Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury

Abstract

Object: Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need.

Methods: The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded.

Results: During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6-131.8; OR 9.7 for SDH, 95% CI 2.4-39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15.

Conclusions: Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.

Fig. 1.

Flowchart illustrating the management of 292 cases from patient arrival at UNM to final outcome. Pink boxes show the patients undergoing surgery and the timing of surgery. Abbreviations: h = hours; m = minutes; OR = operating room.

Fig. 2.

Axial CT scans obtained in 3 of the patients who were initially observed with follow-up imaging and required surgical intervention at some point after the second CT. A: This 23-year-old man presented with headache and confusion (GCS Score 14) 3 days after assault (left image). Given the extensive hematoma and intraventricular hemorrhage, a CT angiogram was performed, showing increased volume of contusion (middle image). Based on this increase, surgical evacuation of the hematoma was performed (postoperative image on right). B: This 77-year-old man, who was in a motor vehicle collision, arrived confused but awake (GCS Score 13) with a left temporoparietal hematoma (left image). On follow-up imaging, the hematoma showed expansion (middle image); therefore, surgical evacuation was performed (postoperative image on right). C: This 27-year-old man was hit in the left temporal region by a falling tree branch. He was neurologically intact on arrival to UNM (GCS Score 15), and initial CT showed an EDH with an associated fracture extending into the middle fossa (left image). The follow-up CT showed slight expansion (middle image), especially in the temporal region, and so surgical evacuation was performed despite a lack of change in findings on neurological examination (postoperative image on right).

Fig. 3.

Proposed algorithm for the treatment of patients referred with mTBI. Anticoagulation1 refers to patients being treated with clopidogrel or with an international normalized ratio > 1.5. DC = discharge.