Traumatic Brain Injury: Original Research on

Repeat Head CTBradley W. Thomas, MD

LCDR MC USNConstanta Trauma Symposium

12 JUNE 2013

Introduction

Traumatic brain injury (TBI) is the foremost

cause of death in children and young

adults

TBI Facts

5.3 million Americans (just over 2% of the population) currently live with a disability resulting from a TBI

1.5 million people sustain an TBI each year

50,000 die due to TBI each year Every 21 seconds a person in the US

sustains an TBI In 2003, the overall expense for

direct TBImedical care was estimated at

more than $56 billion per year

TBI Severity

TBI Treatment Modalities

Observation, Seizure Prophylaxis

Placement of ICP monitor Directed Mannitol/hypertonic Saline/ Chemical Paralysis to maintain CPP of 60mmHg

Ventriculostomy Craniotomy/Craniectomy

J Am Coll Surg. 2010 May;210(5):824-30, 831-2

This data was presented at the Southern Surgical Conference December 2009

No financial disclosures

• Initial evaluation of TBI*– Neurological examination– Initial brain computed tomography (IBCT)

• Subsequent evaluation – Unscheduled repeat brain CT (URBCT) for

neurologic deterioration is standard– Scheduled repeat brain CT (SRBCT) at

specified intervals is controversial

*Cushman. EAST Practice Management Guidelines for Management of Mild Traumatic Brain Injury.:http://www.east.org.

Unscheduled repeat brain CT (URBCT) based on neurological deterioration – May delay treatment – May lead to secondary brain injury and poor

outcome

Scheduled repeat brain CT (SRBCT) – Increases expense– Increases labor– Risks associated with transport– May not improve outcome

Difficult to assess long term functional capacity and productivity following TBI

Can SRBCT identify patients who need neurologic intervention before neurologic deterioration develops on clinical examination?

Setting– Level I Trauma Center

Design– Retrospective observational study– IRB approved

Data– Trauma registry

Patients with TBI on initial brain CT (IBCT) – 50 month period beginning in November

2001– Medical record review

• Initial– Neurologic examination– CT brain (IBCT)

Subsequent– ICU admission– Sequential neurological examinations– SRBCT 6-8 hours following IBCT – URBCT performed for clinical neurological

deterioration

Demographics Age, sex

Mechanism of injury– Blunt injury only

Severity of injury Injury Severity Score (ISS) Admitting GCS

History Use of anticoagulants or anti-platelet

therapy

TBI admission data Type of TBI on IBCT

Subarachnoid hemorrhage Subdural hematoma Epidural hematoma Cerebral contusion Mixed

GCS on admission Mild (13-15) Moderate (9-12) Severe (3-8)

Post admission data Time from IBCT to SRBCT Frequency of SRBCT and URBCT

Outcome data Need for neurologic intervention ICU length of stay Hospital length of stay All cause hospital mortality

• Did patients undergo a neurologic intervention based on clinical change or SRBCT

• Was the 1st SRBCT worse or no worse

Medical intervention New onset administration of mannitol

or hypertonic saline

Surgical intervention Placement of an ICP monitor or

craniotomy

Statistical analysis was performed using SPSS version 17.0

Means are reported ± standard deviation

Chi square analysis and Wilcoxon rank sum test were used to compare groups where appropriate

9,669 patients admitted during the study period

1,019 patients had evidence of TBI on IBCT 132 patients excluded

87 (8.4%) immediate craniotomy 45 (4.5%)

–5 patients had no repeat head CT on file–29 patients died prior to repeat CT–1 loss of airway leading to anoxic injury–2 CVA secondary to other causes–8 patients had interventions based on unclear

indications 887 patients included

How did the results of SRBCT influence

patient management?

1st SRBCT worsen=195

immediate intervention

n=14

intervention secondary to

subsequent SRBCTn=7

intervention secondary to clinical

changen=19

no interventionn=155

intervention preceded by clinical

change ± URBCTn=11

887 undergo SRBCT

1st SRBCT no worse

n=692

no immediate intervention

n=181

no intervention n=681

Management of Patients Worse vs No Worse SRBCT

1st SRBCT worsen=195

immediate intervention

n=14

intervention secondary to

subsequent SRBCTn=7

intervention secondary to clinical

changen=19

no interventionn=155

intervention preceded by clinical

change ± URBCTn=11

887 undergo SRBCT

1st SRBCT no worse

n=692

no immediate intervention

n=181

no intervention n=681

Management of Patients Worse vs No Worse SRBCT

1st SRBCT worsen=195

immediate intervention

n=14

intervention secondary to

subsequent SRBCTn=7

intervention secondary to clinical

changen=19

no interventionn=155

intervention preceded by clinical

change ± URBCTn=11

887 undergo SRBCT

1st SRBCT no worse

n=692

no immediate intervention

n=181

no intervention n=681

Management of Patients Worse vs No Worse SRBCT

1st SRBCT worsen=195

immediate intervention

n=14

intervention secondary to

subsequent SRBCTn=7

intervention secondary to clinical

changen=19

no interventionn=155

intervention preceded by clinical

change ± URBCTn=11

887 undergo SRBCT

1st SRBCT no worse

n=692

no immediate intervention

n=181

no intervention n=681

Management of Patients Worse vs No Worse SRBCT

1st SRBCT worsen=195

immediate intervention

n=14

intervention secondary to subsequent

SRBCTn=7

intervention secondary to

clinical changen=19

no interventionn=155

intervention preceded by

clinical change ± URBCT

n=11

887 undergo SRBCT

1st SRBCT no worse

n=692

no immediate intervention

n=181

no intervention n=681

Neurologic Change

No Neurologic Change

Total

SRBCT Worse 19 21 40/195 (20.5%)

SRBCT No Worse 11 681 11/692 (1.6%)

Chi square analysis shows greater likelihood for a patient with TBI to have aWorse SRBCT before they develop a neurologic change, p < 0.01

Analysis of Need for Neurologic Intervention Based on Worse SRBCT or Neurologic Change

The largest review to date shows that the majority of patients with no worse SRBCT required no further intervention

Patients with worse SRBCT had higher ISS, greater coagulopathy, longer length of stay and higher mortality

The vast majority (165/195, 92.8%) with worse SRBCT had no additional intervention

In 21/195 (10.7%) patients, a worse SRBCT prompted a number of interventions including diuresis for cerebral edema, ICP monitor placement and craniotomy

In 19/195 (10.5%) patients with a worse SRBCT subsequently developed neurologic change requiring an intervention

Patients with TBI are significantly more likely to have a worse SRBCT before they develop neurologic change that requires a neurologic intervention

• Retrospective study• CT findings subjective• Neurologic changes do not

necessarily mean secondary brain injury

• No long term follow-up

Treating a worse SRBCT before neurologic change occurs may prevent secondary brain injury

Protocol development for patients with worse SRBCT may improve outcome

Routine monitoring with SRBCT appears to be useful in managing patients with TBI

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