Predicting Clinically Significant Brain Injuries following Mild TBI: A Comparative Study of Canadian CT Head Rule and New Orleans Criteria at a National Trauma Centre.

Predicting Clinically Significant Brain Injuries following Mild TBI: A Comparative Study of Canadian CT Head Rule and New Orleans Criteria at a National Trauma Centre. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predicting Clinically Significant Brain Injuries following Mild TBI: A Comparative Study of Canadian CT Head Rule and New Orleans Criteria at a National Trauma Centre. Selekeowei Peter Kespi Kpuduwei, Ayodeji Salman Yusuf, Nasir Jinjiri Ismail, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5788971/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Mild traumatic brain injury (mTBI) is one of the most common injuries treated at any trauma centre. Whereas the general use of CT for all patients with mTBI is inefficient and wasteful, the omission of a clinically important brain injury is not desirable. Several guidelines have been developed to assist physicians in determining who actually needs a head CT. For this reason, the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) were compared in this study on their efficacy in predicting surgically significant brain injuries and need for neurosurgical intervention. Materials and Methods The research was a prospective cross-sectional study at a level 1 trauma centre that received ethical approval from the Hospital. Consenting adult patients who presented with mild TBI within 24 hours were recruited. They were assessed with the NOC and CCHR, which decisions were compared between them and with CT head findings. Results A total of 103 patients were successfully enrolled, males were 91 and females were 12 with mean age of 32.48 ± 12.27 years old. The sensitivity, specificity, positive predictive value and negative predictive value of clinically significant brain injury under the NOC guideline compared with that of CCHR guideline were not significantly statistically different with P-value of 0.39. Similarly, there was no statistically significant difference between the two guidelines for need for neurosurgical intervention as P-value was 0.48. Conclusion F ollowing the findings this study either NOC or CCHR is safe to be used for ordering head CT for patients with mild TBI. mild traumatic brain injury computerized tomography scan clinical decision rule predictive value New Orleans Criteria Canadian CT Head Rule Nigeria Figures Figure 1 Highlight This study compared the two most widely used clinical decision rules (Canadian Head CT Rule and New Orleans Criteria) in a sub-Saharan hospital serving as a level 1 trauma centre to enable ER physicians adopt the most efficacious for the management of mild TBI. INTRODUCTION Mild traumatic brain injury (mTBI) has remained one of the most common injuries treated at the trauma centre of any hospital 1,2 and could be a major cause death and disability when missed. 3 Mild TBI is also the most common form of head injuries. It is estimated to have an incidence above 600 per 100,000 annually the US. 4 Mild TBI can be defined as a blunt injury to the head with loss of consciousness less than 30 minutes following the injury, disorientation, posttraumatic amnesia of less than 24 hours following the injury, with or without transient loss of focal neurological deficit and GCS 13–15. Because there exist a wide range of clinical manifestations, which are classified as mild, there is tendency to either ignore neurosurgical consult or overburden the neurosurgeon with patients having mild TBI. And when they present to the emergency room, the decision to do or not to do a head computed tomography (CT) always poses clinical dilemma because of the clinical state of the patients. Whereas, the general use of CT for all patients with mTBI is inefficient and wasteful, the omission of a clinically important brain injury is not desirable. 5 Several criteria or guidelines have been developed to guide physicians in determining who actually would benefit from a head CT in order to both reduce the economic and radiation burden to individuals with minor head injury. 2 Among these decision rules, the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) developed in Northern America are the most widely used by clinicians. In order to encourage adoption of any of the validated criteria, this study was conducted to compare the effectiveness of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) in predicting surgically significant brain injuries and need for neurosurgical intervention among patients with mild TBI at the National Trauma Centre. PATIENTS AND METHODS The research was a cross-sectional study of all consenting adult patients with mild TBI who presented to the Trauma Centre within 24 hours of injury. These patients presented with history of loss of consciousness, disorientation or amnesia and GCS of 13–15. The patients were assessed at presentation by the emergency physicians and were subsequently screened with both the Canadian CT Head Rule and New Orleans Criteria to determine, if they needed head CT scan or not before they were sent to the radiology department for CT according to the independent decision of the trauma surgeon. Following the head CT, patients were assessed again for CT findings of significant brain injury, which is any brain injury that required hospital admission and observation or neurosurgical follow up and need for neurosurgical intervention, which is ICU admission, surgical procedure including ICP monitoring or death within 30 days. Data was entered into IBM SPSS R and analyzed using version 25.0. Ethical clearance was