0148-396 X/88/2203-0449$02.00/0
NEUROSURGERY
Copyright © 1988 by the Congress of Neurological Surgeons.

Vol. 22, No. 3, 1988
Printed in U.S.A.

Experimental and clinical studies

Value of Skull Radiography, Head Computed Tomographic
Scanning, and Admission for Observation in Cases of Minor
Head Injury

Tony Feuerman, M.D., Phillip Ashley Wackym, M.D., George F. Gade, M.D., and Donald P. Becker, M.D.

Division of Neurosurgery, Harbor/UCLA Medical Center, Torrance, California

A retrospective review of 373 adult patients admitted to Harbor General Hospital between 1980 and 1984 for minor
closed head injury (Glasgow coma scale | 3-15) was performed to determine the benefits of skull radiography, computed
tomographic (CT) scanning of the head, and admission for observation. Variables reviewed were mental status,
neurological examination, presence or absence of loss of consciousness, clinical evidence of basilar skull fracture, and
fracture on skull radiography. The neurological examination (including mental status and Glasgow coma scale) in the
emergency room was the best predictor of subsequent deterioration or the presence of an operative hematoma. The
only patients with Glasgow coma scale scores of 15 who required surgical evacuation of an extraaxial hematoma had
focal neurological deficits referable to hemispheric compression, with or without an abnormal mental status. A Glasgow
coma scale score of 13 or 14 places the patient at risk either of having a hematoma requiring surgery or of deteriorating.
We recommend that a head CT scan be obtained on all patients with Glasgow coma scale scores of less than 15,
abnormal mental status, or hemispheric neurological deficits. If no operative lesion is found on the CT scan, the patient
should be admitted for observation because there is still a risk of deterioration. Those with a Glasgow coma scale score
of 15, a normal mental status, and no hemispheric neurological deficit may be discharged to be observed at home by a
competent observer despite basilar or calvarial skull fracture, loss of consciousness, or cranial nerve deficit. No benefit

was gained from skull radiography in any group. (Neurosurger)

2:449-453, 1988)

Key words: Computed tomography, Glasgow coma scale, Head injury, Skull fracture, Skull radiography

Head injury is common in the United States. For the
approximately 70% (5) of head-injured patients with appar-
ently minor head injury (Glasgow coma scale 13-15) (4), the
predictive value of skull radiography, head computed tomo-
graphic (CT) scanning, and admission for observation in
identifying those patients at risk for neurological deterioration
has been unclear. Several recent studies (1-4, 6-10) have
documented conflicting views regarding the importance of
these variables in managing patients with a Glasgow coma
scale (GCS) score of 13, 14, or 15. Consequently, we per-
formed a retrospective review of 373 patients to determine
the benefits of skull radiography. head CT scanning, and
hospital admission for observation.

METHODS

This study was based on a retrospective review of 373 adult
patients admitted to Harbor General Hospital between 1980
and 1984 for minor head injury (GCS 13 to 15) (Table 1).
Demographic. historical, physical examination. and radiolog-
ical data, operative and medical therapies. and sequelae.
outcome, and discharge diagnoses were reviewed.

Demographic data collected included age. sex. dates of
hospitalization. and time period between injury and presen-
tation. To be included in the study. the patient must have
been 16 years of age or older and must have presented to the
emergency room within 24 hours of the time of injury.

449

Historical data included whether consciousness was lost and
the presence of other injuries associated with the cause of
head injury. Physical examination data included neurological
examination including GCS score and the mental status (a
normal mental status was defined as a clear indication in the
patient’s medical record that he or she was alert with no
abnormality in the level of consciousness, oriented to person,
time, and place, and had no dysphasia or dyspraxia); presence
and type of skull fracture (depressed/nondepressed, open/
closed); and evidence of basilar skull fracture, including
hemotympanum, Battle’s sign, periorbital ecchymosis, cere-
brospinal fluid otorrhea, or rhinorrhea.

Radiological studies reviewed included skull radiograms,
head CT scans, and cerebral angiograms. These studies were
obtained as thought necessary by the emergency room physi-
cians and neurosurgical consultants. No standard protocol
was followed in the decision to obtain radiographic studies.

