Outpatient follow-up of nonoperative cerebral contusion and traumatic subarachnoid hemorrhage: does repeat head CT alter clinical decision-making?

Clinical article

Full access

Object

Many neurosurgeons obtain repeat head CT at the first clinic follow-up visit for nonoperative cerebral contusion and traumatic subarachnoid hemorrhage (tSAH). The authors undertook a single-center, retrospective study to determine whether outpatient CT altered clinical decision-making.

Methods

The authors evaluated 173 consecutive adult patients admitted to their institution from April 2006 to August 2012 with an admission diagnosis of cerebral contusion or tSAH and at least 1 clinic follow-up visit with CT. Patients with epidural, subdural, aneurysmal subarachnoid, or intraventricular hemorrhage, and those who underwent craniotomy, were excluded. Patient charts were reviewed for new CT findings, new patient symptoms, and changes in treatment plan. Patients were stratified by neurological symptoms into 3 groups: 1) asymptomatic; 2) mild, nonspecific symptoms; and 3) significant symptoms. Mild, nonspecific symptoms included minor headaches, vertigo, fatigue, and mild difficulties with concentration, short-term memory, or sleep; significant symptoms included moderate to severe headaches, nausea, vomiting, focal neurological complaints, impaired consciousness, or new cognitive impairment evident on routine clinical examination.

Results

One hundred seventy-three patients met inclusion criteria, with initial clinic follow-up obtained within approximately 6 weeks. Of the 173 patients, 104 (60.1%) were asymptomatic, 68 patients (39.3%) had mild, nonspecific neurological symptoms, and 1 patient (1.0%) had significant neurological symptoms. Of the asymptomatic patients, 3 patients (2.9%) had new CT findings and 1 of these patients (1.0%) underwent a change in treatment plan because of these findings. This change involved an additional clinic appointment and CT to monitor a 12-mm chronic subdural hematoma that ultimately resolved without treatment. Of the patients with mild, nonspecific neurological symptoms, 6 patients (8.8%) had new CT findings and 3 of these patients (4.4%) underwent a change in treatment plan because of these findings; none of these patients required surgical intervention. The single patient with significant neurological symptoms did not have any new CT findings.

Conclusions

Repeat outpatient CT of asymptomatic patients after nonoperative cerebral contusion and tSAH is very unlikely to demonstrate significant new pathology. Given the cost and radiation exposure associated with CT, imaging should be reserved for patients with significant symptoms or focal findings on neurological examination.

Abbreviations used in this paper:GCS = Glasgow Coma Scale; SDH = subdural hematoma; TBI = traumatic brain injury; tSAH = traumatic subarachnoid hemorrhage.

Abstract

Object

Many neurosurgeons obtain repeat head CT at the first clinic follow-up visit for nonoperative cerebral contusion and traumatic subarachnoid hemorrhage (tSAH). The authors undertook a single-center, retrospective study to determine whether outpatient CT altered clinical decision-making.

Methods

The authors evaluated 173 consecutive adult patients admitted to their institution from April 2006 to August 2012 with an admission diagnosis of cerebral contusion or tSAH and at least 1 clinic follow-up visit with CT. Patients with epidural, subdural, aneurysmal subarachnoid, or intraventricular hemorrhage, and those who underwent craniotomy, were excluded. Patient charts were reviewed for new CT findings, new patient symptoms, and changes in treatment plan. Patients were stratified by neurological symptoms into 3 groups: 1) asymptomatic; 2) mild, nonspecific symptoms; and 3) significant symptoms. Mild, nonspecific symptoms included minor headaches, vertigo, fatigue, and mild difficulties with concentration, short-term memory, or sleep; significant symptoms included moderate to severe headaches, nausea, vomiting, focal neurological complaints, impaired consciousness, or new cognitive impairment evident on routine clinical examination.

