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