Initial head computed tomographic scan characteristics have a linear relationship with initial intracranial pressure after trauma

BACKGROUND: Despite current recommendations by the Brain Trauma Foundation regarding the placement of intracranial pressure (ICP) monitoring devices, advances in computed tomographic (CT) scan technology have led to the suggestion that increased ICP may be predicted by findings on admission head CT scan and that patients without such findings do not require such monitoring. A linear relationship exists between characteristics of admission head CT scan and initial ICP level, allowing for selective placement of ICP monitoring devices. METHODS: From 1997 to 2001, a retrospective review of patients admitted with a Glasgow Coma Scale (GCS) score < 8 and head CT scan who underwent ventriculostomy placement at our institution, was conducted. Patients undergoing craniotomy with evacuation of mass lesions before ventriculostomy placement were excluded. Age, sex, mechanism of injury, anoxia, osmotic treatment, presence of drugs/alcohol, initial mean arterial pressure, initial GCS score, and initial ICP were recorded. Initial head CT scans were reviewed independently by two neuroradiologists who were blinded to ICP measurements, neurosurgical treatment, patient outcome, and each other's interpretation. Initial CT scans were evaluated and scored on a 1 (normal) to 3 (abnormal) scale with respect to ventricle size, basilar cistern size, sulci size, degree of transfalcine herniation, and gray/white matter differentiation. Initial ICP readings and CT scan findings were compared to determine whether a significant linear relationship existed between the above CT scan findings and ICPs. Logistic and univariate linear regression were used to compare averaged radiologist score versus dichotomized ICP at baseline. RESULTS: Initial head CT scan characteristics show a linear relationship to baseline ICPs. These findings are associative, but are not uniformly predictive. CONCLUSION: Therefore, the current Brain Trauma Foundation recommendation of ICP monitoring in those patients presenting with a GCS score < 8 with an abnormal CT scan or a normal CT scan with age > 40 years, systolic blood pressure < 90 mm Hg, or exhibiting posturing should be followed.     

The use of head CT scan in adult trauma victims: an algorithm

INTRODUCTION: The purpose of this study was to identify, through recursive partitioning, clinically relevant criteria which predict the need for acute neurosurgical intervention in a group of patients with mild head injury. MATERIALS AND METHODS: A retrospective cohort of all adult patients, from April 2000 to March 2001, who sustained a blunt trauma and underwent head CT scan, was reviewed. The following inclusion criteria for mild head injury were used: initial Glasgow Coma Scale (GCS) ranging from 13 to 15; no loss of consciousness lasting more than one hour; no obvious skull fracture; a cranial CT scan performed. We collected demographic and trauma related data, interventions and outcome. Univariate and multivariate analyses were undertaken. In parallel, recursive partitioning was carried out using all variables to elaborate a decision algorithm. RESULTS: There were 405 patients in the sample. CT identified lesions in 12% of patients. Twelve patients (3%) required acute neurosurgical intervention. The recursive partitioning analysis identified three significant sequential nodes: deterioration of the GCS; an initial GCS of 13 vs 14 or 15; and the presence of associated injuries or comorbid conditions. CONCLUSIONS: A simple three step rule predicts the need for acute neurosurgical intervention based on clinical findings: a deteriorating GCS; an initial GCS of 13; and the presence of associated injuries or comorbid conditions.     

Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury

OBJECTIVE: To determine the negative predictive value of cranial computed tomography (CT) scanning in a prospective series of patients and whether hospital admission for observation is mandatory after a negative diagnostic evaluation after minimal head injury (MHI). SUMMARY BACKGROUND DATA: Hospital admission for observation is a current standard of practice for patients who have sustained MHI, despite having undergone diagnostic studies that exclude the presence of an intracranial injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that admission will allow prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. METHODS: In a prospective, multiinstitutional study during a 22-month period at four level I trauma centers, all patients with MHI were evaluated using the following protocol: a standardized physical and neurologic examination in the emergency department, cranial CT scanning, and then admission for observation. MHI was defined as either a documented loss of consciousness or evidence of posttraumatic amnesia and an emergency department Glasgow Coma Scale score of 14 or 15. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, need for craniotomy, and death. RESULTS: Two thousand one hundred fifty-two consecutive patients fulfilled the study protocol. The CT was interpreted as negative for intracranial injury in 1,788, positive in 217, and equivocal in 119. Five patients with CT scans initially interpreted as negative required intervention. There was one craniotomy in a patient whose CT scan was initially interpreted as negative. This patient had facial fractures that required surgical intervention and elevation of depressed intracranial fracture fragments. The negative predictive power of a cranial CT scan based on the preliminary reading of the CT scan and defined by the subsequent need for neurosurgical intervention in the population fully satisfying the protocol was 99.70%. CONCLUSIONS: Patients with a cranial CT scan, obtained on a helical CT scanner, that shows no intracerebral injury and who do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation. Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually.     

Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan

BackgroundWhole-body CT scan is the cornerstone of trauma-related injury assessment. Several lines of evidence indicate that significant number of injuries may remain undetected after the initial hot report of CT. Missed injuries (MI) represent an important issue in trauma patients, for they may increase morbidity, mortality and costs. The aim of this study was to examine incidence and predictors of MI in trauma patients undergoing whole-body CT scan.Methods177 CT scan performed upon admission of trauma patients during year 2005 were reviewed by a radiologist blinded to patient's initial data. MI was defined as injuries not written in the initial report. Patients with and without MI were compared to determine predictors of MI by multivariable analysis.Results157 MI were diagnosed in 85 (47%) patients. MI was predominantly encoded AIS 2 (57%) or 3 (29%). Patients with MI had significantly higher SAPSII, higher ISS and were more frequently sedated. Age over 50 years (OR: 4.37, p = 0.003) and ISS over 14 (OR: 4.17, p < 0.0001) were independent predictors of MI. Median ISS after encoding MI was significantly higher than initial ISS (22 vs. 20 p < 0.0001). After adjustment for severity, mortality and length of stay were not different between patients with or without MI.ConclusionTrauma patients, especially aged and severe, experienced a high rate of missed injuries in the initial hot report which appeared to be predominantly minor and musculoskeletal, advocating a CT scan second reading.     

Necessity of monitoring after negative head CT in acute head injury

Objective

The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT).

Materials and methods

This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010–July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n = 2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72 h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication.

Results

The majority (n = 1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n = 27) of these patients returned to ED within 72 h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72 h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%.

Conclusion

In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.     

Use of direct oral anticoagulants with regional anesthesia in orthopedic patients

The use of direct oral anticoagulants including apixaban, rivaroxaban, and dabigatran, which are approved for several therapeutic indications, can simplify perioperative and postoperative management of anticoagulation. Utilization of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Given the extensive use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. We discuss current data, guideline recommendations, and best practice advice on effective management of the direct oral anticoagulants and regional anesthesia, including in specific clinical situations, such as patients undergoing major orthopedic surgery at high risk of a thromboembolic event, or patients with renal impairment at an increased risk of bleeding.     

Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery

Demographic projections for hip fragility fractures indicate a rising annual incidence by virtue of a multimorbid, ageing population with more noncommunicable diseases (NCDs). NCDs are characterised by slow progression and long duration ranging from ischaemic cardiovascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease to various cancers. Management of this disease burden often involves commencing patients on oral anticoagulants to reduce the risk of thromboembolic events. The use of direct oral anticoagulants (DOACs) in clinical practice has increased due to their rapid onset of action, short half-life and predictable anticoagulant effects, without the need for routine monitoring. Safe and timely surgical intervention relies on reversal of anticoagulants. However, the lack of specific evidence-based guidelines for the perioperative management of patients on DOACs with hip fractures has proved challenging; in particular, the accessibility of DOAC-specific assays, justification of the cost-benefit ratio of targeted reversal agents and indications for neuraxial anaesthesia. This has led to potentially avoidable delays in surgical intervention. Following a literature review of the pharmacokinetic and pharmacodynamics of commonly used DOACs in our region including the role of surrogate markers, we propose a systematic, evidence-based guideline to the perioperative management of hip fractures DOACs. We believe this standardised protocol can be easily replicated between hospitals. We recommend that if patients are deemed suitable for a general anaesthesia, with satisfactory renal function, optimal surgical time should be 24 h following the last ingested dose of DOAC.     

