1. Supercourse 2001-2002 Abel Murgio, M.D.

2. “Is the CT Scan important at the 24 Hours in Children with Mild Traumatic Brain Injury? International Multicentre Study” Authors:°Murgio A.,*Mutluer S., **Fong D., #Hotz G., ^Di Rocco C., ^^Herrera EJ., ^^Viano JC. ºI.S.H.I.P. Group Argentina,*Turkey; **China; #USA; ^Italy; ^^Argentina;

3. Traditionally: “as those with a history of acute injury, a GCS score of 13 to 15, and no focal neurologic deficits”... Traditionally: “as those with a history of acute injury, a GCS score of 13 to 15, and no focal neurologic deficits”... “May or may not associated with a brief LOC that lasts a few seconds to no longer than 30 minutes”...(HIISIGroup) “May or may not associated with a brief LOC that lasts a few seconds to no longer than 30 minutes”...(HIISIGroup) No abnormal Imaging findings and no focal neurologic findings are present on initial clinical evaluation... No abnormal Imaging findings and no focal neurologic findings are present on initial clinical evaluation... Neurologically intact with a GCS of 13 to 15... Neurologically intact with a GCS of 13 to 15... Confusion with Amnesia for the event of trauma, include amnesia for events immediately before or after the accident (time: minutes to a few hours not more than 24 hs).Dec.1998 Confusion with Amnesia for the event of trauma, include amnesia for events immediately before or after the accident (time: minutes to a few hours not more than 24 hs).Dec.1998 Definition of Mild TBI

4. Objectives The principal idea of this study was to evaluate –using an international and multicentre population- the relationships between severity of injury, risk factor and imaging findings by attending physicians.

5. I.S.H.I.P. group Countries Phase I 5 countries 1996-98 1999-2001 Web Site: www.iship-international.org www.iship-international.org Phase II 22 countries

6. Methods Multicentre prospective, randomized, study of children who serially presented to Emergency Department with Traumatic Brain Injury. Phase I: 1996-98 with 4,690 Patients; Phase II: 1999-01 with 4,770 Patients. Neurological Evaluations: GCS and PGCS Follow-up: GOS

7. P.Patrick (Virginia University); G. Zitnay (CEO IBIA) G.Teasdale (Glasgow-UK), M.Choux (Marseille France) C. Di Rocco and F.Servadei (Italy) International Advisory Board Statistical evaluation

8. Results 7 pat. operated 3 pat. operated P= n.s.

9. Severity of TBI by GCS or PGCS PHASE I : 4,690Pat. 96.0% 1.0%3.0% PHASE II:4,6770Pat. 96.4

10. Relationships: Age and Sex P=n.s. p=n.s. Sex Age distribution 40 38.2 6061.8 %

11. Results: Mechanism of TBI Fall: 71.7 70.6 n.s. < 1 mt.: 50 59.0 n.s. 1-2 mts.: 20 32.6 n.s. >2 mts.: 8.0 8.0 n.s. Even surface: 22 0.4 0.001 *Road Acc.:17.0 16.8 n.s. p= n.s. Phase I 9,460 Pat. Phase II Mechanism Percentage Valor p

12. 18.8 1.7 LOC: Loss of Consciousness 24.0 4.0 Phase I: 4,690 Pat.Phase II: 4,770 Pat. P= n.s.

13. Symptoms Phase I 33.6% 23.6% 19.1% 10.4% 1.9% 11.4% 2.3% N. 4690 Pat.

14. S y m p t o m s Symptoms Phase II N. 4770 Pat.

15. Results: Imaging P = n.s.

16. Results: Imaging P=n.s. P < 0.0001

17. Results: CT Scan Phase I N. 4690 Patients 236 9.4% 5% 85.5% 674 CT [ 35% ]

18. Total: 4,770 Patients /15 months – Entry rate: 318 Pat/month Nb: the percentage was calculated of the total patients included. Results: CT Scan Phase II 71.4% 28.5% 47% 2,528 CT scan (53%) 2,242 721 1807

19. Age Group - Type of lesion CT scan 35.4% 40.6% 24.0% 229/721 Cts (31.8%) Phase II ICI AB A: Extradural Haematoma; B: Contusion/Haemorr. Intrap.; C C: Subdural Haemorr./Subarachnoid

