Use of a complete neurological examination to screen for significant intracranial abnormalities in minor head injury

Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation.     

The application of North American CT scan criteria to an Australian population with minor head injury

Objective: To determine potential changes in the number of CT head scans performed if the New Orleans Criteria (NOC) or Canadian CT Head Rule (CCTR) was applied to an Australian emergency department population of minor head injured (MHI) patients. Methods: A retrospective chart review was conducted in an adult metropolitan teaching hospital in Brisbane. All patients presenting over a 3‐month period with a GCS Score of 15 following an MHI and had a CT head scan performed were selected for analysis. Using clinically significant CT abnormalities and neurological intervention as the outcome measures, the NOC and CCTR were applied to determine if CT scanning was considered necessary. Results: Of the 240 patients reviewed, 230 had a normal CT scan and 10 had clinically significant CT abnormalities. One patient with CT abnormality required neurosurgical intervention. Application of the NOC would have resulted in a 3.8% (95% CI 1.7–7.0%) reduction in CT scans performed without missing any patients with CT abnormalities or requiring neurological intervention. Application of the CCTR using both high and low risk factors would have resulted in a 46.7% (95% CI 40.2–53.2%) reduction in CT scans performed without missing the patient requiring neurological intervention, but would not have detected two patients with clinically significant CT abnormalities. Conclusion: Neither the NOC nor the CCRT appear suitable for significantly reducing the number of normal CT head scans performed without missing clinically significant CT abnormalities when applied to our current clinical practice.     

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage

BackgroundPatients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions.MethodsThis was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention.ResultsOf these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2–7.2 95 CI) had neurological decline, 73 (7.5% 5.9–9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5–7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1–0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305.ConclusionsRHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.     

Identification of Ethanol-intoxicated Patients with Minor Head TVauma Requiring Computed Tomography Scans

Objective: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol-intoxicated patients with presumed-minor head injuries.
Methods: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared.
Results: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9–15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2–6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchy-mosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour.
Conclusion: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries as evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.     

Cranial Computed Tomography in the Emergency Evaluation of Adult Patients without a Recent History of Head Trauma: A Prospective Analysis

Objectives: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. Methods: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection, χ² recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. Results: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age ≥60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94–100%) and 31% specific (95% CI: 28–33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8–13%) and 100% (95% CI: 98–100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed.
Conclusion: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high- and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.     

Prospective evaluation of selected clinical criteria for cranial computed tomography in non‐trauma adult patients

Objective: To evaluate the usefulness of previously published criteria by Rothrock et al. and Harris et al. for urgent, cranial CT in non‐trauma presentations. Methods: A prospective, observational study of consecutive adult patients with non‐trauma presentations to Westmead Emergency Department, undergoing urgent cranial CT over a period of 2 years and 10 months. Clinical data were assessed to determine the presence of the proposed Rothrock and Harris criteria. Clinically significant findings defined by CT were intracerebral haemorrhage, acute infarction, intracranial infection, acute hydrocephalus, cerebral oedema and malignancy. Results: A total of 1911 patients were studied. Among them, 21.7% (414/1911) of patients had clinically significant findings on CT. Application of the Harris criteria demonstrated a sensitivity of 93.5% (387/414, 95% CI 90.7–95.7) and a false negative rate of 6.5% (27/414, 95% CI 4.3–9.3) with a potential reduction in number of scans by 27.8%. With application of the Rothrock criteria, the possible scan reduction rate was 15% with a sensitivity of 98.8% (409/414, 95% CI 97.2–99.6) and a false negative rate of 1.2% (5/414, 95% CI 0.4–2.8). Conclusion: The Harris criteria were not validated by our study. The Rothrock criteria are also not confidently validated, but can be a useful guide for emergency physicians to help prioritize high‐risk patients who might have clinically significant cranial CT findings. We have not replicated their very high sensitivity and very low false negative rates.     