obtained from the Hospital’s Research Ethics Committee. RESULTS A total of 103 patients were enrolled, there were 91 males and 12 females with a male to female ratio of 7:1. The mean age of the patients was 32.48 ± 12.27 years with age range of 16 to 76 years. Only 3 (2.9%) patients were above the age of 60 years (Table 1). Injury above the clavicle (64, 62.1%), headache (42, 40.8%), GCS < 15 after 2 hours (48, 46.6%), dangerous mechanism of injury (36, 35.0%) and amnesia (36, 35.0%) were the more common risk factors of the two decision rules (Table 2). The most common mechanism of injury was road traffic accident (Fig. 1 ). NOC guideline had a sensitivity (88.6%), specificity (21.4%), positive predictive value (47.0%) and negative predictive value (70.6%) of clinically significant brain injury; while CCHR guideline showed sensitivity (86.4%), specificity (30.4%), positive predictive value (49.4%) and negative predictive value (73.9%) of clinically significant brain injury (table 3a). There was no statistically significant difference between the two decision rules (P-value > 0.05) (table 3b). For predicting need for neurosurgical intervention, the sensitivity, specificity, positive predictive value and negative predictive value under the NOC guideline were 95.0%, 20.0%, 22.9% and 94.1% respectively; while that under the CCHR guideline were 90.0%, 26.3%, 23.4% and 91.3% respectively (table 4). There was no significant difference between the two decision rules (P- > 0.05). Table 1.0 Socio-demographic Characteristics Variable Gender Age group (years) Male Female Total 16–20 18 3 21 21–30 24 5 29 31–40 29 2 31 41–50 16 0 16 51–60 3 1 4 > 60 2 1 3 Total 91 12 103 Table 2.0 Clinical Characteristics with respect to the decision rules NOC Factors Freq Percent (%) CCHR Factors Freq Percent (%) Headache 42 40.8 GCS 60 3 2.9 Any Sign of Basal Skull Fracture 14 13.6 Drug or Alcohol Intoxication 9 8.7 2 or More Episodes of Vomiting 16 15.5 Persistent Antegrade Amnesia 22 21.4 Age > 65 Years 2 1.9 Visible Trauma Above Clavicle 64 62.1 Retrograde Amnesia ≥ 30min 36 35.0 Seizure 7 6.8 Dangerous Mechanism of Injury 36 35.0 Table 3.0 2 x 2 table for clinically significant brain injury on CT scan NOC Yes No CCHR Yes No Eligible for CT (Yes) Count 39 44 Count 38 39 % Positive Prediction 47.0% % Positive Prediction 49.4% % Outcome (sensitivity) 88.6% % Outcome (sensitivity) 86.4% Not Eligible for CT (No) Count 5 12 Count 6 17 % Negative Prediction 70.6% % Negative Prediction 73.9% % Outcome (specificity) 21.4% % Outcome (specificity) 30.4% Chi-square TP TN P-value NOC 39 12 0.39 (not significant) CCHR 38 17 TP- true positive, TN - true negative, CT- computerized tomography Table 4.0 2 x 2 table for Need for neurosurgical intervention . NOC Yes No CCHR Yes No Eligible For CT (Yes) Count 19 64 Count 18 59 % Positive Prediction 22.9% % Positive Prediction 23.4% % Outcome (sensitivity) 95.0% % Outcome (sensitivity) 90.0% Not Eligible for CT (No) Count 1 16 Count 2 21 % Negative Prediction 94.1% % Negative Prediction 91.3% % Outcome (specificity) 20.0% % Outcome (specificity) 26.3% Chi-square TP TN P-value NOC 19 16 0.48 (not significant) CCHR 18 21 TP- true positive, TN - true negative, CT- computerized tomography DISCUSSION The present study shows that both NOC and CCHR have low positive predictive values (47.0% & 49.4%) but high negative predictive values (70.6% & 73.9%) respectively for significant brain injury. This trend of low positive values and high negative values is consistent with other reports. 1,6 Although, the predictive values of CCHR were higher than those of NOC for significant brain injury. The difference was not significant in this current study. Both guidelines showed similar comparable positive predictive values of 23% and negative predictive values of NOC 95% and CCHR 91%. These findings are consistent with similar studies comparing the two decision rules. Bouida et al in a 3-year prospective study of over a thousand patients in Tunisia demonstrated that the positive predictive values of NOC and CHR for clinically significant brain injury were 16% and 30% respectively and negative predictive values 93% and 99% respectively. In the same vein, the positive predictive values of NOC and CCHR for need for neurosurgical intervention were 2% and 5% respectively and the negative predictive values 99% and 100% for NOC and CCHR respectively. 1 Whereas, Lo et al in a 3 year retrospective study of 474 patients in Hong Kong reported that the negative predictive values of NOC and CCHR for clinically significant brain injury were 91% and 88% respectively and that for need for neurosurgical intervention 100% and 99% respectively. 7 While the negative predictive value of CCHR (73.9%) for clinically significant brain injury was higher than that of NOC (70.6%) in our study like Bouida et al, 1 the negative predictive value of CCHR (91.3%) for need for neurosurgical intervention was lower than that of NOC (94.1%) in our study similar to Lo et al. 7 High negative predictive values have the tendency to reduce unnecessary CT in patients with mild TBI, which is a huge concern for developing countries due to cost of CT scan. 8 This is very important as the index study shows very high negative predictive values for need for neurosurgical intervention, which may not be easily missed when using either of the 2 guidelines in clinical practice at the Accident and Emergency Department or Trauma Centre. NOC tend to have higher sensitivity (88.6%) than CCHR (86.4%) for clinically significant brain injury, while CCHR had a higher specificity (30.4%) than NOC (21.4%). Although, unlike previous studies there was no statistically significant difference between the diagnostic performances of the two rules in this study. Similarly, Lo et al reported sensitivity of NOC and CCHR as 92% and 80% and their specificity as 17% and 39% respectively for predicting clinically significant brain injury. 