Repeat Head Research Articles

Posttraumatic cerebellar infarction after repeated sport-related minor head injuries in a young adult: a case report.

A healthy 23-year-old man suffered helmet-to-helmet collisions with an opponent during American football game twice within 3 days. He then experienced continuous vomiting and dizziness. Magnetic resonance imaging revealed acute infarction in the right cerebellar hemisphere, and magnetic resonance angiography revealed transient stenosis of the right superior cerebellar artery. Although minor head injury is not usually accompanied by complications, posttraumatic ischemic stroke has been reported on rare occasions. We report a case of cerebellar infarction after repeated sports-related minor head injuries in a young adult and discuss the etiology.

Early prediction and outcome of septic encephalopathy in acute stroke patients with nosocomial coma.

BackgroundSeptic encephalopathy (SE) is the most common acute encephalopathy in ICU; however, little attention has been focused on risk of SE in the course of acute stroke. Our aim is to investigate the early prediction and outcome of SE in stroke patients with nosocomial coma (NC).MethodsA retrospective cohort study was conducted in an ICU of the tertiary teaching hospital in China from January 2006 to December 2009. Ninety-four acute stroke patients with NC were grouped according to with or without SE. Risk factors for patients with SE were compared with those without SE by univariate and multivariate analysis.ResultsOf 94 stroke patients with NC, 46 (49%) had NC with SE and 48 (51%) had NC without SE. The onset-to-NC time was significant later in stroke patients with SE than those without SE (P < 0.01). There was a significant difference in body temperature, heart rate, respiratory rate, white blood cell (WBC), systolic blood pressure (SBP), diastolic blood pressure (DBP), systemic inflammatory response syndrome (SIRS), acute respiratory failure, septic shock, hypernatremia, and sequential organ failure assessment (SOFA) score between the SE and non-SE group (P < 0.05). On a repeat head imaging, vasogenic edema (P = 0.023) and subcortical white matter lesions (P = 0.011) were significantly higher in patients with SE than those without SE, while hematoma growth (P = 0.000), infarction progress (P = 0.003), and recurrent subarachnoid hemorrhage (SAH) (P = 0.011) were significantly lower in patients with SE than those without SE. Patients with SE had higher adjusted rates of fever ≥ 39 °C (odds ratio (OR): 2.753; 95% confidence interval (CI): 1.116 - 6.794; P = 0.028) and SIRS ≥ 3 items (OR: 6.459; 95% CI: 2.050 - 20.351; P = 0.001). The 30-day mortality in stroke patients with SE was higher than those without SE (76.1% vs. 45.8%, P = 0.003).ConclusionHigh fever and severe SIRS are two early predictors of stroke patients with SE, and survival rates were worse in stroke patients with SE than those without SE.

Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features.

Emergency department (ED) management of mild traumatic brain injury (TBI) patients with any form of traumatic intracranial hemorrhage (ICH) is variable. Since 2000, our center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable. Whether this practice is safe is unknown. This study characterized clinical outcomes in mild TBI patients with acute traumatic ICH seen on initial ED neuroimaging. This retrospective cohort study included patients presenting to the ED with blunt mild TBI with Glasgow Coma Scale (GCS) scores of 14 or 15 and stable vital signs, during the period from January 2001 to January 2010. Patients with any ICH on initial head CT and repeat head CT within 24 hours were eligible. Cases were excluded for initial GCS < 14, injury > 24 hours old, pregnancy, concomitant nonminor injuries, and coagulopathy. A single investigator abstracted data from records using a standardized case report form and data dictionary. Primary endpoints included death, neurosurgical procedures, and for discharged patients, return to the ED within 7 days. Differences in proportions were computed with 95% confidence intervals (CIs). Of 1,011 patients who presented to the ED and had two head CTs within 24 hours, 323 (32%) met inclusion criteria. The median time between CT scans was 6 hours (interquartile range = 5 to 7 hours). A total of 153 (47%) patients had subarachnoid hemorrhage, 132 (41%) patients had subdural hemorrhage, 11 (3%) patients had epidural hemorrhage, 78 (24%) patients had cerebral contusions, and 59 (18%) patients had intraparenchymal hemorrhage. Four of 323 (1.2%, 95% CI = 0.3% to 3.2%) patients died within 2 weeks of injury. Three of the patients who died had been admitted from the ED on their initial visits, and one had been discharged home. There were 206 patients (64%) discharged from the ED, 28 (13.6%) of whom returned to the ED within 1 week. Of the 92 who were hospitalized, three (0.9%, 95% CI = 0.2% to 2.7%) required neurosurgical intervention. Discharge after a repeat head CT and brief period of observation in the ED allowed early discharge of a cohort of mild TBI patients with traumatic ICH without delayed adverse outcomes. Whether this justifies the cost and radiation exposure involved with this pattern of practice requires further study.

