Mild head injury : inhospital observation or computed tomography?

Background: Patients with mild head injuries are treated every day in emergency departments around the world. The rationale for any management strategy is to identify with a high degree of safety at reasonable costs, patients at risk of deterioration due to serious intracranial injuries. Traditionally, management has been based on admission for inhospital observation. Recently, computed tomography (CT) imaging for patients with mild head injury has increased. This investigation has often been added to inhospital observation, raising the question whether it would be possible to use CT to triage patients for admission. Thereby, fewer patients would be admitted; those with complications would be detected sooner; and resources would be put to better use in emergency care. Aim: To compare CT imaging in triage for admission with inhospital observation - in terms of patient outcome, safety, costs, and feasibility - in managing patients with mild head injury. Methods: In an initial study, the current clinical practise for acute care of patients with mild head injury in Sweden was surveyed. A second study examined the mortality and frequency of complications in patients with mild head injury, in a systematic literature review including a meta-analysis of the findings. The third study assessed the costs of the two strategies of care, by means of a systematic literature review and a decision analysis based on the findings of the meta-analysis. Finally, a pragmatic, multicenter randomised controlled trial (RCT) was conducted to assess patient outcome, and the feasibility and safety of the two strategies. Results: Patients with mild head injury are routinely admitted for inhospital observation in Sweden, with about 20% also undergoing CT imaging. The literature review identified and critically assessed representative series including 24 000 patients. Based on a metaanalysis of their results, it was estimated that: of 1 000 patients arriving at hospital with mild head injury, 1 will die, 9 will require surgery or other intervention and 80 will have pathological findings on CT. In the decision analysis and literature review it was found that the costs of the CT-strategy was one third lower and might save inhospital bed days for other patients. The RCT randomised 2 602 patients to either CT imaging or inhospital observation. Patient outcome at 3-months was not inferior for the CT strategy compared to inhospital observation, None of the patients with normal findings on the acute CT scan later suffered complications. Conclusions: The results of the three initial studies were confirmed in the large RCT. Thus, the use of CT imaging to triage for admission is a safe and feasible management strategy for patients with mild head injury. The CT strategy reduces costs by one third, and is not inferior for patient outcome compared to inhospital observation

Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial

Objective To compare immediate computed tomography during triage for admission with observation in hospital in patients with mild head injury. Design Multicentre, pragmatic, non-inferiority randomised trial. Setting 39 acute hospitals in Sweden. Participants 2602 patients (aged ≥ 6) with mild head injury. Interventions Immediate computed tomography or admission for observation. Main outcome measure Dichotomised extended Glasgow outcome scale (1-7 v 8). The non-inferiority margin was 5 percentage points. Results At three months, 275 patients (21.4%) in the computed tomography group had not recovered completely compared with 300 (24.2%) admitted for observation. The difference was - 2.8 percentage points, non-significantly in favour of computed tomography (95% confidence interval - 6.1% to 0.6%). The worst outcomes (mortality and more severe loss of function) were similar between the groups. In the patients admitted for observation, there was a considerable delay in time to treatment in those who required surgery. None of the patients with normal findings on immediate computed tomography had complications later. Patients' satisfaction with the two strategies was similar. Conclusions The use of computed tomography in the management of patients with mild head injury is feasible and leads to similar clinical outcomes compared with observation in hospital. Trial registration ISRCTN81464462

Immediate computed tomography or admission for observation after mild head injury: cost comparison in randomised controlled trial

Objective To compare the costs of immediate computed tomography during triage for admission with those of observation in hospital in patients with mild head injury. Design Prospective cost effectiveness analysis within a multicentre, pragmatic randomised trial. Setting 39 acute hospitals in Sweden Participants 2602 patients (aged ≥ 6) with mild head injury. Interventions Immediate computed tomography or admission for observation. Main outcome measures Direct and indirect costs related to the mild head injury during the acute and three month follow-up period. Results Outcome after three months was similar for both strategies (non-significantly in favour of computed tomography). For the acute stage and complications, the cost was 461 euros (£314, $582) per patient in the computed tomography group and 677 euros (£462,$854) in the observation group; an average of 32% less in the computed tomography group (216 euros, 95% confidence interval -272 to -164; P < 0.001). Sensitivity analysis showed that computed tomography was the most cost effective strategy under a broad range of assumptions. After three months, total costs were 718 euros and 914 euros per patient—that is, 196 euros less in the computed tomography group (- 281 to - 114; P < 0.001). The lower cost of the computed tomography strategy at the acute stage thus remained unchanged during follow-up. Conclusion Patients with mild head injury attending an emergency department can be managed more cost effectively with computed tomography rather than admission for observation in hospital. Trial registration ISRCTN81464462

Academic achievement after a CT examination toward the head in childhood: Follow up of a randomized controlled trial.

