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Performance of the Canadian CT Head Rule and the New Orleans Criteria in predicting clinically significant head CT findings in the overall population.
Source publication
Study objective:
The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention...
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Citations
... 6 7 Comparative studies have examined various clinical tools, most notably the New Orleans Criteria and the CCHR, revealing that although both demonstrate similar sensitivity, the CCHR generally provides greater specificity. [8][9][10] Several studies have shown that the CCHR achieves 100% sensitivity in identifying neurosurgical needs and captures significant CT findings, offering greater specificity (36-65%) compared with other decision rules. [9][10][11] The National Institute for Health and Care Excellence (NICE) has guidelines that largely follow the CCHR to determine when to perform CT scans in cases of head injury. ...
... [8][9][10] Several studies have shown that the CCHR achieves 100% sensitivity in identifying neurosurgical needs and captures significant CT findings, offering greater specificity (36-65%) compared with other decision rules. [9][10][11] The National Institute for Health and Care Excellence (NICE) has guidelines that largely follow the CCHR to determine when to perform CT scans in cases of head injury. 12 This approach is supported by evidence showing that the CCHR rule is the most cost-effective among various decision rules evaluated. ...
Introduction
Traumatic brain injury (TBI) is a common presentation in the prehospital environment. At present, paramedics do not routinely use tools to identify low-risk patients who could be left at scene or taken to a local hospital rather than a major trauma centre. The Canadian CT Head Rule (CCHR) was developed to guide the use of CT imaging in hospital. It has not been evaluated in the prehospital setting. We aim to address this gap by evaluating the feasibility and acceptability of implementing the CCHR to patients and paramedics, and the feasibility of conducting a full-scale clinical trial of its use.
Methods and analysis
We will recruit adult patients who are being transported to an emergency department (ED) by ambulance after suffering a mild TBI. Paramedics will prospectively collect data for the CCHR. All patients will be transported to the ED, where deferred consent will be taken and the treating clinician will reassess the CCHR, blinded to paramedic interpretation. The primary clinical outcome will be neurosurgically significant TBI. Feasibility outcomes include recruitment and attrition rates. We will assess acceptability of the CCHR to paramedics using the Ottawa Acceptability of Decision Rules Instrument. Interobserver reliability of the CCHR will be assessed between paramedics and the treating clinician in the ED. Participating paramedics and patients will be invited to participate in semistructured interviews to explore the acceptability of trial processes and facilitators and barriers to the use of the CCHR in practice. Data will be analysed thematically. We anticipate recruiting approximately 100 patients over 6 months.
Ethics and dissemination
This study was approved by the Health Research Authority and the Research Ethics Committee (REC reference: 22/NW/0358). The results will be published in a peer-reviewed journal, presented at conferences and will be incorporated into a doctoral thesis.
Trial registration number
ISRCTN92566288 .
... However, mild TBI is also the most common form of head injuries reported in hospitals. [6,7]. Mild TBI constitute about 80-90% of all TBIs, and may have intracranial pathologies requiring neurosurgical intervention in about 10% of cases, 1% of which could be life-threatening [8]. ...
... Mild TBI constitute about 80-90% of all TBIs, and may have intracranial pathologies requiring neurosurgical intervention in about 10% of cases, 1% of which could be life-threatening [8]. The "need for neurosurgical intervention" is defined as either death or need for any of the following procedures within 30 days of the acute head injury: craniotomy, monitoring of intracranial pressure, or the need for intubation for the treatment of head injury [6]. The exact percentage of such injuries with operable lesions is yet to be established in our environment. ...
Background
Mild traumatic brain injury (TBI) occupies majority of head traumas in most emergency units. Although patients with mild TBI can be reviewed and discharged on head injury advice, a sizeable number require admission for observation or intervention due to operable intracranial lesions. The aim of the study was to establish the prevalence of operable lesions in patients with mild TBI.
Materials and methods
This was a prospective study of consecutive adult patients with mild TBI who had cranial computerized tomography (CT) done at the National Trauma Centre, Abuja. All participants gave informed consent and the study had ethical clearance in the Hospital.