Operative therapy (type. response to, and time from injury
to operation) was examined. Medical therapies utilized in-
cluded hyperventilation. hyperosmolar agent. pentobarbital
coma. steroids, and intracranial pressure (ICP) monitoring.

RESULTS

GCS 13

Thirty-four patients each had a GCS score of 13. Of the 34
patients. 31 were male and 3 were female. Men ranged in age

450 FEUERMAN etal

TABLE |
Total Patients Reviewed

No. Patients with:

GCS 15 GCS 14 GCS 13
Total number 236 103 34
Loss of consciousness (by 160 61 27
history)
Basilar skull fracture 86 ai 13
Skull fracture/skull x-ray 72/201 28/88 14/30
film
Hemispheric deficit 5 4 2
Operative hematoma g 3 0
Deteriorated 0 1 2

from 18 to 80 years (mean = 28), and women ranged in age
from 22 to 30 years (mean = 23).

Twenty-seven (79%) had a history of loss of consciousness.
Twelve patients (35%) had severe associated injuries.

Thirteen patients (38%) had basilar skull fractures. Seven
patients (21%) had focal neurological deficits: dysphasia (1
case), upgoing plantar response (1 case), 3rd cranial nerve
palsy (1 case), 6th nerve palsy (1 case), central 7th nerve palsy
(2 cases), peripheral 7th nerve palsy (1 case), and 8th nerve
dysfunction by bedside examination (1 case).

Thirty patients (88%) underwent skull radiography, and 21
patients (62%) had head CT scans. Fourteen patients (41% of
those who had skull radiographs) had skull fractures, Positive
CT findings in 13 of the 21 patients (62%) who had head CT
scans were: pneumocephalus (2 cases), diffuse cerebral edema
(1 case), cerebral contusion (8 cases), subdural hematoma (2
cases), and subarachnoid hemorrhage (1 case).

GCS 14

One hundred three patients each had a GCS score of 14.
Of the 103 patients, 90 were male and 13 were female. Men
ranged in age from 19 to 79 years (mean = 31), and women
ranged in age from 18 to 78 years (mean = 34).

Sixty patients (59%) had histories of loss of consciousness.
Thirty-four patients (33%) had severe associated injuries.

Twenty-seven patients (26%) had basilar skull fractures.
Twelve patients (12%) had focal neurological deficits: 3rd
cranial nerve palsy (2 cases), bilateral 4th nerve palsies (1
case), 6th nerve palsy (1 case), central 7th nerve palsy (2
cases), peripheral 7th nerve palsy (1 case), diminished 8th
nerve function by bedside examination (4 cases), aphasia (1
case), frontal lobe syndrome (1 case), and hemiparesis (1
case).

Eighty-eight patients (85%) underwent skull radiography,
and 49 patients (48%) had head CT scans. Twenty-eight
patients (27% of those who had skull radiographs) had skull
fractures. Positive CT findings in 20 of the 49 patients (41%)
who had head CT scans were: pneumocephalus (1 case),
diffuse cerebral edema (4 cases), cerebral contusion (8 cases),
subdural hematoma (4 cases), epidural hematoma (3 cases),
intracerebral hematoma (1 case), and subarachnoid hemor-
rhage (1 case).

GCS 15

Two hundred thirty-six patients each had a GCS score of
15. Of the 236 patients, 182 were male and 54 were female.
Men ranged in age from 18 to 64 years (mean = 31), and

women ranged in age from 19 to 80 years (mean = 36).
One hundred forty patients (68%) had histories of loss of

Neurosurgery, Vol. 22, No. 3

consciousness. Sixty-four patients (27%) had severe associated
injuries.

Eighty-six patients (36%) had basilar skull fracture. Twenty-
eight patients (12%) had focal neurological deficits: Ist cranial
nerve dysfunction (3 cases), 2nd nerve dysfunction (3 cases),
3rd nerve palsy (2 cases), 4th nerve palsy (1 case), 6th nerve
palsy (1 unilateral, | bilateral), central 7th nerve palsy (3
cases), peripheral 7th nerve palsy (6 cases), 8th nerve dysfunc-
tion by bedside testing (16 unilateral, 1 bilateral), and aphasia
(3 cases).

