PURPOSE: Mild traumatic brain injury (mTBI) is defined as head injury resulting from blunt trauma with one or more of the following conditions: 1) any period of transient confusion, disorientation, or impaired consciousness; 2) any period of dysfunction of memory (amnesia) around the time of injury; 3) observed signs of other neurological or neuropsychological dysfunction; 4) any period of loss of consciousness lasting 30 minutes or less. As a result of its subtle computed tomography (CT) findings, patients with mTBI were almost ordered discharged in the emergency setting. However, postconcussion syndrome (PCS) could develop in approximately 10 to 20% of these patients. This study was conducted in order to investigate the prognostic factors of PCS, and the role of magnetic resonance imaging (MRI) for diagnosis of PCS in mTBI patients. METHODS: This retrospective study was conducted in 397 patients who were admitted with mTBI (GCS=15, age> or =6 years old) for analysis of the prognostic factors of PCS, and 187 patients who underwent both CT scan and MRI for comparison of the sensitivity of CT to that of MRI from January 2009 to December 2010. PCS was defined as a disorder with somatic, cognitive, or affective symptoms. RESULTS: Of the mTBI patients, 44.2% had PCS. The independent prognostic factors were loss of consciousness (LOC)/posttraumatic amnesia (PTA), headache, and intracranial hemorrhage on CT scans. Strong suggestive CT findings of PCS were lesions located in intra-axial and white matter, subdural hematoma, and intraprenchymal contusion of the frontal or temporal lobe. A decision model for prediction of PCS in mTBI consisted of three risk factors: LOC/PTA, headache, facial fracture, and intracranial hemorrhage on CT scans. The sensitivity of MRI was superior to that of CT in detection of PCS (72.4.4% vs 60.9%, p=0.021). CONCLUSION: The possibility of developing PCS was high in mTBI patients with LOC/PTA, headache, and abnormal CT findings. These patients may require MRI evaluation.
Amnesia ; Brain Injuries ; Contusions ; Craniocerebral Trauma ; Emergencies ; Headache ; Hematoma, Subdural ; Humans ; Intracranial Hemorrhages ; Magnetic Resonance Imaging ; Memory ; Retrospective Studies ; Temporal Lobe ; Unconsciousness

PURPOSE: Delayed neuropsychiatric sequelae (DNS) encompass a broad spectrum of neurological deficits, cognitive impairments, and affective disorders which commonly occur after a recovery from acute carbon monoxide (CO) poisoning. The early identification of patients with a high risk of DNS might improve their quality of care. Thus, we studied the role of magnetic resonance imaging (MRI) for the prediction of DNS. METHODS: This retrospective study included 41 patients with CO poisoning from January 2009 to June 2012. Magnetic resonance imaging (MRI) was performed within seven days after CO poisoning. Positive MRI findings were defined as focal or diffuse signals in fluid-attenuated inversion recovery (FLAIR), diffusion weighted imaging (DWI), and T2 weighted imaging (T2WI). DNS was considered present when patients had clinical symptoms and signs of DNS within 3 months after CO poisoning. Clinical and biohumoral data were collected; univariate and multivariate statistical analyses were performed to identify the predictive role of MRI for DNS. RESULTS: DNS occurred at a rate of 58.5%, with abnormal MRI findings associated with the development of DNS in the multivariate analysis. The sensitivity of MRI to DNS was 82.6%. In contrast, a normal MRI was seen in eighteen patients (43.9%). MRI revealed abnormalities in the deep white matter (41.5%), globus pallidus (34.1%), cerebral cortex (12.2%), medial temporal lobe (MTL)/hippocampus (7.3%), and cerebellum (4.9%). Among the MRI abnormalities revealed, lesions in the deep white matter were significantly associated with DNS development. Abnormal findings of the globus pallidus, cerebral cortex, MTL/hippocampus, and cerebellum were not associated with DNS development. CONCLUSION: This study demonstrates the utility of early MRI for the prediction of DNS. Future studies will be required to ascertain the prevention of DNS with hyperbaric treatment in CO poisoning.
Carbon ; Carbon Monoxide ; Carbon Monoxide Poisoning ; Cerebellum ; Cerebral Cortex ; Diffusion ; Globus Pallidus ; Humans ; Hypoxia, Brain ; Magnetic Resonance Imaging ; Magnetic Resonance Spectroscopy ; Magnetics ; Magnets ; Mood Disorders ; Multivariate Analysis ; Retrospective Studies ; Temporal Lobe

