Original Article

Indications for brain computed tomography scan

after minor head injury
Mahdi Sharif-Alhoseini1, Hossein Khodadadi2, Mojtaba Chardoli2,
Vafa Rahimi-Movaghar1,3
1
Department of Neurosurgery, Sina Trauma and Surgery Research Center, 2Emergency, Hazrat-e-Rasool Hospital, Tehran University of Medical
Sciences, 3Research Centre for Neural Repair, University of Tehran, Tehran, Iran

ABSTRACT
Aims: Minor head injury (MHI) is a common injury seen in Emergency Departments (ED). Computed tomography (CT)
scan of the brain is a good method of investigation to diagnose intracranial lesions, but there is a disagreement about
indications in MHI patients. We surveyed the post-traumatic symptoms, signs or past historical matters that can be used
for the indication of brain CT scan. Materials and Methods: All patients with MHI who were older than 2 years, had a
Glasgow Coma Scale score 13 and were referred to the ED, underwent brain CT scan. Data on age, headache, vomiting,
loss of consciousness (LOC) or amnesia, post-traumatic seizure, physical evidence of trauma above the clavicles, alcohol
intoxication, and anticoagulant usage were collected. The main outcome measure was the presence of lesions related to the
trauma in brain CT scan. For categorical variables, Chi-square test was used. Results: Six hundred and forty-two patients
were examined by brain CT scan after MHI, and 388 patients (60.4%) did not have any risk indicator. Twenty patients (3.1%)
had abnormal brain CT scans. The logistic regression model showed that headache (P=0.006), LOC or amnesia (P=0.024)
and alcohol (P=0.036) were associated with abnormal brain CT. Conclusions: We suggested that abnormal brain CT scan
related to the trauma after MHI can be predicted by the presence of one or more of the following risk indicators: Headache,
vomiting, LOC or amnesia, and alcohol intoxication. Thus, if any patient has these indicators following MHI, he must be
considered as a high-risk MHI.

Key Words: Computed tomography, minor head injury, risk factor

INTRODUCTION the main outcome measures, which could be the presence of any
abnormal lesion in CT scan related to the trauma[4-6] or presence
Minor head injury (MHI) is one of the most common injuries of lesions suggested by a surgical operation.[7] But because of
seen in Emergency Departments (ED),[1] which has typically the cost,[8] time, and probable complications of radiation,[9] there
been defined as patients with a history of blunt head trauma who has been significant disagreement about the indications for brain
present findings of a Glasgow Coma Scale (GCS) score of 13-15 CT scan in the large number of MHI cases.[10]
on initial ED evaluation.[2] The brain computed tomography(CT)
scan is a good investigation method to diagnose intracranial Symptoms such as headache,[5] vomiting,[11] loss of consciousness
lesions.[3] Indications for CT scan might be different based on (LOC) or amnesia,[12] and post-traumatic seizure[13] signs such
as physical evidence of trauma above the clavicles,[6] skull
Address for correspondence: fracture or contusion[7,11,13] and raccoon sign,[14] past history
Prof. Vafa Rahimi-Movaghar, E-mail: v_rahimi@sina.tums.ac.ir such as alcohol intoxication[12] or coagulopathy,[15] and age more
than 60 years[16] have been discussed as the risk indicators for
Access this article online abnormalities in brain CT scan of patients with MHI. Thus,
Quick Response Code: several studies have been performed to determine variables for
Website:
www.onlinejets.org brain CT indication.[4,7,17-21] However, no general consensus has
been achieved in the indications for brain CT scan. This study was
DOI:
conducted to survey the post-traumatic symptoms, signs or other
10.4103/0974-2700.86631 important past historical matters of patients as a risk indicator
that can be used for the indication of brain CT scan in the MHI.
472 Journal of Emergencies, Trauma, and Shock I 4:4 I Oct - Dec 2011

