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Mild head injuries: a novelty in the diagnostic and therapeutic pathway

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The report “Headshots, The Importance of Diagnostic Tests in Detecting Mild Head Injury” reviews the diagnostic and therapeutic pathway for patients with head injuries and highlights the unmet needs that still exist in the country. Clinicians stress the importance of the diagnostic use of certain vital signs and the need to update head injury guidelines

July 26

Globally, approximately 70 million people suffer head injuries each year, and it is the most common neurological disorder in the world. The disease has a significant impact on public health due to the high rates of mortality, morbidity and disability associated with it. A group of emergency medicine specialists recently drafted the report Head shots, the importance of diagnostic tests in identifying mild head injury., which measures the diagnostic-therapeutic path of patients with this condition and highlights the unmet needs that still exist in the country. Clinicians also stress the importance of the diagnostic use of certain biomarkers and the need to update TBI guidelines.

Risk classification is needed

The diagnosis and evaluation of the extent of the shock is done in the emergency room. The main symptoms of head trauma are: headache, nausea, vomiting, feeling tired and unconscious. Classification is made into moderate, moderate and severe using the Glasgow Coma Score (GCS), a score that takes into account the opening of the eyes, verbal response, and motor response,” he explains. Mario GuarinoDirector of the Emergency Department of Emergency Medicine at the CTO in Naples and Director of the Summer School of SIMEU (Italian Society for Emergency/Emergency Medicine), who participated in the drafting of the report.

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It is estimated that 90% of brain injuries are classified as mild, and mild brain injuries are about 15 times more common than moderate injuries and 20 times more common than severe ones. Even in mild head trauma (hence with a GCS of 14 or 15), severe intracranial lesions may be present, especially in the presence of specific risk factors, “such as taking anticoagulants and antiplatelet agents (which many older adults take), medications that expose you to For the risk of cerebral hemorrhage, Guarino continues.

That’s why, according to the report, risk categorization is fundamental to the diagnosis, based on the integration of preclinical data, trauma data (dynamics) and drug history.

Diagnostic-therapeutic diversion

He notes “Over the past few years, we have witnessed a shift in the diagnostic-therapeutic course of patients with head injuries, both in terms of diagnostic possibilities and in terms of the epidemiological characteristics of patients,” Andrea FabriD., director of the Emergency Department of Emergency Medicine, 118 Forlì and Treasurer SIMEU, who is also the author of the report.

Twenty years ago, the incidence was high among the young and the elderly (over 65 years of age). Today, thanks to street prevention measures, the infection rate has decreased among the young and increased among the elderly. “There was also a significant increase in non-contrast computed tomography (CT) brain scans.”

Although this imaging technique is effective in detecting traumatic lesions that require observation or neurosurgical evacuation, regular CT is not desirable in all patients due to the limited prevalence of positivity, radiological risks of exposure, and long stays. In emergency departments, And inefficient use of resources, high cost and complexity. These factors are of greater importance for patients with mild head injuries, for whom the prevalence of intracranial lesions detected by CT is generally less than 10%. “For this reason, we are looking at different diagnostic algorithms,” Fabry says.

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It also adds Alessio BertiniMD, director of the Complex Structure of Emergency Medicine and First Aid Hospital Maggiore AUSL Bologna and author of the report, “The use of CT scans can lead to problems, due to the use of radiation, in cases where patients are children or women who are pregnant.”

Possible diagnostic signs of traumatic brain injury
To date, the identification of mild head injury is a major challenge with consequences for the clinical management of patients. Despite the increased interest in recent decades, progress in improving the diagnostic accuracy of these injuries is still minimal. Accurate and timely diagnosis is crucial for patients with mild TBI, to reduce the risk of long-term or permanent neurological damage. As Bertini points out, the guidelines for managing MTI and MBI, as well as the evidence, are quite outdated.

The report lists the most used: Canadian Computed Tomography Rule, Scandinavian Guidelines, New Orleans Standards for TC Screening in Mild Head Injury, National Institute for Health and Care Excellence (NICE 2014) guidelines, and Committee on Neurorheumatology of the World Federation of Neurosurgical Societies (NCWFS) ). Among them, the most recent date back to 2014.

Over the past decade, several candidate biomarkers have emerged as potential diagnostic markers for TBI. More than 20 different proteins have been studied in the brain, and some have shown diagnostic accuracy for distinguishing concussion from ‘non-concussion’ or for predicting the outcome of a head CT scan. Biomarkers have provided information on pathophysiological mechanisms, in particular on the dynamic course of trauma-induced neuronal damage, axons, and astrocytes.
There is a large literature reporting a high sensitivity and usefulness of the biomarkers UCH-L1 and GFAP in predicting the intracranial lesion present on acute-stage CT of the skull.
Bertini says biomarkers can help categorize risk and improve the classification of people with head trauma.

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The combination of GFAP and UCH-L1 appears to have the potential to improve clinical evaluation and management of patients with mild injuries. In cases where it has been used as a surrogate marker for effective diagnostic investigations, this combination has improved diagnostic accuracy by reducing the number of unnecessary CT scans performed on patients with suspected mild head injury.
These two proteins, Guarino says, “have been studied for use in the diagnostic and therapeutic pathway of head trauma, especially mild, to allow you to avoid CT scans and, above all, repetition. All this is inseparable from a proper clinical examination that also uses non-surgical imaging methods.”

Fabri concludes, “The world of scorers is very vast and research is advancing rapidly.
We hope that soon we will have enough indicators to build diagnostic pathways that are also useful for developing guidelines that go in this direction.”


With Abbott’s non-adaptive contribution

26 July 2022
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