Teleneurosurgery: Outcome of Mild Head Injury Patients Managed in Non-Neurosurgical Centre in the State of Johor

Background: With teleneurosurgery, more patients with head injury are managed in the primary hospital under the care of general surgical unit. Growing concerns regarding the safety and outcome of these patients are valid and need to be addressed.Method: This study is to evaluate the outcome of patients with mild head injury which were managed in non-neurosurgical centres with the help of teleneurosurgery. The study recruits samples from five primary hospitals utilising teleneurosurgery for neurosurgical consultations in managing mild head injury cases in Johor state. Two main outcomes were noted; favourable and unfavourable, with a follow up review of the Glasgow Outcome Scale (GOS) at 3 and 6 months.Results: Total of 359 samples were recruited with a total of 11 (3.06%) patients have an unfavourable. no significant difference in GOS at 3 and 6 months for patient in the unfavourable group (P = 0.368).Conclusion: In this study we have found no significant factors affecting the outcome of mild head injury patients managed in non-neurosurgical centres in Johor state using the help of teleneurosurgery.

Indicaciones de TAC de cráneo simple en pacientes menores de 2 años con trauma encefalocraneano leve / Indications for head computed tomography in patients younger than 2 years old with minor head injuries

Resumen Existe gran variabilidad en la práctica clínica en cuanto al uso de estudios imagenológicos, específicamente de la tomografía de cráneo simple en los casos de trauma encefalocraneano leve, más aun en pacientes menores de 2 años. En la mayoría de estos pacientes existe bajo riesgo de injuria intracraneal, sin embargo, este grupo etario plantea mayores retos diagnósticos por las dificultades en su evaluación y las pocas manifestaciones clínicas que podrían presentar dado a sus características anatómicas. Resulta necesario acogerse a las guías de práctica clínica que contengan reglas de decisión clínicas, que incluyan los signos y/o síntomas con mayor valor predictivo para detectar injuria intracraneal, costo efectivas y redundando en el beneficio del paciente.

Summary There is great variability in clinical practice with the use of imaging studies, specifically head computed tomography in cases of minor head injuries, even more so in patients younger than 2 years old. Most of these patients have low risk of intracranial injury; however, this age group represents greater challenges in the diagnosis, because of the difficulties in their assessment and lack of clinical results that could be present due to their anatomical characteristics. It is necessary to make clinical practice guidelines that include some key points like clinical signs and/or symptoms with greater predictive value for detecting intracranial injury, cost-effective interventions resulting in benefits for the patients.

Indicações de tomografia de crânio em crianças com trauma cranioencefálico leve / Indications for head computed tomography in children with mild traumatic brain injury

A reunião de revista "Telemedicina Baseada em Evidência - Cirurgia do Trauma e Emergência" (TBE-CiTE) realizou uma revisão crítica da literatura e selecionou os três artigos mais relevantes e atuais sobre a indicação de tomografia de crânio em pacientes pediátricos com trauma craniencefálico leve (TCE). O primeiro trabalho identificou pacientes vítimas de TCE leve com fatores de alto e baixo risco de apresentarem lesões intracranianas vistas à tomografia computadorizada (TC) de crânio e com necessidade de intervenção neurocirúrgica. O segundo trabalho avaliou o uso das recomendações do "National Institute of Clinical Excellence" em pacientes pediátricos com TCE, e utilizou como variáveis de desfecho a realização de TC ou internação hospitalar. O último artigo analisou e identificou os pacientes onde a TC de crânio seria desnecessária e, portanto, não deve ser feita rotineiramente. Baseado nessa revisão crítica da literatura e a discussão com especialistas, o TBE-CiTE concluiu que é importante evitar a exposição desnecessária de crianças com TCE leve à radiação ionizante da TC de crânio. O grupo favoreceu a utilização do guideline do PECARN onde ECG de 14, alteração do nível de consciência ou fratura do crânio palpável são indicações de TC de crânio, ou quando a experiência do médico, achados múltiplos ou piora dos sintomas ocorrerem.