Computerized tomography (CT) in patients with head injuries. Assessment of outcome based upon initial clinical findings and initial CT scans

Summary In this study, which comprises 144 consecutive head injuries, the initial clinical assessment and the findings of the initial CT scan are related to the outcome. The mortality is related to the patient's level of consciousness and pupillary light reflex on admission. The disability rate (= number of disabled/number of survivors) was independent of the level of consciousness but closely related to pupillary light reaction.Diminished and obliterated basal cisterns were bad prognostic signs, with a mortality rate of 66% in the latter group. Both disability and mortality increase with the number of different lesion types.     

Significance of bilateral abnormalities on the CT scan in patients with severe head injury

One hundred forty head injured patients, managed by a standardized protocol of early diagnosis, surgical decompression, and intensive therapy, had computerized tomographic (CT) scans within 1 hour or arrival in the emergency room. Ninety of these patients had serial scans during the subsequent week. On admission, 26 patients had normal scans, 75 had unilateral lesions, and 39 had bilateral lesions. Thirteen who had unilateral lesions on admission developed contralateral lesions during the first week for a total of 52 patients with bilateral lesions. These 52 patients could be separated into two distinct groups: (a) those with small ventricles and no change or a slight, homogeneous decrease in density of the brain parenchyma, who had better neurological status on admission, lower intracranial pressure (ICP), and better outcome; and (b) those with bilateral increased density lesions, who had poorer motor response on admission, higher ICP, and worse outcome. The value of CT scanning in management, prognosis, and outcome is emphasized.     

The (absence of a) role of venous duplex scan in the diagnosis of pulmonary embolism after severe trauma

Venous duplex scan (VDS) has been used for interim bedside diagnosis of pulmonary embolism (PE) in severely injured patients deemed to be at risk if transported out of the intensive care unit. In combination with the level of clinical suspicion for PE, VDS helps select patients for temporary treatment until definitive diagnosis is made. We evaluate the sensitivity and specificity of VDS in critically injured patients with a high level of clinical suspicion for PE. We performed a prospective observational cohort study at the surgical intensive care unit of an academic level 1 trauma center. Patients were 59 critically injured patients suspected to have PE over a 30-month period. The level of clinical suspicion for PE was classified as low or high according to preset criteria. Interventions were VDS and a PE outcome test (conventional or computed tomographic pulmonary angiography). The sensitivity and specificity of VDS to detect PE in all patients and in patients with high level of clinical suspicion was calculated against the results of the outcome test. PE was diagnosed in 21 patients (35.5%). The sensitivity and specificity of VDS was 33 per cent and 89 per cent, respectively. Among the 28 patients who had a high level of clinical suspicion for PE, the sensitivity of VDS was 23 per cent and the specificity 93 per cent. In this latter population, 1 of the 4 (25%) positive VDS was of a patient without PE and 10 of the 24 (42%) negative VDS were of patients who had PE. VDS does not accurately predict PE in severely injured patients, even in the presence of a high level of clinical suspicion.     

Computerized tomography (CT) in patients with head injuries

Summary In a retrospective series of 144 patients with cranial trauma admitted to the Department of Neurosurgery, 96 were initially examined by CT. The initial clinical assessment, operative findings, if any, and the clinical course were compared to the results of the primary CT scan. In patients presenting lateralizing deficits, 49% had lesions on the expected side, and 23% on the opposite side. Thirty-one per cent of brain stem affected patients had a supratentorial mass lesion requiring craniotomy. Three decerebrate patients who died had an initially normal CT scan. Thirty craniotomies were performed on the basis of the CT scans, and six cases deviated from the expected, but no case showed a false positive indication for surgery. The final diagnosis was in accordance with the initial clinical diagnosis, and with the initial CT scan in 44% and 84%, respectively, of all cases.Parts of the material have been presented at the Congress of Scandinavian Neurosurgical Society at Oulu, 1979.     