PURPOSE: Misdiagnosis of subarachnoid hemorrhage (SAH) can result in considerable mortality and morbidity. Computed tomography (CT) has high sensitivity for detection of acute SAH, but falls off rapidly over time, and approaches 0% at three weeks. The aim of this study was to conduct a comparison of magnetic resonance imaging (MRI) and CT in detection of SAH in acute and subacute, and chronic stages. METHODS: This retrospective study included 62 patients with spontaneous SAH from January 2006 to December 2011. For each patient, we obtained non-enhanced CT scans, fluid-attenuated inversion recovery (FLAIR), and T2-weighted gradient-echo (T2*) MRI images. We defined SAH based on areas of high attenuation on non-enhanced CT scans, regions of hyperintensity on FLAIR images, and regions of hypointensity on T2* images in intracranial subarachnoid spaces. In order to investigate the superiority of tools for diagnosis of SAH, comparison of sensitivity of CT scans and MRI was performed. RESULTS: Sensitivity of CT to SAH was 93.5% on the first day, but fell off rapidly with time, and approached 0% at 20 days. Sensitivity of MRI was not affected by stages and amounts of bleeding (p>0.05). Sensitivity of MRI was higher than that of CT in SAH of Fisher grade 0-1 of subacute stage of bleeding (p=0.001) and in all cases of chronic stage of bleeding (p=0.000). FLAIR images were superior to T2* images, but without statistical significance (p>0.1). CONCLUSION: MRI was superior to CT in detection of subacute and chronic SAH, as well as a small amount of SAH.
Diagnostic Errors ; Hemorrhage ; Humans ; Magnetic Resonance Imaging ; Magnetic Resonance Spectroscopy ; Magnetics ; Magnets ; Retrospective Studies ; Subarachnoid Hemorrhage ; Subarachnoid Space

PURPOSE: Most minor head injury (MHI) patients can be discharged without complication but a small percentage of these patients have intracranial lesions which can be observed by computed tomography (CT), and in these cases, neurosurgical intervention may be necessary. Selective use of the CT-scan in cases of MHI is important in reducing the risks associated with unnecessary radiation exposure. We conducted a retrospective study with the goal of creating a set of clinical criteria for deciding when to utilize the CT scan for MHI cases. METHODS: This retrospective study was conducted using 1,735 patients with MHI (GCS=15, > or =6 years old) from January 2009 to December 2010. Based on literature review results, we selected risk factors associated with the presence of intracranial lesions observable by cranial CT-scan, which may have resulted from MHI. The detection of intracranial lesions by CT scan was regarded as the primary clinical outcome. RESULTS: Of the total cases, 87(5.0%) had intracranial lesions as observed by CT scan. All patients with abnormal CT scans had at least one of the following risk factors: headache, loss of consciousness (LOC)/posttraumatic amnesia (PTA), vomiting, focal neurological deficit, coagulopathy, alcohol intoxication, skull fracture, age greater than 65 years, dangerous mechanism of injury, or facial fracture. A decision model for application of CT scanning in MHI cases was derived which consisted of 5 risk factors: headache, LOC/PTA, skull fracture, and age greater than 65 years. The decision model was 100% sensitive (95% CI, 95.8~100%) and 42.4% specific (95% CI, 40.0~44.8%) for predicting intracranial lesions, and would require only 59.8% of patients to undergo CT. CONCLUSION: The decision model developed for CT scanning in MHI cases was highly sensitive. Patients who meet the criteria of the model require evaluation by CT scan.
Amnesia ; Craniocerebral Trauma ; Headache ; Humans ; Retrospective Studies ; Risk Factors ; Skull Fractures ; Unconsciousness ; Vomiting

PURPOSE: Most minor head injury (MHI) patients can be discharged without complication but a small percentage of these patients have intracranial lesions which can be observed by computed tomography (CT), and in these cases, neurosurgical intervention may be necessary. Selective use of the CT-scan in cases of MHI is important in reducing the risks associated with unnecessary radiation exposure. We conducted a retrospective study with the goal of creating a set of clinical criteria for deciding when to utilize the CT scan for MHI cases. METHODS: This retrospective study was conducted using 1,735 patients with MHI (GCS=15, > or =6 years old) from January 2009 to December 2010. Based on literature review results, we selected risk factors associated with the presence of intracranial lesions observable by cranial CT-scan, which may have resulted from MHI. The detection of intracranial lesions by CT scan was regarded as the primary clinical outcome. RESULTS: Of the total cases, 87(5.0%) had intracranial lesions as observed by CT scan. All patients with abnormal CT scans had at least one of the following risk factors: headache, loss of consciousness (LOC)/posttraumatic amnesia (PTA), vomiting, focal neurological deficit, coagulopathy, alcohol intoxication, skull fracture, age greater than 65 years, dangerous mechanism of injury, or facial fracture. A decision model for application of CT scanning in MHI cases was derived which consisted of 5 risk factors: headache, LOC/PTA, skull fracture, and age greater than 65 years. The decision model was 100% sensitive (95% CI, 95.8~100%) and 42.4% specific (95% CI, 40.0~44.8%) for predicting intracranial lesions, and would require only 59.8% of patients to undergo CT. CONCLUSION: The decision model developed for CT scanning in MHI cases was highly sensitive. Patients who meet the criteria of the model require evaluation by CT scan.
Amnesia ; Craniocerebral Trauma ; Headache ; Humans ; Retrospective Studies ; Risk Factors ; Skull Fractures ; Unconsciousness ; Vomiting

