Penetrating Head Trauma Workup

Updated: Oct 29, 2015
  • Author: Federico C Vinas, MD; Chief Editor: Brian H Kopell, MD  more...
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Laboratory Studies

The assessment of patients with penetrating brain injuries should include routine laboratory tests, electrolytes, and coagulation profile.

Many patients have lost a significant amount of blood before reaching the emergency department or might present with disseminated intravascular coagulation (DIC); consequently, determining the hemoglobin concentration and platelet count is important.

Type and cross match should always be obtained with the initial orders.

Obtaining a toxicology screen, including alcohol levels, is also appropriate.


Imaging Studies

The radiological methods of evaluation depend on the patient's condition. In general, a lateral cervical spine and chest radiographs are obtained in the resuscitation room.

A CT scan of the head should be obtained as soon as the patient's cardiopulmonary condition has been stabilized to determine the extent of intracranial damage and the presence of intracranial metallic fragments. The study always should include bone windows to evaluate for fractures, especially when the skull base or orbits are compromised. Some centers can perform computed tomographic angiography (CTA) for the evaluation of intracranial and extracranial vessels. Multidetector-row CTA has improved the detectability of both vascular and extravascular injuries in patients with penetrating injuries. [8, 18, 19]

If a vascular injury is suspected and the patient is stable, cerebral angiography often is used to diagnose injuries such as carotid and/or vertebral artery dissections, traumatic pseudoaneurysms, or arteriovenous fistulas.

In patients with penetrating injuries and intracranial metallic fragments, an MRI scan is contraindicated. If the presence of bullets or intracranial metallic fragments has been ruled out, an MRI scan of the brain provides valuable information on posterior fossa structures and the extent of sharing injuries.

A fluid-attenuated inversion recovery (FLAIR) sequence allows the evaluation of contusions or hemorrhages.

Diffusion or perfusion scan sequences are useful to evaluate areas of stroke or cerebral ischemia.

Magnetic resonance angiography (MRA) and magnetic resonance venogram (MRV) are useful if vascular or sinus injuries are suspected.