ACR logo

Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. TBI-related Emergency Department (ED) Visits.  Available at: https://www.cdc.gov/traumaticbraininjury/data/tbi-ed-visits.html. Review/Other-Dx N/A To discuss the traumatic brain injury concussion in the ED In 2014, there were approximately 2.5 million TBI-related ED visits in the U.S., including over 812,000 among children.Unintentional falls, being unintentionally struck by or against an object, and motor vehicle crashes were the most common mechanisms of injury contributing to a TBI diagnosis in the ED. These three principal mechanisms of injury accounted for 47.9%, 17.1%, and 13.2%, respectively, of all TBI-related ED visits.Rates of TBI-related ED visits per 100,000 population were highest among older adults aged = 75 years (1,682.0), young children aged 0-4 years (1,618.6), and individuals 15-24 years (1,010.1). 4
2. Wintermark M, Sanelli PC, Anzai Y, et al. Imaging evidence and recommendations for traumatic brain injury: conventional neuroimaging techniques. [Review]. J. Am. Coll. Radiol.. 12(2):e1-14, 2015 Feb. Review/Other-Dx N/A To suggest practical imaging recommendations for patients presenting with TBI across different practice settings and to simultaneously provide the rationale and background evidence supporting their use. These recommendations should ultimately assist referring physicians faced with the task of ordering appropriate imaging tests in particular patients with TBI for whom they are providing care. These recommendations should also help radiologists advise their clinical colleagues on appropriate imaging utilization for patients with TBI. 4
3. Ryan ME, Pruthi S, Desai NK, et al. ACR Appropriateness Criteria R Head Trauma-Child. Journal of the American College of Radiology. 17(5S):S125-S137, 2020 May. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for head trauma of achild. No results stated in abstract. 4
4. Smits M, Dippel DW, de Haan GG, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 294(12):1519-25, 2005 Sep 28. Observational-Dx 3,181 consecutive patients Prospective multicenter study to validate and compare the Canadian CT Head Rule (CCHR) to the New Orleans Criteria (NOR) in Dutch patients with head injuries. Of 3,181 patients with a GCS score of 13 to 15, neurosurgical intervention was performed in 17 patients (0.5%); neurocranial traumatic CT findings were present in 312 patients (9.8%). Sensitivity for neurosurgical intervention was 100% for both the CCHR and the NOC. The NOC had a higher sensitivity for neurocranial traumatic findings and for clinically important findings (97.7%-99.4%) than did the CCHR (83.4%-87.2%). Specificities were very low for the NOC (3.0%-5.6%) and higher for the CCHR (37.2%-39.7%). The estimated potential reduction in CT scans for patients with MHI would be 3.0% for the adapted NOC and 37.3% for the adapted CCHR. CCHR is less sensitive for trauma or clinically relevant findings, but would identify all neurosurgical cases and reduce CT utilization. 3
5. Su YS, Schuster JM, Smith DH, Stein SC. Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury. J Neurotrauma. 36(13):2083-2091, 2019 Jul 01. Review/Other-Dx N/A To perform a  cost analyses of the  Banyan Trauma Indicator (BTI) screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate traumatic brain injury (TBI). No results stated in the abstract. 4
6. Tavender EJ, Bosch M, Green S, et al. Quality and consistency of guidelines for the management of mild traumatic brain injury in the emergency department. Acad Emerg Med. 2011;18(8):880-889. Review/Other-Dx 6 clinical practice guidelines To provide an overview of the recommendations and quality of evidence-based clinical practice guidelines for the emergency management of mTBI, with a view to informing best practice and improving the consistency of recommendations. The search identified 18 potential clinical practice guidelines, of which 6 met the inclusion criteria. The included clinical practice guidelines varied in scope, target population, size, and guideline development processes. Four clinical practice guidelines were assessed as “strongly recommended.” The majority of clinical practice guidelines did not provide information about the level of stakeholder involvement (mean AGREE standardized domain score = 57%, range = 25% to 81%), nor did they address the organizational/cost implications of applying the recommendations or provide criteria for monitoring and review of recommendations in practice (mean AGREE standardized domain score = 46.6%, range = 19% to 94%). Recommendations were mostly consistent in terms of the use of the GCS score (adult and pediatric) to assess the level of consciousness, initial assessment criteria, the use of CT scanning as imaging investigation of choice, and the provision of patient information. The clinical practice guidelines defined mTBI in a variety of ways and described different rules to determine the need for CT scanning and therefore used different criteria to identify high-risk patients. 4
7. Holmes MW, Goodacre S, Stevenson MD, Pandor A, Pickering A. The cost-effectiveness of diagnostic management strategies for adults with minor head injury. Injury. 43(9):1423-31, 2012 Sep. Review/Other-Dx N/A To estimate the cost-effectiveness of diagnostic management strategies for adults with minor head injury. The apparent optimal strategy was based on the high and medium risk Canadian CT Head Rule (CCHRhm), although the costs and outcomes associated with each strategy were broadly similar. Hospital admission for patients with non-neurosurgical injury on CT dominated discharge home, whilst hospital admission for clinically normal patients with a normal CT was not cost-effective compared to discharge home with or without a responsible adult at £39 and £2.5 million per QALY, respectively. A selective CT strategy with discharge home if the CT scan was normal remained optimal compared to not investigating or CT scanning all patients when there was no responsible adult available to observe them after discharge. 4
8. Smits M, Dippel DW, Nederkoorn PJ, et al. Minor head injury: CT-based strategies for management--a cost-effectiveness analysis. Radiology. 2010;254(2):532-540. Observational-Dx 3,181 patients To compare the cost-effectiveness of using selective CT strategies with that of performing CT in all patients with MHI. Data from the multicenter CT in head injury patients Study involving 3,181 patients with MHI were used. Study results showed that performing CT selectively according to the CCHR or the CT in head injury patients rule could lead to substantial U.S. cost savings ($120 million and $71 million, respectively), and the CCHR was the most cost-effective at reference-case analysis. When the prediction rule had lower than 97% sensitivity for the identification of patients who required neurosurgery, performing CT in all patients was cost-effective. The CT in head injury patients rule was most likely to be cost-effective. At value-of-information analysis, the expected value of perfect information was $7 billion, mainly because of uncertainty about long-term functional outcomes. Selecting patients with MHI for CT renders cost savings and may be cost-effective, provided the sensitivity for the identification of patients who require neurosurgery is extremely high. Uncertainty regarding long-term functional outcomes after MHI justifies the routine use of CT in all patients with these injuries. 3
9. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 343(2):100-5, 2000 Jul 13. Observational-Dx 1st phase – 520 consecutive patients; 2nd phase – 909 consecutive patients Prospective study to derive and validate a set of clinical criteria that could be used to identify patients with MHI in whom CT could be forgone. The study was conducted in two phases at a large, inner-city, level 1 trauma center. Of the 520 patients in the first phase, 36 (6.9%) had positive scans. All patients with positive CT scans had one or more of 7 findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3%) had positive scans. In this group of patients, the sensitivity of the 7 findings combined was 100% (95% CI, 95% to 100%). All patients with positive CT scans had at least one of the findings. For the evaluation of patients with MHI, the use of CT can be safely limited to those who have certain clinical findings. 3
10. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 357(9266):1391-6, 2001 May 05. Observational-Dx 3,121 consecutive patients Prospective cohort multicenter study to develop a highly sensitive clinical decision rule for use of CT in patients with minor head injuries. A CT head rule was derived which consists of 5 high-risk factors (failure to reach GCS (G of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years) and two additional medium-risk factors (amnesia before impact >30 min and dangerous mechanism of injury). The high-risk factors were 100% sensitive (95% CI, 92%-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive (95% CI, 96%-99%) and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT. 3
11. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 294(12):1511-8, 2005 Sep 28. Observational-Dx CCHR evaluated in 2,707 adults CCHR and NOC compared in a subgroup of 1,822 adults Prospective multicenter cohort study to compare the clinical performance of CCHR to the NOR for detecting the need for neurosurgical intervention and clinically important brain injury. Among 1,822 patients with GCS of 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P<.001) for predicting need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% CI, 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P<.001), and would result in lower CT rates (52.1% vs 88.0%, P<.001). The kappa values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P=.04). Among all 2,707 patients with a GCS of 13 to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury. For patients with MHI and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates. 2
12. Davey K, Saul T, Russel G, Wassermann J, Quaas J. Application of the Canadian Computed Tomography Head Rule to Patients With Minimal Head Injury. Ann Emerg Med. 72(4):342-350, 2018 10. Observational-Dx 240 patients To evaluate the Canadian CT Head Rule in patients with head injury without loss of consciousness or witnessed disorientation (minimal head injury). wo hundred forty patients with minimal head injury were enrolled. Five patients (2.1%) had head CTs that were positive for intracranial hemorrhage. All instances of intracranial hemorrhage occurred in patients who were at high or moderate risk by the Canadian CT Head Rule (2 high risk [age], 3 moderate risk [mechanism]). No patient with intracranial hemorrhage went to the ICU or underwent any intervention; the average hospital length of stay was 1.25 days. The Canadian CT Head Rule was 100% sensitive (95% confidence interval 40% to 100%) and 29% specific (95% confidence interval 23% to 35%) for the presence of intracranial hemorrhage. Physicians listed their own reassurance (24.6%), patient reassurance (24.2%), patient expectation (14.6%), and reduction of legal liability (11.7%) as the rationale for ordering head CT in patients with minimal head injury. Shared decisionmaking was used in 51% of cases. 1
13. Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. London: National Collaborating Centre for Acute Care (UK); 2007. Review/Other-Dx N/A Updated guideline on the care of adults, children (aged 1–15 years) and infants (<1 year) who present with a suspected or confirmed traumatic head injury with or without other major trauma. n/a 4
14. Mason SM, Evans R, Kuczawski M. Understanding the management of patients with head injury taking warfarin: who should we scan and when? Lessons from the AHEAD study. [Review]. Emerg Med J. 36(1):47-51, 2019 Jan. Review/Other-Dx N/A To provide shop floor clinicians with an understanding of the limitations of the evidence in this field and the limitations of applying 'one-size-fits-all' guidelines to individual patients. No results stated in the abstract. 4
15. Jagoda AS, Bazarian JJ, Bruns JJ Jr, et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 52(6):714-48, 2008 Dec. Review/Other-Dx N/A To provide evidence-based recommendations on select issues in the management of adult patients with mTBI in the acute setting. No abstract available. 4
16. Wei SC, Ulmer S, Lev MH, Pomerantz SR, Gonzalez RG, Henson JW. Value of coronal reformations in the CT evaluation of acute head trauma. AJNR. 2010;31(2):334-339. Observational-Dx 213 patients Prospective study to evaluate whether coronal reformations improve detection of intracranial hemorrhage in noncontrast cranial CT performed for head trauma. Of 213 patients, 32 noncontrast cranial CT demonstrated intracranial hemorrhage (a total of 104 foci). 15/104 (14%) intracranial hemorrhages (8 patients) were detected solely on coronal images. Locations included the floor of the anterior and middle cranial fossas, vertex, corpus callosum, falx, tentorium, and occipital convexity. Coronal reformations allowed exclusion of suspicious findings on axial images in 14 instances (7 patients). Coronal images aided interpretation in 29/104 (28%) findings. Coronal reformations improve the detection of intracranial hemorrhage over axial images alone, especially for lesions that lie in the axial plane immediately adjacent to bony surfaces. The use of coronal reformations should be considered in the routine interpretation of head CT examinations performed for the evaluation of head trauma. 3
17. Zacharia TT, Nguyen DT. Subtle pathology detection with multidetector row coronal and sagittal CT reformations in acute head trauma. Emerg Radiol. 2010;17(2):97-102. Observational-Dx 200 patients To retrospectively analyze the advantages of coronal and sagittal reformations obtained with MDCT in patients with acute head trauma. Images analyzed by two independent, blinded readers. CT imaging abnormalities were detected in 55/200 patients who were scanned for head trauma. Acute traumatic intracranial abnormality was detected on axial scans in 45 patients. Subtle findings were confirmed on coronal and sagittal CT reformations in 10 cases, and these were undetected initially on axial CT. Coronal and sagittal reformations confirmed subtle findings in 18.2% (10/55) of the cases (P=0.001). Indeterminate neuroimaging findings confirmed by coronal and sagittal CT head reformations include tentorial and interhemispheric fissure subdural hemorrhage, subarachnoid hemorrhage, and inferior frontal and temporal lobe contusions. Overall, coronal and sagittal reformations improved diagnostic confidence and interobserver agreement over axial images alone for visualization of normal structures and in the diagnosis of acute abnormality. 2
18. Amyot F, Arciniegas DB, Brazaitis MP, et al. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. [Review]. J Neurotrauma. 32(22):1693-721, 2015 Nov 15. Review/Other-Dx N/A To review the effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. No results stated in abstract. 4