PURPOSE: Facial fractures are highly associated with cervical spine or spinal cord injuries. Nevertheless, disagreement exists as to the actual incidence of cervical spinal trauma in conjunction with various facial fracture patterns. The purpose of this study was to evaluate the incidence of cervical spine injuries associated with various types of facial fractures. METHODS: A retrospective review from 2003 to 2009 was performed on 4440 patients with facial fractures who presented to the emergency room of our hospital. Facial fractures were grouped into thirds. Cervical spine injuries were divided into one of two groups including upper cervical injuries (C0-C2) and lower cervical injuries (C3-C7) and included fractures, dislocation, and disc herniation with or without neurological deficits. The chi-square test and multivariate logistic regression analyses were used to identify associations between facial fractures and cervical spine injuries. RESULTS: Among all patients with facial fractures, 80(1.85%) also had cervical spine injuries. Independent risk factors for cervical spine injury in patients with facial fracture were male gender (odds ratio [OR]=2.0), high velocity mechanism of injury (OR=4.0), and upper-third (OR=2.8) or combined facial fractures (OR=1.8). Cervical spine injuries increased in patients with high-force facial fractures. Fractures of the upper face were associated with an increased likelihood of lower cervical spine injuries and lower-third facial fractures were associated with an increased likelihood of having an upper cervical spine injury. CONCLUSION: Facial fractures were commonly associated with cervical spine injuries. The cervical spine must be examined carefully whenever facial injuries are present.
Dislocations ; Emergencies ; Facial Injuries ; Humans ; Incidence ; Logistic Models ; Male ; Retrospective Studies ; Risk Factors ; Spinal Cord Injuries ; Spinal Injuries ; Spine

PURPOSE: A moderate head injury (Glasgow coma scale 9-13) has the large variability of severity, which accounts for the wide variability in the progression of lesions and in outcomes. Computed tomography (CT) is the standard diagnostic method for head injury, and repeat CTs (RCTs) are often obtained in order to monitor for progression of intracranial lesions. The purpose of this study was to suggest guidelines for RCT for moderate head injury. METHODS: In this study we reviewed data for 219 patients with moderate head injury who were admitted to our hospital via the emergency department between January 2004 and December 2009. The main outcome was worse progression of the intracranial lesions on RCT and neurosurgical intervention. Univariate and multivariate analyses were done for clinical variables to identify risk factors for progression of intracranial lesions and neurosurgical operations. RESULTS: On RCT, progression of injury was seen in 30.1% of patients, and neurosurgical intervention was performed in 14.6% of patients. Sixty percent of CT progression and ninety percent of neurosurgical intervention were occurred in patients with neurological deterioration. Independent risk factors associated with neurosurgical operation were coagulopathy (OR=13.275), amount of intracranial hemorrhage (OR=8.539), Marshall diffuse injury type of III/IV (OR=4.455), and skull fracture (OR=4.495). CONCLUSION: Routine repeat CT is necessary within 6 hour and 24-48 hour post-injury in patients with moderate head injury and without neurological deterioration.
Brain Injuries ; Coma ; Craniocerebral Trauma ; Emergencies ; Head ; Humans ; Intracranial Hemorrhages ; Multivariate Analysis ; Organothiophosphorus Compounds ; Risk Factors ; Skull Fractures ; Tomography Scanners, X-Ray Computed