Results

One hundred seventy-three patients met inclusion criteria, with initial clinic follow-up obtained within approximately 6 weeks. Of the 173 patients, 104 (60.1%) were asymptomatic, 68 patients (39.3%) had mild, nonspecific neurological symptoms, and 1 patient (1.0%) had significant neurological symptoms. Of the asymptomatic patients, 3 patients (2.9%) had new CT findings and 1 of these patients (1.0%) underwent a change in treatment plan because of these findings. This change involved an additional clinic appointment and CT to monitor a 12-mm chronic subdural hematoma that ultimately resolved without treatment. Of the patients with mild, nonspecific neurological symptoms, 6 patients (8.8%) had new CT findings and 3 of these patients (4.4%) underwent a change in treatment plan because of these findings; none of these patients required surgical intervention. The single patient with significant neurological symptoms did not have any new CT findings.

Conclusions

Repeat outpatient CT of asymptomatic patients after nonoperative cerebral contusion and tSAH is very unlikely to demonstrate significant new pathology. Given the cost and radiation exposure associated with CT, imaging should be reserved for patients with significant symptoms or focal findings on neurological examination.

The current US health care crisis has prompted widespread reevaluation of the clinical utility and cost-effectiveness of various diagnostic tests.5 At the same time, there is an increasing awareness of the hazards of iatrogenic ionizing radiation.4

In neurosurgery, these trends coincide with multiple recent studies advocating a more judicious approach to radiography and CT studies. In the area of traumatic brain injury (TBI), the literature has focused on repeat inpatient head CT, particularly for mild TBI. Studies on this issue have been mixed, with some authors advocating that the practice is necessary for early intervention, and others concluding that routine rescanning is unlikely to alter care, in the abscence of associated clinical change.1–3,6,7,9,13,14

This study focuses on outpatient clinic follow-up and asks a related question: how often does routine head CT at clinic follow-up yield clinically useful information? Because head injury encompasses diverse pathologies, we focused our inquiry on two entities that we believed were low risk for worsening after discharge: nonoperative cerebral contusion and traumatic subarachnoid hemorrhage (tSAH). We hypothesized that, for these specific indications, routine CT scanning of an asymptomatic patient is unlikely to alter the treatment plan.

Methods

Study Population

This study was performed in a single rural, academic, Level I trauma center. All data were reviewed retrospectively. For the period in question, it was standard practice among all participating providers to evaluate patients 4–6 weeks after discharge, with a CT scan obtained the same day; however, deviations from this practice did occur, based on clinical concern, scheduling constraints, and patient preference.

Prior to beginning the chart review, institutional review board approval and waiver of consent were sought and obtained. We then reviewed the hospital charts of all adult patients admitted to Dartmouth-Hitchcock Medical Center from April 2006 to August 2012 who had an admission diagnosis of cerebral contusion or tSAH and had at least 1 clinic follow-up examination with a CT scan. Exclusion criteria were concomitant epidural hematoma, subdural hematoma (SDH), aneurysmal SAH, intraventricular hemorrhage, and craniotomy for trauma.

Data Collection

Inpatient notes were reviewed for patient demographic data, type of lesion (cerebral contusion, tSAH, or both), mechanism of injury, presence of isolated head injury, bleeding tendencies on admission, length of hospitalization, and use of blood thinners on discharge. Clinic notes were reviewed for new neurological symptoms, and findings were stratified into 3 groups: 1) asymptomatic; 2) mild, nonspecific symptoms; and 3) significant symptoms. Mild, nonspecific symptoms included nonfocal symptoms known to occur after concussion, which were not severe enough to impair usual activities. This group included minor headaches, vertigo, fatigue, and mild difficulties with concentration, short-term memory, or sleep. Significant symptoms included symptoms interfering with activities of daily living and consisted of moderate to severe headaches, nausea, vomiting, focal neurological complaints, impaired consciousness, or new cognitive impairment evident on routine clinical examination.

Radiology reports and selected images were reviewed for relevant findings. Admission CT scans were reviewed for inclusion and exclusion criteria; clinic CT scans were reviewed for new or worsened findings.

Outcome Variables

The primary outcome measure was the frequency of abnormal radiological findings on clinic CT resulting in a change in treatment plan. This outcome measure was assessed in 3 subgroups: 1) asymptomatic patients; 2) patients with mild, nonspecific symptoms; and 3) patients with significant symptoms. Sensitivity, specificity, positive predictive value, and negative predictive value of symptoms at clinic follow-up were calculated.

