Developing a Clinical Guideline for CT Scans in Closed Head Injury

Abstract

Trauma Several years ago, every patient that was brought to Thomas Jefferson University Hospital with a closed head injury would receive a CT scan — regardless of whether or not that patient already had a scan performed at an outside institution. If the scan demonstrated any intracranial pathology, then a repeat CT scan was performed 12 hours after the initial scan as long as the patient remained neurologically stable. Ultimately, every patient received two CT scans at our institution separated by 12 hours. Now, each patient is followed by a total of three CT scans. If a patient had undergone a CT scan at an outside institution, this scan was loaded onto the Jefferson system and was considered their first CT scan. A follow-up CT scan was to be performed 6 hours after the initial scan if any intracranial pathology was noted. As long as the patient remained neurologically stable, a third and final CT scan was to be performed sometime between 12 to 24 hours after the initial scan. Therefore, patients with non-operative intracranial hemorrhage received two or three CT scans at our institution and were observed for at least 24 hours. In both situations, routine follow-up imaging was performed on all patients with an initial intracranial lesion resulting from head trauma. This practice is founded on the recommendation that " early imaging, rather than awaiting neurological deterioration, reduces the delay in detection and treatment of acute intracranial injury. " This is based largely on the existing literature regarding epidural hematomas (EDH) and severe head injury. More than 50% of patients with severe head injuries have progression of findings on CT scan that otherwise would go undetected due to their poor initial clinical status. 1 Case reports have illustrated the need for repeat imaging in the setting of " ultra-early " CT scans, which may not capture a developing hematoma. 2 In addition, EDHs have been reported to be more likely to enlarge if captured within 6 hours of injury 3 — again enforcing the importance of repeat imaging for these patients. At the same time, while such case reports and small case series have demonstrated the importance of imaging at least 6 hours after the initial injury, patients who have already had a negative CT scan generally do not get a repeated scan, — even if the negative scan was performed within 6 hours of their injury. Overall, …