7 The authors also reported sensitivity of NOC and CCHR as 100% and 80% respectively and their specificity as 15% and 36% respectively for need for neurosurgical intervention. The authors concluded that both rules have excellent prediction to rule out need for neurosurgical intervention due to their very high negative predictive values (100% and 99%) despite their low specificities in comparison to those of the index study. Therefore, the diagnostic performance of a rule is not dependent on a single factor like sensitivity or specificity. 9 Likewise, Mata-Mbemba et al in a prospective study of 142 patients in Japan, also reported that the diagnostic performance of CCHR was higher than that of NOC, where the sensitivity of NOC and CCHR for clinically significant brain injury was 97.9% and 89.8% respectively; and specificity was 9.7% and 24.7% respectively and accuracy of 40.1% and 47.2% respectively. The univariate analysis showed both rules are significantly associated with clinically significant CT findings, however the multivariate and ROC analyses demonstrated superiority of CCHR over NOC as reported previously by large-scale studies in contrast to the findings of the index study. 10 In Netherlands, Smits et al reported the superiority of CCHR over NOC, where sensitivity of NOC and CCHR was 99% and 87% respectively, and specificity was 3.1% and 39% for clinically important CT findings; and for need for neurosurgical intervention, sensitivity was 100% and 100% respectively, while specificity was 3.0% and 38% respectively. 11 These 2 previous findings and conclusions are similar to those by Stiell et al., 2001 in Canada, who were the same authors that developed the CCHR 4 years earlier before doing a comparison study. 12 They reported a sensitivity of 100% for both NOC and CCHR and specificity of 12.1% and 76.3% respectively in predicting need for neurosurgical intervention in mild TBI patients with GCS score of 15; while for clinically important brain injury, the sensitivity was still 100% for both NOC and CCHR but specificity of 12.7% and 50.6%, which was statistically significant. 5 This was similar to the one conducted in the US by Papa et al., 2012, where in detecting any traumatic intracranial lesion on CT, clinically important brain lesion and predicting need for neurosurgical intervention, the CCHR had a higher specificity (36.3%, 35% and 80.7%) while NOC had 10.2%, 9.9% and 9.6% respectively in patients with GCS score of 15. 13 In rare occasions, the NOC has been rated less sensitive than CCHR in predicting significant brain injuries or need for neurosurgical intervention with very high specificity compared to previous studies. Chodari et al ., 2018 in Iran, reported an unusually low sensitivity (31%) and high specificity (69%) for NOC and 76% and 74% respectively for CCHR “in determining the rate of head injury”. 14 There is reason to suggest that sample size, methodology and knowledge of the guidelines could influence the results reported from different studies. Our current study has limitation of sample size and single centre study base. CONCLUSION In the management of mild traumatic brain injury at the National Trauma Centre, there was no comparative advantage of the Canadian CT Head Rule over the New Orleans Criteria in predicting significant brain injury or vice versa as there was no significant difference between them. Therefore, following the findings from this index study either of the guidelines is recommended to be used for ordering head CT for patients with mild TBI. Declarations Ethics approval and consent to participate Study has hospital ethical board approval and all patients gave consent. Institutional Ethical Approval no.: NHA/EC/108/2020. Consent for publication All authors consented to the publication of this manuscript. Availability of data and materials Data is available on request. Competing interests None Funding None Authors' contributions K – concept, data collection, statistics and writing of the original manuscript. Y – concept, supervision and editing of draft. I – supervision and editing of final draft. A – editing of manuscript. Acknowledgements All Resident Doctors and House Officers of the Trauma and Neurosurgery Units at the Trauma centre. Authors' information (optional) All authors are consultant neurosurgeons. References Bouida W, Marghli S, Souissi S, Ksibi H, Methammem M, Haguiga H, et al. Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study. Ann Emerg Med. 2012;61:521–7. Available from: www.annemergmed.com. Kavalci C, Aksel G, Salt O, Yilmaz MS, Demir A, Kavalci G, et al. Comparison of the Canadian CT head rule and the new orleans criteria in patients with minor head injury. World J Emerg Surg. 2014 Apr 17;9(1). Blennow K, Brody DL, Kochanek PM, Levin H, McKee A, Ribbers GM, et al. Traumatic brain injuries. Nat Rev Dis Prim. 2016 Nov 17;2. Marshall S, Bayley M, Mccullagh S, Velikonja D, Berrigan L, Ouchterlony D, et al. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. J Brain Inj. 2015;29(6):688–700. Stiell IG, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, et al. Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury. J Am Med Assoc. 