scholarly journals MP41: Validity of the Canadian CT head rule age criterion for mild traumatic brain injury

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S55-S55
Author(s):  
N. Fournier ◽  
M. Émond ◽  
N. Le Sage ◽  
C. Gariépy ◽  
E. Fortier ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Univariate Analysis ◽  
Trauma Centre ◽  
Emergency Physicians ◽  
Historical Cohort ◽  
Radiological Data ◽  
Ct Head ◽  
Proposed Modification

Introduction: With a Canadian aging population, the prevalence of mild traumatic brain injury (mTBI) among elderly is increasing and the age criterion of the Canadian CT head rule (CCHR) is challenged by many emergency physicians. We evaluated if increasing the age criterion of the CCHR would maintain its validity. Methods: We conducted an historical cohort study using the medical charts of all patients 65 years old or more who consulted at a Level One Trauma Centre emergency department (ED) for a mTBI between 2010 and 2014. The main outcome measures were clinically important brain injury (CIBI) on Computed Tomography (CT) and the presence of the CCHR criteria. The clinical and radiological data collection was standardized. Univariate analysis was performed to measure the predictive capacities of modified age cut-offs at 70 and 75 years old. Results: Out of the 104 confirmed mTBI in this study, 32 (30,8%) had CIBI on CT scan. Sensitivity and specificity [C.I. 95%] of the CCHR were 100% [89.1 - 100] and 0% [0.0 5.0] for an age criterion of 65 years old and above; 100% [89.1 - 100] and 4,2% [0.9 11.7] for a modified criterion of 70 years old; 100% [89.1 - 100] and 13,9% [6.9 24.1] for 75 years old. Furthermore, for an age criterion of 80 and 85 years old, sensitivity was respectively 90,6% [75.0 98.0] and 75,0% [56.6 88.5]. Conclusion: In our cohort, increasing the age criterion of the CCHR for minor head injury to 75 years old would benefit ED by further reducing CT scans without missing CIBI. A larger prospective study is indicated to confirm the proposed modification.

Adapting the Canadian CT head rule age criteria for mild traumatic brain injury

2019 ◽  
Vol 36 (10) ◽  
pp. 617-619 ◽  
Author(s):  
Nicolas Fournier ◽  
Charles Gariepy ◽  
Jean-François Prévost ◽  
Vincent Belhumeur ◽  
Émile Fortier ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Trauma Centre ◽  
Ageing Population ◽  
Predictive Capacity ◽  
Radiological Data ◽  
Future Prospective Study ◽  
Ct Head ◽  
Proposed Modification

ObjectiveWith the ageing population, the prevalence of mild traumatic brain injury (mTBI) among older patients is increasing, and the age criteria of the Canadian CT head rule (CCHR) is challenged by many emergency physicians. We modified the age criteria of the CCHR to evaluate its predictive capacity.MethodsWe conducted a retrospective cohort study at a level 1 trauma centre ED of all mTBI patients 65 years old and over with an mTBI between 2010 and 2014. Main outcome was a clinically important brain injury (CIBI) reported on CT. The clinical and radiological data collection was standardised. Univariate analyses were performed to measure the predictive capacities of different age cut-offs at 70, 75 and 80 years old.Results104 confirmed mTBI were included; CT scan identified 32 (30.8%) CIBI. Sensitivity and specificity (95% CI) of the CCHR were 100% (89.1 to 100) and 4.2% (0.9 to 11.7) for a modified criteria of 70 years old; 100% (89.1 to 100) and 13.9% (6.9 to 24.1) for 75 years old; and 90.6% (75.0 to 98.0) and 23.6% (14.4 to 35.1) for 80 years old. Furthermore, modifying the age criteria to 75 years old showed a reduction of CT up to 25% (n=10/41) among the individuals aged 65–74 without missing CIBI.ConclusionAdjusting the age criteria of the Canadian CT head rule to 75 years old could be safe while reducing radiation and ED resources. A future prospective study is suggested to confirm the proposed modification.

scholarly journals Head CT overuse in children with a mild traumatic brain injury within two Canadian emergency departments

2019 ◽  
Vol 25 (1) ◽  
pp. 26-32
Author(s):  
Martin Gariepy ◽  
Jocelyn Gravel ◽  
France Légaré ◽  
Edward R Melnick ◽  
Erik P Hess ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Emergency Departments ◽  
Retrospective Chart Review ◽  
Trauma Centre ◽  
Diagnostic Tools ◽  
General Level ◽  
Head Ct ◽  
Significant Difference