Elderly patients with closed head trauma after a fall: mechanisms and outcomes

Falls in the elderly leading to closed head trauma represent a significant cause of morbidity and mortality in that population, but are not well-characterized. The purpose of this study was to determine the mechanism of fall, outcome, and additional risk factors in elderly patients who require cranial computed tomography (CT) scan after a fall. We conducted a retrospective case series of patients age 60 years and older with closed head trauma secondary to falling who underwent CT scan in the emergency department (ED). Data were gathered from ED and hospital records. The setting was an urban Level I trauma center. Our series consisted of 189 patients, of whom 31 (16%) had an abnormal head CT scan and four (2%) required neurosurgery. Cerebral contusions (38%) and subdural hematomas (33%) were the most common lesions seen on CT scan. Falls from standing (76%) were more common than falls on stairs (19%) or from height (5%), but the latter two were more likely to result in an abnormal CT scan (stairs 42%, height 40%). An abnormal neurologic examination was associated with a higher risk of the need for neurosurgery (risk ratio 11.5). We conclude that among elderly patients who fall and present to an ED with evidence of closed head trauma, a significant percentage will have abnormal CT scans but only a small minority will require neurosurgery. While falls from standing are more common, falls on stairs or from height are associated with a higher risk of having an abnormal CT scan. A focal neurologic examination is a strong predictor of the need for neurosurgical intervention.     

A New Clinical Scoring System Fails to Differentiate Hemorrhagic from Ischemic Stroke When Used in the Acute Care Setting

Recently, a new diagnostic scoring system has been proposed to help differentiate intracranial hemorrhage (ICH) from ischemic infarct. The system, derived using data from hospitalized stroke patients, is based on eight variables readily available to all clinicians. A diagnostic score <1.0 is reportedly 100% predictive of ischemic infarct. The clinical scoring system is asserted to be a useful adjunct in the initial evaluation of patients with acute stroke syndrome. The purpose of this study was to prospectively evaluate this clinical scoring system in our emergency department (ED). Sixty-one ED patients with focal neurologic deficit undergoing cranial computed tomography (CT) scan to rule out ICH were entered in the study. Thirteen [21% (95% CI, 12–34%)] were found to have an ICH. Twenty-two [36% (95% CI, 24–49%)] had a diagnostic score <1.0. The CT scans on 4 of these 22 patients showed ICH. The positive predictive value for ischemic infarct for these 22 patients using the diagnostic scoring system was 82% (95% CI, 60–95%). Our results suggest that this new clinical scoring system is of no value in helping to differentiate ICH from ischemic stroke in the acute care setting.     

ED utilization of computed tomography in a poisoned population

The objective of this prospective, analytic study was to identify predictors and describe the demographic and clinical correlates of head computed tomography (CT) evaluation in patients with poisoning or drug overdose and altered mental status. Forty-three patients that were evaluated by head CT and 109 that were not evaluated by head CT were entered into the study at a poison control center. None of the 43 scanned patients had any acute findings on head CT. A logistic regression model yielded 4 predictors that were statistically associated with the ordering of a head CT scan: Glasgow Coma Scale (GCS) < or = 8 (odds ratio [OR]: 2.3; 95% confidence interval [CI] 1.03-5.7); age > or = 41 years (OR 5.3; 95% CI 2.2-13); use of drugs or abuse by history (OR 2.8; 95% CI 1.04-7.6); and witnessed seizure activity (OR 4.8; 95% CI 1.3-17.9). We also tested 2 additional models to identify predictors of hospital admission, 1 with and 1 without CT scan included as a covariate. In the first model, only GCS 相似文献   

Computed Tomography Scanning and Delirium in Elder Patients

Objective: 1 ) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions.
Methods : This was a 2-part study. Part 1 was a prospective, observational study of 560 adults >70 years of age evaluated at 3 separate EDs using a 200-hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records ( n = 279) for patients >70 years of age in the prospective sample ( n = 79) and from a sample ( n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan.
Results : Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, impaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned (p < 0.001). Part 2: Of 279 CT scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space-occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED.
Conclusions : Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population.     