MATERIALS AND METHODS
In this prospective study, all patients with blunt traumatic head
injury who were more than 2 years old, had a GCS score13
and were referred to the EDs of Rasoul-Akram and Shohadaye-
Haftome-Tir hospitals (two referral trauma centers in Tehran)
in 2008, underwent non-contrast brain CT scan. They were
scanned on similar CT scanners with the same techniques at
both hospitals. The patients were primarily visited by residents
of Emergency Medicine. Data on age, headache, vomiting, LOC
or amnesia, post traumatic seizure, physical evidence of trauma
above the clavicles, alcohol intoxication and current anticoagulant
usage were collected. The risk indicators were defined based on
Haydels study:[6] Headache was defined as any new head pain,
whether diffused or local. Vomiting was defined as any emesis
after a traumatic occurrence. A deficit in short-term memory was
defined as persistent anterograde amnesia in a patient with an
otherwise normal score on the GCS. The reliability of obtaining
a history of loss of consciousness and post-traumatic amnesia
is a difficult and well-known problem in clinical practice, and
therefore both of them were our practical definition. Seizure was
defined as a suspected or witnessed seizure after the traumatic
event. The physical evidence of trauma above the clavicles was
defined as any external evidence of injury, including contusions,
abrasions, lacerations, deformities, and signs of facial or skull
fracture. Alcohol intoxication was determined on the basis of
the history obtained from the patient or a witness and suggestive
findings such as slurred speech or the odor of alcohol on the
breath on physical examination. Coagulopathy was defined as a
history of bleeding or a clotting disorder or current treatment
with warfarin or other types of anticoagulation.
Instability, additional troubles that required specialized care,
opium-addiction, probability of malingering, and refusing to take
part in the study; factors which excluded the patients from the
study. All questionnaires and clinical assessments were completed
before the brain CT studies; therefore, the evaluating clinician
was blind to the result of scanning.
Brain CT scans were reviewed by the attending physician at
the ED who had 5 years of experience. The main outcome
measured was the presence of lesions related to the trauma in
brain CT scan, which includes depressed fracture, base skull
fracture, epidural hematoma, subdural hematoma, subarachnoid
hemorrhage, pneumocephalus, and contusion.
The hospitalized patients were visited daily by residents of
Emergency Medicine and the other patients were followed-up
after one week using telephone interviews to assess for symptoms
of increased intracranial pressure.
The frequency of positive CT scans was determined for each risk
indicator. The sensitivity, specificity, and positive and negative
predictive values of significant indicators were calculated for those
risk indicators, which had an association with abnormal brain CT
scan related to the trauma. For categorical variables, Chi-square
Journal of Emergencies, Trauma, and Shock I 4:4 I Oct - Dec 2011
Sharif-Alhoseini, etal.: Brain computed tomography scan
test was used. Predictive analytics software (PASW) version18
was utilized for analyzing the data. Logistic regression analysis
was performed using STATA 8, (Special Edition, Texas, USA)
to detect the risk indicators associated with positive findings in
the brain CT scan controlling the effect of other risk indicators.
The study was reviewed and confirmed by the Ethics Committee
of the Iran University of Medical Sciences.
RESULTS
Six hundred and forty-two patients were examined by brain CT
scan after a blunt head trauma. The mean age of the patients was
29.916.7 years (range: 3 to 90), and 74.5% were male. Three
hundred eighty-eight patients (60.4%) did not have any risk
indicator [Table1]. The number of risk indicators was associated
with a higher rate of abnormal finding related to the trauma in
CT scans [Table1].
Twenty patients (3.1%) had abnormal brain CT scans. Among
the patients with abnormal brain CT related to the trauma, one
had no risk indicators, all of the remaining had LOC or amnesia;
thirteen patients had two risk indicators, and six people had
three indicators at the same time. Patients with headache, LOC
or amnesia, and vomiting had a higher rate of abnormal CT
scans [Table2]. A schematic illustration of the sensitivity and
specificity of different symptoms and signs in mild head injury
was shown in Figure1.
Finally, the regression analyses were applied to determine the
effects of variables associated with abnormal brain CT scan
related to the trauma. The logistic regression model showed that
headache (P=0.006), LOC or amnesia (P=0.024), and alcohol
(P=0.036) were associated with abnormal brain CT related to
the trauma [Table3].
DISCUSSION
This study demonstrated that headache, vomiting, LOC or
amnesia, and alcohol intoxication were four risk indicators
suggested for the indication of brain CT scan in MHI.
Hydel etal.,[6] and Miller etal.,[5] showed that headache could be
used as a guide to predict the probability of abnormal brain CT
scan related to the trauma following MHI. Mack and colleagues
Table1: Presence of abnormality in brain CT scan of
patients with minor head injury according to number
of risk indicators*
Abnormal CT Total
-(%) +(%)
Presence of risk indicators
0 387 (99.7) 1 (0.3) 388 (100)
1 235 (92.5) 19 (7.5) 254 (100)
Total 622 (96.9) 20 (3.1) 642 (100)
*P<0.001; CT: Computed tomography
473
Sharif-Alhoseini, etal.: Brain computed tomography scan

