Recommendations from the Society of British Neurological Surgeons

Head CT scan in emergency room: Is it still abused? Quantification and causes analysis of overprescription in an Italian Emergency Department

In recent years, the increasing prescription of diagnostic imaging has been noted, due to advances in imaging technology and the development of defensive medicine. Overuse of diagnostic imaging significantly impacts the quality and costs of health care. Therefore, the purpose of this study was to quantify overprescription and investigate its causes through the evaluation of head computer tomography (CT) scan prescriptions. In this study, a set of 100 requests of CT scans was collected and analysed by three experts in guidelines and scientific evidences, evaluating prescription appropriateness. Then, the rate of overprescription was quantified and its causes identified as incorrect adoption of guidelines indications (32%) and as defensive medicine (6%). Therefore, in order to reduce inappropriate investigations, the findings of the present study suggest that the reduction in overprescription could be reached through the improvement of training of health personnel and the propagation of a no-blame culture aimed at minimizing defensive medicine.

The Role of Temporal Lobectomy as a Part of Surgical Resuscitation in Patients with Severe Traumatic Brain Injury

Background:

Traumatic brain injuries (TBIs) are serious morbidity and mortality risk for especially in the young population. Primary and secondary injury mechanisms may cause cerebral edema and intracranial hypertension. The target point of the TBI treatment is lowering the intracranial pressure medically or surgically if indicated.

Methods:

The files of the patients with severe brain injury admitted between January 2015 and December 2017 were reviewed retrospectively. Patients who underwent decompression surgery due to severe brain injury ([The Glasgow Coma Scale [GCS] score] <8) and additional temporal lobectomy were included in the study group.

Results:

Ten patients were included in the study during the 3 years. All the patients were suffering from blunt severe TBI. Traumatic etiology was vehicle traffic accident in six cases, nonvehicle traffic accident in two cases, and falling from height in two cases. All the cases suffered from blunt trauma. The admission GCS of the patients was 4–7 (mean = 5.5). Right-sided decompression surgery and lobectomy were performed for seven patients and left-sided in three cases. The postoperational survival was 60%. All the survivors were functionally independent with mild cognitive disturbances.

Conclusion:

Temporal lobectomy might be added to the surgery to apply all the interventions available in combat with progressively increasing intracerebral pressure as a part of surgical resuscitation.

Challenges in minor TBI and indications for head CT in pediatric TBI-an update

INTRODUCTION

Pediatric head trauma is one of the commonest presentations to emergency departments. Over 90% of such head injuries are considered mild, but still present risk acute clinical deterioration and longer term morbidity. Identifying which children are at risk of clinically important brain injuries remains challenging and much of the data on minor head injuries is based on the adult population.

CHALLENGES IN PEDIATRICS

Children, however, are different, both anatomically and in terms of mechanism of injury, to adults and, even within the pediatric group, there are differences with age and stage of development.

IMAGING

CT scans have added to the repertoire of clinicians in the assessment of pediatric head injury population, but judicious use is required given radiation exposure, malignancy risk, and resource constraints. Guidelines and head injury rules have been developed, for adults and children, to support decision-making in the emergency department though whether their use is applicable to all population groups is debatable. Further challenges in mild pediatric head trauma also include appropriate recommendations for school attendance and physical activity after discharge.

FURTHER DEVELOPMENTS

Concern remains for second-impact syndrome and, in the longer term, for post-concussive syndrome and further research in both is still needed. Furthermore, the development of clinical decision rules raises further questions on the purpose of admitting children with minor head injuries and answering this question may aid the evolution of clinical decision guidelines.

CONCLUSIONS

The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.

Trauma

Traumatic brain and spine injury (TBI/TSI) is a leading cause of death and lifelong disability in children. The biomechanical properties of the child's brain, skull, and spine, the size of the child, the age-specific activity pattern, and variance in trauma mechanisms result in a wide range of age-specific traumas and patterns of brain and spine injuries. A detailed knowledge about the various types of primary and secondary pediatric head and spine injuries is essential to better identify and understand pediatric TBI/TSI, which enhances sensitivity and specificity of diagnosis, will guide therapy, and may give important information about the prognosis. The purposes of this chapter are to: (1) discuss the unique epidemiology, mechanisms, and characteristics of TBI/TSI in children; (2) review the anatomic and functional imaging techniques that can be used to study common and rare pediatric TBI/TSI and their complications; (3) comprehensively review frequent primary and secondary brain injuries; and (4) to give a short overview of two special types of pediatric TBI/TSI: birth-related and nonaccidental injuries.