Results

During the study period, 891 patients were admitted with the diagnoses of cerebral contusion or tSAH. Of these 891 patients, 508 were excluded because of concurrent extraaxial hematoma, aneurysmal SAH or intraventricular hemorrhage, and craniotomy for trauma. Two hundred ten patients were excluded because they were either lost to clinic follow-up or did not have additional CT imaging after discharge. The final study cohort consisted of 173 patients; of these, 40 patients had only cerebral contusions, 75 patients had only tSAH, and 58 patients had both pathologies. Of the 98 patients with cerebral contusions, 63 patients had a single contusion and 35 patients had “multiple contusions” as described in their radiological report. No penetrating injuries were present within this cohort. Seventy-seven patients had bleeding tendencies on admission caused by anticoagulants, antiplatelet agents, liver disease, or alcohol abuse, and 22 patients were discharged on anticoagulants, antiplatelet agents, or both (Table 1).

TABLE 1:

Cohort characteristics

CharacteristicValue*
total no. of patients173
mean age ± SD (yrs)57.0 ± 19.8
sex
 male97 (56)
 female76 (44)
type of injury
 cerebral contusions40 (23)
 tSAH75 (43)
 cerebral contusions & tSAH58 (34)
bleeding tendencies on admission
 total77 (45)
  anticoagulant (warfarin)14 (8)
  antiplatelet agent (aspirin or clopidogrel)42 (24)
  anticoagulant & antiplatelet agent4 (2)
  liver disease4 (2)
  alcohol abuse13 (8)
discharged on blood thinners
 total22 (13)
  anticoagulant (heparin, enoxaparin, or warfarin)4 (2)
  antiplatelet agent (aspirin or clopidogrel)14 (8)
  anticoagulant & antiplatelet agent4 (2)
mean time to follow-up ± SD (wks)5.8 ± 2.7

Unless otherwise specified, values indicate number (%) of patients.

Initial clinic follow-up was obtained within approximately 6 weeks: within 1 month in 57 patients, between 1 and 3 months in 111 patients, and after 3 months in 5 patients. Of the 173 patients evaluated in the clinic, 104 patients (60.1%) were asymptomatic; 68 patients (39.3%) had mild, nonspecific neurological symptoms; and 1 patient (0.6%) had significant neurological symptoms (Fig. 1).

Fig. 1.
Fig. 1.

Diagram of the study cohort subdivided by symptoms, frequency of new CT findings, and how often new CT findings led to a change in nonoperative treatment plan (non-op tx). Of the asymptomatic patients, only 1 patient (1%) underwent a change in his nonoperative treatment plan based on new CT findings. Of the patients with mild, nonspecific symptoms, 3 patients (4.4%) underwent a change in their nonoperative treatment plan based on new CT findings. One patient had significant symptoms without new CT findings. No patients with new CT findings underwent surgical intervention. *n = total number of patients; bold box outline = important finding (patients in whom new CT findings led to change in nonoperative treatment plan).

The sensitivity and specificity of being symptomatic at follow-up and having a change in CT scan was 66.7% and 61.6%, respectively. The positive predictive value of being symptomatic at follow-up and having a change in CT scan was 8.7%. The negative predictive value of being asymptomatic at follow-up and having no change in CT scan was 97.1%.

Asymptomatic Patients

Of the 104 asymptomatic patients, 3 (2.9%) had new CT findings and 1 (1.0%) of these patients underwent a change in treatment plan because of these findings. This involved an additional clinic appointment and head CT to monitor a 12-mm chronic SDH that ultimately resolved without treatment. The other 2 patients exhibited a slight increase in ventricular size on CT; the treatment plan was not altered and follow-up was discontinued without adverse effects (Table 2). No asymptomatic patient with abnormal findings on follow-up CT required surgical intervention.

TABLE 2:

Asymptomatic patients with new CT findings

Age (yrs)*LesionBleeding Tendency on AdmissionNew FindingsChange in Treatment Plan
56tSAHnoneslight increase in ventricular sizeno; clinic follow-up discontinued
76contusionsnone12-mm chronic SDHyes; further clinic follow-up and CT; self-resolved
79tSAHwarfarinslight increase in ventricular sizeno; clinic follow-up discontinued

All patients were male, had no symptoms at follow-up, and were neurologically intact on the follow-up examination.