Two hundred one patients (85%) had skull radiographs,
and 59 patients (25%) had head CT scans. Seventy-two pa-
tients (31% of those who had skull radiographs) were found
to have skull fractures. Positive CT findings in 20 of the 59
patients (34%) who had head CT scans were: pneumocephalus
(4 cases), diffuse cerebral edema (1 case), cerebral contusion
(11 cases), epidural hematoma (4 cases), subdural hematoma
(2 cases), intracerebral hematoma (2 cases), and subarachnoid
hemorrhage (3 cases).

Case summaries of patients who deteriorated or had
hematomas

These eight cases are summarized in Table 2.

Case 1. A 34-year-old man came to the emergency depart-
ment 72 hours after being struck on the head with a pool cue.
He complained of headache, poor memory, and difficulty
with speech. Neurological examination revealed bilateral
periorbital ecchymoses and a GCS score of 15, with an
expressive aphasia. Skull radiographs showed a linear fracture,
and a CT scan of the head showed a left frontal acute epidural
hematoma with an underlying contusion. A craniotomy con-
firmed the acute epidural hematoma, which was evacuated.
The patient made a complete recovery.

Case 2. A 46-year-old man was involved in a motor vehicle
accident and was brought immediately to the hospital. Ex-
amination showed a left hemotympanum, a GCS score of 15,
a normal mental status, and an upgoing plantar response on
the right. Skull radiographs showed a linear fracture, and a
head CT scan showed an acute epidural hematoma on the
left. The patient had a slight deterioration in mental status
and was taken to the operating room for evacuation of the
hematoma. He subsequently made a full recovery.

Case 3. A 40-year-old woman with a history of alcoholism
was brought to the hospital after a fall. She was disoriented,
with a GCS score of 14. Neurological examination was signif-
icant for right 3rd and 4th cranial nerve palsies, right hemi-
paresis, and an upgoing plantar response on the left. A head
CT scan showed a right-sided acute subdural hematoma. Skull
roentgenography was not performed. A craniotomy was per-
formed and the acute subdural hematoma was evacuated. The
patient had a moderate long term disability.

Case 4. A 65-year-old man who had apparently been
beaten was found in an alley. He initially had a GCS score of
14, but his condition rapidly deteriorated in the emergency
department to a GCS score of 4 with bilateral decerebrate
posturing, midposition and fixed right pupil, diffusely hyper-
active reflexes, and upgoing plantar responses. No skull radio-
graphs were obtained. A head CT scan showed a right-sided
acute subdural hematoma, which was evacuated after crani-
otomy. He recovered consciousness, but suffered a severe
alteration of cognition.

Case 5. A 22-year-old man who was involved in a motor
vehicle accident was brought immediately to the hospital by
paramedics. Upon arrival. he was combative and disoriented.
with a GCS score of 14. Right periorbital ecchymosis was
present. Skull radiographs showed a linear fracture. A head

6 hn EL eee

March 1988 MINOR HEAD INJURY 451
TABLE 2
Summary of Clinical Data of Patients Who Deteriorated or Had Hematomas*
Case Age Sex Cause of GCS Focal Deficit Paull CT Findings Treatment/Outcome
Injury Fracture
i 34 Blow 15 Expressive aphasia + Left EDH Craniotomy for
EDH; full recovery
2 46 MVA 15 Right upgoing plantar + Left EDH Craniotomy for
response EDH: full recovery
3 40 F Fall 14 Right 3rd and 6th ND Right SDH Craniotomy for SDH;
nerve palsies; right mild postoperative
hemiparesis left up- tetraparesis
going plantar re-
sponse
4 65 M Blow 14-4’ — Decerebrate bilaterally; ND Right SDH Craniotomy for SDH;
fixed right pupil severe memory def-
icit
5 22 M MVA 14 None + Right EDH Craniotomy for
EDH; full recovery
6 36 MVA 14 None + Right ICH, contu- Deteriorated 12 hr
sion after injury; crani-
otomy for ICH; full
recovery
7 21 M MVA 13 None initially; 5 d ND Initially normal; 5 d Craniotomy for SDH;
after injury, right after injury, left persistent right
hemiparesis SDH hemiparesis
8 41 M Blow 13 None + Bifrontal contusions; —_ Deteriorated 24 hr

bifrontal SAH

after injury; medi-

cal therapy of in-
creased ICP; died
12 d after injury

“ Abbreviations: EDH, epidural hematoma; MVA, motor vehicle accident; GCS, Glasgow coma scale; SAH, subarachnoid hemorrhage; ICH,

intracerebral hematoma; SDH, subdural hematoma; ND, not obtained.

