Abstract
It has been reported that various clinical criteria indicate computed tomography (CT) examination for mild head injury (MHI). However, the decision to perform CT for MHI largely depends on the physician. Data on severe head injuries is available in sources such as the Japan Neurotrauma Data Bank, but only a few data has been collected on MHI. A total of 1688 patients with MHI (Glasgow Coma Scale 14 and 15) treated at our hospital from June 2017 to May 2019 were reviewed. CT was performed in 1237 patients (73.28%), and intracranial hemorrhage was detected in 50 patients. Three patients deteriorated, and all were surgically treated. Statistical analysis of the presence or absence of acute intracranial hemorrhage and “risk factors for complications of intracranial lesions in MHI” showed significant differences in unclear or ambiguous accident history (p = 0.022), continued post-traumatic amnesia (p < 0.01), trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture) (p = 0.012), age <60 years (p < 0.01), coagulation disorders (p < 0.01), and alcohol or drug intoxication (p < 0.01). The 453 patients who did not satisfy these risk factors included only one patient with intracranial hemorrhage, so the negative predictive value was 99.78%. This study shows that the “risk factors for complications of intracranial lesions in MHI” are effective criteria for excluding acute intracranial hemorrhage and CT should be actively considered for patients with the above factors that showed significant differences.
Keywords: mild head injury, computed tomography (CT), acute intracranial lesions
Introduction
Mild head injury (MHI) is the most commonly encountered pathology in neurosurgical emergency care. It is defined as a level of consciousness assessed at presentation of Japan Coma Scale of 0-3 and Glasgow Coma Scale (GCS) of 13-15. The most important treatment consideration for a physician who examines a patient with MHI is to decide whether the patient can be allowed home or should be hospitalized. Computed tomography (CT) should be considered to avoid the risk of overlooking acute intracranial lesions. It has been reported that various criteria indicate CT for MHI. The European Federation of Neurological Societies (EFNS) guidelines1) and the Canadian CT Head Rule (CCHR)2) are well known, as are Pediatric Emergency Care Applied Research Network (PECARN)3) and Children's Head Injury Algorithm for the Prediction of Important Clinical Events (National Institute for Health and Care Excellence 2014 guideline)4) for children. Based on these proposals, various CT indications for MHI have been studied.5-12) The examining physician's decision to perform head CT largely depends on the mechanism of injury, symptoms, and neurological findings. Head CT of a patient with MHI can easily determine the presence or absence of intracranial hemorrhage, but unnecessary head CT can lead to an increase in radiation exposure and financial burden on the medical economy. In particular, Japan has the highest number of CT facilities in the world at 107 units per million people, according to the Organization for Economic Co-operation and Development, and has universal health insurance. Consequently, the threshold for undergoing head CT is low. Screening criteria for head CT must be highly sensitive to ensure patient safety and minimize treatment costs. Population characteristics in Japan are different from those in Europe and North America, such as more falls and injury due to the increasing number of elderly people, and outdoor drunkenness, so overseas standards are not really suitable in general to establish the indications for CT in patients with MHI. The Japanese guidelines for head injury treatment and management published in 2019 list 13 factors as “risk factors for complications of intracranial lesions in mild head injury,” which were created with reference to the EFNS and CCHR. These 13 factors are not complicated to assess and are easy to use even in emergency situations. Therefore, these factors can be considered as a good indicator for deciding whether to perform CT to determine intracranial hemorrhage if the negative predictive value is high. Data on severe head injury is available in sources such as the Japan Neurotrauma Data Bank, but only a few data has been collected on MHI. Therefore, we reviewed cases of MHI seen at our hospital in patients with head injury. Based on this data, we analyzed the 13 factors listed as “risk factors for complications of intracranial lesions in mild head injury” in the Japanese guidelines for head injury treatment and management.
Materials and Methods
This retrospective observational study analyzed data collected during medical treatment at a single medical institution. Our hospital is located near residential and downtown areas and receives 2-3 head injury patients per day on average. These head injuries are caused by various incidents, such as falls, traffic injury, sports injury, assaults, and abuse, and many falls are caused by alcohol consumption. Our hospital is located in an area with a population of approximately 1.6 million people. The age distribution of the population is similar to that of the general Japanese population, with 10.8% aged under 15 years, 66.0% aged 15-64 years, and 23.2% aged 65 years or older. Based on these characteristics, our hospital was considered suitable for collecting a small but representative number of head injury cases over a 2-year period.
