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Supercourse 2001-2002

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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.,*MutluerS., **Fong D., #Hotz G.,

^Di Rocco C., ^^Herrera EJ., ^^Viano JC.

ºI.S.H.I.P. Group Argentina ,*Turkey; **China; #USA; ^Italy; ^^Argentina;


Definition of Mild TBI

  • Traditionally: “as those with a history of acute injury, a GCS score of 13 to 15, and no focal neurologic deficits”...

  • “May or may not associated with a brief LOC that lasts a few seconds to no longer than 30 minutes”...(HIISIGroup)

  • No abnormal Imaging findings and no focal neurologic findings are present on initial clinical evaluation...

  • Neurologically intact with a GCS of 13 to 15...

  • Confusion with Amnesia for the event of trauma, include amnesia for events immediately before or after the accident (time: minutes to a few hours not more than 24 hs).Dec.1998


Objectives

Theprincipalideaofthisstudy was to

evaluate–usinganinternationaland

multicentrepopulation-

therelationships betweenseverity of injury, risk factor andimagingfindingsbyattending physicians.


I.S.H.I.P. group

Countries

1996-98 1999-2001

Phase I

5 countries

Phase II

22 countries

Web Site: www.iship-international.org


Methods

Multicentreprospective,randomized,

studyofchildrenwhoseriallypresentedto

EmergencyDepartmentwithTraumaticBrain

Injury.

PhaseI:1996-98 with4,690Patients;

Phase II:1999-01 with4,770Patients.

Neurological Evaluations: GCS and PGCS Follow-up: GOS


International Advisory Board Statistical evaluation

P.Patrick (Virginia University); G. Zitnay (CEO IBIA)

G.Teasdale (Glasgow-UK), M.Choux (Marseille France)

C. Di Rocco and F.Servadei (Italy)


Results

7pat.

operated

3 pat.

operated

P= n.s.


Severity of TBI by GCS or PGCS

PHASE II:4,6770Pat.

PHASE I : 4,690Pat.

3.0%

1.0%

96.0%

96.4


Relationships:Age and Sex

Sex

Age distribution

38.2

40

%

60

61.8

P=n.s.

p=n.s.


Results: Mechanism of TBI

Phase I 9,460 Pat.Phase II

Mechanism Percentage Valor p

  • 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 16.8n.s.

  • p= n.s.


LOC:Loss of Consciousness

Phase II: 4,770 Pat.

Phase I: 4,690 Pat.

4.0

1.7

24.0

18.8

P= n.s.


Symptoms PhaseI

N. 4690 Pat.

10.4%

2.3%

11.4%

23.6%

1.9%

19.1%

33.6%


Symptoms Phase II

N. 4770 Pat.

s

m

o

t

p

m

y

S


Results: Imaging

P = n.s.


Results: Imaging

P=n.s.

P < 0.0001


Results: CT Scan Phase I

85.5%

5%

9.4%

236

674 CT

[ 35% ]

N. 4690 Patients


Results: CT Scan Phase II

28.5%

2,528 CT scan

(53%)

721

47%

1807

2,242

71.4%

Total: 4,770 Patients /15 months – Entry rate: 318 Pat/month

Nb: the percentage was calculated of the total patients included.


Age Group - Type of lesion CT scan

Phase II

229/721 Cts (31.8%)

ICI

35.4% 40.6% 24.0%

A: Extradural Haematoma;B: Contusion/Haemorr. Intrap.;

C: Subdural Haemorr./Subarachnoid


Intracranial Injury by CT Scanning

170/236 Cts (72.0%)

229/721 Cts (31.8%)

n.

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”

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”


Pattern of Lesions TBI and CTs

589 101 20 11

217 16 3

( N. 721 CTs + )

( N. 236 CTs + )

Phase II

Phase I

1-81.7% 2-14.0% 3-2.8% 1-91.9%; 2-6.8%; 3-1.3%

4-1.5%


Neurosurgical Intervention: patients description

Phase II

Phase I

31.4%

130 Patients

81 Patients

56%

26.9%

25.4%

MildsTBI 59/81

(72.9%)

MildsTBI 130

(100%)

27.3%

16.4%

7 Pat. Died GCS < 11

16.7%

3 Pat. Died


Outcome at 3 Months

91%

99.8%

5= 99% 5= 99.6%

*Method of evaluation: phone or face to face


Follow-up: Phase II

GOS

3 MONTHS

6 MONTHS

4,760 patients (99.8%) 43 patients (0.9%)

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: 5Goodrecovery ; 4Moderatelydisabled; 3Severelydisabled

2Vegetativestate; 1Death


a-Conclusion

  • Advantage of the multicentre study is that allows us a glimpse of practice in varied setting and makes it possible to compare these experiences with our own;

  • We suggest that some of the beliefs that govern us in decision-making need review, i.e. “older and familiar technologies” (X-rays) to determine the need for a more complex evaluation, including CT;


b-Conclusion

  • The physical and neurological examination are inadequate “predictors” of ICI;

  • The CT Scan is “more sensitive”;

  • Liberal use of CT scans in children under 6 years of age and younger with TBI is because they “may present without symptoms”;


c-Conclusion

  • Until more definitive information is available, clinicians should be liberal in their use of CT so that early identification of significant ICI can be obtained and appropriate management of the injuries initiated.


International Society of Pediatric

Neurosurgery : I.S.P.N.

  • “The critical issue will be to have guidelines that, when used would identify all patients who need surgery, with as few negative scans to achieve this.”

  • “Should we now try to use the data to create guidelines and then validate them…”


Past - Present & Future

1996

Mar del Plata

(Argentina)

1996-98

X-rays-Epidemiology

5 countries

1999-2001

Role X-rays-CTscan

22 countries

*Columella Award: ICRAN’96

*Nomination: (CDC-IBIA)

EH Cristopherson Award:

AAP 2000

2002-2003

CTscan - Mild TBI

26 countries

Contribution:

*Neurosurgical Sciences’99

*Child’s Nerv System’00-01

*Brain Injury Sources’00

*Book: Brain Injury’01-02

Markers Brain Damage-CTscan?

Neuropsychology Tests?


Centers of the I.S.H.I.P. group

UK

Sweden

Russia

India

Hong Kong

Taiwan

Singapore

Indonesia

22

United States

Canada

Uruguay

Chile

Brazil

Argentina

Spain France

Italy Israel

Germany Turkey

Poland Arabia


d-Conclusion

  • We think that is necessary to make an accurate evaluation of each patient with Mild TBI under 12 years of age and considerer order a CT scan into 24 hours to identify ICI and guarantee a good out come .


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