Table2: Presence of abnormality in brain CT scan of patients with minor head injury according to the risk
indicators*
Abnormal CT P value (%) PPV (%) NPV (%) Sensitivity (%) Specificity
(%) +(%)
Male gender
155 (94.5) 9 (5.5) 0.064 2.3 94.5 55 24.9
+ 467 (97.7) 11 (2.3)
Age >60
577 (97) 18 (3) 0.652 4.3 97 10 92.8
+ 45 (95.7) 2 (4.3)
Headache
527 (99.1) 5 (0.9) 0.000 13.6 99.1 75 84.7
+ 95 (86.4) 15 (13.6)
LOC or amnesia 95 68.3
197 (91.2) 19 (8.8) 0.000 8.8 99.8
+ 425 (99.8) 1 (0.2)
TAC 1.000 2.4 96.8 5 93.6
582 (96.8) 19 (3.2)
+ 40 (97.6) 1 (2.4)
Vomiting 0.021 8 97.5 30 88.9
553 (97.5) 14 (2.5)
+ 69 (92.0) 6 (8.0)
Alcohol 0.091 33.3 97 5 99.7
620 (97.0) 19(3.0)
+ 2 (66.7) 1(33.3)
Coagulopathy 1.000 0 96.9 0 99.8
621 (96.9) 20 (3.1)
+ 1 (100) 0 (0)
Seizure 1.000 0 96.9 0 99.4
618 (96.9) 20 (3.1)
+ 4 (100) 0 (0)
Age >60 and headache 0.009 40.0 97.2 10 99.5
619 (97.2) 18 (2.8)
+ 3 (60.0) 2 (40.0)
Age >60 and LOC or amnesia 0.048 11.1 97.1 0.1 97.4
606 (7.1) 18 (2.9)
+ 16 (88.9) 2 (11.1)
Age >60 and TAC 1.000 0.0 96.9 0.0 99.7
620 (96.9) 20 (3.1)
+ 2 (100) 0 (0)
Age >60 and coagulopathy 1.000 0.0 96.9 0.0 99.8
621 (96.9) 20 (3.1)
+ 1 (100) 0 (0)
Headache and vomiting 0.016 16.7 97.3 15 97.6
607 (97.3) 17 (2.7)
+ 15 (83.3) 3 (16.7)
Headache and TAC 0.031 100 97 5 100
622 (97.0) 19 (3.0)
+ 0 (0) 1 (100.0)
Vomiting and LOC or amnesia 0.000 8.7 99.8 95.0 67.8
422(99.8) 1 (0.2)
+ 200(91.3) 19 (8.7)
Vomiting and TAC 1.000 0.0 96.9 0.0 99.5
619 (96.9) 20 (3.1)
+ 3 (100) 0 (0)
Vomiting and seizure 1.000 0.0 96.9 0.0 99.8
621 (96.9) 20 (3.1)
+ 1 (100) 0(0)
LOC or Amnesia and TAC 0.000 8.8 99.8 95.0 68.2
424 (99.8) 1 (0.2)
+ 198 (91.2) 19 (8.8)
Headache and LOC or amnesia 0.000 8.6 99.8 95.0 67.5
420 (99.8) 1 (0.2)
+ 202 (91.4) 19 (8.6)
*Other combinations of risk indicators were omitted if there was no positive CT scan finding; TAC: Trauma above the Clavicles; PPV: Positive Predictive Value; NPV: Negative Predictive Value;
LOC: Loss of consciousness; CT: Computed tomography

