Routine reimaging unnecessary after mild head injury

By Eleanor McDermid, Senior medwireNews Reporter

Scheduling a repeat computed tomography (CT) scan for patients with mild traumatic brain injury and stable neurologic signs is unnecessary, given that it rarely changes management, say Canadian researchers.

"Considering that this practice is neither risk nor cost free, evidence-based rules should be implemented," say Saleh Almenawer (McMaster University, Hamilton, Ontario) and team. "Furthermore, we found that the simple yet important neurological examination is the predictive factor of changing the management and guiding the need for repeat imaging after mild head injury."

They note that the standard of care in many trauma centers is to schedule a repeat CT scan within 24 hours to rule out secondary changes that might warrant intervention, even if patients have stable or improving neurologic signs.

But in their study, reimaging led to intervention for just two of 445 patients in the absence of neurologic deterioration, they report in Neurosurgery. Both were given a single dose of mannitol because of increasing edema on the CT images, despite stable neurologic signs.

Another 23 patients had a change in management because of deteriorating neurologic signs, with 21 of these patients requiring surgery and two just receiving mannitol.

"Although the radiological evidence in addition to clinical stability obtained from repeat imaging that rules out possible secondary changes is an assuring factor for the managing physician and the patient, a common clinical practice cannot be based on this reassurance alone," comment Almenawer et al.

The team also reviewed the literature, identifying an additional 2248 patients from 15 eligible studies. Among all patients, the weighted rate of intervention based on neurologic examination was 2.7%, which was significantly higher than the 0.6% rate based on CT findings in the absence of neurologic changes.

The researchers caution that they have not addressed the value of routine reimaging in patients with more severe head injuries. "Considering our hypothesis that the neurological examination is a better and risk-free indicator of intervention, we excluded the population of patients with moderate and severe head injuries because monitoring these groups is more difficult and less sensitive," they explain.

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