Necessity of repeat head computed tomography (CT) scans in mild traumatic brain injury patients

CONCLUSIONS: Green light reflectance PPG could allow for earlier surgical intervention in those at risk of CS, especially children, unconscious or polytrauma patients, potentially reducing morbidity. This inexpensive and non-invasive sensor may also have other roles in detecting cardiovascular deterioration preceding the onset of hypotension, such as early shock in septicaemia. Additional work in these settings and CS are required.

A case of acute cerebral ischemia following inhalation of a synthetic cannabinoid

Objective. Synthetic cannabinoids are increasingly used in the United States as marijuana substitutes. However, reports of severe toxicity, resulting from their use, are limited. We present the case of acute cerebral infarction following synthetic cannabinoid inhalation. Case report. A 33-year-old man with no significant medical history presented at the emergency department with right-sided weakness and aphasia. He had smoked a synthetic cannabinoid (SC) product called “WTF” prior to the onset of symptoms. Physical examination showed right hemiparesis, dysarthria, and aphasia. Laboratory evaluation, electrocardiography, and computed tomography (CT) of the head were unremarkable. Following administration of intravenous tissue plasminogen activator, his symptoms improved. A repeat head CT showed acute infarction in the left insular cortex. His hypercoagulability panel was unremarkable, and the patient was discharged neurologically intact. Urine toxicology results were unremarkable. Analysis of the product by gas chromatography–mass spectrometry (GC–MS) procedure confirmed the presence of a synthetic cannabinoid known as XLR-11. Conclusion. XLR-11 has previously been associated with acute kidney injury in humans. However, there are no reports of it causing acute cerebral ischemic events. The close temporal association between XLR-11 inhalation and his stroke is concerning. Acute cerebral infarction may occur after XLR-11 use in healthy patients.

The significance of platelet count in traumatic brain injury patients on antiplatelet therapy.

Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy. We performed a prospective cohort analysis of all traumatic brain injury patients with an ICH on prehospital antiplatelet therapy. Antiplatelet therapy was defined as aspirin, clopidogrel, or a combination of both. Admission platelet count was recorded and used for analysis. Receiver operating characteristic curves were plotted to identify the optimal platelet count for progression on RHCT scan and neurosurgical intervention in patients on antiplatelet therapy. A total of 264 patients were enrolled. Platelet count of 135,000/µL or less (area under the curve, 0.80) and platelet count of 95,000/µL or less (area under the curve, 0.92) were the optimal threshold points for progression on RHCT scan and neurosurgical intervention, respectively. Patients with platelet count of 135,000/µL or less were 12.4 times (95% confidence interval, 7.1-18.4) more likely to have progression on RHCT scan and patients with platelet count 95,000/µL or less were 31.5 times (95% confidence interval, 19.7-96.2) more likely to require neurosurgical intervention. A platelet count of less than 135,000/µL in patients on antiplatelet therapy is predictive of both radiographic and clinical worsening. This is a clinically relevant target intended to help tailor and improve management in patients on antiplatelet therapy. Therapeutic study, level III.

Mild traumatic brain injury defined by Glasgow Coma Scale: Is it really mild?

Introduction: Conventionally, a Glasgow Coma Scale (GCS) score of 13–15 defines mild traumatic brain injury (mTBI). The aim of this study was to identify the factors that predict progression on repeat head computed tomography (RHCT) and neurosurgical intervention (NSI) in patients categorized as mild TBI with intracranial injury (intracranial haemorrhage and/or skull fracture).Methods: This study performed a retrospective chart review of all patients with traumatic brain injury who presented to a level 1 trauma centre. Patients with blunt TBI, an intracranial injury and admission GCS of 13–15 without anti-platelet and anti-coagulation therapy were included. The outcome measures were: progression on RHCT and need for neurosurgical intervention (craniotomy and/or craniectomy).Results: A total of 1800 patients were reviewed, of which 876 patients were included. One hundred and fifteen (13.1%) patients had progression on RHCT scan. Progression on RHCT was 8-times more likely in patients with subdural haemorrhage ≥10 mm, 5-times more likely with epidural haemorrhage ≥10 mm and 3-times more likely with base deficit ≥4. Forty-seven patients underwent a neurosurgical intervention. Patients with displaced skull fracture were 10-times more likely and patients with base deficit >4 were 21-times more likely to have a neurosurgical intervention.Conclusion: In patients with intracranial injury, a mild GCS score (GCS 13–15) in patients with an intracranial injury does not preclude progression on repeat head CT and the need for a neurosurgical intervention. Base deficit greater than four and displaced skull fracture are the greatest predictors for neurosurgical intervention in patients with mild TBI and an intracranial injury.

