Transcript Journal Club_CLINICAL EFFICACY OF REPEAT BRAIN CT

THE CLINICAL EFFICACY
OF REPEAT BRAIN CT IN
PATIENTS WITH
TRAUMATIC
INTRACRANIAL
HAEMORRHAGE WITHIN 24
HRS AFTER BLUNT HEAD
INJURY
INTRODUCTION
• Widespread availability of CT scanners in
emergency &intensive care units have led
to increase utilization of CT scanning in
patients with traumatic brain injury(TBI)
• Repeat brain CT scans for all patients with
TBI may facilitate early medical and
surgical intervention and minimize
secondary brain injury.
Contd.
• On the contrary repeat CT scan may
increase
the unnecessary costs and risk of
exposure to
ionizing radiation as well as risk involved
in
the transfer of patients out of intensive
care
settings causing harm to critically ill
patients.
• The aim of this study was to study the
efficacy
& variables associated with radiological
deterioration from repeat brain CT
scans
possibly necessitating surgical
Patient selection &methods
• It was retrospective review (Jan’03Dec’06) of
all the blunt head trauma patients with
traumatic intracranial haemorrhage.
INCLUSION CRITERIAN:
• Adult patients older than 16 yrs. of age.
• Initial GCS score of 8 or greater as long as
they have no planned immediate
neurosurgical intervention after their initial
CT scan.
• A repeat brain CT within 24 hrs. after
trauma.
EXCLUSION CRITERIAN
•
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Patients with ventilatory support.
History of prior brain surgery.
Chronic neurological conditions.
Associate spinal cord injury.
Patients with bleeding diathesis.
Previous use of
antiplatelets/anticoagulants.
• Patients undergone immediate craniotomy
based on initial brain CT at admission.
• In addition to above criterion other
variables collected on admission included :
-age
-gender
-mechanism of injury
-GCS score.
Probability value less than 0.05 were
accepted as statistically significant.
• Findings of initial brain CT were
categorized as:
-subdural haematoma(SDH)
-epidural haematoma(EDH)
-intraparenchymal haematoma(IPH)
-subarachnoid haemorrhage(SAH)
-intraventricular haemorrhage(IVH)
• On repeat brain CT scans patient were
categorized as:
-group 1(improved or unchanged conditions)
-group 2(obvious increase in size of ICH
,amounting to 1 mm or more at least in
one dimension or whose radiology reports
declared an increase of one or more
lesions)
• Patient’s sex,initial GCS score and timing
of the repeat CT scans were the strong
predictors for the worsening of the lesions
on repeat brain CT scans lesions.
• There were significantly more men in
group 2(80%) than in group 1(61.6%)
• Mean GCS score was significantly higher
in patients from group 1(14.3+_0.96)than
in patients from group 2(11.9+_2.6)
• The mean time between the initial and
repeat
brain CT scan was significantly shorter for
group 2(7.41+_5.98) than group
1(11.6+_7.52)
• Intraparenchymal haematoma, subdural
haematoma, subarachnoid haemorrhage
were common occurrence in group 1.
• Epidural haematoma and multiple lesions
were more common in patients from group
2 as evident from radiological progression
in same category.
• After repeat brain CT scans, 28(47%)of the
patients in group 2 ,comprising 17% of the
entire population in this study group,
underwent neurosurgical interventions.
• Of the 28 surgically treated patients of group
2 ,6(10%) exhibited neurological worsening
and 22(37%) appear neurologically stable.
• No patient in group 1 underwent
neurosurgical intervention.
• 22 out of 28 patients who underwent
neurosurgical interventions were
neurologically were stable at the time of
repeat brain CT scans.
• Surgically treated lesions included:
- 1/36(3%) SDH’s
- 15/29(52%) EDH’s
- 1/41(2%) IPH’s
- 3/5(60%) IVH’s
- 8/26(31%) multiple lesions
Discussion
• Optimal management of patients with TBI
includes neurosurgical intervention if
needed, reduction of ICP, prevention of
seizures and avoidance of hypoxia and
hypotension.
• Patients with documented intracranial
injuries often undergo frequent routine
brain CT scans given that significant
radiological changes may occur with
minimal or no clinical and neurological
changes.
• Previous reports state that routine repeat
brain CT scans are of little value in
clinically observed patients with traumatic
ICH,unless there is a corresponding
deterioration of neurologic status.
However;
• 22/60(37%) patients in group 2 who had
undergone neurosurgical interventions had
no neurological changes at the time of
repeat CT scans.
• These results indicate that radiological
deterioration on repeat brain CT scan might
precede a significant neurological worsening in an
affected patient.
• It will allow for the utilization of appropriate
neurosurgical interventions to prevent the ongoing neurological deterioration.
• The possibility exists that minor changes observed
in patients from group 2 such as headache,
nausea and drowsiness without a worsening GCS
score, might be overlooked.
• Predictors of radiological progression in
current study were male sex, a short time
interval between initial and repeat brain
CT scans, a lower GCS at admission and
subtypes of EDH or multiple lesions on the
initial CT scans.
• It has also been supported by Oertel et al.
• Certain subtypes of ICH’s were associated with
radiological worsening (group 2):
-17(28%) EDH
-20(33%) multiple injuries
3/5(60%) IVH
These results demonstrate that presence of
EDH,IVH,AND multiple lesions on the initial brain CT
scan is a risk factor of neurosurgical intervention.
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• As a result of this study,it is suggested that
repeat brain CT scans be performed in the
24 hrs. following blunt head trauma.
• It may minimise the potential neurological
deterioration in patients with initial GCS
score lower than 12 or with EDH or
multiple lesions on their initial brain CT
scan.
CONCLUSION
• Routine repeat brain CT scans within 24
hrs. in the blunt head trauma patients with
traumatic ICH ,who were treated initially
nonsurgically and remained neurologically
stable,revealed radiological worsening in
34% of such patients.
• Of the patients who showed radiological
worsening on repeat brain CT scans,37%
underwent neurosurgical interventions
despite lack of significant neurological
deterioration.
• Based on these findings ,it is proposed
that in those patients with an admission
GCS score lower that 12 or with the EDH
or multiple lesions on their initial brain CT
scan, routine repeat scans should be
performed within 24 hrs. of injury.