Hafif kafa travmalarında bilgisayarlı tomografi endikasyonunu belirlemede Miller kriterlerinin yeri

Amaç: Hafif şiddette kafa travmalı olgularda kraniyografi ve klinik özelliklerin, bilgisayarlı beyin tomografisi sonuçları ile ilişkisi araştırıldı.Gereç ve yöntem: Acil servisimize hafif kafa travması nedeniyle başvuran 133 olgunun kayıtları retrospektif olarak incelendi. Olgular GKS skoru 13, 14 ve 15 olan üç ayrı gruba ayrıldı. Anamnezde bulantı, kusma, geçici bilinç kaybı veya amnezinin olup olmadığı, bilinç düzeyi, fizik bala sonuçları, nöroradyolojik sonuçlar ve operasyon gereksinimleri araştırıldı. Elde edilen verilerin geçerliliği (duyarlılık, seçicilik, pozitif ve negatif prediktif değer) belirlendi.Bulgular: 114 olguda GKS:15 (%85,7), 12 olguda GKS:14 (%9) ve 7 olguda GKS: 13 (%5,3) olarak saptandı. Bilgisayarlı beyin tomografisinde patolojik bulgu, GKS skoru 13 olan olguların %71,4'ünde, GKS skoru 14 olanların %33,3'ünde ve GKS skoru 15 olanların %9,6'sında saptandı. Miller kriterlerinden en az birinin var olmasının duyarlılığı, GKS skoru 13 olanlarda %100, GKS skoru 14 olanlarda %75, GKS skoru 15 olanlarda ise %81,8 idi.Sonuç: Elde edilen sonuçlar, GKS skoru 13 ve 14 olan olgularda kraniyografinin patolojiyi yeterince yansıtamadığını ve bilgisayarlı beyin tomografisi çekilmesinin çok yararh olduğunu, GKS skoru 15 olan olgularda ise Miller kriterlerinden en az birinin varlığının bilgisayarlı beyin tomografisine gereksinimi gösterdiğini düşündürmektedir.

Anahtar Kelimeler:

Acil servis, hastane, Kranioserebral travma, Geriyedönük çalışma, Tomografi, x-ışınlı bilgisayarlı, Glasgow koma skalası

The place of Miller criteria in determining the necessity of computerized tomographic examination

Objective: The relation of craniography and clinical findings with computed tomography was evaluated in cases with mild head trauma. Material and methods: Records of cases applying to our emergency unit were reviewed retrospectively. The cases were divided into three groups as GCS 13, 14 and 15. The presence of nausea / vomiting, temporary loss of consciousness or amnesia in history, level of consciousness, physical examination results and neuroradiologic results, and necessity for operations were investigated. The validity (sensitivity, spesificity, positive predictive value and negative predictive value) of data obtained were evaluated. Results: The distribution of cases with GCS between 13-15 were examined. 114 (85.7%) cases were determined as GCS:15, 12 (9%) as GCS: 14 and 7 (5.3%) as GCS:13. Pathological cranial CT findings were found in 71.4% of cases with GCS 13, in 33.3% of cases with GCS 14 and in 9,6% of cases with GCS 15. Sensitivity of the presence of at least one of Miller's criteria was 100% in cases with GCS 13, 75% in cases with GCS 14 and 81.8% in cases with GCS 15. Conclusion: The results obtained leads to think that craniography will not be enough to show the pathology and cranial CT examination may become necessary in cases with GCS 13-14, and CT may be needed if at least one of Miller's criteria are present in patients with GCS 15.

Keywords:

Emergency Service, Hospital, Craniocerebral Trauma, Retrospective Studies, Tomography, X-Ray Computed, Glasgow Coma Scale,

PDF

___

1. Brown L, Moynihan JA, Denmark TK. Blunt pediatric head trauma requiring neurosurgical intervention: how subtle can be? Am J Emerg Med 2003; 21: 467-472.
2. Thurman DJ, Alverson C, Dunn KA, Guerrera J, Sniezek JE. Traumatic brain injury in the United States. J Head Trauma Rehabil 1999; 14: 602-615.
3. Davis RL, Mullen N, Makela M, Taylor JA, Cohen W, Rivara FP. Cranial computed tomography scans in children after minimal head injury with loss of cons-ciousness. Ann Emerg Med 1994; 24: 640-645.
4. Gökalp HZ, Erongun U. Nöroşirürji Ders Kitabı. Ankara: Mars Matbaası, 1988; 202.
5. Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med 1997; 15: 453-457.
6. Dawson- Saunders B, Trapp RG. Basic and Clinical Biostatistics. Second Edition. New Jersey: Prentice- Hall International Inc; 1994; 57.
7. Stein SC, Spettell C, Young G, Ross SE. Limitations of neurolojical assessment in mild head injury. Brain Inj 1993; 7: 425-430.
8. Harad FT, Kerstein MD. Inadequacy of bedside clinical indicators in identifying significant intracranial injuri in trauma patients. J Trauma 1992; 32: 359-361.
9. Simon B, Letourneau P, Vitorino E, McCall J. Pediatrik minor head trauma: indications for computed tomographic scanning revisited. J Trauma 2001; 51: 231-237.
10. Wang MY, Griffith P, Sterling J, McComb JG, Levy ML. A Prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow Coma Scale score of 13- 14). Neurosurgery 2000; 46: 1093- 1099.
11. Stein SC, Ross SE. Mild Head injury: a plea for routine early CT scanning. J Trauma 1992; 33: 11-13.
12. Holmes JF, Baier ME, Derlet RW. Failure of the Miller criteria to predict significant intracranial injury in pati-ents with a Glasgow, Coma Scale score of 14 after minor head truma. Acad Emerg Med 1997; 4: 788-792.
13. Gomez PA, Lobato RD, Ortega JM, De La Cruz J. Mild head injury: differences in prognosis among patient with a Glosgow Coma Scale score of 13 to 15 and analysis of factors associated with abnormal CT findings. J Neurosurg 1996; 10: 453-460.
14. Mack LR, Chan SB, Silva JC, Hogan TM. The use of head computed tomography in elderly patients sus-taining minor head trauma. J Emerg Med 2003; 24: 157-162.
15. Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning pediatric pa-tients with normal neurologic examination in emer-gency department. Pediatr Emerg Care 1996; 12: 160-165.
16. 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 2000; 13: 100-105.
17. Miller EC, Derlet RW, Kinser D. Minor head trauma: Is computed tomography always necessary? Ann Emerg Med 1996; 27: 290-294.
18. Moran SG, McCarthy MC, Uddin DE, Poelstra RJ. Predictors of positive Ct scans in the trauma patient with minor head injury. Am Surg 1994; 60: 533-535.
19. Aygün D, Güven H, İncesu L ve ark. Hafif kafa travmalı olguların kraniyal tomografisindeki patolojik bulgu sıklığının yaş grupları ve klinik ile korelasyonu. Ulus Travma Derg. 2003; 9:129- 133.
20. Stein SC, Ross SE. The value of computed tomographic scans in patients with lowrisk head injuries. Neurosurgery 1990; 26: 638-640.
21. Lloyd DA, Carty H, Patterson M, Butcher CK, Roe D. Predictive value of skull radiography for intracranial injury in children with blunt head injury. The Lancet. 1997; 349: 821-824.
22. Stein SC, O’Malley KF, Ross SE. Is routine computed tomography scanning too expensive for mild head injury? Ann Emerg Med 1991; 20: 1286-1289.