Supercourse 2001-2002 Abel Murgio, M.D.
“Is the CT Scan important at the 24 Hours in Children with Mild Traumatic Brain Injury? International Multicentre Study”
Authors:°Murgio A.,*Mutluer S., **Fong D., #Hotz G., ^Di Rocco C., ^^Herrera EJ., ^^Viano JC.
ºI.S.H.I.P. Group Argentina ,*Turkey; **China; #USA; ^Italy; ^^Argentina;
TraditionallyTraditionally: : “as those with a history of acute injury, a “as those with a history of acute injury, a GCS score of 13 to 15, and no focal neurologic deficits”...GCS score of 13 to 15, and no focal neurologic deficits”...
““May or may not associated with a brief LOC that lasts May or may not associated with a brief LOC that lasts a few seconds to no longer than 30 minutes”...a few seconds to no longer than 30 minutes”...(HIISIGroup)(HIISIGroup)
No abnormal ImagingNo abnormal Imaging findings and no focal neurologic findings and no focal neurologic findings are present on initial clinical evaluation...findings are present on initial clinical evaluation...
Neurologically intact with a Neurologically intact with a GCS of 13 to 15GCS of 13 to 15...... Confusion with Amnesia for the event of trauma, Confusion with Amnesia for the event of trauma,
include amnesia for events immediately before or after include amnesia for events immediately before or after the accident (time: minutes to a few hours not more than the accident (time: minutes to a few hours not more than 24 hs).Dec.199824 hs).Dec.1998
Definition of Mild TBI
Objectives
The principal idea of this study was toevaluate –using an international and multicentre population- the relationships between severity of injury, risk factor and imaging findings by attending physicians.
I.S.H.I.P. groupCountriesCountries
Phase I 5 countries
1996-98 1999-2001
Web Site: www.iship-international.org
Phase II
22 countries
Methods
Multicentre prospective, randomized, study of children who serially presented to Emergency Department with Traumatic Brain Injury. Phase I: 1996-98 with 4,690 Patients; Phase II: 1999-01 with 4,770 Patients.Neurological Evaluations: GCS and PGCS Follow-up: GOS
In te rna tiona l A dvisory BoardU S A - U K - F R A N C E - ITA L Y
A na lys is - E va lua tionP ro f. J .K rau s (U C L A -U S A )
P ro f. T . S on g er (P ittsb u rg h U n iver.)
Eva lua tion1999 -2001
P.Patrick (Virginia University); G. Zitnay (CEO IBIA)G.Teasdale (Glasgow-UK), M.Choux (Marseille France)C. Di Rocco and F.Servadei (Italy)
International Advisory Board Statistical evaluation
Results
Phase I(1 9 9 6 -9 8 )
4 ,6 9 0 p a tien ts
Phase II(1 9 9 9 -2 0 0 1 )
4 ,7 7 0 p a tien ts
TOTAL SAM PLE9 ,4 6 0 p a tien ts
7 pat.operated
3 pat.operated
P= n.s.
Severity of TBI by GCS or PGCS
Mild: 13-15Moderate: 9-12Severe: < 8
PHASE I : 4,690Pat.
96.0%
1.0%3.0%
0
100
200
300
400
500
600
700
800
13 14 15
0-2 years3-6 years7-9 years10-12 yearsPercentage
PHASE II:4,6770Pat.
96.4
Relationships: Age and Sex
Phase I Phase II
Girls
Boys
0
10
20
30
40
50
0-2 y. 3-6 y. 7-9 y. 10-12 y.
Phase IPhase II
P=n.s. p=n.s.
Sex Age distribution
4038.2
60 61.8
%
Results: Mechanism of TBI
•Fall: 71.7 70.6 n.s. < 1 mt.: 50 59.0 n.s.1-2 mts.: 20 32.6 n.s.>2 mts.: 8.0 8.0 n.s.Even surface: 22 0.4 0.001*Road Acc.:17.0 16.8 n.s. p= n.s.
