. We have developed the Canadian CT Head Rule, a highly sensitive decision rule for use of CT. This rule has the potential to significantly standardise and improve the emergency management of patients with minor head injury.