Delayed Neurological Deterioration After Mild Head Injury

Choudhry, Osamah J.; Prestigiacomo, Charles J.; Gala, Nihar B.; Slasky, Shira E.; Sifri, Ziad C.

doi:10.1227/neu.0000000000000105

Cited by 23 publications

(27 citation statements)

References 26 publications

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“…Intracranial bleed complicates initial evaluation of mild head injury since a small percentage of patients with intracranial hemorrhage remain neurologically stable during clinical evaluation but then deteriorate within 24 hours of injury. 12 , 13 We suspect that the significant rate of return ED visits associated with bleed on head CT is driven by two factors. First, neurological symptoms do not appear immediately with intracranial hemorrhage, so patients may be discharged before clinical assessment can identify anything of medical concern.…”

Section: Discussionmentioning

confidence: 99%

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

Ganti¹,

Conroy²,

Bodhit³

et al. 2015

WestJEM

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IntroductionAlthough there are approximately 1.1 million case presentations of mild traumatic brain injury (mTBI) in the emergency department (ED) each year, little data is available to clinicians to identify patients who are at risk for poor outcomes, including 72-hour ED return after discharge. An understanding of patients at risk for ED return visits during the hyperacute phase following head injury would allow ED providers to develop clinical interventions that reduce its occurrence and improve outcomes.MethodsThis institutional review board-approved consecutive cohort study collected injury and outcome variables on adults with the purpose of identifying positive predictors for 72-hour ED return visits in mTBI patients.ResultsOf 2,787 mTBI patients, 145 (5%) returned unexpectedly to the ED within 72 hours of hospital discharge. Positive predictors for ED return visits included being male (p=0.0298), being black (p=0.0456), having a lower prehospital Glasgow Coma Score (p=0.0335), suffering the injury due to a motor vehicle collision (p=0.0065), or having a bleed on head computed tomography (CT) (p=0.0334). ED return visits were not significantly associated with age, fracture on head CT, or symptomology following head trauma. Patients with return visits most commonly reported post-concussion syndrome (43.1%), pain (18.7%), and recall for further clinical evaluation (14.6%) as the reason for return. Of the 124 patients who returned to the ED within 72 hours, one out of five were admitted to the hospital for further care, with five requiring intensive care unit stays and four undergoing neurosurgery.ConclusionApproximately 5% of adult patients who present to the ED for mTBI will return within 72 hours of discharge for further care. Clinicians should identify at-risk individuals during their initial visits and attempt to provide anticipatory guidance when possible.

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Section: Discussionmentioning

confidence: 99%

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

Ganti¹,

Conroy²,

Bodhit³

et al. 2015

WestJEM

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“…Other excluding factors, given evidence suggestive of higher risk, included GCS <15, epidural hemorrhage (EDH), anticoagulation or coagulopathy, hemodynamic instability, and additional systemic injuries. 2,21,22 Aspirin usage was not considered a high-risk feature. 22 Although subdural hematomas were excluded from our initial protocol, subsequent studies have suggested that some subdural hematomas in the setting of mTBI are at low risk of progression.…”

Section: Discussionmentioning

confidence: 99%

Emergency department observation of mild traumatic brain injury with minor radiographic findings: shorter stays, less expensive, and no increased risk compared to hospital admission

et al. 2020

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Objective The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome. Methods mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3‐year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non‐displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years. Results Sixty patients were observed in the EDOU over the 3‐year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), P = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], P = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], P = 0.008). There were no differences in 30‐day re‐admission, 30‐day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow‐up in both groups. Conclusions Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow‐up.

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“…Older age, brain atrophy and coagulopathy are the risk factors associated with haematoma formation and progression after head injury. 5–9 Coagulation disorder and brain atrophy accompanied by anorexia nervosa are considered the primary causes underlying the formation of acute subdural haematoma in young woman despite minor head injury. But few intracranial haemorrhages have been reported as a complication of anorexia nervosa.…”

Section: Discussionmentioning

confidence: 99%

“…Patients with anorexia nervosa can easily experience falls because of decreased muscle strength, syncope and hypoglycaemic faints, which lead to complications such as intracranial haemorrhage and haematoma enlargement because of brain atrophy, coagulation disturbances and vascular fragility. 4 6 Treatment is inaccessible in numerous cases of anorexia nervosa. 11 The age of patients with eating disorders is advancing 18 ; the number of traumatic intracranial haemorrhage with minor head trauma is expected to increase in future.…”

Section: Discussionmentioning

confidence: 99%

Acute subdural haematoma accompanied by anorexia nervosa

Isono

Santou

Ueda³

et al. 2019

BMJ Case Rep

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We report the case of a patient with anorexia nervosa accompanied by acute subdural haematoma following a fall. A 34-year-old Japanese woman had serious medical complications and brain atrophy. After careful nutritional treatment, her laboratory test results improved and brain atrophy was reversed, and we prevented to perform surgery. However, unexpected prominent oedema of her lower legs and pleural effusion occurred. After receiving treatment for these symptoms, she eventually returned to her former occupation and started following a normal diet. Very few cases of anorexia nervosa accompanied by intracranial haemorrhage have been reported. Coagulation disorder and brain atrophy are supposed to be the primary causes of haematoma formation in the present case. Intracranial haemorrhage likely occurs in patients with anorexia nervosa despite minor head trauma. Because anorexia nervosa is not rare and the age of such patients is advancing, knowledge regarding this disorder would be useful for neurosurgeons.

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Delayed Neurological Deterioration After Mild Head Injury

Cited by 23 publications

References 26 publications

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

Emergency department observation of mild traumatic brain injury with minor radiographic findings: shorter stays, less expensive, and no increased risk compared to hospital admission

Acute subdural haematoma accompanied by anorexia nervosa

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