Category Archives: Head

Complications, Head

EAST 2017 #8: When Is “Mild TBI” Not So Mild?

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Traumatic brain injury (TBI) is very common, with the majority falling into the “mild” category. This is usually defined as patients with injury to the head and a GCS of 13-15. These uncomplicated patients are frequently discharged from the emergency department, or undergo only a brief evaluation if admitted for other reasons.

The group at Shock Trauma focused on a less appreciated subset of mild TBI patients, those whose condition is a little more complicated. Specifically, these are patients with GCS 13-14 with positive findings on head CT leading to a calculated abbreviated injury score (head) of > 2, and some persistence of their symptoms while in the hospital. At many hospitals (including my own), these patients receive an inpatient TBI evaluation. But if they pass this initial screening, they are not consistently referred for any outpatient TBI followup.

Are these mild, complicated TBI patients (mcTBI) unique? Do they behave the same as the uncomplicated ones? The research group performed a prospective study on patients who sustained an mcTBI over a 4 month period.  They excluded patients with mental illness, dementia, and non-English speaking and homeless patients. They tried to contact patients up to three times after discharge to administer several standard tests and determine if they had any specific residual symptoms.

Here are the factoids:

  • Of the 142 patients with mcTBI during the study period, there was substantial attrition over time, with only 25 remaining at 6 months and 10 at one year
  • 64% of patients who responded at 6 months remained symptomatic. Depression, dizziness, and a feeling of impaired health were common.
  • 80% of patients still described symptoms at one year. The same complaints were most common, and some required changes in activities of daily living or assistive devices.

Bottom line: Although small and fraught with the usual problems in long-term tracking of urban trauma patients, this study is eye-opening. We too often dismiss “mild TBI” and being almost nothing, even in patients with positive findings on head CT. This work suggests that we are underestimating the needs of those patients. The authors used this data to design longer-term care processes for this subset of patients. Other centers should follow suit to make sure these patients’ post-injury needs are better met.

Questions and comments for the authors/presenters:

  • Describe the possible biases that patient selection and attrition may have had on the study
  • What type of TBI screening do you use in the hospital?
  • Given that a number of assessments were administered over the phone, I look forward to hearing some of the other details not listed in the abstract
  • Was there any correlation between specific CT findings and later symptoms?
  • Provide details of your long-term care programs for these patients
  • I enjoyed this thought provoking abstract!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Mild TBI is not ‘mild’… survivors tell their complicated stories. Quick Shot #3, EAST 2017.

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Head, Imaging

EAST 2017 #5: Subarachnoid Hemorrhage, Neurosurgical Consults, and Repeat Head CT

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Neurosurgical involvement in the management of simple traumatic brain injury (TBI) has been slowly dwindling over the past several years. This is the result of the general consensus that very few of these patients progress to need neurosurgical procedures.

A group at Wright State University in Dayton sought to define the progression of one specific finding in TBI, the subarachnoid hemorrhage (SAH). Secondarily, the wanted to determine if a neurosurgery consultation was warranted in these patients.

They performed a five year retrospective review of their registry data, identifying patients with both mild TBI (GCS 13-15) and SAH. They excluded patients with any other brain lesion on CT.

Here are the factoids:

  • 301 patients were enrolled during the 5 year period
  • All had a neurosurgical consultation
  • Time between the initial CT and a followup scan was about 11 hours
  • 91% showed stable or resolving SAH on the followup scan
  • 9% showed a worsening SAH or additional lesions on the repeat scan

Bottom line: The authors conclude that initial neurosurgical consultation is not needed, since only 9% of patients have worrisome findings on repeat CT. They do, however, recommend that the practice of repeat scanning be continued because of this same number.

Our trauma service looked at this issue a year ago, and determined that most of these lesions either do not progress, or never require any intervention if they do, with a few notable exceptions. For that reason, we abandoned both neurosurgical consultation and repeat CT scans for patients with non-aneurysmal SAH, a single parenchymal hemorrhage, or linear skull fractures. We continue to do both for patients with epidural and/or subdural hemorrhage. You can download a copy of this protocol here.

Questions and comments for the authors/presenters:

  • Did you look at platelet count or INR in the study. Were patients excluded based on abnormal values?
  • Did every patient get a repeat scan?
  • Break down the lesions in the 9% of patients who had some sort of progression or new finding. Did you see any common themes (age, chronic alcohol use, etc.)?
  • Did you encounter any patients with “non-central SAH”, that might indicate an aneurysm? How were they dealt with?
  • How has or will your trauma service change its practice based on your findings.

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference:   Management of subarachnoid hemorrhage (SAH) by the trauma service: are repeat CT scanning & routine neurosurgical consultation necessary? Poster #16, EAST 2017.

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Anatomy, Head

What You Need To Know About Frontal Sinus Fractures

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Fracture of the frontal sinus is less common than other facial injuries, but can be more complex to deal with, both in the shorter and longer terms. These are generally high energy injuries, and facial impact in car crashes is the most common mechanism. Fists generally can’t cause the injury, but blunt objects like baseball bats can.

Here’s the normal anatomy:

sinus-fracture-treatment

 

Source: www.facialtraumamd.com

There are two “tables”, the anterior and the posterior. The anterior is covered with skin and a small amount of subcutaneous tissue. The posterior table is separated from the brain by the meninges.

Here’s an image of an open fracture involving both tables. Note the underlying pneumocephalus.

frontal_sinus1

A third of injuries violate the anterior table, and two thirds violate both. Posterior table fractures are very rare. A third of all patients will develop a CSF leak, typically from their nose.

