ER, Trauma Doctors Often Miss Diagnosis of Mild Brain Injury

WASHINGTON -- Many of the estimated 1.5 million Americans who sustain mild traumatic brain injury each year are never diagnosed, Dr. Tova Alladice said at the annual meeting of the American Academy of Physical Medicine and Rehabilitation.

"Mild traumatic brain injury is an epidemic in the United States, and fewer than 1 in 20 patients get the rehabilitation they need," said Dr. Alladice of Baylor College of Medicine, Houston.

Postconcussive symptoms, including headache, memory loss, and cognitive dysfunction, develop in 10%-15% of these patients and may be disabling, she noted.

To examine underdiagnosis of this condition, Dr. Alladice reviewed the medical records of 29 patients who were evaluated for head injury at a single urban trauma center. All of the subjects met criteria for mild traumatic brain injury: an abnormal result on the Glasgow Coma Scale plus the presence of confusion, amnesia, loss of consciousness, or focal neurologic deficits.

The subjects included 21 males and 8 females aged 15 to 75 years. They had sustained head injuries in falls (69%), car accidents (7%), pedestrian accidents (7%), assaults (3%), or unknown circumstances (14%), Dr. Alladice reported in a poster presentation.

Among these patients, 18 (62%) had abnormal ratings on the Glasgow Coma Scale; 22(76%) had documented loss of consciousness and the remainder had probable loss of consciousness. Two patients showed swelling and hemorrhage in the brain on CT scans.

Yet 26 (90%) of the patients were not diagnosed as having mild traumatic brain injury by trauma physicians and 22 (76%) were not so diagnosed by emergency room physicians.

Even in the subgroup of patients with clearly documented loss of consciousness, trauma physicians missed the diagnosis in 72% and emergency room physicians missed it in 52%, she said.

All of the undiagnosed patients were discharged home within 72 hours or less without having any cognitive, neurologic, neuropsychological, or rehabilitation evaluations. These patients did not get appropriate therapy, and some could well go on to develop postconcussive symptoms that they mightnot realize are related to their injury, Dr. Alladice noted.

Moreover, their high risk for subsequent brain injury was never identified so they were not warned to take precautions against it, she added.

"It is important that all physicians caring for this patient population be able to recognize mild traumatic brain injury and to facilitate referrals and management of postconcussive symptoms. Education of physicians across disciplines and a standard protocol for diagnosis and management of mild traumatic brain injury are needed," Dr. Alladice said.

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