Clinical outcomes in patients on preinjury ibuprofen with traumatic brain injury

BackgroundThe aim of our study was to evaluate the clinical outcomes in patients on preinjury Ibuprofen with traumatic brain injury. MethodsWe performed a 2-year analysis of all patients on prehospital Ibuprofen with traumatic brain injury and intracranial hemorrhage. Patients on preinjury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale, head-abbreviated injury scale, injury severity score, International Normalized Ratio, and neurologic examination. Outcome measures were progression on repeat head computed tomography (RHCT) and neurosurgical intervention. ResultsA total of 195 matched (Ibuprofen 65, no-Ibuprofen 130) patients were included. There was no difference in the progression on RHCT (Ibuprofen 18% vs no-Ibuprofen 24%; P = .50). The neurosurgical intervention rate was 18.9% (n = 37). There was no difference for need for neurosurgical intervention (26% vs 16%; P = .10) between the 2 groups. ConclusionsIn a matched cohort of trauma patients, preinjury Ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Preinjury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan.

Utility of Clinical and Radiographic Findings in the Management of Traumatic Epidural Hematoma

Background: There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups. Methods: We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center. Results: Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation. Conclusions: Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.

Outpatient follow-up of nonoperative cerebral contusion and traumatic subarachnoid hemorrhage: does repeat head CT alter clinical decision-making?

Many neurosurgeons obtain repeat head CT at the first clinic follow-up visit for nonoperative cerebral contusion and traumatic subarachnoid hemorrhage (tSAH). The authors undertook a single-center, retrospective study to determine whether outpatient CT altered clinical decision-making. The authors evaluated 173 consecutive adult patients admitted to their institution from April 2006 to August 2012 with an admission diagnosis of cerebral contusion or tSAH and at least 1 clinic follow-up visit with CT. Patients with epidural, subdural, aneurysmal subarachnoid, or intraventricular hemorrhage, and those who underwent craniotomy, were excluded. Patient charts were reviewed for new CT findings, new patient symptoms, and changes in treatment plan. Patients were stratified by neurological symptoms into 3 groups: 1) asymptomatic; 2) mild, nonspecific symptoms; and 3) significant symptoms. Mild, nonspecific symptoms included minor headaches, vertigo, fatigue, and mild difficulties with concentration, short-term memory, or sleep; significant symptoms included moderate to severe headaches, nausea, vomiting, focal neurological complaints, impaired consciousness, or new cognitive impairment evident on routine clinical examination. One hundred seventy-three patients met inclusion criteria, with initial clinic follow-up obtained within approximately 6 weeks. Of the 173 patients, 104 (60.1%) were asymptomatic, 68 patients (39.3%) had mild, nonspecific neurological symptoms, and 1 patient (1.0%) had significant neurological symptoms. Of the asymptomatic patients, 3 patients (2.9%) had new CT findings and 1 of these patients (1.0%) underwent a change in treatment plan because of these findings. This change involved an additional clinic appointment and CT to monitor a 12-mm chronic subdural hematoma that ultimately resolved without treatment. Of the patients with mild, nonspecific neurological symptoms, 6 patients (8.8%) had new CT findings and 3 of these patients (4.4%) underwent a change in treatment plan because of these findings; none of these patients required surgical intervention. The single patient with significant neurological symptoms did not have any new CT findings. Repeat outpatient CT of asymptomatic patients after nonoperative cerebral contusion and tSAH is very unlikely to demonstrate significant new pathology. Given the cost and radiation exposure associated with CT, imaging should be reserved for patients with significant symptoms or focal findings on neurological examination.

