BACKGROUND: The routine transfer of mild to moderate traumatic brain injuries (TBIs) to trauma centers with neurosurgical capabilities has recently been re-evaluated. The Brain Injury Guidelines (BIG) were developed to categorize TBI patients into three categories (BIG-1, BIG-2, and BIG-3), each representing a progressively increasing risk of clinical deterioration. This classification system has been previously validated at both level I and level III trauma centers. The authors hypothesized the population of their rural level II trauma center would further validate the BIG criteria.
METHODS: Using the institutional trauma registry, a retrospective analysis was performed on all patients with isolated TBIs who presented to our rural level II trauma center from 2018 to 2022. Patients were categorized according to the previously validated BIG criteria. All head computed tomography (CT) imaging studies were reviewed by one neurosurgeon. Outcomes and adverse events were compared to previously published data.
RESULTS: Four hundred fifty four patients were captured with our inquiry; 138 matched BIG-1 criteria, 51 matched BIG-2 criteria, and 263 matched BIG-3 criteria. Two patients in BIG-1 (6%) and two patients in BIG-2 (12.5%) showed progression of their bleed on CT. No patients in BIG-1 or BIG-2 groups, including those showing progression on repeat CT, required a neurosurgical intervention.
CONCLUSIONS: Our results support the suppositions of the BIG authors who suggest patients categorized as BIG-1 or BIG-2 do not require repeat head CT scans, neurosurgery consultation, or transfer to a tertiary center.

BACKGROUND: Emergency Department (ED) Observation Units (OU) can provide safe, effective care for low risk patients with intracranial hemorrhages. We compared current ED OU use for patients with subdural hematomas (SDH) to the validated Brain Injury Guidelines (BIG) to evaluate the potential impact of implementing this risk stratification tool.
METHODS: Retrospective cohort of patients ≥18 years old with SDH of any cause from 2014 to 2020 to evaluate for potential missed OU cases. Missed OU cases were defined as patients with an initial Glasgow Coma Score (GCS) of 15 with hospital length of stays (LOS) <2 days, who did not meet the composite outcome and were not cared for in the OU or discharged from the ED. Composite outcome included in-hospital death or transition to hospice care, neurosurgical intervention, GCS decline, and worsening SDH size. Secondary outcomes were whether application of BIG would increase ED OU use or reduce CT use.
RESULTS: 264 patients met inclusion criteria over 5.3 year study timeframe. Mean age was 61 years (range 19-93) and 61.4% were male. SDH were traumatic in 76.9% and 60.2% of the cohort had additional injuries. The admission rate was 81.4% (n = 215). Fourteen (6.5%) missed OU cases were identified (2.6/year). Retrospective application of BIG resulted in 82.6% (n = 217) at BIG 3, 10.2% (n = 27) at BIG 2 and 7.6% (n = 20) at BIG 1. Application of BIG would not have decreased admission rates (82.6% BIG 3) and BIG 1 and 2 admissions were often for medical co-morbidities. The composite outcome was met in 50% of BIG 3, 22% of BIG 2, and no BIG 1 patients.
CONCLUSIONS: In a level 1 trauma center with an established observation unit, current clinical care processes missed very few patients who could be discharged or placed in ED OU for SDH. Hospital admissions in BIG 1/2 were driven by co-morbidities and/or injuries, limiting applicability of BIG to this population.

The primary aim was to evaluate the compliance of cranial CT indication with the national guideline-based decision rules in patients after mTBI. The secondary aim was to determine the incidence of CT pathologies among justified and unjustified CT scans and to investigate the diagnostic value of these decision rules. This is a retrospective, single-center study on 1837 patients (mean age = 70.7 years) referred to a clinic of oral and maxillofacial surgery following mTBI over a five-year period. The current national clinical decision rules and recommendations for mTBI were retrospectively applied to calculate the incidence of unjustified CT imaging. The intracranial pathologies among the justified and unjustified CT scans were presented using descriptive statistical analysis. The performance of the decision rules was ascertained by calculating the sensitivity, specificity, and predictive values. A total of 123 intracerebral lesions were radiologically detected in 102 (5.5%) of the study patients. Most (62.1%) of the CT scans strictly complied with the guideline recommendations, and 37.8% were not justified and likely avoidable. A significantly higher incidence of intracranial pathology was observed in patients with justified CT scans compared with patients with unjustified CT scans (7.9% vs. 2.5%, p < 0.0001). Patients with loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures presented pathologic CT findings more frequently (p < 0.05). The decision rules identified CT pathologies with 92.28% sensitivity and 39.08% specificity. To conclude, compliance with the national decision rules for mTBI was low, and more than a third of the CT scans performed were identified as \"likely avoidable\". A higher incidence of pathologic CT findings was detected in patients with justified cranial CT imaging. The investigated decision rules showed a high sensitivity but low specificity for predicting CT pathologies.