proved that headache is a low-risk predictor.[2] But some studies Several studies have reported vomiting as a post-traumatic
did not lead to similar results and showed that headache could symptom, which predicts abnormality related to the trauma in
not be used as a risk indicator.[4,7,21,22] brain CT scan, but Viola etal. said that vomiting was insignificant.[23]
474 Journal of Emergencies, Trauma, and Shock I 4:4 I Oct - Dec 2011
 Sharif-Alhoseini, etal.: Brain computed tomography scan

100%

80%

60% Sen
Spe
40%

20%

0%
Male

Age>60

Headache

LOC

TAC

Vomiting

Alcohol

Coagulopathy

Seizure

Age>60 & Headache

Age>60 & LOC

Age>60 & TAC

Age>60 & Coagulopathy

Headache & Vomiting

Headache & TAC

Vomiting & LOC

Vomiting & TAC

Vomiting & Seizure

LOC &TAC

Headache & LOC

Figure1: Schematic illustration of sensitivity and specificity of different symptoms and signs in mild head injury. Sen: Sensitivity, Spe:
Specificity, TAC: Trauma above Clavicles

Table3: Regression analysis for risk indicators* and a specificity of 25%.[6]

Risk indicator Coefficient Standard error Odds ratio P value
Headache 1.737 0.636
LOC or amnesia 2.571 1.137
Alcohol 2.841 1.353
Constant -6.105 1.002
*Variables that failed to represent significant P values (P<0.05) were excluded from the
model using a backward elimination procedure; LOC: Loss of consciousness
Based on some researches, LOC or amnesia could be used as a
guide to predict the probability of abnormal CT scan following
MHI.[6,14,24] Murshid etal.[25] and Gomez etal.[26] found the converse
result.
Alcohol intoxication had been demonstrated as a risk predictor
in the investigations of Hydel etal.[6] and Reinus etal.,[12] but other
reports said that alcohol usage could not be a predictor sign.[2,4,14]
In our study, only 3.2% of the patients with MHI had positive
findings related to the trauma in brain CT scan. The same result
was seen in other studies, i.e., abnormal CT was seen in about
less than 10 percent of the patients with MHI and less than 1%
of all patients with MHI requiring neurosurgical intervention.[11]
The rate of brain CT abnormality was seen in 3% to 13% of the
patients with GCS score 15 and LOC or amnesia and 4.9% to
6.3% in patients with GCS 15 and without LOC or amnesia.[9]
In our study, the presence of headache, vomiting, and LOC or
amnesia was separately associated with abnormal brain CT scan
related to the trauma. Stein etal. suggested that any patient who
has experienced LOC or amnesia following head injury should
undergo brain CT scan.[27] Haydel etal. have expanded the criteria
for brain CT scan in patients with MHI that consist of headache,
vomiting, age >60 years, drug or alcohol intoxication, deficits
in short-term memory, physical evidence of trauma above the
clavicles, and seizure. These criteria led to a sensitivity of 100%
Journal of Emergencies, Trauma, and Shock I 4:4 I Oct - Dec 2011
5.68 0.006
Miller etal. planned the application of severe headache, nausea,
13.08 0.024 vomiting, and depressed skull fracture on physical examination
17.13 0.036 to identify patients with MHI, which led to a 61% decline in
0.002 brain CT scan.[11]
Both Miller and Hydels criteria were developed for patients with
GCS 15, while our study included patients with GCS 13-15.
We demonstrated that each combination of age >60 and
headache, headache and vomiting, and headache and trauma
above the clavicles led to a significantly higher rate of abnormal
brain CT scans [Table2]. Several studies have evaluated various
combinations of clinical findings as predictors of positive brain
CT scans in patients with MHI.[5]
