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Table of Content - Volume 19 Issue 2- August 2021
Prospective study of role of routine CT scan of head and brain in head injury patients
Kumar Gaurav1, G C Karan2*
1Junior Resident, 2Associate Professor, Department of Surgery, Darbhanga Medical College and Hospital, Laheriasarai, INDIA. Email: gaurav74@gmail.com
Abstract Background: Cranio-cerebral injuries have been one of the most prevalent reasons of hospitalization following trauma for as long as anybody can remember, and they are linked with considerable morbidity, death, and long-term disability. CT-assisted early identification of extra-axial hematomas leads to earlier surgical intervention and a significant reduction death in head injury patients. Methods: It was observational study and carried out on 208 patients with complaints of head trauma and admitted to surgical ward of Upgraded Department of General Surgery at Darbhanga Medical College and Hospital, Laheriasarai. Study period was January 2019 to December 2020. After taking a thorough history, general, systemic and local examinations were done to assess the site, size, type and severity of the injury. In all subjects, the level of consciousness was assessed on admission by the GCS score and its severity was categorized as – Mild- 13 -15, Moderate- 9 – 12, Severe- <9. Results: The incidence of Head trauma has been recorded highest in Adult Males (62.9%) between 15 to 59 years of age. The lowest incidence of head trauma is in Elderly people (7.2%) above 60 years of age. The incidence of head trauma as observed in this series is 73.6% in Males and 26.4% in Females. In Severe Trauma CT scans showed positive results in 92% of cases but patients with Minor Head Trauma also had positive results on their CT scan reports in 39% of cases. In Severe Head Trauma patients with presence of neurological signs and evident skull fracture, CT scan reports came out to be positive in almost 97% of cases. Also in patients with Minor Head Trauma, combinations of clinical features at presentation led to a significantly higher rate of CT scans with positive findings. Conclusion:According to our results there is a significant relation between signs and symptoms and positive findings of brain CT scan; and increase in number of clinical complaints would increase the risk of presence of cerebral pathologies. The goal of imaging in the management of head trauma should be to identify treatable injuries to prevent secondary damage. In children Observation approach is recommended in minor head trauma to reduce brain CT scan which is risky and expensive.
INTRODUCTION According to the published reports, head trauma is a major cause of death in young adults, as well as physical and psychological disabilities in more than half of the affected individuals with a head injury1. The management of head trauma patients is clinically based on the Glasgow Coma Scale (GCS) that can present a comprehensive framework for assessing three clinical aspects of visual, verbal, and motor responses indicating severity of neural impairment2. In this regard , the degree of head injury can be scored as Mild (GCS 13-15), Moderate (GCS 9-12), and Severe (GCS=/<8). It has been found in previous studies, that of all attendance to clinical settings because of head trauma, 93% of adults and 96% of children suffer mild head injury, 6% of adults and 5% of children suffer moderate head injury and only 1% of adults and 0.5% of children suffer severe head injury according to GCS scoring system3. Besides clinical management of head trauma patients, intracranial lesions in these patients can be detected by NCCT head even before appearing clinical manifestations. Early detection of extra-axial hematomas made possible by CT results in early surgical intervention with marked improvement in morbidity and mortality in head injury patients.4 CT remains essential for detecting lesions that require immediate neurosurgical intervention as well as those that require in-hospital observation and medical management.5 CT advantages for evaluation of the head-injured patients include its sensitivity for demonstrating mass effect, ventricular size and configuration, bone injuries and acute hemorrhage.6 Limitations of CT include insensitivity in detecting small and non-hemorrhagic lesions such as contusion, particularly adjacent to bony surfaces. CT is also relatively insensitive for detecting increased intracranial pressure or cerebral edema. Also, potential risks of exposure to ionizing radiation warrant judicious patient selection for CT scanning as well as radiation dose management.7 There is a consensus that patients identified as Moderate-risk or High-risk for intracranial injury should undergo early NCCT for evidence of intracerebral hematoma, midline shift, or increased intracranial pressure. But, clinical selection criteria for CT scanning of patients with minor or mild head injuries with GCS > 12 who harbor significant intracranial pathology and require acute surgical intervention have been problematic. Furthermore, clinical criteria for scanning of children with head injury have been less reliable than those for adults, particularly for children younger than age 2 years. For this reason more liberal use of CT scanning has been suggested for pediatric patients. This must be balanced with higher risk of radiation exposure in childhood via judicious patient selection for scanning as well as management of radiation dose. Still, CT has value as a screening tool to triage minor or mild head injury patients who require hospital admission and surgery from those who can be safely discharged without hospital admission, as rapid CT scans are readily available in most hospitals that treat head injury patients.8 Although, this approach offers reduced inpatient services and reduced cost, the result is – greater CT use in emergency settings. Repeated CT scanning may also be required for deterioration, especially in the first 72hrs after head injury, to detect delayed hematoma, hypoxic ischemic lesions, or cerebral oedema. CT has also a role in subacute or chronic head injury for depicting atrophy, focal encephalomalacia, hydrocephalous, and chronic subdural hematoma. These days about 50-60% cases admitted in our Surgical emergency (Darbhanga Medical College and Hospital) are of head injury. In our hospital, the most frequent cause of head injury is Road Traffic Accident, followed by Physical assault, Fall from height, Injuries due to sports and recreational activities, Firearm injuries, Industrial injuries etc. Majority of these cases are of mild and moderate severity.
