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Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
Head CT for Acute Head Traumas
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Head CT for Acute Head Traumas

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  • 1. Head CT for Mild Traumatic Brain Injuries Michael Oh MS4 Radiology March 2007
  • 2. Mild Traumatic Brain Injury (MTBI)
    • Injury caused by blunt contact and/or acceleration/deceleration forces
    • Also known as concussion
      • AAN defines concussion as altered mental status +/- LOC due to trauma
    • Main criteria : Glasgow Coma Scale (GCS) score of 13-15
    • LOC <20min +/- brief retrograde amnesia (<1hr)
    • no focal neurological deficits
    • no intracranial complications (i.e. seizures)
  • 3. Incidence of MTBI
    • ~1.4 million all traumatic brain injuries per year in US
      • ~75-95% are MTBIs (~1-1.3 million per year!!!)
    • $56 billion / year cost for TBIs in US
      • 44% due to MTBIs
    • MVI (45%), falls (30%), occupational accidents (10%), recreational accidents (10%), assaults (5%).
    • MTBI also very common in contact sports
      • 10% of college and 20% of high school football players each season
  • 4. Neuropathophysiology of MTBI
    • Diffuse axonal injury (DAI)
      • Shear forces in brain caused by sudden deceleration
    • Impairments in axonal transport, axonal swelling, Wallerian degeneration, and axonal transection
    • Cortical contusions due to coup and contrecoup injuries
    • Release of excitatory neurotransmitters (Ach, glutamate, aspartate) generates free radicals and excitotoxicity, leading to secondary injuries
  • 5. Clinical Features
    • Confusion and amnesia +/- brief LOC
    • Early symptoms (min to hrs): HA, dizziness, vertigo, N/V
    • Late symptoms (hrs to days): mood and cognitive disturbances, sensitivity to light and noise, sleep disturbances
  • 6. Indications for further evaluation
    • Impaired consciousness (GCS < 15)
    • Amnesia
    • Neuro symptoms: HA, N/V, AMS, seizures
    • Evidence of skull fx: CSF leak, periorbital hematoma
    • EtOH or anticoagulation
    • Mechanism of injury:
      • High energy injury (MVI, fall, etc.)
      • Possible penetrating injury
      • Possible non-accidental injury (child abuse)
    • Poor social conditions: i.e. no supervision at home
  • 7. MTBI can progress to more serious Complications
    • Intracranial complications: 6-21%
    • Neurosurgical intervention: only 0.4-1%!!!
    • Brain contusions
      • Localized ischemia, edema, and mass effect
    • Hemorrhage
      • Highly suspicious if neurological deterioration follows
      • Worsening HA, focal neurologic signs, confusion, and lethargy  LOC or death.
      • Intraparenchymal, subarachnoid, subdural, or epidural
    • Both contusions and hemorrhage can cause mass effect and brain herniations/death
  • 8. Indications for Neurosurgical Consult
    • Bleed in Head CT
    • Persisting coma (GCS < 8)
    • Confusion > 4hrs
    • Deterioration of consciousness
    • Focal neurological signs
    • Seizures without full recovery
    • Depressed skull fx
    • Penetrating injury
  • 9. Evaluation of MTBI
    • First: medical evaluation
    • Simple questions of orientation is insensitive
    • Standardized Assessment of Concussion (SAC, McCrea et al.)
      • Orientation (to time)
      • Immediate memory (repeating words)
      • Concentration (repeating string of numbers in reverse)
      • Delayed recall (recall of words after 5 min)
      • Neurologic screening (neuro exam)
      • Exertional maneuvers (sprint, sit-ups, push-ups, knee bends)
  • 10. Neuroimaging
    • Imaging: Head CT is the gold standard
    • MRI is more sensitive for axonal injuries, but not always specific and do not correlate with TBI severity or outcome.
    • Cost: MRI >>> CT
    • Plus all clinically important and neurosurgical injuries are detected by CT
    • Functional scans are not cost-effective and have not been standardized
  • 11. Intraparenchymal Hemorrhage
  • 12. Subarachnoid Hemorrhage
  • 13. Subdural Hemorrhage (acute)
  • 14. Epidural Hemorrhage
  • 15. GCS is critical in determining the need for Head CT
    • GCS < 8 requires intubation for airway protection  obtain Head CT
    • GCS 9-12 is moderate TBI  obtain Head CT
    • GCS 13-15 in mild TBI. Do we need to scan 1-1.3 million heads per year??? No!!!