19. Shackford SR, Wald SL, Ross SE, et al. The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma. 1992;33(3):385-394. Observational-Dx 2,766 patients To determine the value of CT and neurologic examination in the management of patients with minor injuries. Hypothesis that normal CT and MHI have negligible risk of neurosurgical deterioration. A neurologic examination and a CT scan were performed on 2,166 patients; 933 patients had normal neurologic examinations and normal CT scans and none required craniotomy; 1,170 patients had normal CT scans and none required craniotomy; 2,112 patients had normal neurologic examinations and 59 required craniotomy. The sensitivity of the CT scan was 100%, with PPV of 10%, NPV of 100%, and specificity of 51%. The use of CT alone as a diagnostic modality would have saved 3,924 hospital days, including 814 ICU days, and $1,509,012 in hospital charges. CT scanning is essential in the management of patients with minor head injuries and if the neurologic examination is normal and the scan is negative patients can be safely discharged from the emergency room. 3
20. Bruns JJ Jr, Jagoda AS. Mild traumatic brain injury. [Review] [51 refs]. Mt Sinai J Med. 76(2):129-37, 2009 Apr. Review/Other-Dx N/A To generate evidence-based guidelines to assist in clinical decision making. No results stated in the abstract. 4
21. Pons E, Foks KA, Dippel DWJ, Hunink MGM. Impact of guidelines for the management of minor head injury on the utilization and diagnostic yield of CT over two decades, using natural language processing in a large dataset. Eur Radiol. 29(5):2632-2640, 2019 May. Review/Other-Dx  9109 patients To  investigate the impact of clinical guidelines for the management of minor head injury on utilization and diagnostic yield of head CT over two decades. The yield was initially nearly 60%, but in a decreasing trend dropped below 20% when CT became routinely used for head trauma. Between 2009 and 2014, of 4554 minor head injury patients overall, 85.4% underwent head CT. After guideline implementation in 2011, CT utilization significantly increased from 81.6 to 87.6% (p?=?7?×?10-7), while yield significantly decreased from 12.2 to 9.6% (p?=?0.029). 4
22. Babl FE, Oakley E, Dalziel SR, et al. Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study. Ann Emerg Med. 71(6):703-710, 2018 06. Observational-Dx 20,137 patients To assess the accuracy of clinician practice in detecting clinically important traumatic brain injury. Of 20,137 children, 18,913 had a mild head injury. Of these patients, 1,579 (8.3%) received a CT scan during the ED visit, 160 (0.8%) had clinically important traumatic brain injury, and 24 (0.1%) underwent neurosurgery. Clinician identification of clinically important traumatic brain injury based on CT performed had a sensitivity of 158 of 160, or 98.8% (95% confidence interval [CI] 95.6% to 99.8%) and a specificity of 17,332 of 18,753, or 92.4% (95% CI 92.0% to 92.8%). Sensitivity of PECARN for children younger than 2 years was 42 of 42 (100.0%; 95% CI 91.6% to 100.0%), and for those 2 years and older, it was 117 of 118 (99.2%; 95% CI 95.4% to 100.0%); for CATCH (high/medium risk), it was 147 of 160 (91.9%; 95% CI 86.5% to 95.6%); and for CHALICE, 148 of 160 (92.5%; 95% CI 87.3% to 96.1%). 2
23. Dalziel K, Cheek JA, Fanning L, et al. A Cost-Effectiveness Analysis Comparing Clinical Decision Rules PECARN, CATCH, and CHALICE With Usual Care for the Management of Pediatric Head Injury. Ann Emerg Med. 73(5):429-439, 2019 May. Observational-Dx 18,913 patients To determine the cost-effectiveness of 3 clinical decision rules in comparison to Australian and New Zealand usual care: the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), the Pediatric Emergency Care Applied Research Network (PECARN), and the Canadian Assessment of Tomography for Childhood Head Injury (CATCH). Usual care, CHALICE, PECARN, and CATCH strategies cost on average AUD $6,390, $6,423, $6,433, and $6,457 per patient, respectively. Usual care was more effective and less costly than all other strategies and is therefore the dominant strategy. Probabilistic sensitivity analyses showed that when simulated 1,000 times, usual care dominated all clinical decision rules in 61%, 62%, and 60% of simulations (CHALICE, PECARN, and CATCH, respectively). The difference in cost between all rules was less than $36 (95% confidence interval -$7 to $77) and the difference in quality-adjusted life-years was less than 0.00097 (95% confidence interval 0.0015 to 0.00044). Results remained robust under sensitivity analyses. 2
24. Bertsimas D, Dunn J, Steele DW, Trikalinos TA, Wang Y. Comparison of Machine Learning Optimal Classification Trees With the Pediatric Emergency Care Applied Research Network Head Trauma Decision Rules. Jama, Pediatr.. 173(7):648-656, 2019 Jul 01. Observational-Dx 42 412 patients To examine whether optimal classification trees (OCTs), which are novel machine-learning classifiers, improve on PECARN rules' predictive accuracy. Of the 42?412 children (15 996 [37.7%] girls) included in the analysis, 10?718 were younger than 2 years (25.3%; mean [SD] age, 11.6 [0.6] months) and 31?694 were 2 years or older (74.7%; age, 9.1 [4.9] years). Compared with PECARN rules, OCTs misclassified 0 vs 1 child with ciTBI in the younger and 10 vs 9 children with ciTBI in the older cohort, and correctly identified more children with very low risk of ciTBI in the younger (7605 vs 5701) and older (20 594 vs 18 134) cohorts. In the validation cohorts, compared with the PECARN rules, the OCTs had statistically significantly better specificity (in the younger cohort: 69.3%; 95% CI, 67.4%-71.2% vs 52.8%; 95% CI, 50.8%-54.9%; in the older cohort: 65.6%; 95% CI, 64.5%-66.8% vs 57.6%; 95% CI, 56.4%-58.8%), positive predictive value (odds ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively), and positive likelihood ratio (risk ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively). There were no statistically significant differences in the sensitivity, negative predictive value, and negative likelihood ratio between the 2 sets of rules. 2
25. Hale AT, Stonko DP, Lim J, Guillamondegui OD, Shannon CN, Patel MB. Using an artificial neural network to predict traumatic brain injury. J Neurosurg Pediatrics. 23(2):219-226, 2018 11 02. Review/Other-Dx 12,902 patients To  utilize artificial intelligence to predict clinically relevant TBI (CRTBI) using radiologist-interpreted CT information with > 99% sensitivity and an AUC of 0.99. No results stated in the abstract. 4
26. Korley FK, Yue JK, Wilson DH, et al. Performance Evaluation of a Multiplex Assay for Simultaneous Detection of Four Clinically Relevant Traumatic Brain Injury Biomarkers. J Neurotrauma. 2018 Jul 23. Observational-Dx 107 patients To  measure glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase L1 (UCH-L1), neurofilament light chain (NF-L) and total tau in plasma samples obtained from 107 subjects enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) Study using the Quanterix Simoa 4-Plex assay We found a strong correlation between NF-L values derived from the multiplex and singleplex assays (correlation coefficient?=?0.997). Among biomarker values derived from the multiplex assay, the strongest correlation was between the axonal and neuronal markers, NF-L and UCH-L1 (coefficient?=?0.71). The weakest correlation was between the glial marker GFAP and the axonal marker tau (coefficient?=?0.06). The areas under the curves for distinguishing between subjects with/without abnormal head CT for multiplex GFAP, UCH-L1, NF-L, and total tau were: 0.88 (95% confidence interval 0.81-0.95), 0.86 (0.79-0.93), 0.84 (0.77-0.92), and 0.77 0.67-0.86), respectively. We conclude that the multiplex assay provides simultaneous quantification of GFAP, UCH-L1, NF-L, and tau, and may be clinically useful in the diagnosis of TBI as well as identifying different types of cellular injury. 2