Phase I 9,460 Pat. Phase IIMechanism Percentage Valor p
0 50 100
Ranging 6 to 15 minutesRanging 1 to 5 minutesNo
18.81.7
LOC: Loss of Consciousness LOC: Loss of Consciousness
0 50 100
Ranging 6 to 15 minutesRanging 1 to 5 minutesNo
24.04.0
Phase I: 4,690 Pat.Phase II: 4,770 Pat.
P= n.s.
headachesemisisdrowsinessseizuresamnesiachild abuseother
Symptoms Phase I Symptoms Phase I
33.6%
23.6%
19.1%
10.4%
1.9%
11.4%2.3%
N. 4690 Pat.
0
20
40
60
80
Loss of Consciousness 24%
Amnesia 5.4%
Headache 17.9%
Vomiting 63.7%
Seizures 2.1%
Child abuse 1.2%
Politraumatysm 6.5%S
ym p
t o ms
Symptoms Phase II Symptoms Phase II
N. 4770 Pat.
Pa thologic10%
(453 /4204 )
Pha se I4204/4690
(89% )
Pa thologic14.9%
(629 /4226 )
Pha se II4226/4770
(88 .6% )
8 ,430 S kul l X -rays(o rd ered )
Results: Imaging
P = n.s.
Results: Imaging
Pha se I8 9 % (4 2 0 4 )
Pha se II8 8 .6 % (4 2 2 6 )
H ea d X -ra ys8 ,4 3 0 p a t.
Pha se I14.3% (6 7 4 )
Pha se II53% (2 ,5 2 8 )
C T Sca nning3 ,2 0 2 p a t.
9, 460 Pa tients
P=n.s. P < 0.0001
Results: CT Scan Phase IResults: CT Scan Phase I
NegativeNon doneAbnormal
0102030405060708090
100Cerebral Edema
Cerebral Contusion
Intrap. Hemor.
Subdural Hem.
Epidural Hem.
N. 4690 Patients
236
9.4% 5%
85.5%
674 CT[ 35% ]
AbnormalNegativeNot done
Total: 4,770 Patients /15 months – Entry rate: 318 Pat/monthNb: the percentage was calculated of the total patients included.
Results: CT Scan Phase IIResults: CT Scan Phase II
71.4%
28.5%
47%2,528 CT scan (53%)2,242
721
1807
Age Group - Type of lesion CT scanAge Group - Type of lesion CT scan
0
10
20
30
40
50
60
70
80
A B C Total
0-2 years3-6 years7-9 years10-12 years
35.4% 40.6% 24.0%
229/721 Cts (31.8%)Phase II
ICI
AA: Extradural Haematoma; BB: Contusion/Haemorr. Intrap.;CC: Subdural Haemorr./Subarachnoid
0
5
10
15
20
25
30
35
40
45
Phase I Phase II
Extradural
Contusion/Haemorr.Intrap.
Subdural Haemat./Subaracn.
229/721 Cts (31.8%)
170/236 Cts (72.0%)
n.
Intracranial Injury by CT Scanning
a b c a b c
Abnormal CT Scan: “focuses only on acute changes to the contents of the cranial vault with an special interest Neurosurgical aspects, example: Contusion, Extradural Haematoma, Subaracnoid Haemorrhage, Intraparenchymatous Haemorrhage, Subdural”
0
10
20
30
40
50
60
70
80
90
1 2 3 4
0
10
20
30
40
50
60
70
80
90
100
1 2 3
589 101 20 11 217 16 3
( N. 721 CTs + ) ( N. 236 CTs + )
Pattern of Lesions TBI and CTsPattern of Lesions TBI and CTs
1-81.7% 2-14.0% 3-2.8% 1-91.9%; 2-6.8%; 3-1.3%4-1.5%
Phase II Phase I
Neurosurgical Intervention: patients description
0
10
20
30
40
50
60
70
80
13 14 15
Phase II
0
5
10
15
20
25
13 14 15 <12
Phase I
56%
27.3%
16.7%
31.4%
16.4%
25.4% 26.9%
81 Patients130 Patients
MildsTBI 59/81 (72.9%)
MildsTBI 130 (100%)
7 Pat. Died GCS < 113 Pat. Died
Pha se I4,301 /4 ,6 9 0 p a t
Pha se II4,760 /4 ,7 7 0 p a t.