Continuous measurement of the cumulative amplitude and duration of hyperglycemia best predicts outcome after traumatic brain injury

BACKGROUND

This study aimed to assess the accuracy and utility of high-resolution continuous glucose recording in patients with traumatic brain injury (TBI) and to establish whether a relationship exists between the cumulative amplitude and duration of hyperglycemia and outcome after TBI.

METHODS

Glucose data for 56 TBI patients were collected continuously at 5-min intervals. The degree and duration of hyperglycemia above treatment thresholds were calculated as "glucose times time dose" (GTD; mg/dL d) using continuous recordings (GTD) for early stage (first 3 days). Long-term neurological functional outcome was assessed using the extended Glasgow Outcome Scale (GOSE). Receiver operating characteristic (ROC) curves were constructed to determine the predictive values of GTD, percentage readings, mean, and range of glucose for in-hospital mortality and GOSE.

RESULTS

All measurements of GTD were statistically significantly higher in the group that died. GTD of glucose >150 and glucose >180 had a high-predictive power for in-hospital mortality (areas under the ROC curve [AUC] = 0.917; 95 % CI, 0.837-0.998 and 0.876; 95 % CI, 0.784-0.967, respectively) and demonstrated significantly higher predictive power for mortality when compared with %reading >150 and %reading >180, respectively (p < 0.05). GTD of glucose >150 also had a significantly higher predictive power for mortality than mean glucose and range of glucose. GTD of glucose >150 and glucose >180 also had a high-predictive power for poor outcome (areas under the ROC curve [AUC] = 0.913; 95 % CI, 0.843-0.983 and 0.858; 95 % CI, 0.760-0.956, respectively).

CONCLUSIONS

Continuous collection of glucose recordings is more reliable and accurate than routine discontinuous recordings. Assessing both the duration and the amplitude of the episodes using continuous collection of glucose data helps in better predicting outcomes than the total duration of episodes.

Suicide, fatal injuries, and other causes of premature mortality in patients with traumatic brain injury: a 41-year Swedish population study

:

IMPORTANCE

Longer-term mortality in individuals who have survived a traumatic brain injury (TBI) is not known.

OBJECTIVES

To examine the relationship between TBI and premature mortality, particularly by external causes, and determine the role of psychiatric comorbidity.

DESIGN, SETTING, AND PATIENTS

We studied all persons born in 1954 or later in Sweden who received inpatient and outpatient International Classification of Diseases-based diagnoses of TBI from 1969 to 2009 (n = 218,300). We compared mortality rates 6 months or more after TBI to general population controls matched on age and sex (n = 2,163,190) and to unaffected siblings of patients with TBI (n = 150,513). Furthermore, we specifically examined external causes of death (suicide, injury, or assault). We conducted sensitivity analyses to investigate whether mortality rates differed by sex, age at death, severity (including concussion), and different follow-up times after diagnosis.

MAIN OUTCOMES AND MEASURES

Adjusted odds ratios (AORs) of premature death by external causes in patients with TBI compared with general population controls.

RESULTS

Among those who survived 6 months after TBI, we found a 3-fold increased odds of mortality (AOR, 3.2; 95% CI, 3.0-3.4) compared with general population controls and an adjusted increased odds of mortality of 2.6 (95% CI, 2.3-2.8) compared with unaffected siblings. Risks of mortality from external causes were elevated, including for suicide (AOR, 3.3; 95% CI, 2.9-3.7), injuries (AOR, 4.3; 95% CI, 3.8-4.8), and assault (AOR, 3.9; 95% CI, 2.7-5.7). Among those with TBI, absolute rates of death were high in those with any psychiatric or substance abuse comorbidity (3.8% died prematurely) and those with solely substance abuse (6.2%) compared with those without comorbidity (0.5%).

CONCLUSIONS AND RELEVANCE

Traumatic brain injury is associated with substantially elevated risks of premature mortality, particularly for suicide, injuries, and assaults, even after adjustment for sociodemographic and familial factors. Current clinical guidelines may need revision to reduce mortality risks beyond the first few months after injury and address high rates of psychiatric comorbidity and substance abuse.