      • How often does head CT pick up abnormalities that require neurosurgical interventions?
  • 16. Head CT in MTBI
    • GCS = 15  5% abnormal CT
    • GCS = 14  20% abnormal CT
    • GCS = 13  30% abnormal CT
    • However, only 1% all pts with MTBI (GCS 13-15) have abnormalities on CT that require neurosurgical intervention
  • 17. How to determine the need for Head CT
    • Two clinical criteria have been proposed to help determine the need for Head CT in MTBI
      • Canadian CT Head Rule (CCHR: Stiell et al. 2001)
      • New Orleans Criteria (NOC: Haydel et al. 2000)
  • 18. Canadian CT Head Rule (CCHR)
    • Patient population: GCS 13-15, +LOC, no neuro deficits, no seizure, no anticoagulation, aged > 16
    • Mandatory for head CT if any one:
      • GCS < 15 at 2hrs postinjury
      • Suspected skull fx
      • Any signs of basilar skull fx: hemotympanum, raccoon eyes, Battle’s sign, CSF leak
      • Vomiting ( ≥ 2)
      • Aged ≥ 65
    • Head CT recommended, otherwise close clinical observation
      • Retrograde amnesia >30min
      • Dangerous mechanism (MVI, fall, etc.)
  • 19. Canadian CT Head Rule (CCHR)
    • Sensitivity 98.4%
    • Specificity 49.6%
    • Potential reduction in number of Head CTs in ERs: 46%!!!
  • 20. New Orleans Criteria (NOC)
    • GCS = 15, +LOC, no neuro deficit, aged >3yrs
    • Indication for Head CT if any one:
      • HA
      • Vomiting
      • Seizure
      • Intoxication or drug involvement
      • Short-term memory deficit
      • Aged >60yrs
      • Other visible injuries above clavicle
  • 21. New Orleans Criteria (NOC)
    • Sensitivity 100%
    • Specificity 24.5%
    • Potential reduction in number of Head CTs in ERs: 23% (vs. 46% in CCHR)
    • Less specific compared to Canadian CT Head Rule due to EtOH/drug criteria
  • 22. CCHR vs. NOC
    • Stiell et al. JAMA (2005)
      • For patients with GCS = 15
      • Neurosurgical patients = 0.4%
      • CCHR and NOC have equivalent high sensitivities for neurosurgical cases and clinically important brain injury (100% for both)
      • Specificity for clinically important brain injury
        • CCHR (50.6%) > NOC (12.7%)
      • Specificity for neurosurgical cases
        • CCHR (76.3%) > NOC (12.1%)
      • CCHR (52.1%) would result in lower CT rates compared to NOC (88.0%)!!!
  • 23. CCHR vs. NOC
    • Smits et al. JAMA 2005
      • For patients with GCS 13-15
      • Neurosurgical patients = 0.5%
      • CCHR and NOC have equivalent high sensitivities for neurosurgical cases (100% for both)
      • NOC (97.7-99.4%) has higher sensitivity for clinically important brain injury than CCHR (83.4-87.2%)
      • BUT…Specificity was very low for NOC
        • CCHR (37.2-39.7%) > NOC (3.0-5.6%)
      • CCHR would lower CT rates by 37.3% compared to only 3.0% for NOC!!!
      • Thus, CCHR seems better compared to NOC
  • 24. Further studies still required!
    • Do we need 100% sensitivity on Head CT for clinically important brain injury that does not require further interventions (neurosurgery)?
      • Can some of these patients do well with observation alone without the initial head CT?
    • Which group of patient would benefit from head CT for clinical follow-up, despite not requiring neurosurgery?
    • Which patients can be sent home rather than admitted or held in ER for observation?
  • 25. References
    • Borg et al. Diagnostic procedures in mild traumatic brain injury: results of the WHO collaborating centre task force on mild traumatic brain injury. J Rehabil Med (2004) 43 Suppl:61.
    • Cushman et al. Practice management guidelines for the management of mild traumatic brain injury: The EAST practice management guidelines work group. (2001).
    • Haydel et al. Indications for computed tomography in patients with minor head injury. N Engl J Med (2000) 343:100.
    • McCrea et al. Standardized assessment of concussion in football players. Neurology (1997) 48:586.
    • Smits et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA (2005) 294:1519.
    • Stiell et al. The Canadian CT Head Rule for patients with minor head injury. Lancet (2001) 357:1391.
    • Stiell et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA (2005) 294:1511.
    • UpToDate : Concussion and mild traumatic brain injury (2007).

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