27. Bazarian JJ, Biberthaler P, Welch RD, et al. Serum GFAP and UCH-L1 for prediction of absence of intracranial injuries on head CT (ALERT-TBI): a multicentre observational study. Lancet neurol.. 17(9):782-789, 2018 09. Observational-Dx 1977 patients To validate a test combining ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), at predetermined cutoff values, to predict traumatic intracranial injuries on head CT scan acutely after traumatic brain injury (TBI). Between Dec 6, 2012, and March 20, 2014, 1977 patients were recruited, of whom 1959 had analysable data. 125 (6%) patients had CT-detected intracranial injuries and eight (<1%) had neurosurgically manageable injuries. 1288 (66%) patients had a positive UCH-L1 and GFAP test result and 671 (34%) had a negative test result. For detection of intracranial injury, the test had a sensitivity of 0·976 (95% CI 0·931-0·995) and an NPV of 0·996 (0·987-0·999). In three (<1%) of 1959 patients, the CT scan was positive when the test was negative. 2
28. Calcagnile O, Unden L, Unden J. Clinical validation of S100B use in management of mild head injury. BMC emerg. med.. 12:13, 2012 Oct 27. Observational-Dx 512 patients To examine the clinical impact and performance of S100B in clinical use for MHI patients. 512 patients were included. 24 (4.7%) showed traumatic abnormalities on CT and 1 patient died (0.2%). 138 patients (27%) had normal S100B levels and 374 patients (73%) showed elevated S100B levels. No patients with a normal S100B level showed significant intracranial complication. 44 patients (32%) were managed with CT despite the guidelines recommending discharge (all these CT scans were normal) and 28 patients (7%) were discharged despite a CT recommendation (follow-up was normal in all these patients). S100B had a sensitivity of 100% (95% CI 83-100%) and a specificity of 28% (95% CI 24-33%) for significant intracranial complications. 2
29. Linsenmaier U, Wirth S, Kanz KG, Geyer LL. Imaging minor head injury (MHI) in emergency radiology: MRI highlights additional intracranial findings after measurement of trauma biomarker S-100B in patients with normal CCT. Br J Radiol. 89(1061):20150827, 2016. Observational-Dx 41 patients To investigate whether MRI in emergency radiology can detect (a) additional trauma-related findings after minor head injury (MHI) or (b) structural, non-trauma-related intracranial lesions when trauma biomarker S-100B concentration is raised, or clinical symptoms are unexplained, or both. Compared with CCT, MRI detected 10 additional lesions. 5 patients had abnormal MRI with a total of 15 trauma-related lesions and showed elevated S-100B concentrations. Although sensitivity of S-100B was 100%, specificity was only 25%. Patients with structural brain lesions showed significantly higher S-100B serum levels (0.50 and 0.14?µg?l(-1), p?=?0.01). 1
30. Vakil MT, Singh AK. A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. [Review]. EMERG. RADIOL.. 24(3):301-309, 2017 Jun. Review/Other-Dx N/A To describe the imaging features of various post-traumatic complications and their treatment implications. No results stated in the abstract 4
31. Kido DK, Cox C, Hamill RW, Rothenberg BM, Woolf PD. Traumatic brain injuries: predictive usefulness of CT. Radiology. 1992;182(3):777-781. Observational-Dx 72 patients CT scans from patients with TBI were reviewed to determine whether a specific type, location, or size of lesion correlated with changes in neurologic function (assessed with the GCS), patient outcome (assessed with the GOS), or catecholamine levels. GOS changed as a function of lesions size (P=.00004) in the 48 patients with focal hemorrhages, regardless of whether the lesions were intra- or extraaxial, and in the 19 patients with normal CT scans. Patients with lesions larger than 4,100 mm3 had a twofold greater risk of a poor outcome than patients with smaller lesions (100% vs 50%). Patients with normal CT scans were significantly more likely to have mild neurological dysfunction or none than patients with abnormal CT scans (P=.03), but lesion location, skull fracture, and pineal shift were not significant predictors of GCS or GOS scores. A positive relationship existed between lesion size and both plasma norepinephrine and epinephrine levels (P<.02); a significant relationship existed between lesion size and GCS score (P=.02). 2
32. Haacke EM, Duhaime AC, Gean AD, et al. Common data elements in radiologic imaging of traumatic brain injury. [Review]. J Magn Reson Imaging. 32(3):516-43, 2010 Sep. Review/Other-Dx N/A To evaluate the common data elements (CDEs) that cut across the imaging field and given the charge to review the contributions of the various imaging modalities to Traumatic brain injury (TBI) and to prepare an overview of the various clinical manifestations of TBI and their interpretation. No results stated in the abstract. 4
33. Zhou B, Ding VY, Li Y, et al. Validation of the NeuroImaging Radiological Interpretation System for Acute Traumatic Brain Injury. J Comput Assist Tomogr. 43(5):690-696, 2019 Sep/Oct. Observational-Dx 648 patients To refine and validate the NeuroImaging Radiological Interpretation System (NIRIS), which was developed to predict management and clinical outcome based on noncontrast head computerized tomography findings in patients suspected of acute traumatic brain injury (TBI). The NIRIS performed similarly to the Marshall and Rotterdam scoring systems in predicting mortality and markedly better in terms of predicting more granular elements of disposition and management of TBI patients, such as admission, follow-up imaging, intensive care unit stay, and neurosurgical procedures. The revised NIRIS classification correctly predicted disposition and outcome in 91.2% (331/363) after excluding patients with other major extracranial traumatic injuries or intracranial nontraumatic injuries. 2
34. Isokuortti H, Luoto TM, Kataja A, et al. Necessity of monitoring after negative head CT in acute head injury. Injury. 45(9):1340-4, 2014 Sep. Review/Other-Dx 3023 patients To evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT). The majority (n=1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n=27) of these patients returned to ED within 72h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%. 4
35. Chenoweth JA, Gaona SD, Faul M, Holmes JF, Nishijima DK, Sacramento County Prehospital Research Consortium. Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma. JAMA Surg. 153(6):570-575, 2018 06 01. Observational-Dx 859 patients To investigate the incidence of delayed traumatic intracranial hemorrhage in older adults with head trauma, including those taking anticoagulant and antiplatelet medications. Among 859 patients enrolled in the study, the median age was 75 years (interquartile range, 64-85 years), and 389 (45.3%) were male. A total of 343 patients (39.9%) were taking an anticoagulant or antiplatelet medication. Three patients (0.3%; 95% CI, 0.1%-1.0%) had a delayed traumatic intracranial hemorrhage. Of the 3 patients, 1 of 75 patients (1.3%; 95% CI, 0.0%-7.2%) who were taking warfarin sodium alone and 2 of 516 patients (0.4%; 95% CI, 0.1%-1.4%) who were not taking any anticoagulant or antiplatelet medication had a delayed traumatic intracranial hemorrhage. Thirty-nine patients (4.5%; 95% CI, 3.2%-6.2%) were lost to follow-up. 2