These fractures may be (rarely) identified on physical exam if deformity and flattening is noted over the forehead. Most of the time, these patients undergo imaging for brain injury and the fracture is found incidentally. Once identified, go back and specifically look for a CSF leak. Clear fluid in the nose is, by definition, CSF. Don’t waste time on a beta-2 transferring (see below).

If a laceration is clearly visible over the fracture, or if a CSF leak was identified, notify your maxillofacial specialist immediately. If more than a little pneumocephalus is present, let your neurosurgeon know. Otherwise, your consults can wait until the next morning.

In general, these patients frequently require surgery for the fracture, either to restore cosmetic contours or to avoid mucocele formation. However, these are seldom needed urgently unless the fracture is an open fracture with contamination or there is a significant CSF leak. If in doubt, though, consult your specialist.

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Head

Managing Mild TBI Without A Neurosurgeon

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TBI is a very common injury, and neurosurgeons are relatively rare resources for trauma centers. That mismatch can create significant problems for trauma programs. Reflexively, we consult neurosurgeons for a wide variety of neurotrauma, ranging from the very severe to the extremely mild.

sah

Can we intelligently and selectively utilize the skills of our neurosurgeons, and not jeopardize patient safety? Surgeons at Baystate Medical Center in Springfield MA reviewed their own experience managing mild TBI.

They defined a mild TBI as one with patient GCS of 13-15. However, their study included only patients with “GCS>14”, which I presume means all patients with GCS=15 (unless this is a typo). They allowed patients with normal GCS and intoxication, epidural (EDH) or subdural hematoma (SDH)<4mm, small subarachnoid hemorrhage (SAH), and non-displaced skull fracture (Fx). Any patient taking any type of anticoagulant or anti-platelet drug was excluded. They looked at need for neurosurgical consultation or intervention, readmission, and 30 day mortality.

This prospective study spanned 13 months. This lower volume center admitted 1341 patients, of which 77 were included in the study. Average age was 55, and average ISS was 16. A total of 97% presented for a followup visit (!).

Here are the factoids:

  • 47% had SAH, 43% SDH, 16% intraparenchymal hemorrhage (not mentioned in inclusion criteria), 14% Fx, and no EDH
  • Only one patient required neurosurgery consult, and none required intervention
  • There were no mortalities
  • Most (62%) were admitted to a ward bed, and the average length of stay for all patients was 3 days
  • Cost savings was estimated at about $16,000

Bottom line: Yes there is no magic in getting a neurosurgical consult for most mild TBI. The study is small, but telling. A carefully crafted practice guideline can dramatically decrease the (over)use of our neurosurgeons, saving both time and money.

In reviewing their guideline, I would recommend shaving even one more point off the GCS (>14), but stipulating that any central subarachnoid hemorrhage require consultation because of the possibility of an aneurysm being the culprit.

Check out the guideline in use at my hospital below. Also, look at the first related post, which is similar in idea to this one, but you can see the difference in management by surgeons vs neurosurgeons.

Related posts:

Reference: Mild traumatic brain injuries can be safely managed without neurosurgical consultation: the end of a neurosurgical “nonsult”? AAST 2016, Poster 51.

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Head

Cognitive Rest??

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One of the more commonplace recommendations for recovery from mild traumatic brain injury (TBI) is “cognitive rest.” Sports medicine professionals recommend it, physiatrists recommend it, and trauma professionals talk about it.

First, what is it, exactly? I’ve seen a number of descriptions, and they vary quite a bit. The main concept is to avoid all activities that involve mental exertion. This includes using a computer, watching TV, talking on a cell phone, reading, playing video games, and listening to loud music. Huh?

What good does this allegedly do? Most articles that I’ve read theorize that cognitive activity somehow increases the metabolic activity of the brain and that this is bad. One of the more interesting papers I read (from 2010!) says it best: “It is now well-accepted that excessive neurometabolic activity can interfere with recovery from a concussion and that physical rest is needed.”

Read carefully. Well-accepted. The paper cites unpublished data on children by one of the authors, 2 meta-analyses and 2 consensus opinions. In other words, no data at all. Yet somehow the concept has caught on.

First of all, I don’t think it’s possible for most people to realistically practice cognitive rest. Who knows if there is really any difference in metabolism and energy use by the brain if you are engaging in any of the banned activities above? And let’s go to the other extreme: if one lies quietly in bed meditating, shouldn’t this be the ultimate cognitive rest? Yet fMRI and PET studies suggest (also limited data) that cerebral flow in specific areas of the brain increases during this state.

Maybe a modest increase in activity is good. Physical activity (within limits) has been shown to be very beneficial to physical and psychological well being time and time again. And the only paper I could find on the topic with respect to TBI showed that randomization to bedrest vs normal physical activity had no difference in post-concussive syndrome incidence or severity. However, the active group recovered with significantly less dizziness.

Bottom line: There is no data to support the concept of cognitive rest. Any type of activity, either mental or physical, can cause fatigue in a variable amount of time in people with mild TBI. It is probably best to interpret this as a signal to take it easy and recover for a while before exerting oneself again. But so far there is no objective data to show that cognitive activity either helps or hinders recovery.

References:

  • Cognitive rest: the often neglected aspect of concussion management. Athletic Therapy Today, March 2010, pg 1-3.
  • Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry 73:167-172, 2002.
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