Repeated Head Injuries in Australia’s Collision Sports Highlight Ethical and Evidential Gaps in Concussion Management Policies

Head injuries (including concussion) are an inherent risk of participating in the major collision sports played in Australia (rugby league, rugby union and Australian Rules football). Protocols introduced by the governing bodies of these sports are ostensibly designed to improve player safety but do not prevent players suffering from repeated concussions. There is evidence that repeated traumatic brain injuries increase the risk of developing a number of long term problems but scientific and popular debates have largely focused on whether there is a causal link between concussion and chronic traumatic encephalopathy (CTE). We argue that the governing bodies of collision sports played in Australia have used uncertainty about CTE to justify a “wait and see” approach instead of attempting to prevent repeated head injuries. This stance is difficult to defend when these governing bodies claim to give a high priority to protecting player welfare.

Role of routine repeat head imaging in paediatric traumatic brain injury

Paediatric traumatic brain injuries (TBI) remain a leading cause of morbidity and mortality in Australia. There are clear guidelines on head imaging for children with TBI, but there is conflicting evidence on the role of routine repeat head computed tomography (CT) scan. This study aims to determine whether routine repeat head CT scans in paediatric TBI alter surgical or medical management. A retrospective study was performed at a level 1 tertiary paediatric trauma centre between January 2002 and July 2012. Patients with TBI who were admitted with acute intracranial injury and at least one repeat head CT scan were included. Mechanism of injury, severity of TBI, Glasgow Coma Score, use of intracranial pressure monitoring and operative procedures were listed. The need for operative management was compared for routine and clinically indicated head scans. Routine head CT scan was done in 36 out of 71 patients (51%). None from this group required craniotomy, but two children (6%) needed delayed ICP monitoring. Three patients with moderate to severe TBI required intracranial pressure monitor or external ventricular drain insertion based on a clinically indicated repeat head CT. Repeat head imaging is more likely to alter management of children with moderate to severe TBI. There is no role for routine repeat CT scan on mild TBI. Results of repeat cranial imaging should be correlated with the clinical status of the patient.

The BIG (brain injury guidelines) project

It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation. In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. κ statistic is equal to 0.98. We have proposed BIG based on patient's history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation. Epidemiologic study, level III.

Clinical outcomes in traumatic brain injury patients on preinjury clopidogrel

Patients receiving antiplatelet medications are considered to be at an increased risk for traumatic intracranial hemorrhage after blunt head trauma. However, most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate clinical outcomes and the requirement of a repeat head computed tomography (RHCT) in patients on preinjury clopidogrel therapy. Patients with traumatic brain injury with intracranial hemorrhage on initial head CT were prospectively enrolled. Patients on preinjury clopidogrel were matched with patients exclusive of antiplatelet and anticoagulation therapy using a propensity score in a 1:1 ratio for age, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (h-AIS), Injury Severity Score (ISS), neurologic examination, and platelet transfusion. Outcome measures were progression on RHCT scan and need for neurosurgical intervention. A total of 142 patients with intracranial hemorrhage on initial head CT scan (clopidogrel, 71; no clopidogrel, 71) were enrolled. The mean (SD) age was 70.5 (15.1) years, 66% were male, median GCS score was 14 (range, 3-15), and median h-AIS (ISS) was 3 (range, 2-5). The mean (SD) platelet count was 210 (101), and 61% (n = 86) of the patients received platelet transfusion. Patients on preinjury clopidogrel were more likely to have progression on RHCT (odds ratio [OR], 5.1; 95% confidence interval [CI], 3.1-7.1) and RHCT as a result of clinical deterioration (OR, 2.1; 95% CI, 1.8-3.5). The overall rate of neurosurgical intervention was 4.2% (n = 6). Patients on clopidogrel therapy were more likely to require a neurosurgical intervention (OR, 1.8; 95% CI, 1.4-3.1). Preinjury clopidogrel therapy is associated with progression of initial insult on RHCT scan and need for neurosurgical intervention. Preinjury clopidogrel therapy as an independent variable should warrant the need for a routine RHCT scan in patients with traumatic brain injury. Prognostic study, level I; therapeutic study, level II.

Repeat Head Computed Tomography in Anticoagulated Traumatic Brain Injury Patients: Still Warranted

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neurosurgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ(2) and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older (P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission (P < 0.001), were more likely to present with an abnormal neurologic examination (P = 0.004), and had higher hospital and intensive care unit lengths of stay (P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information.

