Mallika Khwanmuang

Phatcharapol Udomluck

Jitsupa Litleangdej

-------------------------------------------------------------------

5th year medical students of

Naresuan university, Phitsanulok , Thailand

The Corre lat ion between Mi ld Head In jury and Pos i t ive CT Scan o f the Bra in in the Pat ients wi th Moderate R isks at Naresuan Un ivers i ty Hosp i ta l

Magn i tude o f p rob lem

Casualty due to accident is the third cause of

death following to cancer and cardiovascular

disease

Head injury is the most common site (30%) of

all injuries. Mortality rate of severe head

injury is 29% and is increasing steadily

CT brain is gold standard for diagnosis of

intracerebral hemorrhage which requires

specialized instruments and only available in

tertiary center

Magn i tude o f p rob lem

There is increasing trends of screening

patient before performing CT brain based on

clinical characteristics of patient because of

its availability , cost and specialist

requirements .

The study objective is to define clinical

characteristic criteria for screening patient

who is at risk of intracerebral hemorrhage ,

which is insight for diagnosis , treatment ,

referral to reduce morbidity , mortality rate

and cost for health on source section

Mild head

injury

patients with GCS score of 13-15

Positive CT scan one that demonstrated an acute pathological state

in the skull or brain attributable to head injury

(Epidural hematoma, Subdural hematoma,

Subarachnoid hemorrhage, Intracerebral

hemorrhage, Hemorrhagic contusion,

Hydrocephalus).

Basal skull

fractures

Evidence of basilar skull fracture including

Raccoon’s eyes: periorbital ecchymoses,

Battle’s sign: postauricular ecchymoses

(around mastoid air sinuses), CSF

rhinorrhea/otorrhea, Hemotympanum or

laceration of external auditory canal

Opera t i ona l defi n i t i ons

Head injuryMild head injury

(GCS 13-15)Low risk criteria

Moderate risk criteria

High risk criteria

Moderate head injury(GCS 9-12)

Severe head injury(GCS ≤ 8 )

Gap of Knowledge

Research Quest ion

Clinical characteristic findings

for abnormal CT brain results

Li terature ReviewThe relevant literature contains many studies

on the use of CT scan in patients with minor

head injury, yet no consensus has been

reached.

Li terature ReviewA study by Haydel et al. suggested that CT

scan is indicated only in patients with minor

head injury with any one of seven risk

factors, the New Orleans Criteria. A similar

study by Stiell et al. identified a different set

of factors, the Canadian CT Head Rule. Both

decision rules had 100% sensitivity for

identifying patients with traumatic brain

injury, but both rules had low specificities.

Li terature ReviewServadei et al. classified patients with minor

head injury as low-, medium-, or high-risk

They evaluated patients with a GCS score of

15 requiring surgical intervention in these

patients as 0.2%.

Patients with one or more of these four

symptoms (temporary loss of consciousness,

amnesia, vomiting, or widespread headache)

were classified as medium-risk head injury,

and the risk of intracranial hemorrhage in

these patients was determined to be 1–3%.

They recommended CT scan for medium-risk

patients.

Object ive

1. Define definitive clinical characteristics

associated with abnormal computed

tomographic scan finding in mild head

injuries

2. Guideline for appropriate requirement to

perform CT brain

3. Guideline for management and referral

Advantages

1. Can predict clinical characteristics of

patients at risk for intracerebral

hemorrhage in mild head injuries

2. Can reduce cost for health on source

section for performing CT brain

3. Can discharge patients with mild head

injuries who do not require CT brain and

with no consequences after discharge

MethodsRetrospective cohort studies

Mild head injury + Moderate risks

+ CT scanModerate risksYes

Abnormal CT

Normal CT

No

Abnormal CT

Normal CT

Reference population

Inclusion criteria

Patients treated at the emergency

department between January 1, 2008 and

May 31, 2011

Mild head injury (GCS score of 13 to 15)

CT performed within 3 hours of the admit

Inclusion criteria Moderate risk criteria

Significant subgaleal swelling Post traumatic seizure Retrograde amnesia Alcohol consumption Basal skull fractures Serious facial injury Loss of consciousness Vomiting Progressive headache Multiple traumas

Reference population

Exclusion criteria

Bleeding disorder or used anticoagulants

Coumadin

Spontaneous intracerebral hemorrhage

Idiopathic thrombocytopenic purpura

Leukemia

Stroke

Reference population

Data were collected on patient

characteristics (age, sex time of injury),

mechanisms of trauma and CT scan

findings.

Data were analyzed with chi-squared

tests.

The research ethics committees of the

study hospitals approved.

Methods

Results

Medical charts of 64 males and 45 females.

An average age of 17-60 years.

Mechanisms of trauma were motorcycle

accident, 74; fall 21; and other, 12.

Initial CT scan was performed on all 109

patients.

Abnormal findings were identified in 28

(25.7%).

