Transcranial Ultrasonography for the Management of Patients With Mild TBI

Mild Traumatic Brain Injury Clinical Trial

— TRUST  

Official title:

Transcranial Ultrasonography for the Management of Patients With Mild Traumatic Brain Injury

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03989999
• Other study ID #: 38RC19.106
• Status: Recruiting
• Phase: N/A
• Start date: February 1, 2020
• Est. completion date: July 2026

Study information

• Verified date: December 2023
• Source: University Hospital, Grenoble
• Contact: Pierre BOUZAT, MD, PhD
• Phone: +33 (0)4 76 76 67 29
• Email: pbouzat[@]chu-grenoble.fr
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The investigators hypothesize that patients with mild TBI and normal TCD can be safely discharged home immediately after the ED. The targeted population is the category of patients eligible for early discharge: 1) patients with mild lesions on the initial CT scan and a GCS 15 after CT scan completion and, 2) patients with no lesion on the initial cerebral CT scan with at least one of the following risk factors: GCS 14 after CT scan completion, persisting post-traumatic nausea/vomiting/headaches, concomitant alcoholic intoxication or patients treated with aspirin. The study will not include mild TBI patients who are not eligible for early discharge: patients with no possibility of home supervision, those with a GCS lower than 14 after the CT scan or those treated with anticoagulant/antiplatelet drugs other than aspirin. The investigators expect the TCD-based strategy to be non-inferior compared to the standard strategy according to French recommendations in terms of the 3-months neurological outcome. From a public health standpoint, the use of TCD as a triage tool may change current guidelines regarding mild TBI management.

Description:

Patients with mild traumatic brain injury (TBI) represent the vast majority of TBI patients admitted in the emergency department (ED). According to French recommendations, mild TBI patients with brain lesions on initial CT scan are directed to a standard ward, where neurologic monitoring consists of repeated CT scanning and clinical exams. Patients with no lesion on initial cerebral CT scan are also hospitalized 1) when their GCS after CT scan is lower than 15, 2) in case of persisting nausea, vomiting or headache, 3) in case of concomitant alcoholic intoxication and, 4) in case of on-going treatment with aspirin. This strategy induces significant hospital stay with potential morbidity, whereas neurologic worsening rarely occurs.

In this context, the implementation of a triage tool in the ED would be useful to screen patients at risk of early neurologic worsening. Hence, low risk patients may be discharged at home immediately after the ED. Transcranial Doppler (TCD) is a non-invasive technique that measures cerebral blood flow velocities in intracranial cerebral arteries. These velocities and a derivated parameter (pulsatility index, PI), estimate cerebral blood flow (CBF) and have become a standard of care to optimize CBF in after severe TBI. Only few studies report the use of TCD after mild TBI. In a single-center cohort of patients with mild-to-moderate TBI, TCD parameters measured at hospital admission accurately predicted early neurologic worsening. These encouraging results indicate that TCD, in combination with CT scan findings, could play a role in the management of patients with mild TBI.

The aim of this project is to determine whether a TCD-based strategy is non-inferior to the standard management in terms of the overall neurological outcome at 3 months after mild TBI with no/minor lesions detected on a cerebral CT scan.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 984
• Est. completion date: July 2026
• Est. primary completion date: May 2025
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 75 Years

Eligibility

Inclusion Criteria:

• Mild TBI (GCS 13-15 on ED admission) with one of the following:

• Patient with minor cerebral lesion on initial CT scan (TCDBII i.e. no midline shift, visible basal cisterns and haemorrhagic lesion < 25 cc) and GCS 15 after CT scan

• OR * Patient with normal initial CT scan (TCDB I) with at least one risk factor :

• GCS = 14 after CT scan

• and/or alcoholic intoxication

• and/or on-going treatment with aspirin

• and /or persisting nausea, and/or vomiting and/or headaches

• Early initial CT scan (< 4 hours after TBI)

• Possibility of home supervision by a third-party

• Affiliation to the French social security system

• Patient have signed consent form

• Possibility to perform a TCD within 8 hours

• Stable hemodynamics: systolic blood pressure >90 mmHg, peripheral capillary oxygen saturation >92%, hemoglobin > 8 g/dl

Exclusion Criteria:

• CT scan classified as TCDB III - VI

• Penetrating head-trauma

• Patient under mechanical ventilation

• Patients treated with anticoagulants or anti-platelet therapy (except Aspirin)

• Hospitalization required by post-traumatic extra-cranial lesion, intoxication (except alcoholic), pre-existing condition (including congenital hemostasis disorders) or social factors at the discretion of the physician.

