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Supercourse 2001 2002 abel murgio m d l.jpg
Supercourse 2001-2002 Abel Murgio, M.D.


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“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 l.jpg
Definition of Mild TBI Mild Traumatic Brain Injury? International Multicentre Study”

  • 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 l.jpg
Objectives Mild Traumatic Brain Injury? International Multicentre Study”

Theprincipalideaofthisstudy was to

evaluate–usinganinternationaland

multicentrepopulation-

therelationships betweenseverity of injury, risk factor andimagingfindingsbyattending physicians.


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I.S.H.I.P. group Mild Traumatic Brain Injury? International Multicentre Study”

Countries

1996-98 1999-2001

Phase I

5 countries

Phase II

22 countries

Web Site: www.iship-international.org


Methods l.jpg
Methods Mild Traumatic Brain Injury? International Multicentre Study”

Multicentreprospective,randomized,

studyofchildrenwhoseriallypresentedto

EmergencyDepartmentwithTraumaticBrain

Injury.

PhaseI:1996-98 with4,690Patients;

Phase II:1999-01 with4,770Patients.

Neurological Evaluations: GCS and PGCS Follow-up: GOS


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International Advisory Board Mild Traumatic Brain Injury? International Multicentre Study” 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)


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Results Mild Traumatic Brain Injury? International Multicentre Study”

7pat.

operated

3 pat.

operated

P= n.s.


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Severity of TBI by GCS or PGCS Mild Traumatic Brain Injury? International Multicentre Study”

PHASE II:4,6770Pat.

PHASE I : 4,690Pat.

3.0%

1.0%

96.0%

96.4


Slide10 l.jpg

Relationships: Mild Traumatic Brain Injury? International Multicentre Study”Age and Sex

Sex

Age distribution

38.2

40

%

60

61.8

P=n.s.

p=n.s.


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Results: Mechanism of TBI Mild Traumatic Brain Injury? International Multicentre Study”

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.


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LOC: Mild Traumatic Brain Injury? International Multicentre Study”Loss of Consciousness

Phase II: 4,770 Pat.

Phase I: 4,690 Pat.

4.0

1.7

24.0

18.8

P= n.s.


Slide13 l.jpg

Symptoms Phase Mild Traumatic Brain Injury? International Multicentre Study”I

N. 4690 Pat.

10.4%

2.3%

11.4%

23.6%

1.9%

19.1%

33.6%


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Symptoms Phase II Mild Traumatic Brain Injury? International Multicentre Study”

N. 4770 Pat.

s

m

o

t

p

m

y

S


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Results: Imaging Mild Traumatic Brain Injury? International Multicentre Study”

P = n.s.


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Results: Imaging Mild Traumatic Brain Injury? International Multicentre Study”

P=n.s.

P < 0.0001


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Results: CT Scan Phase I Mild Traumatic Brain Injury? International Multicentre Study”

85.5%

5%

9.4%

236

674 CT

[ 35% ]

N. 4690 Patients


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Results: CT Scan Phase II Mild Traumatic Brain Injury? International Multicentre Study”

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.


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Age Group - Type of lesion CT scan Mild Traumatic Brain Injury? International Multicentre Study”

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


Slide20 l.jpg

Intracranial Injury by CT Scanning Mild Traumatic Brain Injury? International Multicentre Study”

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”


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Pattern of Lesions TBI and CTs Mild Traumatic Brain Injury? International Multicentre Study”

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%


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Neurosurgical Intervention: Mild Traumatic Brain Injury? International Multicentre Study” 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


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Outcome at 3 Months Mild Traumatic Brain Injury? International Multicentre Study”

91%

99.8%

5= 99% 5= 99.6%

*Method of evaluation: phone or face to face


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Follow-up: Phase II Mild Traumatic Brain Injury? International Multicentre Study”

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


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a-Conclusion Mild Traumatic Brain Injury? International Multicentre Study”

  • 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;


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b-Conclusion Mild Traumatic Brain Injury? International Multicentre Study”

  • 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”;


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c-Conclusion Mild Traumatic Brain Injury? International Multicentre Study”

  • 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.


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International Society of Pediatric Mild Traumatic Brain Injury? International Multicentre Study”

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…”


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Past - Present & Future Mild Traumatic Brain Injury? International Multicentre Study”

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?


Slide30 l.jpg

Centers of the I.S.H.I.P. group Mild Traumatic Brain Injury? International Multicentre Study”

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


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d-Conclusion Mild Traumatic Brain Injury? International Multicentre Study”

  • 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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