Minor Head Injury: Guidelines for the Use of CT A Multicenter Validation Study

doi:10.1148/radiol.2452061509

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Neuroradiology

Minor Head Injury: Guidelines for the Use of CT—A Multicenter Validation Study¹

Marion Smits, MD, Diederik W. J. Dippel, MD, PhD, Gijs G. de Haan, MD, Helena M. Dekker, MD, Pieter E. Vos, MD, PhD, Digna R. Kool, MD, Paul J. Nederkoorn, MD, PhD, Paul A. M. Hofman, MD, PhD, Albert Twijnstra, MD, PhD, Hervé L. J. Tanghe, MD, and M. G. Myriam Hunink, MD, PhD

¹ From the Departments of Radiology (M.S., H.L.J.T., M.G.M.H.), Neurology (D.W.J.D.), Medical Informatics (G.G.d.H.), and Epidemiology and Biostatistics (M.G.M.H.), Erasmus MC-University Medical Center Rotterdam, 's Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands; Departments of Radiology (H.M.D.) and Neurology (P.E.V.), University Medical Center Nijmegen St Radboud, Nijmegen, the Netherlands; Departments of Radiology (D.R.K.) and Neurology (P.J.N.), Academic Medical Center, Amsterdam, the Netherlands; Departments of Radiology (P.A.M.H.) and Neurology (A.T.), University Hospital Maastricht, Maastricht, the Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (M.G.M.H.). From the 2005 RSNA Annual Meeting. Received August 31, 2006; revision requested October 26; revision received December 19; accepted January 23, 2007; final version accepted March 14. Supported by grants from CVZ (College voor zorgverzekeringen: VAZ 01-104) and RADION (Radiologisch onderzoek Nederland). The authors' work was independent of the funding organizations. Address correspondence to M.G.M.H. (e-mail: m.hunink{at}erasmusmc.nl).

Purpose: To prospectively and externally validate published nationaland international guidelines for the indications of computed tomography(CT) in patients with a minor head injury.

Materials and Methods: The study protocol was institutional reviewboard approved. All patients implicitly consented to use of theirdeidentified data for research purposes. Between February 2002 andAugust 2004, data were collected in consecutive adult patients withblunt minor head injury (Glasgow Coma Scale score of 13–14or 15) and a risk factor for neurocranial traumatic complicationsat presentation at four Dutch university hospitals. Primary outcomewas any neurocranial traumatic CT finding. Secondary outcomes wereclinically relevant traumatic CT findings and neurosurgical intervention.Sensitivity and specificity of each guideline for all outcomes andthe number of patients needed to scan to detect one outcome (ie,the number of patients needed to undergo CT to find one patient witha neurocranial traumatic CT finding, a clinically relevant traumaticCT finding, or a CT finding that required neurosurgical intervention)were estimated.

Results: Data were available for 3181 patients. Only the EuropeanFederation of Neurological Societies guidelines reached a sensitivityof 100% for all outcomes. Specificity was 0.0%–0.5%. The Dutchguidelines had the lowest sensitivity (76.5%) for neurosurgical interventions.The best specificities for traumatic CT findings and neurosurgicalinterventions were reached with the criteria proposed by the UnitedKingdom National Institute for Clinical Excellence (NICE) (46.1%and 43.6%, respectively), albeit at relatively low sensitivities(82.1% and 94.1%, respectively). The number of patients needed toscan ranged from six to 13 for traumatic CT findings and from 79to 193 for neurosurgical interventions.

Conclusion: All validated guidelines demonstrated a trade-off betweensensitivity and specificity. The lowest number of patients neededto scan for either of the outcomes was reached with the NICE criteria.