1. Skull X-ray in trauma To do or not to do?
Dr Pauline Louw
Who has done a Skull Xray on a trauma patient this past year? What was the indications?
The uncertainty that exists about the likely outcome after traumatic brain injury (TBI) is encapsulated in the Hippocratic aphorism “No head injury is so serious that it should be despaired of nor so trivial that it can be ignored.”
“No head injury is so serious that it should be
despaired of nor so trivial that it can be ignored.”

2. 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??
Most mild head injury don’t require admission or further work-up. In evaluation of 13 studies with patients mean prevalence of intracranial head injury was 8%

3. Does this patient need a CT head?
Depressed skull fracture

4. Does this patient need a CT head?

5. Does this patient need a CT head?
Leptomeningeal cyst
Traumatic meningocele
Cerebrocranial erosion
Cephalhydrocele
Meningocele
Spuria
infant linear fracture, baseline skull x-ray needed for comparison on return visit to exclude growing fracture or evaluate growing fracture
Growing skull fractures:
In children, most skull fractures heal rapidly, with no long-term sequelae. However, in a small minority of children, a fracture may remain un-united and enlarge to form a growing skull fracture First case described in 1816, John Hopkins described an infant with growing skull fracture after a head injury. Since then, cases of growing skull fracture continue to appear in the literature, with various names such as a leptomeningeal cyst, traumatic meningocele, cerebrocranial erosion, cephalhydrocele, meningocele, and spuria. Growing skull fracture is rare and affects % of patients with severe head injury, with a vast majority occurring in children younger than 3 years. The exact pathophysiology remains elusive. Serial conventional radiographs of the skull show evolution of the initial diastatic fracture into a larger defect. Although plain radiographs are sufficient for diagnosis, brain CT better defines the exact pathology. Growing skull fracture are treated surgically to reduce the herniated cerebral tissue and repair the dural laceration or to perform cranioplasty. Early recognition is crucial to prevent long-term neurologic sequelae. Hence, radiologic and clinical follow-up is essential in cases of head trauma in children.
Growing fracture
Linear skull fracture

6. Does this patient need a CT head?
Right parietal
fracture
Right parietal fracture

7. Does this patient need a CT head?
Pneumocephalus

8. Does this patient need a CT head?
Maybe, depend on clinical picture of patient
Normal X-ray

9. Does this patient need a CT head?B A
A: Penetrating brain injury resulting from nail-gun use is a well-characterized entity, one that is increasing in frequency as nail guns become more powerful and more readily available to the public. 50-year-old male present with two intracranial penetrating nail gun injuries. Nail gun brain injuries are commonly intentionally self-inflicted. Suicide should be considered when straight nails cause wounds to the chest, head, or abdomen. The primary preoperative concern is formation of a traumatic pseudoaneurism, which prompts both preoperative and follow-up cerebral angiography.
B: A 44 year old man was referred to the accident and emergency department by the psychiatric services, having claimed to have hammered several nails through his skull over a three month period. The patient had a long history of depression, personality disorder, and previous deliberate self-harm. He had remained well throughout this period and had been cleaning the wounds with weak antiseptic on a regular basis. He had concealed the injuries by wearing a hat. Two days prior to admission he had inserted a much larger 12.7 cm (5 inch) masonry nail and had developed left sided weakness and unsteadiness of gait.
Examination showed that the patient remained well with no evidence of infection in the central nervous system. Neurological examination revealed a mild left sided weakness affecting both the arm and leg. The patient was fully alert and orientated and conversed normally. Inspection of the scalp revealed a large masonry nail protruding from the scalp with several other healed puncture wounds. Plain skull X-rays revealed a total of ten 5 cm nails and a larger, 12.7 cm masonry nail penetrating the skull. A computed tomography (CT) scan was performed, which despite considerable artefact confirmed that the nails had penetrated the brain substance. The patient was later transferred to the local neurosurgical unit for further management where, after angiography, all the nails were removed under general anaesthetic. He subsequently made an uneventful recovery.