Results
One hundred and three mild TBI patients with cranial CTs were recruited aged 16–76 years with mean age of 32.25 $$\pm$$ ± 12.35 years. With intention to treat, twenty (20.4%) of them were diagnosed with operable intracranial lesions on CT scans, 19 males and 2 females. Majority of them (14; 66.7%) were young adults within 20–40 years of age. The lesions were 16 extradural haematomas (76.2%), 3 subdural haematomas (14.3%) and 2 depressed skull fractures (9.5%) of the operable cohort.
Conclusions
Significant number of patients with mild TBI had operable intracranial lesions. Therefore, there is need to screen patients with mild TBI appropriately in order to avoid missed operable lesions.
... The guidelines may not consider individual risk factors or clinical characteristics that may require further imaging, leading to a general recommendation for CT scanning for all patients with mild head injury [34]. Another potential factor contributing to differences in rate estimates is the use of different criteria to diagnose mild head injury in different studies [28,33,35]. This can result in differences in patient selection and ultimately the prevalence of overuse observed in each study. ...
... Patient or family pressure, fear of litigation, and limited access to alternative diagnostic methods, such as MRI or ultrasound, are recognized factors that can contribute to the overuse of CT scans [6]. Furthermore, some emergency departments may lack the necessary resources, such as trained personnel or suitable equipment, to perform alternative diagnostic tests, leading to an over-reliance on CT scans as the primary diagnostic tool [35]. These factors may have contributed to the high rate of CT scan overuse observed in our study. ...
Background
Computed tomography (CT) scan is a common imaging technique used to evaluate the severity of a head injury. The overuse of diagnostic interventions in the health system is a growing concern worldwide.
Objectives: The aim of this systematic review is to investigate the rate of CT scan overuse in cases of mild head injury.
Methods
Eligibility criteria: We encompassed observational studies—either designed as cohort, case-control, or cross-sectional investigations—that reported on CT scan overuse rates for mild head injuries. Studies had to be published in peer-reviewed, English-language sources and provide full content access
Information sources: Web of Sciences, Scopus, Medline via PubMed, the Cochrane Library and Embase were searched from inception until April 1, 2023. Studies were included if reporting the overuse of CT scans for mild head injuries using validated criteria.
Risk of bias: We used the Risk Of Bias In Non-randomised Studies ‐ of Interventions (ROBINS-I) tool to evaluate the risk bias assessment of included studies. Two independent reviewers evaluated the eligibility of studies, extracted data, and assessed study quality by using the Newcastle-Ottawa Scale.
Synthesis of results: Overuse estimates were calculated using a random-effects model. Subgroup analyses were performed to investigate any sources of heterogeneity. Point rate of overuse of CT scans for mild head injuries was the main outcome measured as percentage point estimates with corresponding 95% CIs.
Results
Included studies: Of the 913 potentially relevant studies identified, eight studies were selected for the final analysis.
Synthesis of results: The pooled rate of CT scan overuse in patients with mild head injury was found to be 27% [95% CI: 16–43; I ² = 99%]. The rate of CT scan overuse in mild head injury cases varied depending on the criteria used. The rate of CT scan overuse was 37% [95% CI: 32–42; I ² = 0%] with the Glasgow Coma Scale (GCS), 30% [95% CI: 16–49; I ² = 99%] with the Canadian computed tomography head rule, and 10% [95% CI: 8–14; I ² = 0%] with the Pediatric Emergency Care Applied Research Network criterion (PERCAN). Based on subgroup analyses, the rate of CT scan overuse in mild head injury cases was observed to be 30% with the Canadian computed tomography head rule criterion, 43% with the National Institute for Health and Clinical Excellence criterion, and 18% with the New Orleans criterion.
Conclusion
Limitations of evidence: The restricted number of included studies may impact generalizability. High heterogeneity was observed, leading to subgroup analyses based on age, assessment criteria, and study region. Absent data on overuse causes hinders drawing conclusions on contributing factors. Furthermore, this study solely addressed overuse rates, not associated harm or benefits.