We entered data on every case of head injury treated at our hospital as part of a prospective observational study (cohort study). As a result, 1823 cases of head injury were seen at our hospital from June 2017 to May 2019, including 1688 cases of MHI (GCS 14 and 15). The patients with GCS 13 were excluded from the MHI subjects in this study. GCS 13 is often associated with intracranial hemorrhage and deterioration5,13) and is also excluded from MHI in Japan Advanced Trauma Evaluation and Care and Scandinavian guidelines.14) Neurosurgeons are involved in all MHI cases at our hospital from the initial response. The necessity of head CT was evaluated in the 1688 cases of MHI. The presence or absence of intracranial hemorrhage in the acute phase was evaluated as an indicator. Diagnoses of intracranial hemorrhage included “intracerebral,” “extradural,” “subdural,” “subarachnoid,” or “intraventricular hemorrhage” and “cerebral contusion.” A statistical study was conducted on the “risk factors for complications of intracranial lesions in mild head injury” (Table 1). Cases that satisfied at least one factor from (1) to (13) were considered “indicated for CT,” and those that did not were considered “not indicated for CT.” Factor (10) specifies age <60 years, whereas the CCHR found that age above 65 years is a risk factor. In contrast, the standard for elderly people in Japan is over 65 and 75 years for early and late elderly people, respectively, in the Act on Securing Medical Care for Persons (Act No. 80 of 1981). Therefore, age over 65 years was specified as a factor. Factor (11) “coagulation disorders” included history of taking anticoagulants and antiplatelet drugs and abnormalities such as D-dimer levels in blood examinations. According to Advanced Trauma Life Support principles, Factor (12) “High-energy accident” is defined as initial speed >64 km/h, major auto-deformity, intrusion into passenger compartment >30 cm, extrication time from vehicle >20 min, falls >6 m, rollover, auto-pedestrian accidents, or motorcycle crash >32 km/h or with separation of rider and bike.1)
Table 1.
Risk factors for complications of intracranial lesions in mild head injury
| ① | Unclear or ambiguous accident history |
| ② | Continued post-traumatic amnesia |
| ③ | Retrograde amnesia longer than 30 min |
| ④ | Trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture) |
| ⑤ | Severe headache |
| ⑥ | Vomiting |
| ⑦ | Focal neurological deficit |
| ⑧ | Seizure |
| ⑨ | Age <2 years |
| ⑩ | Age >60 (the Canadian CT head rule found that age above 65 is a risk factor) |
| ⑪ | Coagulation disorders |
| ⑫ | High-energy accident |
| ⑬ | Alcohol or drug intoxication |
The Shapiro-Wilk test was used to test the normal distribution of the data. Data following a normal distribution is expressed as the mean value ± standard deviation. Student's t-test and Fisher's exact test were used for analysis of study items (1) to (13). Multivariate analysis used intracranial hemorrhage as the dependent variable, and logistic regression analysis was performed using six factors with a large number of cases in “risk factors for complications of intracranial lesions in mild head injury.” The significance level was set at less than 5%. EZR (R version 4.0.2) was used for statistical analysis. This study was conducted with the approval of the Nihon University School of Medicine Ethics Committee (RK-170509-2). Information about the study was made public, and the medical information collected was analyzed after allowing opting out with a clear opportunity to refuse. The collected data was anonymized and stored with sufficient care to prevent leakage of personal information.
Results
This study excluded GCS 13 as a MHI. Our hospital's data showed that patients with GCS 13 more likely have intracranial lesions than those with GCS 14 and 15 and more patients deteriorated (Table 2). Therefore, GCS 13 was excluded from MHI.
Table 2.
Comparison of GCS 13 and GCS 14 and 15 in the intracranial bleeding and deterioration
| GCS 14, 15 | GCS 13 | P-value | |
|---|---|---|---|
| Intracranial bleeding | 50 | 14 | 0.005* |
| No intracranial bleeding | 1638 | 7 | |
| Deterioration | 3 | 5 | 0.00086* |
| No deterioration | 1685 | 16 |
* p < 0.05.
