Quantitative brain electrical activity in the initial screening of mild traumatic brain injuries

Brian O'Neil, Leslie S Prichep, Roseanne Naunheim, Robert Chabot, Brian O'Neil, Leslie S Prichep, Roseanne Naunheim, Robert Chabot

Abstract

Introduction: The incidence of emergency department (ED) visits for Traumatic Brain Injury (TBI) in the United States exceeds 1,000,000 cases/year with the vast majority classified as mild (mTBI). Using existing computed tomography (CT) decision rules for selecting patients to be referred for CT, such as the New Orleans Criteria (NOC), approximately 70% of those scanned are found to have a negative CT. This study investigates the use of quantified brain electrical activity to assess its possible role in the initial screening of ED mTBI patients as compared to NOC.

Methods: We studied 119 patients who reported to the ED with mTBI and received a CT. Using a hand-held electroencephalogram (EEG) acquisition device, we collected data from frontal leads to determine the likelihood of a positive CT. The brain electrical activity was processed off-line to generate an index (TBI-Index, biomarker). This index was previously derived using an independent population, and the value found to be sensitive for significant brain dysfunction in TBI patients. We compared this performance of the TBI-Index to the NOC for accuracy in prediction of positive CT findings.

Results: Both the brain electrical activity TBI-Index and the NOC had sensitivities, at 94.7% and 92.1% respectively. The specificity of the TBI-Index was more than twice that of NOC, 49.4% and 23.5% respectively. The positive predictive value, negative predictive value and the positive likelihood ratio were better with the TBI-Index. When either the TBI-Index or the NOC are positive (combining both indices) the sensitivity to detect a positive CT increases to 97%.

Conclusion: The hand-held EEG device with a limited frontal montage is applicable to the ED environment and its performance was superior to that obtained using the New Orleans criteria. This study suggests a possible role for an index of brain function based on EEG to aid in the acute assessment of mTBI patients.

Figures

Figure.
Figure.
Schematic showing the location of the five frontal electrode sites of the International 10/20 system.

