Traumatic Brain Injury Management

Imaging Guidelines

• The American College of Radiology recommends CT scans for patients with severe or moderate traumatic brain injury, and for patients with mild injury who have specific risk factors, such as signs of basilar skull fracture, displaced skull fracture, post-traumatic seizure, focal neurological deficit, coagulation disorders, or anticoagulant therapy 1
• Patients with mild head injury (GCS 15) should undergo CT scan if they have risk factors such as age >60-65 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, headache, vomiting, or dangerous mechanism of injury 2
• The New Orleans Criteria has high sensitivity (97.7%-99.4%) but low specificity (3.0%-5.6%) for detecting intracranial injury, while the Canadian CT Head Rule has essentially 100% sensitivity for detecting injuries requiring neurosurgical intervention 2, 3
• CT scan should be considered for patients on anticoagulants, even with minimal trauma, due to higher bleeding risk, and anticoagulation should be considered a significant risk factor for intracranial injury, even with minor trauma 2
• A decrease of at least two points in Glasgow Coma Score or secondary neurological deterioration is an indication for a second CT scan, and imaging decisions should be guided by validated clinical decision rules that identify patients at higher risk for clinically significant intracranial injuries 1, 2
• The American College of Radiology recommends using CT Head (Non-contrast) as the first-line imaging modality for acute evaluation, especially when concerned about hemorrhage, mass effect, or hydrocephalus, with advantages including fast and widely available, and highly sensitive for acute hemorrhage and skull fractures 4, 2, 5
• Follow-up imaging with MRI may be necessary if symptoms persist despite normal initial CT, according to the American College of Radiology, and MRI may be considered as a second-line test due to its higher sensitivity for small ischemic infarcts, encephalitis, and subtle cases of subarachnoid hemorrhage (SAH) 4, 5, 6
• The following table summarizes the characteristics of acute and chronic subdural hematomas on CT:

• CT angiography (CTA) should be performed if hemorrhage is identified and underlying vascular abnormality is suspected, with >90% sensitivity and specificity compared to catheter arteriography for identifying vascular lesions 7, 8
• A normal CT with normal neurologic examination has a very low risk (0.006%) of deterioration, allowing for close observation in such cases, according to the American College of Radiology and the American College of Emergency Physicians 2, 3
• Clinicians should adhere to evidence-based guidelines, consider patient age, and avoid routine repeat CT in the absence of neurologic deterioration, as suggested by the Journal of the American College of Radiology and the American College of Radiology 2, 5
• The American Academy of Pediatrics recommends neuroimaging only when there is concern for structural brain abnormality in children with suspected concussion, with clinical assessment including mental status, balance, and cognitive function evaluation 9

Special Considerations

• Forehead trauma is particularly concerning due to the proximity to frontal lobes, potential for frontal skull fractures, and risk of epidural or subdural hematomas that may initially be asymptomatic, and patients with initially normal neurologic exams can deteriorate hours after injury due to expanding hematomas, a phenomenon known as delayed deterioration 3, 7
• Patients with loss of consciousness or posttraumatic amnesia should undergo a non-contrast head CT if they have headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy 3
• A non-contrast head CT scan is indicated in patients with forehead hematoma after a fall if they exhibit any of the following neurologic symptoms: decreased level of consciousness, focal neurologic deficits, seizures, persistent vomiting, severe headache, or signs of basilar skull fracture, according to the American College of Emergency Physicians guidelines 3

Management

• Management decisions should be guided by CT findings, with negative results potentially allowing for close observation and positive results potentially requiring neurosurgical consultation or intervention 2, 1
• CT findings will guide management, with negative results potentially allowing for close observation and positive results potentially requiring neurosurgical consultation or intervention, and if hemorrhage is identified and underlying vascular abnormality is suspected, CT angiography (CTA) should be performed 2, 7, 1, 8