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JOURNAL CLUB SESSION

JOURNAL CLUB SESSION. Chairperson Dr. Sankar Narayan Dey Associate professor & Ex-Head of the department of Radiology Mymensingh Medical College Co-Chairperson Dr. MISBAH UDDIN AHMED Assistant professor & Head of the department of Radiology & Imaging Mymensingh Medical College PRESENTER

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JOURNAL CLUB SESSION

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  1. JOURNAL CLUB SESSION ChairpersonDr. Sankar Narayan DeyAssociate professor & Ex-Head of the department of Radiology Mymensingh Medical College Co-ChairpersonDr. MISBAH UDDIN AHMEDAssistant professor & Head of the department of Radiology & ImagingMymensingh Medical College PRESENTER Dr. SYED ABDUL QUADER(Ashraf) Student (MD-Final part) of Radiology & Imaging Mymensingh Medical college

  2. Title Computed Tomographic Evaluation of Traumatic Epidural and Subdural Haematoma with post operative correlation.

  3. Author : • Islam MS, Azad SA, Habib MA, Alam MR, Bhuiyan MSI. • Source : • Bangladesh Journal of Radiology and Imaging, 2009 ; Volume 17(2) : 40–45.

  4. Introduction • Head Injury is a serious health problem in all nations and responsible for approximately half of all deaths related to trauma. • Intracranial lesions may be focal or diffuse, although these two forms frequently coexist. • Focal lesions include epidural haematomas, subdural haematomas and contusions(or intracerebralhaematomas). • Epidural haematoma(EDH) lies in between the inner surface of the skull and stripes of the dural membrane. • EDH are nearly always caused by, and located near a skull fracture.

  5. Introductioncontinues.. • EDH, more common in temporal and temporoparietal areas(70% cases), usually forms within an hour from the time of injury but some time run a more chronic course. • The classic CT appearance of EDH in 84% case is high density biconvex shape adjacent to the skull. • Surgical evacuation is recommended for symptomatic lesions. Mortality is ~26%, is more related to growing speed of haematoma than to its location, being higher for the haematoma located in the temporal fossa.

  6. Introductioncontinues.. • Subdural Haematoma(SDH) are much more common than EDH. They occur most frequently from a tearing of bridging veins between the cerebral cortex and draining sinuses. • The injury in patients with SDH is usually much more severe, and prognosis is much worse than for EDH. • Mortality in general is 60% but can be lowered by very rapid diagnosis & rapid surgical intervention and aggressive medical management. • Computed Tomography(CT) scan of the head is currently the imaging modality of choice.

  7. Introductioncontinues.. • Early recovery of traumatic head injury patients largely depends upon the prompt diagnosis and meticulous management of these patients. • Lots of lives can be spared by early and accurate diagnosis if CT scan can be established as a sensitive and specific modality for the diagnosis of EDH and SDH in patients having head injury.

  8. Objectives • To establish the CT scan as a good diagnostic modality for the diagnosis of EDH and SDH after head injury by considering surgical finding as a gold standard.

  9. Materials and Methods • Study Design : Cross sectional study. • Place of study: • Department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University & Dhaka Medical College Hospital, Dhaka in collaboration with department of Neurosurgery of the same hospitals. • Study Period: From January 2010 to November 2010. • Sample Size : 91 • Sampling Technique : Purposive sampling

  10. Materials and Methodscontinues.. • Inclusion Criteria : Patients with head injury having epidural & / or subdural haematoma on CT and subsequently treated surgically. • Exclusion Criteria : Non traumatic cases.

  11. Ethical Consideration • Informed consent was required from all patients & / or from their guardians after the potential risks and benefits were explained.

  12. Study Procedure • Traumatic head injury patients who were admitted in the department of Neurosurgery BSMMU & DMCH, Dhaka with the clinical suspicion of having epidural & subdural haematoma and sent for CT scan in Radiology &Imaging department of the same hospital were initially enrolled for the study. • 110 patients with traumatic intracranial haematoma(EDH/SDH) confirmed by CT scan who subsequently underwent surgical intervention were finally included in the study.

  13. Study ProcedureContinues… • CT scan was performed with a third generation CT, Siemens at DMCH & Hitachi CT scan Machine in BSMMU. • Sample size was calculated for a power level of greater than 80%, an error of .05 and expected sensitivity of 94 to 96% based on previous report. • 19 patients were withdrawn from the study as they were shifted to different hospitals other than BSMMU or DMCH for surgical procedure.

  14. Study ProcedureContinues… • For rest of the 91 patients diagnosis was established after surgical intervention. • Surgical findings of all patients were correlated with CT scan findings. • For the validity of study outcome, sensitivity, specificity, accuracy, positive predictive value and negative predictive value of CT scan in the diagnosis of EDH & SDH was calculated out after confirmation of the diagnosis by surgical intervention.