Acquired coagulopathy of traumatic brain injury defined by routine laboratory tests

Coagulopathy is a major determinant of disability and death in patients with traumatic intracranial hemorrhage. However, the correlation between coagulopathy defined by routine coagulation tests and clinical outcomes in traumatic brain injury (TBI) is not well defined. The aim of our study was to determine the effect of coagulopathy diagnosed by routine laboratory tests on outcomes in TBI patients. We performed a retrospective cohort analysis of all isolated TBI patients exclusive of prehospital antiplatelet and anticoagulants with coagulation tests, namely, international normalized ratio (INR), platelet count, and partial thromboplastin time at admission. We defined coagulopathy by an INR of 1.5 or greater, partial thromboplastin time of 35 or greater, or platelet count of 100 × 10(3)/µL or less. Outcome measures were progression on repeat head computed tomography (RHCT), need for neurosurgical intervention, and mortality. A total of 591 patients were enrolled, with a mean (SD) age of 47.4 (26.5) years and 67% being male. Of the patients, 13.3% were coagulopathic at admission. Platelet count of 100 × 10(3)/µL or less was an independent predictor of progression on RHCT (odd ratio [OR], 4; 95% confidence interval [CI], 1.7-10), need for neurosurgical intervention (OR, 3.6; 95% CI, 1.2-6.1), and mortality (OR, 2.6; 95% CI, 1.1-4.8). INR was an independent predictor of progression on RHCT (OR, 2; 95% CI, 1.1-4.3). Routine bedside coagulation parameters at admission play an important role in predicting outcomes in blunt TBI. Platelet count is the strongest predictor for progression of initial insult on RHCT, need for neurosurgical intervention, and mortality. Prognostic study, level III.

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Introduction: Delayed intracranial hemorrhage (DICH) is a recognized complication of blunt head trauma in anticoagulated patients even after initially negative head CT. The reported incidence and complication rate of delayed ICH is inconsistent in existing literature. Routine repeat head CT at 24–48 hours after admission is standard practice in many institutions. We postulate that in the anticoagulated blunt trauma patient, the incidence and complication rate of delayed ICH after an initially negative head CT is low and that routine repeat head CT is not warranted. Methods: The aim of this retrospective, observational study was to determine if a routine repeat CT scan is necessary for patients to identify new, DICH. Data were collected from 338 trauma patients with pre-admission history of any anticoagulant use (including low dose ASA), who had an initially negative head CT, followed by a repeat CT within 12–24 hours. Results: Our sample were 57.7% male, had a mean age of 69.3 (SD14.47). Nearly 55% of the sample had obvious head trauma by observation, 27.2% reported LOC, with an average GCS of 14.5 (SD1.97). DICH was identified in 2.4% (n=8) of the sample on follow-up head CT. All eight patients were taking ASA. Of the eight patients with DICH: 3 were on ASA only, 4 on ASA and Plavix, and 1 on ASA and Coumadin. None of the patients with ICH on repeat CT scan required any surgical intervention. Conclusions: The incidence of delayed ICH in our population was only 2.4% (8/338). Of these 8, none required clinical intervention and there were no mortalities. We identified no significant predictors of delayed ICH, but all were taking ASA either alone or in combination with another anticoagulant. This data suggests that, while a period of clinical follow up is advised, routine repeat head CT is unnecessary in patients who have an initially negative head CT even in the presence of chronic anticoagulant use. This study demonstrates similar incidence of delayed ICH to other studies but includes all forms and doses of anticoagulation.

