Journal Article

Assessing the efficacy of mild traumatic brain injury management

Espinosa, Jose A., Nie, Jeffrey Z., Weber, Matthew W., Delfino, Kristin R., Michael, Alex P.

2021

Overview

•Repeat imaging has limited utility in low-risk, mild traumatic brain injury patients.•No patient with low-risk, mild traumatic brain injury had neurosurgical intervention.•Performing serial neurological examinations may be a safe, cost-effective alternative.•Transferring low-risk, mild traumatic brain injury patients may be unnecessary. Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

• Publisher: Elsevier B.V,Elsevier Limited
• Subject: Adolescent / Adult / Aged / Aged, 80 and over / Anticoagulants / Brain Concussion - diagnostic imaging / Brain Concussion - economics / Brain Concussion - therapy / Cerebral Hemorrhage, Traumatic - diagnostic imaging / Cerebral Hemorrhage, Traumatic - economics / Cerebral Hemorrhage, Traumatic - therapy / Computed tomography / Cost-Benefit Analysis / Disease Management / Female / Fractures / Head computed tomography / Health services utilization / Healthcare utilization / Hematoma / Hematoma, Subdural - diagnostic imaging / Hematoma, Subdural - economics / Hematoma, Subdural - therapy / Hemorrhage / Hospital Mortality / Hospitals / Humans / Intracranial Hemorrhage, Traumatic - diagnostic imaging / Intracranial Hemorrhage, Traumatic - economics / Intracranial Hemorrhage, Traumatic - therapy / Male / Management of traumatic brain injury / Medical imaging / Middle Aged / Mild traumatic brain injury / Neuroimaging / Neurologic Examination / Neurology / Neurosurgery / Patient Readmission / Patient Transfer - economics / Patients / Referral and Consultation / Retrospective Studies / Risk Assessment / Skull Fractures - diagnostic imaging / Skull Fractures - economics / Skull Fractures - therapy / Subarachnoid Hemorrhage, Traumatic - diagnostic imaging / Subarachnoid Hemorrhage, Traumatic - economics / Subarachnoid Hemorrhage, Traumatic - therapy / Tertiary Care Centers / Tomography, X-Ray Computed - economics / Trauma / Trauma Centers / Traumatic brain injury / Treatment Outcome / Young Adult