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ORIGINAL ARTICLE
Year : 2016  |  Volume : 64  |  Issue : 1  |  Page : 62-65

Bedside computed tomography in traumatic brain injury: Experience of 10,000 consecutive cases in neurosurgery at a level 1 trauma center in India


1 Department of Neurosurgery, All Institute of Medical Sciences, New Delhi, India
2 Chief, JPNA Trauma Centre, All Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Jan-2016

Correspondence Address:
Deepak Agrawal
Department of Neurosurgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.173649

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 » Abstract 

Introduction: Patients with traumatic brain injury (TBI) need frequent computed tomography (CT) of the head for assessment and management. In view of the associated polytrauma, hemodynamic instability, and various in-dwelling catheters and tubes, shifting of patients for CT scans may be difficult.
Aims and Objectives: To assess the role of mobile CT (Ceretom®; NeuroLogica Corporation, Boston, MA, USA) in a trauma center with respect to patient management.
Materials and Methods: In this retrospective study over 67 months (June 2009 to January 2015), the number of CT scans done, the time taken for CT and downtime were evaluated. Also, for the first 1000 mobile CT scans, the clinical and radiological records of all patients with TBI who underwent imaging using the mobile CT scanner in the intensive care units (ICUs) were analyzed.
Observations and Results: A total of 10,000 mobile CT scans were done on the mobile CT scanner till January 5, 2015. Of the first 1000 patients evaluated, 75.3% had severe TBI, 15.1% had moderate TBI, and 9.6% had mild TBI. 78.1% patients were on ventilator, with 80.2% requiring sedation and 8.4%, an inotropic support. An in situ intracranial pressure monitoring was present in 21.1% of patients. In all, 12.4% of patients had long-bone fractures requiring skeletal traction; and, the tube thoracostomy was in-situ in 7.4%. No adverse events related to line malfunction/pullout occurred. The mean time for the performance of imaging using the mobile CT scan was 11.6 minutes compared with 47.8 minutes when patients were shifted to a conventional CT scan suite. The machine was nonfunctional 94 times, with an average downtime of 4.2 hours (range 2–72 hours). The life-cycle cost per mobile CT scan was Rs. 1340.
Conclusions: A mobile CT has considerably changed the management response time in the neurosurgical intensive care unit (ICU) setup and decreased patient transfer times and the associated complications. Inclusion of a mobile CT scanner in the armamentarium of a neurosurgeon as a “bedside tool” can dramatically change decision making and the response time. It should be considered as the standard of care in any large-volume emergency department or neurosurgical facility.


Keywords: Computed tomography; head injury; mobile CT; severe traumatic brain injury


How to cite this article:
Agrawal D, Saini R, Singh PK, Sinha S, Gupta DK, Satyarthee GD, Misra MC. Bedside computed tomography in traumatic brain injury: Experience of 10,000 consecutive cases in neurosurgery at a level 1 trauma center in India. Neurol India 2016;64:62-5

How to cite this URL:
Agrawal D, Saini R, Singh PK, Sinha S, Gupta DK, Satyarthee GD, Misra MC. Bedside computed tomography in traumatic brain injury: Experience of 10,000 consecutive cases in neurosurgery at a level 1 trauma center in India. Neurol India [serial online] 2016 [cited 2019 Sep 18];64:62-5. Available from: http://www.neurologyindia.com/text.asp?2016/64/1/62/173649



 » Introduction Top


The World Health Organization (WHO) estimates that almost 90% of deaths due to TBI occur in low- and middle income countries (LAMIC), where 85% of the world's population lives.[1] TBI remains the leading cause of disability in people younger than 40 years of age, severely disabling 150–200 per million individuals annually.[2],[3] In 2005, road traffic injuries resulted in the death of an estimated 110,000 persons, and was responsible for 2.5 million hospitalizations, 8–9 million minor injuries, and economic losses to the tune of 3% of the gross domestic product (GDP) in India.[4] The accident rate of 35 per 1000 vehicles in India is also among the highest in the world.[5]

These patients, particularly those suffering from severe head injury require frequent computed tomographic scans (CT scans) of the head, usually at a short notice. As most of these patients are ventilated and also have multiple infusion lines, it is a difficult task to shift them for CT scan of the head. Also, incidences of endotracheal tube dislodgement, ventilator failure, or oxygen supply issues that occur while shifting these patients to the radiological suite are not unheard of. A mobile CT scanner obviates the need for transferring the patient out of the intensive care (ICU) setting and may prove to be invaluable for these patients.[6],[7],[8],[9],[10],[11] We assessed our experience

in performing 10,000 consecutive mobile CT scans (Ceretom ®) at a level 1 trauma center in India.