The impact of a negative (111)indium-capromab pendetide scan before salvage radiotherapy

PURPOSE: We determined the prognostic role, if any, of the ProstaScint (111)indium-capromab pendetide scan before salvage radiotherapy for biochemical recurrence after RP for localized prostate cancer. MATERIALS AND METHODS: We reviewed the records of 649 patients who underwent a ProstaScint scan from 1998 to 2004. A total of 44 patients were identified who had biochemical recurrence after RP and underwent a ProstaScint scan immediately before salvage radiotherapy. All patients received salvage radiotherapy to the prostatic bed unless pelvic lymph node uptake was identified on the scan, resulting in initial whole pelvic radiotherapy with 45 Gy, followed by a conformal boost to the prostate bed in 6. The median salvage radiotherapy dose to the prostate bed was 72 Gy. Patient demographics, pathological information, PSA values and ProstaScint results were collected retrospectively. The majority of ProstaScint scans were digitally fused with noncontrast pelvic computerized tomography images for interpretation. PSA progression after radiotherapy was defined using American Society for Therapeutic Radiation and Oncology criteria. RESULTS: At a mean followup of 22 months 43 of 44 patients (97%) experienced a PSA decrease after salvage radiotherapy with a mean PSA nadir of 0.16 ng/ml compared to a mean pre-radiotherapy PSA of 1.7 ng/ml. Of the 44 patients 15 (34%) showed post-radiotherapy PSA progression. When the entire cohort was analyzed, patients with negative ProstaScint scans had statistically lower post-radiotherapy PSA progression rates than patients with positive scans (1 of 10 or 10% vs 14 of 34 or 41%, p = 0.026). Patients with negative ProstaScint results were also statistically more likely to have a pre-radiotherapy PSA of less than 1.0 ng/ml (p = 0.005), no seminal vesicle involvement (p = 0.006), a greater mean PSA doubling time (p = 0.008) and received no hormone therapy (p = 0.003). When patients with pre-radiotherapy PSA less than 1.0 ng/ml were analyzed, a negative ProstaScint scan suggested but did not provide a statistically significant advantage over pre-radiotherapy PSA alone for predicting post-radiotherapy PSA progression (1 of 9 or 11% for negative vs 5 of 15 or 33% for positive scans, p = 0.20). CONCLUSIONS: Our early experience supports an improved prognosis in patients receiving salvage pelvic radiotherapy for biochemical recurrence after RP who have a negative pre-radiotherapy ProstaScint scan. However, this finding is not necessarily independent of pre-radiotherapy PSA.     

Comparison of the diagnostic accuracy of CT scan with oral and intravenous contrast versus CT scan with intravenous contrast alone in the diagnosis of blunt abdominal trauma

PurposeAbdominal CT scan using oral and intravenous (IV) contrast is helpful in the diagnosis of intra-abdominal injuries. However, the use of oral and IV contrast delays the process of diagnosis and increases the risk of aspiration. It has also been shown that CT scan with IV contrast alone is as helpful as CT scan with oral and IV contrast and rectal CT scan in detecting abdominal injuries. Therefore, the present study aims to prospectively compare the diagnostic value of CT scan with oral and IV contrast versus CT scan with IV contrast alone in the diagnosis of blunt abdominal trauma (BAT).MethodsAltogether 123 BAT patients, 60 (48.8%) women and 63 (51.2%) men with the mean age of (40.4 ± 18.7) years who referred to the emergency department of Imam Khomeini Educational and Medical Center in Sari, Iran (a tertiary trauma center in north of Iran) from November 2014 to March 2017 and underwent abdominal CT scans + laparotomy were investigated. Those with penetrating trauma or hemodynamically unstable patients were excluded. The participants were randomly allocated to two groups: abdominal CT scan with oral and IV contrast (n = 63) and CT scan with IV contrast alone (n = 60). No statistically significant difference was found between two groups regarding the hemodynamic parameters, age, gender, injury mechanisms (all p > 0.05). The results of CT scan were compared with that of laparotomy results. The collected data were recorded in SPSS version 22.0 for Windows. Quantitative data were presented as mean and SD.ResultsThe sensitivity and specificity of CT scan using oral and IV contrast in the diagnosis of BAT were estimated at 96.48 (95% CI: 90.73 – 99.92) and 92.67 (95% CI: 89.65 – 94.88), respectively; while CT scan with IV contrast alone achieved a comparable sensitivity and specificity of 96.6 (95% CI: 87.45 – 99,42 and 92.84 (95% CI: 89.88 – 95.00), respectively.ConclusionCT scan with IV contrast alone can be used to assess visceral injuries in BAT patients with normal hemodynamics to avoid diagnostic delay.