Relative risk of deterioration after mild closed head injury

Mixed messages from the 'Mild Traumatic Brain Injury' and 'Sport-related Concussion' literatures: Clinical implications

Objectives: The Sport-related Concussion (SRC) literature has three areas of emphasis which in some circumstances can be detrimental to the recovery of a patient after a mild traumatic brain injury (MTBI). These include the role of organic factors in post-concussion symptoms, the need to be asymptomatic to return to play and the later-life complications of sustaining multiple MTBIs. These contrast with quite different emphases in the broader MTBI literature and can cause significant anxiety for some patients with prolonged post-concussion symptoms (PCS).Methods: This paper presents for the first time a case where such factors operated.Results: Five sessions of cognitive-behavioural therapy (CBT) to address these elements resulted in the complete amelioration of persisting PCS.Conclusions: Anxiety due to maladaptive cognitions influenced by the 'mixed messages' from the SRC literature can exacerbate or solely maintain persisting PCS but may be successfully addressed with CBT.

Delayed neurological deterioration after mild head injury: cause, temporal course, and outcomes

BACKGROUND

Mild head injury (MHI) complicated by an intracranial hemorrhage (ICH) is a common cause of hospital admission after head trauma. Most patients are treated nonoperatively, remain neurologically stable, and are discharged uneventfully. However, a small percentage of patients suffer delayed neurological deterioration (DND). Little is known about the characteristics of DND after an MHI complicated by ICH.

OBJECTIVE

To identify the cause, temporal course, and outcomes of patients who deteriorated neurologically after presenting with MHI and ICH.

METHODS

A retrospective review was performed of all adult patients presenting over 54 consecutive months with MHI and ICH. Patients who were treated nonoperatively after initial head computed tomography and had a subsequent DND (Glasgow Coma Scale score decrease ≥2) were identified. Demographics, neurological status, clinical course, radiographic findings, and outcome data were collected.

RESULTS

Over 54 months, 757 patients with MHI plus ICH were admitted for observation; of these, 31 (4.1%) experienced DND. Eighty-seven percent of patients deteriorated within 24 hours after admission. Twenty-one patients (68%) deteriorated as a result of progressive intracranial hemorrhage, and 10 patients (32%) deteriorated as a result of medical causes. Seven patients (23%) died. Variables significantly associated with mortality included age > 60 years, coagulopathy, and change in Marshall computed tomography classification.

CONCLUSION

The incidence of delayed neurological deterioration after MHI with ICH is low and usually occurs within 24 hours after admission. It results in significant morbidity and mortality if it is the result of progressive intracranial hemorrhage. Further research is needed to identify risk factors that can allow early detection and improve outcomes in these patients.

Minor head injury in the elderly at very low risk: a retrospective study of 6 years in an Emergency Department (ED)

INTRODUCTION

Mild head injury (MHI) is a common clinical problem in emergency departments (EDs). Long-standing debate is still going on about MHI in the elderly: current guidelines recommend to perform a CT scan on this group.

MATERIALS AND METHODS

We performed a retrospective study by reviewing patients older than 65 years, evaluated in our ED for which a CT scan of the head was performed for MHI, between 2004 and 2010. According to Italian Guidelines, we considered only patients with low-risk MHI.

RESULTS

We considered 2149 eligible patients: we recorded 47 pathological acute findings on CT scan (2.18%), but only 3 patients (0.14%) underwent neurosurgery. We analysed our patients according to different age groups: in patients in the 65- to 79-year-old group, we documented pathological findings on CT in 0.66% of cases, with a significant increase in the group older than 80 years, with a rate of 3.33% of acute findings on CT (OR 5.22, P < .001); 617 patients were on antiplatelet therapy: 22 of these patients (3.72%) had a pathological finding on CT scan (OR 2.23, P < .005).

DISCUSSION

Our retrospective analyses demonstrated that the incidence of intracranial complications after MHI is not different from that of the general population, and based on this finding, a CT does not seem to be necessary, at least up to 80 years old. Our data suggest that antiplatelet therapy could be a significant risk factor. Our results suggest that elderly patients between 65 and 79 years old without risk factors could be managed as younger patients.

Transcranial Doppler to screen on admission patients with mild to moderate traumatic brain injury

BACKGROUND

Detecting patients at risk for secondary neurological deterioration (SND) after mild to moderate traumatic brain injury is challenging.

OBJECTIVE

To assess the diagnostic accuracy of transcranial Doppler (TCD) on admission in screening these patients.