36. Fiser SM, Johnson SB, Fortune JB. Resource utilization in traumatic brain injury: the role of magnetic resonance imaging. Am Surg. 1998;64(11):1088-1093. Observational-Dx 40 patients had 79 CT scans and 40 MRIs Retrospective review to determine whether MRI influenced the acute diagnosis and management of TBI patients. 9 patients (22.5%) had injuries on CT scan but not on MRI; most commonly skull fractures or small subarachnoid hemorrhages. 24 patients (60%) had injuries on MRI but not on CT scan, most commonly corpus callosum shear injuries. There were 2 cases of child abuse and both had injuries of varying ages identified by MRI, but not CT. All injuries requiring a therapeutic intervention or change in management were identified by CT scan. MRI identified one patient with a traumatic ICA thrombosis. The performance of MRI resulted in additional charges of $75,640 or $3,152/patient identified with a new lesion. Although MRI identifies lesions not evident on CT scan, MRI does not alter management plans and is of limited value in the acute management of TBI. MRI may be of medicolegal benefit in cases of child abuse. 3
37. Manolakaki D, Velmahos GC, Spaniolas K, de Moya M, Alam HB. Early magnetic resonance imaging is unnecessary in patients with traumatic brain injury. J Trauma. 2009;66(4):1008-1012; discussion 1012-1004. Observational-Dx 123 trauma patients To evaluate the role of early MRI in the initial management of patients with TBI. The authors identified 123 trauma patients who had MRI within 18 hours +/- 14.5 hours of CT (median: 12 hours). In 82 (67%) patients, the findings of CT and MRI were identical. In the remaining 41 patients there were discrepancies between CT and MRI: 35 patients had slight differences in the location or size of the lesions found and 6 had minor brain lesion detected by MRI and not CT. Compared with patients who had identical CT and MRI, those who showed differences in the 2 tests had higher severity of head injury, lower initial blood pressure, and a higher rate of intubation. Based on CT findings, 78 (63%) patients received TBI-related interventions: 8 craniotomies, 12 intracranial pressure monitoring catheters, 14 mannitol infusions, and 72 antiepileptic medications. There was no change in treatment because of MRI. 2
38. Yuh EL, Mukherjee P, Lingsma HF, et al. Magnetic resonance imaging improves 3-month outcome prediction in mild traumatic brain injury. Ann Neurol. 73(2):224-35, 2013 Feb. Observational-Dx 135 patients To determine the clinical relevance, if any, of traumatic intracranial findings on early head CT and brain MRI to 3-month outcome in mTBI. 27% of mTBI patients with normal admission head CT had abnormal early brain MRI. CT evidence of subarachnoid hemorrhage was associated with a multivariate OR of 3.5 (P=0.01) for poorer 3-month outcome, after adjusting for demographic, clinical, and socioeconomic factors. One or more brain contusions on MRI, and =4 foci of hemorrhagic axonal injury on MRI, were each independently associated with poorer 3-month outcome, with multivariate ORs of 4.5 (P=0.01) and 3.2 (P=0.03), respectively, after adjusting for head CT findings and demographic, clinical, and socioeconomic factors. 2
39. Yue JK, Yuh EL, Korley FK, et al. Association between plasma GFAP concentrations and MRI abnormalities in patients with CT-negative traumatic brain injury in the TRACK-TBI cohort: a prospective multicentre study. Lancet neurol.. 18(10):953-961, 2019 Oct. Observational-Dx 450 patients To assess the discriminative ability of glial fibrillary acidic protein (GFAP)  to identify MRI abnormalities in patients with normal CT findings. Between Feb 26, 2014, and June 15, 2018, we recruited 450 patients with normal head CT scans (of whom 330 had negative MRI scans and 120 had positive MRI scans), 122 orthopaedic trauma controls, and 209 healthy controls. AUC for GFAP in patients with CT-negative and MRI-positive findings versus patients with CT-negative and MRI-negative findings was 0·777 (95% CI 0·726-0·829) over 24 h. Median plasma GFAP concentration was highest in patients with CT-negative and MRI-positive findings (414·4 pg/mL, 25-75th percentile 139·3-813·4), followed by patients with CT-negative and MRI-negative findings (74·0 pg/mL, 17·5-214·4), orthopaedic trauma controls (13·1 pg/mL, 6·9-20·0), and healthy controls (8·0 pg/mL, 3·0-14·0; all comparisons between patients with CT-negative MRI-positive findings and other groups p<0·0001). 2
40. Reljic T, Mahony H, Djulbegovic B, et al. Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis. [Review]. J Neurotrauma. 31(1):78-98, 2014 Jan 01. Meta-analysis 41 studies enrolling 10,501 patients Systematic review and meta-analysis were performed to determine the value of repeat head CT after TBI. Change in management following repeat CT was reported in 13 prospective and 28 retrospective studies and yielded a pooled proportion of 11.4% (95% CI, 5.9–18.4) and 9.6% (95% CI, 6.5–13.2), respectively. In a subgroup analysis of mTBI patients (GCS score 13 to 15), 5 prospective and 9 retrospective studies reported on change in management following repeat CT with the pooled proportion across prospective studies at 2.3% (95% CI, 0.3–6.3) and across retrospective studies at 3.9% (95% CI, 2.3–5.7), respectively. The evidence suggests that repeat CT in patients with TBI results in a change in management for only a minority of patients. Better designed studies are needed to address the issue of the value of repeat CT in the management of TBI. M
41. Joseph B, Sadoun M, Aziz H, et al. Repeat head computed tomography in anticoagulated traumatic brain injury patients: still warranted. Am Surg. 80(1):43-7, 2014 Jan. Review/Other-Dx 1606 patients To describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with  intracranial hemorrhage (ICH)and evaluate the use of repeat head computed tomography (CT) in this group. A comparison between prehospital CAP and no-CAP patients was done using ?(2) and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older (P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission (P < 0.001), were more likely to present with an abnormal neurologic examination (P = 0.004), and had higher hospital and intensive care unit lengths of stay (P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information. 4
42. Washington CW, Grubb RL, Jr. Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? J Neurosurg. 2012;116(3):549-557. Review/Other-Dx 321 patients To determine if there exists a subpopulation of mTBI patients with an abnormal head CT scan that requires neither repeat brain imaging nor admission to an ICU. 321/1,101 reviewed cases that met inclusion criteria for the study. Only 4 patients (1%) suffered a neurological decline and 4 (1%) required nonemergent neurosurgical intervention. There was a medical decline in 18 of the patients (6%) as a result of a combination of events such as respiratory distress, myocardial infarction, and sepsis. Both patient age and the transfusion of blood products were significant predictors of medical decline. Overall patient mortality was 1%. Based on imaging data, the rate of injury progression was 6%. The only type of ICH found to have a significant rate of progression (53%) was a subfrontal/temporal intraparenchymal contusion. Other variables found to be significant predictors of progression on head CT scans were the use of anticoagulation, an age >65 years, and a volume of ICH >10 mL. 4
