Background and clinical questions
2. Serial CTSs in acute patients
Among patients with acute TBI without clinical deterioration or ICP elevation, how does the practice of serial CTSs affect the indication for surgery treatment, the short-term mortality and the probability of acute complications?
CTS is the current standard imaging method for diagnosing intracranial pathology following acute traumatic head injury.
It is well known that intracranial lesions after TBI are not static and develop over time. As a result of the improve-ments in the trauma system, emergency transport practices and reduced times between trauma and initial CTS, the chances of finding an intracranial lesion very early in its course and evolution are high. The use of sequential CTS to evaluate progression of injury is considered common prac-tice [6] even though the evidence of its impact in outcome is unknown. The utility of repeated head CT performed solely for routine follow-up has not yet been defined [7].
Given the conflicting results regarding the indication for a second scheduled head CT in patients with severe closed brain injury, it is disappointing that we did not find any RCTs evalu-ating the utility of routine repeated CTS in these patients.
Only eight prospective non-RCTs, were identified (Table 15.2).
Lobato et al. [8] reported a prospective study of 56 patients.
The author’s intention was to determine the incidence of pathological ICP changes during the acute post-traumatic period in patients with severe acute TBI presenting with diffuse injury (DI) I–II (TCDB classification) on the admission CTS.
The aim was to define the most appropriate strategy of sequen-tial CTS and ICP monitoring for detecting new intracranial Table 15.1 Conservative treatment versus surgical evacuation of acute subdural haematoma in patients with acute severe TBI.
Reference Type of study Patients Intervention Outcome Results
Servadei [4] Non-randomized, 65 patients –15 patients GOS at 6 months Conservative treatment:
non-controlled, severe acute conservative treatment post trauma – mortality 20%,
prospective TBI, GCS8 CTS: haematoma10 mm – severe disability 13%,
and MLS5 mm – good recovery 67%
ICP:20 mmHg or between Surgery:
20 and 30 mmHg if CPP – mortality 48%
75 mmHg – severe disability 22%
–50 patients surgical – good recovery 28%
evacuation of haematoma
Servadei [5] Non-randomized, 206 patients Conservative treatment: GOS at 6 months – mortality 46%, observational study, with TBI and Serial CT scan. First within 3 h post trauma – vegetative state 2%,
prospective GCS3 and of admission, second within – severe disability 6%,
ASDH5 mm 12 h of admission. Subsequent – favourable outcome 46%
according to the clinical First CTS findings
condition associated with poor
neurological outcome
GCS: Glasgow Coma Scale; CTS: computed tomographic scan; ICP: intracranial pressure; CPP: cerebral perfusion pressure; ICU: intensive care unit;
ASDH: acute subdural haematoma; TBI: traumatic brain injury; MLS: midline shift; GOS: Glasgow Outcome scale.
144 Part 3: Neurological diseases
mass effect and improving the final outcome. All patients had the initial CTS less than 24 h after injury, several control CTS within the first days of the trauma and ICP monitoring after admission. The mean GCS was 5, 57.1% of the patients showed CTS changes: new contusion (26.8% of the cases), growth of previous contusion (68.2%), previous extra axial haematoma (10.7%), and generalized brain swelling (10.7%).
64.9% of the patients had a favourable outcome and 35.1%
an unfavourable outcome. Overall, 27 (48.9%) patients developed clinical deterioration, 21 (37.5%) with concurrent CTS changes and 6 (10.7%) without new pathology. The remaining 29 (51.7%) patients did not develop deteriora-tion in spite of 11(19.6%) showing CTS changes. The pres-ence of contusion at the initial CTS (P 0.01) and the presence of generalized brain swelling (P 0.003) in poste-rior CTS significantly correlated with the risk of deteposte-riora- deteriora-tion. This worsening in neurological status increased the risk of death by a factor of 10 (OR 9.8). Eight (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CTS changes, but another 11 patients in a similar condi-tion were able to be managed without surgery. Over 50% of the patients with initial DI I–II lesions developed new CTS
changes and nearly 50% showed intracranial hypertension.
The discordances between ICP and CTS deterioration were seen in 30.3% of patients. Therefore, the authors recommend ICP monitoring in all patients and serial CTS at 2–4, 12, 24, 48, and 72 h after injury with additional controls as indicated by clinical or ICP changes in all cases.
Brown et al. [6] reported a prospective analysis of 100 patients with GSC14. The study intended to examine the value of routine serial CTS after TBI in a single Level I trauma centre. Repeated CTS was ordered at the discretion of the trauma team or the neurosurgical consultant with no protocol in place. Only patients who showed abnormalities subsequent to the initial CTS scan were included. Patents that died within 24 h were excluded. Patients with moderate TBI were also included. Sixty eight patients who underwent a repeat CTS (Repeat Group, RG) were compared with 32 patients who had CTS only at admission (No Repeat Group, NRG) to evaluate the effect of repeat CTS on patient out-come. Primary outcome was the need for TBI-related inter-vention. The 68 patients in the RG underwent 90 repeat CTS.