20. 229/721 Cts (31.8%) 170/236 Cts (72.0%) n. Intracranial Injury by CT Scanning a b c Abnormal CT Scan: “focuses only on acute changes to the contents of the cranial vault with an special interest Neurosurgical aspects, example: Contusion, Extradural Haematoma, Subaracnoid Haemorrhage, Intraparenchymatous Haemorrhage, Subdural” Abnormal CT Scan: “focuses only on acute changes to the contents of the cranial vault with an special interest Neurosurgical aspects, example: Contusion, Extradural Haematoma, Subaracnoid Haemorrhage, Intraparenchymatous Haemorrhage, Subdural”

21. 589 101 20 11 217 16 3 ( N. 721 CTs + )( N. 236 CTs + ) Pattern of Lesions TBI and CTs 1-81.7% 2-14.0% 3-2.8% 1-91.9%; 2-6.8%; 3-1.3% 4-1.5% Phase IIPhase I

22. Neurosurgical Intervention: patients description Phase IIPhase I 56% 27.3% 16.7% 31.4% 16.4% 25.4% 26.9% 81 Patients 130 Patients MildsTBI 59/81 (72.9%) MildsTBI 130 (100%) 7 Pat. Died GCS < 11 3 Pat. Died

23. 5= 99% 5= 99.6% 91%99.8% Outcome at 3 Months *Method of evaluation: phone or face to face

24. 5 : 99.6% (4,745 Pat.) 5 : 94.1% ( 40 pat.) 4 : 0.3% (14 pat.) 4 : 2.9% ( 2 pat.) 3 : 0.04% ( 2 pat.) 1 : 0.04% (2 pat.) 1: 2.9% (1 pat.) * GOS : 5 Good recovery ; 4 Moderately disabled ; 3 Severely disabled 2 Vegetative state ; 1 Death 4,760 patients (99.8%) 43 patients (0.9%) 3 MONTHS6 MONTHS GOS Follow-up: Phase II

25. Advantage of the multicentre study is that allows us a glimpse of practice in varied setting and makes it possible to compare these experiences with our own; Advantage of the multicentre study is that allows us a glimpse of practice in varied setting and makes it possible to compare these experiences with our own; We suggest that some of the beliefs that govern us in decision-making need review, i.e. “older and familiar technologies” (X- rays) to determine the need for a more complex evaluation, including CT; We suggest that some of the beliefs that govern us in decision-making need review, i.e. “older and familiar technologies” (X- rays) to determine the need for a more complex evaluation, including CT; a-Conclusion

26. The physical and neurological examination are inadequate “predictors” of ICI; The physical and neurological examination are inadequate “predictors” of ICI; The CT Scan is “more sensitive”; The CT Scan is “more sensitive”; Liberal use of CT scans in children under 6 years of age and younger with TBI is because they “may present without symptoms”; Liberal use of CT scans in children under 6 years of age and younger with TBI is because they “may present without symptoms”; b-Conclusion

27. Until more definitive information is available, clinicians should be liberal in their use of CT so that early identification of significant ICI can be obtained and appropriate management of the injuries initiated. Until more definitive information is available, clinicians should be liberal in their use of CT so that early identification of significant ICI can be obtained and appropriate management of the injuries initiated. c-Conclusion

28. “The critical issue will be to have guidelines that, when used would identify all patients who need surgery, with as few negative scans to achieve this.” “The critical issue will be to have guidelines that, when used would identify all patients who need surgery, with as few negative scans to achieve this.” “Should we now try to use the data to create guidelines and then validate them…” “Should we now try to use the data to create guidelines and then validate them…” International Society of Pediatric Neurosurgery : I.S.P.N.

29. Past - Present & Future Mar del Plata (Argentina) 5 countries 22 countries 26 countries X-rays-Epidemiology Role X-rays-CTscan *Columella Award: ICRAN’96 *Nomination: (CDC-IBIA) EH Cristopherson Award: AAP 2000 CTscan - Mild TBI Markers Brain Damage-CTscan? Neuropsychology Tests? 1996 1996-98 1999-2001 2002-2003 *Neurosurgical Sciences’99 *Child’s Nerv System’00-01 *Brain Injury Sources’00 *Book: Brain Injury’01-02 Contribution:

30. Centers of the I.S.H.I.P. group United States CanadaUruguayChileBrazilArgentina Spain France Italy Israel Germany Turkey Poland Arabia India Hong Kong TaiwanSingaporeIndonesia UK Sweden Russia 22

31. We think that is necessary to make an accurate evaluation of each patient with Mild TBI under 12 years of age and considerer order a CT scan into 24 hours to identify ICI and guarantee a good out come. We think that is necessary to make an accurate evaluation of each patient with Mild TBI under 12 years of age and considerer order a CT scan into 24 hours to identify ICI and guarantee a good out come. d-Conclusion