BACKGROUND: The Scandinavian Neurotrauma Committee (SNC) has recommended the use of serum S100B as a biomarker for mild low-risk Traumatic brain injuries (TBI). This study aimed to assess the adherence to the SNC guidelines in clinical practice and the diagnostic performance of S100B in patients with TBI. The aims of this study were to examine adherence to the SNC guideline and the diagnostic accuracy of serum protein S100B.
METHODS: Data of consecutive patients of 18 years and above who presented to the emergency department (ED) at Helsingborg Hospital with isolated head injuries, were retrieved from hospital records. Patients with multitrauma, follow-up visits, and visits managed by a nurse without physician involvement were excluded.
RESULTS: A total of 1671 patients were included of which 93 (5.6%) had intracranial hemorrhage. CT scans were performed in 62% of patients. S100B was measured in 26% of patients and 30% of all measurements targeted the low-risk mild head injuries indicated by the guideline. S100B\'s recommended cut-off value (≥ 0.10 µg/L) had a 100% sensitivity, 47% specificity, 10.1% positive predictive value, and 100% negative predictive value-if applied to the target SNC category (SNC 4). If applied to all patients tested, the sensitivity was 93% for traumatic intracranial hemorrhage (TICH). Current ED practices were adherent to the SNC guideline in 55% of patients. Non-adherent practices occurred in 64% of patients with low-risk mild head injuries (SNC4) including overtesting or undertesting of S100B and CT scans.
CONCLUSIONS: Adherence to guidelines was low and associated with a higher admission rate than non-adherence practice but no significant increase in missed TICH or death associated with non-adherence to guideline was found. In routine care, we found that the sensitivity and NPV of serum protein S100B was excellent and safely ruled out TICH when measured in the patient category recommended by the guideline. However, measuring serum protein S100B in patients not recommended by the guideline rendered unacceptably low sensitivity with possible missed TICHs as a consequence. To further delineate the magnitude and impact of non-adherence, more studies are needed.

暂无摘要。

OBJECTIVE: Approximately 10% of patients with mild traumatic brain injury (mTBI) have intracranial bleeding (complicated mTBI) and 3.5% eventually require neurosurgical intervention, which is mostly available at centers with a higher level of trauma care designation and often requires interhospital transfer. In 2018, the Brain Injury Guidelines (BIG) were updated in the United States to guide emergency department care and patient disposition for complicated mild to moderate TBI. The aim of this study was to validate the sensitivity and specificity of the updated BIG (uBIG) for predicting the need for interhospital transfer in Canadian patients with complicated mTBI.
METHODS: This study took place at three level I trauma centers. Consecutive medical records of patients with complicated mTBI (Glasgow Coma Scale score 13-15) who were aged ≥ 16 years and presented between September 2016 and December 2017 were retrospectively reviewed. Patients with a penetrating trauma and those who had a documented cerebral tumor or aneurysm were excluded. The primary outcome was a combination of neurosurgical intervention and/or mTBI-related death. Sensitivity and specificity analyses were performed.
RESULTS: A total of 477 patients were included, of whom 8.4% received neurosurgical intervention and 3% died as a result of their mTBI. Forty patients (8%) were classified as uBIG-1, 168 (35%) as uBIG-2, and 269 (56%) as uBIG-3. No patients in uBIG-1 underwent neurosurgical intervention or died as a result of their injury. This translates into a sensitivity for predicting the need for a transfer of 100% (95% CI 93.2%-100%) and a specificity of 9.4% (95% CI 6.8%-12.6%). Using the uBIG could potentially reduce the number of transfers by 6% to 25%.
CONCLUSIONS: The patients in uBIG-1 could be safely managed at their initial center without the need for transfer to a center with a higher level of neurotrauma care. Although the uBIG could decrease the number of transfers, further refinement of the criteria could improve its specificity.