Abstract Background The validated Pediatric Emergency Care Applied Network (PECARN) rule helps determine the relevance of a head computerized tomography (CT) for children with mild traumatic brain injury (mTBI). We sought to estimate the potential overuse of head CT within two Canadian emergency departments (EDs). Methods We conducted a retrospective chart review of children seen in 2016 in a paediatric Level I (site 1) and a general Level II (site 2) trauma centre. We reviewed charts to determine the appropriateness of head CT use according to the PECARN rule in a random subset of children presenting with head trauma. Simple descriptive statistics were applied. Results One thousand five hundred and forty-six eligible patients younger than 17 years consulted during the study period. Of the 203 randomly selected cases per setting, 16 (7.9%) and 24 (12%), respectively from sites 1 and 2 had a head CT performed. Based on the PECARN rule, we estimated the overuse for the younger group (<2 years) to be below 3% for both hospitals without significant difference between them. For the older group (≥2 years), the overuse rate was higher at site 2 (9.3%, 95% confidence interval [CI]: 4.8 to 17% versus 1.2%, 95% CI: 0.2 to 6.5%, P=0.03). Conclusion Both EDs demonstrated overuse rates below 10% although it was higher for the older group at site 2. Such low rates can potentially be explained by the university affiliation of both hospitals and by two Canadian organizations working to raise awareness among physicians about the overuse of diagnostic tools and dangers inherent to radiation.

scholarly journals P008: Implementation of a voluntary provincial knowledge translation intervention project to improve the appropriateness of CT imaging for patients with mild traumatic brain injury and suspected pulmonary embolism

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S80
Author(s):  
J. Andruchow ◽  
D. Grigat ◽  
A. McRae ◽  
G. Innes ◽  
E. Lang
Keyword(s):  
Traumatic Brain Injury ◽  
Pulmonary Embolism ◽  
Decision Support ◽  
Brain Injury ◽  
Diagnostic Imaging ◽  
Patient Outcomes ◽  
Mild Traumatic Brain Injury ◽  
Emergency Physicians ◽  
Suspected Pulmonary Embolism ◽  
Ct Utilization

Introduction: Utilization of CT imaging has risen dramatically with increases in availability, but without corresponding improvements in patient outcomes. Previous attempts to improve imaging appropriateness via guideline implementation have met with limited success, with commonly cited barriers including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. The objective of this project is to improve CT utilization and appropriateness by addressing common barriers through clinical decision support (CDS) embedded in clinical practice. Methods: This matched-pair cluster-randomized trial saw 12 Alberta EDs with CT scanners randomized to receive CDS for diagnostic imaging. After extensive site engagement to recruit emergency medicine and diagnostic imaging leadership and stakeholders and understand local contexts, half of the sites received CDS for mild traumatic brain injury (MTBI) based on the Canadian CT Head Rule, while the remainder received CDS for suspected pulmonary embolism (PE), including the Pulmonary Embolism Rule-out Criteria (PERC), Wells Score, age-adjusted D-dimer and CT pulmonary angiography (CTPA) use. Hardcopy CT order forms including quantitative decision support, source literature and patient handouts were developed and adapted and integrated into workflow as per local site preference. Regular physician and site report cards on CT utilization and CDS use were also provided. The primary outcome was diagnostic imaging utilization for patients with MTBI and suspected PE. Results: During the study period, 144 emergency physicians at 6 EDs saw 3,278 patients with MTBI and 146 emergency physicians at six matched comparison EDs saw 18,606 patients with suspected PE. Use of CDS was highly variable by site, ranging from 0% to 29% of CT orders for MTBI and from 13% to 75% of CTPA orders for suspected PE. Impact on CT utilization, appropriateness, diagnostic yield is currently under investigation, but is expected to be limited at many sites given the variable adoption of decision support. Conclusion: A comprehensive CDS intervention to improve evidence-based imaging has met with variable uptake. Meaningful and widespread sustained improvements in practice will likely require incentives, accountability measures and leadership authority to enforce change.