Repeat scan were mainly done 34 32 h after admission.
This group had a higher incidence of extradural haematoma Table 15.2 Effect on outcome and management of serial brain CTS policy.
Reference Type of study Patients Intervention Outcome Results
Lobato [8] Non-randomized, 56 patients acute severe Serial CTS admission, Surgery, clinical CTS add information prospective TBI, diffuse CTS 24, 48, and 72 h deterioration and respect to ICP
damage, ICP monitoring death monitoring alone
Brown [6] Non-randomized, 100 patients moderate– 68 repeated CTS Surgery None patient with
prospective severe acute TBI, CTS (no protocol). 32 patients repeated CTS had
abnormality at admission only one CTS on admission. surgery
Oertel [9] Non-randomized, 142 patients acute TBI Early repeated CTS in Progression of 50% had PHI and prospective any severity, mean patients with ‘progressive intracranial haemorrhagic 25% required
GCS 8 shift and brain swelling’ injury (PHI) surgery
Servadei [5] Non-randomized, 206 patients TBI and GCS Serial CTS. First within 3 h, CTS worsening CTS evolution:
prospective between3 and ASDH second within 12 h DI l I 4%,
5 mm Subsequent according to DI lI–IV 13–20%
the clinical condition
Lubillo [10] Non-randomized, 82 patients intracranial CTS within 2–12 h Mortality and CTS findings prospective haematoma and surgery after surgery long-term outcome associated with final
outcome Cope [11] Non-randomized, 47 patients acute TBI CTS at admission, Surgery CTS allows early
prospective traumatic head injuries 1 month, and diagnosis of lesion
3 months later requiring surgery
Roberson [12] Non-randomised, 107 patients acute Serial CTS from day Delayed intracranial 18% of patients with
prospective TBI, coma 1 to 12 months lesions normal CTS at
admission present delayed intracranial lesion requiring surgical decompression
GCS: Glasgow Coma Scale; CTS: Computed Tomographic Scan; ICP: Intracranial Pressure; ICU: Intensive Care Unit; ASDH: Acute Subdural Haematoma; TBI: Traumatic Brain Injury; DI: diffuse injury.
Chapter 15: Acute traumatic brain injury 145
(EDH), and a trend towards more SDH. Of those undergoing repeat CTS, 90% (n 81) were performed on a routine basis without neurological changes. Of those routine CTS, 26%, 52%, and 22% were classified as ‘better’, ‘the same’, and
‘worse’, respectively. No patient had any neurosurgical inter-vention after having a routine repeated CTS. In the RG, every patient (100% of cases) with EDH, intraventricular haemorrhage (IVH) underwent sequential CTS, but only in 70% of the cases of patients with SDH, Intraparenchymal haemorrhage (IPH), contusion, MLS, or multiple injuries.
83% of patients GCS8 underwent repeat CTS scan and showed a trend towards a higher injury severly scane (ISS) and lower GCS. The authors concluded that the use of rou-tine serial CTS in patients without neurological deterioration was not supported.
In a prospective study Oertel et al. [9] looked at patients who underwent two CTS within 24 h after acute TBI to deter-mine the incidence, risks factors, and clinical significance of progressive haemorrhagic injury (PHI). One single Level I Trauma centre, 142 patients with mild, moderate, and severe, closed and penetrating TBI were included. The diagnosis of PHI was determined by comparing the first and second CTS and defined as an unambiguous increase in the full film appearance of lesion size; this amounted to a25% increase in at least one dimension of1 lesion seen on the first post-injury CTS. The mean GCS was 8. Potential risk factors, coagulation status, temperature, ethanol, ICP, and CPP were analysed. Increased MLS, hemispheric swelling, or progressive loss of basilar cisterns on the second CTS was defined as ‘pro-gressive shift and swelling’. Similarly, ‘pro‘pro-gressive brain shift and swelling’ was present in 23% of patients with PHI but in only 4% of patients without PHI (P 0.003). The second CTS scan was performed earlier in patients ‘with progressive brain shift and swelling’ than in patients without this finding (6.4 4.2 h post injury versus 9.3 3.9 h post injury;
P 0.01). Of the 17 patients with progressive shift and swelling, eight underwent craniotomy after the second CTS.
Male sex (P 0.01), older age (P 0.01), time from injury to first CTS (P 0.02), and initial partial thromboplastin time (P 0.02) were the best predictors of PHI. Of the 46 patients who underwent craniotomy for haematoma evacuation, 24%
present the haematoma after the second CTS. Early CTS after moderate or severe TBI did not reveal the full extent of haemorrhagic injury in 45% of patients. PHI approached 50% in patients undergoing scanning within 2 h of injury.
