Repeat Head CT for Expectant Management of Traumatic Epidural Hematoma

Critical Emergency Department Interventions and Clinical Deterioration in Children With Nonsevere Traumatic Intracranial Hemorrhage

OBJECTIVE

Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification.

METHODS

We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models.

RESULTS

Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS ( P = 0.001) and nonaccidental trauma ( P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH.

CONCLUSIONS

Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics.

Predictive Factors for Delayed Surgical Intervention in Children With Epidural Hematomas

BACKGROUND

Optimal treatment of children with traumatic intracranial epidural hematomas (EDHs) is unknown. We sought to identify clinical and radiographic predictors of delayed surgical intervention among children with EDH admitted for observation.

METHODS

We retrospectively identified patients younger than 15 years with acute traumatic EDHs evaluated at our level 1 pediatric trauma center. We excluded patients with penetrating head injuries, recent surgical evacuation of EDH, or depressed skull fracture requiring surgical repair and assigned the remaining subjects to the immediate surgery group if they underwent immediate surgical evacuation, to the supportive-therapy-only group if they underwent observation only, and to the delayed surgery group if they underwent surgery after observation. We abstracted clinical and laboratory findings, surgical interventions, and neurological outcome and measured EDH dimensions and volumes, adjusting for cranial size. We compared clinical and radiographic characteristics among groups and performed receiver-operator characteristic analyses of predictors of delayed surgery.

RESULTS

Of 172 patients with EDH, 103 patients met the inclusion criteria, with 6 (6%) in the immediate surgery group, 87 (84%) in the supportive-therapy-only group, and 10 (10%) in the delayed surgery group. Headache, prothrombin time of >14 seconds, EDH maximal thickness of ≥1.1 cm, volume of ≥14 mL, EDH thickness/cranial width index of ≥0.08 and EDH volume/cranial volume index of ≥0.18, and mass effect were associated with delayed surgical intervention. There was no difference in length of stay or functional impairment between the immediate and delayed surgery groups. However, patients in delayed surgery group were more likely to have subjective symptoms at discharge than those in immediate surgery group.

CONCLUSIONS

Among patients with EDH admitted for observation, larger EDH, mass effect, headaches, and prothrombin time of >14 seconds were associated with delayed surgical intervention. A larger-scale study is warranted to identify independent predictors of delayed surgery in children under observation for EDH.

Delayed progressive intracranial bleeding in pediatric acute epidural hemorrhage treated expectantly

INTRODUCTION AND IMPORTANCE

Progressive epidural hematoma (PEDH) after traumatic brain injury is usually found in the first 24 h after accident. However, EDH enlargement on day six after admission is rarely observed.

PRESENTATION OF CASE

We present the case of a 14-year-old boy who presented to the emergency room after a car accident with only a headache without any neurological deficit. The computed tomography (CT) scan revealed a slight epidural hematoma, which then treated expectantly. On day 6, the patient developed severe headache. CT-Scan showed enlarged epidural hematoma with significant mass effect. The emergency clot evacuation was completed successfully.

CLINICAL DISCUSSION

Progressive intracranial hemorrhage is any increase in pre-existing intracranial bleeding or the presence of a new hematoma on a CT scan. Young age and cranial fracture have been identified as risk factors for PEDH morbidity and mortality. Coagulation parameters may be a predictor of progressive intracranial bleeding, but their accuracy remains unclear. Still, the decision to conduct a CT scan as a follow-up is debatable, but it should be performed when neurological deterioration occurs.

CONCLUSION

Although rare, PEDH could still be occurred six days after trauma. Linear fracture and young age are among the risk factors. A thorough routine neurological examination is crucial in treating this condition.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Quality Indicators for Children With Traumatic Brain Injury After Transition to an American College of Surgeons Level I Pediatric Trauma Center

OBJECTIVE

The aim of the study was to compare quality indicators, including frequency of acute surgical and emergent interventions, and resource utilization before and after American College of Surgeons (ACS) level I trauma verification among children with moderate or severe traumatic brain injury (TBI).

METHODS

This is a retrospective review of patients younger than 18 years treated for moderate or severe TBI, as determined by International Classification of Disease codes. Our institution obtained ACS level I trauma verification in 2013. Outcomes during the pre-ACS (June 2003-May 2008), interim (June 2008-May 2013), and post-ACS (June 2013-May 2018) periods were compared via nonparametric tests. Tests for linear trend were conducted using Cochran-Armitage tests for categorical data and by linear regression for continuous variables.