The role of neurosciences intensive care in trauma and neurosurgical conditions

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.

The effectiveness of specialist neuroscience care in severe traumatic brain injury: a systematic review

BACKGROUND

UK trauma services are currently undergoing reconfiguration, but the optimum management pathway for head-injured patients is uncertain. We therefore performed a systematic review to assess the effects of routine inter-hospital transfer and specialist neuroscience care on mortality and disability in patients with non-surgical severe traumatic brain injury injured nearest to a non-specialist acute hospital.

METHODS

A protocol was registered with PROSPERO (CRD42012002021) and review methodology followed Cochrane Collaboration recommendations. A peer reviewed search strategy was implemented in an exhaustive range of information sources, including all major bibliographic databases, between 1973 and July 2013. Selection of eligible studies, extraction of relevant data and bias assessment were then performed by two independent reviewers. In the absence of homogeneous effect estimates at low risk of bias a narrative synthesis was pre-specified.

RESULTS

Four cohort studies, including a total of 4688 patients, were identified as potentially eligible after screening and bias assessment. Confounding by indication, arising from selective transfer of less severely injured patients, was the main limitation of included studies, with overall risk of bias rated as high for both mortality and disability effect estimates. Adjusted odds ratios for mortality favoured secondary transfer, ranging from 1.92 (95% CI 1.25-2.95) to 2.09 (95% CI 1.59-2.74). No convincing association was observed between non-specialist care and unfavourable outcome with a conditional odds ratio of 1.13 (95% CI 0.36-3.6).

CONCLUSIONS

There is limited evidence supporting a strategy of secondary transfer of severe non-surgical traumatic brain injury patients to specialist neuroscience centres. Randomised controlled trials powered to detect clinically plausible treatment effects should be considered to definitively investigate effectiveness.

Mild traumatic brain injury

Traumatic Brain Injury (TBI) is among the most frequent neurological disorders. Of all TBIs 90% are considered mild with an annual incidence of 100–300/100.000. Intracranial complications of Mild Traumatic Brain Injury (MTBI) are infrequent (10%), requiring neurosurgical intervention in a minority of cases (1%), but potentially life-threatening (case fatality rate 0,1%). Hence, a true health management problem exists because of the need to exclude the small chance of a life threatening complication in large numbers of individual patients. The 2002 EFNS guidelines used a best evidence approach based on the literature until 2001 to guide initial management with respect to indications for CT, hospital admission, observation and follow up of MTBI patients. This updated EFNS guideline version for initial management inMTBI proposes a more selectively strategy for CT when major (dangerous mechanism, GCS<15, 2 points deterioration on the GCS, clinical signs of (basal) skull fracture, vomiting, anticoagulation therapy, post traumatic seizure) or minor (age, loss of consciousness, persistent anterograde amnesia, focal deficit, skull contusion, deterioration on the GCS) risk factors are present based on published decision rules with a high level of evidence. In addition clinical decision rules for CT now exist for children as well. Since 2001 recommendations, although with a lower level of evidence, have been published for clinical in hospital observation to prevent and treat other potential threads to the patient including behavioral disturbances (amnesia, confusion and agitation) and infection.

CT Scans in Young People in Great Britain: Temporal and Descriptive Patterns, 1993-2002

Background. Although using computed tomography (CT) can be greatly beneficial, the associated relatively high radiation doses have led to growing concerns in relation to potential associations with risk of future cancer. Very little has been published regarding the trends of CT use in young people. Therefore, our objective was to assess temporal and other patterns in CT usage among patients aged under 22 years in Great Britain from 1993 to 2002. Methods. Electronic data were obtained from the Radiology Information Systems of 81 hospital trusts within Great Britain. All included patients were aged under 22 years and examined using CT between 1993 and 2002, with accessible radiology records. Results. The number of CT examinations doubled over the study period. While increases in numbers of recorded examinations were seen across all age groups, the greatest increases were in the older patients, most notably those aged 15-19 years of age. Sixty percent of CT examinations were of the head, with the percentages varying with calendar year and patient age. Conclusions. In contrast to previous data from the North of England, the doubling of CT use was not accompanied by an increase in numbers of multiple examinations to the same individual.