IntroductionIncreasing use of CT examinations has led to concerns of possible negative cognitive effects for children. The objective of this study is to examine if the ionizing radiation dose from a CT head scan at the age of 6-16 years affects academic performance and high school eligibility at the end of compulsory school.Materials and methodsA total of 832 children, 535 boys and 297 girls, from a previous trial where CT head scan was randomized on patients presenting with mild traumatic brain injury, were followed. Age at inclusion was 6-16 years (mean of 12.1), age at follow up 15-18 years (mean of 16.0), and time between injury and follow up one week up to 10 years (mean of 3.9). Participants' radiation exposure status was linked with the total grade score, grades in mathematics and the Swedish language, eligibility for high school at the end of compulsory school, previously measured GOSE-score, and their mothers' education level. The Chi-Square Test, Student's t-Test and factorial logistics were used to analyze data.ResultsAlthough estimates of school grades and high school eligibility were generally higher for the unexposed, the results showed no statistically significant differences between the exposed and unexposed participants in any of the aforementioned variables.ConclusionsAny effect on high school eligibility and school grades from a CT head scan at the age of 6-16 years is too small to be detected in a study of more than 800 patients, half of whom were randomly assigned to CT head scan exposure

Academic achievement after a CT examination toward the head in childhood: Follow up of a randomized controlled trial

Introduction Increasing use of CT examinations has led to concerns of possible negative cognitive effects for children. The objective of this study is to examine if the ionizing radiation dose from a CT head scan at the age of 6–16 years affects academic performance and high school eligibility at the end of compulsory school. Materials and methods A total of 832 children, 535 boys and 297 girls, from a previous trial where CT head scan was randomized on patients presenting with mild traumatic brain injury, were followed. Age at inclusion was 6–16 years (mean of 12.1), age at follow up 15–18 years (mean of 16.0), and time between injury and follow up one week up to 10 years (mean of 3.9). Participants’ radiation exposure status was linked with the total grade score, grades in mathematics and the Swedish language, eligibility for high school at the end of compulsory school, previously measured GOSE-score, and their mothers’ education level. The Chi-Square Test, Student’s t-Test and factorial logistics were used to analyze data. Results Although estimates of school grades and high school eligibility were generally higher for the unexposed, the results showed no statistically significant differences between the exposed and unexposed participants in any of the aforementioned variables. Conclusions Any effect on high school eligibility and school grades from a CT head scan at the age of 6–16 years is too small to be detected in a study of more than 800 patients, half of whom were randomly assigned to CT head scan exposure

Protocol for a systematic review of prognosis after mild traumatic brain injury: an update of the WHO Collaborating Centre Task Force findings

Abstract Background Mild traumatic brain injury (MTBI) is a major public-health concern and represents 70-90% of all treated traumatic brain injuries. The last best-evidence synthesis, conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002, found few quality studies on prognosis. The objective of this review is to update these findings. Specifically, we aim to describe the course, identify modifiable prognostic factors, determine long-term sequelae, and identify effects of interventions for MTBI. Finally, we will identify gaps in the literature, and make recommendations for future research. Methods The databases MEDLINE, PsychINFO, Embase, CINAHL and SPORTDiscus were systematically searched (2001 to date). The search terms included 'traumatic brain injury', 'craniocerebral trauma', 'prognosis', and 'recovery of function'. Reference lists of eligible papers were also searched. Studies were screened according to pre-defined inclusion and exclusion criteria. Inclusion criteria included original, published peer-reviewed research reports in English, French, Swedish, Norwegian, Danish and Spanish, and human participants of all ages with an accepted definition of MTBI. Exclusion criteria included publication types other than systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies; as well as cadaveric, biomechanical, and laboratory studies. All eligible papers were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers performed independent, in-depth reviews of each eligible study, and a third reviewer was consulted for disagreements. Data from accepted papers were extracted into evidence tables, and the evidence was synthesized according to the modified SIGN criteria. Conclusion The results of this study form the basis for a better understanding of recovery after MTBI, and will allow development of prediction tools and recommendation of interventions, as well as informing health policy and setting a future research agenda

Protocol for a systematic review of prognosis after mild traumatic brain injury : an update of the WHO Collaborating Centre Task Force findings

Background: Mild traumatic brain injury (MTBI) is a major public-health concern and represents 70-90% of all treated traumatic brain injuries. The last best-evidence synthesis, conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002, found few quality studies on prognosis. The objective of this review is to update these findings. Specifically, we aim to describe the course, identify modifiable prognostic factors, determine long-term sequelae, and identify effects of interventions for MTBI. Finally, we will identify gaps in the literature, and make recommendations for future research. Methods: The databases MEDLINE, PsychINFO, Embase, CINAHL and SPORTDiscus were systematically searched (2001 to date). The search terms included 'traumatic brain injury', 'craniocerebral trauma', 'prognosis', and 'recovery of function'. Reference lists of eligible papers were also searched. Studies were screened according to pre-defined inclusion and exclusion criteria. Inclusion criteria included original, published peer-reviewed research reports in English, French, Swedish, Norwegian, Danish and Spanish, and human participants of all ages with an accepted definition of MTBI. Exclusion criteria included publication types other than systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies; as well as cadaveric, biomechanical, and laboratory studies. All eligible papers were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers performed independent, in-depth reviews of each eligible study, and a third reviewer was consulted for disagreements. Data from accepted papers were extracted into evidence tables, and the evidence was synthesized according to the modified SIGN criteria. Conclusion: The results of this study form the basis for a better understanding of recovery after MTBI, and will allow development of prediction tools and recommendation of interventions, as well as informing health policy and setting a future research agenda