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Logo of emermedjEmergency Medical JournalCurrent TOCInstructions to authors
Emerg Med J. Feb 2005; 22(2): 103–107.
PMCID: PMC1726668

Mild head injury: reliability of early computed tomographic findings in triage for admission


Objective: To search the literature for case reports on adverse outcomes in patients with mild head injury where acute computed tomography (CT) findings had been normal.

Methods: Mild head injury was defined as head trauma involving amnesia or loss of consciousness, but where neurological findings are normal on arrival at hospital (GCS 15). The scientific literature was systematically searched for case reports where an early CT was normal and the patient deteriorated within two days. In these cases, early discharge despite a normal CT head scan would have been hazardous.

Results: Two prospective studies were found that investigated the safety of early CT in 3300 patients with mild head injury, as were 39 reports on adverse outcomes describing 821 patients. In addition, 52 studies containing over 62 000 patients with mild head injury were reviewed. In total, only three cases were deemed to have experienced an early adverse outcome despite a normal CT and GCS 15 on initial presentation. In another eight cases with incomplete descriptions, the interpretation was doubtful. Many reports of complications were not relevant to our question and excluded. These reports included cases with more severe head injury/not GCS 15 at presentation, complications that occurred after more than two days, or initial CT findings that were not fully normal.

Conclusion: Very few cases were found where an early adverse event occurred after normal acute CT in patients with mild head injury. The strongest scientific evidence available at this time shows that a CT strategy is a safe way to triage patients for admission.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Williams RJ, Hittinger R, Glazer G. Resource implications of head injuries on an acute surgical unit. J R Soc Med. 1994 Feb;87(2):83–86. [PMC free article] [PubMed]
  • von Wild K, Terwey S. Diagnostic confusion in mild traumatic brain injury (MTBI). Lessons from clinical practice and EFNS--inquiry. European Federation of Neurological Societies. Brain Inj. 2001 Mar;15(3):273–277. [PubMed]
  • Ingebrigtsen T, Romner B. Management of minor head injuries in hospitals in Norway. Acta Neurol Scand. 1997 Jan;95(1):51–55. [PubMed]
  • af Geijerstam JL, Britton M, Mebius C. Management of minor head injuries in emergency departments in Sweden. Time for a new strategy? Eur J Surg. 2000 Jul;166(7):526–529. [PubMed]
  • De Kruijk JR, Twijnstra A, Meerhoff S, Leffers P. Management of mild traumatic brain injury: lack of consensus in Europe. Brain Inj. 2001 Feb;15(2):117–123. [PubMed]
  • Stein SC, Ross SE. The value of computed tomographic scans in patients with low-risk head injuries. Neurosurgery. 1990 Apr;26(4):638–640. [PubMed]
  • af Geijerstam J-L, Britton M. Mild head injury - mortality and complication rate: meta-analysis of findings in a systematic literature review. Acta Neurochir (Wien) 2003 Oct;145(10):843–850. [PubMed]
  • Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Choi SC. Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med. 1981 Jun 18;304(25):1511–1518. [PubMed]
  • Klauber MR, Marshall LF, Luerssen TG, Frankowski R, Tabaddor K, Eisenberg HM. Determinants of head injury mortality: importance of the low risk patient. Neurosurgery. 1989 Jan;24(1):31–36. [PubMed]
  • Rockswold GL, Pheley PJ. Patients who talk and deteriorate. Ann Emerg Med. 1993 Jun;22(6):1004–1007. [PubMed]
  • Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, Klug G, Wallace D, Henning R, Tibballs J. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst. 2001 Feb;17(3):154–162. [PubMed]
  • Milo R, Razon N, Schiffer J. Delayed epidural hematoma. A review. Acta Neurochir (Wien) 1987;84(1-2):13–23. [PubMed]
  • Bor-Seng-Shu E, Aguiar PH, Matushita H, Manreza LA, Ferreira AA. Actual asymptomatic epidural hematomas in childhood. Report of three cases. Childs Nerv Syst. 1997 Nov-Dec;13(11-12):605–607. [PubMed]
  • Snoey ER, Levitt MA. Delayed diagnosis of subdural hematoma following normal computed tomography scan. Ann Emerg Med. 1994 May;23(5):1127–1131. [PubMed]
  • Glasziou Paul, Vandenbroucke Jan P, Chalmers Iain. Assessing the quality of research. BMJ. 2004 Jan 3;328(7430):39–41. [PMC free article] [PubMed]
  • Jagoda Andy S, Cantrill Stephen V, Wears Robert L, Valadka Alex, Gallagher E John, Gottesfeld Steven H, Pietrzak Michael P, Bolden Jason, Bruns John J, Jr, Zimmerman Robert, et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2002 Aug;40(2):231–249. [PubMed]
  • Servadei F, Teasdale G, Merry G. Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma. 2001 Jul;18(7):657–664. [PubMed]
  • Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81–84. [PubMed]
  • Borczuk P. Mild head trauma. Emerg Med Clin North Am. 1997 Aug;15(3):563–579. [PubMed]
  • Culotta VP, Sementilli ME, Gerold K, Watts CC. Clinicopathological heterogeneity in the classification of mild head injury. Neurosurgery. 1996 Feb;38(2):245–250. [PubMed]
  • Teasdale GM. Head injury. J Neurol Neurosurg Psychiatry. 1995 May;58(5):526–539. [PMC free article] [PubMed]
  • Egger M, Juni P, Bartlett C, Holenstein F, Sterne J. How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study. Health Technol Assess. 2003;7(1):1–76. [PubMed]
  • Nagy KK, Joseph KT, Krosner SM, Roberts RR, Leslie CL, Dufty K, Smith RF, Barrett J. The utility of head computed tomography after minimal head injury. J Trauma. 1999 Feb;46(2):268–270. [PubMed]
  • Livingston DH, Lavery RF, Passannante MR, Skurnick JH, Baker S, Fabian TC, Fry DE, Malangoni MA. Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. Ann Surg. 2000 Jul;232(1):126–132. [PMC free article] [PubMed]
  • Hemphill RR, Santen SA, Kleinschmidt PE. Delayed presentation after head injury: is a computed tomography scan necessary? Acad Emerg Med. 1999 Sep;6(9):957–960. [PubMed]
  • Domenicucci M, Signorini P, Strzelecki J, Delfini R. Delayed post-traumatic epidural hematoma. A review. Neurosurg Rev. 1995;18(2):109–122. [PubMed]
  • Ciquini Júnior O, Dos Santos AL, Manreza LA, Plese JP, Marino Júnior R. Hematoma extradural traumático na infância e tomografia computadorizada precoce normal. Relato de dois casos. Arq Neuropsiquiatr. 1992 Sep;50(3):361–364. [PubMed]
  • Keskil IS, Baykaner MK, Ceviker N, Kaymaz M. Assessment of mortality associated with mild head injury in the pediatric age group. Childs Nerv Syst. 1995 Aug;11(8):467–473. [PubMed]
  • Arienta C, Caroli M, Balbi S. Management of head-injured patients in the emergency department: a practical protocol. Surg Neurol. 1997 Sep;48(3):213–219. [PubMed]
  • Hahn YS, McLone DG. Risk factors in the outcome of children with minor head injury. Pediatr Neurosurg. 1993 May-Jun;19(3):135–142. [PubMed]
  • Borovich B, Braun J, Guilburd JN, Zaaroor M, Michich M, Levy L, Lemberger A, Grushkiewicz I, Feinsod M, Schächter I. Delayed onset of traumatic extradural hematoma. J Neurosurg. 1985 Jul;63(1):30–34. [PubMed]
  • Brunetti J, Zingesser L, Dunn J, Rovit RL. Delayed intracerebral hemorrhage as demonstrated by CT scanning. Neuroradiology. 1979 Jul 1;18(1):43–46. [PubMed]
  • Cervantes LA. Concurrent delayed temporal and posterior fossa epidural hematomas. Case report. J Neurosurg. 1983 Aug;59(2):351–353. [PubMed]