2005;294(12):1511–8. Svensson S, Vedin T, Clausen L, Larsson PA, Edelhamre M. Application of NICE or SNC guidelines may reduce the need for computerized tomographies in patients with mild traumatic brain injury: A retrospective chart review and theoretical application of five guidelines. Scand J Trauma Resusc Emerg Med. 2019;27(1):99. Lo WS., Shih YN, Leung CS., Cheung LW., Leung M, Heung HC., et al. A retrospective study of patients with minor head injury to compare the Canadian CT Head Rule and the New Orleans Criteria. Hong Kong J Emerg Med. 2016;23(1):25–32. Kinyua J. The Canadian Head CT Rule ; A Hospital Audit. Ann African Surg. 2018;15(2):57–61. Trevethan R. Sensitivity, Specificity, and Predictive Values: Foundations, Pliabilities, and Pitfalls in Research and Practice. Front Public Heal 5307. 2017;5(307):1–7. Mata-Mbemba D, Mugikura S, Nakagawa A, Murata T, Kato Y, Tatewaki Y, et al. Canadian CT head rule and New Orleans Criteria in mild traumatic brain injury: comparison at a tertiary referral hospital in Japan. Springerplus. 2016;5(1):176. Smits M, Dippel DWJ, De Haan GG, Dekker HM, Vos PE, Kool DR, et al. External validation of the Canadian CT head rule and the New Orleans criteria for CT scanning in patients with minor head injury. J Am Med Assoc. 2005;294(12):1519–25. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391–6. Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Traumatic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center. Acad Emerg Med [Internet]. 2012;19(1):2–10. Chobdari N, Davood Sharifi M, Kakhki BR, Shamsaei S, Disfani HF, Hashemian AM. Evaluation of sensitivity and the specificity of Canadian CT head rule and New Orleans criteria in patients with head injury. Australas Med J. 2018;11(3). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Jan, 2025 Editor assigned by journal 09 Jan, 2025 Submission checks completed at journal 09 Jan, 2025 First submitted to journal 08 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5788971","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":400161849,"identity":"46e5266a-7961-49b4-8397-86a56f7c50b8","order_by":0,"name":"Selekeowei Peter Kespi Kpuduwei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYDCCAwzMQBKEGRsfAEkePlK0NBuAtLCRoIWBTQJMEtLBd/sAs3Fhm3XihuPNbZVfc+xk2BiYHz66gUeL5LkE5uSZbemJG84cbLstuy0Z6DA2Y+McPFoMzjAwH+ZtO5y47UZi223JbcxALTxs0sRpuf+wrVhyWz1xWpIhtjC2MX7cdpiwFskzjM3GM86lG+8/k9gszbjtOA8bMwG/8J1hPixdUGYtO7P9+MOPP7dV2/OzNz98jE8LMAYbmGFMZh4wiVc5VCVc9w8iVI+CUTAKRsHIAwAgPkhHeR3tUQAAAABJRU5ErkJggg==","orcid":"","institution":"National Hospital Abuja","correspondingAuthor":true,"prefix":"","firstName":"Selekeowei","middleName":"Peter Kespi","lastName":"Kpuduwei","suffix":""},{"id":400161850,"identity":"c1451648-de05-4166-b826-286cf0ddb477","order_by":1,"name":"Ayodeji Salman Yusuf","email":"","orcid":"","institution":"National Hospital Abuja","correspondingAuthor":false,"prefix":"","firstName":"Ayodeji","middleName":"Salman","lastName":"Yusuf","suffix":""},{"id":400161851,"identity":"945b6382-34a9-4578-b1be-e149e98f907f","order_by":2,"name":"Nasir Jinjiri Ismail","email":"","orcid":"","institution":"Usmanu Danfodiyo University Teaching Hospital, Sokoto","correspondingAuthor":false,"prefix":"","firstName":"Nasir","middleName":"Jinjiri","lastName":"Ismail","suffix":""},{"id":400161852,"identity":"dc5c4d41-b456-48bf-b950-a9191b0799f5","order_by":3,"name":"Jamiu Ayodele Adebiyi","email":"","orcid":"","institution":"National Hospital Abuja","correspondingAuthor":false,"prefix":"","firstName":"Jamiu","middleName":"Ayodele","lastName":"Adebiyi","suffix":""}],"badges":[],"createdAt":"2025-01-08 12:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5788971/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5788971/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73865153,"identity":"b787e50c-1eb3-484f-a352-78ca20186761","added_by":"auto","created_at":"2025-01-15 11:41:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23061,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003emechanism of injuries\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5788971/v1/77d591a34107c1ed8f609f9b.png"},{"id":73865728,"identity":"d449e52e-94b0-4322-9a5a-1b1f719de15b","added_by":"auto","created_at":"2025-01-15 11:49:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":624086,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5788971/v1/c607204e-25ed-4c51-a200-e9349fd3242a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predicting Clinically Significant Brain Injuries following Mild TBI: A Comparative Study of Canadian CT Head Rule and New Orleans Criteria at a National Trauma Centre.","fulltext":[{"header":"Highlight","content":"\u003cp\u003eThis study compared the two most widely used clinical decision rules (Canadian Head CT Rule and New Orleans Criteria) in a sub-Saharan hospital serving as a level 1 trauma centre to enable ER physicians adopt the most efficacious for the management of mild TBI.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eMild traumatic brain injury (mTBI) has remained one of the most common injuries treated at the trauma centre of any hospital\u003csup\u003e1,2\u003c/sup\u003e and could be a major cause death and disability when missed.\u003csup\u003e3\u003c/sup\u003e Mild TBI is also the most common form of head injuries. It is estimated to have an incidence above 600 per 100,000 annually the US.\u003csup\u003e4\u003c/sup\u003e Mild TBI can be defined as a blunt injury to the head with loss of consciousness less than 30 minutes following the injury, disorientation, posttraumatic amnesia of less than 24 hours following the injury, with or without transient loss of focal neurological deficit and GCS 13\u0026ndash;15. Because there exist a wide range of clinical manifestations, which are classified as mild, there is tendency to either ignore neurosurgical consult or overburden the neurosurgeon with patients having mild TBI. And when they present to the emergency room, the decision to do or not to do a head computed tomography (CT) always poses clinical dilemma because of the clinical state of the patients. Whereas, the general use of CT for all patients with mTBI is inefficient and wasteful, the omission of a clinically important brain injury is not desirable.