A new clinical score for cranial CT in ED non-trauma patients: Definition and first validation

IntroductionWell recognized guidelines are available for the use of cranial computed tomography (CCT) in traumatic patients, while no definitely accepted standards exists to for CCT in patients without history of head injury. The aim of this study is to propose an easy clinical score to stratify the need of CCT in emergency department (ED) patients with suspect non-traumatic intracranial pathology.MethodsWe retrospectively evaluated patients presenting to the ED for neurological deficit, postural instability, acute headache, altered mental status, seizures, confusion, dizziness, vertigo, syncope, and pre-syncope. We build a score for positive CCT prediction by using a logistic regression model on clinical factors significant at univariate analysis. The score was validated on a population of prospectively observed patients.ResultsWe reviewed clinical data of 1156 patients; positivity of CCT was 15.2%. Persistent neurological deficit, new onset acute headache, seizures and/or altered state of consciousness, and transient neurological disorders were independent predictors of positive CCT. We observed 508 patients in a validation prospective cohort; CCT was positive in 11.3%. Our score performed well in validation population with a ROC AUC of 0.787 (CI 95% 0.748–0.822). Avoiding CT in score 0 patients would have saved 82 (16.2%) exams. No patients with score 0 had a positive CCT findings; score sensitivity was 100.0 (CI 95% 93.7–100.0).ConclusionsA score for risk stratification of patients with suspect of intra-cranial pathology could reduce CT request in ED, avoiding a significant number of CCT while minimizing the risk of missing positive results.     

Low Yield of Paired Head and Cervical Spine Computed Tomography in Blunt Trauma Evaluation

Background

With increased computed tomography (CT) utilization, clinicians may simultaneously order head and neck CT scans, even when injury is suspected only in one region.

D ETERMINATION OF M EDICAL N ECESSITY FOR A IR AND C RITICAL C ARE M EDICAL T RANSPORTATION

Abstract

Objective. We aimed to assess the diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations when used by emergency medical technicians (EMTs) to detect the presence of free abdominal fluid. Methods. Six level 1 EMTs (similar to intermediate EMTs in the United States) who worked at a tertiary emergency department in Korea underwent an educational program consisting of two one-hour didactic lectures that included the principles of ultrasonography, the anatomy of the abdomen, and two hours of hands-on practice. After this educational session, the EMTs performed FAST examinations on a convenience sample of patients from July 1 to October 5, 2009. These patients also received an abdominal computed tomography (CT) scan regardless of their chief complaints. The CT findings served as the definitive standard and were interpreted routinely and independently by emergency radiologists who were blinded to the study protocol. In addition, the EMTs were blinded to the CT findings. A positive CT finding was defined as the presence of free fluid, as interpreted by the radiologist. The sensitivity, specificity, predictive values, and their 95% confidence intervals (CIs) were calculated. Informed consent was obtained from all participating patients. Results. Among the 1,060 eligible patients with abdominal CT scans, 403 patients were asked to participate in the study, and 240 patients agreed. Of these 240 patients, 80 (33.3%) had results showing the presence of free fluid. Fourteen patients had a significant amount of peritoneal cavity fluid, 15 had a moderate amount of peritoneal cavity fluid, and 51 had a minimal amount of peritoneal cavity fluid. Compared with the CT findings, the diagnostic performance of the FAST examination had a sensitivity of 61.3% (95% CI, 50.3%–71.2%), specificity of 96.3% (95% CI, 92.1%–98.3%), positive predictive value of 89.1% (95% CI, 77.0%–95.4%), and negative predictive value of 83.2% (95% CI, 76.9%–88.2%). For a significant or moderate amount of peritoneal cavity fluid, the sensitivity was considerably higher (86.2%). Conclusion. EMTs in Korea showed a high diagnostic performance that was comparable to that of surgeons and physicians when detecting peritoneal cavity free fluid in a Korean emergency department setting. The validity of FAST examinations in prehospital care situations should be investigated further.     