The unique features of traumatic brain injury in children. Review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications and their imaging findings--part 1

Traumatic head/brain injury (TBI) is a leading cause of death and life-long disability in children. The biomechanical properties of the child's brain and skull, the size of the child, the age-specific activity pattern, and higher degree of brain plasticity result in a unique distribution, degree, and quality of TBI compared to adult TBI. A detailed knowledge about the various types of primary and secondary pediatric head injuries is essential to better identify and understand pediatric TBI. The goals of this review article are (1) to discuss the unique epidemiology, mechanisms, and characteristics of TBI in children, and (2) to review the anatomical and functional imaging techniques that can be used to study common and rare pediatric traumatic brain injuries and their complications.

Glucose variability negatively impacts long-term functional outcome in patients with traumatic brain injury

PURPOSE

Significant glycemic excursions (so-called glucose variability) affect the outcome of generic critically ill patients but has not been well studied in patients with traumatic brain injury (TBI). The purpose of this study was to evaluate the impact of glucose variability on long-term functional outcome of patients with TBI.

MATERIAL AND METHODS

A noncomputerized tight glucose control protocol was used in our intensivist model surgical intensive care unit. The relationship between the glucose variability and long-term (a median of 6 months after injury) functional outcome defined by extended Glasgow Outcome Scale (GOSE) was analyzed using ordinal logistic regression models. Glucose variability was defined by SD and percentage of excursion (POE) from the preset range glucose level.

RESULTS

A total of 109 patients with TBI under tight glucose control had long-term GOSE evaluated. In univariable analysis, there was a significant association between lower GOSE score and higher mean glucose, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL but not POE 80 to 110. After adjusting for possible confounding variables in multivariable ordinal logistic regression models, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL were significantly associated with lower GOSE score.

CONCLUSIONS

Glucose variability was significantly associated with poorer long-term functional outcome in patients with TBI as measured by the GOSE score. Well-designed protocols to minimize glucose variability may be key in improving long-term functional outcome.

Cautious observation or blanket scanning? An investigation into paediatric attendances to an emergency department after head injury

In September 2007, the National Institute for Health and Clinical Excellence (NICE) in the UK issued a newly updated guideline (CG56) on the early care of adults and children with head injuries.(8) The guideline gives some new recommendations, in particular with regards to imaging of children with head injury. We undertook a study to investigate the management of children presenting with head injury to our emergency department and to assess their outcomes and the CT scanning rate. We then retrospectively applied the new NICE guidelines, using information documented in the case notes, to establish whether adherence to the guidelines would significantly affect CT scanning rates. 237 paediatric head injury cases were seen over the 2-month period that was studied. The actual CT scanning rate observed was 2.1%, rising to 18.1% after strictly applying NICE criteria. This increased scanning rate raises some important issues with regards to patient safety and service provision.

CT scans in young people in Northern England: trends and patterns 1993-2002

BACKGROUND

Although CT can be greatly beneficial, its relatively high radiation doses have caused public health concerns.

OBJECTIVE

To assess patterns in CT usage among patients aged less than 22 years in Northern England during the period 1993-2002.

MATERIALS AND METHODS

Electronic data were obtained from radiology information systems of all nine National Health Service trusts in the region.

RESULTS

A total of 38,681 scans had been performed in 20,483 patients aged less than 22 years. The number of CT examinations rose, with the steepest increase between 1997 and 2000. The number of patients scanned per year increased less dramatically, with 2.24/1,000 population aged less than 22 years having one scan or more in 1993 compared to 3.54/1,000 in 2002. This reflects an increase in the median number of scans per patient, which rose from 1 in 1993 to 2 by 1999. More than 70% of CT examinations were of the head, with the number of head examinations varying with time and patient age.

CONCLUSION

The frequency of CT scans in this population more than doubled during the study period. This is partly, but not wholly, explained by an increase in the number of scans per patient.