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Introduction: A 16 year-old female presented to an outside hospital after being found unresponsive at home. The day prior to presentation the patient was treated for tonsillitis with ceftriaxone. Because of depressed mental status, she was intubated and a head CT was obtained and read as normal. She was severely acidotic with an initial arterial pH of 6.7 and a bicarbonate of 5 mmol/L. A measured glucose was 482 mg/dL. During transport to our ED, the patient developed shock resulting in a total of 5L fluid resuscitation (115 ml/kg). In the ED dopamine and norepinephrine were initiated for fluid-refractory shock. A repeat head CT was again normal. She was started on an insulin drip and isotonic fluid at 2 times maintenance for DKA. In the PICU the patient required ongoing fluid resuscitation (30 ml/kg) and titration of vasopressors. The patient's serum osmolality was followed hourly during shock management. Her lowest recorded value was 301 mosmol/kg (normal range 270-310 mosml/kg). The patient's corrected serum sodium was also followed closely, ranging from 145-148 mmol/L. Within 24 hours of admission the patient's acidosis and hyperglycemia resolved. Shock resolved within 34 hours and she weaned from all vasopressor support. She was extubated to room air and had no neurologic deficits on examination. She was transitioned to intermittent insulin and transferred to the Endocrinology service on day #3 of admission. A 3 year-old female presented to our ED after being found unresponsive at home. The day prior to admission she was treated with IM penicillin for Streptococcal pharyngitis. In the ED the patient was intubated for lack of respiratory effort, leading to bradycardic arrest resulting in 2 minutes of CPR and 2 doses of epinephrine. She was in profound shock requiring 60 ml/kg of resuscitative fluid and a dopamine drip. Initial venous pH was 6.84 and bicarbonate was 6 mmol/L. Her first glucose was 1450 mg/dL. She was started on an insulin drip and isotonic fluid at 2 times maintenance for DKA. A head CT obtained was normal. In the PICU the patient had persistence of shock requiring further fluid resuscitation and the addition of an epinephrine drip. Stress-dose hydrocortisone was added for catecholamine-refractory shock. During the first 24 hours of admission the patient demonstrated dramatic urine output and glucosuria, prompting urine replacements in order to maintain her intravascular volume. She received a total of 280 ml/kg of resuscitative fluid. During active resuscitation, calculated serum osmolality ranged from 330-356 mosmol/kg, corrected sodium from 138-167 mmol/L. A head CT was repeated on day #2 and was again negative. By 48 hours of admission the patient's shock, acidosis, and hyperglycemia resolved. She weaned off vasopressors, hydrocortisone was discontinued, and urine replacements were stopped. She was extubated on day #5 of admission. Neurologically the patient could follow commands, but was noted to have mildly increased tone in her upper and lower extremities. She was transferred to the Endocrinology service on day #8 of admission. At 6 months post-discharge she was reported to be back to her neurologic baseline with normal tone. Cerebral edema remains the major life-threatening complication of children with DKA. Though the mechanism for cerebral edema remains unclear, one theory is grounded in rapid osmotic shifts and supports the use of judicious fluid administration. In circumstances of both DKA and persistent shock, conservative fluid administration may be inadequate to maintain perfusion. In such extreme cases, no established guideline exists. This report describes 2 patients with new onset DKA and shock who had consistently normal head CTs and mild, reversible neurological deficits despite large resuscitative fluid volumes. Further study is warranted before change in standard resuscitative practice can be advocated for in these fragile patients.

Routine Repeat Head CT for Children with Traumatic Brain Injury Is Unwarranted

To evaluate efficacy of repeat head computed tomography (CT) in pediatric patients with traumatic brain injuries (TBIs), investigators retrospectively

Value of Repeat Head Computed Tomography after Traumatic Brain Injury: Systematic Review and Meta-Analysis

Diagnosis and management of traumatic brain injury (TBI) is crucial to improve patient outcomes. While initial head computed tomography (CT) scan is the optimum tool for quick and accurate detection of intracranial hemorrhage, the guidelines on use of repeat CT differ among institutions. Three systematic reviews have been conducted on a similar topic; none have performed a comprehensive meta-analysis of all studies. Search of Medline, the Cochrane Library database, and Clinicaltrials.gov , and a hand search of conference abstracts and references for all completed studies reporting data on change in management following repeat CT was conducted. Two authors reviewed all studies and extracted data using a standardized form. A proportional meta-analysis was conducted using the random-effects model for outcomes related to any change in management following repeat CT. Any change in management included intracranial intervention, change in intracranial pressure monitoring, and/or administration of drug therapy. Search results yielded 6982 references. In all, 41 studies enrolling 10,501 patients were included. Change in management following repeat CT was reported in 13 prospective and 28 retrospective studies and yielded a pooled proportion of 11.4% (95% confidence interval [CI] 5.9-18.4) and 9.6% (95% CI 6.5-13.2), respectively. In a subgroup analysis of mild TBI patients (Glasgow Coma Scale score 13 to 15), five prospective and nine retrospective studies reported on change in management following repeat CT with the pooled proportion across prospective studies at 2.3% (95% CI 0.3-6.3) and across retrospective studies at 3.9% (95% CI 2.3-5.7), respectively. The evidence suggests that repeat CT in patients with TBI results in a change in management for only a minority of patients. Better designed studies are needed to address the issue of the value of repeat CT in the management of TBI.