Introduction: Traumatic brain injury (TBI) is a major public health issue with 1.7 million cases/year1-2. Mild TBI represents 75% of all TBI and costs $17 billion/year1-2. Routine repeat head CT for hospitalized patients with mild TBI is controversial3-5. No guidelines exist for post-hospitalization follow-up. Most patients are at their neurologic baseline at follow-up, which questions the utility of routine CT. Limiting routine CT scanning would be beneficial as cumulative diagnostic radiation exposure is associated with an increased risk of cancer and increased medical cost6.

Methods: Retrospective analysis of non-operative mild and moderate TBI patients over a 5-year interval was conducted. We examined whether follow up imaging initiated a change in management (CIM). CIM included return to clinic, surgery, further imaging, and restarting antiplatelet/anticoagulant therapy. Clinical characteristics considered included: age, sex, diagnosis, admission GCS, mechanism of injury, antiplatelet/anticoagulant therapy, symptomatic, and changes on imaging.

Results: 191 patients were identified. 31(16.2%) had CIM. CIM was associated with older age(65 yo vs. 55 yo, p=0.011), diagnosis of subdural hematoma(p=0.041), patients on antiplatelet/anticoagulant therapy(p=0.009), imaging performed(p=0.16), and increased blood products on CT(p=<0.0001). Subgroup analysis of patients on antiplatelet/anticoagulant therapy and those not showed only those with worsening findings on CT was significant for CIM(p=0.0002, 0.039). Delayed surgical intervention occurred in only 2 patients(1.0%), both of whom had subdural hematomas and were not on antiplatelet/anticoagulant therapy.

Conclusions: Asymptomatic patients and those without subdural hematoma did not require delayed surgical intervention, and should not undergo routine imaging. Patients on antiplatelet/anticoagulation therapy do not appear to have increased risk for delayed surgical intervention. Clinical judgment can be used to decide routine imaging in other mild to moderate TBI patients, knowing that only 2% of patients in our review had worsening CT findings.

Patient Care: From this study, clinicians will be able to provide high quality medical care without increasing radiation exposure and medical costs for patients

Learning Objectives: By the conclusion of this session, participants should be able to identify the limited number of TBI patients who would benefit from routine post-hospitalization CT imaging and will be able to provide high quality medical care without increasing radiation exposure and medical costs for patients.

References: 1.Faul M, Xu L, et al.. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. 2. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003. 3. Thomas BW, Mejia VA, et al. Scheduled repeat CT scanning for traumatic brain injury remains important in assessing head injury progression. J Am Coll Surg. 2010 May;210(5):824-30, 831-2. doi: 10.1016/j.jamcollsurg.2009.12.039. PubMed PMID: 20421059. 4. Almenawer S, Bogza I, et al. The Value of Scheduled Repeat Cranial Computed Tomography Following Mild Head Injury: Single-Center Series and Meta-Analysis. Neurosurgery. 2012 Oct 23. [Epub ahead of print] PubMed PMID: 23096421. 5. AbdelFattah KR, Eastman AL, et al.. A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15. J Trauma Acute Care Surg. 2012 Sep;73(3):685-8. doi: 10.1097/TA.0b013e318265ccd9. PubMed PMID: 22929497. 6. Sodickson A, Baeyens PF, et al. Recurrent CT, cumulative radiation exposure, and associated radiation-induced cancer risks from CT of adults. Radiology. 2009 Apr;251(1):175-84. doi: 10.1148/radiol.2511081296. PubMed PMID: 19332852.