• Internal Carotid dissection

• Post-traumatic lesion in the posterior cerebral fossa

• Subject in exclusion period of another interventional study,

• Pregnant women, breastfeeding women

• Subject under administrative or judicial control, under protection

Related Conditions & MeSH terms

• Brain Concussion
• Brain Injuries
• Brain Injuries, Traumatic
• Mild Traumatic Brain Injury

Intervention

Procedure:
• Transcranial Doppler (TCD)
In the Emergency Department (ED): After the initial cerebral CT scan, the patient will be included in the study when he/she satisfies inclusion criteria. TCD will be performed within 8 hours of the brain injury. If TCD is normal (FVd>25 cm/sec and PI <1.25), the patient will return home under third-party supervision. An advice sheet will be given to the patient according to the SFMU guidelines and another one will be sent to the general practitioner. If initial cerebral CT scan is performed early (< 4-6 hours after TBI), CT scan should not be controlled before patient discharge. If the TCD is abnormal (FVd=25 cm/sec or PI = 1.25) the patient will be hospitalized. There is no recommendation regarding the type of hospitalization (ICU or standard ward). No other diagnostic procedure is allowed in the ED (S-100 protein dosing is not allowed). All therapies recommended by the SFMU for mild TBI are allowed in this group.

Locations

Country	Name	City	State
France	CH Bourg-en-bresse	Bourg-en-Bresse
France	CHU Clermont-Ferrand	Clermont-Ferrand
France	CHU Grenoble Alpes	Grenoble
France	CHRU Lille	Lille
France	HCL - Edouard Herriot	Lyon
France	HCL - Lyon Sud	Lyon
France	AP-HM Timone	Marseille
France	CH Melun	Melun
France	CHRU Montpellier	Montpellier
France	CHU Nantes	Nantes
France	CHU Nîmes	Nîmes
France	AP-HP - Avicenne	Paris
France	AP-HP Lariboisière	Paris
France	AP-HP Pitié Salpetrière	Paris
France	CHU Poitiers	Poitiers
France	Chu Reunion	Saint Pierre
France	CHU Réunion	Saint-Denis
France	CHU Toulouse	Toulouse
Monaco	CH Monaco	Monaco

Sponsors (1)

Lead Sponsor	Collaborator
University Hospital, Grenoble

Countries where clinical trial is conducted

France,  Monaco, 

References & Publications (4)

af Geijerstam JL, Britton M. Mild head injury: reliability of early computed tomographic findings in triage for admission. Emerg Med J. 2005 Feb;22(2):103-7. doi: 10.1136/emj.2004.015396. — View Citation

Davis DP, Kene M, Vilke GM, Sise MJ, Kennedy F, Eastman AB, Velky T, Hoyt DB. Head-injured patients who "talk and die": the San Diego perspective. J Trauma. 2007 Feb;62(2):277-81. doi: 10.1097/TA.0b013e31802ef4a3. — View Citation

Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Buki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Soderberg J, Stanworth SJ, Stein MB, von Steinbuchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K; InTBIR Participants and Investigators. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017 Dec;16(12):987-1048. doi: 10.1016/S1474-4422(17)30371-X. Epub 2017 Nov 6. No abstract available. — View Citation

Tagliaferri F, Compagnone C, Korsic M, Servadei F, Kraus J. A systematic review of brain injury epidemiology in Europe. Acta Neurochir (Wien). 2006 Mar;148(3):255-68; discussion 268. doi: 10.1007/s00701-005-0651-y. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Non-inferiority of a TCD-based strategy after a mild TBI to the standard management in terms of the overall neurological outcome	GOS-E will be dichotomized as good recovery (GOS-E 7 or 8) vs. disability (GOS-E 1 to 6). Evaluation is centralized and blinded.	3 months after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on the overall neurological outcome	GOS-E will be dichotomized as good recovery (GOS-E 7 or 8) vs. disability (GOS-E 1 to 6). Evaluation is centralized and blinded.	1 month after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on the quality of life	Questionnaires QOLIBRI (Quality of life after TBI) and EQ-5D-5L	1 months after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on the quality of life	Questionnaires QOLIBRI (Quality of life after TBI) and EQ-5D-5L	3 months after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on Post-concussive syndrome	Rivermead Post-Concussion Symptoms questionnaire at 1 month and 3 months after TBI ("Rivermead positive" patients are patients with at least 3 symptoms rated = 2)	1 month after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on Post-concussive syndrome	Rivermead Post-Concussion Symptoms questionnaire at 1 month and 3 months after TBI ("Rivermead positive" patients are patients with at least 3 symptoms rated = 2)	3 months after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on Morbidity after TBI	Number of cerebral CT scans within the hospital stay, • Thromboembolic events or diagnosed nosocomial infections stay	1 months after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on mortality after TBI	Mortality within the first 3 months	3 months after TBI
Secondary	Effects of a TCD-based strategy after a mild TBI on patient safety	Number of patients with neurologic worsening within the first week after TBI.	3 months after TBI