The temporal course of intracranial haemorrhage progression: How long is observation necessary?
Introduction
Traumatic brain injury (TBI) is an epidemic in the U.S., with approximately 1.1 million patients evaluated annually for acute TBI.1 While the majority of TBI is considered mild (MTBI),2 this definition is based on initial Glasgow Coma Scale scores (GCS) of >12 and underestimates the potentially severe and debilitating sequela of MTBI.
Up to 15% of patients evaluated in the emergency department (ED) for MTBI with normal cognitive and neurologic examinations have an intracranial haemorrhage (ICH) identified on cranial computed tomography scan (HCT).3 Patients with ICH are routinely hospitalized and monitored for progression of neurologic injury. Approximately one third of patients with ICH in MTBI will progress and a small percentage (1–3%) will require neurosurgical intervention (NSI).4, 5
Recent studies have questioned the utility of routine repeat HCT in the majority of neurologically stable patients.4, 5, 6, 7 Serial neurologic examinations have been shown to identify clinically significant injury progression in MTBI potentially replacing the need for routine repeat HCT.4, 5, 6, 7. With this evolution in MTBI management, the necessary duration for neurologic monitoring prior to hospital discharge has yet to be defined. Currently, the time it takes for ICH progression to occur is unknown and the optimal duration and location of neurologic observation are generally discretionary. Therefore, the goal of this study was to examine the temporal course of ICH progression and establish a timeframe for when ICH progression ceases.
Section snippets
Materials and methods
This study is a retrospective observational cohort design that began after approval by the Internal Review Board at the University of Medicine and Dentistry of New Jersey – New Jersey Medical School. All adult (age > 17 years) patients admitted to the University of Medicine and Dentistry of New Jersey (UMDNJ) Level 1 Trauma Centre over a consecutive 36 month period from July 2002 through June 2005 following blunt trauma to the head with MTBI (GCS score of >12) and an initially positive HCT were
Study population
Over the 36-month study period, 474 adult patients (age > 17 years) were identified with MTBI and an initially positive HCT. Of those, 8 (1.6%) patients were excluded because of a history of previous NSI and 6 (1%) were excluded for the concomitant presence of a non-traumatic intracranial mass seen on initial HCT. 34 (7%) were excluded because they underwent immediate NSI following their first HCT, and 85 (18%) were excluded from the study because they had a single HCT without a follow up HCT
Discussion
Currently there are no published studies defining the temporal course of ICH progression in MTBI. This information is important to determine the timeframe for neurologic monitoring and hospitalization and the optimal time of repeat HCT. While the literature describes specific management practices for the timing of repeat HCT in MTBI, the timeframe for observation for potential ICH progression without repeat HCT has not been well studied. To this end, early studies on the temporal course of ICH
Conclusion
Almost all ICH in MTBI (>97%) stop progressing within the first 24 h post injury, supporting a recommendation for a 24-h observational period. In fact, more than 2/3rds of ICH have stopped by the time of the initial HCT (<2 h from arrival). This suggests that early repeat HCT in the ED may identify those ICH no longer progressing, and possibly reduce unnecessary monitoring and prolonged observation in select patients not requiring admission for post-TBI symptom management. Prospective data is
Conflict of interest statement
No author has any conflict of interest in regards to this research that might potentially inappropriately influence their work. There is no financial or personal relationship with other people or organizations that could inappropriately influence this work.
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