The breakdown by age of the 1688 MHI cases (GCS 14 and 15) was as follows: under 2 years, 260 (15.40%); from 2 years to 65 years, 859 (50.89%); and over 65 years, 569 (33.71%). CT was performed in 1237 patients (73.28%): aged under 2 years, 107 (41.15%); under 65 years, 595 (69.27%); and over 65 years, 535 (94.02%). The 50 cases had intracranial bleeding: aged under 2 years, 2 (0.77%); under 65 years, 19 (2.21%); and over 65 years, 29 (5.10%). The 3 cases deteriorated: aged under 2 years, 0 (0%); under 65 years, 1 (0.12%); and over 65 years, 2 (0.35%). Univariate analysis of the 1688 MHI cases (GCS 14 and 15) for the presence or absence of intracranial lesions and “risk factors for complications of intracranial lesions in mild head injury” showed significant differences in unclear or ambiguous accident history (p = 0.022), continued post-traumatic amnesia (p < 0.01), trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture) (p = 0.012), age > 65 years (p < 0.01), coagulation disorders (p < 0.01), and alcohol or drug intoxication (p < 0.01) (Table 3). Multivariate analysis showed significant differences in vomiting (p < 0.05, odds ratio [OR] 3.24, 95% confidence interval [CI] 1.26-8.35), age >65 years (p < 0.05, OR 1.97, 95% CI 1.03-3.78), coagulation disorders (p < 0.01, OR 3.75, 95% CI 1.82-7.70), and alcohol or drug intoxication (p < 0.05, OR 2.52, 95% CI 1.11-5.68) (Table 4). We also considered “no indication for CT” in 453 cases that did not meet “risk factors for complications of intracranial lesions in mild head injury,” but only one patient had intracranial hemorrhage, so the negative predictive value was 99.78%.
Table 3.
Univariate analysis of the 1688 MHI cases (GCS 14 and 15) for the presence or absence of intracranial lesions and “risk factors for complications of intracranial lesions in mild head injury”
| Intracranial bleeding | No intracranial bleeding | P-value | ||
|---|---|---|---|---|
| Age1 | 61.500 ± 25.674 | 38.8130 ± 33.46601 | 0.000000120* | |
| Male/female2 | 957/730 | 31/19 | 926/711 | 0.472 |
| Unclear or ambiguous accident history2 | Y | 3 | 18 | 0.0223* |
| N | 47 | 1620 | ||
| Continued post-traumatic amnesia2 | Y | 10 | 74 | 0.000112* |
| N | 40 | 1559 | ||
| Retrograde amnesia longer than 30 min2 | Y | 1 | 8 | 0.238 |
| N | 49 | 1630 | ||
| Trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture) 2 | Y | 2 | 4 | 0.0120* |
| N | 48 | 1634 | ||
| Severe headache2 | Y | 3 | 179 | 0.357 |
| N | 47 | 1459 | ||
| Vomiting2 | Y | 6 | 109 | 0.148 |
| N | 44 | 1529 | ||
| Focal neurological deficit2 | Y | 1 | 12 | 0.325 |
| N | 49 | 1626 | ||
| Seizure2 | Y | 0 | 8 | 1 |
| N | 50 | 1630 | ||
| Age <2 years2 | Y | 2 | 258 | 0.191 |
| N | 19 | 840 | ||
| Age <60 (the Canadian CT head rule found that age above 65 is a risk factor) 2 | Y | 29 | 540 | 0.00405* |
| N | 19 | 840 | ||
| Coagulation disorders2 | Y | 13 | 91 | 0.00000457* |
| N | 37 | 1547 | ||
| High-energy accident2 | Y | 0 | 1 | 1 |
| N | 50 | 1637 | ||
| Alcohol or drug intoxication2 | Y | 8 | 93 | 0.00830* |
| N | 42 | 1541 |
1. Student t-test, 2. Fisher’s exact test, * p < 0.05, Y: yes, N: no
Table 4.