Interpretation: The overuse of CT scans in mild head injury patients is concerning, as it can result in unnecessary radiation exposure and higher healthcare costs. Clinicians and policymakers should prioritize the implementation of guidelines to reduce unnecessary radiation exposure, healthcare costs, and potential harm to patients.
Trial registration
The study protocol of this review was registered in PROSPERO under the identification code CRD42023416080 . https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023416080 .
... Research supporting those guidelines indicated that clinicians often order medical imaging for patients with these 3 conditions, even though imaging is not generally necessary for diagnosis, increases costs, and exposes patients to unnecessary radiation. [6][7][8] Our safe harbors provide clinicians specific directions as to when they could avoid medical imaging among patients presenting with 1 of these 3 conditions. ...
This Viewpoint discusses the feasibility of developing safe harbors that account for the role of medical malpractice liability and go beyond generic guidelines discouraging the overuse of health care resources.
... Keywords Traumatic brain injury · Brain injuries · Diagnostic imaging · Craniocerebral trauma · Complications · Tomography · X-ray computed · Decision support systems · Clinical and vomiting [2,3]. Although intracranial complications of mTBI are not common, there might be a need for emergent neurosurgical interventions in less than 1% of the patients because they can be life threatening [3,4]. ...
Purpose: In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran.
Methods: The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes.
Results: In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models.
Conclusion: The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria have higher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.
... Bouida et al, 53 in a Class III comparison study from Tunisia, prospectively enrolled 1,582 patients in an observational cohort of patients with a mild head injury, comparing the CCHR and the NOC. The sensitivity and specificity for patients requiring neurosurgical intervention were 100% (95% CI 90% to 100%) and 60% (95% CI 44% to 76%) for the CCHR, and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the NOC. ...
... -53 Stiell et al50 in a Class II study from 2005, applied these 2 decision tools to a prospective cohort in 9 Canadian community and academic EDs. In this study, 1,822 patients with a GCS score of 15 were included, and both the CCHR and the NOC had 100% sensitivity (95% CI 63% to 100%) for predicting the need for neurosurgical intervention. ...
... Canadian CT Head Rule, National Institute for health and care excellence (NICE) and Scandinavian Neurotrauma Committee (SNC)). Theses algorithms have high negative predictive values (> 99%) but lower specificity (45-60% [9,10] for detecting TICH requiring neurosurgical intervention. The specificity for TICH might be as low as 34% [11]. ...
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.
Conclusion:
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.
... However, since most trauma cases are mild, we observe head injuries in less than 15% 6 . There is a significant number of negative CTs, which results in lower method availability and higher cost, in addition to the excessive use of ionizing radiation [7][8][9] . ...
... The remaining 191 formed our sample, composed of 181 (94.0%) males, all wearing helmets (Table 1) 6 . This is the reason for the use of objective criteria for requesting cranial CT in trauma patients. ...
Objective: to review the clinical assessment of head injuries in motorcyclists involved in traffic accidents. Method: prospective
observational study, including adult motorcyclists involved in traffic accidents in a period of 12 months. Patients sustaining signs of
intoxication were excluded. A modification of the Canadian Head CT Rules was used to indicate computed tomography (CT). Patients not
undergoing CT were followed by phone calls for three months. Collected variables were compared between the group sustaining head
injuries and the others. We used chi-square, Fisher, and Student’s t for statistical analysis, considering p<0.05 as significant. Results:
we included 208 patients, 99.0% were wearing helmets. Seventeen sustained signs of intoxication and were excluded. Ninety (47.1%)
underwent CT and 12 (6.3%) sustained head injuries. Head injuries were significantly associated with Glasgow Coma Scale<15 (52.3%
vs. 2.8% - p<0,001) and a positive physical exam (17.1% vs. zero - p<0,05). Four (2.1%) patients with intracranial mass lesions needed
surgical interventions. None helmet-wearing patients admitted with GCS=15 and normal physical examination sustained head injuries.