Subarachnoid Hemorrhage Diagnosis: Lumbar Puncture Is Still Needed When the Computed Tomography Scan Is Normal

Objectives: To determine the sensitivity of third-generation CT scanners for diagnosed nontraumatic subarachnoid hemorrhage (SAH) and to assess the impact of symptom duration on sensitivity.
Methods: A retrospective chart review was performed in a university-affiliated tertiary care hospital with an annual ED volume of >100,000 patients. The target population was all patients who presented to the ED from January 1991 to September 1994 with symptoms suggestive of SAH and who had a final diagnosis of nontraumatic SAH based on either a positive CT scan or positive spinal fluid analysis. Patients referred from outside facilities were included if they had a CT done at the study site. All CT scans were done using third-generation scanners. Official CT scan reports were used to categorize scans as positive or negative.
Results: There were 140 patients identified with SAH, with a mean age of 56 years (range 10–88). The sensitivity of CT in the diagnosis of nontraumatic SAH when performed at or before 12 hours of symptom duration was 100% (80/80), and 81.7% (49/60) after 12 hours of symptom duration (95% CI 95–100% and 69.5–90.4%, respectively; p < 0.0001). Eleven of the 140 patients had a negative CT and positive spinal fluid analysis, yielding an overall sensitivity of 92.1% (129/140).
Conclusion: The sensitivity of third-generation CT scans for SAH decreases with time from the onset of symptoms. In this sample population, CT was able to detect all patients scanned ^12 hours after symptom onset. Although the study demonstrated good sensitivity of CT scan reports for SAH when the scan was performed after S12 hours of symptom onset, additional real-time experience is needed to better define the potential risk of a missed SAH should this population not receive the customary lumbar puncture examination in the setting of a negative CT scan.     

Neurologic complaints in young children in the ED: when is cranial computed tomography helpful?

Main Objective

The objective of this study is to describe the use of emergent head computed tomography (CT) in young children and ask in which circumstances scans contributed to immediate management.

Methods

We reviewed electronic records of children, aged 1 month through 6 years, who received a head CT at a large suburban emergency department between February 2008 and February 2009. Age, sex, chief complaint, history, physical examination, indication for and results of head CT, red flags in history or physical examination, final disposition, and number of head CT scans performed to date were recorded. Abnormalities on CT scans were classified as significant or incidental, and subsequent interventions were documented.

Results

Emergent head CTs were performed on 394 children. The most common indications were trauma, 65%; seizure, 11%; and headache, 6%. Computed tomographic abnormalities were found in 40% (154 children): 32 significant findings,104 incidental findings, and 22 preexisting abnormalities. Four children with significant findings required immediate intervention. They all had red flags in both history and physical examination, and 3 of 4 children had known preexisting pathology; 1 child had nonaccidental trauma. Only 1 child had a significantly abnormal CT with no identifiable red flags; this child was admitted for observation and was discharged within 24 hours. Approximately a third of children had no readily identifiable red flag for the CT scans that they received. Of note, 20% of the young children had received more than 1 head CT scan to date, and 6% had between 6 and 20 scans.

Conclusions

Every child in this sample who required emergency intervention had red flags on history and physical examination. The 35% of CT scans performed in young children without red flags did not contribute usefully to their acute management.     