\u003csup\u003e5\u003c/sup\u003e Several criteria or guidelines have been developed to guide physicians in determining who actually would benefit from a head CT in order to both reduce the economic and radiation burden to individuals with minor head injury.\u003csup\u003e2\u003c/sup\u003e Among these decision rules, the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) developed in Northern America are the most widely used by clinicians.\u003c/p\u003e \u003cp\u003eIn order to encourage adoption of any of the validated criteria, this study was conducted to compare the effectiveness of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) in predicting surgically significant brain injuries and need for neurosurgical intervention among patients with mild TBI at the National Trauma Centre.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003eThe research was a cross-sectional study of all consenting adult patients with mild TBI who presented to the Trauma Centre within 24 hours of injury. These patients presented with history of loss of consciousness, disorientation or amnesia and GCS of 13\u0026ndash;15. The patients were assessed at presentation by the emergency physicians and were subsequently screened with both the Canadian CT Head Rule and New Orleans Criteria to determine, if they needed head CT scan or not before they were sent to the radiology department for CT according to the independent decision of the trauma surgeon. Following the head CT, patients were assessed again for CT findings of significant brain injury, which is any brain injury that required hospital admission and observation or neurosurgical follow up and need for neurosurgical intervention, which is ICU admission, surgical procedure including ICP monitoring or death within 30 days. Data was entered into IBM SPSS\u003csup\u003eR\u003c/sup\u003e and analyzed using version 25.0. Ethical clearance was obtained from the Hospital\u0026rsquo;s Research Ethics Committee.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 103 patients were enrolled, there were 91 males and 12 females with a male to female ratio of 7:1. The mean age of the patients was 32.48\u0026thinsp;\u0026plusmn;\u0026thinsp;12.27 years with age range of 16 to 76 years. Only 3 (2.9%) patients were above the age of 60 years (Table\u0026nbsp;1). Injury above the clavicle (64, 62.1%), headache (42, 40.8%), GCS\u0026thinsp;\u0026lt;\u0026thinsp;15 after 2 hours (48, 46.6%), dangerous mechanism of injury (36, 35.0%) and amnesia (36, 35.0%) were the more common risk factors of the two decision rules (Table\u0026nbsp;2). The most common mechanism of injury was road traffic accident (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). NOC guideline had a sensitivity (88.6%), specificity (21.4%), positive predictive value (47.0%) and negative predictive value (70.6%) of clinically significant brain injury; while CCHR guideline showed sensitivity (86.4%), specificity (30.4%), positive predictive value (49.4%) and negative predictive value (73.9%) of clinically significant brain injury (table 3a). There was no statistically significant difference between the two decision rules (P-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (table 3b). For predicting need for neurosurgical intervention, the sensitivity, specificity, positive predictive value and negative predictive value under the NOC guideline were 95.0%, 20.0%, 22.9% and 94.1% respectively; while that under the CCHR guideline were 90.0%, 26.3%, 23.4% and 91.3% respectively (table 4). There was no significant difference between the two decision rules (P- \u0026gt; 0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1.0\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e91\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e103\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2.0\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Characteristics with respect to the decision rules\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNOC Factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFreq\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCCHR Factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFreq\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGCS\u0026thinsp;\u0026lt;\u0026thinsp;15 After 2 Hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuspected Open or Depressed Skull Fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAny Sign of Basal Skull Fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrug or Alcohol Intoxication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 or More Episodes of Vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent Antegrade Amnesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;65 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisible Trauma Above Clavicle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetrograde Amnesia\u0026thinsp;\u0026ge;\u0026thinsp;30min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDangerous Mechanism of Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3.0\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e2 x 2 table for clinically significant brain injury on CT scan\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNOC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eCCHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEligible for CT (Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Positive Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e% Positive Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e49.