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The clinical relevance of perfusion-CT in the acute phase of head injury

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Titel The clinical relevance of perfusion-CT in the acute phase of head injury
Looptijd 01 / 2005 - onbekend
Status Afgesloten
Onderzoeknummer OND1318041
Leverancier gegevens ZonMw

Samenvatting (EN)

Traumatic brain injury is one of the most common neurological disorders, especially affecting young adults in the second and third decades of life. In the Netherlands, the reported annual incidence of patients with a head injury (HI) admitted to the hospital is 113 per 100.000 inhabitants, resulting in approximately 20.000 admissions annually. The majority of patients (80-85%) are classified as mild HI, 10% as moderate and 5-10% as severe. Most patients with severe head HI and a subgroup of patients with mild to moderate HI continue to have residual symptoms interfering with return to work or resumption of social activities. As young people are involved, head injury constitutes an important health care problem. In the United States, traumatic brain injury is referred to as the silent epidemic and lifetime costs is estimated on 56 billion USD. Final outcome of HI patients is not only determined by the extent of primary damage but also by the development of secondary (ischemic) damage. The major goal of patient care in the acute phase of HI is prevention of secondary brain damage and to optimise therapy for each HI patient. In the setting of acute trauma care it is not always possible to obtain reliable information on the extent of cerebral injury. At present the therapeutic strategy is determined by a few variables, which are known to be of prognostic significance. One of these factors is the presence of abnormalities on CT imaging. However, approximately 25% of performed CT-scans are false negative and fail to identify patients with cerebral damage who are likely to experience problem Traumatic HI is one of the most common neurological disorders, especially affecting young adults in the second and third decades of life. In the Netherlands, at least an estimated 20.000 patients with HI are admitted to a hospital each year. The majority of the patients (80-85%) are classified as mild HI, while 10% are defined as moderate and 5-10% as severe (1). Depending on the severity of injury, a subgroup of patients continues to have residual symptoms interfering with return to work or resumption of social activities (2-6). In general, in patients with mild to moderate HI, which constitute the major part of the HI population, working on full capacity is only possible several months after discharge, mainly because of cognitive complaints they experience (5). In order to optimise therapy in each patient it is essential to obtain objective information on the extent of cerebral damage in the acute phase. Outcome studies in traumatic HI reveal several prognostic factors with the neurological condition on admission, as determined by the Glasgow Coma Score (GCS), pupil reactions, CT-abnormalities and age as most important (7). However, in the setting of acute trauma care it is not always possible to obtain information on all these variables. First, the GCS cannot be assessed when a patient is intubated and sedated. Second, pupil reactivity predicts mortality only in severe HI patients but has no prognostic or therapeutic significance in less severe HI. Third, it is known that CT on admission does not detect all cerebral abnormalities, especially axonal injury and ischemic changes (8). The overall accuracy for detecting abnormalities has been estimated on 64% (9). However, approximately 25% of performed CT scans are false negative and fail to identify patients with cerebral damage who are likely to experience problems resuming work or social activities (10-12). Patients who are dismissed after HI without a proper diagnosis seek help only after a long period of time when they have failed to resume previous activities (13). When this category of patients already would have been recognized in the acute phase, the therapeutic strategy could have been altered. The disciplines primarily involved in the usual care for HI patients are the Departments of Surgery, Neurology, Anaesthesiology and Radiology. Trauma patients, with or without head injury, are admitted to the neurological or surgical (intensive) care units. To optimise patient care and management, several protocols have been developed. According to national guidelines in all patients with a GCS of 14 or less a CT scan is performed, including every poly-trauma patient irrespective of GCS (14). In general, follow-up of p The primary goal of the present study is to investigate whether the use of perfusion-CT for the identification of patients at risk for developing residual cognitive disability can result in faster and more efficient reintegration in the working process in patients with HI. Traumatic brain injury is the major cause of morbidity and mortality in young male adults (20) and constitutes a major health problem (25). Epidemiological studies in the USA and UK reveal an incidence varying between 180-300/100.000 inhabitants (26,27). In the Netherlands, at least an estimated 20.000 patients with HI are admitted to a hospital, based on an annual incidence of 113 patients per 100.000 inhabitants per year (28). The actual incidence of all persons sustaining a HI is higher, with reported incidence of 567 patients per 100.000 per year seen at the emergency department, revealing that one in five patients is admitted to the hospital (29). Almost one in four patients with mild-to moderate HI and half of patients with severe HI are not able to resume previous activities due to residual deficits (3,5,6,30). With an estimated hospital admission rate of at least 20.000 patients per year approximately 6000 patients are excluded from full participation in activities of society. It is known that the outcome in HI patients is mostly determined by cognitive deficits. Initially one month after injury, return to work was found to be related to both brain and system injuries (31,32). With follow-up more than three months after injury, unemployment was related to severity of brain injury (33) due to improvement of physical limitations (34). In recent years, guidelines have been proposed to standardise the follow-up and therapeutic-protocol in HI patients (35). Intervention shortly after the injury has been proven equally effective compared to intensive follow-up during one year (36). Especially patients with mild to moderate HI would gain from this therapeutic strategy (37). The results of the proposed study will show whether use of perfusion-CT instead of conventional CT for the early identification of patients at risk of developing residual cognitive disability after HI, will result in better resumption of work 6 months after injury. Moreover, this study will reveal the cost-effectiveness of application of perfusion-CT in this target group, as determined by the balance between additional costs of the perfusion-CT and the supposed costs savings by increased work participation. To our knowledge, there are no similar studies underway, or recent reports by national advisory boards regarding this subject. A prospective, randomised study will be performed including patients with a traumatic HI admitted to the emergency department of the University Hospital of Groningen. Patients will be included in the study after informed consent is obtained from family or next of kin. In patients with a normal conventional CT scan a perfusion CT will be performed. Disclosure of the results of the perfusion CT will be randomised, so that one group of patients receives care as usual without knowledge of the result of the perfusion CT and a second group of patients is treated on the basis of the results of the perfusion CT (see flowchart). The primary outcome measure of the study is the percentage of patients who resume work or social activities at full capacity after 6 months. The secondary outcome measure of the study are the test-properties of the perfusion-CT, costs of treatment and diagnosis in both study groups. Study population: On a yearly base a total of 600 patients with HI are admitted to our hospital. The majority of patients have sustained a minor HI with a Glasgow Coma Scale (GCS) of 15 on admission. Almost 200 patients are classified as poly-trauma patients with approximately one-third of patients having sustained a severe HI, with a GCS on admission of 8 or less, and two-third having sustained a mild to moderate HI, with a GCS between 9 and 14. These last two groups of patients will be eligible for the study.

Betrokken organisaties

Penvoerder Afdeling Neurologie (RUG)
Financier ZonMw

Betrokken personen

Projectleider Dr. J. van der Naalt

Classificatie

D23230 Neurologie, KNO , oogheelkunde

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