43. Salmela MB, Mortazavi S, Jagadeesan BD, et al. ACR Appropriateness Criteria® Cerebrovascular Disease. J Am Coll Radiol 2017;14:S34-S61. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for cerebrovascular disease. No results stated in abstract. 4
44. Peskind ER, Petrie EC, Cross DJ, et al. Cerebrocerebellar hypometabolism associated with repetitive blast exposure mild traumatic brain injury in 12 Iraq war Veterans with persistent post-concussive symptoms. Neuroimage. 2011;54 Suppl 1:S76-82. Review/Other-Dx 12 Iraq war Veterans with mTBI and 12 controls To determine the extent to which persistent post-concussive symptoms reported by Iraq combat Veterans with repeated episodes of mTBI from explosive blasts represent structural or functional brain damage or an epiphenomenon of comorbid depression or post-traumatic stress disorder. Compared to controls, Veterans with mTBI (with or without post-traumatic stress disorder) exhibited decreased cerebral metabolic rate of glucose in the cerebellum, vermis, pons, and medial temporal lobe. They also exhibited subtle impairments in verbal fluency, cognitive processing speed, attention, and working memory, similar to those reported in the literature for patients with cerebellar lesions. These FDG-PET imaging findings suggest that regional brain hypometabolism may constitute a neurobiological substrate for chronic post-concussive symptoms in Iraq combat Veterans with repetitive blast-trauma mTBI. 4
45. Wintermark M, Sanelli PC, Anzai Y, Tsiouris AJ, Whitlow CT, American College of Radiology Head Injury Institute. Imaging evidence and recommendations for traumatic brain injury: advanced neuro- and neurovascular imaging techniques. AJNR Am J Neuroradiol. 36(2):E1-E11, 2015 Feb. Review/Other-Dx N/A To review advanced neuroimaging techniques in the evaluation of patients with TBI. Advanced neuroimaging techniques, including MRI diffusion-tensor imaging, blood oxygen level–dependent fMRI, MRS, perfusion imaging, PET/SPECT, and magnetoencephalography, are of particular interest in identifying further injury in patients with TBI when conventional non-contrast CT and MRI findings are normal, as well as for prognostication in patients with persistent symptoms. These advanced neuroimaging techniques are currently under investigation in an attempt to optimize them and substantiate their clinical relevance in individual patients. However, the data currently available confine their use to the research arena for group comparisons, and there remains insufficient evidence at the time of this writing to conclude that these advanced techniques can be used for routine clinical use at the individual patient level. 4
46. Dhandapani S, Sharma A, Sharma K, Das L. Comparative evaluation of MRS and SPECT in prognostication of patients with mild to moderate head injury. J Clin Neurosci. 21(5):745-50, 2014 May. Observational-Dx 53 patients To comparatively assess both in patients with mild to moderate head injury. There were 56 SPECT (Tc99m-ethylcysteinate dimer [ECD]) studies and 41 single voxel proton MRS performed in 53 patients, with 41 patients having both. Of the 41 who underwent MRS, 13 had a lower N-acetyl-aspartate/creatine (NAA/Cr) ratio, 14 had a higher choline (Cho)/Cr ratio, 19 were normal, and nine had bilateral MRS abnormalities. Of the 56 who underwent SPECT, 22 and 19 had severe and moderate hypoperfusion, respectively. Among those in Traumatic Coma Data Bank CT scan category 1 and 2, 50% had MRS abnormalities, whereas 64% had SPECT hypoperfusion, suggesting greater incremental validity of SPECT over MRS. In univariate analyses, GCS, moderate/severe hypoperfusion and bilateral SPECT changes were found to have significant association with unfavorable outcome (odds ratio 13.2, 15.9, and 4.4, and p values <0.01, 0.01, and 0.05, respectively). Patients with lower NAA/Cr ratio in MRS had more unfavorable outcomes, however this was not significant. In multivariate analysis employing binary logistic regression, GCS and severe hypoperfusion on SPECT were noted to have significant association with unfavorable outcome, independent of age, CT scan category, and MRS abnormalities (p values=0.02 and 0.04, respectively). To conclude, ECD-SPECT seems to have greater sensitivity, incremental validity and prognostic value than single voxel proton MRS in select patients with head injury, with only severe hypoperfusion in SPECT significantly associated with unfavorable outcome independent of other confounding factors. 2
47. Jantzen KJ. Functional magnetic resonance imaging of mild traumatic brain injury. J Head Trauma Rehabil. 2010;25(4):256-266. Review/Other-Dx N/A To review the recent fMRI literature relevant to the study of mTBI. The pathophysiology of mTBI and the neural basis of the blood oxygen level-dependent fMRI response are also considered with particular focus on important issues for using fMRI to investigate mTBI. fMRI offers potential for understanding the neural and functional basis of mTBI and the relationship to behavioral and somatic symptoms. 4
48. Palacios EM, Yuh EL, Chang YS, et al. Resting-State Functional Connectivity Alterations Associated with Six-Month Outcomes in Mild Traumatic Brain Injury. J Neurotrauma. 34(8):1546-1557, 2017 04 15. Review/Other-Dx 75 patients To investigate resting-state functional MRI (rsfMRI) to assess semiacute alterations in brain connectivity and its relationship with outcome measures assessed 6 months after injury. Alterations were found in the spatial maps of the RSNs between mTBI patients and healthy controls in networks involved in behavioral and cognition processes. These alterations were predictive of mTBI patients' outcomes at 6 months post-injury. Moreover, different patterns of reduced network interactions were found between the CT/MRI positive and CT/MRI negative patients and the control group. These rsfMRI results demonstrate that even mTBI patients not showing brain lesions on conventional CT/MRI scans can have alterations of functional connectivity at the semiacute stage that help explain their outcomes. These results suggest rsfMRI as a sensitive biomarker both for early diagnosis and for prediction of the cognitive and behavioral performance of these patients. 4
49. Wooten DW, Ortiz-Teran L, Zubcevik N, et al. Multi-Modal Signatures of Tau Pathology, Neuronal Fiber Integrity, and Functional Connectivity in Traumatic Brain Injury. J Neurotrauma. 2019 Aug 01. Review/Other-Dx 19 patients To explore the utility of such multi-modal imaging in a case series based on a population of  traumatic brain injury (TBI). Nineteen subjects (11 controls, five former contact sports athletes, one automotive accident, and two with military-related injury) underwent [18F]AV-1451 PET and magnetic resonance scanning procedures. [18F]AV-1451 distribution volume ratio (DVR) was estimated using the Logan method and the cerebellum as a reference region. Diffusion tractography images and fractional anisotropy (FA) images were generated using diffusion toolkit and FSL. Resting-state functional MRI (fMRI) analysis was based on a graph theory metric, namely weighted degree centrality. TBI subjects showed greater heterogeneity in [18F]AV-1451 DVR when compared with control subjects. In a subset of TBI subjects, areas with high [18F]AV-1451 binding corresponded with increased FA and diminished white matter tract density in DTI. Functional MRI results exhibited an increase in functional connectivity, particularly among local connections, in the areas where tau aggregates were more prevalent. In a case series of a diverse group of TBI subjects, brain regions with elevated tau burden exhibited increased functional connectivity as well as decreased white matter integrity. These findings portray molecular, microstructural, and functional corollaries of TBI that spatially coincide and can be measured in the living human brain using noninvasive neuroimaging techniques. 4