The "Evidence Based Telemedicine - Trauma and Emergency Surgery" (TBE-CITE) performed a critical appraisal of the literature and selected the three most relevant and recent publications on the indications for head computed tomography (CT) scan in pediatric patients with mild traumatic brain injury (TBI). The first study identified patients with mild TBI, high and low risk factors for intracranial injuries detected on CT scan and need for neurosurgical intervention. The second study evaluated the guidelines of the National Institute of Clinical Excellence for pediatric patients with TBI. The outcome of this study was either performing a head CT scan or hospital admission. The last study identified and analyzed the patients in whom the CT scan is not necessary and consequently should not be routinely indicated. Based on the critical appraisal of the literature and expert discussion, the opinion of the TBE-CITE was to favor the adoption of the PECARN guidelines, proposing CT scans for children with GCS of 14, altered level of consciousness and palpable skull fracture, or when the physician experience, multiple findings or worsening symptoms warrant it.

O que todo pediatra deve saber sobre traumatismo cranioencefálico leve na infância / What the pediatrician should know about mild head injury in childhood

Introdução: O traumatismo cranioencefálico (TCE) leve é comum na população pediátrica. Não existe consenso para indicação de tomografia computadorizada de rotina. O cuidado inicial por parte da Pediatria é comum. É importante orientar ao pediatra na emergência a detectar precocemente uma lesão intracraniana que pode levar risco de morte, se não receber um tratamento inicial adequado. Metodologia: Revisão bibliográfica sobre o tema, utilizando como base de dados Medline. Resultados: A maioria dos casos de TCE leve na infância não necessita de exames de imagens e tratamento especializado. Apenas 3% dos pacientes apresentam complicações neurológicas. Observação na emergência por 24 horas em casos de sintomas leves e instrução familiar após a alta, por escrito, para retorno hospitalar, tem sido realizadas na maioria dos serviços de emergência pediátrica a criança vítima de TCE leve. Conclusões: A maioria dos casos de TCE em criança é de natureza leve. A apresentação clínica muitas vezes é assintomática. Avaliação inicial deve ser feita pela Pediatria. As crianças chegam na emergência em boas condições, podendo apresentar cefaleia discreta, vômitos e sem déficit neurológico, sem história de perda da consciência nem amnésia pós-traumática. A conduta em casos de TCE leve nesta faixa etária é diferenciada. Tomografia computadorizada tem indicação quando existem critérios clínicos estabelecidos, evitando, assim, necessidade de exames desnecessários, que em muitos casos necessitam de sedação e aumento dos gastos hospitalares...

The Usefulness of Brain Magnetic Resonance Imaging with Mild Head Injury and the Negative Findings of Brain Computed Tomography

OBJECTIVE: To investigate the cases of intracranial abnormal brain MRI findings even in the negative brain CT scan after mild head injury. METHODS: During a 2-year period (January 2009-December 2010), we prospectively evaluated both brain CT and brain MRI of 180 patients with mild head injury. Patients were classified into two groups according to presence or absence of abnormal brain MRI finding even in the negative brain CT scan after mild head injury. Two neurosurgeons and one neuroradiologist validated the images from both brain CT scan and brain MRI double blindly. RESULTS: Intracranial injury with negative brain CT scan after mild head injury occurred in 18 patients (10.0%). Headache (51.7%) without neurologic signs was the most common symptom. Locations of intracranial lesions showing abnormal brain MRI were as follows; temporal base (n=8), frontal pole (n=5), falx cerebri (n=2), basal ganglia (n=1), tentorium (n=1), and sylvian fissure (n=1). Intracranial injury was common in patients with a loss of consciousness, symptom duration >2 weeks, or in cases of patients with linear skull fracture (p=0.00013), and also more frequent in multiple associated injury than simple one (35.7%>8.6%) (p=0.105). CONCLUSION: Our investigation showed that patients with mild head injury even in the negative brain CT scan had a few cases of intracranial injury. These findings indicate that even though the brain CT does not show abnormal findings, they should be thoroughly watched in further study including brain MRI in cases of multiple injuries and when their complaints are sustained.

