Role of Emergency Skull X-ray Films in the Evaluation of the Head-injured Patient: A Retrospective Study

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Abstract
Hospital admission of the patient with apparently minor head injury with a normal level of consciousness is generally unnecessary. However, a certain number of these patients will deteriorate neurologically because of the development of a post-traumatic intracranial mass lesion. Skull roentgenograms are commonly obtained in these patients in a search for a linear skull fracture on the assumption that a skull fracture predisposes the patient to the development of an intracranial mass. To determine the utility of emergency skull x-ray films. we retrospectively reviewed the records of 207 patients with known traumatic intracranial masses. We specifically sought to determine the number of patients who were neurologically intact at the time of presentation, were admitted solely because of the presence of a skull fracture, and then went on to develop signs or symptoms of an intracranial mass lesion. Of the 207 patients, 119 patients had cerebral contusions. 89 had subdural hematomas, 50 had intracerebral hematomas, and 31 had epidural hematomas (some patients had two or more lesions). Seventy-six of the 207 patients (37%) had skull fractures. One hundred ninety-one of 207 patients (92%) had an abnormal level of consciousness at the time of presentation and would have been admitted regardless of their skull film findings. Of the 16 patients who were fully alert, 10 had normal skull x-ray films: all were admitted for focal neurological deficits, nausea and vomiting, amnesia, etc., but would have been discharged had the skull x-ray films been the only determinant for admission. Six of the 16 patients who were alert had skull fractures. All but 1 of these patients had systemic injuries, focal deficit, or other reasons for admission. Only 1 patient of the entire series was completely intact neurologically, had a skull fracture, was sent out, and returned having experienced neurological deterioration. This patient had an epidural hematoma and made a good recovery after operation. We conclude that skull roentgenograms performed to identify linear skull fractures in the head-injured patient are neither cost-effective nor useful in predicting deterioration from a mass lesion and should not be used for this purpose or as a determinant for hospital admission.

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