Patients With Mild, Nonspecific Neurological Symptoms

Of the 68 patients with mild, nonspecific neurological symptoms, 6 (8.8%) had new CT findings and 3 of these patients (4.4%) underwent a change in treatment plan because of these findings (Table 3). Of the 3 patients who did not undergo a change in treatment plan, 2 had a slight increase in ventricular size; the treatment plan was not altered and follow-up was discontinued without adverse effects. One of these 3 patients had a 4-mm chronic SDH that was considered stable and believed to be unrelated to her symptoms; therefore, follow-up was discontinued without adverse effects. Of the 3 patients who did have a change in treatment plan, the first patient presented with confusion and was found to have a slight increase in ventricular size. He received additional clinic follow-up, which was discontinued after 4 months, when the ventriculomegaly resolved spontaneously. The second patient had a 9-mm subdural fluid collection, minor headaches, a wide-based gait, and bilateral sixth cranial nerve palsy on examination. None of his symptomology or examination findings correlated with the location of the subdural fluid collection and he was referred to neurology for his chronic gait abnormalities and persistent diplopia. The third patient complained of significant fatigue and was found to have a 5-mm acute SDH. He received an additional follow-up CT scan at an outside hospital closer to his home. To our knowledge, no patients with mild, nonspecific symptoms and abnormal findings on follow-up CT required surgical intervention.

TABLE 3:

Patients with mild, nonspecific symptoms and new CT findings

Age (yrs), SexLesionBleeding Tendency on AdmissionSymptoms at Follow-UpExamination at Follow-UpNew FindingsChange in Treatment Plan
74, Mboth*warfarinconfusion & gait instabilitynot oriented to timeslight increase in ventricular sizeyes; received further clinic follow-up
49, FtSAHalcohol abuseminor headacheswide-based gait; bilateral cranial nerve VI palsy9-mm subdural fluid collectionyes; referred to neurology
62, Mbothnonedifficulty w/ memory & irritability w/fatiguedecreased foot sensationslight increase in ventricular sizeno; clinic follow-up discontinued
87, FtSAHwarfarinintermittent, minor headache & persistent diplopiaslightly wide-based gait & decreased thigh sensation secondary to traumaslight increase in ventricular sizeno; clinic follow-up discontinued
83, FtSAHaspirinimbalancewide-based gait & hearing difficulties4-mm chronic SDHno; clinic follow-up discontinued
55, FtSAHnoneeasily fatigued; required more time to complete tasks at workneurologically intact5-mm acute SDHyes; repeat CT at outside hospital; clinic follow-up discontinued

Both = cerebral contusions and tSAH.

Patient With Significant Symptoms

The single patient with significant neurological symptoms did not have any new CT findings. On admission, his lesion was a small (< 1 cm), right-sided parietal contusion; his symptoms at follow-up included insomnia, anorexia, irritability, and severe occipital headache. He was evaluated in our clinic and ultimately treated for postconcussion syndrome and chronic posttraumatic headaches.

Patients Discharged on Anticoagulants and/or Antiplatelet Agents

Of the 22 patients discharged on anticoagulants and/or antiplatelet agents, no patient had an increase in the size of the original cerebral contusion or tSAH and no patient developed any new extraaxial hemorrhage.

Discussion

This study suggests 3 general conclusions. First, repeat outpatient CT of asymptomatic patients after nonoperative cerebral contusion and tSAH is unlikely to demonstrate significant new pathology. Given the cost and radiation exposure associated with CT, it may be reasonable to forgo imaging in clinically asymptomatic patients. Second, patients with mild, nonspecific symptoms have a slightly higher likelihood of new CT findings (8.8%) at outpatient follow-up; however, these findings are very unlikely to result in additional surgical intervention. Instead of routinely scanning these patients, it may be reasonable to simply schedule additional follow-up; reimaging could be considered if symptoms persisted at this second visit. Third, active treatment with anticoagulant or antiplatelet medication at discharge should not necessarily change the approach to surveillance imaging.

