Results
Baseline characteristics of the study population are shown in Table
1. In total, 1083 patients were enrolled, of which 541 patients were randomized for TBCT (
n = 49.9 %). The median age was 42 years (IQR 27–59) in the TBCT group and 45 years (IQR 26–59) in the STWU group (
p = 0.746). The baseline characteristics were comparable between groups except for the number of multitrauma patients: TBCT
n = 362 (66.9 %) vs. STWU
n = 331 (61.1 %),
p = 0.045. Median ISS did not differ between groups: TBCT 20 (IQR 10–29) vs. STWU 19 (9–29),
p = 0.405.
Table 1
Baseline demographic and clinical characteristics of patients*
Age (years) | 42 (27–59) | 45 (26–59) |
Male sex, n (%) | 413 (76.3) | 411 (75.8) |
Blunt trauma, n (%) | 530 (98.0) | 534 (98.5) |
Trauma mechanism blunt trauma, n (%) |
Fall from height | 170 (32.1) | 178 (33.3) |
MVC – patient as occupant | 201 (37.9) | 190 (35.6) |
MVC – patient as cyclist | 65 (12.3) | 60 (11.2) |
MVC – patient as pedestrian | 29 (5.5) | 45 (8.4) |
Other | 65 (12.3) | 61 (11.4) |
Comorbidity, n (%) |
ASA I or II | 495 (95.7) | 501 (96.2) |
ASA III, IV or V | 22 (4.3) | 20 (3.8) |
CT performed at ED, n (%)* |
Head | 539 (99.6) | 483 (89.1) |
Neck | 535 (98.9) | 480 (88.6) |
Chest | 529 (97.8) | 315 (58.1) |
Abdomen/pelvis | 528 (97.6) | 278 (51.3) |
Abbreviated Injury Scale ≥3, n (%) |
Head | 247 (45.7) | 218 (40.2) |
Chest | 229 (42.3) | 206 (38.0) |
Abdomen/pelvic content | 49 (9.1) | 67 (12.4) |
Pelvis and extremities | 150 (27.7) | 154 (28.4) |
Injury Severity Score (points) | 20 (10–29) | 19 (9–29) |
Multitrauma patients, n (%)*†
| 362 (66.9) | 331 (61.1) |
TBI patients, n (%)†
| 178 (32.9) | 151 (27.9) |
In total, 441 incidental findings were found in 233 of the patients (42.9 %) randomized for TBCT, compared to 290 findings in 167 of the patients (32.5 %) randomized for the STWU (adjusted rate ratio 1.531; 95 % confidence interval [95%CI] 1.274–1.840;
p < 0.001), as shown in Table
2. Major findings were detected in 23 patients (4.3 %) in the TBCT group, compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337–6.077;
p < 0.007). Moderate findings were detected in 120 patients (22.2 %) and 86 patients (15.9 %) in the TBCT and STWU groups, respectively (adjusted rate ratio 1.421; 95%CI 1.088–1.854;
p < 0.010).
Table 2
Trauma patients with incidental findings
Patients with incidental findings, n (%) | 232 (42.9) | 176 (32.5) | 1.524 (1.251–1.856) | <0.001†
| 1.531 (1.274–1.840) | <0.001†
|
Major relevance | 23 (4.3) | 9 (1.7) | 2.672 (1.243–5.744) | 0.012‡
| 2.851 (1.337–6.077) | 0.007‡
|
Moderate relevance | 120 (22.2) | 86 (15.9) | 1.394 (1.051–1.849) | 0.021‡
| 1.421 (1.088–1.854) | 0.010‡
|
Minor relevance | 172 (31.8) | 129 (23.8) | 1.551 (1.240–1.940) | <0.001†
| 1.536 (1.238–1.905) | <0.001†
|
Table
3 shows comparisons of the distribution of the incidental findings over clinical categories between the two groups. Distribution over categories of relevance, body regions, organ systems or neoplasms was similar between the imaging groups. Tables
5 and
6 in the appendix show the follow-up and medical documentation of incidental findings per category of relevance. These characteristics were comparable between the imaging groups; however, follow-up rates were low, and documentation of incidental findings was poor in both groups. In the discharge letters, 39.3 % of the major findings and 13.8 % of the moderate findings were mentioned.
Table 3
Characteristics of incidental findings
Incidental findings, n
| 441 | 290 | |
Body region, n (%) |
Head | 56 (12.7) | 39 (13.4) | 0.786 |
Neck | 26 (5.9) | 22 (7.6) |
Thorax | 65 (14.7) | 47 (16.2) |
Abdomen/pelvis | 292 (66.2) | 180 (62.1) |
Extremities | 2 (0.5) | 2 (0.7) |
Organ system, n (%) |
Reno-adrenal | 112 (25.4) | 75 (25.9) | 0.696 |
Hepatobiliary | 92 (20.9) | 64 (22.1) |
Respiratory | 55 (12.5) | 27 (9.3) |
Reticuloendothelial | 49 (11.1) | 33 (11.4) |
Neurological | 33 (7.5) | 25 (8.6) |
Endocrine | 27 (6.1) | 21 (7.2) |
Gastrointestinal | 27 (6.1) | 11 (3.8) |
Urethro-genital | 18 (4.1) | 15 (5.2) |
Cardiovascular | 16 (3.6) | 15 (5.2) |
Musculoskeletal | 11 (2.5) | 4 (1.4) |
Cutaneous | 1 (0.2) | 0 (0) |
Neoplasm |
Confirmed | 20 (4.5) | 10 (3.4) | 0.456 |
Suspected | 29 (6.6) | 14 (4.8) |
The complete list of all findings arranged by body region and relevance is presented in Table
7 in the appendix. Simple renal and hepatic cysts were the most common of all incidental findings for patients in both imaging groups. Suspicious pulmonary nodules were the most described potentially lethal finding (
n = 6). Of all findings of moderate relevance, gallstones and hepatic steatosis were most frequently described. One in every 24 incidental findings was a pathologically confirmed neoplasm (4.1 %).