 » Materials and Methods Top


A mobile CT scanner (Ceretom; NeuroLogica Corporation, Boston, USA) was installed in the Neurosurgery ICU at our institution [Figure 1] and [Figure 2] in June 2009. In this retrospective study over 67 months (June 2009 to January 2015), the number of CT scans done, the time taken to perform a CT scan, and the downtime were evaluated. Also, for the first 1000 mobile CT scans, the clinical and radiological records of all patients with traumatic brain injury (TBI) who underwent the mobile CT scanning in the ICU setting were assessed. Administrative and clinical data were reviewed and analyzed. For the first 6 months, only the number of CT scans done and the time taken to perform them were available. Subsequently, data was collected prospectively from January 1, 2010 to include variables like the Glasgow Coma Score (GCS), ventilatory status and pressor support (dopamine and noradrenaline) at the time of performing the CT scan. Our initial experience with the mobile CT has been previously published in another study.[12]
Figure 1: A mobile CT scanner showing its small footprint

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Figure 2: A bed-side mobile CT scanning being performed

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 » Observations and Results Top


The mobile CT scanner (Ceretom) became functional in the Neurosurgery ICU on July 18, 2009, at our institution. A total of 10,000 mobile CT scans have been done on the mobile CT scanner until January 5, 2015. Of the first 1000 patients evaluated, 75.3% had severe TBI, 15.1% had moderate TBI, and 9.6% had mild TBI. Ventilatory support was required in 78.1% of the patients, with 80.2% requiring sedation and 8.4% requiring an inotropic support. In situ intracranial pressure (ICP) monitoring was done for 21.1% of patients. In all, 12.4% of patients had long-bone fractures requiring skeletal traction, and tube thoracostomy was in-situ in 7.4% [Table 1]. No adverse events related to line malfunction/pullout occurred. The mean time for performing a mobile CT scan was 11.6 minutes compared with 47.8 minutes when patients were shifted to a conventional CT suite. The machine was nonfunctional 94 times, with an average downtime of 4.2 hours (range, 2–72 hours) [Table 2].
Table 1: Parameters assessed for patients in the neurotrauma ICU in whom the mobile CT scanning was done

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Table 2: CT scan time (from ordering of CT scan to return of patient on bed), downtime and costing of mobile CT scan

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The purchase cost was Rs. 20,000,000 (which included a 5 year comprehensive maintenance contract), and for the 6th to 10th year, the maintenance contract was fixed at Rs. 800,000 per year (including the tube of the machine). The total cost of the machine over 10 years was, therefore, Rs. 24,000,000. Extrapolating this data of 10,000 head CT scans performed in 67 months, 1791 CT scans would be done yearly (17,910 CT scans over 10 years). Therefore, the cost per CT scan worked out to be Rs. 1340.


 » Discussion Top


Worldwide, traumatic head injury is the single largest cause of death and disability.[1] Most head injuries are due to road-side accidents.[13] The burden of head injury is the greatest in low- and middle-income countries (LAMIC), where 85% of the world's population lives.[14] Despite major advances in imaging of the brain, plain CT scan of the head remains the gold standard for the management of head trauma. The usefulness of serial CT scans of the head in head injuries remains unquestionable, and many times, multiple head CT scanning may be required to evaluate for various causes of neurological deterioration in a given patient.[9],[10] No emergency department (ED) or neurosurgical center can function without a CT scanner being available round the clock.

Increasingly, patients with severe head injuries in the EDs and ICUs are managed with ventilation, intracranial pressure and other vital sign monitoring, as well as sedation, which require multiple infusion lines (with the medication usually administered using infusion pumps). In this scenario, there is a significant risk in transferring patients for performing a CT scan of the head. It is not uncommon to have endotracheal tube dislodgement and other ventilatory problems during the transfer. Furthermore, nurses and doctors are required to accompany the patient during the transferring process, placing an additional burden on the manpower resources.[9] Under these circumstances, a mobile CT scanner appears a very useful tool for healthcare professionals. Our study shows that the mobile CT scanner was extremely useful in eliminating issues relating to the transfer of patients for the conventional CT scan of the head.

The mobile CT scanner has also changed the way we manage patients in the EDs and ICUs. Previously, patients who were hemodynamically unstable were considered unsuitable for shifting for the CT scanning. However, with the installation of a mobile CT scan, we were able to comfortably do a head CT in all our patients, whenever it was required to be done. In our study, 8.4% of the patients were on inotropic support at the time of performing the mobile CT scanning. With the ready availability of a mobile CT scanning facility, patients were also routinely subjected to a head CT scanning in the immediate postoperative period in the ICU. This has helped us in picking up any expanding operative site hematoma or contralateral bleed early, thus helping in initiating immediate remedial action.

The most important factors that are required to be assessed for a mobile CT scanner are the image quality and the ease of use. Despite being an eight-slice scanner, the image quality rivaled that of the 64-slice machines in the market, and the image quality was assessed as being “excellent” by all the faculty members using this equipment [Figure 3]. Also, the average time taken to do a CT scan (from ordering to transmission into the picture archiving and communication system [PACS]) was 11.6 minutes, which makes it a true “bedside” tool that helped in dramatically improving the decision making and patient care.
Figure 3: Images of CT head done using a mobile CT scanner at standard setting showing an excellent image quality

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Since our first publication,[12] the support system and maintenance facilities of the equipment have greatly improved for the Indian subcontinent. During the study period, however, the machine was nonfunctional 94 times, with an average downtime of 4.2 hours (range, 2–72 hours). The cost of the equipment also remains a major issue, with our purchase cost being around 2 crores (INR 20,000,000), which included a motorized mobility system and 5-year comprehensive maintenance contract (including all spares). Assuming the life span of a CT scanner to be 10 years, we calculated the cost per CT scan to be Rs. 1340. This is reasonable, considering the immense benefits provided by it. We do expect the cost to reduce dramatically as more vendors are introduced into the field.

