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PAPER |
1 Dipartimento Emergenza-Urgenza Accettazione, Ospedale GB Morgagni, Azienda Unità Sanitaria Locale di Forlì, Italy
2 Divisione di Neurochirurgia per la Traumatologia, Ospedale M. Bufalini, Azienda Unità Sanitaria Locale di Cesena, Italy
3 Dipartimento di Medicina Interna e Gastroenterologia, Università degli Studi di Bologna, Italy
Correspondence to:
Correspondence to:
Dr A Fabbri
Dipartimento Emergenza-Urgenza Accettazione, Ospedale GB Morgagni, Azienda USL di Forlì, 1 P.le Solieri-I-47100 Forlì, Italy; andfabbri{at}libero.it
Methods: In a three year period, 5578 adolescent and adult subjects were prospectively recruited and managed according to the proposed protocol. Outcome measures were: (a) any post-traumatic lesion; (b) need for neurosurgical intervention; (c) unfavourable outcome (death, permanent vegetative state or severe disability) after six months. The predictive value of a model based on five variables (Glasgow coma score, clinical findings, risk factors, neurological deficits, and skull fracture) was tested by logistic regression analysis.
Findings: At first CT evaluation 327 patients (5.9%) had intracranial post-traumatic lesions. In 16 cases (0.3%) previously undiagnosed lesions were detected after re-evaluation within seven days. Neurosurgical intervention was needed in 71 patients (1.3%) and an unfavourable outcome occurred in 39 cases (0.7%). The area under the ROC curve of the variables in predicting post-traumatic lesions was 0.906 (0.009) (sensitivity 70.0%, specificity 94.1% at best cut off), neurosurgical intervention was 0.926 (0.016) (sensitivity 81.7%, specificity 94.1%), and unfavourable outcome was 0.953 (0.014) (sensitivity 88.1%, specificity 95.1%).
Interpretation: The variables prove highly accurate in the prediction of clinically meaningful outcomes, when applied to a consecutive set of patients with mild head injury in the clinical setting of a 1st level emergency department.
Keywords: mild head injury; diagnosis; management; head CT; neuroimaging; neurosurgery; outcome
Abbreviations: AUC, area under the curve; CI, confidence interval; CT, computed tomography; DSF, depressed skull fracture; ED, emergency department; EDH, epidural haematoma; GCS, Glasgow coma scale; GOS, Glasgow outcome scale; ICH, intracerebral haematoma; IQR, interquartile range; IVH, intraventricular haemorrhage; LR, likelihood ratio; NCWFNS, Neurotraumatology Committee of the World Federation of Neurosurgical Societies; NPV, negative predictive value; OR, odds ratio; PCS, post-concussion syndrome; PPV, positive predictive value; ROC, receiver operating characteristic; SAH, subarachnoid haemorrhage; SD, standard deviation; SDH, subdural haematoma; SR, skull radiography
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