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Table 1 Characteristics of included studies

From: The risk of intra-cranial haemorrhage in those presenting late to the ED following a head injury: a systematic review

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