* Arrival GCS deteriorated to 4 while in emergency department.

CT scan showed a right-sided acute epidural hematoma. A
craniotomy was performed, and the hematoma was evacu-
ated. The patient made a full recovery.

Case 6. A 36-year-old man was involved in a motor vehicle
accident. He had a GCS score of 14. Neurological examina-
tion was nonlocalizing. Skull radiographs showed a linear
skull fracture. A head CT scan showed a right temporal
intracerebral hematoma and right parietal contusion with a
right-to-left shift. The patient was observed in the hospital for
12 hours before his mental status deteriorated. He was taken
to the operating room for evacuation of the intracerebral
hematoma. He subsequently made an excellent recovery.

Case 7. A 21-year-old man was involved in a motor vehicle
accident. Upon arrival at the emergency department, he was
confused and somnolent, with a GCS score of 13. Neurolog-
ical examination was nonlocalizing. Skull radiographs were
not obtained. A head CT scan was unremarkable. He was
taken to the operating room for repair of facial and oral
injuries. On the 5th postoperative day, he was still disoriented
and developed a right hemiparesis. Repeat head CT scanning
revealed a left acute subdural hematoma, which was evacuated
by craniotomy. Postoperatively, his mental status improved,
but his right hemiparesis persisted.

Case 8. A 41-year-old man was brought to the hospital
after suffering a blow to the head. He was disoriented, with a
GCS score of 13. He had a right hemotympanum. Neurolog-
ical examination was nonlocalizing. Skull radiographs showed
two linear fractures. A head CT scan showed bifrontal con-
tusions and a small bifrontal subarachnoid hemorrhage.
Within the next 24 hours, he became comatose with a dilated

right pupil and decerebrate posturing. The findings of repeat
CT scanning were unchanged. An ICP monitor was placed
and showed an ICP elevated to 25 to 30 mm Hg. The patient
was treated with hyperventilation, dexamethasone, mannitol,
and barbiturate coma, but never regained consciousness. He
died of pneumonia on the 12th day after his injury.

DISCUSSION

In performing this study, we attempted to determine which
criteria could predict the presence of an operative intracranial
hematoma or a posttraumatic deterioration in neurological
status. Either of these complications of head injury necessi-
tates admission to the hospital. Patients with the predictive
factors will need to be admitted to the hospital, and the
remainder of the patients could be observed at home. Estab-
lishing these predictive factors is of medical, social, and eco-
nomic value.

Of the 236 patients with a GCS score of 15, the only 2 who
proved to have operative intracranial hematomas had focal
deficits on their neurological examination referable to a hem-
ispheric lesion. In addition, 1 of these patients had an abnor-
mal mental status manifested by poor memory. None of the
remaining 234 patients deteriorated while in the hospital
under observation. Therefore, with a GCS score of 15, a
normal mental status, and a normal neurological examination
in the emergency room, the chance of a patient developing a
serious complication from a minor head injury is exceedingly
small. These patients may be observed at home by a compe-
tent observer. In the GCS 15 group, if either an abnormal

452 FEUERMAN etal

mental status or a focal neurological deficit is present. an
emergency CT scan should be obtained. If no operative lesion
is present, the patient should be admitted to the hospital for
observation. We are not concluding that a normal neurolog-
ical examination (including normal mental status) eliminates
the possibility of a complication: there are many anecdotal
stories of a patient being neurologically normal in the emer-
gency room after a minor head injury only to deteriorate
later. We are recommending that these patients be observed
at home because the chance of this deterioration is so small.

If a patient’s GCS is 13 or 14, we recommend that a CT
scan of the head be obtained emergently. If this scan is
unremarkable, the patient should be admitted for observation.
This is based on the finding that 3 of the 137 patients with
GCS scores of 13 or 14 had operative hematomas and another
3 had significant deterioration while in the hospital under
observation.