Owing to the small bore of the gantry of the machine, the mobile CT scanner can perform scans of the cervical spine up to C3 and occasionally up to C4 level in adult patients. The limiting factor is usually the shoulder of the patient. Although it is applicable for high cervical trauma, the mobile CT scanner is not useful for the majority of cervical spine injuries, as these injuries usually occur below C4. In infants, however, the mobile CT scanner may be able to perform a whole-body scan without any issues. Inability to perform a scan for anatomical structures below the head in adult patients is a major drawback, as many hospitals may not find the equipment as a very cost-effective proposition. Another issue relates to radiation to the surrounding personnel and patients.[7] As per the radiation data given by the manufacturers of the equipment, one can stand as close as 2 meters without needing to wear even a lead apron. However, radiation safety standards need to be implemented meticulously while performing the CT scanning.


 » Conclusions Top


A mobile CT scan has dramatically changed the management in the neurosurgical ICU setup and has decreased the patient transfer time for the scanning and the associated complications that may occur during the mobilization of the patient to the CT scanning facility. Inclusion of a mobile CT scanner in the armamentarium of a neurosurgeon as a “bedside tool” can dramatically change the ease of decision making and the time of response and should be considered as the standard of care in any large-volume ED or neurosurgical facility.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global burden of disease study. Lancet 1997;349:1436-42.  Back to cited text no. 1
    
2.
Fleminger S, Ponsford J. Long term outcome after traumatic brain injury. BMJ 2005;331:1419-20.  Back to cited text no. 2
    
3.
Bruns J Jr, Hauser WA. The epidemiology of traumatic brain injury: A review. Epilepsia 2003;44(Suppl 10):2-10.  Back to cited text no. 3
    
4.
Gururaj G. Road traffic deaths, injuries and disabilities in India: Current scenario. Natl Med J India 2008;21:14-20.  Back to cited text no. 4
    
5.
Dandona R, Kumar GA, Ameer MA, Ahmed GM, Dandona L. Incidence and burden of road traffic injuries in urban India. Inj Prev 2008;14:354-9.  Back to cited text no. 5
    
6.
Stevens GC, Rowles NP, Foy RT, Loader R, Barua N, Williams A, et al. The use of mobile computed tomography in intensive care: Regulatory compliance and radiation protection. J Radiol Prot 2009;29:483-90.  Back to cited text no. 6
    
7.
Mobile computed tomography evaluation of the NeuroLogica CereTom. Health Devices 2008;37:325-42.  Back to cited text no. 7
    
8.
Masaryk T, Kolonick R, Painter T, Weinreb DB. The economic and clinical benefits of portable head/neck CT imaging in the intensive care unit. Radiol Manage 2008;30:50-4.  Back to cited text no. 8
    
9.
Gunnarsson T, Theodorsson A, Karlsson P, Fridriksson S, Boström S, Persliden J, et al. Mobile computerized tomography scanning in the neurosurgery intensive care unit: Increase in patient safety and reduction of staff workload. J Neurosurg 2000;93:432-6.  Back to cited text no. 9
    
10.
Mirvis SE. Use of portable CT in the R Adams Cowley Shock Trauma Center. Experiences in the admitting area, ICU, and operating room. Surg Clin North Am 1999;79:1317-30.  Back to cited text no. 10
    
11.
Butler WE, Piaggio CM, Constantinou C, Niklason L, Gonzalez RG, Cosgrove GR, et al. A mobile computed tomographic scanner with intraoperative and intensive care unit applications. Neurosurgery 1998;42:1304-11.  Back to cited text no. 11
    
12.
Agrawal D, Sahoo S, Satyarthee GD, Gupta D, Sinha S, Misra MC. Initial experience with mobile computed tomogram in neurosurgery intensive care unit in a level 1 trauma center in India. Neurol India 2011;59:739-42.  Back to cited text no. 12
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13.
Rajendra PB, Mathew TP, Agrawal A, Sabharawal G. Characteristics of associated craniofacial trauma in patients with head injuries: An experience with 100 cases. J Emerg Trauma Shock 2009;2:89-94.  Back to cited text no. 13
[PUBMED]  Medknow Journal  
14.
De Silva MJ, Roberts I, Perel P, Edwards P, Kenward MG, Fernandes J, et al. Patient outcome after traumatic brain injury in high-, middle- and low-income countries: Analysis of data on 8927 patients in 46 countries. Int J Epidemiol 2009;38:452-8.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]

This article has been cited by
1 Bedside computed tomography in traumatic brain injury: Experience of consecutive 10,000 cases in neurosurgery at a level 1 trauma center in India
Satoshi Tsutsumi
Neurology India. 2016; 64(1): 199
[Pubmed] | [DOI]



 

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