Journal Club

Dr. Dhiraj Prasad Jaiswal

MDGP & EM, 3^rd Year Resident

MMC, IOM

Moderator: Asso. Prof. Dr. Ramesh Kumar Maharjan

Topic

6/7/2021

Article

• Title:
• Clinical indicators for traumatic intracranial findings in mild traumatic brain injury patients
• Published by:
• Surgical Neurology International

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Summary of publication

• Received : 26 September 18
• Accepted : 06 February 19
• Published : 24 April 19

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• Digital Object Identifier (DOI):
• 10.25259/SNI-101-2019

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Authors

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Not mentioned about the qualification or designation of the author

• An open access, internet-only journal
• Not affiliated to any society or organization
• Is a double blinded peer review journal
• Publishes articles on monthly basis
• Can be downloaded freely
• Publisher: Medknows Publications and Media Pvt. Ltd

6/7/2021

Journal metrics

• Impact factor: 0.97
• Overall rank: 11428

Pros:

• Double blinded peer review
• Strong publisher

Cons:

• Low impact factor
• No association with academic society

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Why this article???

• Clearly explained the objective
• Published in a double blinded peer review journal
• Relevant in our setting
• Can be a parent article for thesis of residents
• The results could have good clinical implications

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Well structured and reflects a good summary

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Introduction

• TBI is one of the world’s significant health-care problems
• MTBI, accounting for 80% of TBI, is one of the most common conditions seen in the ED
• Early detection of intracranial injury by brain CT is the mainstay of the investigation
• Mandatory CT scans in MTBI unnecessarily waste money and time due to low yield

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Contd…

• Increase brain cancer incidence ----- 1 in 5000–1 by 10,000 for a single head CT scan in young adults
• Intended :
• find out the clinical predictors for intracranial bleeding
• represent MTBI mechanisms

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About introduction

• Pros:
• Short and precise
• Aim of objective mentioned
• Rational of this study mentioned
• References mentioned after each statement

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Methodology

• Study Design: prospective
• Sample Size: 1164 patients

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• Place of Study: Department of Maharaj Nakorn Chiang Mai Hospital and Nakornping Hospital
• the trauma centers in Chiang Mai, Thailand

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• From December 1, 2013, to January 31, 2016

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Contd…

• Inclusion criteria: patients with a history of blunt head trauma age ≥16 years and GCS 13–14 or GCS 15 with one of the following sign/symptoms:
• Headache
• Vomiting
• loss of consciousness (LOC)
• Amnesia
• diffuse headache
• sign of skull base fracture
• skull fracture palpable
• Coagulopathy
• drug of alcoholic intoxication
• previous neurosurgical procedure
• posttraumatic seizure

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Contd…

• Exclusion criteria: were injuries >24 h old and uncertain history of trauma
• Patient management:
• Patients eligible for inclusion criteria were interviewed and managed according to local guidelines for MTBI
• Patients in whom ER doctors decided to perform CT scans would proceed to CT scan and be treated as usual
• Patients that ER doctors decided to admit for observation were observed for at least 24 h

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Contd…

• Patients who were in stable condition with no sign of intracranial lesion (such as headache, nausea, and vomiting) were discharged from hospital after 24 h

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• If admitted patients had the suspected signs, he/she were sent for a CT scan and managed as indicated

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• No additional CT scan was required than usual in this study

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• Retrospective review of the CT scan reports given by neuroradiologists
• After discharge, all patients had an appointment at day 7 for follow-up and had a structured questionnaire

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Contd…

• Case definition and Outcome:
• Primary outcomes were defined ciTBI as any intracranial traumatic finding by CT scan including intracranial hemorrhage, brain edema, and depressed skull fracture

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• Secondary outcomes were neurosurgical procedures including craniotomy or craniectomy, intracranial pressure monitoring, external ventricular drainage, and elevation of skull fracture

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Contd...

• Statistical analysis:
• The association between outcomes and predicting factors was tested by Fisher’s exact test for proportional parameters and Student’s t-test and Mann–Whitney U-test for continuous data with a significance level at 0.05
• Generalized linear model regression was used for multivariable analysis
• We included all variables that had a P ≤ 0.05 for analysis and used backward stepwise method with a P > 0.05 for variable removal
• Calculations were performed with STATA software version 14.0

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Results

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Contd…

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Contd…

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Primary outcome

• Multivariate analysis done, eight predicting factors found to be associated with ciTBI
• diffuse headache, which had highest risk ratio at 3.3 (95%, CI 2.52–4.31)
• neurological deficits
• sign of skull base fracture
• GCS < 13–14 after 2-h observation
• wound at scalp
• palpable skull fracture
• dangerous mechanism
• and vomiting 2 times or more

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Secondary outcome

• Five predicting factors found to be significantly associated with the neurosurgical procedure
• diffuse headache, which had highest risk ratio (RR) at 10.04 (95%, CI 4.76–21.17)
• GCS 13–14 after 2 h
• Neurodeficit
• sign of skull base fracture
• palpable skull fracture

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About result

• Objective and results of the study are in accordance

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• Results are tabulated in simple manner and are easily understandable

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Discussion

• In MTBI patients, identification of the patients who need a CT scan is important

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• Identifying clinical predictors to predict intracranial lesions are necessary to screen the patients before CT scan

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• Predicting factors for intracranial injury in MTBI vary between studies and guidelines

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Contd…

• LOC alone in this study is not found to be the predictor of ciTBI

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• Amnesia, history of antithrombotic medication (excluding acetylsalicylic acid), previous surgery, alcohol intoxication, and seizure are predictors in some studies but not found significantly related to an intracranial lesion in our study

(Haydel MJ. The canadian CT head rule. Lancet 2001;358:1013-4.)

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Limitations

• CT rate is 40% and the rest “no ciTBI” patients are dependent on history taking on the 7th day after injury

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• Some missing data that could not obtain from patients and had to impute as “have” that risk factor (as in clinical practice).
• These imputations are < 5% which need to be mentioned

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• Further analysis to create prediction rules to predict intracranial bleeding and guidelines for MTBI model from this data is to be done in the future

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Conclusion

We found eight indicators to associate with ciTBI after MTBI which can be used to develop further clinical guidelines for computed tomography scans

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• Short and synchronous with the objective
• Further study suggested
• No definite guideline suggested

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Contd…

Financial support and sponsorship

• Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Conflicts of interest

• There are no conflicts of interest

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References

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Overall

• It is a well-written article relevant to our setting
• Objective is clearly mentioned
• Methodology is well explained
• Results are consistent with the objective
• Further study is suggested
• References are in order and well cited

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6/7/2021

THANK YOU

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