Reference | Population | Study design | Outcome measures | Results | Quality appraisal |
---|---|---|---|---|---|
Barrow et al. [10] | Inclusion criteria: • Age ≥ 17 years • GCS 14 or 15 at presentation • Presenting to ED >4 h after injury Exclusions: • Patients with only facial injuries Single-site: large central-east London teaching hospital 1st Jan. 2008–10th May 2009 | Prospective observational study | ‘Positive CT’: any traumatic finding related to presenting injury | Detailed patient demographics not reported 497 patients included: • 193 presented 4–12 h • 140 presented 12–24 h • 62 presented 24–28 h • 58 presented 24–168 h • 44 presented ≥ 1 week 147/497 (29.6 %) had CT head; 64/147 presented 4–12 h, 50/147 12–24 h, 11/147 24–48 h, 21/147 48 h–1 week, 1/147 > 1 week 11/497 (2.21 %) positive CT scans; 1/11 presented 4–12 h, 3/11 12–24 h, 4/11 24–48 h, 3/11 48–168 h 4/497 (0.80 %) had neurosurgery; 3/4 (75 %) presented 12–48 h after injury, 1/4 (25 %) 48–168 h 1/497 died (0.20 %)—time since presentation not reported 69/497 (13.9 %) contactable at 2 weeks; 11/69 (15.9 %) symptomatic Lower rates of intra-cranial injury compared to previous studies Similar rates of CT and neurosurgical intervention compared to previous studies Statistically significant predictors of intra-cranial injury: LOC, coagulopathy, evidence of injury above the clavicles, open or depressed skull fracture and acute alcohol/drug use | Prospective and contemporaneous review of notes—likely that most eligible cases were identified and included |
NICE guidelines used for triage patients to CT head and discharge | 2–4 week telephone interview follow-up for further treatment/deterioration | 4 h is not a long delay | |||
Data collection: Daily identification of cases from search of paper records and review of computerised discharges | Identification of clinical risk factors predictive of intra-cranial injury | No control or comparison group | |||
Sampling biases: small numbers, young population, >50 % from Indian subcontinent | |||||
Small absolute rates of pathology, therefore prone to outlier bias | |||||
Very high loss to follow-up | |||||
Hemphill et al. [23] | Inclusion criteria: • Any age • GCS 15 at presentation • Presenting to ED >12 h after injury • Re-attenders included Exclusions: • None stated Dual-site: academic Level I Trauma Centres (San Antonio, USA) Jan.–Dec. 1996 | Retrospective chart review Searched 85,000 ED charts | ‘Significant delayed injury’. Defined as ‘abnormal CT results such as: intracerebral bleeding, skull fracture, or subdural or epidural haematoma’ | 2900 patients with head injury 194 (6.69 %) presented >12 h: • 112/194 (56.9 %) female • 34 ± 24 years (mean ± SD) • 21/194 (10.8 %) re-attenders 101/194 (52.1 %) patients had CT head; 9/21 (42.9 %) of re-attenders had CT head scan 6/194 (3.1 %) patients had abnormal CT scans: • 2 infants (aged 1 and 5 months) • 4 adults (29F, 46F, 60M, 74M) • Note: one patient (74M) presented GCS 3 with large DSH at 25 h after normal CT acutely after injury—required neurosurgery and died 1 patient re-presented at 3 months with headache: chronic SDH—did not originally have CT head Mean time to presentation: • Overall: 73 ± 105 h • If abnormal CT: 29.3 ± 10.7 h | Retrospective review—data may be missing |
Comparisons between patients with/without CT | Exclusions not stated | ||||
Comparisons between hospitals | No formal follow-up of patients who did not have CT head scans | ||||
Sampling bias: small numbers | |||||
Small absolute rates of pathology, therefore prone to outlier bias | |||||
Includes re-attenders: a distinct and possibly higher-risk group than delayed (first-time) presenters | |||||
Borczuk et al. [28] Abstract only | Inclusion criteria: • Age > 16 years • Presenting to ED >24 h after injury • Blunt head injury • Had CT head Exclusions: • Not stated Single-site: MA, USA Conducted ‘over a 2-year period’ (dates not reported) | Case series | Any abnormality on CT head | 206 consecutive patients identified GCS on presentation not stated 13/206 (6.3 %) had abnormality on CT head No patient required neurosurgery Time to presentation (mean ± SD): • Positive CT findings: 5.03 ± 6.52 days • Negative CT findings: 5.79 ± 7.09 days Positive CT findings more likely if LOC or amnesia of the event reported | Case series—does not state which patients were excluded or how |
Sampling biases: small numbers, only those who had CT head after injury were included | |||||
GCS/other indicators of injury severity not discussed | |||||
Abstract only—unable to contact authors for further information | |||||
‘Abnormality’ on CT not defined or explained further |