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Head Injury (cont.)

Exams and Tests

Despite the availability of modern diagnostic tools such as CT scanning, the physical examination and the history of the exact details of the injury, the person's past medical history, and the symptoms are often the most important information the doctor uses to make treatment decisions. When possible be sure to bring all medications or a list of medications with the injured person to the hospital or doctor's office.

Skull x-rays: The doctor may order x-rays to look for a fracture (break) in the skull bone. The presence of a skull fracture on x-ray does not mean there has been an injury to the brain, and the absence of a fracture does not exclude a brain injury. With or without a fracture, the most critical factor is determining if a brain injury is present. Even if a fracture is found, doctors do not put casts on the heads of people with skull fractures like they would with a broken arm. The fracture itself will seldom need treatment, but an underlying brain injury may. Skull x-rays are not taken as frequently now as in the past.
- If the potential for a serious injury to the brain exists, the doctor may order a CT scan.
- Many doctors will order skull x-rays in children younger than 1 year.
- Skull x-rays are also often used for people with a history of penetrating injuries or possible penetrating injuries to the skull (a bullet may appear to have been a graze wound, but an x-ray may tell for sure).
- It may be easier to see where foreign bodies are located and how many there are with a regular x-ray than with a CT scan.
One reason for doctors to order skull x-rays for a child is in anticipation of a possible leptomeningeal cyst. Also known as growing skull fracture, this is a rare complication of skull fracture seen in children younger than 3 years. It occurs when a skull fracture fails to heal properly. Six or more months after the initial injury, the fracture may begin to widen instead of healing. Usually parents will notice swelling, which gradually increases in size. This is not predictable nor preventable but should be treated by a neurosurgeon if it occurs. Swelling or masses noted in the first few weeks to months after a head injury in children are referred to as a "pseudo-growing fracture." They do not need treatment and will go away on their own but should be brought to your pediatrician's attention so they can be watched.
CT scan is the test used most often to evaluate acute head injuries. A CT is useful for identifying injuries to the brain itself. Not all head injuries require the brain to be imaged. Clinical judgment is important, and decision-making rules have been developed to help health care practitioners use technology wisely and limit the amount of lifetime radiation provided to patients. These decision rules can help predict which patients will have a normal CT scan of the head.

The CT is essentially an X-ray machine that takes multiple X-rays from many angles around the head. A computer uses these X-ray images to make a picture of the brain and other structures inside the skull. The picture is usually displayed as two-dimensional "slices" of various levels of the brain. Three-dimensional images may be made but are usually not necessary for evaluation of head injuries. The details on a CT scan are very good, and even small spots of blood may be identified.

MRI scans are rarely used immediately after head injuries. The MRI may be used later for additional information about a brain injury.
In some cases of bleeding in or around the brain, angiography may be performed to visualize the blood vessels. This test involves injecting dye into the arteries of the head. X-rays are taken that show the blood vessels and may show exactly where bleeding is occurring. In some cases it is possible to stop the bleeding during angiography. This involves injecting special materials into the bleeding blood vessel and causing a clot to form. If this procedure is successful, the bleeding is stopped without the need for surgery. Alternatively, computerized tomography with angiography can be done to look at blood vessel anatomy.
Other x-rays and lab tests may be performed to look for other illnesses or injuries. For example, neck injuries are common in people with severe head trauma. Spine x-rays are usually ordered before the head is moved if there is any neck pain or other symptoms of a neck injury. In a car accident, there may also be chest or abdominal injuries.