Whats New in Emergencies, Trauma and Shock? Computed Tomography Profile and its Utilization in Traumatic Brain Injury.

The present study examines the role of computed tomography (CT) scan in patients with traumatic brain injury and discusses the demographic details, injury distribution, intracranial imaging findings, and identifies the risk factors to request a CT scan in patients with suspected traumatic brain injury (TBI).[1] It is beyond doubt that the CT is rapid, widely available, and one of the most valuable imaging modality to investigate patients with TBI in the emergency department.[2] The use of CT scan in the emergency department has been progressively increasing[3456] which not only has the potential to increase the cost of care[78] but also the increased radiation exposure can lead to a harmful sequel.[391011] This study clearly identifies that CT is indicated in all patients with moderate and severe head injury (Glasgow Coma Scale ≤12), and there should be low threshold for asking a CT scan in elderly and in patients who are under influence of alcohol.[1]

In this study, the authors have found that in patients with minor head injury, there was strong association between CT scan positivity rate and the history of loss of consciousness of >5 min, history of vomiting, seizures, ear bleed, and/or nasal bleed.[1] Out of 1782 patients, 1341 patients were investigated for minor head injury, and only 38% of patients had a positive-CT scan with different pathologies and variable extent of intracranial lesions (might or might not had required neurosurgical intervention). The authors rightly point that the use of clinical predictors in patients with TBI may help to reduce unnecessary CT scans by a significant number. It is important to note that although the proportion of patients with positive CT scan was more in the moderate and severe head injury group, still a large number of patients in this group had apparently normal CT scan. It is well known that CT scan alone cannot rule out the structural damage to the brain and hence magnetic resonance imaging is a better modality to investigate such cases. It is known that CT has limitations in diagnosing diffuse axonal injury in early stages (it may be present in milder form in minor head injury group as well).

One more aspect we need to take into consideration is nonclinical factors, which include relative decision to get a CT scan in minor head injury patients, patient expectations, anxiety, fear of litigation, risk missed diagnoses, and where there are inadequate facilities to monitor the patients.[121314] Ultimately based on the circumstances, there will be a need to continue to make individual decisions as “Clinical practice guidelines are not perfect as they apply to populations, not to individual patients.”[12]