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Three Part Question

In [patients who return unplanned following a minor head injury with persistant but not increasing headache and no signs] does [clinical examination alone or examination combined with a CT scan] result in a maximally sensitive exclusion of [serious intracranial pathology which would necessitate surgical intervention]?

Clinical Scenario

A 35 year old man returns unplanned to the emergency department. He had been assaulted a week previously and suffered a blow to the head. At the time of initial presentation a skull x-ray did not reveal a fracture and he had been discharged home with head injury instructions. Currently he describes non-specific symptoms of a persistent but not progressive headache. Examination does not reveal any abnormal neurological signs. You wonder about his further management and specifically as to whether he requires a CT scan of his brain.

Search Strategy

Medline 1966-10/03 using the OVID interface via ATHENS.
[(exp head injuries, closed OR head injur$.mp OR head trauma.mp OR exp brain injuries OR exp craniocerebral trauma) AND (exp headache OR headache$.mp OR post concussional syndrome.mp OR PCS.mp or exp brain concussion) AND (exp tomography, x-ray computed OR tomography.mp OR CT.mp) AND (exp patient readmission OR return.mp OR readmiss$.mp OR reattend$.mp OR readmitt$.mp OR follow-up.mp)] LIMIT to human AND English language AND Abstracts.

Search Outcome

146 papers were identified. None addressed the three part question directly. Two papers provided some information relevant to the question, one of which is an additional known reference. The two papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Voss M et al, 1995, South Africa	606 patients who reattended a trauma unit after minor head injury.	Retrospective study	Intracranial abnormality detected on CT or the need for neurosurgical intervention	The only significant predictor following multiple regression analysis for both abnormality on CT scan and the need for operation was a vault fracture on the skull radiograph. There was a significant association between neurological abnormality and both an abnormal CT scan and the need for operation. Headache, diziness, nausea and vomiting were common in reattenders but were found to have no independent significance.	Population studies was unrepresentative of that attending a UK department with 'minor' head injury. (eg only 0.5% of the study population had been engaged in sporting activity at the time of the injury, compared with 14.4% who had sustained a stab wound to the head).
Swann IJ and McCarter DH, 1998, UK	Non systematic review	Non systematic review	There is a group of patients with persisting symptoms who should be considered for an urgent CT scan. These are the elderly confused, patients suffering with epilepsy, alcohol and drug related illness or those with a bleeding tendency (including patients receiving anti-coagulants). Otherwise in patients who have a non-progressive headache and no neurological signs on clinical examination a CT scan is not indicated. It is recommended that a further review of such patients by an experienced clinician is arranged. The authors also comment that the development of a severe headache a few days after mild head injury means that a CT scan should be urgently arranged even in the absence of neurological signs.

Comment(s)

The authors state that patients who reattend following a 'minor' head injury are a high risk group. Ideally all of these should receive a CT scan but recognise that this is not practical.

Editor Comment

Search repeated 10/03. Although many more papers now investigate the role of CT in head injury, it was not possible to identify any new studies looking at reattendance following head injury. In the UK the NICE recommendations for CT scanning may result in a greater proportion of patients having CT scans on their first attendance.

Clinical Bottom Line

Patients who reattend following a 'minor' head injury are a high risk group. An immediate CT scan is necessary in those patients who have a progressive headache or any nerological signs, especially if there is a co-existent skull fracture. Non-specific symptoms including persistent but not worsening headache may be managed expectantly. Such patients though merit regular review by an experienced clinician and must be scanned if there is a change in their symptoms or signs.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Voss M, Knottenbelt JD, Peden MM. Patients who reattend after head injury: a high risk group. BMJ 1995;311:1395-98.
2. Swann IJ, McCarter DH. Later investigation of head injury. Emergency Medicine Journal 1998;15(5):344-48.