Skull x-ray examinations after head trauma. Recommendations by a multidisciplinary panel and validation study

N Engl J Med. 1987 Jan 8;316(2):84-91. doi: 10.1056/NEJM198701083160205.


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.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Brain Injuries / diagnostic imaging
  • Child
  • Child, Preschool
  • Craniocerebral Trauma / diagnostic imaging*
  • Diagnostic Tests, Routine
  • Emergencies
  • Humans
  • Prospective Studies
  • Risk
  • Skull / diagnostic imaging*
  • Tomography, X-Ray Computed