50. Wang X, Wei XE, Li MH, et al. Microbleeds on susceptibility-weighted MRI in depressive and non-depressive patients after mild traumatic brain injury. Neurol Sci. 2014;35(10):1533-1539. Review/Other-Dx 200 patients To explore the relationship between abnormality on SWI and newly-developed depression after mTBI. The difference in microbleed lesions on SWI was compared between the depressive and nondepressive groups. The depressive group had a higher rate of abnormality on SWI than did the non-depressive group (P<0.001). Among patients that had exhibited microbleed lesions, the number and volume of lesions were greater in the depressive group than the nondepressive group (both P<0.001). These differences in numbers and volume of lesions were found only at the frontal, parietal and temporal lobes (all P<0.001). Among patients that had exhibited microbleed lesions, the number and volume of lesions in other areas were not significantly different between the depressive and nondepressive groups (all P>0.05). 4
51. Skandsen T, Kvistad KA, Solheim O, Strand IH, Folvik M, Vik A. Prevalence and impact of diffuse axonal injury in patients with moderate and severe head injury: a cohort study of early magnetic resonance imaging findings and 1-year outcome. J Neurosurg. 2010;113(3):556-563. Observational-Dx 106 patients To explore the occurrence of DAI and determine whether DAI was related to level of consciousness and patient outcome. DAI was detected in 72% of the patients and a combination of DAI and contusions or hematomas was found in 50%. The GCS was significantly lower in patients with "pure DAI" (median GCS 9) than in patients without DAI (median GCS 12; P<0.001). The GCS score was related to outcome only in those patients with DAI (r = 0.47; P=0.001). Patients with DAI had a median GOSE score of 7, and patients without DAI had a median GOSE score of 8 (P=0.10). Outcome was better in patients with DAI Stage 1 (median GOSE Score 8) and DAI Stage 2 (median GOSE Score 7.5) than in patients with DAI Stage 3 (median GOSE Score 4; P<0.001). Thus, in patients without any brainstem injury, there was no difference in good recovery between patients with DAI (67%) and patients without DAI (66%). 2
52. Kampfl A, Schmutzhard E, Franz G, et al. Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging. Lancet. 1998;351(9118):1763-1767. Observational-Dx 80 patients; 3 blinded reviewers To define the MRI signs of cerebral injury in patients in post-traumatic vegetative state. Authors also examined whether lesions in certain brain areas can predict that there will be non-recovery from a post-traumatic vegetative state. Cerebral MRI findings in the subacute stage after head injury can predict the outcome of the post-traumatic vegetative state. Corpus callosum and dorsolateral brainstem lesions are highly significant in predicting non-recovery. 2
53. Douglas DB, Muldermans JL, Wintermark M. Neuroimaging of brain trauma. [Review]. Curr Opin Neurol. 31(4):362-370, 2018 08. Review/Other-Dx N/A To provide an update on advanced neuroimaging techniques in traumatic brain injury (TBI). We will focus this review on recent literature published within the last 18 months and the advanced neuroimaging techniques of perfusion imaging and diffusion tensor imaging (DTI). In the setting of a moderate or severe acute closed head injury (Glasgow Coma Scale <13), the most appropriate neuroimaging study is a noncontrast computed tomography (CT) scan. In the setting of mild TBI, the indication for neuroimaging can be determined using the New Orleans Criteria or Canadian CT Head Rules or National Emergency X-Ray Utilization Study-II clinical criteria. Two advanced neuroimaging techniques that are currently being researched in TBI include perfusion imaging and DTI. Perfusion CT has a higher sensitivity for detecting cerebral contusions than noncontrast CT examinations. DTI is a sensitive at detecting TBI at the group level (TBI-group versus control group), but there is insufficient evidence to suggest that DTI plays a clinical role for diagnosing mild TBI at the individual patient level. 4
54. Mayer AR, Ling J, Mannell MV, et al. A prospective diffusion tensor imaging study in mild traumatic brain injury. Neurology. 2010;74(8):643-650. Observational-Dx 22 patients with semi-acute mTBI, 21 matched healthy controls. 32 healthy controls from independent sample To investigate white matter integrity and compare the accuracy of traditional anatomic scans, neuropsychological testing, and diffusion tensor imaging for objectively classifying mTBI patients from controls. mTBI patients did not differ from controls on clinical imaging scans or neuropsychological performance, although effect sizes were consistent with literature values. In contrast, mTBI patients demonstrated significantly greater fractional anisotropy as a result of reduced radial diffusivity in the corpus callosum and several left hemisphere tracts. Diffusion tensor imaging measures were more accurate than traditional clinical measures in classifying patients from controls. Longitudinal data provided preliminary evidence of partial normalization of diffusion tensor imaging values in several white matter tracts. 3
55. Strauss SB, Kim N, Branch CA, et al. Bidirectional Changes in Anisotropy Are Associated with Outcomes in Mild Traumatic Brain Injury. AJNR Am J Neuroradiol. 37(11):1983-1991, 2016 Nov. Observational-Dx 39 patients To identify early diffusion tensor imaging biomarkers of mild traumatic brain injury that significantly relate to outcomes at 1 year following injury. Significant associations of brain-wide DTI measures and outcomes included the following: mean radial diffusivity and mean diffusivity with memory; and mean fractional anisotropy, radial diffusivity, and mean diffusivity with health-related quality of life. Significant differences in outcomes were found between subjects with and without abnormally high fractional anisotropy for the following white matter regions and outcome measures: left frontal lobe and left temporal lobe with attention at 1 year, left and right cerebelli with somatic postconcussion symptoms at 1 year, and right thalamus with emotional postconcussion symptoms at 1 year. 1
56. Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 68(2):471-7, 2010 Feb. Review/Other-Dx 68 articles EBM guideline for the screening, diagnosis, and treatment of BCVI by the Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee. The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified, screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (=8 slice) CTA may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population. 4
57. George E, Khandelwal A, Potter C, et al. Blunt traumatic vascular injuries of the head and neck in the ED. [Review]. EMERG. RADIOL.. 26(1):75-85, 2019 Feb. Review/Other-Dx N/A To  review the epidemiology of and the various proposed screening criteria for blunt cerebrovascular injury. No results stated in the abstract. 4