The Nottingham Head Injury Register: A Survey of 1,276 Adult Cases of Moderate and Severe Traumatic Brain Injury in a British Neurosurgery Centre

The Nottingham Head Injury Register was established as an audit and research tool for traumatic brain injury (TBI). Study aims included examination of the epidemiology of UK TBI and identification of factors improving management and outcome. Moderate and severe TBI patients admitted to a UK neurosurgery centre were recruited over a 10-year period from 1993 to 2003. A dataset covering all aspects of TBI, including demography, clinical features, investigations, management, complications and outcome were captured prospectively into a computerised database. The study group comprised 1,276 adult patients aged more than 16 years old. The median age of subjects was 35 years, with 78% of the population consisting of male patients. Road traffic accidents were responsible for 49% of injuries; 37% of the study population had moderate TBI and 63% severe TBI. CT brain scan was performed in 92% of cases showing a mass lesion in 41% and diffuse lesion in 59%. Traumatic subarachnoid haemorrhage was present in 34%. At 12 months 32% of patients had died, 13% were severely disabled, 22% were moderately disabled and 33% had made a good recovery. Findings were comparable with other previous large series of TBI patients from international studies. Registry data is useful to define TBI epidemiology and management, and in validation of prognostic scoring systems.

Moderate and severe traumatic brain injury in adults

Traumatic brain injury (TBI) is a major health and socioeconomic problem that affects all societies. In recent years, patterns of injury have been changing, with more injuries, particularly contusions, occurring in older patients. Blast injuries have been identified as a novel entity with specific characteristics. Traditional approaches to the classification of clinical severity are the subject of debate owing to the widespread policy of early sedation and ventilation in more severely injured patients, and are being supplemented with structural and functional neuroimaging. Basic science research has greatly advanced our knowledge of the mechanisms involved in secondary damage, creating opportunities for medical intervention and targeted therapies; however, translating this research into patient benefit remains a challenge. Clinical management has become much more structured and evidence based since the publication of guidelines covering many aspects of care. In this Review, we summarise new developments and current knowledge and controversies, focusing on moderate and severe TBI in adults. Suggestions are provided for the way forward, with an emphasis on epidemiological monitoring, trauma organisation, and approaches to management.

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.

An unusual presentation of a minor head injury sustained during a game of rugby

In the UK, about 2% of the population attend the accident and emergency (A&E) department every year after a head injury. A majority of the patients have minor head injury and are discharged. Studies reveal that patients who reattend the A&E after a minor head injury represent a high-risk group. Concussion injuries are common and not all require treatment at the time of presentation. However, some may worsen after initial presentation and develop signs of serious head injury. A case of minor head injury as a result of head butt during a game of rugby, not associated with alteration in conscious state or focal neurological signs, and subsequent development of frontal lobe abscess a month later is reported. It is important that patients fit to be discharged at the time of consultation are discharged in the care of a responsible adult with clear head injury instruction sheets and are advised to return should their symptoms change. A high index of suspicion should be maintained and an early imaging technique, such as CT scan should be considered in patients reattending the A&E with persistent symptoms even after minor head injury.

Association Between Implementation of Clinical Practice Guidelines and Outcome for Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of death in the population under 40 years of age in Western countries, and the same was true for Latvia in 1999. This indicated a strong need to improve the management of TBI. The Latvian Society of Neurosurgeons in collaboration with related societies created a dedicated working group, and the Guidelines for Medical Management of TBI in Latvia (Guidelines) were developed in 2001. This study aimed to assess the association between implementation of the Guidelines and the outcome of TBI patients.

METHODS

The Guidelines were printed and distributed to relevant clinical units and teaching institutions. To assess the impact of the Guidelines on the outcome of TBI, Latvian medical statistics were researched. All patients admitted to emergency departments and registered as either discharged or dead with a diagnosis of head trauma from 1998 to 2004 were included in a retrospective survey. The primary endpoint accepted for analysis was the hospital case fatality rate (HCFR).

RESULTS

The survey included 73,062 consecutive cases. The annual incidence rate of TBI admissions was stable during the period 1998 to 2004 (range 41.5-46.0/10,000), and the incidence of moderate and severe TBI (range 7.2-8.7/10,000) showed no significant trends. There was a reduction of HCFR from 3.7% during 1998-2000 to 2.6% during 2002-2004 (relative risk 0.72; 95% confidence interval 0.67-0.76; p = 0.03).

CONCLUSION

Implementation of the Guidelines was associated with a statistically significant decrease of HCFR in TBI patients.