Limitations of the Study

There are a number of methodological limitations in this study. First, it is retrospective and therefore suffers from selection bias and other related design limitations. While a common practice of scanning all patients with cerebral contusion and traumatic intracranial hemorrhage theoretically mitigates selection bias, there were a large number of patients in this study who did not undergo their planned surveillance CT scan. The reasons for this are not known in every case, and this is a potential source of bias. The study's retrospective nature also introduces the inherent subjectivity of clinical decision-making. Decisions about when to discharge a patient from follow-up or whether a particular radiological finding explains a given symptom are two areas in which study conclusions might be colored by provider impressions.

Another limitation of the study is that we were unable to quantify the total number or size of lesions per patient due to variable charting. Some radiology reports only listed “multiple contusions” and not all CT scans were available for independent review. In the absence of a volumetric analysis, we cannot rule out the possibility that our patient cohort was skewed toward smaller hemorrhages; however, the authors feel that this type of generalizability problem is unlikely at a major trauma center that covers a large geographic region.

Current Practice

With health care reform aiming to achieve better health outcomes at lower costs, there is an increasing focus on evidence-based practice. Currently, many physicians obtain repeat head CT scans at the first clinic follow-up examination to evaluate a variety of possible delayed complications, including posttraumatic hydrocephalus, delayed extraaxial hematoma, and worsened cerebral edema; however, there are no data in the current literature to either support or refute these practices. Early prospective studies advocating serial routine head CT up to 3 months8 and 12 months11 after TBI have limited relevance, because patients in these studies had a clinical change in their examination findings, and the decision to undergo neurosurgical intervention was not made solely on routine CT findings.6

Although management of inpatient serial head CT is not the focus of this study, it is worth discussing the current literature regarding surveillance CT imaging in the inpatient setting. Currently, there is conflicting literature regarding serial head CT for inpatient management of mild, nonoperative head injury, in the absence of a decline in neurological examination results.1–3,6,7,9,13,14 Some studies have shown a lack of benefit1,2,6,7,9,14 while others support the usefulness of this practice.3,13 In one of the stronger studies, Brown et al. prospectively studied 354 patients with intracranial hemorrhage, stratifying their results by mild (Glasgow Coma Scale [GCS] score 13–15), moderate (GCS score 9–12), and severe (GCS score ≤ 8) head injury. Excluding patients with neurological decline, no patient with mild or moderate injury underwent medical or surgical intervention after routine repeat head CT.7 The authors therefore recommended routine repeat head CT only in patients with GCS scores ≤ 8. This study of inpatient management reflects our findings in the outpatient setting; no asymptomatic or minimally symptomatic patient underwent medical or surgical intervention based on routine repeat outpatient CT alone.

Medicolegal ramifications of undocumented radiological abnormalities also may be a significant driver of some physicians' decisions to scan all patients. Clinicians may fear being blamed for a subsequent, unrelated pathology and thus may obtain imaging to document resolution of traumatic sequelae. Admittedly, this practice is unlikely to be altered by the findings of this study.

Iatrogenic Cancer Implications of CT

The downside of excessive use of CT scanning is significant. Biological and biophysical data regarding radiation exposure supports a “linear-no-threshold” risk model, which stipulates that the risk of cancer proceeds in a linear fashion at lower doses and does not require an exposure threshold.10 Therefore, even the smallest dose of radiation has the potential to increase patients' risk of developing cancer. The FDA estimates that a CT examination with an effective dose of 10 mSv may be associated with the development of fatal cancer in approximately 1 in every 2000 patients, whereas a report by the National Research Council predicts development of cancer in 1 in every 1000 patients.12 The effective dose of a standard head CT is 2 mSv. The linear-no-threshold model implies an additive nature to radiation exposure, which may quickly surpass 10 mSv when also accounting for serial CT scans that occur during hospitalization. Even if risk to any one individual is small, extrapolation of these data to the population level suggests the possibility of significant iatrogenic injury.