58. Baugnon KL, Hudgins PA. Skull base fractures and their complications. [Review]. Neuroimaging Clin N Am. 24(3):439-65, vii-viii, 2014 Aug. Review/Other-Dx N/A To review skull base anatomy; morphology of the common fracture patterns within the anterior, central, and posterior skull base; associated complications; imaging findings; and possible pitfalls in imaging of skull base trauma. Transverse middle cranial fossa fractures extending through the carotid canal are at increased risk for vascular injury, and should prompt screening with vascular studies, such as CTA. Thin-section multiplanar CT reformations, as well as 3-D reconstructions, are helpful in the detection of subtle skull base fractures. 4
59. Schroeder JW, Ptak T, Corey AS, et al. ACR Appropriateness Criteria® Penetrating Neck Injury. J Am Coll Radiol 2017;14:S500-S05. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for penetrating neck injury. No results stated in abstract. 4
60. Eastman AL, Chason DP, Perez CL, McAnulty AL, Minei JP. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma. 2006;60(5):925-929; discussion 929. Observational-Dx 162 patients To determine the sensitivity of CTA for the diagnosis of BCVI. The authors hypothesized that advances in CT technology have improved the diagnostic sensitivity of CTA at least to that of invasive catheter angiography. Over 11 months, 162 patients were at risk for BCVI. In all, 146 patients received both CTA and CA. 46 BCVIs were identified among 43 patients. In 45/46 cases (98%), the results of CTA and catheter angiography were concordant. There was a single false-negative CTA in a patient with a grade I vertebral artery injury. The remaining 103 patients had normal CTAs confirmed by a normal catheter angiography. The overall sensitivity, specificity, PPV, NPV, and accuracy of CTA for the diagnosis of BCVI were 97.7%, 100%, 100%, 99.3%, and 99.3%, respectively. 3
61. Slasky SE, Rivaud Y, Suberlak M, et al. Venous Sinus Thrombosis in Blunt Trauma: Incidence and Risk Factors. J Comput Assist Tomogr. 41(6):891-897, 2017 Nov/Dec. Observational-Dx 472 patients To determine the incidence and risk factors of dural venous sinus thrombosis and epidural hemorrhage in the setting of a blunt trauma causing a calvarial fracture crossing a dural venous sinus. We found a 23% incidence of dural venous sinus thrombosis in patients with a fracture traversing a dural venous sinus. Significant predictors of thrombosis included temporal fracture (38% incidence) and skull base fracture (31% incidence). Occipital fracture not involving the skull base was associated with a significantly decreased risk of thrombosis, with an incidence of 9%. Decreased GCS score and fall from height greater than 10 feet additionally predicted dural venous sinus thrombosis. Significant predictors of epidural hemorrhage included parietal fractures and displaced fractures, although a large percentage of nondisplaced fractures in other bones demonstrated epidural hemorrhage as well. 2
62. Delgado Almandoz JE, Kelly HR, Schaefer PW, Lev MH, Gonzalez RG, Romero JM. Prevalence of traumatic dural venous sinus thrombosis in high-risk acute blunt head trauma patients evaluated with multidetector CT venography. Radiology. 2010;255(2):570-577. Review/Other-Dx 195 patients To determine the prevalence of trauma-related dural venous sinus thrombosis in high-risk patients with blunt head trauma who are examined with MDCT venography. MDCT venography depicted thrombosis of 98 dural sinuses or jugular bulbs in 57 (40.7%) of the 140 patients with skull fractures extending to a dural sinus or jugular bulb. 54 (55%) of the 98 sinuses or bulbs had occlusive thrombosis. dural venous sinus thrombosis was seen in only those patients with skull fractures extending to a dural sinus or jugular bulb. Among the skull fractures extending to the transverse sinus, sigmoid sinus, or jugular bulb, those of the petrous temporal bone had a higher risk (50%, 36/72 fractures) of traumatic dural venous sinus thrombosis than did those of the occipital bone (34% risk [32/93 fractures]) (P=.044). However, among the skull fractures extending to the superior sagittal sinus, those of the occipital bone had a higher risk (67% [8/12 fractures]) of traumatic dural venous sinus thrombosis than did those of the parietal (39% risk [11/28 fractures]) and frontal (24% risk [4/17 fractures]) bones (P=.065). 4 (7%) patients with traumatic dural venous sinus thrombosis had associated hemorrhagic venous infarctions, all secondary to occlusive dural venous sinus thrombosis. 4
63. Oh JW, Kim SH, Whang K. Traumatic Cerebrospinal Fluid Leak: Diagnosis and Management. [Review]. Korean j. neurotrauma. 13(2):63-67, 2017 Oct. Review/Other-Dx N/A To review the pathophysiology, manifestations as well as the update of the clinical diagnosis and current management of Cerebrospinal fluid (CSF) leaks. No results stated in the abstract 4
64. Hiremath SB, Gautam AA, Sasindran V, Therakathu J, Benjamin G. Cerebrospinal fluid rhinorrhea and otorrhea: A multimodality imaging approach. [Review]. Diagn Interv Imaging. 100(1):3-15, 2019 Jan. Review/Other-Dx N/A To discuss relevant anatomy, clinical diagnosis, imaging modalities and associated findings along with a brief mention about management. No results stated in the abstract. 4
65. Stone JA, Castillo M, Neelon B, Mukherji SK. Evaluation of CSF leaks: high-resolution CT compared with contrast-enhanced CT and radionuclide cisternography. AJNR Am J Neuroradiol. 1999;20(4):706-712. Observational-Dx 42 patients To evaluate the use of screening noncontrast high-resolution CT in identifying the presence and site of CSF rhinorrhea and otorrhea and compare it with contrast-enhanced CT cisternography and radionuclide cisternography. High-resolution CT showed bone defects in 30/42 patients (71%) with CSF leak. High-resolution, radionuclide cisternography and CT cisternography did not show bone defects or CSF leak for 12 patients (29%) who had clinical evidence of CSF leak. Among the 30 patients with bone defects, 20 (66%) had positive results of their radionuclide cisternography and/or CT cisternography. For the 21 patients who underwent surgical exploration and repair, intraoperative findings correlated with the defects revealed by high-resolution CT in all cases. High-resolution CT identified significantly more patients with CSF leak than did radionuclide cisternography and CT cisternography, with a moderate degree of agreement. 3
66. Zapalac JS, Marple BF, Schwade ND. Skull base cerebrospinal fluid fistulas: a comprehensive diagnostic algorithm. Otolaryngol Head Neck Surg. 2002;126(6):669-676. Observational-Dx 52 patients To assess the efficacy of current diagnostic modalities in the management of skull base CSF fistulas. beta2-Transferrin analysis of collected specimen was the most efficacious means of confirming a CSF leak. High-resolution CT was the most informative radiographic study, yielding a sensitivity and an accuracy of 87%. MR cisternography, yielding a sensitivity and an accuracy of 78%, was instrumental in localizing the site of leak for a few cases but was most commonly corroborative. Using a graduated diagnostic approach, successful repair was attained in 88% of cases after 1 attempt and 98% after 1 or 2 attempts. 3
67. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
No of Rows: 67