Head Injury (Adult)

Pathway

Images

Image Gallery Note: These images open in a new page
1		Subdural Haematoma Image 1 (Computed Tomography): Acute post-traumatic right fronto-parietal subdural haematoma with midline shift showing the typical crescent shape (arrow).
2		Bilateral Chronic Subdural Haematoma Image 2 : Post-mortem specimen of the dura matter peeled back to reveal old haematoma within the subdural space (arrow).
3		Extradural Haematoma Image 3 (Computed Tomography): Acute traumatic left extradural haematoma (arrow) showing the typical lens or convex shape with compression of the lateral ventricle.

Pathology images courtesy of PathWest Laboratory Medicine.

Teaching Points

Teaching Points

• Certain clinical findings mandate urgent CT head - focal neurological deficit, patients on anticoagulation/antiplatelets or suffering with a bleeding diathesis, penetrating skull injury, depressed skull fracture, signs of a base of skull fracture, < GCS 13 at any time since injury, post-traumatic seizure, unstable vital signs with major trauma
• Patients with a history of loss of consciousness (LOC), amnesia/disorientation and a GCS > 13 must be further risk assessed based on clinical findings. The criteria used in this pathway are based on the Canadian CT Head Rule, which is most widely validated clinical decision making tool. Observation or CT head may be indicated
• The decision to perform imaging on patients with no LOC, amnesia or disorientation and GCS 15 should be based on the judgement of the managing physician after history and examination
• Patients who present without loss of consciousness or amnesia are not included by the Canadian CT Head rule, but there is evidence that there is still a risk of intracranial injury if other risk factors from the rule are present

References

References

Date of literature search: December 2017 - April 2018

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. National Institute for Health and Care Excellence (UK). National institute for health and clinical excellence: guidance. Head injury: triage, assessment, investigation and early management of head injury in children, young people and adults. London: National Clinical Guideline Centre; 2014. Guideline. View the reference
2. Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol. 2002;12(6):1237-52. (Review article). View the reference
3. 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. (Level II evidence). View the reference
4. Teasdale GM, Murray G, Anderson E, Mendelow AD, MacMillan R, Jennett B, et al. Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries. BMJ. 1990;300(6721):363-7. (Level II evidence). View the reference
5. Alcala Minagorre PJ, Aranaz Andres J, Flores Serrano J, Asensio Garcia L, Herrero Galiana A. Diagnostic utility of radiography in head trauma: a critical review of the literature. Anales de pediatria (Barcelona, Spain : 2003). 2004;60(6):561-8. (Review article). View the reference
6. Abdul Rahman YS, Al Den AS, Maull KI. Prospective study of validity of neurologic signs in predicting positive cranial computed tomography following minor head trauma. Prehosp Disaster Med. 2010;25(1):59-62. (Level III evidence). View the reference
7. Holmes JF, Baier ME, Derlet RW. Failure of the Miller criteria to predict significant intracranial injury in patients with a Glasgow coma scale score of 14 after minor head trauma. Acad Emerg Med. 1997;4(8):788-92. (Level II evidence). View the reference
8. Livingston DH, Loder PA, Hunt CD. Minimal head injury: is admission necessary? Am Surg. 1991;57(1):14-7. (Level III evidence). View the reference
9. Shackford SR, Wald SL, Ross SE, Cogbill TH, Hoyt DB, Morris JA, et al. The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma. 1992;33(3):385-94. (Level III evidence). View the reference
10. Deitch D, Kirshner HS. Subdural hematoma after normal CT. Neurology. 1989;39(7):985-7. (Level IV evidence). View the reference
11. Snoey ER, Levitt MA. Delayed diagnosis of subdural hematoma following normal computed tomography scan. Ann Emerg Med. 1994;23(5):1127-31. (Level IV evidence). View the reference
12. Isokuortti H, Luoto TM, Kataja A, Brander A, Siironen J, Liimatainen S, et al. Necessity of monitoring after negative head CT in acute head injury. Injury. 2014:1340-4. (Level II evidence). View the reference
13. Livingston DH, Lavery RF, Passannante MR, Skurnick JH, Baker S, Fabian TC, et al. Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. Ann Surg. 2000;232(1):126-32. (Level II evidence). View the reference
14. Levine M, Wyler B, Lovecchio F, Roque P, Raja AS. Risk of intracranial injury after minor head trauma in patients with pre-injury use of clopidogrel. Am J Emerg Med. 2014;32(1):71-4. (Level III evidence). View the reference
15. Batchelor JS, Grayson A. A meta-analysis to determine the effect of preinjury antiplatelet agents on mortality in patients with blunt head trauma Br J Neurosurg. 2013;27(1):12-8. (Level II evidence). View the reference
16. Easter JS, Haukoos JS, Meehan WP, Novack V, Edlow JA. Will neuroimaging reveal a severe intracranial injury in this adult with minor head trauma?: The rational clinical examination systematic review. JAMA. 2015;314(24):2672-81. (Level I evidence). View the reference
17. Ono K, Wada K, Takahara T, Shirotani T. Indications for computed tomography in patients with mild head injury. Neurol Med Chir (Tokyo). 2007;47(7):291-7; discussion 7-8. (Level II evidence). View the reference
18. Smits M, Hunink MGM, Nederkoorn PJ, Dekker HM, Vos PE, Kool DR, et al. A history of loss of consciousness or post‐traumatic amnesia in minor head injury: “conditio sine qua non” or one of the risk factors? Journal of Neurology, Neurosurgery, and Psychiatry. 2007;78(12):1359-64. (Level II evidence). View the reference
19. Royal Australian and New Zealand College of Radiologists. Adult head trauma. 2015. (Guideline). View the reference
20. Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, et al. The Canadian CT head rule study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. 2001;38(2):160-9. (Methodology article). View the reference
21. Stiell IG, Lesiuk H, Wells GA, Coyle D, McKnight RD, Brison R, et al. Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis). Ann Emerg Med. 2001;38(3):317-22. (Methodology article). View the reference
22. 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. JAMA. 2005;294(12):1511-8. (Level I evidence). View the reference
23. Smits M, Dippel DW, 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. JAMA. 2005;294(12):1519-25. (Level I evidence). View the reference
24. Rosengren D, Rothwell S, Brown AF, Chu K. The application of North American CT scan criteria to an Australian population with minor head injury. Emerg Med Australas. 2004;16(3):195-200. (Level IV evidence). View the reference
25. 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;9:31. (Level III evidence). View the reference
26. 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. 2012;19(1):2-10. (Level III evidence). View the reference
27. Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical decision rules for adults with minor head injury: a systematic review. J Trauma. 2011;71(1):245-51. (Level I evidence). View the reference
28. Pandor A, Goodacre S, Harnan S, Holmes M, Pickering A, Fitzgerald P, et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011;15(27):1-202. (Level I evidence). View the reference
29. Bruce DA. Imaging after head trauma: why, when and which. Childs Nerv Syst. 2000;16(10-11):755-9. (Review article). View the reference
30. Orrison WW, Gentry LR, Stimac GK, Tarrel RM, Espinosa MC, Cobb LC. Blinded comparison of cranial CT and MR in closed head injury evaluation. AJNR Am J Neuroradiol. 1994;15(2):351-6. (Level II evidence). View the reference
31. Mittl RL, Grossman RI, Hiehle JF, Hurst RW, Kauder DR, Gennarelli TA, et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. AJNR Am J Neuroradiol. 1994;15(8):1583-9. (Level III evidence). View the reference

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