Mild Paediatric Head Injury: The Diagnostic Value of Physical Examinations Compared with Computed Tomographic Scans

The study objective was to determine the diagnostic value of physical examinations for positive computer tomography (CT) scans in children with mild head injuries. Retrospective data of patients evaluated for mild head injuries with loss of consciousness (LOC) or amnesia were reviewed. Estimations of prevalence, sensitivity, specificity, and predictive values were calculated. Agreement between the physical examinations and CT brain scans was calculated using the Kappa test. 225 patients were included in the study. Of this group, 19.56% of patients had positive CT scans, and 7.56% had normal physical examinations. 15 underwent neurosurgical intervention. For positive CT scans, sensitivity and specificity were 61.36% and 60.22%, respectively. Agreement between physical examinations and CT scans was Kappa = 0.147 (P < 0.05), 95% CI (0.035, 0.259). The present study demonstrated that physical examinations were significantly associated with positive CT scans (P = 0.01). However, the calculated Kappa value showed only slight agreement between these 2 variables, and the low sensitivity and specificity of the physical examinations suggest that intracranial pathology in children with mild head injuries and LOC or amnesia cannot be excluded based on physical examinations alone.

A More Detailed Classification of Mild Head Injury in Adults and Treatment Guidelines

OBJECTIVE: The purpose of this study was to analyze risk factors that are associated with intracranial lesion, and to propose criteria for classification of mild head injury (MHI), and appropriate treatment guidelines. METHODS: The study was based on 898 patients who were admitted to our hospital with Glasgow Coma Scale (GCS) score of 13 to 15 between 2003 and 2007. The patients' initial computerized tomography (CT) findings were reviewed and clinical findings that were associated with intracranial lesions were analyzed. RESULTS: GCS score, loss of consciousness (LOC), age and skull fracture were identified as independent risk factors for intracranial lesions. Based on the data analysed in this study, MHI patients were divided into four subgroups : very low risk MHI patients are those with a GCS score of 15 and without a history of LOC or headache; low risk MHI patients have a GCS score of 15 and with LOC and/or headache; medium risk MHI patients are those with a GCS score of 15 and with a skull fracture, neurological deficits or with one or more of the risk factors; high risk MHI patients are those with a GCS score of 15 with abnormal CT findings and GCS score of 14 and 13. CONCLUSION: A more detailed classification of MHI based on brain CT scan findings and clinical risk factors can potentially improve patient diagnosis. In light of our findings, high risk MHI patients should be admitted and treated in same manner as those with moderate head injury.

The use of brain CT Scan in craniocerebral trauma with Glasgow coma scale scores of 13 – 15 in Dr. Cipto Mangunkusumo Hospital 1999-2001.

There is still a controversy among the neurologists whether brain CT scan must be performed on the mild head trauma patients. This study was executed to find out the correlation between the brain CT scan image findings and its clinical impairment among the mild head trauma patients with Glasgow coma scale (GCS) score of 13 to 15. The study was a retrospective study by analyzing the uniform medical records of the head trauma patients hospitalized at the Neurology ward of Dr. Cipto Mangunkusumo Hospital within the period of 1999 to 2001. During that period 1,663 patients were hospitalized due to head trauma, and 1,166 of them (70.1 %) were suffered from mild head trauma patients with GCS score of 13-15. Among those with brain CT scan examinations (N: 271), the neurological abnormalities were found on 144 (53.1%) of patients, consisted of cerebral edema (11,4%), intracerebral hemorrhage (5.5%), epidural hemorrhage (16.2%), subdural hemorrhage (18.1%), subarachnoid hemorrhage (5.5%), and combination (13.8%). The further analysis showed that cranial nerves disturbance, amnesia, loss of conciousness for more than 10 minutes, and vomiting are significantly correlated to the brain CT scan abnormality. Combination of the above four clinical signs and symptoms have sensitivity of 90 % in predicting brain insults. This findings may be used as a simple set of clinical criteria for identifying mild head trauma patients who need undergo CT scan examination.