  • Di Rocco A, Ellis SJ, Landes C. Delayed epidural hematoma. Neuroradiology. 1991;33(3):253–254. [PubMed]
  • Fankhauser H, Uske A, de Tribolet N. Les hématomes épiduraux retardés. A propos d'une série de 8 cas. Neurochirurgie. 1983;29(4):255–260. [PubMed]
  • Ferrera PC, Mayer DM. Delayed presentation of an epidural hematoma. Am J Emerg Med. 1997 Jan;15(1):76–78. [PubMed]
  • Fukamachi A, Misumi S, Kaneko M, Wakao T. Traumatic extradural hematomas with delayed development. Comput Radiol. 1984 Jul-Aug;8(4):197–201. [PubMed]
  • Jaimovich R, Monges JA. Delayed posttraumatic intracranial lesions in children. Pediatr Neurosurg. 1991;17(1):25–29. [PubMed]
  • Lee ST, Lui TN. Delayed intracranial haemorrhage in patients with multiple trauma and shock-related hypotension. Acta Neurochir (Wien) 1991;113(3-4):121–124. [PubMed]
  • Poon WS, Rehman SU, Poon CY, Li AK. Traumatic extradural hematoma of delayed onset is not a rarity. Neurosurgery. 1992 May;30(5):681–686. [PubMed]
  • Rivara F, Tanaguchi D, Parish RA, Stimac GK, Mueller B. Poor prediction of positive computed tomographic scans by clinical criteria in symptomatic pediatric head trauma. Pediatrics. 1987 Oct;80(4):579–584. [PubMed]
  • Smith HK, Miller JD. The danger of an ultra-early computed tomographic scan in a patient with an evolving acute epidural hematoma. Neurosurgery. 1991 Aug;29(2):258–260. [PubMed]
  • Stein SC, Young GS, Talucci RC, Greenbaum BH, Ross SE. Delayed brain injury after head trauma: significance of coagulopathy. Neurosurgery. 1992 Feb;30(2):160–165. [PubMed]
  • Dunn Laurence T, Fitzpatrick Michael O, Beard Diana, Henry Jennifer M. Patients with a head injury who "talk and die" in the 1990s. J Trauma. 2003 Mar;54(3):497–502. [PubMed]
  • Riesgo P, Piquer J, Botella C, Orozco M, Navarro J, Cabanes J. Delayed extradural hematoma after mild head injury: report of three cases. Surg Neurol. 1997 Sep;48(3):226–231. [PubMed]
  • Lobato RD, Rivas JJ, Gomez PA, Castañeda M, Cañizal JM, Sarabia R, Cabrera A, Muñoz MJ. Head-injured patients who talk and deteriorate into coma. Analysis of 211 cases studied with computerized tomography. J Neurosurg. 1991 Aug;75(2):256–261. [PubMed]
  • Feuerman T, Wackym PA, Gade GF, Becker DP. Value of skull radiography, head computed tomographic scanning, and admission for observation in cases of minor head injury. Neurosurgery. 1988 Mar;22(3):449–453. [PubMed]
  • Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatr Emerg Care. 1996 Jun;12(3):160–165. [PubMed]
  • Cook LS, Levitt MA, Simon B, Williams VL. Identification of ethanol-intoxicated patients with minor head trauma requiring computed tomography scans. Acad Emerg Med. 1994 May-Jun;1(3):227–234. [PubMed]
  • Davies KG, Jamjoom AB, Burgess NA. Childhood extradural haematomas, not always obvious. Br J Clin Pract. 1990 Oct;44(10):420–421. [PubMed]
  • Deitch D, Kirshner HS. Subdural hematoma after normal CT. Neurology. 1989 Jul;39(7):985–987. [PubMed]
  • Lee ST, Lui TN. Early seizures after mild closed head injury. J Neurosurg. 1992 Mar;76(3):435–439. [PubMed]
  • Davis RL, Hughes M, Gubler KD, Waller PL, Rivara FP. The use of cranial CT scans in the triage of pediatric patients with mild head injury. Pediatrics. 1995 Mar;95(3):345–349. [PubMed]
  • Chang Jong Hee, Choi Jae Young, Chang Jin Woo, Park Yong Gou, Kim Tai Seung, Chung Sang Sup. Chronic epidural hematoma with rapid ossification. Childs Nerv Syst. 2002 Dec;18(12):712–716. [PubMed]
  • Atkinson John L D, Lane John I, Aksamit Allen J. MRI depiction of chronic intradural (subdural) hematoma in evolution. J Magn Reson Imaging. 2003 Apr;17(4):484–486. [PubMed]