Management of minor head injuries according to NICE guidelines and changes in the number of patients requiring computerised tomography imaging in a district general hospital: a retrospective study

The objective of this study was to investigate how many patients with minor head injury would have required computerised tomography (CT) imaging if they were to be managed according to the National Institute of Clinical Excellence (NICE) guidelines (June 2003) and the difference in workload for patients presenting out of hours at Calderdale Royal Hospital, Halifax. The study was a retrospective cohort analysis of patient's notes presenting with head injury at Calderdale Royal Hospital, Halifax. The data set comprised case notes of 844 patients with head injuries, 400 adults and 444 children attending the Accident and Emergency department from January to June 2003. The case notes were evaluated according to the NICE guidelines for the indications for CT imaging for the time that they presented to the Accident and Emergency department, and how many of them actually underwent CT imaging. The number of patients who required CT imaging and how many of them presented out of hours (between 17:00 and 21:00 hours on weekdays and at any time on weekends). Ten patients underwent CT imaging for minor head injuries from January to June 2003. Eighty-eight patients required CT imaging if they were to be managed according to the NICE guidelines. Sixty-three per cent of these patients presented out of hours when a radiologist was not available in the hospital. Adhering to the NICE guidelines would significantly increase the number of patients requiring CT imaging. A significant proportion of these patients would present out of hours.

Transfer of intubated patients with traumatic brain injury to Auckland City Hospital

BACKGROUND

Delays in patient transfer to definitive neurosurgical care after traumatic brain injury are important in determining neurological outcome. The efficiency of interhospital transfer of patients to Auckland City Hospital (ACH) was analysed and compared with international standards.

METHODS

The ACH Department of Critical Care Medicine database for the year 2002 was reviewed, with supplementary information obtained from transfer organizations, hospital notes, radiology archives, and operative logbooks.

RESULTS

Thirty-four adult patients with traumatic brain injury and no special reasons for delayed transfer were transported intubated from other hospitals in the North Island of New Zealand. The median time from injury to arrival at ACH was 6.5 h. It took a median 4.4 h for patients to get from initial computed tomographic imaging to ACH. For those requiring evacuation of haematomas, the mean time from arrival at ACH to the start of the operation was 1.4 h. Only 33% of patients from other metropolitan Auckland hospitals, and none from hospitals outside the city, arrived within 4 h from the time of injury.

CONCLUSION

Transfer times for brain trauma patients are currently longer than recommended for optimal neurological outcome. Referring hospitals and transfer organizations should review their systems to identify areas for improvement. Direct admission to theatre needs to be expedited within ACH when required. Triage of all trauma patients in metropolitan Auckland with a Glasgow Coma Scale score of less than 14 to ACH would be likely to improve time to treatment. A mobile acute neurosurgical service based in Auckland that would support general surgeons initiating acute decompressive cranial operations would be likely to reduce time to surgery and improve outcomes for patients admitted to hospitals outside Auckland. The development of a mobile acute neurosurgery service which would complete decompressive procedures started by general surgeons would likely improve trauma outcomes for patients injured outside Auckland.

New developments in the neuroradiological diagnosis of craniocerebral trauma

Accurate radiographic diagnosis is a cornerstone of the clinical management and outcome prediction of the head-injured patient. New technological advances, such as multi-detector computed tomography (MDCT) scanning and diffusion-weighted magnetic resonance imaging (MRI) have influenced imaging strategy. In this article we review the impact of these developments on the neuroradiological diagnosis of acute head injury. In the acute phase, multi-detector CT has supplanted plain X-ray films of the skull as the initial imaging study of choice. MRI, including fluid-attenuated inversion recovery, gradient echo T2* and diffusion-weighted sequences, is useful in determining the severity of acute brain tissue injury and may help to predict outcome. The role of MRI in showing diffuse axonal injuries is emphasized. We review the different patterns of primary and secondary extra-axial and intra-axial traumatic brain lesions and integrate new insights. Assessment of intracranial hypertension and cerebral herniation are of major clinical importance in patient management. We discuss the issue of pediatric brain trauma and stress the importance of MRI in non-accidental injury. In summary, new developments in imaging technology have advanced our understanding of the pathophysiology of brain trauma and contribute to improving the survival of patients with craniocerebral injuries.

Evaluation of Management of Road Trauma Survivors with Brain Injury and Neurologic Disability in Victoria

BACKGROUND

Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999.

METHODS

The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records.

RESULTS

The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units.

