Physical Examination Should Dictate the Necessity for Repeat Head Computed Tomography in Moderate Traumatic Brain Injury
Karl Pilson, MD, Shane Hawksworth, MD,
PURPOSE OF STUDY
Considerable controversy surrounds routine repeat head CT scanning for traumatic brain injury (TBI). This strategy in patients with moderate TBI (GCS 9-12) was evaluated and the implication of the results in intervention in the absence of neurologic deterioration was determined.
Retrospective review of all patients admitted to an academic, urban, level I trauma center with blunt head trauma and GCS between 9 and 12 over a 5 year period.† Initial and subsequent head CTs and patient records were reviewed.† CTís repeated within 24 hours without specific indications were considered routine.† Patients were defined as having minor changes to their head CTs if they had small changes in the size of collections, the appearance of edema, hemorrhagic conversion of contusion, all without new shift or compression of brain structures.
SUMMARY OF RESULTS
From 2004-8, 71 patients were admitted with GCS 9-12. †Routine CT scans were performed on 37 patients: 19 patients (51%) had stable findings on repeat CT, 15 patients (41%) had minor changes which did not require intervention, and 3 patients (8%) had neurologic deterioration and subsequent CT worsening that led to intervention.† Routine repeat CT was not performed on 34 patients: 8 patients had immediate surgical intervention and 26 patients had no initial head CT findings.
In patients with moderate TBI, signs of clinical neurologic deterioration are the key determinants as to whether repeat CT scanning should be performed.† The likelihood of finding significant changes in head CT scans without these clinical signs is low and the evolution of intracranial injuries other than epidural hematoma is largely predictable.† Patients in whom a reliable exam cannot be obtained or who have risk factors such as severe coagulopathies are going to remain a difficult problem.† The risks of transporting critically ill patients, utilization of resources and significant radiation exposure should be considered before ordering routine head CT in patients with moderate TBI.†† Larger trials examining TBI are necessary to make definitive conclusions.