Utility of surveillance imaging after minor blunt head trauma

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Nonoperative blunt head trauma is a common reason for admission in a pediatric hospital. Adverse events, such as growing skull fracture, are rare, and the incidence of such morbidity is not known. As a result, optimal follow-up care is not clear.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Patients admitted after minor blunt head trauma between May 1, 2009, and April 30, 2013, were identified at a single institution. Demographic, socioeconomic, and clinical characteristics were retrieved from administrative and outpatient databases. Clinical events within the 180-day period following discharge were reviewed and analyzed. These events included emergency department (ED) visits, need for surgical procedures, clinic visits, and surveillance imaging utilization. Associations among these clinical events and potential contributing factors were analyzed using appropriate statistical methods.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>There were 937 admissions for minor blunt head trauma in the 4-year period. Patients who required surgical interventions during the index admission were excluded. The average age of the admitted patients was 5.53 years, and the average length of stay was 1.7 days; 15.7% of patients were admitted for concussion symptoms with negative imaging findings, and 26.4% of patients suffered a skull fracture without intracranial injury. Patients presented with subdural, subarachnoid, or intraventricular hemorrhage in 11.6%, 9.19%, and 0.53% of cases, respectively. After discharge, 672 patients returned for at least 1 follow-up clinic visit (71.7%), and surveillance imaging was obtained at the time of the visit in 343 instances.</jats:p> <jats:p>The number of adverse events was small and consisted of 34 ED visits and 3 surgeries. Some of the ED visits could have been prevented with better discharge instructions, but none of the surgery was preventable. Furthermore, the pattern of postinjury surveillance imaging utilization correlated with physician identity but not with injury severity. Because the number of adverse events was small, surveillance imaging could not be shown to positively influence outcomes.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Adverse events after nonoperative mild traumatic injury are rare. The routine use of postinjury surveillance imaging remains controversial, but these data suggest that such imaging does not effectively identify those who require operative intervention.</jats:p></jats:sec>

Clinical Predictors of Progressive Hemorrhagic Injury in Children with Mild Traumatic Brain Injury

“…As shown above, PHI was strongly associated with the type of TBI. Similar to previous studies, we found that children with mild TBI yielding normal cranial CT scans ( 19 , 20 ) or exhibiting ISFs ( 6 , 21 , 22 ) were at very low risk for PHI and at an extremely low risk of neurosurgical intervention. In our present study, 33 patients with initial normal cranial CT scans and 49 with ISFs underwent repeat CT scans, and 1 patient in each group developed PHI.…”

Mild traumatic brain injury in children is associated with a low risk for posttraumatic seizures

“…We have used the same databases and similar methodology for prior studies of patients in our health care system. 7,8,23,26 Demographic data fields were collected at the time of admission (index admission) and included age, primary language, race/ethnicity, zip code, and primary payer status (public assistance, self-pay vs private insurance). All of the radiology reports for each patient during the index admission were reviewed manually.…”

“…Recent literature has shown that a low percentage of children with severe injury mechanisms require emergency neuroimaging 20 and has focused on reducing the number of unneeded CT scans in children. 8,24 With the negative predictive value of a normal head CT scan for neurosurgical intervention being 100%, 14 there is great incentive to reduce the number of children undergoing negative imaging because even children with mild TBI and intracranial hemorrhage are at a low risk for deterioration. 13 A recent study examining 312 pediatric patients with neurologist-diagnosed PTE (defined as 2 or more unprovoked seizures) revealed that only 17% of these patients had suffered mild TBI.…”

Should an increase in cerebral neurochemicals following head kicks in full contact karate influence return to play?

“…9 Moreover, the routine use of post-head injury surveillance imaging has been considered controversial in terms not only of cost, but also efficacy in identifying those who require operative intervention. 10 Despite these facts, the determination of neurochemical markers does not appear to be available routinely as either a diagnostic or prognostic markers of cerebral injury in primary or secondary care in the UK. Such information may be useful to set standards where elevations are observed post-head injury, providing a referral system to manage safe and effective return-to-play and prevention of any associated long-term sequelae.…”