Cranial CT for Minor Head Trauma
ABSTRACT & COMMENTARY
Source: Haydel MJ, et al. Indications for computed tomography in patients with minor head injury. New Engl J Med 2000;343:100-105.
This was a prospective, multicenter study designed to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury (MHI) who do not require cranial computed tomography (CT). In the first phase of the study, the authors recorded clinical findings in 520 consecutive patients with MHI, defined by a loss of consciousness (LOC) and, on arrival to the emergency department (ED), a Glasgow Coma Scale (GCS) score of 15 and a normal neurologic examination. All patients underwent cranial CT. Using recursive partitioning, a set of clinical criteria was derived to identify all patients who had abnormalities on CT. In the second phase, the sensitivity and specificity of these criteria were evaluated in a cohort of 909 patients.
Of the 520 patients in the first phase, 36 (6.9%) had positive scans. All patients with positive CT scans had one or more of seven clinical findings: headache, vomiting, age older than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, or seizures. Among the 909 patients in the second phase, 57 (6.3%) had positive scans. In this group, the sensitivity of the seven findings combined was 100% (95%, CI 95-100%). All patients with positive CT scans had at least one of these findings.
Comment by Michael A. Gibbs, MD, FACEP
Each year, more than two million Americans present to the ED following head trauma. Current recommendations suggest that neuroimaging be performed in the vast majority of these patients. In the population with MHI (i.e., history of LOC or amnesia, GCS = 15), the yield of this conservative approach is quite low: Between 6% and 9% will have a "positive" CT, and less than 1% will require neurosurgical intervention.1-3
In keeping with other recently developed clinical decision rules, Haydel and colleagues have developed a straightforward set of criteria that can be applied at the bedside. While prospective validation at other centers would be helpful, the high negative predictive value (100%) of this rule for excluding intracranial abnormalities in this patient population is impressive.
References
1. Marx JM, Biros MH. Who is at low risk after head or neck trauma? New Engl J Med 2000;343:138-139.
2. Miller EC, et al. Minor head trauma: Is computed tomography always necessary? Ann Emerg Med 1996;27:290-294.
3. Borczuk P, et al. Mild head trauma. Emerg Med Clin North Am 1997;15:563-579.
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