The value of skull radiography in identifying intracranial injury has not yet been satisfactorily defined. A multidisciplinary panel of medical experts was assembled to review the issue of skull radiography for head trauma. The panel identified two main groups of patients–those at high risk of intracranial injury and those at low risk of such injury–and developed a management strategy for imaging in the two groups. The high-risk group consists primarily of patients with severe open or closed-head injuries who have a constellation of findings that are usually clinically obvious. These patients are candidates for emergency CT scanning, neurosurgical consultation, or both. The low-risk group includes patients who are asymptomatic or who have one or more of the following: headache, dizziness, scalp hematoma, laceration, contusion, or abrasion. Radiographic imaging is not recommended for the low-risk group and should be omitted. An intermediate moderate-risk group is less well defined, and skull radiography in this group may sometimes be appropriate. A prospective study of 7035 patients with head trauma at 31 hospital emergency rooms was conducted to validate the management strategy. No intracranial injuries were discovered in any of the low-risk patients. Therefore, no intracranial injury would have been missed by excluding skull radiography for low-risk patients, according to the protocol. We conclude that use of the management strategy is safe and that it would result in a large decrease in the use of skull radiography, with concomitant reductions in unnecessary exposure to radiation and savings of millions of dollars annually 1).
A skull fracture increases the probability of a surgical intracranial injury (ICI) (in a comatose patient it is a 20-fold increase, in a conscious patient it is a 400-fold increase 2) 3). However, significant ICI can occur with a normal Skull radiography (SR) (SR was normal in 75% of minor head injury patients found to have intracranial lesions on CT, attesting to the insensitivity of SRs 4)). SRs affect management of only 0.4–2%of patients in most reports 5)
SR may be helpful in the following:
1. in patients with moderate risk for intracranial injury by detecting an unsuspected depressed skull fracture (however, most of these patients will get a CT scan, which obviates the need for SR)
2. if a CT scan cannot be obtained,a SR may identify significant findings such as pineal shift, pneumocephalus, air-fluid levels in the air sinuses, skull fracture (depressed or linear)… (however, sensitivity for detecting ICI is very low)
3. with penetrating injuries: helps in visualization of some metallic objects