RESULTS

There were 677 children with moderate or severe TBIs (pre-ACS, 125; interim, 198; post-ACS, 354). Frequency of any surgical intervention increased significantly in the post-ACS period (12.2%) compared with interim (5.1%) and pre-ACS periods (5.6%, P = 0.007). More children in the post-ACS period required intracranial pressure monitoring (P = 0.017), external ventricular drain placement (P = 0.003), or endotracheal intubation (P = 0.001) compared with interim and pre-ACS periods. There was no significant change in time to operating room (P = 0.514), frequency of decompression (P = 0.096), or time to decompression (P = 0.788) between study periods. The median time to head CT decreased significantly in the post-ACS period (26 minutes; interquartile range [IQR], 9-60) compared with interim (36 minutes; IQR, 21-69) and pre-ACS periods (53 minutes; IQR, 36-89; P < 0.001). Frequency of repeat head computed tomography decreased significantly in the post-ACS period (30.2%) compared with interim (56.1%) and pre-ACS periods (64.0%, Ptrend = 0.044).

CONCLUSIONS

Transition to an ACS level I trauma verification was associated with improvements in quality indicators for children with moderate or severe TBI.

Traumatic epidural hematoma treated with endovascular coil embolization

Background:

Traumatic cerebrovascular injury may result in epidural hematoma (EDH) from laceration of the middle meningeal artery (MMA), which is a potentially life-threatening emergency. Treatment ranges from surgical evacuation to conservative management based on a variety of clinical and imaging factors.

Case Description:

A 14-year-old male presented to our institution after falling from his bicycle with traumatic subarachnoid hemorrhage and a right frontotemporal EDH. The patient did not meet criteria for surgical evacuation and endovascular embolization of the right MMA was performed. Rapid resolution of the EDH was observed.

Conclusion:

This case corroborates the sparse existing literature for the potential role of endovascular embolization to treat acute EDH in carefully selected patients who do not meet or have borderline indications for surgical management.

Epidemiology of Critical Interventions in Children With Traumatic Intracranial Hemorrhage

OBJECTIVE

To estimate rates of critical medical and neurosurgical interventions and resource utilization for children with traumatic intracranial hemorrhage (ICH).

METHODS

This was a retrospective study of children younger than 18 years hospitalized in 1 of 35 hospitals in the Pediatric Health Information System from 2009 to 2019 for ICH. We defined critical intervention as a critical medical (hyperosmotic agents and intubation) or neurosurgical intervention. We determined rates of critical interventions, intensive care unit (ICU) admission, and repeat neuroimaging. We used hierarchical logistic regression to identify high-level factors associated with undergoing critical interventions, controlling for hospital-level effects.

RESULTS

There were 12,714 children with ICH included in the study. Median (interquartile range) age was 4.3 (0.7-11.0) years. Twelve percent (n = 1470) of children underwent a critical clinical intervention. Critical medical interventions occurred in 10% (n = 1219), and neurosurgical interventions occurred in 3% (n = 419). Intensive care unit admission occurred in 44% (n = 5565), whereas repeat neuroimaging occurred in 40% (n = 5072). Among ICU patients, 79% (n = 4366) did not undergo a critical intervention. Of the 11,244 children with no critical interventions, 39% (n = 4366) underwent ICU admission, and 37% (n = 4099) repeat neuroimaging. After controlling for hospital, children with isolated subdural (P = 0.013) and isolated subarachnoid (P < 0.001) hemorrhage were less likely to receive critical interventions.

CONCLUSIONS

Critical medical interventions occurred in 10% of children with ICH, and neurosurgical interventions occurred in 3%. Intensive care unit admission and repeat neuroimaging are common, even among those who did not undergo critical interventions. Selective utilization of ICU admission and repeat neuroimaging in children who are at low risk of requiring critical interventions could improve overall quality of care and decrease unnecessary resource utilization.

Trends and variation in repeat neuroimaging for children with traumatic intracranial hemorrhage

OBJECTIVES

We aimed to determine trends and institutional variation in repeat neuroimaging in children with traumatic intracranial hemorrhage and to identify factors associated with neuroimaging modality (subsequent magnetic resonance imaging [MRI] vs computed tomography [CT]).

