title: Risk factors for delayed neuro-surgical intervention in patients with acute mild traumatic brain injury and intracranial hemorrhage.
abstract: BACKGROUND
  Mild traumatic brain injury (TBI) patients with initial traumatic intracranial hemorrhage (tICH) and without immediate neuro-surgical intervention require close monitoring of their neurologic status. Progressive hemorrhage and neurologic deterioration may need delayed neuro-surgical intervention. This study aimed to determine the potential risk factors of delayed neuro-surgical intervention in mild TBI patients with tICH on admission.
  
  
  METHODS
  Three hundred and forty patients with mild TBI and tICH who did not need immediate neuro-surgical intervention on admission were evaluated retrospectively. Their demographic information, clinical evaluation, laboratory data, and brain CT was reviewed. Delayed neuro-surgical intervention was defined as failure of non-operative management after initial evaluation. Risk factors of delayed neuro-surgical intervention on admission were analyzed.
  
  
  RESULTS
  Delayed neuro-surgical intervention in mild TBI with tICH on initial brain CT accounted for 3.8 % (13/340) of all episodes. Higher WBC concentration, higher initial ISS, epidural hemorrhage (EDH), higher volume of EDH, midline shift, and skull fracture were risk factors of delayed neuro-surgical intervention. The volume of EDH and skull fracture is independent risk factors. One cubic centimeter (cm3) increase in EDH on initial brain CT increased the risk of delayed neurosurgical intervention by 16 % (p = 0.011; OR: 1.190, 95 % CI:1.041-1.362).
  
  
  CONCLUSIONS
  Mild TBI patients with larger volume of EDH have higher risk of delayed neuro-surgical interventions after neurosurgeon assessment. Longer and closer neurological function monitor and repeated brain image is required for those patients had initial larger EDH. A large-scale, multi-centric trial with a bigger study population should be performed to validate the findings.
authors.affiliation: Departments of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Fu-Yuan
authors.initials: FY
authors.lastname: Shih
authors.affiliation: Departments of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Hsin-Huan
authors.initials: HH
authors.lastname: Chang
authors.affiliation: Departments of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Hung-Chen
authors.initials: HC
authors.lastname: Wang
authors.affiliation: Departments of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Tsung-Han
authors.initials: TH
authors.lastname: Lee
authors.affiliation: Departments of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Yu-Jun
authors.initials: YJ
authors.lastname: Lin
authors.affiliation: Departments of Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Wei-Che
authors.initials: WC
authors.lastname: Lin
authors.affiliation: Departments of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Wu-Fu
authors.initials: WF
authors.lastname: Chen
authors.affiliation: Departments of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Jih-Tsun
authors.initials: JT
authors.lastname: Ho
authors.affiliation: Departments of Neurology, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Cheng-Hsien
authors.initials: CH
authors.lastname: Lu
keywords: Mild traumatic brain injury; Risk factor; Surgical intervention