THE CLINICAL EFFICACY OF REPEAT BRAIN CT IN PATIENTS WITH TRAUMATIC INTRACRANIAL HAEMORRHAGE WITHIN 24 HRS AFTER BLUNT HEAD INJURY

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THE CLINICAL EFFICACY OF REPEAT BRAIN CT IN
PATIENTS WITH TRAUMATIC INTRACRANIAL HAEMORRHAGE
WITHIN 24 HRS AFTER BLUNT HEAD INJURY
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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.

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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.

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• The aim of this study was to study the efficacy
• variables associated with radiological
• deterioration from repeat brain CT scans
• possibly necessitating surgical
  interventions.

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Patient selection methods

• It was retrospective review (Jan03-Dec06) of
• all the blunt head trauma patients with
• traumatic intracranial haemorrhage.

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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.

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EXCLUSION CRITERIAN

• 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.

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• 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.

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• Findings of initial brain CT were categorized
  as
• -subdural haematoma(SDH)
• -epidural haematoma(EDH)
• -intraparenchymal haematoma(IPH)
• -subarachnoid haemorrhage(SAH)
• -intraventricular haemorrhage(IVH)

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• 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)

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• Patients 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)

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• 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)

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• 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.

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• 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.

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• 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) SDHs
• 15/29(52) EDHs
• 1/41(2) IPHs
• 3/5(60) IVHs
• 8/26(31) multiple lesions

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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.

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• 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.

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• 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
  on-going 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.

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• 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.

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• Certain subtypes of ICHs 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.

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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.

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• Of the patients who showed radiological worsening
  on repeat brain CT scans,37 underwent
  neurosurgical interventions despite lack of
  significant neurological deterioration.

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• 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.