Necessity of repeat head CT and ICU monitoring in patients with minimal brain injury.

BACKGROUND: Recent publications have dismissed the need for routine repeat computed tomography (CT) scans in patients with minimal brain injury (MBI) (Glasgow Coma Scale score 13-15 with positive initial CT) unless physical examination changes. In an attempt to better allocate scarce resources, we hypothesized that not only was repeat head CT unnecessary but also routine intensive care unit (ICU) monitoring of these patients with MBI and stable examinations were unnecessary.

METHODS: All blunt injured patients admitted to a level I trauma center from January 2005 through December 2007 who met our criteria for MBI (Glasgow Coma Scale score 14-15 with positive initial CT) were reviewed. All patients had ICU monitoring and repeat CT done (at 12-24 hours) regardless of clinical examination. Patients with skull fractures, facial fractures needing urgent repair, those requiring immediate neurosurgical intervention and those with other injuries requiring ICU monitoring were excluded. Data including demographics, initial brain injury, follow-up CT scan results, changes in clinical examination, neurosurgical interventions, and ICU days were recorded.

RESULTS: Two hundred seven patients met criteria. Fifty-eight patients (28%) developed worsening findings on follow-up CT or examination. Eighteen required invasive neurosurgical intervention (6 intracranial pressure [ICP] monitors, 12 craniotomies) and 1 died (stroke). Those requiring ICP monitors had worsening intracranial hemorrhages (IPHs) with clinical examination changes or examination changes only, whereas those requiring craniotomy had worsening subarachnoid hemorrhage (2 patient), epidural hematoma (1 patient), and subdural hematoma (8 patients). Five of the subdural hematoma patients remained asymptomatic before craniotomy. ICU days were significantly increased in those patients with worsening CT findings who did not require neurosurgical intervention compared with those patients with unchanged or improved CT scans (5 days vs. 2.7 days, p < or = 0002).

CONCLUSIONS: Routine follow-up CT scans are beneficial in those patients with MBI and may lead to higher levels of medical management or neurosurgical intervention in patients with worsening CT findings. These patients should be kept in an ICU setting until head CT has stabilized. With these dissimilar results from previous studies, a prospectively randomized multicentered trial would be beneficial.