Elder Patients with Closed Head Trauma: A Comparison with Nonelder Patients

Abstract. Objective: Little is known about the circumstances surrounding closed head trauma (CHT) in elders, and how they differ from nonelders. The study objective was to compare the 2 populations for outcome (positive cranial CT scan depicting traumatic injury, or the need for neurosurgery), mechanism of injury, and the value of the neurologic examination to predict a CT scan positive for traumatic injury or the need for neurosurgical intervention. Methods: A retrospective study was conducted by collecting a case series of patients with blunt head trauma who underwent CT scanning, and comparing elder (aged s60 years) with nonelder patients. The setting was the ED of a university-affiliated Level-1 trauma center. Results: Twenty percent of the elders and 13% of the nonelders had CT scans positive for traumatic injury, which conferred a risk ratio of 1.58 (95% CI 1.21–2.05). Older women were more at risk for the need for neurosurgery than were younger ones (3.1 vs 0.3%, RR 10.66, 95% CI 1.26–90.46). Among the elders, falls were the dominant mechanism of closed head trauma, followed by motor vehicle collisions (MVCs), then being struck as a pedestrian. In the nonelders, MVCs, falls, and assaults were the most important mechanisms of injury. A focally abnormal neurologic examination imparted an increased risk for both a CT scan positive for traumatic injury (elder 4.39, 95% CI 2.91–6.62; nonelder 7.75, 95% CI 5.53–10.72) and the need for neurosurgery (elder 35.68, 95% CI 4.58–275.89; nonelder 142.58, 95% CI 19.11–1064.22) in both age groups. Conclusions : Significant differences exist between elder and nonelder victims of CHT with respect to mechanisms of trauma and outcomes (CT scan positive for traumatic injury, or the need for neurosurgery).     

The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations

OBJECTIVES: To assess the utility of neuroimaging in the evaluation of children presenting with two of the most common forms of headache, migraine and chronic daily headache, and to determine the utility and pathological yield of neuroimaging in specific headache syndromes in children whose neurological examinations are normal. METHODS: We retrospectively reviewed the medical records of patients coded for headache (ICD 784) in the Pediatric Neurology Clinic at Children's Hospital of the King's Daughters between 1997 and 1999. The age range considered was between 6 and 18 years. The study focused on the two most common types of headache, uncomplicated migraine and chronic daily headache. Only patients with normal physical and neurological examinations were considered in this analysis. RESULTS: Three hundred two patients were coded for headache within the defined age group. One hundred seven (35.4%) patients fulfilled IHS-R criteria as having uncomplicated migraine with a normal examination, and 30 (9.9%) patients fulfilled criteria for chronic daily headache. Twenty-nine (9.6%) patients presented with migrainelike symptoms, and 6 (2.0%) presented with chronic daily symptoms, but had neurological abnormalities present on examination. The remainder of the patients with headache had the following etiologies: 50 (16.6%) with secondary headache, 22 (7.3%) with complicated migraine, 20 (6.6%) with posttraumatic headache, 13 (4.3%) with seizure-related headache, 11 (3.6%) with brain tumors, 10 (3.3%) with tension-type headache, and 4 (1.3%) with pseudotumor cerebri. Of the 107 patients with migraine, 42 (39.3%) received CT scans; 2 (4.8%) of which were considered "abnormal." One of the abnormalities was an arachnoid cyst and the other was a dilated Virchow-Robin space. Twelve (11.2%) patients with migraine received an MRI, 2 (16.7%) of which were considered abnormal. Both of the abnormal findings were Chiari type I malformations. Of the 30 patients with chronic daily headache, 17 (56.7%) received CT scans, 3 (17.6%) of which were considered abnormal. The abnormalities consisted of a maxillary opacification, a mucous retention cyst, and an occult vascular malformation. Eight (26.7%) of the patients with chronic daily headache had an MRI, 2 (25.0%) of which were abnormal. One of the abnormalities was a Chiari I malformation, and the other was an occult vascular malformation. CONCLUSION: The yield of neuroimaging in children with uncomplicated migraine and normal neurological examination was 3.7%. The yield in children with chronic daily headache and normal neurological examination was higher at 16.6%. The abnormalities discovered included arachnoid cysts, Chiari I malformations, sinus disease, occult vascular malformations and "dilated Virchow-Robin spaces." While none of the neuroimaging findings were apparent clinically, their discovery did not influence the diagnosis, management, or outcome of the patients. None of the abnormalities necessitated surgical intervention or were associated with the headache presentation. Therefore, neuroimaging is not warranted in children and adolescents with defined clinical headache syndrome diagnoses whose neurological examinations are normal.     

Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients

Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings.     

Performance of the Pediatric Glasgow Coma Scale in Children with Blunt Head Trauma

Objectives: To compare the accuracy of a pediatric Glasgow Coma Scale (GCS) score in preverbal children with blunt head trauma with the standard GCS score in older children. Methods: The authors prospectively enrolled children younger than 18 years with blunt head trauma. Patients were divided into cohorts of those 2 years and younger and those older than 2 years. The authors assigned a pediatric GCS score to the younger cohort and the standard GCS score to the older cohort. Outcomes were 1) traumatic brain injury (TBI) on computed tomography (CT) scan or 2) TBI in need of acute intervention. The authors created and compared receiver operating characteristic (ROC) curves between the age cohorts for the association of GCS scores and TBI. Results: The authors enrolled 2,043 children, and 327 were 2 years and younger. Among these 327, 15 (7.7%; 95% confidence interval [CI] = 4.4% to 12.4%) of 194 who underwent imaging with CT had TBI visible and nine (2.8%; 95% CI = 1.3% to 5.2%) had TBI needing acute intervention. In children older than 2 years, 83 (7.7%; 95% CI = 6.2% to 9.5%) of the 1,077 who underwent imaging with CT had TBI visible and 96 (5.6%; 95% CI = 4.6% to 6.8%) had TBI needing acute intervention. For the pediatric GCS in children 2 years and younger, the area under the ROC curve was 0.72 (95% CI = 0.56 to 0.87) for TBI on CT scan and 0.97 (95% CI = 0.94 to 1.00) for TBI needing acute intervention. For the standard GCS in older children, the area under the ROC curve was 0.82 (95% CI = 0.76 to 0.87) for TBI on CT scan and 0.87 (95% CI = 0.83 to 0.92) for TBI needing acute intervention. Conclusions: This pediatric GCS for children 2 years and younger compares favorably with the standard GCS in the evaluation of children with blunt head trauma. The pediatric GCS is particularly accurate in evaluating preverbal children with blunt head trauma with regard to the need for acute intervention.     

Traumatic Brain Injury in Patients Receiving Direct Oral Anticoagulants

BackgroundEmergency departments (EDs) are faced with a growing number of patients with traumatic brain injury (TBI) using direct oral anticoagulants (DOACs). However, there remains uncertainty about the bleeding risk, rate of hematoma expansion, and the efficacy of reversal strategies in these patients.ObjectiveThis study aims to identify the risk of traumatic hemorrhagic complications in patients with TBI using DOACs.MethodsIn this retrospective study we included patients with TBI. All TBI patients were using DOACs, attended one of the three EDs of our hospital between January 2016 and October 2019, and received a computed tomography (CT) scan of the brain. The primary outcome was any traumatic intracranial hemorrhage on CT. Secondary outcomes were the use of reversal agents, secondary neurological deterioration, a neurosurgical intervention within 30 days after the injury, length of stay (LOS), Glasgow Outcome Scale (GOS) at discharge, and mortality.ResultsOf the included patients (N = 316), 24 patients (7.6%, 95% confidence interval [CI] 4.2–9.8) presented with a traumatic intracranial hematoma (ICH). Seven patients (2.2%, 95% CI 0.6–3.8) received a reversal agent and 1 patient (0.3%, 95% CI ?0.3–0.9) underwent a neurosurgical intervention. Of the 24 patients with a traumatic ICH, progression of the lesion was seen in 6 patients (1.9%, 95% CI 0.4–3.4). The mean LOS was 6.5 days (95% CI 3.0–10.1) and the mean GOS at discharge was 4 (95% CI 3.6–4.6). Death occurred in 1 patient (0.3%, 95% CI ?0.3–0.9) suffering from an ICH.ConclusionBased on the present findings it can be postulated that TBI patients using DOACs have a low risk for ICH. Hematoma progression occurred, however, in a substantial number of patients. Considering the retrospective nature of the present study, future prospective trials are needed to confirm this finding.