Multivariate analysis using these significant factors of univariate analysis for the presence or absence of intracranial lesions and “risk factors for complications of intracranial lesions in mild head injury”
| Odds ratio | 95% confidence interval | P-value | ||
|---|---|---|---|---|
| Severe headache | 0.712 | 0.248 | 2.05 | 0.528 |
| Vomiting | 3.24 | 1.26 | 8.35 | 0.015* |
| Age <2 years | 0.33 | 0.0752 | 1.45 | 0.142 |
| Age >60 (the Canadian CT head rule found that age above 65 is a risk factor) | 1.97 | 1.03 | 3.78 | 0.04* |
| Coagulation disorders | 3.75 | 1.82 | 7.7 | 0.0003* |
| Alcohol or drug intoxication | 2.52 | 1.11 | 5.68 | 0.026* |
* p < 0.05.
Discussion
Consideration of GCS 13
The inclusion of GCS 13 in MHI is still undecided. GCS 13 frequently presents with intracranial hemorrhage, and many cases of deterioration require surgery.5) The MHI in Japan Advanced Trauma Evaluation and Care and Scandinavian guideline is GCS 14 and 15.14) Our hospital's data included significantly more cases of intracranial lesions and deterioration as shown in Table 4; therefore, we concluded that GCS 13 should not be treated as MHI. All 21 cases of GCS 13 at our hospital were associated with disorientation, which resulted in deduction of points for best verbal response. Moreover, GCS 14 shows a significant correlation between best verbal response score and presence of intracranial lesions (p = 0.00012 < 0.01, OR 15.53, 95% CI 3.18-90.15). Such disorientation resulting in reduced score for best verbal response on the GCS was one of the factors predicting intracranial lesions.
Consideration of the elderly
The “risk factors for complications of intracranial lesions in mild head injury” indicate CT investigation for all patients aged over 65 years due to the intracranial hemorrhage.
The “risk factors for complications of intracranial lesions in mild head injury” show that patients aged over 60 years (65 years) are at risk. Univariate analysis found that age >60 years (CCHR found that age above 65 years is a risk factor) was associated with a significant risk of intracranial hemorrhage. Patients aged over 60 years (65 years) more likely have declining physical strength and a history of disease or take oral antithrombotic drugs than younger patients.15,16) However, 65- and 85-year-old patients cannot be considered together. The Japan Sports Agency's Physical Fitness and Athletic Abilities Survey in 2015 reported that physical fitness test scores are increasing for subjects aged 65-69, 70-74, and 75-79 years and equivalent fitness are 5 years younger compared to 2000. The Japan Geriatrics Society and The Japan Federation of Gerontological Societies in 2017 classified the subjects aged 65-74 years, 75-89 years, and 90 years or older as “semi-elderly,” “elderly,” and “very elderly,” respectively. The background to this classification is that rejuvenation of the physical abilities of the elderly has been confirmed, so defining all subjects over 65 years as the elderly seemed inappropriate. Therefore, the elderly were categorized as 65-74 years, 75-89 years, and 90 years or older. In this categorization of the elderly, factors other than (under 2 years and over 65 years) among the “risk factors for complications of intracranial lesions in mild head injury” and the “indication for CT” were examined.
This study included 569 patients aged over 65 years (65-74 years, 166; 75-89 years, 325; and 90 years or older, 78). Patients included in the “indication for CT” were 67 aged 65-74 years (39.76%), 126 aged 75-89 years (38.77%), and 19 aged 90 years or older (23.08%). CT was performed in 156 aged 65-74 years (93.98%), 306 aged 75-89 years (94.15%), and 73 aged 90 years or older (93.59%). In each age category, CT was performed in most included in “no indication for CT.” Intracranial hemorrhage was detected in 8 patients aged 65-74 years, 19 aged 75-89 years, and 2 aged 90 years or older. Fisher's exact test was performed on the risk of intracranial hemorrhage for patients aged 65-74 years, 75-89 years, and 90 years or older, but there was no significant difference (p = 0.511). Logistic regression analysis with intracranial hemorrhage as the dependent variable and age (65-74 years, 75-89 years, 90 years or older) and “risk factors for complications of intracranial lesions in mild head injury” as independent variables found that unclear or ambiguous accident history (p < 0.01, OR 11.30, 95% CI 2.03-62.80) and coagulation disorders (p < 0.01, OR 5.16, 95% CI 2.19-12.20) showed significant differences, but age (p = 0.49, OR 1.02, 95% CI 0.96-1.07) did not show significant differences.
