Do routinely repeated computed tomography scans in traumatic brain injury influence management? A prospective...

To prospectively examine the clinical role of routine repeat computed tomographic scans of the brain (CTB) in patients with traumatic head injury.

The use of routine serial CTB after traumatic head injury is recommended by some authors, but remains controversial.

From March 2007 to October 2008, all patients with traumatic head injury admitted to the Royal Melbourne Hospital, a metropolitan, Level I trauma center, were prospectively studied. After the initial computed tomography brain scans, any subsequent CTBs were assessed and were recorded as being either "clinically indicated" or "routine" and ensuing medical and surgical management. Inpatient information was recorded and comparisons made according to indication for CTB, Glasgow Coma Scale, and management changes.

A total of 651 patients were admitted with traumatic head injury over the 20-month study period. Of those, 39 underwent immediate craniotomy/craniectomy and were excluded from analysis. Another 25 were excluded due to incomplete data, leaving 591 patients for analysis. Of the 591 assessed, 401 were discharged with no further computed tomography investigation. One hundred and ninety patients underwent a total of 305 repeat brain scans, of which 149 were clinically indicated, whereas 156 were obtained as a "routine" investigation with no deterioration in patients' neurological status. Of the repeated scans, 71 were improved, 169 were unchanged, and 64 were worse. None of the 156 patients who received a "routine" CTB required a change in management. The 149 CTB performed for clinical deterioration resulted in a change in management in 28 patients (19%). The patients who underwent "indicated" computed tomographic scans and subsequently required a change in management were on average younger (P < 0.001) and more severely head injured (P = 0.001) than the patients not requiring a change in management.

No patients from our cohort with a "routine" repeat CTB required a change in management. Given the costs and potential risks of routine repeat CTB, and lack of demonstrable benefit, the practice should be reconsidered. Repeat CTB is clearly indicated in patients with deteriorating neurological status, especially younger and more severely head-injured patients.