  • Inamasu J, Nakamura Y, Saito R, Horiguchi T, Kanai R, Ichikizaki K. Delayed, but acutely progressive epidural hematoma after mild head injury. Am J Emerg Med. 2001 Jul;19(4):324–325. [PubMed]
  • Livingston DH, Loder PA, Hunt CD. Minimal head injury: is admission necessary? Am Surg. 1991 Jan;57(1):14–17. [PubMed]
  • Young HA, Gleave JR, Schmidek HH, Gregory S. Delayed traumatic intracerebral hematoma: report of 15 cases operatively treated. Neurosurgery. 1984 Jan;14(1):22–25. [PubMed]
  • Mertol T, Guner M, Acar U, Atabay H, Kirisoglu U. Delayed traumatic intracerebral hematoma. Br J Neurosurg. 1991;5(5):491–498. [PubMed]
  • Fankhauser H, Kiener M. Delayed development of extradural haematomas. Acta Neurochir (Wien) 1982;60(1-2):29–35. [PubMed]
  • Mandavia DP, Villagomez J. The importance of serial neurologic examination and repeat cranial tomography in acute evolving epidural hematoma. Pediatr Emerg Care. 2001 Jun;17(3):193–195. [PubMed]
  • Bor Seng Shu E, de Almeida Leme RJ, Aguiar PH, de Andrade AF, Teixeira MJ, Plese JP. Traumatic acute giant epidural hematoma in a hydrocephalic shunted child. Pediatr Neurosurg. 2000 Apr;32(4):176–179. [PubMed]
  • Servadei F, Vergoni G, Staffa G, Zappi D, Nasi MT, Donati R, Arista A. Extradural haematomas: how many deaths can be avoided? Protocol for early detection of haematoma in minor head injuries. Acta Neurochir (Wien) 1995;133(1-2):50–55. [PubMed]
  • Arendts Glenn, Manovel Alvaro, Chai Alan. Cranial CT interpretation by senior emergency department staff. Australas Radiol. 2003 Dec;47(4):368–374. [PubMed]
  • Alfaro D, Levitt MA, English DK, Williams V, Eisenberg R. Accuracy of interpretation of cranial computed tomography scans in an emergency medicine residency program. Ann Emerg Med. 1995 Feb;25(2):169–174. [PubMed]
  • Lal NR, Murray UM, Eldevik OP, Desmond JS. Clinical consequences of misinterpretations of neuroradiologic CT scans by on-call radiology residents. AJNR Am J Neuroradiol. 2000 Jan;21(1):124–129. [PubMed]
  • Cushman JG, Agarwal N, Fabian TC, Garcia V, Nagy KK, Pasquale MD, Salotto AG. Practice management guidelines for the management of mild traumatic brain injury: the EAST practice management guidelines work group. J Trauma. 2001 Nov;51(5):1016–1026. [PubMed]
  • Kamerling Susan N, Lutz Nicolas, Posner Jill C, Vanore Marla. Mild traumatic brain injury in children: practice guidelines for emergency department and hospitalized patients. The Trauma Program, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine. Pediatr Emerg Care. 2003 Dec;19(6):431–440. [PubMed]
  • Vos PE, Battistin L, Birbamer G, Gerstenbrand F, Potapov A, Prevec T, Stepan Ch A, Traubner P, Twijnstra A, Vecsei L, et al. EFNS guideline on mild traumatic brain injury: report of an EFNS task force. Eur J Neurol. 2002 May;9(3):207–219. [PubMed]
  • Fabbri A, Servadei F, Marchesini G, Morselli-Labate AM, Dente M, Iervese T, Spada M, Vandelli A. Prospective validation of a proposal for diagnosis and management of patients attending the emergency department for mild head injury. J Neurol Neurosurg Psychiatry. 2004 Mar;75(3):410–416. [PMC free article] [PubMed]
  • Fabbri Andrea, Servadei Franco, Marchesini Giulio, Dente Massimo, Iervese Tiziana, Spada Marco, Vandelli Alberto. Which type of observation for patients with high-risk mild head injury and negative computed tomography? Eur J Emerg Med. 2004 Apr;11(2):65–69. [PubMed]
  • Peloso Paul M, Carroll Linda J, Cassidy J David, Borg Jörgen, von Holst Hans, Holm Lena, Yates David. Critical evaluation of the existing guidelines on mild traumatic brain injury. J Rehabil Med. 2004 Feb;(43 Suppl):106–112. [PubMed]
  • Newman Thomas B. The power of stories over statistics. BMJ. 2003 Dec 20;327(7429):1424–1427. [PMC free article] [PubMed]

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