  15. Data Analysis • Data were processed and analysed by using soft-ware SPSS (Statistical Package for Social Sciences) version 11.5. The test statistics used to analyzed the data were descriptive statistics, Kappa test. • The level of significance was 0.05 and p <0.05 was considered significant.

  16. Result and observations • 110 patients with head injury were initially enrolled for the study. • 19 patients were withdrawn from study. • Mean age of the patients was 37.2(+/- 18.18) years with maximum patients(36.2%) belonging to 16 to 30 years age group. • Male and female ratio was 2.8: 1. • 64.8% had history of road traffic accident as the cause of head injury.

  17. Result and observationsContinues… • CT scan diagnosis showed that 13.2% had EDH, 54.9% had SDH and 31.9% had both EDH & SDH.

  18. 31.9 54.9 Pie diagram

  19. Result and observationsContinues… • Intraoperative diagnosis showed that 12.1% had EDH, 53.8% had SDH and 34.1% had both EDH & SDH.

  20. 53.8 Pie diagram

  21. Result and observationsContinues… • 11 cases were diagnosed as EDH by CT scan and confirmed by intraoperative evaluation. • One case was diagnosed as EDH by CT scan but could not be confirmed intraoperatively. • Of 79 cases of other than EDH, which were diagnosed by CT scan, all were diagnosed other than EDH intraoperatively. • Sensitvity of CT scan to diagnose EDH was 100%, specificity 98.8%, positive predictive value 91.7%, negative predictive value 100%, & accuracy 98.9%.

  22. Result and observationsContinues… Table-1 Distribution of EDH by CT scan & intraoperative diagnosis(n=91)

  23. Result and observationsContinues… • 48 cases were diagnosed as SDH by CT scan and confirmed by intraoperative evaluation. • Two cases were diagnosed as SDH by CT scan but could not be confirmed intraoperatively. • Of 41 cases of other than SDH, which were diagnosed by CT scan, one was diagnosed as having SDH & 40, other than SDH intraoperatively. • Sensitvity of CT scan to diagnose SDH was 98.0%, specificity 95.2%, positive predictive value 96.0%, negative predictive value 97.6%, & accuracy 96.7%.

  24. Result and observationsContinues… Table-2 Distribution of SDH by CT scan & intraoperative diagnosis(n=91)

  25. Result and observationsContinues… • 28 cases were diagnosed as both EDH & SDH by CT scan and confirmed by intraoperative evaluation. • One case was diagnosed as combined EDH & SDH by CT scan but could not be confirmed intraoperatively. • Of 62 cases of not having both EDH & SDH, which was diagnosed by CT scan, three were diagnosed as having both EDH & SDH, 59 other than combined EDH & SDH intraoperatively. • Sensitivity of CT scan to diagnose both EDH & SDH was 96.5%, specificity 98.3%, positive predictive value 96.6%, negative predictive value 95.2%, & accuracy 95.6%.

  26. Result and observationsContinues… Table-3 Distribution of both EDH & SDH by CT scan & intraoperative diagnosis(n=91)

  27. Discussion • Mean age of patient was 37.02(+/- 18.18) years and maximum 36.3% belonged to 16 to 30 years age group. • Men receive more head injuries than women & it appears that their incidence is two to three times greater. • RTA was the commonest mode of injury in this study(64.8%). • Almost maximum(97.8%) patients had complaints of headache, 85.7% vomiting, 58.2% history of unconsciousness, 47.3% had clinical signs of skull fracture, 5.5% had post traumatic amnesia, 4.4% posttraumatic seizure & 3.3% neurological deficit.

  28. Discussion Continues… • After CT evaluation 82.4% had skull fracture, 13.2% patients were diagnosed as EDH, 54.9% SDH, 31.9% both EDH & SDH. • But intraoperatively 12.1% were evaluated as having EDH, 53.8% SDH, 34.1% both EDH & SDH. • Sensitivity of CT scan to diagnose different type of haematoma ranged from 96.5% to 100%. Specificity 95.2% to 98.8%, positive predictive value 91.7% to 96.6%, negative predictive value 95.2% to 100% and accuracy 95.6% to 98.8%.

  29. Limitation • Sampling technique was purposive • Small sample size • CT scan was not compared with any other imaging modality like MRI

  30. Recommendation • Large scale study is required including both traumatic and non-traumatic head injury evaluated by same CT &/or MRI machine and operated by same surgeon.

  31. Conclusion • CT scan is usually the 1st choice in the evaluation of EDH & SDH, primarily due to the rapidity of diagnosis. • The present study also found its excellent efficacy. • In Bangladesh this imaging modality is becoming available all over the country. • Considering as a test of reference we can straight forwardly recommend this modality for early diagnosis of intracranial haematoma. • So mortality & morbidity due to EDH & SDH can be reduced by early diagnosis & promt management.

  32. Thank You All

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