This was a prospective observational study done to evaluate the role of a repeat head CT in patients with mild traumatic brain injury. The aim was to evaluate wether the repeat head CT were useful in providing information that leads to any neurosurgical intervention. 279 adult patients with a mild head injury (GCS 13-15) were enrolled, and these comprised of patients with an initial traumatic intracranial haemorrhage not warranting any surgical intervention. All patients were subjected to a repeat head CT within 48 hours of admission and these showed no change or improvements of the brain lesion in 217 patients (79.2%) and worsening in 62 patients (20.8%). In thirty-one patients, surgical intervention was done following the repeat head CT. All of these patients had a clinical deterioration prior to the repeat head CT. Even if a repeat head CT had not been ordered on these patients, they would have had a repeat head CT due to deteriorating neurological status. When the 62 patients with a worsening repeat head CT were compared with the 217 patients with an improved or unchanged repeat head CT, they were found to have older age, lower GCS on admission, presenting symptoms of headache, higher incidence of multiple traumatic intracranial pathology and lower haemoglobin level on admission. On stepwise multiple logistic regression analysis, three factors were found to independently predict a worse repeat head CT (Table IV). This includes age of 65 years or older, GCS score of less than 15 and multiple traumatic intracranial lesion on initial head CT. As a conclusion, we recommend that, in patients with a MTBI and a normal neurological examination, a repeat cranial CT is not indicated, as it resulted in no change in management or neurosurgical intervention. Close monitoring is warranted in a subset of patients with risk factors for a worsening repeat head CT.
Keywords: Computed tomography, brain injury, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
Nitric oxide has a definitive role in the complex pathophysiology of traumatc brain injury (TBI). This prospective cohort study investigated the changes in nitric oxide metabolite (NOx) levels in cerebrospinal fluid (CSF) and their correlation with factors associated with severity and prognosis after severe TBI. NOx levels were measured in CSF obtained via ventriculostomy in 44 adult patients admitted after severe TBI (Glasgow Coma Scale ≤ 8/15). The overall mean level of CSF NOx in the study population was 7.40 ± 1.59 μmol/L. Levels of CSF NOx were found to be significantly higher in subgroups of patients with poorer outcome measured by Glasgow Outcome Scale score (p < 0.042), in patients with high intracranial pressure (ICP) readings (p < 0.027) and in those with higher Marshall computed tomography (CT) grading scores (p < 0.026). Simple logistic regression demonstrated that CSF NOx levels were a significant predictor of ICP (b = 0.493, 95%CI: 1.03, 2.58, p = 0.033). A patient with 1 μmol/L increase in NOx level had 1.6 times the odds to have an ICP ≥ 20 mmHg when other confounders were not adjusted. NOx level is also a significant predictor of Marshall CT grading (b = 0.473, 95%CI: 1.02, 2.50, p = 0.037). A patient with 1 μmol/L increase in NOx level had 1.6 times the odds to have a high Marshall grade when other confounders were not adjusted. It can be concluded that CSF NOx levels may serve as a potentially useful biomarker in severe TBI given its significant association with ICP readings as well as Marshall CT grading.