References

    1. Jager TE, Weiss HB, Coben JH, et al. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Acad Emerg Med. 2000;7:134–40.
    1. Rutland- Brown W, Langlois JAS, Thomas KEM, et al. Incidence of Traumatic Brain Injury in the United States, 2003. J Head Trauma Rehabil. 2006;21:544–8.
    1. Semelka RC, Armao DM, Elias J, Jr, et al. Imaging strategies to reduce the risk of radiation in CT studies, including selective substitution with MRI. J Magn Reson Imaging. 2007;25:900–9.
    1. Haydel MJ, Preston CA, Mills TJ, et al. Indications for Computed Tomography in Patients with Minor Head Injury. N Engl J Med. 2000;343:100–5.
    1. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. The Lancet. 2001;357:1391–6.
    1. Stein SC, Fabbri A, Servadei F, et al. A Critical Comparison of Clinical Decision Instruments for Computed Tomographic Scanning in Mild Closed Traumatic Brain Injury in Adolescents and Adults. Ann Emerg Med. 2009;53:180–8.
    1. Tebano MT, Cameroni M, Gallozzi G, et al. EEG spectral analysis after minor head injury in man. Electroencephalogr Clin Neurophysiol. 1988;70:185–9.
    1. Thatcher RW, Walker RA, Gerson I, et al. EEG discriminant analyses of mild head trauma. EEG Clin Neurophysiol. 1989;73:94–106.
    1. Thornton KE. Exploratory investigation into mild brain injury and discriminant analysis with high frequency bands (32–64 Hz) Brain Inj. 1999;13:477–88.
    1. Thatcher RW, North DM, Curtin RT, et al. An EEG severity index of traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2001;13:77–81.
    1. Chen XP, Tao LY, Chen AC. Electroencephalogram and evoked potential parameters examined in Chinese mild head injury patients for forensic medicine. Neuroscience Bulletin. 2006;22:165–70.
    1. Duff J. The Usefulness of Quantitative EEG (QEEG) and Neurotherapy in the Assessment and Treatment of Post-Concussion Syndrome. Clinical EEG and Neuroscience. 2004;35
    1. Watson MR, Fenton GW, McClelland RJ, et al. The post-concussional state: neurophysiological aspects. Br J Psychiatry. 1995;167:514–21.
    1. Trudeau DL, Anderson J, Hansen L, et al. Findings of mild traumatic brain injury in combat veterans with PTSD and a history of blast concussion. J Neuropsychiatry Clin Neurosci. 1998;10:308–13.
    1. Cao C, Tutwiler RI, Slobounov S. Automatic Classification of Athletes With Residual Functional Deficits Following Concussion by Means of EEG Signal Using Support Vector Machine. Neural Systems and Rehabilitation Engineering. 2008;16:327–35.
    1. Povlishock JT, Katz DI. Update of Neuropathology and Neurological Recovery After Traumatic Brain Injury. J Head Trauma Rehabil. 2005;20
    1. Naunheim RS, Treaster M, English J, et al. Use of Brain Electrical Activity to Quantify Traumatic Brain Injury in the Emergency Department. Brain Inj. 2010;24:1324–9.
    1. McCrea M, Prichep LS, Powell MR, et al. Acute Effects and Recovery After Sport-Related Concussion: A Neurocognitive and Quantitative Brain Electrical Activity Study. J Head Trauma Rehabil. 2010;25:283–92.
    1. Barr WB, Prichep LS, Chabot RJ, et al. Measuring brain eletrical activity to track recovery from sport related concussion. Brain Inj. In press.
    1. Marshall LF, Marshall SB, Klauber M, et al. The diagnosis of head injury requires a classification based on computed axial tomography. Journal of Neurotrauma. 1992;9:S287–S292.
    1. John ER, Prichep LS, Friedman J, et al. Neurometrics: Computer-assisted differential diagnosis of brain dysfunctions. Science. 1988;293:162–9.
    1. Prichep LS. Use of normative databases and statistical methods in demonstrating clinical utility of QEEG: Importance and cautions. Clinical EEG. 2005;36:82–7.
    1. Kondacs A, Szabo M. Long-term intra-individual variability of the background EEG in normals. Clinical Neurophysiology. 1999;110:1708.
    1. Thakor NV, Tong S. Advances In Quantitative Electroencephalogram Analysis Methods. Annu Rev Biomed Eng. 2004;6:453–95.
    1. Kohavi R. A study of cross-validation and bootstrap for accuracy estimation and model selection. International Conference on Artificial Intelligence; 1995.
    1. Levin H, Williams D, Eisenberg H, et al. Serial MRI and neurobehavioural findings after mild to moderate closed head injury. Journal of Neurology, Neurosurgery & Psychiatry. 1992;55:255–62.
    1. Levin H, Kraus MF. The frontal lobes and traumatic brain injury. J Neuropsychiatry Clin Neurosci. 1994;6:443–54.
    1. Ptito A, Chen JK, Johnston KM. Contributions of functional Magnetic Resonance Imaging (fMRI) to sport concussion evaluation. NeuroRehabilitation. 2007;22:217–27.
    1. Malloy PF, Aloia M. Frontal Lobe Dysfunction in Traumatic Brain Injury. Seminars in Clinical Neuropsychiatry. 1998;3:186–94.
    1. Bazarian JJ, Blyth B, Cincotti F. Bench to Bedside: Evidence for Brain Injury after Concussion-- Looking beyond the Computed Tomography Scan. Acad Emerg Med. 2006;13:199–214.
    1. Bey T, Ostick B. Second Impact Syndrome. WestJEM. 2009;10:6–10.
    1. Slobounov S, Cao C, Sebastianelli W. Differential effect of first versus second concussive episodes on wavelet information quality of EEG. Clinical Neurophysiology. 2009;120:862–7.
    1. Jagoda AS, Bazarian JJ, Bruns JJ, Jr, et al. Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting. Ann Emerg Med. 2008;52:714–48.
    1. Smits M, Dippel DWJ, de Haan GG, et al. External Validation of the Canadian CT Head Rule and the New Orleans Criteria for CT Scanning in Patients With Minor Head Injury. JAMA. 2005;294:1519–25.
    1. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients With Minor Head Injury. JAMA. 2005;294:1511–8.
    1. Redberg RF. Cancer Risks and Radiation Exposure From Computed Tomographic Scans: How Can We Be Sure That the Benefits Outweigh the Risks? Archives of Internal Medicine. 2009;169:2049–50.
    1. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation Dose ssociated With Common Computed Tomography Examinations and the Associated Lifetime Attributable Risk of Cancer. Archives of Internal Medicine. 2009;169:2078–86.

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