METHODS

We conducted a retrospective cross-sectional study of 35 hospitals in the Pediatric Health Information System database. We included children <18 years of age hospitalized from 2010-2019 with intracranial hemorrhage and who underwent a brain CT. We calculated repeat neuroimaging rates by modality and used regression analyses to examine temporal trends. We used hierarchical logistic regression to identify factors associated with subsequent MRI versus repeat CT, controlling for hospital.

RESULTS

We identified 12,714 children with intracranial hemorrhage, of which 5072 with repeat neuroimaging were studied. Of the 5072 children with repeat neuroimaging, repeat CT was performed in 67.6% (n = 3429) and subsequent MRI in 32.4% (n = 1643). Overall repeat neuroimaging with either a CT or MRI remained similar from 2010-2019 (P = 0.431); however, repeat CT scans significantly decreased (P = 0.001); whereas, MRIs significantly increased (P < 0.001). Repeat neuroimaging by hospital ranged from 20%-80%. After controlling for institution, subsequent MRI was more likely to be used in younger children and children who did not receive hyperosmotic agents, neurosurgical interventions, or intensive care unit admission (all P-values <0.001).

CONCLUSIONS

We found that repeat neuroimaging rates for children with intracranial hemorrhage vary substantially by institution. We also found that although MRI was increasingly used to re-image these children, overall repeat neuroimaging rates (CT or MRI) have not decreased over the past decade. Future work to implement optimal utilization of neuroimaging in these children is needed.

Role of routine post-operative CT brain following evacuation of extradural haematoma in children: a single-centre experience

PURPOSE

Extradural haematoma (EDH) is a serious neurosurgical emergency in children, which confers significant morbidity and mortality rates. The objective of this study was to retrospectively evaluate the role of post-operative imaging in children with EDH who were managed surgically in a national paediatric neurosurgical unit over a 9-year period (January 2008 to December 2016).

METHODS

A retrospective case review of paediatric patients who underwent surgical evacuation of extradural haematoma between January 2008 and December 2016 was performed. This included demographic and clinical details, indications for post-operative imaging and outcomes.

RESULTS

Seventy patients underwent surgical management of EDH during this time period, with a male preponderance (69%) and a mean age of 8 years. The commonest location of haematoma in this cohort was in the parietal region (n = 24), with a mean maximum thickness of 25.9 mm and mean volume of 57 ml. Post-operative imaging was performed in 84% of patients. However, only one patient had a change in the course of their post-operative management as a result of post-operative imaging findings.

CONCLUSIONS

Post-operative imaging in asymptomatic paediatric patients after evacuation of EDH could therefore be avoided as a routine investigation.

Development and Implementation of a Pilot Radiation Reduction Protocol for Pediatric Head Injury

BACKGROUND

Traumatic brain injury is the leading cause of morbidity and mortality for children in the United States. The aim of this study was to develop and implement a guideline to reduce radiation exposure in the pediatric head injury patient by identifying the patient population where repeat imaging is necessary and to establish rapid brain protocol magnetic resonance imaging as the first-line modality.

METHODS

A retrospective chart review of trauma patients between 0 and 14 y of age admitted at a pediatric level 2 trauma center was performed between January 2013 and June 2019. The guideline established the appropriateness of repeat scans for patients with Glasgow Coma Scale >13 with clinical neurological deterioration or patients with Glasgow Coma Scale ≤13 and intracranial hemorrhagic lesion on initial head computed tomography (CT).

RESULTS

Our trauma registry included 592 patients during the study period, 415 before implementation and 161 after implementation. A total of 132 patients met inclusion criteria, 116 pre-guideline and 16 post-guideline. The number of patients receiving repeat head CTs significantly decreased from 34.5% to 6.3% (P < 0.02). There was also a significant decrease in the mean number of head CT/patient pre-guideline 1.63 (range 1-7) compared with post-guideline 1.06 (range 1-2) (P < 0.02).

CONCLUSIONS

CT head imaging is invaluable in the initial trauma evaluation of pediatric patients. However, it can be overused, and the radiation may lead to long-term deleterious effects. Establishing a head imaging guideline which limits use with clinical criteria can be effective in reducing radiation exposure without missing injuries.

Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas

INTRODUCTION

Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making.

METHODS

A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon.

RESULTS

Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline.

CONCLUSION

Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.