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

https://doi.org/10.1016/j.ajem.2018.12.012Get rights and content

Abstract

Background

Patients 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.

Methods

This 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.

Results

Of 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.

Conclusions

RHCT 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.

Introduction

Over 1.7 million people in the United States sustain traumatic brain injury (TBI) each year. Head injury encompasses a wide spectrum of clinical symptoms including coma and mild scalp contusions. Patients with a Glasgow Coma Scale (GCS) ≥ 13 are categorized as having a mild traumatic brain injury (mTBI) [1]. A subset of these patients will have findings of intracranial hemorrhage (ICH) on CT imaging and are labelled as having mild traumatic intracranial hemorrhage (mTIH) [2].

Patients with mTIH frequently undergo an observation period for neurologic deterioration and repeat head CT (RHCT), although the vast majority of these patients are managed non-operatively [3,4]. Early head CT ordering and the use of RHCT has been based on experiences reported in the initial National Coma Data Bank on observed patients who suffered a significant neurologic decline due to an expanding hematoma (“talk and deteriorate”) [5]. Even with surgical intervention, such patients experienced significant disability and poor long term outcomes. After these reports and others [6,7], clinical decision rules [8,9] were developed to better define who needed immediate scanning. The practice of repeat scanning has been appealing to clinicians to detect expanding hematoma before clinical decline yet had not been formally studies until recently. Further arguments for RHCT include documentation of hemorrhage stability to aid in triage of patients (ICU versus hospital floor), as well as duration of ICU stay [[10], [11], [12], [13]].

However, more recent data regarding the effect of RHCT on patient management has been nebulous as a meta-analysis of 30 studies demonstrated that a RHCT prompted neurosurgical intervention in as few as 0% to as many as 54% of admitted patients [14]. Furthermore, its value in lower risk patients has come into question as mounting research also suggests it can be avoided in those who do not exhibit neurological decline [3,4,15].

Since the RHCT is still used widely as an aid for clinical decision making in patients with TIH [3], this study was designed to investigate the value of the RHCT in this lower risk population. The objective of this study was to determine how frequently RHCT is performed at a single center and how often it leads to a neurosurgical intervention, especially interventions that occur in the absence of other clinical indications.

Section snippets

Study design

Retrospective cohort study of 1126 consecutive patients with mild traumatic intracranial hemorrhage (GCS 13–15) who presented to an urban level 1 trauma center from January 1, 2009 to December 31, 2013. Patients were identified by running a query of a proprietary electronic medical record using the International Statistical Classification of Diseases and Related Health Problems (ninth edition) codes for traumatic intracranial hemorrhage (852.00–853.10, 851.00–851.90, 800.00–801.9,

Results

Of the 1126 patients with traumatic intracranial hemorrhage and GCS ≥ 13, 975 patients received a RHCT as part of their management. In the other 151 patients, the primary team (trauma surgery, emergency medicine, neurology, and/or neurosurgery) judged the patients as stable enough to forego a RHCT. Table 1 compares patients who underwent RHCT with those who received only a single scan. Patient who had multiple RHCT were older and more likely to be on antiplatelet or anticoagulant medications.

Discussion

In the largest cohort of patients with mild traumatic intracranial hemorrhage undergoing repeat CT scans to date, our results suggest that RHCT is rarely associated with intervention in the absence of change in neurologic exam. There were three patients who had a RHCT that prompted neurosurgical intervention; all of these patients had an initial subdural hematoma larger than 1 cm.

Our results are in agreement with similar studies investigating the utility of repeat CT scans in patients with TIH.

Limitations

This study's retrospective nature limits its ability to determine causality, namely if the findings on RHCT or neurological deterioration led to neurosurgical management. In addition, its origin at a single academic center in which all patients received a neurosurgery consult does not necessarily carry over to community or other academic centers. We utilized progression of hemorrhage as a binary clinical endpoint, and this doesn't reflect changes in size or development of mass effect. Finally,

Conclusion

Repeat head CT in patients with mTIH rarely leads to a neurosurgical operative intervention in the absence of any neurologic deterioration. The number of patients needed to scan to identify this rare event is 305. This evidence may form the basis for safely proceeding to the next step, a randomized controlled trial for patients with isolated mTIH between obtaining a RHCT and simply observing for neurological decline.

Disclosures

None of the authors have conflicts of interest or disclosures.

Author contributions

Jonathan van Ornam, data collection, manuscript preparation.

Peter Pruitt, data collection, manuscript preparation.

Pierre Borczuk, PI, data collection, analysis, manuscript.

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  • Cited by (14)

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    Presented at the 2017 Society for Academic Emergency Medicine Annual Meeting, Orlando, FL.

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