Comparison of Clinical Performance of Cranial Computed Tomography Rules in Patients With Minor Head Injury: A Multicenter Prospective Study

Abstract

Objectives: The objective was to compare the predictive performance of three previously derived cranial computed tomography (CT) rules, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and National Emergency X-Ray Utilization Study (NEXUS)-II, for detecting clinically important traumatic brain injury (TBI) and the need for neurosurgical intervention in patients with blunt head trauma.Methods: This was a prospective, multicenter, observational cohort study of patients with blunt head trauma from June 2008 to May 2009. The historical and physical examination components of the CCHR, NOC, and NEXUS-II were documented on a data collection form and the performance of each of the three rules was compared. Patient eligibility for each specific rule was defined exactly as previously described for each specific rule. To compare the three decision rules in terms of sensitivity and specificity, an intersection cohort satisfying inclusion criteria of all three decision rules was derived. The primary outcome was clinically important TBI, and the secondary outcome was neurosurgical intervention. The sensitivity and specificity of each rule were calculated with 95% confidence intervals (95% CIs). We also calculated the potential reduction rate in cranial CT scan utilization realized by theoretical implementation of these rules.Results: A total of 7,131 patients were prospectively enrolled, including 692 (9.7%) with clinical TBI. Among the enrolled population, patients eligible for CCHR, NOC, and NEXUS-II totaled 696, 677, and 2,951, respectively. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 112 of 144 (79.2%, 95% CI = 70.8% to 86.0%) and 228 of 552 (41.3%, 95% CI = 37.3% to 45.5%); NOC, 91 of 99 (91.9%, 95% CI = 84.7% to 96.5%) and 125 of 558 (22.4%, 95% CI = 19.0% to 26.1%); and NEXUS-II, 511 of 576 (88.7%, 95% CI = 85.8% to 91.2%) and 1,104 of 2,375 (46.5%, 95% CI = 44.5% to ª

Imaging Evidence and Recommendations for Traumatic Brain Injury: Conventional Neuroimaging Techniques

“…When rules such as the New Orleans Criteria (NOC), Canadian CT Head Rule (CCHR), or National Emergency X-Ray Utilization Study (NEXUS-II) are used to select patients for NCCT, the sensitivity of NCCT to detect brain injuries requiring neurosurgical intervention is considered to be almost 100% [84] (evidence level Ib). A prospective study in 2,152 patients with mild TBI reported that NCCT has a very high negative predictive value (99.7%) for excluding significant intracranial injury; thus, patients can be safely discharged home without admission in the absence of other significant extracranial injuries or neurologic symptoms (evidence level Ib) [85].…”

A Retrospective Study of Patients with Minor Head Injury to Compare the Canadian CT Head Rule and the New Orleans Criteria

“…Some studies demonstrated that the NOC is more sensitive than the CCHR in predicting clinically important brain injury, 7,11,12 whilst some studies demonstrated that the CCHR is more sensitive. 8 Some demonstrated equal sensitivity of both clinical rules in predicting clinically important brain injury.…”

Evaluation and treatment of trauma related collapse in athletes

“…Using studies from emergency/trauma literature can aid in determining the need for further imaging. Several clinical decision rules (Canadian CT Rules, New Orleans Criteria and National Emergency X-Radiography Utilization Study (Nexus II)) have been developed by studying emergency room patients [24,25]. These rules in general apply only to those patients >16 years old.…”

“…Athletes with worsening clinical symptoms should also be considered [23]. Although likely not as common in most sideline evaluations anticoagulation and age >65 should also prompt consideration [24,25].There is little data on length of loss of consciousness as a need for imaging. In contrast to the adult decision rules the pediatric rules use loss of consciousness, varying from suspected to greater than 5 minutes, as a variable [24, 25, 26•].…”