MATERIALS AND METHODS It was observational study and carried out on 208 patients with complaints of head trauma and admitted to surgical ward of Upgraded Department of General Surgery at Darbhanga Medical College and Hospital, Laheriasarai. Study period was January 2019 to December 2020. After taking a thorough history, general, systemic and local examinations were done to assess the site, size, type and severity of the injury. In all subjects, the level of consciousness was assessed on admission by the GCS score and its severity was categorized as – Mild- 13 -15, Moderate- 9 – 12, Severe- <9. After a thorough neurological assessment these patients were subjected to a treatment plan based on the following modalities –
Surgical Treatment: Patients intended to require surgical interventions were transferred to Department of Neurosurgery based on the following indications –
CT scanning has no absolute contraindications. Caution is indicated in pregnant women, particularly during the first trimester to avoid fetal abnormalities. Risk-to-benefit considerations should be evaluated. Repeated x-ray exposure may increase the patient's risk for cancer. However, the risk from any one scan is small, with the benefit of an accurate diagnosis outweighing the risks. In certain clinical situations, intravenous contrast administration is indicated. Contrast media is safe in most patients; however, adverse reactions may range from mild to severe. It is recommended that nursing mothers should wait 24 hours after contrast administration to resume breastfeeding. Procedure Planning If a patient has experienced a prior contrast reaction or has an allergic predisposition or asthma, his or her physician should, when appropriate, consider prescribing medications to reduce the risk of such reactions. The physician should inquire about any history of heart disease, asthma, diabetes, or kidney or thyroid disease. Typically, patients are asked not to eat or drink for a few hours before the procedure, especially if contrast media is to be administered. Any metallic object worn or carried by the patient should be stored away, as it can result in image artifact, degrading the study. Patients should wear comfortable clothing, although they might be given a gown to wear during the test. Female patients should be queried not only at the time of scheduling but also again by the CT technologist just prior to the scan as to whether they are or think they could be pregnant. It also very important for the patient to bring with them any previous radiographs, CT scans, MRIs or other medical images, with reports, for comparison. Outcomes: When performed in accordance with ACR guidelines, CT scanning is a fast, painless, typically noninvasive, and accurate. A trained radiologist reviews and communicates the results to the referring physician, who can then determine the next course of action. The results may eliminate the need for explorative surgery or biopsy. RESULTS Table 1: Showing distribution of age and sex
The incidence of Head trauma has been recorded highest in Adult Males (62.9%) between 15 to 59 years of age. The lowest incidence of head trauma is in Elderly people (7.2%) above 60 years of age. The incidence of head trauma as observed in this series is 73.6% in Males and 26.4% in Females. Table 2: Showing Causes of Injury
Road Traffic Accident has been found to cause largest number of head injury with 43.3% of cases. This is the commonest cause of head injury worldwide. This is followed by Physical Assault in this area with 40.9% of cases.
Table 3: Showing GCS score at presentation
In Severe Trauma CT scans showed positive results in 92% of cases but patients with Minor Head Trauma also had positive results on their CT scan reports in 39% of cases.
Table 4: Tables Showing combinations of clinical features at presentation as Risk Indicators
In Severe Head Trauma patients with presence of neurological signs and evident skull fracture, CT scan reports came out to be positive in almost 97% of cases. Also in patients with Minor Head Trauma, combinations of clinical features at presentation led to a significantly higher rate of CT scans with positive findings.