Admission Variables Associated with a Favorable Outcome after Mild Traumatic Brain Injury

2016 ◽  
Vol 82 (10) ◽  
pp. 898-902 ◽  
Author(s):  
Alexander C. Schwed ◽  
Monica M. Boggs ◽  
Drew Watanabe ◽  
David S. Plurad ◽  
Brant A. Putnam ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Subarachnoid Hemorrhage ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Univariate Analysis ◽  
Vital Signs ◽  
Multivariate Regression Analysis ◽  
Favorable Outcome ◽  
Imaging Results ◽  
Admission Variables

Consensus is lacking for ideal management of mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH). Patients are often monitored in the intensive care unit (ICU) without additional interventions. We sought to identify admission variables associated with a favorable outcome (ICU admission for 24 hours, no neurosurgical interventions, no complications or mortality) to divert these patients to a non-ICU setting in the future. We reviewed all patients with mTBI [Glasgow Coma Scale (GCS) = 13–15] and concomitant ICH between July 1, 2012, and June 30, 2015. Variables collected included demographics, vital signs, neurologic examination, imaging results, ICU course, mortality, and disposition. Of 201 patients, 78 (39%) had a favorable outcome. On univariate analysis, these patients were younger, more often had an isolated subarachnoid hemorrhage, and were more likely to have a GCS of 15 at admission. On multivariate regression analysis, after controlling for admission blood pressure, time to CT scan, and Marshall Score, age <55, GCS of 15 on arrival to the ICU, and isolated subarachnoid hemorrhage remained independent predictors of a favorable outcome. Patients meeting these criteria after mTBI with ICH likely do not require ICU-level care.

scholarly journals What Is the Incidence of Intracranial Bleeding in Patients with Mild Traumatic Brain Injury? A Retrospective Study in 3088 Canadian CT Head Rule Patients

2013 ◽  
Vol 2013 ◽  
pp. 1-4 ◽  
Author(s):  
C. E. Albers ◽  
M. von Allmen ◽  
D. S. Evangelopoulos ◽  
A. K. Zisakis ◽  
H. Zimmermann ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Platelet Aggregation Inhibitors ◽  
Intracranial Bleeding ◽  
Limited Data ◽  
Neurosurgical Treatment ◽  
Clinical Surveillance ◽  
Aggregation Inhibitors ◽  
Ct Head

Objective. Only limited data exists in terms of the incidence of intracranial bleeding (ICB) in patients with mild traumatic brain injury (MTBI).Methods. We retrospectively identified 3088 patients (mean age 41 range (7–99) years) presenting with isolated MTBI and GCS 14-15 at our Emergency Department who had undergone cranial CT (CCT) between 2002 and 2011. Indication for CCT was according to the “Canadian CT head rules.” Patients with ICB were either submitted for neurosurgical treatment or kept under surveillance for at least 24 hours. Pearson’s correlation coefficient was used to correlate the incidence of ICB with age, gender, or intake of coumarins, platelet aggregation inhibitors, or heparins.Results. 149 patients (4.8%) had ICB on CCT. No patient with ICB died or deteriorated neurologically. The incidence of ICB increased with age and intake of anticoagulants without clinically relevant correlation (R=0.11;P<0.001;R=-0.06;P<0.001).Conclusion. Our data show an incidence of 4.8% for ICB after MTBI. However, neurological deterioration after MTBI seems to be rare, and the need for neurosurgical intervention is only required in selected cases. The general need for CCT in patients after MTBI is therefore questionable, and clinical surveillance may be sufficient when CCT is not available.

scholarly journals P048: Current practices of management for mild traumatic brain injuries with intracranial hemorrhage

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S80
Author(s):  
É. Fortier ◽  
V. Paquet ◽  
M. Émond ◽  
J. Chauny ◽  
S. Hegg ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Ct Scan ◽  
Mild Traumatic Brain Injury ◽  
Intracranial Hemorrhage ◽  
Management Practices ◽  
Brain Injuries ◽  
Quebec City ◽  
Historical Cohort ◽  
Public Sector Health