Patients aged over 65 years more likely have intracranial hemorrhage than those aged under 65 years in univariate analysis, so aged over 65 years should be considered a risk factor for intracranial hemorrhage. The negative predictive value of “no indication for CT” was 97.78% (65-74 years), 98.37% (75-89 years), and 100% (90 years or older), which were all as high as for pediatric patients. However, intracranial hemorrhage was found in two patients aged 65-74 years and three aged 75-89 years in “no indication for CT,” which does not apply to the category “risk factors for complications of intracranial lesions in mild head injury.” Thin acute subdural hematoma or traumatic subarachnoid hematoma was found in all these cases, and conservative treatment was performed without deterioration. Therefore, intracranial hemorrhage cannot be completely excluded even in patients not included in the “risk factors for complications of intracranial lesions in mild head injury” in the elderly, and severe head injury causing deterioration and that requires surgery may occur. We consider that CT is useful in identifying severe head injury cases at risk of deterioration and that subsequently require surgery.
Risk factors for complications of intracranial lesions in mild head injury
The 13 factors included in the “risk factors for complications of intracranial lesions in mild head injury” have a very high negative predictive value of 99.78% in all cases and are good criteria for ruling out intracranial hemorrhage. Since the “risk factors for complications of intracranial lesions in mild head injury” are intended only to rule out intracranial hemorrhage, high sensitivity or positive predictive value is not necessary. In recent years, biomarkers such as S100B, interleukin-10, blood glucose level, glial fibrillary acidic protein, and ubiquitin carboxy-terminal hydrolase L1 from blood and cerebrospinal fluid samples have been used to determine intracranial hemorrhage and deterioration without imaging examinations.17-21) If investigations of factors other than imaging examinations, such as biomarkers, can be applied in clinical practice, the risk of radiation exposure may be avoided. However, patients with MHI are often seen in small hospitals that do not have facilities for these specific examinations, so determination of intracranial hemorrhage from biomarkers is unrealistic without imaging examinations. Multivariate analysis of our hospital data found that unclear or ambiguous accident history, continued post-traumatic amnesia, trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture), and coagulation disorders were significant factors. If these characteristics are observed, CT may be actively recommended. Coagulation disorders are an important factor, especially in the elderly, as the use of antithrombotic drugs has increased since the early 2000s based on the EFNS and CCTR.16,22) Artificial intelligence (AI) has also been investigated to determine the need for CT in MHI.23) In the future, AI based on various studies will be used to determine whether or not head CT should be performed. Meanwhile, the “risk factors for complications of intracranial lesions in mild head injury” examined in this study are very simple and are effective for deteriorating intracranial hemorrhage.
Limitation
The detection of intracranial hemorrhage and the negative predictive value apply only for cases in which CT was performed. We cannot deny the possibility that intracranial hemorrhage had occurred in cases in which CT was not performed. However, even in cases in which CT was not performed and patients were sent home, we always supply written precautions to take after MHI. Of the 451 cases in which CT was not performed, 71 underwent follow-up examination (including suture removal), but none showed any worsening of symptoms. Regarding pediatrics, there are some reports of effects due to radiation exposure.24,25) There are CT implementation standards such as PECARN, CHALLICE, and CATDH, so further consideration is required taking these into account.
Conclusion
The 13 factors in the Japanese guidelines for head injury treatment and management, “risk factors for complications of intracranial lesions in mild head injury,” had a very high negative predictive value of 99.78% in patients with MHI at our hospital. Therefore, these are good criteria for ruling out intracranial hemorrhage. In addition, “vomiting,” “age >65 years,” “coagulation disorders,” “alcohol or drug intoxication,” and, especially in elderly people over 65 years, “unclear or ambiguous accident history” and “coagulation disorders” were significant factors indicating the risk of intracranial hemorrhage, so CT should be performed in these patients.
Abbreviations
EFNS: The European Federation of Neurological Societies
CT: computer tomography
GCS: Glasgow Coma Scale
MHI: mild head injury
PECARN: Pediatric Emergency Care Applied Research Network
Conflicts of Interest Disclosure
All authors declare no conflicts of interest. All Japan Neurosurgical Society members and authors have online self-reported COI Disclosure Statement Forms through the website.
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