Parenchymal lesions in the frontal and temporal lobes are the most likely to progress. Patients with PHI had a greater degree of subsequent ICP elevations, and 25% required a craniotomy. The neurological outcome at 6 months post injury was similar in both groups. The authors recommended early repeated CTS in patients with no surgically treated haemorrhage revealed on the first CTS.
In a prospective study Servadei et al. [5] intended to establish the frequency of deterioration in CTS appearance
from an admission scan to subsequent scans and the prognos-tic significance of such deterioration. Data has been gathered prospectively for 206 patients with moderate and severe head injury. The findings of the initial and the final (‘worst’) CTS were classified according to the Traumatic Coma Data Bank (TCDB) system and were related to outcome using the GOS at 6 months after injury. The initial CTS findings were classified as a DI for 53% of the cohort, with 16% of these DI demonstrating deterioration on a subsequent scan. In 56(74%) of 76 deteriorations, the change was from a DI to a mass lesion. Patients with normal CTS or with a DI I at admission showed a low rate of evolution (4%). Patients with DI II, III, and IV showed high rates of progression to mass lesion (13–14 for DI II and III and 20% for type IV). A third CTS may be scheduled on the third day post trauma.
When the initial CTS demonstrated a DI without swelling or shift, evolution to a mass lesion was associated with a signifi-cant increase in the risk of an unfavourable outcome (62%
versus 38%). The author recommended follow-up scans when admission CTS demonstrates evidence of a DI, because approximately 1/6 of patients will demonstrate significant CT evolution of this lesions. The CTS may be repeated within 12 h whenever the first scan is obtained within the 3 h after injury and within 24 h in all other situations. A third scan was also recommended on the third day after trauma, even though the author accepted that this recommendation is empiric.
Lubillo et al. [10] prospectively studied 82 patients with isolated, severe TBI (GCS8), all of whom had intracranial haematoma. The author analysed the CTS appearance after evacuation of a mass lesion in relation to outcome. The CTS was performed within 2–12 h after craniotomy; continuous monitoring of the ICP and CPP were also done after the sur-gery. The mortality rate during the hospital stay was 37%;
50% of the patients achieved a favourable outcome. The postoperative scan revealed DI III–IV in 53 patients and DI I–II in 29 patients. The percentage of time presenting an ICP
20 mmHg and CPP 70 mmHg were higher in the group of patients with DI III–IV (P 0.001); these patients also revealed an unfavourable neurological outcome. Patients with a motor (m) GCS3, bilateral unreactive pupils, asso-ciated intracranial injuries, and hypotension demonstrate high incidence of raised ICP, CPP70 mmHg, DI III–IV, and unfavourable outcome (P 0.001). The author concluded that the features on CTS obtained shortly after craniotomy constitute an independent predictor of outcome in patients with traumatic haematoma.
Cope et al. [11] reported a prospective study looking at routine serial CTS in 47 patients with TBI. This study analysed patients who were admitted to a rehabilitation unit after ini-tial hospitalization. Under a prospective protocol of routine scans (admission, 1 month and 3 months), 22% of patients required neurosurgical intervention for a variety of findings.
Most patients had chronic manifestations of TBI not applicable to acutely head injured patients. Though there is no reference
146 Part 3: Neurological diseases
regarding exact neurological disability before routine repeat CTS, the patients who underwent neurosurgical intervention had a higher disability rating score. This would imply that the clinical status of the patient, not scan findings alone, played a major role in determining the need for surgical inter-vention versus observation. These authors concluded that routine serial scanning may allow earlier diagnosis of a pro-gressive intracranial lesion and thereby minimize further brain injury in the rehabilitation setting.
In a prospective study, Servadei et al. [4] looked at patients with large ASDH. Of 65 comatose patients, 15 patients were initially managed conservatively according to a protocol based on clinical, CTS and ICP parameters. Two patients failed non-operative management and underwent a craniotomy after sequential scan. When comparing the different param-eters between the surgical group and the patients initially managed conservative, haematoma thickness and shift of the midline structures were predictive of the need of sur-gery. The authors concluded that GCS scoring at the scene and in the emergency room combined with early and subse-quent CTS is crucial when making the decision for non-operative management for selected cases with ASDH with a thickness 10 mm and with a shift of the midline struc-tures 5 mm.
Roberson et al. [12] reported a prospective study of coma-tose TBI patients who had routine CTS (on days 1, 3, 5, 7, 14, and at 3 and 12 months). The author compared the value of sequential scans, neurological status, and ICP in 107 patients.
Thirty eight (40%) of 95 patients had a normal CTS on admission. Seven (18%) of these 38 patients had scans demonstrating a delayed intracranial lesion requiring surgi-cal decompression. It is important to note that all seven