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Original article
Routine repeat head CT may not be necessary for patients with mild TBI
  1. Claire B Rosen1,
  2. Diego D Luy2,
  3. Molly R Deane3,
  4. Thomas M Scalea1,
  5. Deborah M Stein1
  1. 1 Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
  2. 2 Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  3. 3 Los Angeles County Harbor-UCLA Medical Center, Department of Surgery, Torrance, California, USA
  1. Correspondence to Dr Thomas M Scalea, Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA; tscalea{at}umm.edu

Abstract

Background Routine repeat cranial CT (RHCT) is standard of care for CT-verified traumatic brain injury (TBI). Despite mixed evidence, those with mild TBI are subject to radiation and expense from serial CT scans. Thus, we investigated the necessity and utility of RHCT for patients with mild TBI. We hypothesized that repeat head CT in these patients would not alter patient care or outcomes.

Methods We retrospectively studied patients suffering from mild TBI (Glasgow Coma Scale (GCS) score 13–15) and treated at the R Adams Cowley Shock Trauma Center from November 2014 through January 2015. The primary outcome was the need for surgical intervention. Outcomes were compared using paired Student’s t-test, and stratified by injury on initial CT, GCS change, demographics, and presenting vital signs (mean ± SD).

Results Eighty-five patients met inclusion criteria with an average initial GCS score=14.6±0.57. Our center sees about 2800 patients with TBI per year, or about 230 per month. This includes patients with concussions. This sample represents about 30% of patients with TBI seen during the study period. Ten patients required operation (four based on initial CT and others for worsening GCS, headaches, large unresolving injury). There was progression of injury on repeat CT scan in only two patients that required operation, and this accompanied clinical deterioration. The mean brain Abbreviated Injury Scale (AIS) score was 4.8±0.3 for surgical patients on initial CT scan compared with 3.4±0.6 (P<0.001) for non-surgical patients. Initial CT subdural hematoma size was 1.1±0.6 cm for surgical patients compared with 0.49±0.3 cm (P=0.05) for non-surgical patients. There was no significant difference between intervention groups in terms of other intracranial injuries, demographics, vital signs, or change in GCS. Overall, 75 patients that did not require surgical intervention received RHCT. At $340 per CT, $51 000 was spent on unnecessary imaging ($367 000/year, extrapolated).

Discussion In an environment of increased scrutiny on healthcare expenditures, it is necessary to question dogma and eliminate unnecessary cost. Our data questions the use of routine repeat head CT scans in every patient with anatomic TBI and suggests that clinically stable patients with small injury can simply be followed clinically.

Level of evidence Level III.

  • mild traumatic brain injury
  • routine
  • ct

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/tsaco-2017-000129

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    Footnotes

    • Contributors CBR, MRD, TMS and DMS conceived the study. CBR and TMS analyzed the data, CBR, MRD, TMS, DMS and DDL drafted the manuscript. All authors provided critical feedback and contributed to final revisions.

    • Funding This research was supported in part by the University of Maryland, School of Medicine, Office of Student Research, the Shock Trauma Registry, The R Adams Cowley Shock Trauma Center, and the University of Maryland Medical System.

    • Competing interests None declared.

    • Ethics approval Approval for retrospective data analysis was obtained from the University of Maryland, Baltimore Institutional Review Board.

    • Provenance and peer review Not commissioned; externally peer reviewed.