Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting

Jagoda, Andy; Cantrill, Stephen V.; Wears, Robert L.; Valadka, Alex B.; Gallagher, E.John; Gottesfeld, Steven H.; Pietrzak, Michael P; Bolden, Jason; Bruns, John; Zimmerman, Robert D.

doi:10.1016/j.annemergmed.2008.08.021

Cited by 432 publications

(202 citation statements)

References 72 publications

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“…However, our clinicians were not informed that the CDS was part of a research study. Second, it is possible that our observed decline in imaging use may not be solely due to our intervention but also confounders, such as increased public awareness of harm associated with inappropriate imaging and the publication of a related American College of Emergency Physicians' clinical policy during the study period [11]. However, no change in imaging use was observed in the control cohort, supporting previous findings that guideline publication alone may be a weak intervention for changing clinical practice [36].…”

Section: Discussionsupporting

confidence: 52%

“…When used appropriately, they can help avoid unnecessary head CTs, without jeopardizing patient safety [6]. Despite their potential utility [7][8][9][10] and acceptance by professional societies [11], their clinical adoption remains scarce. It is estimated that 10% to 35% of CTs obtained in the ED for MTBI are not recommended according to the guidelines [12], and head CT utilization varies significantly both nationwide and within institutions [13,14].…”

Section: Introductionmentioning

confidence: 99%

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Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED

Raja

Gupta

et al. 2015

The American Journal of Emergency Medicine

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Section: Discussionsupporting

confidence: 52%

Section: Introductionmentioning

confidence: 99%

Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED

Raja

Gupta

et al. 2015

The American Journal of Emergency Medicine

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“…CT is currently the only imaging modality for which there is class I evidence to support use in routine clinical practice, 4 and only in a limited population. 5,6 However, a growing body of evidence indicates that subtle injuries to the brain structure go undetected with CT in patients with mild TBI (mTBI).…”

Section: Introductionmentioning

confidence: 99%

Trauma-Specific Brain Abnormalities in Suspected Mild Traumatic Brain Injury Patients Identified in the First 48 Hours after Injury: A Blinded Magnetic Resonance Imaging Comparative Study Including Suspected Acute Minor Stroke Patients

Ricciardi

Bokkers

Butman

et al. 2017

Journal of Neurotrauma

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We assessed the utility of a brief MRI protocol, appropriate for the acute setting, to detect acute traumatic brain injury (TBI) in patients with suspected mild TBI (mTBI) and distinguish traumatic from nontraumatic brain injury by comparing trauma with nontrauma patients. Twenty-two patients with suspected mTBI were included in this exploratory study over a period of 9 months. Median time from injury to MR scanning was 5.4 h (interquartile range 3.6-15.3). To determine the specificity of certain findings for TBI, 61 patients presenting with suspected minor acute stroke were included as a comparative group using the same MRI methods. A selected series of MRI sequences (diffusion-weighted imaging, fluid attenuated inversion recovery [FLAIR], and T2* weighted) were independently evaluated by two neuroradiologists blinded to clinical diagnosis, for presence of specific findings. In a separate session, all cases in which at least one MRI sequence above was positive were classified as TBI, stroke, or indeterminate. Intracranial MRI abnormalities were observed in 47 (57%) of the 83 studied patients. Based on findings on MRI, 12 (55%) of 22 suspected mTBI patients were classified as having traumatic injury. Nine (47%) of the 19 suspected mTBI patients with a negative CT had findings on MRI. Abnormalities on MRI consistent with trauma were observed most frequently on postcontrast FLAIR (83%) and T2*-weighted (58%) sequences. We demonstrated the ability of a fast MRI protocol to identify trauma-related abnormalities not seen on CT, and differentiate acute trauma from nonspecific chronic disease in a blinded cohort of mTBI patients.

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“…As stated in current guidelines discussing head injury and warfarin use, liberal CT scanning of the head seems to be a reasonable strategy, even for those who present with normal mental status and a GCS score of 15. [10][11][12][13] The risk of delayed bleeding appears to be very close to zero with clopidogrel, suggesting that routine hospitalization and follow-up scanning might not be necessary. Patients taking warfarin are not without risk and probably do require follow-up but not necessarily routine (second) CT.…”

Section: Resultsmentioning

confidence: 99%

Traumatic intracranial hemorrhage in patients using warfarin or clopidogrel

Alsakha

Guttman

2014

CJEM

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Clinical questionWhat is the prevalence of immediate and incidence of delayed intracranial hemorrhage in patients with blunt head trauma who use warfarin or clopidogrel? Article chosen Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-8.e7. Study objectiveTo assess the prevalence of immediate and the cumulative incidence of delayed traumatic intracranial hemorrhage in patients using warfarin or clopidogrel.

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Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting

Cited by 432 publications

References 72 publications

Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED

Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED

Trauma-Specific Brain Abnormalities in Suspected Mild Traumatic Brain Injury Patients Identified in the First 48 Hours after Injury: A Blinded Magnetic Resonance Imaging Comparative Study Including Suspected Acute Minor Stroke Patients

Traumatic intracranial hemorrhage in patients using warfarin or clopidogrel

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