In our study, all of the patients with positive brain CT scans had
at least one risk indicator. Saadat etal. showed that the brain CT
scans were always normal in patients <65 years old who did not
have an obvious head wound, a raccoon sign, vomiting, memory
deficit, or a decrease in their GCS score.[14]
Stiell etal. have developed the Canadian CT head rule consisting
of 5 high-risk criteria including age >65 years, suspected open
or depressed skull fracture, vomiting more than two episodes,
sign of basal skull fracture and GCS score <15 at 2 hours
after trauma that suggest the risk of neurological intervention
and 2 medium-risk criteria including amnesia before impact
>30minutes and dangerous mechanism of injury that suggest
the risk of significant brain injury on brain CT scan.[7] Using
these criteria, 46% of the patients would not need to undergo
CT scanning. In this rule, patients without LOC, amnesia or
disorientation were not evaluated in the study, but we included
all patients with a history of blunt head trauma.
475
Sharif-Alhoseini, etal.: Brain computed tomography scan
Smith etal. have reported that the Canadian CT head rule
has a lower sensitivity than Hydels criteria for CT, but would
recognize all patients necessitating neurosurgical intervention,
and has a greater potential for reducing brain CT scan.[28] A larger
patient sample could increase the possibility of detecting other
neurological signs and indicators in patients with MHI and result
in a better predictive power of the model.[14]
CONCLUSIONS
We suggested that abnormal brain CT scan related to the trauma
after MHI can be predicted by the presence of one or more of the
following risk indicators: Headache, vomiting, LOC or amnesia
and alcohol intoxication. Thus, if any patient has these indicators
following MHI, he must be considered a high-risk MHI.
ACKNOWLEDGEMENT
The authors thank Mrs. Bita Pourmand for her edit of the manuscript.
REFERENCES
1. Cassidy JD, Carroll LJ, Peloso PM, Borg J, von HH, Holm L, etal. Incidence,
risk factors and prevention of mild traumatic brain injury: Results of the
WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.
J Rehabil Med 2004;(43 Suppl):28-60.
2. Mack LR, Chan SB, Silva JC, Hogan TM. The use of head computed
tomography in elderly patients sustaining minor head trauma. J Emerg
Med 2003;24:157-62.
3. Stein SC, Ross SE. Minor head injury: A proposed strategy for emergency
management. Ann Emerg Med 1993;22:1193-6.
4. Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, etal.
Minor head injury: Guidelines for the use of CT A multicenter validation
study. Radiology 2007;245:831-8.
5. Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce
head CT scan ordering for minor head trauma patients. J Emerg Med
1997;15:453-7.
6. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM.
Indications for computed tomography in patients with minor head injury.
N Engl J Med 2000;343:100-5.
7. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A,
etal. The Canadian CT Head Rule for patients with minor head injury.
Lancet 2001;357:1391-6.
8. Abdul Latip LS, Ahmad Alias NA, Ariff AR, Shuaib IL, Abdullah J,
Naing NN. CT scan in minor head injury: A guide for rural doctors. J Clin
Neurosci 2004;11:835-9.
9. Ono K, Wada K, Takahara T, Shirotani T. Indications for computed
tomography in patients with mild head injury. Neurol Med Chir (Tokyo)
2007;47:291-7.
10. Shackford SR, Wald SL, Ross SE, Cogbill TH, Hoyt DB, Morris JA, etal.
The clinical utility of computed tomographic scanning and neurologic
examination in the management of patients with minor head injuries.