Cost Implications of CT

Cost is another rationale for eliminating routine CT scanning of the asymptomatic patient. According to the Healthcare Blue Book, a patient consumer website, the cost of nonenhanced head CT in our region is approximately $302 dollars; this includes both physician interpretation and technical imaging fees. Thus, the estimated total cost of routine outpatient CT scanning for our patient cohort was $52,246 ($302 × 173 patients). Of this total cost, at least 60%, or $31,408, would have been saved if outpatient CT scans had not been performed in asymptomatic patients. If an additional clinic visit, rather than a CT scan, were conducted in mildly symptomatic patients, the radiology savings would increase to 99.4%, or $51,932; however, this figure does not account for the additional cost of a clinic visit. Unfortunately, it is impossible to calculate the potential national savings for this practice change, because we do not know how many outpatient CT scans are conducted for nonoperative cerebral contusion and tSAH within the US.

Logistical Challenges of Unscheduled CT Scans

Admittedly, breaking away from a “scan everyone” policy poses logistical challenges to health care providers. If concerning symptoms are detected during a follow-up clinic visit, a patient may require the scheduling of a semiurgent or urgent CT scan; he or she may subsequently need to return to clinic to review the results, and these efforts can be disruptive to a provider's schedule. However, the authors believe that this disruption can be mitigated and that inconvenience alone should not be used to justify a test that is costly, potentially harmful, and of dubious benefit. The authors also acknowledge that the potential injury of a “missed” diagnosis in the neurosurgical realm is potentially devastating. This phenomenon is common to all reviews of neurosurgical practice, but research such as this gives our field a better framework within which to make clinical decisions.

Conclusions

Asymptomatic patients presenting to clinic for routine follow-up after nonoperative cerebral contusion and tSAH are at low risk for new structural pathology; therefore, it is reasonable to forgo outpatient CT in these patients. Patients with mild, nonspecific symptoms are at a slightly higher risk for new structural pathology, and a clinical approach to these patients may include cross-sectional imaging or solely additional follow-up. For patients with significant symptoms, the authors recommend cross-sectional imaging, although the current study did not include a sufficient number of these patients to provide evidentiary support for this recommendation.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Fried, Desai, Simmons, Lollis. Acquisition of data: Rubino, Zaman, Sturge. Analysis and interpretation of data: Rubino, Lollis. Drafting the article: Rubino, Lollis. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Rubino. Statistical analysis: Rubino. Study supervision: Lollis.

The results of this study were presented at the New England Neurosurgical Society 2013 Annual Meeting in Brewster, Massachusetts, in the form of an oral presentation.

References

  • 1

    AbdelFattah KREastman ALAldy KNWolf SEMinei JPScott WW: A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15. J Trauma Acute Care Surg 73:6856882012

  • 2

    Almenawer SABogza IYarascavitch BSne NFarrokhyar FMurty N: The value of scheduled repeat cranial computed tomography after mild head injury: single-center series and meta-analysis. Neurosurgery 72:56642013

  • 3

    Bee TKMagnotti LJCroce MAMaish GOMinard GSchroeppel TJ: Necessity of repeat head CT and ICU monitoring in patients with minimal brain injury. J Trauma 66:101510182009

  • 4

    Berrington de González AMahesh MKim KPBhargavan MLewis RMettler F: Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 169:207120772009

  • 5

    Bodenheimer T: High and rising health care costs. Part 1: seeking an explanation. Ann Intern Med 142:8478542005

  • 6

    Brown CVRWeng JOh DSalim AKasotakis GDemetriades D: Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation. J Trauma 57:9399432004

  • 7

    Brown CVRZada GSalim AInaba KKasotakis GHadjizacharia P: Indications for routine repeat head computed tomography (CT) stratified by severity of traumatic brain injury. J Trauma 62:133913452007

  • 8

    Cope DNDate ESMar EY: Serial computerized tomographic evaluations in traumatic head injury. Arch Phys Med Rehabil 69:4834861988

  • 9

    Kaups KLDavis JWParks SN: Routinely repeated computed tomography after blunt head trauma: does it benefit patients?. J Trauma 56:4754812004

  • 10

    National Research Council of the National Academies: BEIR VII: Health Risks from Exposure to Low Levels of Ionizing Radiation Washington, DCNational Research Council of the National Academies2005. (http://dels.nas.edu/resources/static-assets/materials-based-on-reports/reports-in-brief/beir_vii_final.pdf) [Accessed June 26 2014]

  • 11

    Roberson FCKishore PRMiller JDLipper MHBecker DP: The value of serial computerized tomography in the management of severe head injury. Surg Neurol 12:1611671979