Patients with skull fractures on radiography were at greater
risk of having a hematoma or deteriorating. This information,
however, does not improve upon the predictive value of the
neurological examination. None of the patients with GCS 15,
normal mental status, and normal neurological examination
had operative hematomas or consciousness deterioration, so
skull radiography may be superfluous. The two patients with
GCS scores of 15 who had operative hematomas had focal
neurological deficits referable to the location of the hema-
toma, and one had an abnormal mental status. The infor-
mation gained by skull radiography would not have altered
the management course of either of these patients. If a patient
is found to have a GCS score of less than 15, he is at risk for
a hematoma or deterioration regardless of the presence or
absence of a skull fracture, and, therefore, a CT scan should
be obtained. Data from skull radiography again would be
superfluous.

There has been controversy in the recent neurosurgical
literature about the indications for diagnostic tests and ad-
mission for observation in cases of minor head injury. The
question of whether to admit patients to the hospital based
on the presence or absence of a skull fracture has been
addressed in several studies (2-4, 6, 8, 9). Most studies con-
clude that the presence of a skull fracture increases the prob-
ability that a patient will have an intracranial hematoma or
deteriorate (3, 4, 6, 8, 9). This, however, is not an indication
to obtain skull radiograms because patients both with and
without skull fractures may be at serious risk for deterioration
and, with clinical neurological examination, skull radiography
is redundant. For example, Mendelow et al. demonstrated
that the risk of a disoriented patient with a skull fracture
having a hematoma was 18 times greater than the risk for a
patient without a fracture (9). The disoriented patient without
a fracture, however, was found to have a 1.5% chance of
having an intracranial hematoma. A disoriented patient,
therefore, will need a head CT scan regardless of the skull
roentgenographic finding. If the CT scan is negative, the
patient should be admitted for observation because of the risk
of deterioration. Unfortunately, in discussing their subgroup
of oriented patients, Mendelow et al. failed to describe either
the GCS status or the neurological examination of their
patients (9), data that are extremely important. A previous
study by the same group also failed to discuss the details of
the neurological examination in alert and oriented patients
who developed intracranial hematomas. so it is not possible
to determine whether skull radiography was indeed beneficial
in that group of patients (8). Another study showed that the
presence of a skull fracture increased the possibility of the
patient having an intracranial hematoma. but it did not

:

Neurosurgery, Vol. 22, No. 3

differentiate between oriented and disoriented patients (4).
Thus. the failure to consider carefully level of alertness, ori-
entation, and neurological examination may have led to the
conclusion that the presence or absence of a skull fracture
would change management in minor head injury. We found
that skull radiographs added nothing to the clinical data
obtained from a careful neurological examination. This con-
clusion is supported by a study by Cooper et al., who found
that, with judicious ordering of CT scans, no change in
management was made based on skull radiographs (2).

Several other studies have demonstrated the safety of dis-
charging patients with normal mental status and normal
findings of neurological examination after minor head injury
(1, 7, 10). They support our conclusion that these patients do
not need skull radiographs or a head CT scan, but can be
discharged home to be observed by a competent adult.

In a large prospective study on minor head injury by Dacey
et al., several patients who presented with GCS scores of 15
either had intracranial hematomas or deteriorated while under
observation in the hospital (3). Dacey et al. did not describe
the details of the neurological examinations of these patients,
however. Focal neurological deficits or mental status abnor-
malities may have been present, which would have been an
indication that these patients had suffered more serious inju-
ries than might have been suspected based on their mental
status.

It cannot be overemphasized that a careful, detailed neu-
rological examination must be done in the evaluation of
minor head injury. This examination should include a GCS
score and a mental status examination. The GCS is not the
equivalent of the mental status examination. Indeed, a patient
with a GCS scale of 15 may be mildly lethargic or have a
memory deficit. Findings as subtle as these or a mild paresis
or reflex asymmetry may be the only clues to the presence of
an operative extraaxial hematoma.

We conclude that the neurological examination (including
GCS score and mental status) is the best predictor of serious
complications of minor head injury. A patient with a GCS
score of 15 with normal mental status and no focal hemi-
spheric deficit may be discharged from the emergency room
to be observed at home by a competent observer. Of the 234
patients in this category who were admitted to the hospital
for observation, none deteriorated. In a patient with a GCS
score of 15 and a focal hemispheric deficit or an abnormal
mental status, a CT scan of the head should be obtained
because an operative intracranial hematoma may be present.
If the CT scan does not reveal an operative lesion, the patient
should be admitted to the hospital for observation. If the
patient has a GCS score of 13 or 14, a CT scan should be
obtained. If the scan does not show an operative lesion, the
patient should be admitted to the hospital for observation
because a significant number of these patients are at risk of
deterioration. Skull radiographs are unnecessary in the deci-
sion-making process in minor head injury because manage-
ment decisions can be based on a careful neurological exam-
ination.