Introduction: The radiological and clinical follow-up of patients with a mild traumatic brain injury (mTBI) and an intracranial hemorrhage (ICH) is often heterogeneous, as there is no official guideline for CT scan control. Furthermore, public sector health expenditure has increased significantly as the number of MRI and CT scan almost doubled in Canada in the last decade. Therefore, the main objective of this study was to describe the current management practices of mTBI patients with intracranial hemorrhage at two level-1 trauma centers. Methods: Design: An historical cohort was created at the CHU de Québec – Hôpital de l'Enfant-Jésus (Québec City) and Hôpital du Sacré-Coeur (Montréal). Consecutive medical records were reviewed from the end of 2017 backwards until sample saturation using a standardized checklist. Participants: mTBI patients aged ⩾16 with an ICH were included. Measures: The main and secondary outcomes were the presence of a control CT scan and neurosurgical consultation/admission. Analyses: Univariate descriptive analyses were performed. Inter-observer measures were calculated. Results: Two hundred seventy-four patients were included, of which 51.1% (n = 140) came from a transfer. Mean age was 60.8 and 68.9% (n = 188) were men. Repeat CT scan was performed in 73.6% (n = 201) of our patients as 12.5% showed a clinical deterioration. The following factors might have influenced clinician decision to proceed to a repeat scan: anticoagulation (association of 87.1% with scanning; n = 27), antiplatelet (84.1%; 58), GCS of 13 (94.1%; 16), GCS of 14 (75%; 72) and GCS of 15 (70.2%; 111). 93.0% (n = 254) of patients had a neurosurgical consultation and only 6.7% (17) underwent a neurosurgical intervention. Conclusion: The management of mild traumatic brain injury with hemorrhage uses a lot of resources that might be disproportionate with regards to risks. Further research to identify predictive factors of deterioration is needed.

scholarly journals Predictors of six-month inability to return to work in previously employed subjects after mild traumatic brain injury: A TRACK-TBI pilot study

2021 ◽  
Vol 5 ◽  
pp. 205970022110072
Author(s):  
John K Yue ◽  
Ryan RL Phelps ◽  
Debra D Hemmerle ◽  
Pavan S Upadhyayula ◽  
Ethan A Winkler ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Pilot Study ◽  
Return To Work ◽  
Mild Traumatic Brain Injury ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Full Time ◽  
Emotional Symptoms ◽  
Post Injury

Introduction Return to work (RTW) is an important milestone of mild traumatic brain injury (mTBI) recovery. The objective of this study was to evaluate whether baseline clinical variables, three-month RTW, and three-month postconcussional symptoms (PCS) were associated with six-month RTW after mTBI. Methods Adult subjects from the prospective multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot study with mTBI (Glasgow Coma Scale 13–15) who were employed at baseline, with completed three- and six-month RTW status, and three-month Acute Concussion Evaluation (ACE), were extracted. Univariate and multivariable analyses were performed for six-month RTW, with focus on baseline employment, three-month RTW, and three-month ACE domains (physical, cognitive, sleep, and/or emotional postconcussional symptoms (PCS)). Odds ratios (OR) and 95% confidence intervals [CI] were reported. Significance was assessed at p < 0.05. Results In 152 patients aged 40.7 ± 15.0 years, 72% were employed full-time at baseline. Three- and six-month RTW were 77.6% and 78.9%, respectively. At three months, 59.2%, 47.4%, 46.1% and 31.6% scored positive for ACE physical, cognitive, sleep, and emotional PCS domains, respectively. Three-month RTW predicted six-month RTW (OR = 19.80, 95% CI [7.61–51.52]). On univariate analysis, scoring positive in any three-month ACE domain predicted inability for six-month RTW (OR = 0.10–0.11). On multivariable analysis, emotional symptoms predicted inability to six-month RTW (OR = 0.19 [0.04–0.85]). Subjects who scored positive in all four ACE domains were more likely to be unable to RTW at six months (4 domains: 58.3%, vs. 0-to-3 domains: 9.5%; multivariable OR = 0.09 [0.02–0.33]). Conclusions Three-month post-injury is an important time point at which RTW status and PCS should be assessed, as both are prognostic markers for six-month RTW. Clinicians should be particularly vigilant of patients who present with emotional symptoms, and patients with symptoms across multiple PCS categories, as these patients are at further risk of inability to RTW and may benefit from targeted evaluation and support.

scholarly journals Brain white matter after pediatric mild traumatic brain injury: a diffusion tensor and neurite orientation and dispersion imaging study