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Outcome (sensitivity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e% Outcome (sensitivity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e86.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNot Eligible for CT (No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Negative Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e70.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e% Negative Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e73.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Outcome (specificity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e21.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e% Outcome (specificity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e30.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eTP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNOC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c10\" namest=\"c8\" rowspan=\"2\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003cp\u003e(not significant)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCCHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTP- true positive, TN - true negative, CT- computerized tomography\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4.0\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003e2 x 2 table for Need for neurosurgical intervention\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNOC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCCHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEligible For CT (Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Positive Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% Positive Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e23.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Outcome (sensitivity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% Outcome (sensitivity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e90.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNot Eligible for CT (No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Negative Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e94.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% Negative Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e91.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e% Outcome (specificity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e20.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% Outcome (specificity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e26.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eTP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNOC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c10\" namest=\"c9\" rowspan=\"2\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003cp\u003e(not significant)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCCHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTP- true positive, TN - true negative, CT- computerized tomography\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study shows that both NOC and CCHR have low positive predictive values (47.0% \u0026amp; 49.4%) but high negative predictive values (70.6% \u0026amp; 73.9%) respectively for significant brain injury. This trend of low positive values and high negative values is consistent with other reports.\u003csup\u003e1,6\u003c/sup\u003e Although, the predictive values of CCHR were higher than those of NOC for significant brain injury. The difference was not significant in this current study. Both guidelines showed similar comparable positive predictive values of 23% and negative predictive values of NOC 95% and CCHR 91%. These findings are consistent with similar studies comparing the two decision rules. Bouida et al in a 3-year prospective study of over a thousand patients in Tunisia demonstrated that the positive predictive values of NOC and CHR for clinically significant brain injury were 16% and 30% respectively and negative predictive values 93% and 99% respectively. In the same vein, the positive predictive values of NOC and CCHR for need for neurosurgical intervention were 2% and 5% respectively and the negative predictive values 99% and 100% for NOC and CCHR respectively.\u003csup\u003e1\u003c/sup\u003e Whereas, Lo et al in a 3 year retrospective study of 474 patients in Hong Kong reported that the negative predictive values of NOC and CCHR for clinically significant brain injury were 91% and 88% respectively and that for need for neurosurgical intervention 100% and 99% respectively.\u003csup\u003e7\u003c/sup\u003e While the negative predictive value of CCHR (73.9%) for clinically significant brain injury was higher than that of NOC (70.6%) in our study like Bouida et al,\u003csup\u003e1\u003c/sup\u003e the negative predictive value of CCHR (91.3%) for need for neurosurgical intervention was lower than that of NOC (94.1%) in our study similar to Lo et al.\u003csup\u003e7\u003c/sup\u003e High negative predictive values have the tendency to reduce unnecessary CT in patients with mild TBI, which is a huge concern for developing countries due to cost of CT scan.\u003csup\u003e8\u003c/sup\u003e This is very important as the index study shows very high negative predictive values for need for neurosurgical intervention, which may not be easily missed when using either of the 2 guidelines in clinical practice at the Accident and Emergency Department or Trauma Centre.