Conclusion: Head CT is not necessary for helmet-wearing motorcyclists admitted with GCS=15 and normal physical examination.
... Both, CCHR and NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in less CT scans performed. (Stiell et al., 2005;Bouida et al., 2013). Since the inception of these guidelines little has been added to guide the management and prognosticate clinical outcome in patient with mTBI. ...
Traumatic brain injury remains a leading cause of death and disability across the globe. Substantial uncertainty in outcome prediction continues to be the rule notwithstanding the existing prediction models. Additionally, despite very promising preclinical data, randomized clinical trials (RCTs) of neuroprotective strategies in moderate and severe TBI have failed to demonstrate significant treatment effects. Better predictive models are needed, as the existing validated ones are more useful in prognosticating poor outcome and do not include biomarkers, genomics, proteonomics, metabolomics, etc. Invasive neuromonitoring long believed to be a “game changer” in the care of TBI patients have shown mixed results, and the level of evidence to support its widespread use remains insufficient. This is due in part to the extremely heterogenous nature of the disease regarding its etiology, pathology and severity. Currently, the diagnosis of traumatic brain injury (TBI) in the acute setting is centered on neurological examination and neuroimaging tools such as CT scanning and MRI, and its treatment has been largely confronted using a “one-size-fits-all” approach, that has left us with many unanswered questions. Precision medicine is an innovative approach for TBI treatment that considers individual variability in genes, environment, and lifestyle and has expanded across the medical fields. In this article, we briefly explore the field of precision medicine in TBI including biomarkers for therapeutic decision-making, multimodal neuromonitoring, and genomics.
... The Canadian CT Head Rule (CCHR) is a common starting place for interventions to reduce head CT utilization and is comparable to other similar instruments such as the CHIP Prediction Rule or the New Orleans Criteria [18][19][20] . While the NTDB does not have sufficiently granular data to assess whether patients met CCHR criteria, several studies over the last decade have found that its use significantly reduces head CT use in trauma patients. ...
Introduction
: Computerized tomography (CT) imaging is a standard part of traumatic brain injury (TBI) evaluation but not all patients require it after mild head injury. Given the increasing incidence of TBI in the United States, there is an urgent need to better characterize CT head imaging utilization in evaluating trauma patients, especially patients at low risk of requiring intervention, such as those presenting with a normal GCS.
Methods
: We analyzed the 2017-2019 National Trauma Databank using ICD-10 codes to identify patients who received a head CT. We used Abbreviated Injury Scale (AIS) scores to identify patients with a moderate to severe head injury defined as an AIS severity ≥ 3. Procedural TBI management was defined as having an intracranial monitor or operative decompression. We used a modified Poisson modeling to identify risk factors for a moderate/severe TBI and risk factors for undergoing procedural management among patients with head CT and GCS 15.
Results
: Of 2,850,036 patients, 1,502,039 (52.7%) had a head CT. Among patients who had a head CT, 1,078,093 patients (74.9%) had a GCS 15 on arrival. Of this group, only 16.6% (n=176,431) had a moderate/severe head injury. For those with moderate/severe head injury, 6.0% (n=10,544/176,431) of patients underwent procedural head injury management. Risk factors for undergoing procedural head injury management included: isolated head injury (RR 2.43, 95% CI 2.34, 2.53), male sex (RR 1.73, 95% CI 1.67, 1.80), age > 50 years (RR 1.39 95% CI 1.32, 1.47), falls (RR 1.28, 95% CI 1.22, 1.35), and the use of anti-coagulation (RR 1.16, 95% CI 1.11, 1.21).
Conclusion
: Few patients had moderate/severe head injury when presenting with a GCS 15. However, patients ≥ 50 years, men, and those who suffered falls were at higher risk. Anti-coagulation use was not associated with moderate/severe head injury but did increase the risk of procedural TBI management. Given the cost and associated radiation, reducing CT utilization for younger patients while using a more liberal head CT strategy for high-risk patients may provide substantial patient value.