CONCLUSION

Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury care.

Future perspectives in the acute management of head injury

Observations on one of the commonest reasons for admission to hospital

Talked and deteriorated head injury patients: how many poor outcomes can be avoided?

The objective of this study was to assess the effectiveness of head injury management on the incidence and outcome of talked and deteriorated patients. Of 337 severe head injury patients admitted to Songklanagarind Hospital during 1994 to 1997, 30 were identified as 'talked and deteriorated'. Most deterioration was due to intracranial haematomas. The incidence (8.9%) and poor outcome (40%) were lower than those from a previous study in 1990 (incidence 15.8% and poor outcome 50%). The poor outcome in this group should not be more than 10%, which may be achieved by appropriate practice guidelines combined with a multidisciplinary team approach in caring for head injury patients, and the collaboration of hospitals within a regional trauma system.

Critical decision making in severe head injury management

The management of severe head injury (SHI) remains a major challenge not only for neurosurgeons but also for all other health professionals involved in the care of trauma patients. Any trauma patient with SHI is at risk of further neurological deterioration if appropriate measures are not instituted from the start of his or her treatment. Secondary insults due to ischaemic, hypotensive, and metabolic or other causes are still common, even in the most advanced neurocritical care settings. Management controversies are widespread and few decision options can be supported by Class I evidence. This article attempts to provide an up-to-date review of the published recommendations that could help health professionals in their management of SHI.

Principles of quality management in medicine: the British concept

The National Health Service in Great Britain is undergoing radical change particularly with regard to clinical governance, self-regulation, revalidation, career structures and training and patterns of healthcare delivery. All these changes are relevant to risk-control and quality management. This review surveys these generic changes and illustrates the implications for neurosurgery. Neurosurgery in the UK has the opportunity to enhance their patients care by expanding the number of consultants, developing further sub-specialisation and enhancing its training and review and dissemination programmes but only if extra resources are provided.

Assessment and management of the head-injured patient

Head injury is one of the most important causes of serious morbidity and mortality in young adults. Each year in Britain, there are approximately 5000 deaths from serious head injuries. Appropriate multidisciplinary assessment and management of systemic and intracranial pathology can significantly improve the outcome.

EFNS guideline on mild traumatic brain injury: report of an EFNS task force

In 1999, a Task Force on Mild Traumatic Brain Injury (MTBI) was set up under the auspices of the European Federation of Neurological Societies. Its aim was to propose an acceptable uniform nomenclature for MTBI and definition of MTBI, and to develop a set of rules to guide initial management with respect to ancillary investigations, hospital admission, observation and follow-up.

Guidelines for head injury: their use and limitations

Within medicine in general, and particularly in the field of head injury, a revolution is currently occurring wherein the traditional expert opinion-based approach to therapy is quickly changing towards a standardized approach, based on scientific analysis of available evidence. The guideline movement may be considered a child of this revolution. Correct understanding, interpretation and application of guidelines requires an understanding of the reasons for formulating the guidelines and of the methodology on which they are based. From this perspective the North American guidelines and the EBIC guidelines, as main international exponents towards guidelines in head injury, are discussed. Specific attention is focussed on the interpretation of the practice recommendations from the North American guidelines at the level of a standard. The evidence underlying these standards is critically discussed and the conclusions put in to further perspective. The EBIC guidelines were formulated from a desire to obtain a 'common core approach' to basic therapy in centers participating in clinical trials. The recommendations are more pragmatic, based on an understanding of the pathophysiology, and address various issues not analyzed in the North American guidelines. The recommendations of both initiatives however are very similar, illustrating the consensus that already exists to general approach of management in head injury. Guidelines should be considered a very important topic in clinical practice, but on the other hand recommendations should not always be accepted uncritically. The lack of evidence underlying many aspects of management in head injury, as illustrated by the North American approach, should form an incentive for further scientific studies, especially towards targeted therapy. Clinical experience and an understanding of the pathophysiology are the basic ingredients for developing alternative and more targeted approaches which can then be subjected to scientific analysis. Guidelines should be considered a tool which we need to learn how to use; they form part of a process which, following implementation and dissemination should lead to standardized registration, an important element in facilitating improved quality control and assurance.