METHODS

This prospective, observational cohort study enrolled 98 traumatic brain injury patients with an initial Glasgow Coma Scale score of 9 to 15 whose initial computed tomography (CT) scan showed either absent or mild lesions according to the Trauma Coma Data Bank (TCDB) classification, ie, TCDB I and TCDB II, respectively. TCD measurements of the 2 middle cerebral arteries were obtained on admission under stable conditions in all patients. Neurological outcome was reassessed on day 7.

RESULTS

Of the 98 patients, 21 showed SND, ie, a decrease of ≥ 2 points from the initial Glasgow Coma Scale or requiring any treatment for neurological deterioration. Diastolic cerebral blood flow velocities and pulsatility index measurements were different between patients with SND and patients with no SND. Using receiver-operating characteristic analysis, we found the best threshold limits to be 25 cm/s (sensitivity, 92%; specificity, 76%; area under curve, 0.93) for diastolic cerebral blood flow velocity and 1.25 (sensitivity, 90%; specificity, 91%; area under curve, 0.95) for pulsatility index. According to a recursive-partitioning analysis, TCDB classification and TCD measurements were the most discriminative among variables to detect patients at risk for SND.

CONCLUSION

In patients with no severe brain lesions on CT after mild to moderate traumatic brain injury, TCD on admission, in complement with brain CT scan, could accurately screen patients at risk for SND.

Indications for computed tomography in patients with mild head injury

The factors affecting outcome were analyzed in 1,064 patients, 621 males and 443 females aged 10 to 104 years (mean 46 +/- 23 years), with mild head injury (Glasgow Coma Scale [GCS] score > or =14) but no neurological signs presenting within 6 hours after injury. Intracranial lesion was found in 4.7% (50/1,064), and 0.66% (7/1,064) required surgical treatment. The Japan Coma Scale (JCS) and GCS assessments were well correlated (r = 0.797). Multivariate analysis revealed significant correlations between computed tomography (CT) abnormality and age > or =60 years, male sex, JCS score > or =1, alcohol consumption, headache, nausea/vomiting, and transient loss of consciousness (LOC)/amnesia. Univariate analysis revealed that pedestrian in a motor vehicle accident, falling from height, and mechanisms of injuries except blows were correlated to intracranial injury. No significant correlations were found between craniofacial soft tissue injury and intracranial injury. Patients with occipital impact, nonfrontal impact, or skull fracture were more likely have intracranial lesions. Bleeding tendency was not correlated with CT abnormality. The following indications were proposed for CT: JCS score >0, presence of accessory symptoms (headache, nausea/vomiting, LOC/amnesia), and age > or =60 years. These criteria would reduce the frequency of CT by 29% (309/1,064). Applying these indications to subsequent patients with GCS scores 14-15, 114 of 168 patients required CT, and intracranial lesions were found in 13. Two refused CT. Fifty-four of the 168 patients did not need CT according to the indications, but 38 of the 54 patients actually underwent CT because of social reasons (n = 21) or patient request (n = 17). These indications for CT including JCS may be useful in the management of patients with mild head injury.

Management of concussion and post-concussion syndrome

Concussion and mild traumatic brain injury (mTBI) are common clinical problems. However, the literature is not consistent in defining how concussion and mTBI are related. Although most patients with concussion recover within days to weeks, approximately 10% develop persistent signs and symptoms of post-concussion syndrome (PCS). There are no scientifically established treatments for concussion or PCS and thus rest and cognitive rehabilitation are traditionally applied, with limited effectiveness. This article presents a clinical model to suggest that concussion evolves to become mTBI after PCS has developed, representing a more severe form of brain injury. The basic pathophysiology of concussion is presented, followed by a recommended approach to the clinical evaluation of concussion in the emergency department and the physician's office. We evaluate the limited evidence-based pharmacologic treatment of acute concussion symptoms and PCS symptoms and also discuss return to activity recommendations, with an emphasis on athletes. Lastly, we suggest a promising new direction for helping patients recover from PCS.

Delayed Intracranial Complications After Concussion

BACKGROUND AND METHODS

The incidence of readmissions because of delayed intracranial complications within 3 weeks after observation for the sole diagnosis of concussion was examined in a national cohort. A nested case-control design was used to analyze the association between clinical factors as well as early computed tomography (CT) scan examination and these complications.

RESULTS

Out of 100,784 patients hospitalized because of concussion during ten years, 127 (0.13%) patients were readmitted because of a delayed intracranial complication. High clinical severity grade (odds ratio [OR] 2.0, confidence interval [CI] 1.2-3.6), minor CT scan abnormalities (OR 1.7, CI 0.8-3.4) and male gender (OR 2.2, CI 1.4-3.5) were associated with an increased risk of delayed, intracranial complications.

