Skull X-ray in traumaTo do or not to do?

Dr Pauline Louw

“No head injury is so serious that it should bedespaired of nor so trivial that it can be ignored.”

Introduction• Head injury common presentation to EC• Most mild TBI (70-90% worldwide)• 8% of Mild TBI has intracranial pathology

(95% CI 3-13%)• 1% of these will require neurosurgical

intervention

Does plain Scull X-ray have a place in the assessment of mild TBI in the EC??

Does this patient need a CT head?

Depressed skull fracture

Does this patient need a CT head?

Does this patient need a CT head?

Linear skull fracture Growing fracture

Leptomeningeal cystTraumatic meningoceleCerebrocranial erosionCephalhydroceleMeningoceleSpuria

Does this patient need a CT head?

Right parietal fracture

Does this patient need a CT head?

Pneumocephalus

Does this patient need a CT head?

Normal X-ray

Does this patient need a CT head?A B

Guidelines

• Different guidelines available:– North America – No SXR, CT choice– ACEP – No SXR, CT choice– Europe (EBIC) – CT choice– NICE – CT choice, SXR for NAI and per discussion– SIGN – CT but pro SXR where risk factors present– Australia – No SXR, Use Canadian CT rule– SA – WC guidelines

• Consensus in most guidelines = CT choice, No SXR• ?MRI emerging modality to use in future

Canadian CT rule• Validated rule• 100% Sensitive • 2 risk groups– High risk:• At risk for neurosurgical intervention• CT mandatory

– Medium risk• May have clinically important injury on CT, but not at

risk for neurosurgery intervention• CT/observation depending on resources

Canadian CT rule

• Inclusion:– Minor head injury, GCS 13-15– Witnessed LOC, confusion or amnesia

• Exclusion– No trauma experienced– Younger than 16– GCS <13– On warfarin or coagulopathy– Has obvious open skull fracture

Canadian CT rule• High risk:– Failure to reach GCS of 15 within 2 hours– Suspected open or depressed skull fracture– Sign of basal skull fracture– Vomiting more than once– Age over 65

• Medium risk– Retrograde amnesia >30 min– Dangerous mechanism

New Orleans Criteria

• Recommend CT after minor TBI if:• GCS=15 and one of the following– Headache– Vomiting– Age >60 years– Drug or alcohol intoxication– Deficits in short term memory– Seizure– Evidence of injury above clavicle

• 100% Sensitive

Western Cape

• What are the Western Cape guidelines?• What are the WC indications for CT scan?• What are the place of SXR in WC EC’s?

SXR Studies

• Multitude of studies looked at abolishing SXR• From as early as 1977 and early 1980’s• Included adult and paediatric population• Still ongoing studies - 2008• Consensus in most countries other still

debating especially in areas with limited CT access

• Most concluded that SXR is not needed

Cost effectiveness of CT

• Less than 10% of CT scans in Mild TBI positive findings, thus > 90% CT’s normal

• Are we wasting money with all these normal CT’s?

• Compare– CT vs. admission for observation– Discharge safely vs. lack of supervision at home– CT alone vs. CT and SXR + extra radiation– Guidelines vs. CT all

MRI in TBI

• Emerging modality to use – Controversial • 10-20% missed injuries from CT• MRI 30% more sensitive than CT in picking up

intracranial injury in acute mild TBI• Not shown yet if picking up additional injuries

would change acute management of TBI• Currently need more studies in EC timeframe• No current EBM recommendations

MRI in TBI

• Advantages– Useful in sub-acute/chronic and limited acute

setting– Better soft tissue definition– Better at • Detecting DAI• Small areas of contusion• Subtle neuronal damage• Posterior fossa: Cerebellum and brainstem

MRI in TBI

• Disadvantages– Not widely available and accessible– Patient monitoring problem– Long imaging time– Foreign bodies– Patient safety (pacemakers, previous ferromagnetic

foreign bodies)– Cost constraints– Insensitive to acute SAH, parenchymal haemorrhage and

fracture compared to CT– Patient motion artefacts

MRI images

MRI images

Positron Emission Tomography (PET)

Important Points on SXR

• Not all skull fractures have intracranial injury• Not all intracranial injuries have a skull

fracture• Objective not to diagnose skull fracture but

risk for intracranial injury• SXR low diagnostic yield• Fractures easily missed or over diagnosed• SXR give false sense of reassurance if normal

Summary

• CT modality of choice in whole spectrum of TBI

• No place for EC Skull X-ray in trauma

• MRI starting to gain favour, but limitations issue

So when do we use Skull X-ray?

• Trauma– Foreign body– Penetrating injuries (slot fracture and compound)– Growing fracture in child less than 1 year

• Medical– Multiple myeloma

• Paeds– NAI as part of skeletal survey

Multiple Myeloma

?

References• Reed MJ, Browning JG, Wilkinson AG. Can we abolish skull xrays for head

injury? Arch Dis Child 2005;90:859–864• Glauser J. Head injury: Which patients need imaging? Which test is best?

Clevelend Clin J Med 2004;71(4):353-357• Coles JP. Imaging after brain injury. Br J Anaesth 2007; 99: 49–60• Lee B, Newberg A. Neuroimaging in traumatic brain injury. NeuroRx 2005;2(2):

372-382• ACEP/CDC. Clinical Policy: Neuroimaging and decision making in adult mild

traumatic brain injury in the acute setting. Ann Emerg Med 2008;52:714-748• NICE clinical guideline 56: Head injury: Triage, assessment, investigation and

early management of head injury in infants, children and adults. NICE update 2007

• Stiell IG, Wells G et al. Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1391-6