\u003c/p\u003e \u003cp\u003eNOC tend to have higher sensitivity (88.6%) than CCHR (86.4%) for clinically significant brain injury, while CCHR had a higher specificity (30.4%) than NOC (21.4%). Although, unlike previous studies there was no statistically significant difference between the diagnostic performances of the two rules in this study. Similarly, Lo et al reported sensitivity of NOC and CCHR as 92% and 80% and their specificity as 17% and 39% respectively for predicting clinically significant brain injury.\u003csup\u003e7\u003c/sup\u003e The authors also reported sensitivity of NOC and CCHR as 100% and 80% respectively and their specificity as 15% and 36% respectively for need for neurosurgical intervention. The authors concluded that both rules have excellent prediction to rule out need for neurosurgical intervention due to their very high negative predictive values (100% and 99%) despite their low specificities in comparison to those of the index study. Therefore, the diagnostic performance of a rule is not dependent on a single factor like sensitivity or specificity.\u003csup\u003e9\u003c/sup\u003e Likewise, Mata-Mbemba et al in a prospective study of 142 patients in Japan, also reported that the diagnostic performance of CCHR was higher than that of NOC, where the sensitivity of NOC and CCHR for clinically significant brain injury was 97.9% and 89.8% respectively; and specificity was 9.7% and 24.7% respectively and accuracy of 40.1% and 47.2% respectively. The univariate analysis showed both rules are significantly associated with clinically significant CT findings, however the multivariate and ROC analyses demonstrated superiority of CCHR over NOC as reported previously by large-scale studies in contrast to the findings of the index study.\u003csup\u003e10\u003c/sup\u003e In Netherlands, Smits et al reported the superiority of CCHR over NOC, where sensitivity of NOC and CCHR was 99% and 87% respectively, and specificity was 3.1% and 39% for clinically important CT findings; and for need for neurosurgical intervention, sensitivity was 100% and 100% respectively, while specificity was 3.0% and 38% respectively.\u003csup\u003e11\u003c/sup\u003e These 2 previous findings and conclusions are similar to those by Stiell et al., 2001 in Canada, who were the same authors that developed the CCHR 4 years earlier before doing a comparison study.\u003csup\u003e12\u003c/sup\u003e They reported a sensitivity of 100% for both NOC and CCHR and specificity of 12.1% and 76.3% respectively in predicting need for neurosurgical intervention in mild TBI patients with GCS score of 15; while for clinically important brain injury, the sensitivity was still 100% for both NOC and CCHR but specificity of 12.7% and 50.6%, which was statistically significant.\u003csup\u003e5\u003c/sup\u003e This was similar to the one conducted in the US by Papa et al., 2012, where in detecting any traumatic intracranial lesion on CT, clinically important brain lesion and predicting need for neurosurgical intervention, the CCHR had a higher specificity (36.3%, 35% and 80.7%) while NOC had 10.2%, 9.9% and 9.6% respectively in patients with GCS score of 15.\u003csup\u003e13\u003c/sup\u003e In rare occasions, the NOC has been rated less sensitive than CCHR in predicting significant brain injuries or need for neurosurgical intervention with very high specificity compared to previous studies. Chodari \u003cem\u003eet al\u003c/em\u003e., 2018 in Iran, reported an unusually low sensitivity (31%) and high specificity (69%) for NOC and 76% and 74% respectively for CCHR \u0026ldquo;in determining the rate of head injury\u0026rdquo;.\u003csup\u003e14\u003c/sup\u003e There is reason to suggest that sample size, methodology and knowledge of the guidelines could influence the results reported from different studies. Our current study has limitation of sample size and single centre study base.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn the management of mild traumatic brain injury at the National Trauma Centre, there was no comparative advantage of the Canadian CT Head Rule over the New Orleans Criteria in predicting significant brain injury or vice versa as there was no significant difference between them. Therefore, following the findings from this index study either of the guidelines is recommended to be used for ordering head CT for patients with mild TBI.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy has hospital ethical board approval and all patients gave consent.\u0026nbsp;Institutional Ethical Approval no.: NHA/EC/108/2020.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consented to the publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eK – concept, data collection, statistics and writing of the original manuscript. Y – concept, supervision and editing of draft. I – supervision and editing of final draft. A – editing of manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll Resident Doctors and House Officers of the Trauma and Neurosurgery Units at the Trauma centre.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors are consultant neurosurgeons.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBouida W, Marghli S, Souissi S, Ksibi H, Methammem M, Haguiga H, et al. Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study. Ann Emerg Med. 2012;61:521\u0026ndash;7. Available from: www.annemergmed.com.\u003c/li\u003e\n\u003cli\u003eKavalci C, Aksel G, Salt O, Yilmaz MS, Demir A, Kavalci G, et al. Comparison of the Canadian CT head rule and the new orleans criteria in patients with minor head injury. World J Emerg Surg. 2014 Apr 17;9(1). \u003c/li\u003e\n\u003cli\u003eBlennow K, Brody DL, Kochanek PM, Levin H, McKee A, Ribbers GM, et al. Traumatic brain injuries. Nat Rev Dis Prim. 2016 Nov 17;2. \u003c/li\u003e\n\u003cli\u003eMarshall S, Bayley M, Mccullagh S, Velikonja D, Berrigan L, Ouchterlony D, et al. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. J Brain Inj. 2015;29(6):688\u0026ndash;700. \u003c/li\u003e\n\u003cli\u003eStiell IG, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, et al. Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury. J Am Med Assoc. 2005;294(12):1511\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eSvensson S, Vedin T, Clausen L, Larsson PA, Edelhamre M. Application of NICE or SNC guidelines may reduce the need for computerized tomographies in patients with mild traumatic brain injury: A retrospective chart review and theoretical application of five guidelines. Scand J Trauma Resusc Emerg Med. 2019;27(1):99. \u003c/li\u003e\n\u003cli\u003eLo WS., Shih YN, Leung CS., Cheung LW., Leung M, Heung HC., et al. A retrospective study of patients with minor head injury to compare the Canadian CT Head Rule and the New Orleans Criteria. Hong Kong J Emerg Med. 2016;23(1):25\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eKinyua J. The Canadian Head CT Rule ; A Hospital Audit. Ann African Surg. 2018;15(2):57\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eTrevethan R. Sensitivity, Specificity, and Predictive Values: Foundations, Pliabilities, and Pitfalls in Research and Practice. Front Public Heal 5307. 2017;5(307):1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMata-Mbemba D, Mugikura S, Nakagawa A, Murata T, Kato Y, Tatewaki Y, et al. Canadian CT head rule and New Orleans Criteria in mild traumatic brain injury: comparison at a tertiary referral hospital in Japan. Springerplus. 2016;5(1):176. \u003c/li\u003e\n\u003cli\u003eSmits M, Dippel DWJ, De Haan GG, Dekker HM, Vos PE, Kool DR, et al. External validation of the Canadian CT head rule and the New Orleans criteria for CT scanning in patients with minor head injury. J Am Med Assoc. 2005;294(12):1519\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eStiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003ePapa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Traumatic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center. Acad Emerg Med [Internet]. 2012;19(1):2\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eChobdari N, Davood Sharifi M, Kakhki BR, Shamsaei S, Disfani HF, Hashemian AM. Evaluation of sensitivity and the specificity of Canadian CT head rule and New Orleans criteria in patients with head injury. Australas Med J. 2018;11(3). \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mild traumatic brain injury, computerized tomography scan, clinical decision rule, predictive value, New Orleans Criteria, Canadian CT Head Rule, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-5788971/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5788971/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMild traumatic brain injury (mTBI) is one of the most common injuries treated at any trauma centre. Whereas the general use of CT for all patients with mTBI is inefficient and wasteful, the omission of a clinically important brain injury is not desirable. Several guidelines have been developed to assist physicians in determining who actually needs a head CT. For this reason, the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) were compared in this study on their efficacy in predicting surgically significant brain injuries and need for neurosurgical intervention.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003e The research was a prospective cross-sectional study at a level 1 trauma centre that received ethical approval from the Hospital. Consenting adult patients who presented with mild TBI within 24 hours were recruited. They were assessed with the NOC and CCHR, which decisions were compared between them and with CT head findings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 103 patients were successfully enrolled, males were 91 and females were 12 with mean age of 32.48\u0026thinsp;\u0026plusmn;\u0026thinsp;12.27 years old. The sensitivity, specificity, positive predictive value and negative predictive value of clinically significant brain injury under the NOC guideline compared with that of CCHR guideline were not significantly statistically different with P-value of 0.39. Similarly, there was no statistically significant difference between the two guidelines for need for neurosurgical intervention as P-value was 0.48.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e \u003cb\u003eF\u003c/b\u003eollowing the findings this study either NOC or CCHR is safe to be used for ordering head CT for patients with mild TBI.\u003c/p\u003e","manuscriptTitle":"Predicting Clinically Significant Brain Injuries following Mild TBI: A Comparative Study of Canadian CT Head Rule and New Orleans Criteria at a National Trauma Centre.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 11:41:04","doi":"10.21203/rs.3.rs-5788971/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-09T21:06:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-09T11:51:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-09T11:50:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-01-08T12:11:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0972d096-ca53-4133-9f6c-1e585ceb3922","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-28T19:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 11:41:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5788971","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5788971","identity":"rs-5788971","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}