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Repeat head computed tomography after minimal brain injury identifies the need for craniotomy in the absence of neurologic change

Thorson, Chad M. MD, MSPH; Van Haren, Robert M. MD; Otero, Christian A. MD; Guarch, Gerardo A. MD; Curia, Emiliano MD; Barrera, Jose M. MD; Busko, Alexander M. BS; Namias, Nicholas MD, MBA; Bullock, M. Ross MD, PhD; Livingstone, Alan S. MD; Proctor, Kenneth G. PhD

Journal of Trauma and Acute Care Surgery: April 2013 - Volume 74 - Issue 4 - p 967–975
doi: 10.1097/TA.0b013e3182877fed
AAST 2012 Plenary Papers

BACKGROUND: In this era of cost containment, the value of routine repeat head computed tomography (CT) in patients with mild TBI (mTBI) and no interval neurologic change has been challenged. The purpose of this study was to test the hypothesis that routine repeat head CT provides critical information after mTBI even with no neurologic change.

METHODS: From January 1996 to May 2010, records from all patients admitted to our Level I trauma center with an arrival Glasgow Coma Scale (GCS) score of 13 to 15 and at least one head CT were retrospectively reviewed.

RESULTS: In 360 patients with mTBI and positive initial head CT finding, the most common abnormalities were subarachnoid hemorrhage (64%), intraparenchymal hemorrhage (57%), and subdural hemorrhage (40%). Scans were repeated in 8 ± 6 hours; 11% were recalled, 59% remained stable, but 30% showed injury progression. Those patients with worsening repeat head CT finding had higher Injury Severity Score (ISS), were more likely to be intubated and require craniotomy, had longer stay, and had higher mortality (all p < 0.001). On multiple logistic regression, altered GCS score (odds ratio, 3.1–4.0), ISS (odds ratio, 1.1), and presence of mass effect (odds ratio, 2.0) were independently associated with worsening repeat head CT finding. In patients receiving a neurosurgical operative intervention, 32% to 59% had no clinical decline before the worsening repeat CT finding.

CONCLUSION: After mTBI, worsening of repeat head CT finding is seen in a third of patients and is associated with worse outcomes. A substantial fraction of patients who require operative intervention will have no clinical changes in the first 8 hours, supporting the value of repeat head CT within this time frame.

LEVEL OF EVIDENCE: Care management study, level III.

Divisions of Trauma and Surgical Critical Care (C.M.T., R.M.V.H., C.A.O., G.A.G., E.C., J.M.B., A.M.B., N.N., A.S.L., K.G.P.), Dewitt-Daughtry Family Department of Surgery, and Department of Neurological Surgery (M.R.B.), University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida.

Submitted: July 31, 2012, Revised: December 19, 2012, Accepted: December 20, 2012.

This study was presented at the 71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, September 12–15, 2012, in Kauai, Hawaii.

Address for reprints: Kenneth G. Proctor, PhD, Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami School of Medicine, Ryder Trauma Center, 1800 NW 10th Ave, Miami, FL 33136; email: kproctor@miami.edu.

© 2013 Lippincott Williams & Wilkins, Inc.