Cerebral Infarction Caused by Mild Head Injury in a Child with Iron Deficiency Anemia from Prolonged Breast Feeding: Case Report

A child who had iron deficiency anemia(IDA) resulted from the prolonged breast feeding presented with left side hemiparesis following mild head injury. The serial computed tomography and magnetic resonance imaging showed right internal carotid artery territory infarction. It has been generally accepted that prolonged breast feeding causes IDA. A few cases of infarction caused by IDA have been reported. A few cases of cerebral infarction caused by mild head injury have been also reported. However, few have been reported nonhemorrhagic cerebral infarction caused by mild head injury associated with IDA from prolonged breast feeding. We reviewed the literature that prolonged breast feeding causes IDA and in this case, mild head injury could cause the cerebral infarction. We think that it is important to have clinical suspicion of cerebral infarction in a child with IDA from prolonged breast feeding who has mild head injury because early diagnosis is difficult.

Clinical Usefulness of MR FLAIR Image in Mild Head Injuries

OBJECTIVES: MR fluid-attenuated inversion recovery(FLAIR) image uses paired long inversion time and relaxation time that nulls the signal from CSF. With nulling of the CSF long echo time readout could be used to increase T2-weighting, hence improving the conspicuousness of most tissue lesions without the deleterious effects of CSF artifact seen on T2 weighted sequence. We examed the usefulness of FALIR image in the diagnosis of mild head injury. METHODS: A total of 38 patients with mild head injury were examined by FLAIR image. We compared those images with CT scan and T1, T2-weighted images. Careful observation of MR images were done by two well-trained neuroradiologists. Each image was compared for conspicuousness and detectability of traumatic lesions might have shown abnormal signal intensities. The Wilcoxon signed ranks test was used for statistical evaluation. RESULTS: The FLAIR image was significantly more sensitive than those of other images(p<0.001). T2 FFE(Fast Field Echo) image was more useful for detection of small petechial hemorrhages. CONCLUSION: FLAIR image is considered to be more sensitive than those of conventional MR images in the evaluation of mild head injuries.

Clinical Analysis of the Risk Factors and Prognostic Factors of Delayed Deterioration Following Mild Head Injury

OBJECTIVE: The objective of this study was to analyze the clinical course of mild head injury patients and to investigate the risk and prognostic factors of delayed deterioration. METHODS: We retrospectively studied 366 consecutive patients with Glasgow Coma Scale scores ranging from 13 to 15 who were admitted to the neurosugery department from January 1995 to December 1997. RESULTS: Among 51(13.9%) patients with delayed deterioration, 13(25.5%) died and 36(70.6%) patients had favorable outcomes. Statistically correlated risk factors of delayed deterioration were: old age, drowsiness or speech disturbance, a low GCS score, abnormal laboratory findings including coagulopathy, electrolyte imbalance, hyperglycemia, and presence of subdural hematoma in initial brain CT. Twentyeight(54.9%) patients with delayed deterioration underwent neurosurgical intervention and 229(72.1%) patients without delayed deterioration were treated conservatively. Only sex, age and the GCS score on admission or deterioration were statistically correlated with prognosis of delayed deteriorated patients. CONCLUSION: Delayed deterioration following mild head injury may need an urgent operation, or lead to serious complication or disability. Therefore, physicians treating these patients must aware of the risk factors and prognostic factors of delayed deterioration to prevent more serious sequelae or to make an early diagnosis allowing for proper treatment. We also recommend special caution in patients with the abovementioned risk factors to ensure a even better prognosis for patients with mild head injury.

