The use of repeated head computed tomography in blunt pediatric head trauma: Factors predicting new and worsening brain injury*

Hollingworth, William; Vavilala, Monica S.; Jarvik, Jeffrey G.; Chaudhry, Sidhartha; Johnston, Brian; Layman, Sarah; Tontisirin, Nuj; Muangman, Saipin; Wang, Marjorie C.

doi:10.1097/01.pcc.0000270837.66217.3b

Cited by 50 publications

(84 citation statements)

References 35 publications

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“…These large studies suggest that repeat imaging studies in the early timeframe are rarely beneficial in the absence of clinical deterioration. 1,9,12,20,21 Our study of outpatient imaging is in agreement with this principle, as no patients without clinical deterioration required intervention.…”

Section: Discussionsupporting

confidence: 68%

“…Nonetheless, these studies did find that neurosurgical interventions in hospitalized TBI patients are typically based on clinical changes in most circumstances. Hollingworth et al 9 retrospectively evaluated children admitted to their trauma center over a 9-year period and found that early repeat CT-within 24 hours-was frequently worse in patients at a rate of 30%. Worsened imaging, however, rarely resulted in neurosurgical intervention without associated clinical worsening.…”

Section: Discussionmentioning

confidence: 99%

“…1,9,12,20 These studies focused on early repeat imaging but did not address outpatient follow-up imaging to detect delayed changes such as chronic subdural hematomas, subdural hygromas, or hydrocephalus. Nonetheless, these studies did find that neurosurgical interventions in hospitalized TBI patients are typically based on clinical changes in most circumstances.…”

Section: Discussionmentioning

confidence: 99%

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Results of delayed follow-up imaging in traumatic brain injury

Befeler

Gordon

Khan

et al. 2016

JNS

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OBJECT There is a paucity of scientific evidence available about the benefits of outpatient follow-up imaging for traumatic brain injury patients. In this study, 1 year of consecutive patients at a Level 1 trauma center were analyzed to determine if there is any benefit to routinely obtaining CT of the head at the outpatient follow-up visit. METHODS This single-institution retrospective review was performed on all patients with a traumatic brain injury seen at a Level 1 trauma center in 2013. Demographic data, types of injuries, surgical interventions, radiographic imaging in inpatient and outpatient settings, and outcomes were assessed through a review of the institution’s trauma registry, patient charts, and imaging. RESULTS Five hundred twenty-five patients were seen for traumatic brain injury in 2013 at Regional One Health in Memphis, Tennessee. One hundred eighty-five patients (35%) presented for outpatient follow-up, all with CT scans of the head. Seven of these patients (4%) showed worsening of their intracranial injuries on outpatient imaging studies; however, surgical intervention was recommended for only 3 of these patients (2%). All patients requiring an intervention had neurological deterioration prior to their follow-up appointment. CONCLUSIONS These experiences suggest that outpatient follow-up imaging for traumatic brain injury should be done selectively, as it was not helpful for patients who did not exhibit worsening of neurological signs or symptoms. Furthermore, routine outpatient imaging results in unnecessary resource utilization and radiation exposure.

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Section: Discussionsupporting

confidence: 68%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Results of delayed follow-up imaging in traumatic brain injury

Befeler

Gordon

Khan

et al. 2016

JNS

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“…Tabori et al [27] and Hollingworth et al [28 ] each noted 1 EDH patient with changed management after a second repeat scan, but these patients also had clinical deterioration. These observations highlight the need for a better understanding of the utility of multiple repeat CT scans in clinically stable EDH patients so that CT imaging may be optimally used to direct treatment while minimizing radiation exposure and its associated risks [29,30].…”

Section: Discussionmentioning

confidence: 99%

Utility of Clinical and Radiographic Findings in the Management of Traumatic Epidural Hematoma

Flaherty¹,

Loya²,

Alexander³

et al. 2013

Pediatr Neurosurg

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Background: There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups. Methods: We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center. Results: Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation. Conclusions: Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.

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“…In the first stage, imputation models were specified for predictors and for mortality at six months, considering other fullyobserved covariates (such as age and GCS score). In the second stage, for each of the previously imputed datasets, imputation models were specified for the Extended Glasgow Outcome Scale for those patients who were either known to be alive at six months or were predicted to be alive by the first stage imputation model, considering fully-observed covariates and intermediate endpoints [28,59] 30 [21,45] Male, n .8) 1116 (20.5) [2800]…”

Section: Handling Of Missing Datamentioning

confidence: 99%

External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom

Harrison

Griggs

Prabhu

et al. 2015

Journal of Neurotrauma

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This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Scale score of less than 15 were recruited. The primary outcomes were mortality and unfavorable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3626 critical care unit admissions, 2975 were analyzed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavorable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven and colleagues, the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head Injury (CRASH) Trial Collaborators, and the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) group. The model with the best discrimination was the IMPACT ''Lab'' model (C index, 0.779 for mortality and 0.713 for unfavorable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavorable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavorable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research.

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The use of repeated head computed tomography in blunt pediatric head trauma: Factors predicting new and worsening brain injury*

Cited by 50 publications

References 35 publications

Results of delayed follow-up imaging in traumatic brain injury

Results of delayed follow-up imaging in traumatic brain injury

Utility of Clinical and Radiographic Findings in the Management of Traumatic Epidural Hematoma

External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom

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