7%

18%

61%

14%

Traumatic findings at CT

Hemorrhagic con-tusion

Traumatic sub-arachnoid hemor-rhageSubdural hematoma

Epidural hematoma

Traumatic findings at CT

Sign

ifica

nt sub

gale

al swel

ling

Post t

raum

atic sei

zure

Retro

grad

e am

nesia

Alcoh

ol o

r dr

ug in

toxica

tion

20

3

65

35

91

14 9

Correlation between moderate-risk criteria and initial abnormal CT scan

in all patientsNumber of patients Abnormal CT scan number

Corre lat ion between moderate-r isk cr i ter ia and in i t ia l abnormal CT scan in a l l pat ients

Basal

sku

ll frac

ture

s

Seriou

s fa

cial

inju

ry

Loss

of c

onsc

ious

ness

Vomiti

ng

16 15

68

27

7 3

219

Correlation between moderate-risk criteria and initial abnormal CT scan

in all patientsNumber of patients Abnormal CT scan number

Corre lat ion between moderate-r isk cr i ter ia and in i t ia l abnormal CT scan in a l l pat ients

Univariable analysis from this study was

found that age and sex were not

significant risk factor associated with

intracranial hemorrhage

Clinical characteristics that had significant

associated with abnormal CT brain scan

(p<0.05) was significant subgaleal swelling

Discussion

All patients who had significant subgaleal

swelling were found that accompanied with

other symptoms.

Therefore, we used the Crude analysis to find

the potential confounder by choose co-

symptoms which had p-value<0.2.

There were loss of consciousness, basal skull

fracture, and multiple traumas. But, from

analysis, these symptoms did not affect the

relation.

Discussion

We cannot certainly conclude that the

patients who had subgaleal swelling

symptom were also associated with

abnormal CT brain scan everyone.

Because of

Small size of sample

Incomplete medical record

some patients did not perform the CT brain scan

Discussion

This research was studied only at

Naresuan university hospital that can not

refer to another population of patients

with mild head injury.

Design of this study would be better in

prospective cohort study design

Suggestion

Patients with mild head injury who had

significant subgaleal swelling and other

symptoms which were risk to intracranial

hemorrhage should perform computed

tomography brain scan.

Current study findings demand future

researches in larger population by

prospective cohort study design in the future.

Conclusion

Bahner J, Don R, Stein S, Ross S. The value of computed tomographic scans in patients with low-risk head injuries [Online]1990 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/073646799190431E.

Cattamanchi S, Siva A, Raja A, Thiagarajan NR, Trichur RV. 86: Comparison of the Canadian CT Head Rule and the New Orleans Criteria In Minor Head Injury Patients With Glasgow Coma Scale 15/15.[Online]2010 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0196064410007134.

de Andrade AF, de Almeida AN, Bor-Seng-Shu E, Lourenço L, Mandel M, Marino JR. The value of cranial computed tomography in high-risk, mildly head-injured patients.[Online]2006 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0090301905007937.

Falimirski ME, Gonzalez R, Rodriguez A, Wilberger J. The need for head computed tomography in patients sustaining loss of consciousness after mild head injury. [Online] 2003 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12855873 2003

Havdel M, Preston C, Mills T, al. e. Indications for computed tomography in patients with minor head injury [Online]2001 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S073567570180111X.

References

References Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce

head CT scan ordering for minor head trauma patients.[Online]1997 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0736467997000711.

Murshid WR. Management of minor head injuries: admission criteria, radiological evaluation and treatment of complications.[Online]1998 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9522909.

Ratanalert S, Kornsilp T, Chintragoolpradub N and Kongchoochouys. The impacts and outcomes of implementing head injury guidelines: clinical experience in Thailand. [Online] 2007 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17183038

Royal college of surgeons of Thailand. Head injury. [Online] 2008 [cited 29 July 2554]. Available from: http://www.surgeons.or.th/view.php?group=8&id=208

References

References

Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury.[Online]2005 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16189365.

Stein SC, Ross SE. Mild head injury: a plea for routine early CT scanning.[Online]1992 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1635094.

Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. . [Online] 2001 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11356436

Süleyman Türedi MD , Altug Hasanbasoglu MD, Abdulkadir Gunduz MD ,Mustafa Yandi MD. Clinical Decision Instruments for CT scan in Minor Head Trauma. [Online] 2008 [cited 29 July 2554]. Available from: http://www.sciencedirect.com/science/article/pii/S0736467907006117

References

References Voss M, Knottenbelt J, PEEDEN M. Patients who reattend after

head injury: A high-risk group [Online]1995 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S073646799785175X.

Yavuz MS, Asirdizer M, Cetin G, Gunay Balci Y, Altinkok M. The correlation between skull fractures and intracranial lesions due to traffic accidents.[Online]2003 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14634472.

กองพั�ฒนาการจราจรและบร�การประชาชนสำ�าน�กงานตำ�ารวจแห่�งชาตำ�, เอกสำารประกอบโครงการสำ�มมนาการกวดขั�นว�น�ยจราจรและลดอ�บ�ตำ�เห่ตำ�ทั่�!วประเทั่ศ. 2008.

ด�านาคแก#ว, ก., การบาดเจ$บร�นแรงจากอ�บ�ตำ�เห่ตำ�ขันสำ�ง พั.ศ.2550. 2008, สำ�าน�กระบาด ว�ทั่ยากรมควบค�มโรค กระทั่รวงสำาธารณสำ�ขั.

อ�ตำราตำายปร�บฐานอาย� (age-adjusted death rate) ตำ�อประชากร 100,000 คน ด#วย กล��มโรคห่�วใจ ห่ลอดเล)อด กล��มโรคมะเร$ง และการบาดเจ$บ และโรคในกล��มโรคห่�วใจห่ลอดเล)อด

และ โรคเบาห่วาน ป* 2539-2548. 2548, ศ+นย,ขั#อม+ลโรคไม�ตำ�ดตำ�อ สำ�าน�กโรคไม�ตำ�ดตำ�อ กรม ควบค�มโรค กระทั่รวงสำาธารณสำ�ขั.

References