Discussion
This study shows that TBCT imaging is more likely to detect an incidental finding than the standard work-up with selective CT scanning. In every category of clinical relevance, the TBCT scan detected significantly more findings. The incidental findings did not differ in distribution over body regions or tissue types, although the abdominal region showed the largest difference. We could not demonstrate a significant difference in follow-up, which could be explained by low follow-up rates in general and poor documentation of incidental findings and their management in trauma patients. Trauma teams using TBCT scanning should be aware of an increase in relevant incidental findings and should pay special attention to the reporting and management of these additional findings.
In the present study, incidental findings occurred in 43 % of patients undergoing TBCT scanning, of which 42 % could cause serious morbidity. Similar results were reported in previous studies on incidental findings in TBCT scans for initial trauma evaluation. These studies, however, did not directly compare these to incidental findings with selective CT scanning. The study by Hofstetter et al. found incidental findings in 50 % of their patients, with 29 % of these possibly requiring follow-up [
7]. In a study by Barett et al., findings were detected in 53 % of all patients by TBCT, 59 % of which required urgent follow-up [
6]. Sierink et al. recently reported incidental findings in 45 % of all patients, with possible follow-up required in 31 % [
8]. Thus, with the present study included, the percentage of trauma patients with incidental findings detected by TBCT ranges from 43 % to 53 %. Of these findings, 29 % to 59 % have clinical relevance; however, the definition of clinical relevance will be interpreted differently.
Considering future diagnostic work-up, the separate and detailed inclusion of moderate and major findings in the trauma room report's conclusion may help communicate these findings to the general practitioner and other treating physicians. Poor documentation could result in lack of further diagnostic work-up or treatment in other facilities, a structural problem that has been described in previous reports on CT in trauma and emergency imaging [
4,
5,
13,
17‐
20]. Complete and clear documentation thus might save costs in the long term by eliminating repeated work-up for incidental findings. Future research should aim to establish effective methods for proper reporting and management of incidental findings in trauma patients.
Limitations and strengths
One limitation of the present study is that the categorization of incidental findings into three relevance groups was subject to personal interpretation, as there is no consensus guideline. Discrepancies between previous studies show that specific findings are not always classified in the same category of clinical relevance. To minimize the effect of interpretation, the categorization of expected incidental findings was performed before data acquisition, in accordance with previous literature and under the supervision of an experienced radiologist. The classification system used in this study closely resembled those of previous studies [
4,
6‐
8,
14].
Second, the documentation of incidental findings in the radiology reports could be incomplete. The number of incidental findings may have been influenced by the acute setting of trauma care, and therefore findings of minor or moderate interest may not have been reported at all, since they seemed irrelevant during primary trauma care. However, the risk of underestimation was reduced by the double-reading system. On the other hand, the rate of unknown findings might be overestimated, because previous imaging of the patient might not have been available during formulation of the radiology report.
Third, the follow-up is likely underestimated due to reporting issues as well. Follow-up was between 6 months and 2 years after the first trauma presentation, and only within the in-hospital documentation of the trauma centres where the patient was initially seen. Subsequently, some patients—for example, those with pulmonary nodules—would receive their first follow-up after 1 year or in a different hospital. Furthermore, it is possible that the finding was discussed and that a watchful waiting approach was preferred but not reported in the patient’s file.
This study, which investigated the frequency and clinical relevance of incidental findings in trauma, is the first to directly compare TBCT scanning with conventional imaging supplemented with selective CT. Additional strengths include the international multicentre setting, large comparable patient groups and its randomization setting. Lastly, the list of expected incidental findings aided in adequate prospective categorization.
Acknowledgments
The scientific guarantor of this publication is Prof. J.C. Goslings. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The REACT-2 has received funding by ZonMw, the Netherlands Organisation for Health Research and Development (grant number: 171102023); Dr. M.G.W. Dijkgraaf has significant statistical expertise. Institutional Review Board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study. All study subjects will be reported in another article reporting the main outcome measures of the REACT-2 trial. [Sierink JC, Treskes K, Edwards MJ et al., Immediate total-body CT scanning versus conventional imaging and selective CT scanning in severe trauma patients: A randomised controlled trial (REACT-2 trial), accepted for publication]. Methodology: prospective, randomised controlled trial, multicentre study.
Collaborators
TP Saltzherr1, MD, PhD; T Schepers1, MD, PhD, VM de Jong1, MD; R van Vugt3, MD, PhD; M Brink9, MD, PhD; J Peters3, MD; M El Moumni4, MD; JS Harbers4, MD; KW Wendt4, MD; EMM van Lieshout10, MSc PhD; MJ Elzinga10, MD; EH Jansen11, MD; C Zähringer6, MD; N Bless12, MD; R Bingisser13, MD
1 Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
2 Department of Radiology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
3 Department of Trauma and emergency surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
4 Trauma Unit, Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
5 Department of Radiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
6 Department of Radiology and Nuclear Medicine, University of Basel Hospital, Petersgraben 4 4031 Basel, Switzerland
7 Department of Anaesthesiology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
8 Clinical Research Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
9 Department of Radiology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
10 Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
11 Accident and Emergency Department, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
12 Department of Traumatology, University of Basel Hospital, Petersgraben 4, 4031 Basel, Switzerland
13 Emergency Unit, University of Basel Hospital, Petersgraben 4, 4031 Basel, Switzerland