JTrauma 1992;33:385-94.
11. Miller EC, Derlet RW, Kinser D. Minor head trauma: Is computed
tomography always necessary? Ann Emerg Med 1996;27:290-4.
12. Reinus WR, Wippold FJ 2nd, Erickson KK. Practical selection criteria for
noncontrast cranial computed tomography in patients with head trauma.
476
Ann Emerg Med 1993;22:1148-55.
13. Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM, Vos PE,
etal. Predicting intracranial traumatic findings on computed tomography
in patients with minor head injury: The CHIP prediction rule. Ann Intern
Med 2007;146:397-405.
14. Saadat S, Ghodsi SM, Naieni KH, Firouznia K, Hosseini M, KadkhodaieHR,
etal. Prediction of intracranial computed tomography findings in patients
with minor head injury by using logistic regression. J Neurosurg
2009;111:688-94.
15. Stein SC, Young GS, Talucci RC, Greenbaum BH, Ross SE. Delayed brain
injury after head trauma: Significance of coagulopathy. Neurosurgery
1992;30:160-5.
16. Haydel MJ. Clinical decision instruments for CT scanning in minor head
injury. JAMA 2005;294:1551-3.
17. Stein SC, Burnett MG, Glick HA. Indications for CT scanning in mild
traumatic brain injury: A cost-effectiveness study. J Trauma 2006;61:558-66.
18. Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR,
etal. External validation of the Canadian CT Head Rule and the New
Orleans Criteria for CT scanning in patients with minor head injury. JAMA
2005;294:1519-25.
19. Eng J, Chanmugam A. Examining the role of cranial CT in the evaluation
of patients with minor head injury: A systematic review. Neuroimaging
Clin N Am 2003;13:273-82.
20. Smits M, Dippel DW, Nederkoorn PJ, Dekker HM, Vos PE, Kool DR,
etal. Minor head injury: CT-based strategies for management-a cost-
effectiveness analysis. Radiology 2010;254:532-40.
21. Saboori M, Ahmadi J, Farajzadegan Z. Indications for brain CT
scan in patients with minor head injury. Clin Neurol Neurosurg
2007;109:399-405.
22. Shiomi N, Echigo T. A guide to initial management of minor head injury.
No Shinkei Geka 2004;32:465-70.
23. Viola L, Zotta D, Martino V, Barbato R, Schisano G. Minor head injuries:
One year experience according to the new Italian guideline. Acta Neurochir
(Wien) 2000;142:1281-5.
24. Stiell IG, Laupacis A, Wells GA; Canadian CT Head and Cervical-Spine
Study Group. Indications for computed tomography after minor head
injury. N Engl J Med 2000;343:1570-1.
25. Murshid WR. Management of minor head injuries: Admission criteria,
radiological evaluation and treatment of complications. Acta Neurochir
(Wien) 1998;140:56-64.
26. Gomez PA, Lobato RD, Ortega JM, De La CJ. Mild head injury: Differences
in prognosis among patients with a glasgow coma scale score of 13 to
15 and analysis of factors associated with abnormal CT findings. Br J
Neurosurg 1996;10:453-60.
27. Stein SC, Spettell C, Young G, Ross SE. Limitations of neurological
assessment in mild head injury. Brain Inj 1993;7:425-30.
28. Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR,
etal. External validation of the Canadian CT Head Rule and the New
Orleans Criteria for CT scanning in patients with minor head injury. JAMA
2005;294:1519-25.
How to cite this article: Sharif-Alhoseini M, Khodadadi H, Chardoli
M, Rahimi-Movaghar V. Indications for brain computed tomography
scan after minor head injury. J Emerg Trauma Shock 2011;4:472-6.
Received: 05.08.10. Accepted: 12.05.11.
Source of Support: Nil. Conflict of Interest: None declared.
Journal of Emergencies, Trauma, and Shock I 4:4 I Oct - Dec 2011
Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt.
Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for individual use.