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The use of NICE Head Injury Guidelines in Delayed Presentation of Head Injury to the Emergency Department

Three Part Question

In [patients with a delayed presentation of head injury] are [NICE Head Injury CT criteria] still applicable when [determining the need for CT scanning]?

Clinical Scenario

25 year old male patient presenting to ED 3 days after a head injury where a heavy wooden door swung into his head. He presented with ongoing symptoms of nausea and headache

Search Strategy

Embase (2003-2021)
[Delayed presentation OR presenting late] AND [Head injury] AND [CT]

Search Outcome

25 results were found with the above search strategy of which 5 were relevant to the question. Of these 5 results two of them were essentially duplicate findings. As a result 3 results have been included in this submission.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Carl Marincowitz
18 November 2015
United Kingdom
Systematic review identifying studies evaluating the risk of intracranial injury in patients presenting to the Emergency Department (ED) > 24 hours after head injurySystematic ReviewPrevalence of intracranial injury in patients presenting >24 hours after head injuryBetween 2.2 and 6.3% - this is generally lower than the reported prevalence in the non-delayed presentation group (approximately 7.2%)Small number of studies/data looking at prevalence of intracranial injury in delayed presentations of head injury
Carl Marincowitz
19th May 2016
CT Head requests from a 6 month period at the Hull Royal Infirmary were compared to ED records. 650 CT scans were made available for analysisObservational study650 CT head scans over a 6 month period were analysed. The time of presentation after head injury was recorded. The outcomes between those presenting before and after 24 hours was then measured. A comparison was also made between groups fulfilling NICE guideline criteria and the subsequent incidence of intracranial injuryThe CT abnormality rate was 8.4% for those presenting within and 9.9% for those presenting after 24 hours. The sensitivity of the NICE guidelines for intracranial injuries was 98% in those presenting within 24 hours and 70% in those presenting after 24 hours of injury.
Carl Marincowitz
19th May 2016
4073 ED consultants were surveyed of which 449 (11%) respondedClinical vignette based survey. Conference abstractVignettes produced based on hypothetical cases of delayed presentation of head injury. Vignettes were based n patients with head injuries meeting NICE CT head criteria, presenting in an increasingly delayed fashion. Significant variation in clinicians application of NICE guidelines to these delayed head injury vignettes was found. Factors such as headache which do not make up part of the NICE criteria were found to increase the likelihood of clinicians requesting a CT scan. It was also found that patients who were asymptomatic at their delayed presentation would be less likely to have NICE guidelines applied, even if a NICE indication was present. Clinicans are less likely to apply NICE guidelines when deciding to request CT scans for delayed presentations of head injuryStudy based on clinical vignettes of hypothetical cases rather than measuring actual clinical decision making for 'real' patients


Research in delayed presentations of head injury to the ED is sparse. There is significant variation in clinicians approach to determining which patients will need CT imaging of the head to investigate for intracranial injury. NICE head injury guidelines are less sensitive in patients with a delayed presentation to ED. Other factors which are not included in NICE guidelines, such as headache, have been used by clinicians to determine which patients have further imaging. Further research is required to provide a more evidence based approach to CT scanning delayed presentations of head injury

Clinical Bottom Line

For patients with delayed presentation of head injury NICE guidelines are less sensitive for intracranial injury


  1. Marincowitz C.; Smith C.M.; Townend W The risk of intra-cranial haemorrhage in those presenting late to the ED following a head injury: A systematic review. BioMed Central Ltd November 18, 2015.
  2. Marincowitz C.; Allgar V.; Townend W. Delayed presentation head injuries: Which patients presenting after 24 hours need a scan? An observational study. Taylor and Francis Ltd 19th May 2016
  3. Marincowitz C.; Chapman A.; Townend W. Does delay in presentation affect application of UK NICE head injury guidelines? A clinical-vignette based survey. 19th May 2016