OBJECTIVE: To determine and compare the sensitivity, specificity, and proportion of patients eligible for discharge by the Brain Injury Guidelines and the Mild TBI Risk Score in patients with mild traumatic brain injury and concomitant intracranial injury.
METHODS: Retrospective review of the medical records of adult patients with traumatic intracranial injuries and an initial Glasgow Coma Scale score of 14-15, who sought care at Helsingborg Hospital between 2014/01/01 and 2019/12/31. Both guidelines were theoretically applied. The sensitivity, specificity, and percentage of the cohort that theoretically could have been discharged by either guideline were calculated. The outcome was defined as death, in-hospital intervention, admission to the intensive care unit, requiring emergency intubation due to intracranial injury, decreased consciousness, or seizure within 30 days of presentation.
RESULTS: Of the 538 patients included, 8 (1.5%) and 10 (1.9%) were eligible for discharge according to the Brain Injury Guidelines and the Mild TBI Risk Score, respectively. Both guidelines had a sensitivity of 100%. The Brain Injury Guidelines had a specificity of 2.3% and the Mild TBI Risk Score had a specificity of 2.9%.
CONCLUSIONS: There was no difference between the two guidelines in sensitivity, specificity, or proportion of the cohort eligible for discharge. Specificity and proportion of cohort eligible for discharge were lower than each guideline\'s original study. At present, neither guideline can be recommended for implementation in the current or similar settings.

Infection with the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leads to a previously unknown clinical picture, which is known as COVID-19 (COrona VIrus Disease-2019) and was first described in the Hubei region of China. The SARS-CoV-2 pandemic has implications for all areas of medicine. It directly and indirectly affects the care of neurological diseases. SARS-CoV-2 infection may be associated with an increased incidence of neurological manifestations such as encephalopathy and encephalomyelitis, ischemic stroke and intracerebral hemorrhage, anosmia and neuromuscular diseases. In October 2020, the German Society of Neurology (DGN, Deutsche Gesellschaft für Neurologie) published the first guideline on the neurological manifestations of the new infection. This S1 guideline provides guidance for the care of patients with SARS-CoV-2 infection regarding neurological manifestations, patients with neurological disease with and without SARS-CoV-2 infection, and for the protection of healthcare workers. This is an abbreviated version of the guideline issued by the German Neurological society and published in the Guideline repository of the AWMF (Working Group of Scientific Medical Societies; Arbeitsgemeinschaft wissenschaftlicher Medizinischer Fachgesellschaften).

Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC.
A retrospective chart review of a Level I Adult and Pediatric Trauma Center\'s pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included.
Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I.
Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.

The American Stroke Association and the European Stroke Organization have established guidelines on cerebral venous thrombosis (CVT); however, questions remain when an individual case does not fall within the inclusion criteria on which these guidelines are based. This is relevant when considering the use of anticoagulation in cases of CVT regarding whether or not associated hemorrhage is present and whether the hemorrhage is currently expanding.
A 16-year-old right-handed female G2P2 (gravidity 2 [2 pregnancies] and parity 2 [2 live births after at least 24 weeks) presented 8 days postpartum with complaints of slurred speech, right facial droop, and right upper extremity numbness that had progressed over the course of 4 hours before presentation. On imaging the patient had a CVT with associated hemorrhage progressing in size at serial 6-hour stability computed tomography scans for 24 hours post arrival. At 24 hours the patient went into disseminated intravascular coagulation and demonstrated signs of herniation. The patient underwent an emergency hemicraniectomy along with a right frontal external ventricular drain for intracranial pressure monitoring. Most recently, the patient had a Glasgow Coma Scale score of 15 and had a modified Rankin Scale score of 4 and was ultimately discovered to have antiphospholipid syndrome.
This case of CVT demonstrates the need for critically reading guidelines, as in this case the time to anticoagulation treatment was shorter than in cases included in guideline construction and repeated computed tomography examination demonstrated expansion suggesting it is unsuitable for immediate anticoagulation. Certain cases may fall outside of the study parameters on which guidelines are constructed, and clinicians should be aware of these exceptions.