Common head injuries, their diagnosis and treatment

Head injuries are common. Between three-quarters and one million cases, ranging from superficial to life threatening injuries, attend accident and emergency (A&E) departments in the UK each year. This new series on neurosurgery was inspired by head injuries recently suffered by boxers. It does not deal directly with neurosurgery undertaken for other reasons. The series begins with this article by consultant neurosurgeon Graham Flint. It will be followed by other articles on neurosurgical nursing and on the experiences of a neurosurgical patient who also happens, at the present time, to be a nurse in training. The fourth article will describe the rehabilitation of patients by the charity, Headway.

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.

The value of the "worst" computed tomographic scan in clinical studies of moderate and severe head injury. European Brain Injury Consortium

OBJECTIVE

Computed tomographic (CT) scanning can reveal the pattern and severity of structural brain damage after head injury. With the proliferation of CT scanners in general hospitals, and with improvements in patient transport, the interval from injury to the first CT scan is decreasing. The potential result is an "admission" scan missing an evolving and potentially operable lesion. Furthermore, the literature is confusing regarding the timing and coding of CT findings. We sought to establish the frequency of deterioration in CT appearance from an admission scan to subsequent scans and the prognostic significance of such deterioration.

METHODS

In a survey organized by the European Brain Injury Consortium, data on initial severity, management, and subsequent outcome were gathered prospectively for 1005 patients with moderate or severe head injury admitted to one of 67 European neurosurgical units during a 3-month period in 1995. The findings of the initial and the final ("worst") CT scan were classified according to the Traumatic Coma Data Bank system and were related to outcome as assessed using the Glasgow Outcome Scale 6 months after injury.

RESULTS

Data on an initial and a final CT scan were available for 897 patients; of these, 724 patients were assessed using the Glasgow Outcome Scale at 6 months. The initial CT findings were classified as a diffuse injury for 53% of the cohort, with 16% of these diffuse injuries demonstrating deterioration on a subsequent scan. In 56 (74%) of 76 deteriorations, the change was from a diffuse injury to a mass lesion. When the initial CT scan demonstrated a diffuse injury without swelling or shift, evolution to a mass lesion was associated with a statistically significant increase in the risk of an unfavorable outcome (62% versus 38%). When the initial scan demonstrated evidence of swelling or shift, there was a nonsignificant trend in the opposite direction, although the numbers were limited.

CONCLUSION

When an admission CT scan demonstrates evidence of a diffuse injury, follow-up scans should be performed, because approximately one in six such patients will demonstrate significant CT evolution. In studies comparing series of head-injured patients, correspondence of timing of CT scans is necessary for valid comparison.

Snapshot view of emergency neurosurgical head injury care in Great Britain and Ireland

OBJECTIVES

To study the availability of neurosurgical intensive care for the traumatically brain injured in all 36 neurosurgical centres in the United Kingdom and Ireland receiving head injuries, the response times to referral, and the advice given to the referring hospitals.

METHODS

Telephone survey of receiving neurosurgeons regarding their bed status and their advice on three hypothetical case scenarios. Outcome measures included response times for an acute head injury to be accepted to a neurosurgical centre; the intensive care bed status; variations in advice given to the referring hospitals with regard to ventilation, use of mannitol, steroids, anticonvulsants, and antibiotics.

RESULTS

There were 43 neurosurgical intensive care beds available for an overall estimated population of 63.6 million. There were 1.8 beds available/million of the population for non-ventilated patients, 0.64 beds available/million for ventilated patients, and 0.55 beds available/million for ventilated paediatric patients. London had a shortage of beds with 0.19 adult beds for ventilation/million north of the Thames and 0.14 adult beds for ventilation/million south of the Thames. The median response time for a patient with an extradural haematoma to be accepted for transfer was 6 minutes and 89% of such a referral was accepted within 30 minutes. Clinically significant delays in receiving referrals (over 30 minutes) occurred in four units. Practices regarding the use of hyperventilation, mannitol, anticonvulsants, and antibiotics showed little conformity and in some cases were against the available evidence and advice given by published guidelines.

CONCLUSIONS

There is a severe shortage of available emergency neurosurgical beds especially in the south east of England. The lack of immediately available neurosurgical intensive care beds results in delays of transfer that could adversely affect the outcome of surgery for traumatic intracranial haematoma. Advice given to the referring units by the receiving doctors is very variable.

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.