Guidelines Summary

Guidelines for the evaluation of patients with head trauma were published in May 2021 by the American College of Radiology (ACR) in Journal of the American College of Radiology.^[31]

For initial imaging of patients with mild (Glasgow Coma Scale [GCS] 13-15) acute head trauma when imaging is not indicated by a clinical decision rule, imaging is usually not appropriate.

For initial imaging of patients with mild acute head trauma when imaging is indicated by a clinical decision rule, noncontrast computed tomography (CT) of the head is usually appropriate.

For initial imaging of patients with acute head trauma that is moderate (GCS 9-12) or severe (GCS 3-8) or penetrating, noncontrast head CT is usually appropriate.

For short-term follow-up imaging of patients with acute head trauma who have an unchanged neurologic examination and unremarkable initial imaging, especially when the neurologic examination is abnormal (GCS < 15), noncontrast brain magnetic resonance imaging (MRI) or noncontrast head CT may be appropriate.

For short-term follow-up imaging of patients with acute head trauma who have an unchanged neurologic examination and one or more positive findings (eg, subdural hematoma) on initial imaging, noncontrast head CT is usually appropriate. Some such patients (eg, those with a normal neurologic examination and intracranial hemorrhage < 10 mL) may not require routine repeat imaging.

For short-term follow-up imaging of patients with acute head trauma who have a new or progressive neurologic deficit, noncontrast head CT is usually appropriate.

For initial imaging of patients with subacute or chronic head trauma and an unexplained cognitive or neurologic deficit, noncontrast brain MRI or noncontrast head CT is usually appropriate; these procedures are equivalent alternatives, and only one need be ordered in this setting.

For patients with head trauma and suspected intracranial arterial injury due to clinical risk factors or positive findings on prior imaging, CT angiography (CTA) of the head and neck is usually appropriate.

For patients with head trauma and suspected intracranial venous injury due to clinical risk factors or positive findings on prior imaging, CT venography (CTV) of the head is usually appropriate.

For initial imaging of patients with head trauma and suspected cerebrospinal fluid (CSF) leakage, noncontrast head CT, noncontrast maxillofacial CT, and noncontrast temporal bone CT are usually appropriate; depending on the clinical setting, these procedures can be complementary or concurrent.

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Table 1. Glasgow Coma Scale

Table 1. Glasgow Coma Scale

Eye Opening
Score	1 Year or Older		0-1 Year
4	Spontaneously		Spontaneously
3	To verbal command		To shout
2	To pain		To pain
1	No response		No response
Best Motor Response
Score	1 Year or Older		0-1 Year
6	Obeys command
5	Localizes pain		Localizes pain
4	Flexion withdrawal		Flexion withdrawal
3	Flexion abnormal (decorticate)		Flexion abnormal (decorticate)
2	Extension (decerebrate)		Extension (decerebrate)
1	No response		No response
Best Verbal Response
Score	>5 Years	2-5 Years	0-2 Years
5	Oriented and converses	Appropriate words	Cries appropriately
4	Disoriented and converses	Inappropriate words	Cries
3	Inappropriate words; cries	Screams	Inappropriate crying/screaming
2	Incomprehensible sounds	Grunts	Grunts
1	No response	No response	No response

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Author

Craig R Ainsworth, MD Medical Director, Intensive Care Unit, Associate Program Director, Internal Medicine Residency Program, Critical Care Medicine Physician, William Beaumont Army Medical Center

Craig R Ainsworth, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Gregory S Brown, Jr, MD Staff Physician, Department of Pulmonary and Critical Care, William Beaumont Army Medical Center

Gregory S Brown, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

David W Crippen, MD, FCCM Associate Professor, Department of Critical Care Medicine, University of Pittsburgh Medical Center; Medical Director, Neurovascular Critical Care, Presbyterian-University Hospital

David W Crippen, MD, FCCM is a member of the following medical societies: American College of Critical Care Medicine, European Society of Intensive Care Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Scott Shepard, MD Assistant Professor, Department of Surgery, Section of Neurosurgery, UMDNJ-Robert Wood Johnson School of Medicine

Disclosure: Nothing to disclose.