10. 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
NICE: New amended guidelines 2007: Plain X-rays of the skull should not be used to diagnose significant brain injury without prior discussion with a neuroscience unit. However, they are useful as part of the skeletal survey in children presenting with suspected non-accidental injury.
Scottish Intercollegiate Guideline Network (SIGN) guidelines place more emphasis on skull x rays where there are risk factors for fracture or intracranial injury, although they acknowledge that skull fractures in children are less commonly associated with intracranial injury, and therefore their detection is less helpful than in the adult population.

11. 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
Prospective validation was carried out in Canada and reported a sensitivity of 100% and a specificity of 52.1% for clinically important brain injury
100% sensitive for need for neurosurgical intervention
Don’t cover whole spectrum including coagulopathy, seizures, focal neurology ect..

12. Canadian CT rule Inclusion: Exclusion 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

13. Canadian CT rule High risk: Medium 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
Dangerous mechanism: PVA, ejected from vehicle, fall from height >3feet or 5 stairs
Dangerous mechanism form part of Level B recommendations

14. 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
All of above are level A evidence together with GCS <15, focal neurology deficit and coagolopathy

15. 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?

16. 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
Consensus in most countries other still debating especially in areas with limited CT access
Most concluded that SXR is not needed

17. 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
CT scan vs need for admission in hospital for neuro-observations, care from nursing staff including regular neuro-observations, food/catering, bed, lined, bed occupancy in overfull hospitals ect
Discharge safely after CT normal vs discharge home without CT but no supervision at home, no transport, delay return to hospital with resultant longer hospital stay or increase morbidity and mortality
Guidelines help to identify high risk cases needing CT vs CT scan for all. Guidelines decrease need for CT and saving money and radiation exposure. Remember 1 CT in a child = 100 CXR’s

18. 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
EBM=Evidence based medicine recommendations. Need more studies, ACEP currently no level A/b/c recommendations
Forty-eight to 72 h after injury, MRI is generally considered to be superior to CT. Although CT is better at detecting bony pathology and certain types of early bleeds, the ability of MRI to detect hematomas improves over time as the composition of the blood changes. The overwhelming majority of patients with mild brain injury show no abnormality on MRI
Studies have shown that CT missed approximately 10–20% of abnormalities seen on MRI
New MRI technology and acquisition sequences have improved the sensitivity of MRI

19. 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
CT posterior fossa – bone artifacts

20. 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
Patient motion artefacts more of an issue with MRI than with CT

21. MRI images
MRI of brain stem injury. This patient presented with a Glasgow Coma Score of 4 after a road traffic accident and failed to improve, despite maximal medical therapy, and therefore underwent MRI to assess the extent of injury. The T1 weighted images are displayed in axial (A) and coronal (B) section. These demonstrate a high signal abnormality within the pons (arrow) which extended from the basal ganglia through the midbrain and into the pons

22. MRI images
FLAIR images from two levels in a patient who sustained a severe head injury after a road
traffic accident. The left image appears unremarkable except for a thin collection of subdural fluid and loss of volume within the underlying right
temporo-parietal cortex. The right image demonstrates high signal within the right internal carotid (arrow) consistent with dissection and thrombosis
secondary to basal skull fracture

23. Positron Emission Tomography (PET)
Fig 7 Assessment of the efficacy of acute hyperventilation using PET imaging. Gray scale PET CBF images obtained from a headinjury patient
at relative normocapnia (A) and hypocapnia (B). Voxels with a CBF less than 20 ml 100 ml21 min21 are picked out in red. Baseline ICP was
21 mm Hg and supports the use of hyperventilation to lower PaCO2 and improve ICP control. Hyperventilation did result in a reduction in ICP to
17 mm Hg but, in this individual, led to a substantial increase in the volume of hypoperfused brain.

24. 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
Low sensitivity to use as screening test

25. 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

26. 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

27. Multiple Myeloma

28. ?

29. 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):
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):
ACEP/CDC. Clinical Policy: Neuroimaging and decision making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008;52:
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