Table 5: Showing different Age groups as Risk Indicators
Table 6: Showing different types of Brain Lesions reported on NCCT Head
DISCUSSION The question of which patients with head trauma should undergo scanning has remained controversial since the introduction of Computed Tomography (CT) in the early 1970s. Initially, CT was a scarce resource reserved for severely injured patients. As CT scanners became more widely available, numerous studies of CT have focused on patients with Minor Head Injury (MHI) who have intracranial lesions. In the early 1990s, several retrospective studies of patients with minor head injury reported substantial proportions with intracranial lesions on CT (17 - 20 %). These studies included patients with scores of 13 to 15 on the Glasgow Coma Scale, indicating little or no impairment in consciousness. The authors concluded that CT was indicated in all patients with minor head injury.9 In subsequent prospective studies of patients with a score of 15 on the Glasgow Coma Scale, the rate of intracranial lesions on CT was much lower (6 - 9 %).10 The use of clinical findings as predictors of intracranial lesions in patients with minor head injury has been evaluated in several studies.11 In two studies, selective use of CT on the basis of clinical findings identified 96 % and 98 % of patients with abnormalities on CT scanning12, and none of the patients with abnormalities who did not have the specified clinical findings required neurosurgery.11 However, some physicians are not willing to accept the risk of missing an abnormality. In a survey of emergency physicians, more than half insisted that a clinical decision rule for minor head injury must have a sensitivity of 100 %.13 Thus, the use of CT to screen patients with minor head injury for intracranial lesions has become routine, but such screening is expensive. According to one estimate, even a 10 percent reduction in the number of CT scans in patients with minor head injury would save more than $20 million per year.14 In this study, Demographic data, Symptoms, and the results of Physical examination were prospectively recorded. The demographic data associated with abnormalities on CT in patients with minor head injury includes an age over 60 years, alcohol intoxication, and coagulopathy. Symptoms associated with positive CT scans includes Headache, Nausea and Vomiting, Amnesia, ENT bleed and Seizures.11,12 The findings with respect to Minimal Confusion are controversial.15 Although most patients with loss of consciousness do not subsequently remember the traumatic event, some patients also have persistent anterograde amnesia, as evidenced by deficits in short-term memory, but are oriented and can follow commands. Such patients are considered to have a score of 15 on the Glasgow Coma Scale.16 We included deficits in short-term memory as a criterion in order to account for patients with persistent anterograde amnesia and an otherwise normal score on the Glasgow Coma Scale. Findings on physical examination that have been associated with a positive CT scan include signs of linear, basilar, or depressed skull fracture and scalp hematoma or soft-tissue injury. In our study, the presence of headache, vomiting, LOC or amnesia, seizures and ENT bleed was separately associated with abnormal brain CT scan related to the trauma. Stein et al. suggested that any patient who has experienced LOC or amnesia following head injury should undergo brain CT scan17. Haydelet al. have expanded the criteria for brain CT scan in patients with MHI that consist of headache, vomiting, age >60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. These criteria led to a sensitivity of 100% and a specificity of 25%.18 In our study, all of the patients with positive brain CT scans had at least one risk indicator. The brain CT scans were always normal in patients <65 years old who did not have an obvious head wound, a raccoon sign, vomiting, memory deficit, or a decrease in their GCS score.19 The goal of our study is to derive and validate a set of clinical findings that could be used to identify patients with minor head injury who should undergo CT scan. Our results suggest that such patients can be identified by the presence of one or more of the following findings: Headache, Vomiting, An age over 60 years, Drug or Alcohol intoxication, Deficits in short-term memory, Physical evidence of trauma above the clavicles, and Seizure. The combination of these findings increases sensitivity up to 100 percent for identifying patients with positive CT scans.
CONCLUSION According to our results there is a significant relation between signs and symptoms and positive findings of brain CT scan; and increase in number of clinical complaints would increase the risk of presence of cerebral pathologies. The goal of imaging in the management of head trauma should be to identify treatable injuries to prevent secondary damage. In children Observation approach is recommended in minor head trauma to reduce brain CT scan which is risky and expensive. If any patient has these indicators following MHI, he should be considered as a high-risk MHI. CT scanning of brain should be indicated in all cases of Severe TBI, but for MHI (Minor Head Injury) patients,
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