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  • Single cranial CT protocol for patients with MHI and ICH : is it safe?

    Final Number:

    Neil J. Majmundar BS; Chirag G. Gordhan; Seema Anandalwar BS; Rachid Assina MD; Charles J. Prestigiacomo MD FACS; Ziad S Sifri

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Benefit of routine repeat head computed tomography (RHCT) in minimal head injury (MHI) patients (GCS greater than 12) has been debated. With increasing concern over the use of hospital resources, our institution undertook several studies revealing little benefit from routine RHCTs. As a result we devised a new single CT protocol whereby MHI patients with an intracranial hemorrhage (ICH) and a GCS=15 at 24 hours do not receive a routine RHCT. This study was undertaken to determine the safety and outcomes of this protocol.

    Methods: Retrospective cohort study of patients >/= 18 years-old admitted to our institution over 48 months with MHI and ICH on initial CT. Patients were included if they had a GCS=15 at 24 hours and did not receive a RHCT, those that did receive a routine RHCT were excluded for protocol deviation. Exclusion criteria included anticoagulation therapy, delayed presentation after injury, or incomplete records.

    Results: 533 patients were retrieved, 391 (73%) were excluded, 48 (9%) deviated from protocol, and 94 (18%) met criteria. Of the 94, median age was 34 (IQR,29.5), 78 (83%) were male, and most common ICH was a subdural hemorrhage (72%). 3 (3%) patients suffered delayed neurologic decline (change in mental status prompting RHCT greater than or equal to 24 hours from presentation). All 3 had worsened findings on RHCT, 0/3 required any neurosurgical intervention, and 2/3 required upgrading of care without medical intervention (Table 1). Median time to deterioration was 70 hours (IQR, 9). All three patients recovered to full neurologic function prior to discharge.

    Conclusions: This new institutional single CT protocol for patients with MHI and ICH resulted in no delay of neurosurgical intervention or adverse neurologic outcome, indicating its safety. Larger prospective patient multicenter series are need to further validate this conclusion in this select group of MHI patients.

    Patient Care: This retrospective study investigates the effectiveness of the stated protocol and prevents unnecessary imaging and use of resources.

    Learning Objectives: By the conclusion of this session, participants should be able to 1) Understand the clinical characteristics and risk factors leading to delayed neurological deterioration, 2) Discuss when to forego RHCT in patients with normal neurological exam after 24 hours and 3) Identify or investigate similar protocols preventing unnecessary RHCT.

    References: Thorson CM, Van Haren RM, Otero CA, et al. Repeat head computed tomography after minimal brain injury identifies the need for craniotomy in the absence of neurologic change. The journal of trauma and acute care surgery. Apr 2013;74(4):967-973 ; discussion 973-965. Bee TK, Magnotti LJ, Croce MA, et al. Necessity of repeat head CT and ICU monitoring in patients with minimal brain injury. The Journal of trauma. Apr 2009;66(4):1015-1018. Stein SC, Fabbri A, Servadei F. Routine serial computed tomographic scans in mild traumatic brain injury: when are they cost-effective? The Journal of trauma. Jul 2008;65(1):66-72. Washington CW, Grubb RL, Jr. Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? Journal of neurosurgery. Mar 2012;116(3):549-557. Velmahos GC, Gervasini A, Petrovick L, et al. Routine repeat head CT for minimal head injury is unnecessary. The Journal of trauma. Mar 2006;60(3):494-499; discussion 499-501. Sifri ZC, Homnick AT, Vaynman A, et al. A prospective evaluation of the value of repeat cranial computed tomography in patients with minimal head injury and an intracranial bleed. The Journal of trauma. Oct 2006;61(4):862-867. Sifri ZC, Nayak N, Homnick AT, Mohr AA, Yonclas P, Livingston DH. Utility of repeat head computed tomography in patients with an abnormal neurologic examination after minimal head injury. The Journal of trauma. Dec 2011;71(6):1605-1610.

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