T ota l sa m ple9 ,4 6 0 p a t.
5= 99% 5= 99.6%
91% 99.8%
Outcome at 3 Months
*Method of evaluation: phone or face to face*Method of evaluation: phone or face to face
5: 99.6% (4,745 Pat.) 5: 94.1% ( 40 pat.)
4: 0.3% (14 pat.) 4: 2.9% ( 2 pat.)
3: 0.04% ( 2 pat.)
1: 0.04% (2 pat.) 1: 2.9% (1 pat.)
*GOS: 5 Good recovery ; 4 Moderately disabled; 3 Severely disabled
2 Vegetative state; 1 Death
4,760 patients (99.8%) 43 patients (0.9%)
3 MONTHS 6 MONTHS
GOS
Follow-up: Phase II
Advantage of the multicentre study is that Advantage of the multicentre study is that allows us a glimpse of practice in varied allows us a glimpse of practice in varied setting and makes it possible to compare setting and makes it possible to compare these experiences with our own;these experiences with our own;
We suggest that some of the beliefs that We suggest that some of the beliefs that govern us in decision-making need review, govern us in decision-making need review, i.e. “older and familiar technologies” (X-i.e. “older and familiar technologies” (X-rays) to determine the need for a more rays) to determine the need for a more complex evaluation, including CT;complex evaluation, including CT;
a-Conclusion
The physical and neurological The physical and neurological examination are inadequate “predictors” examination are inadequate “predictors” of ICI;of ICI;
The CT Scan is “more sensitive”;The CT Scan is “more sensitive”; Liberal use of CT scans in children under Liberal use of CT scans in children under
6 years of age and younger with TBI is 6 years of age and younger with TBI is because they “may present without because they “may present without symptoms”;symptoms”;
b-Conclusion
Until more definitive information is Until more definitive information is available, clinicians should be liberal in available, clinicians should be liberal in their use of CT so that early their use of CT so that early identification of significant ICI can be identification of significant ICI can be obtained and appropriate management of obtained and appropriate management of the injuries initiated.the injuries initiated.
c-Conclusion
““The critical issue will be to have The critical issue will be to have guidelines that, when used would guidelines that, when used would identify all patients who need identify all patients who need surgery, with as few negative scans to surgery, with as few negative scans to achieve this.” achieve this.”
““Should we now try to use the data to Should we now try to use the data to create guidelines and then validate create guidelines and then validate them…”them…”
International Society of Pediatric Neurosurgery : I.S.P.N.
Past - Present & Future
Mar del Plata(Argentina)
5 countries
22 countries
26 countries
X-rays-Epidemiology
Role X-rays-CTscan *Columella Award: ICRAN’96*Nomination: (CDC-IBIA)EH Cristopherson Award: AAP 2000
CTscan - Mild TBI
Markers Brain Damage-CTscan?Neuropsychology Tests?
1996
1996-98
1999-2001
2002-2003
*Neurosurgical Sciences’99*Child’s Nerv System’00-01*Brain Injury Sources’00*Book: Brain Injury’01-02
Contribution:
Centers of the I.S.H.I.P. groupCenters of the I.S.H.I.P. group
United StatesUnited StatesCanadaCanadaUruguayUruguayChileChileBrazilBrazilArgentinaArgentina
Spain France Spain France Italy IsraelItaly IsraelGermany TurkeyGermany TurkeyPoland Arabia Poland Arabia
IndiaIndiaHong KongHong KongTaiwanTaiwanSingaporeSingaporeIndonesiaIndonesia
UKSwedenRussia
2222
We think that is necessary to make an We think that is necessary to make an accurate evaluation of each patient with accurate evaluation of each patient with Mild TBI under 12 years of age and Mild TBI under 12 years of age and considerer order a CT scan into 24 hours considerer order a CT scan into 24 hours to identify ICI and guarantee a good out to identify ICI and guarantee a good out come .come .
d-Conclusion