  • 12

    Semelka RCArmao DMElias J JrHuda W: Imaging strategies to reduce the risk of radiation in CT studies, including selective substitution with MRI. J Magn Reson Imaging 25:9009092007

  • 13

    Thorson CMVan Haren RMOtero CAGuarch GACuria EBarrera JM: Repeat head computed tomography after minimal brain injury identifies the need for craniotomy in the absence of neurologic change. J Trauma Acute Care Surg 74:9679752013

  • 14

    Washington CWGrubb RL Jr: Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? Clinical article. J Neurosurg 116:5495572012

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Address correspondence to: Sebastian Rubino, B.S., Section of Neurosurgery, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756-0001. email: sebastian.rubino.med@dartmouth.edu.

S. Rubino and R. Zaman contributed equally to this work.

Please include this information when citing this paper: published online July 25, 2014; DOI: 10.3171/2014.6.JNS132204.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Diagram of the study cohort subdivided by symptoms, frequency of new CT findings, and how often new CT findings led to a change in nonoperative treatment plan (non-op tx). Of the asymptomatic patients, only 1 patient (1%) underwent a change in his nonoperative treatment plan based on new CT findings. Of the patients with mild, nonspecific symptoms, 3 patients (4.4%) underwent a change in their nonoperative treatment plan based on new CT findings. One patient had significant symptoms without new CT findings. No patients with new CT findings underwent surgical intervention. *n = total number of patients; bold box outline = important finding (patients in whom new CT findings led to change in nonoperative treatment plan).

References

1

AbdelFattah KREastman ALAldy KNWolf SEMinei JPScott WW: A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15. J Trauma Acute Care Surg 73:6856882012

2

Almenawer SABogza IYarascavitch BSne NFarrokhyar FMurty N: The value of scheduled repeat cranial computed tomography after mild head injury: single-center series and meta-analysis. Neurosurgery 72:56642013

3

Bee TKMagnotti LJCroce MAMaish GOMinard GSchroeppel TJ: Necessity of repeat head CT and ICU monitoring in patients with minimal brain injury. J Trauma 66:101510182009

4

Berrington de González AMahesh MKim KPBhargavan MLewis RMettler F: Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 169:207120772009

5

Bodenheimer T: High and rising health care costs. Part 1: seeking an explanation. Ann Intern Med 142:8478542005

6

Brown CVRWeng JOh DSalim AKasotakis GDemetriades D: Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation. J Trauma 57:9399432004

7

Brown CVRZada GSalim AInaba KKasotakis GHadjizacharia P: Indications for routine repeat head computed tomography (CT) stratified by severity of traumatic brain injury. J Trauma 62:133913452007

8

Cope DNDate ESMar EY: Serial computerized tomographic evaluations in traumatic head injury. Arch Phys Med Rehabil 69:4834861988

9

Kaups KLDavis JWParks SN: Routinely repeated computed tomography after blunt head trauma: does it benefit patients?. J Trauma 56:4754812004

10

National Research Council of the National Academies: BEIR VII: Health Risks from Exposure to Low Levels of Ionizing Radiation Washington, DCNational Research Council of the National Academies2005. (http://dels.nas.edu/resources/static-assets/materials-based-on-reports/reports-in-brief/beir_vii_final.pdf) [Accessed June 26 2014]

11

Roberson FCKishore PRMiller JDLipper MHBecker DP: The value of serial computerized tomography in the management of severe head injury. Surg Neurol 12:1611671979

12

Semelka RCArmao DMElias J JrHuda W: Imaging strategies to reduce the risk of radiation in CT studies, including selective substitution with MRI. J Magn Reson Imaging 25:9009092007

13

Thorson CMVan Haren RMOtero CAGuarch GACuria EBarrera JM: Repeat head computed tomography after minimal brain injury identifies the need for craniotomy in the absence of neurologic change. J Trauma Acute Care Surg 74:9679752013

14

Washington CWGrubb RL Jr: Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? Clinical article. J Neurosurg 116:5495572012

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 320 320 53
PDF Downloads 213 213 23
EPUB Downloads 0 0 0

PubMed

Google Scholar