In proposing these guidelines to the management of minor
head injury, we emphasize the importance of careful clinical
evaluation of these patients. The physician should not allow
a management algorithm to replace the exercise of clinical
judgment. For example, if a patient with a GCS score of 15,
normal mental status, and nonfocal neurological examination
complains of severe headache or nausea and vomiting. a CT
scan or admission for observation may be warranted. As in
all aspects of medicine. a patient must be evaluated and

March 1988

managed on an individual basis and algorithms should be
used to guide rather than to dictate management.

Received for publication, May 11, 1987: accepted, October 23,
1987

Reprint requests: Tony Feuerman. M.D.. Division of Neurosur-
gery, UCLA Center for the Health Sciences, 10833 LeConte Avenue,
Los Angeles. CA 90024.

REFERENCES

1. Coonley-Hoganson R. Sachs N, Desai BT, Whitman S: Sequelae
associated with head injuries in patients who were not hospital-
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2. Cooper PR. Ho V: Role of emergency skull x-ray films in the
evaluation of the head injured patient: A retrospective study.
Neurosurgery 13:136-140, 1983.

3. Dacey RG, Alves WM, Rimel RW, Winn HR, Jane JJ:
surgical complications after apparently minor head inju
sessment of risk in a series of 610 patients. J Neurosurg 6
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4. Fischer RP, Carlson J, Perry JF: Postconcussive hospital obser-
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679, 1984.

6. Jones JJ, Jeffreys RV: Relative risk of alternative admission
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7. Karpman RR, Weinstein PR, Silverstein ME, Hughes J: Obser-
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8. Mendelow AD, Campbell DA, Jeffrey RR, Miller JD, Hessett C.
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9, Mendelow AD, Teasdale G, Jennett B, Bryden J, Hessett C.
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Neuro-

203-

COMMENTS

Feuerman et al. have provided an interesting retrospective
review of the clinical evaluation of a large number of adult
patients presenting to the emergency room with minor closed
head injuries. These data are important because the patients
have been assessed with respect to their Glasgow coma scales,

MINOR HEAD INJURY 453

which are currently commonly used in most emergency
rooms. In addition, the sensitivity and specificity of the var-
ious diagnostic tests commonly used have been evaluated.
Again, skull radiographs were found not to be of diagnostic
benefit and mental status was found to be the best predictor
of subsequent deterioration. The authors have thus provided
the data supporting their guidelines for performing cranial
CT scans on all patients with abnormal mental status or
hemispheric neurological deficits. In addition, guidelines with
respect to admission and overnight observation have also
been provided. This report is important to all physicians who
care for head-injured patients, especially those affiliated with
emergency rooms.

James H. Wood
Atlanta, Georgia

The authors have provided critical information in the eval-
uation and management of patients with minor head injury.
Previous authors have commented on the association of skull
fractures and intracranial hematomas without specifying the
importance of the neurological examination. Patients have
been categorized by Glasgow coma score (GCS) without fur-
ther subdivision regarding degree of disorientation, lethargy,
etc. Feuerman and colleagues have documented that patients
with a GCS of 15 and with a “normal mental status” are at
extremely low risk of developing complications after head
injury. In contrast, patients with head injury characterized by
GCS scores of 13 and 14, plus those patients oriented to time.
person, and place, following commands, opening eyes spon-
taneously (i.e.,GCS 15), but who are somewhat lethargic and
not thinking clearly, are at risk for significant intracranial
complications. The authors rightly recommend CT scanning
and admission of these patients to minimize their risk of
deterioration from significant intracranial lesions that might
be treated appropriately by operation or active nonsurgical
therapy. This report thus provides a basis for obtaining CT
scans and admitting selected patients with “minor head in-
jury;” it also suggests a rational basis for discharge home for
some patients, avoiding unnecessary CT scanning and skull
roentgenography.

Lawrence H. Pitts
San Francisco, California