CONCLUSION

The incidence of delayed intracranial complications after primarily uncomplicated concussion was low. High clinical severity grade and male gender were risk factors. We failed to demonstrate an additional value of the acute CT scan examination to predict these complications.

Trauma in the anticoagulated patient

An increasing number of people are taking anticoagulants for the prophylaxis of thromboembolic disease. This may cause problems when they attend hospital following trauma. Patients may also develop spontaneous bleeding that may have similar effects to bleeding after an injury.

This article discusses the risks of bleeding (especially in head injury); the risks of stopping anticoagulation; how anticoagulation should be reversed and how anticoagulation should affect the approach to the head-injured patient.

Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study

OBJECT

The aims of this study were to analyze the relevance of risk factors in mild head injury (MHI) by studying the possibility of establishing prediction models based on these factors and to evaluate the reliability of the clinical guidelines proposed for the management of MHI.

METHODS

A series of 1101 patients with MHI were prospectively enrolled in this study. In all cases clinical data were collected and a computerized tomography (CT) scan was obtained. The relationship between clinical findings and the presence of intracranial lesions was studied to establish prediction models based on logistic regression and recursive partitioning analysis. Recently proposed guidelines and recommendations for the treatment of MHI were selected, calculating their diagnostic efficiency when applying each of them to our series. The incidence of acute intracranial lesions was 7.5% (83 patients). A Glasgow Coma Scale score of 14, loss of consciousness, vomiting, headache, signs of basilar skull fracture, neurological deficit, coagulopathies, hydrocephalus treated with shunt insertion, associated extracranial lesions, and patient age greater than 65 years were identified as independent risk factors. Prediction models built on clinical variables were able to indicate patients with clinically important lesions, but failed to achieve 100% sensitivity in the detection of all patients with CT scans positive for intracranial lesions within reasonable specificity limits.

CONCLUSIONS

Clinical variables are insufficient to predict all cases of intracranial lesions following MHI, although they can be used to detect patients with relevant injuries. Avoiding systematic CT scan indication implies a rate of misdiagnosis that should be known and assumed when planning treatment in these patients by using guidelines based on clinical parameters.

Traumatic brain and spinal cord injury

The management of pediatric head injuries has evolved over the past decade,and a number of significant advances have been made. Evidence-based guide-lines and algorithms for the management of severe pediatric head injuries have recently been published, and all pediatricians who care for children with severe head injuries should be familiar with these guidelines. It is hoped the guidelines will streamline the clinical management of these children and stimulate future research into the many areas that require further investigation.

A meta-analysis of GCS 15 head injured patients with loss of consciousness or post-traumatic amnesia

OBJECTIVES

The classification of patients with "minor head injury" has relied largely upon the Glasgow Coma Scale (GCS). The GCS however is an insensitive way of defining this heterogeneous subgroup of patients. The aim of the study was to develop an extended GCS 15 category by meta-analysis of previously published case-control studies that have identified symptom risk factors for an abnormal head tomogram.

METHODS

Eligibility for the study was defined as: (1) Full papers and not abstracts. (2) Case-control or nested case-control studies on GCS 15 patients (adults or adults plus children). Outcome variable being head tomography: normal or abnormal. (3) Documentation of one or more symptom variables such that the odds ratio could be calculated. Five symptom variables were defined for the purpose of the study: headache, nausea, vomiting, blurred vision, and dizziness.

RESULTS

Three articles fulfilled the criteria for the study. The Mantel-Haenszel test using a pooled estimate was used to calculate the common odds ratio for an abnormal head tomogram for each of the five symptom variables. The odds ratio for the symptom variables was: dizziness 0.594 (95%CI 0.296 to 1.193), blurred vision 0.836 (95%CI 0.369 to 1.893), headache 0.909 (95% CI: 0.601 to 1.375), severe headache 3.211 (95% CI: 2.212 to 4.584), nausea 2.125 (95% CI 1.467 to 3.057), vomiting 4.398 (95% CI 2.790 to 6.932).

CONCLUSION

The results of this study provide a framework on which GCS category 15 patients can be stratified into four risk categories based upon their symptoms.

Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management

The lack of a common, widely acceptable criterion for the definition of trivial, minor, or mild head injury has led to confusion and difficulty in comparing findings in published series. This review proposes that acute head-injured patients previously described as minor, mild, or trivial are defined as "mild head injury," and that further groups are recognized and classified as "low-risk mild head injury," "medium risk mild head injury," or "high-risk mild head injury." Low-risk mild injury patients are those with a Glasgow Coma Score (GCS) of 15 and without a history of loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is definitively less than 0.1:100. These patients can be sent home with written recommendations. Medium risk mild injury patients have a GCS of 15 and one or more of the following symptoms: loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is in the range of 1-3:100. Where there is one computed tomography (CT) scanner available in an area for 100,000 people or less, a CT scan should be obtained for such patients. If CT scanning is not so readily available, adults should have a skull x-ray and, if this shows a fracture, should be moved to the "high-risk" category and undergo CT scanning. High-risk mild head injury patients are those with an admission GCS of 14 or 15, with a skull fracture and/or neurological deficits. The risk of intracranial hematoma requiring surgical evacuation is in the range 6-10:100. If a CT scan is available for 500,000 people or less, this examination must be obtained. Patients with one of the following risk factors--coagulopathy, drug or alcohol consumption, previous neurosurgical procedures, pretrauma epilepsy, or age over 60 years--are included in the high-risk group independent of the clinical presentation.

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee

BACKGROUND

The Scandinavian Neurotrauma Committee was initiated by the Scandinavian Neurosurgical Society to develop evidence-based guidelines for improved care of neurotrauma patients.

METHODS

A MEDLINE search identified 475 papers dealing with the management of minimal, mild, and moderate head injuries. Forty-two studies presenting class II evidence on the initial management of such injuries were reviewed and management guidelines were developed.

RESULTS

Implementation of the Head Injury Severity Scale is advocated. Patients with minimal injuries (no loss of consciousness, Glasgow Coma Scale score of 15) can be safely discharged. Routine early computed tomographic scan is recommended in cases with mild injuries (history of loss of consciousness, Glasgow Coma Scale score = 14-15) and patients with normal scans may be discharged. Computed tomographic scan and admission is mandatory in moderate injuries (Glasgow Coma Scale score = 13). All patients harboring additional risk factors should be scanned and admitted. A flow-chart for clinical decision making and a Head Injury Instruction card is introduced.

CONCLUSIONS

The Scandinavian Neurotrauma Committee suggests guidelines that should be safe and cost-effective for the initial management of minimal, mild, and moderate head injuries.

Current controversies in the management of minor pediatric head injuries

Each year hundreds of thousands of children receive care in emergency departments after head injury. Minor head injuries account for a majority of these injuries. The prevalence, morbidity, and costs associated with pediatric minor head injuries make it an important topic. We review the management of pediatric minor head injury, emphasizing current areas of controversy, including criteria for neuroimaging, indications for hospitalization, the role of anticonvulsant therapy, and the long-term neurobehavioral sequelae of pediatric minor head injury.

Current concepts in the management of patients with so-called ‘minor’ or ‘mild’ head injury

‘Mild’ head injury is increasingly recognized as a potential source of physical and psychological disability, but there is a lack of consistency about the definition and management of these patients. We discuss and define the terms ‘mild’ and ‘minor’, the assessment of post-traumatic amnesia, and the relevance of other signs and symptoms.

Previous guidelines and recent evidence that a ‘mild’ injury may be followed by an intracranial complication are reviewed as a basis for recommendations for investigation and management in accident and emergency departments, for in-patient observation and for discharge planning.

Significance of vomiting after head injury

OBJECTIVES

To determine whether the presence and severity of post-traumatic vomiting can predict the risk of a skull vault fracture in adults and children.

METHODS

Data were analysed relating to a consecutive series of 5416 patients including children who presented to an emergency service in the United Kingdom during a 1 year study period with a principal diagnosis of head injury. Characteristics studied were age, sex, speed of impact, level of consciousness on arrival, incidence of skull fracture, and the presence and severity of post-traumatic vomiting.

RESULTS

The overall incidence of post-traumatic vomiting was 7% in adults and 12% in children. In patients with a skull fracture the incidence of post-traumatic vomiting was 28% in adults and 33% in children. Post-traumatic vomiting was associated with a fourfold increase in the relative risk for a skull fracture. Nausea alone did not increase the risk of a skull fracture and multiple episodes of vomiting were no more significant than a single episode. In patients who were fully alert at presentation, post-traumatic vomiting was associated with a twofold increase in relative risk for a skull fracture.

CONCLUSION

These results support the incorporation of enquiry about vomiting into the guidelines for skull radiography. One episode of vomiting seems to be as significant as multiple episodes.