THE VALUE OF BRAIN CT SCANNING FOR ALERT PATIENTS FOLLOWING MILD HEAD INJURY

A standardized approch to serious head injury employing immediate CT scanning and aggressive medical and surgical therapy has improved outcomes in cases of intracranial lesions. Unfortunately, there is less agreement on how patients with mild head injury should be handled when first seen in an emergency department setting. The ideal policy in mild head injury would be diagnosis or rule-out intracranial lesions as quickly as possible. We reviewed the records of 126 mild head injury patients admitted during 6-month period to the Chonnam University Hospital to identify a group of mild head injury patients having lesions on brain CT scanning and to investigate the risk factors affecting abnormal lesions on brain CT scanning. All patients had alert mental status without neurological deficit and signs of skull fracture. Routine brain CT scans were obtained on all patients. Fifteen patients(12%) had 17 lesions on brain CT scans. Three patients needed surgery for their intracranial lesions. The initial Glasgow Coma Scale(GCS) was 15 in 107 patients and 14 in 19 patients. The incidence of abnormal brain CT lesions for each GCS was 9% in 15 and 26% in 14. The common symptoms of patients who had abnormal brain CT lesions was headache in 7(47%) cases, loss of consciousness in 7(47%) cases, amnesia in 4(27%) cases, dizziness in 4(27%) cases, vomiting in 3(20%) cases, and lethargy in 3(20%) cases. These data suggest that early brain CT scanning is necessary in alert patients who have GCS in 14, headache loss of consciousness, amnesia, dizziness, vomiting, or lethargy following mild head injury.

Significance of CT Scans in Mild Head Injury Patients

The purpose of this study is to identify a group of mild head injury patients having lesions on computerized tomography(CT) and to investigate the risk factors affecting the abnormal findings on CT scan. The study was limited to patients 16 years of age and older with a initial Glasgow Coma Scale(GCS) scores of at least 13 at the time of admission. Of a total of 243 patients studied, 156(64.2%) had abnormal CT findings. 49 patients(20.2%) required neurosurgical intervention(craniotomies for hematoma in 33, hematoma in 1 and subdural hygroma in 3). Four patients(2.4%) died of their cranial injury and three died of extracranial causes. The incidence of CT abnormalities for each GCS score was 86.7% in GCS of 13, 68.6% in GCS of 14, and 58.6% in GCS of 5. The factors affecting GCS scores at the time of admission were the presence of loss of consciousness and posttraumatic amnesia. The factors affecting abnormal CT scans were the presence of posttraumatic amnesia and skull fracture. A new lesion of extension of the initial finding on follow-up CT scans was found in 9.3% of 75 patients who underwent follow-up CT scans. Even though routine CT scans for mild head injury patients are not always necessary, these result suggest that all patients admitted to hospital after mild head injury should undergo CT scanning to enable early detection of an intracranial lesion.

Clinical Course and Outcome Following Mild Head Injury

A retrospective analysis of 219 mild head injured patients who were admitted to Chung-Ang University Hospital from January 1990 to December 1991 was made to correlate outcome to initial Glasgow coma scale(GCS) score, combined injuries and radiologic findings. The results were as follows: 1) The young males were most frequently affected. 2) The most common cause was motor vehicle accident followed by fall. 3) The most common combined injury was cervical sprain followed by subgaleal hematoma. 4) The skull fractures were shown in 29.2% but there was no correlation between outcome and skull fracture. 5) The most common abnormal CT finding was the subdural hematoma(20.3%). 6) The positive blood alcohol test was not correlated with the outcome. 7) The majority of the patients(91.8%) made a good recovery. 8) Thirteen patients(5.9%) were performed cranial operation under the diagnosis of epidural hematoma(5 patients), subdural hematoma(4 patients), contusion and FCCD.

STUDY ON THE ELECTROPYSIOLOGICAL FINDINGS OF MILD HEAD INJURY AND ITS APPLICATION CLINICAL FORENSIC MEDICINE / 中国法医学杂志

Changes of ABR and LEDVEP in 60 patients with mild head injury and of ABR LEDVEP BEAM in 40 out of 60 patienites were studied. The results were as folls:we:①The Chief abnormality of ABR. was the prolongation of Ⅰ- Ⅲ interpeak latency ②The appaent abnomality of the LEDVEP was the prolongation of N70 latency and the drop of N70-P100 amplitude ③The characteristic change of BEAM was the incre ment of average ?1 power. The increment of ?/?2 power ratio suggested the presence of supertentorial lesions.According to the follow up study of clectrophysiological findings, a scale of brain dysfunction was created,It provides an objective criterion for clinical diagnosis and prognostic determination. In forensic practicl. Grade O and Ⅰ could be considered as minimal wound and Grade Ⅱ as slight wound,