2021 ◽  
Author(s):  
Ayushi Shukla ◽  
Ashley L Ware ◽  
Sunny Guo ◽  
Bradley Gooodyear ◽  
Miriam H Beauchamp ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
White Matter ◽  
Mild Traumatic Brain Injury ◽  
Diffusion Tensor ◽  
Univariate Analysis ◽  
Significant Group ◽  
Brain White Matter ◽  
Orthopedic Injury ◽  
White Matter Microstructure

Background: Pediatric mild traumatic brain injury (mTBI) affects millions of children annually. Diffusion tensor imaging (DTI) is sensitive to axonal injuries and white matter microstructure and has been used to characterize the brain changes associated with mild traumatic brain injury (mTBI). Neurite orientation dispersion and density imaging (NODDI) is a diffusion model that can provide additional insight beyond traditional DTI metrics, but has not been examined in pediatric mTBI. The goal of this study was to employ DTI and NODDI to gain added insight into white matter alterations in children with mTBI compared to children with mild orthopedic injury (OI). Methods: Children (mTBI n=320, OI n=176) aged 8-16.99 years (12.39 ± 2.32 years) were recruited from emergency departments at five hospitals across Canada and underwent 3T MRI on average 11 days post-injury. DTI and NODDI metrics were calculated for seven major white matter tracts and compared between groups using univariate analysis of covariance controlling for age, sex, and scanner type. False discovery rate (FDR) was used to correct for multiple comparisons. Results: Univariate analysis revealed no significant group main effects or interactions in DTI or NODDI metrics. Fractional anisotropy and neurite density index in all tracts exhibited a significant positive association with age and mean diffusivity in all tracts exhibited a significant negative association with age in the whole sample. Conclusions: Overall, there were no differences between mTBI and OI groups in brain white matter microstructure from either DTI or NODDI in the seven tracts. This indicates that mTBI is associated with only relatively minor white matter differences, if any, at the post-acute stage. Brain differences may evolve at later stages of injury, so longitudinal studies with long-term follow-up are needed.

scholarly journals LO053: Follow-up head CT scan after mild traumatic brain injury: is it really necessary?

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S48-S48
Author(s):  
C. Gariepy ◽  
M. Émond ◽  
N. Le Sage ◽  
P. Lavergne ◽  
C. Malo
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Elderly Patients ◽  
Ct Scan ◽  
Mild Traumatic Brain Injury ◽  
Trauma Center ◽  
Antiplatelet Drug ◽  
Head Ct ◽  
Ct Head

Introduction: Injured seniors visits are on the rise in the emergency department (ED) and up to 30 % are traumatic brain injury (TBI). Many patients suffer from comorbidities that require the use of anticoagulant drugs. The use of these drugs usually modify the trajectory patients will undergo in the ED. In the last decade, some authors suggested a systematic follow-up CT head scan 8 hours after the initial, while others didn’t see the need to scan, referring only to the clinical features. We sought to evaluate the presence of delayed intracranial bleeding, evolution and investigation at the ED of elderly patients presenting for a mild TBI, with or without anticoagulotherapy. Methods: A retrospective cohort was built with hospital administrative clinical data for year 2014 at a Canadian Level 1 trauma center. Patients 65 years and older with traumatic brain injury and residing in the trauma center catching area were included. Data were extracted from medical files using a standardized collection tool in a consecutive pattern. Patients were classified in three groups: use of anticoagulant drug, use of antiplatelet drug and no anticoagulotherapy. Clinico-administrative data, intervention delay, investigations, comorbidities, medication and physiological status were collected. Intra and extra-hospital data were collected for a period of 90 days and the use of imaging and trajectories were analysed. Univariate and multivariate analysis were conducted. Results: 93 of the 189 TBI injury were mild TBI. The 93 patients were divided in patients using anticoagulotherapy (n = 9, 10 %), using antiplatelet drug (n = 58, 62.4 %) and no use of drug (n = 29, 31.2 %). Each group respectively undergo an initial head CT scan in a proportion of 88.9 %, 93 % and 76 %. Follow-up head CT scan were seen in 43 %, 16 % and 10 %. Delayed intra-cranial hemorrhage were identified in respectively 0 %, 2 % and 0 %. Conclusion: With the increase in patients presenting at Canadian ED for head trauma, our study suggests that anticoagulated elderly patients suffering from a mild traumatic brain injury do not systematically require a follow up CT head scan or longer observation time at the ED. A future clinical decision rule to determine the need of follow-up CT could be of benefit to emergency physicians.

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