PURPOSE: Traumatic subarachnoid hemorrhage (TSAH) is frequently found after traumatic brain injury (TBI) and its presence is a powerful predictor for the computed tomography (CT) assessed progression of intracranial lesions. The initial CT findings of progressing intracranial lesions in patients with tSAH are poorly understood. The aim of this study was to identify the factors that may predict the progression of lesions on the initial CT scans of patients with tSAH. METHODS: We evaluated 224 patients with tSAH and who were consecutively admitted from January 1, 2004 to December 31, 2008. The CT progression, the amount of SAH, the site of SAH, the presence and volume of associated intracranial lesion and the bilaterality of lesions were examined to identify the factors to predict CT progression of lesion. The initial and "worst" CT scans were compared. The CT scan changes were classified as "any CT progression" or "significant CT progression" (changes in the Marshall score). RESULTS: Eighty-two patients with tSAH (36.6%) had some CT progression and thirty-seven patients with tSAH (16.5%) had significant CT progression among the patients with tSAH. The initial CT findings according to the Marshall classification, the amount of SAH, the site of SAH and the associated intracranial lesions were significantly related to CT progression (p<0.05). The prognostic model to predict CT evolution, which consisted of the four initial CT findings described above, had high sensitivity (96.6~100%) and a high negative predictive value (94.1~100%). The area under the receiver operating characteristic (ROC) curve for the predictive model to predict the CT assessed evolution of SAH lesions was 0.701 (95% CI, 0.633~0.770). CONCLUSION: The prognostic model to predict CT progression of SAH lesions can help emergency medicine physicians decide when to perform repeat head CT scans in patients with tSAH.
Brain Injuries ; Disease Progression ; Emergency Medicine ; Head ; Humans ; ROC Curve ; Subarachnoid Hemorrhage, Traumatic ; Tomography, X-Ray Computed

Despite aggressive management, severe emotional and physical disability or death occurs in the majority of patients with severe head injury. Significant recovery of function of impaired neuronal cells is possible if patients are rapidly and effectively resuscitated after focal or diffuse brain insults. However, if secondary insults such as hypotension, hypoxia, or intracranial hypertension occur, many vulnerable cells may be irreversibly damaged by a cerebral ischemia. The most important points in the management of traumatic brain insults are the maintenance of an adequate cerebral perfusion pressure rather than the control of intracranial hypertension as a means of averting cerebral ischemia, and recognition that aggressive hyperventilation to control increased cerebral pressure may aggravate cerebral ischemia. So it is recommended that cerebral perfusion pressure be maintained at or above 70mmHg and that use of prophylactic hyperventilation (PaCO2 < 35mmHg) should be avoided within the 1st 24 hours after brain injury.
Anoxia ; Brain ; Brain Injuries ; Brain Ischemia ; Craniocerebral Trauma* ; Emergencies* ; Emergency Service, Hospital* ; Head* ; Humans ; Hyperventilation ; Hypotension ; Intracranial Hypertension ; Neurons ; Perfusion ; Recovery of Function

PURPOSE: Prolonged emergency department (ED) lengthof-stay (LOS) may cause ED overcrowding and worse outcome in traumatic surgical critically ill patients. In this study, we examined characteristics to be associated with prolonged ED LOS, including use of CT scanning and other ED-based special procedures (eg, radiologic diagnostic tests or therapeutic procedures performed in the ED). METHODS: A retrospective cohort study was conducted at an academic medical center with 458 traumatic surgical critically ill patients from 2003 to 2004. Critical care patients were defined as those sent to the operating room (OR) or intensive care unit (ICU) directly from the ED. Information was extracted from each ED chart on use and the number of CT scanning, other special radiologic diagnostic procedures (eg, magnetic resonance imaging, angiogram, cystogram), the number of plain radiographs performed, the emergent therapeutic procedures (intubation, closed thoracotomy, central venous line), the waiting times and number of consultants called, and holding times for decision of admission. ED LOS was defined as the time from presentation until transfer to the OR or ICU. To assess the effect of multiple simultaneous factors affecting ED LOS, a Cox proportional hazard model of time-to-ED discharge was used. RESULTS: The average overall ED LOS was 256.4+/-153.2 minutes (16 to 1465 minutes). Use of special radiologic diagnostic procedures was most strongly associated with an increased ED LOS. Use of either CT scanning or emergent therapeutic procedures, the number of plain radiographs, waiting times and numbers of consultants, and holding times for decision of admission were also affected a prolonged ED LOS independently. CONCLUSION: ED-based patient management decisions such as use of CT and ED-based special diagnostic and therapeutic procedures strongly associated affected ED LOS in traumatic surgical critically ill patients.
Academic Medical Centers ; Cohort Studies ; Consultants ; Critical Care ; Critical Illness* ; Diagnostic Tests, Routine ; Emergencies* ; Emergency Service, Hospital* ; Humans ; Intensive Care Units ; Length of Stay* ; Magnetic Resonance Imaging ; Operating Rooms ; Overall ; Proportional Hazards Models ; Retrospective Studies ; Thoracotomy ; Tomography, X-Ray Computed