Recommendations
Urgent
Take an Airway, Breathing, Circulation (ABC) approach to assessing and stabilising a patient with a traumatic brain injury.[42]
If you suspect a cervical spine injury ensure full cervical spine immobilisation (before the patient is transferred to hospital, if presenting in the community).[42] See Acute cervical spine trauma in adults.
Use the Glasgow Coma Scale (GCS) to assess the patient's neurological status at initial presentation.[42] [ Glasgow Coma Scale Opens in new window ]
The National Institute for Health and Care Excellence (NICE) recommends using the paediatric GCS in children under 1 year old. In practice, the paediatric GCS is typically used until age 18-24 months since the standard GCS requires assessment of a verbal response as 'orientated' which is typically not possible in younger children and infants. BPNA: Child’s Glasgow Coma Scale Opens in new window
In the paediatric version of the GCS, include a 'grimace' alternative to the verbal score to enable scoring in children who are preverbal.[42]
Also use the GCS/paediatric GCS for subsequent monitoring to help guide management decisions.[42]
For assessment of a patient with moderate (Glasgow Coma Scale [GCS] score 9-12) or severe (GCS score ≤8) traumatic brain injury see Assessment of traumatic brain injury, acute. [ Glasgow Coma Scale Opens in new window ]
Assess the patient within 15 minutes of arrival at hospital for the presence of any risk factors for brain injury (i.e., intracranial complication).[42]
Ensure safeguarding is part of the initial assessment of all patients.[42]
Request an urgent (within 1 hour of identifying a risk factor) computed tomographic (CT) head scan if the patient is considered high-risk for brain injury and/or cervical spine injury or has deteriorating neurological status.[42] Use the criteria listed in the two flowcharts below to carefully identify who to send for a CT scan and the appropriate time frame required to exclude serious complications.[42]
In the community refer any adult or child with a head injury to the accident and emergency department if you identify any of the following risk factors (which may indicate an intracranial complication or cervical spine injury):[42]
GCS score <15 on initial assessment
Any loss of consciousness as a result of the injury
Any focal neurological deficit since the injury
Any suspicion of a skull fracture or penetrating head injury since the injury
Amnesia for events before or after the injury
Persistent headache since the injury
Any vomiting episodes since the injury (use clinical judgement regarding the cause of vomiting in children ≤12 years and the need for referral)
Any seizure since the injury
Any previous brain surgery
A high-energy head injury
Any history of bleeding or clotting disorders
Current anticoagulant therapy or antiplatelet therapy (excluding aspirin monotherapy)
Current drug or alcohol intoxication
Any safeguarding concerns (e.g., possible non-accidental injury or vulnerable person affected)
Continuing concern about the diagnosis.
In the absence of any of the risk factors above, consider referral to an emergency department if any of the following factors are present, depending on judgement of severity:[42]
Irritability or altered behaviour, particularly in babies and children aged under 5
Visible trauma to the head not covered in the recommendations above but still of concern to the professional
No one is able to observe the injured person at home
Continuing concern by the injured person, or their family or carer, about the diagnosis.
Consider a CT scan within 8 hours of the head injury in adults and children on anticoagulant treatment or antiplatelet treatment (excluding aspirin monotherapy) who have no other indications for a CT head scan.[42] Request a CT scan within the hour if they present more than 8 hours after the injury.[42]
Key Recommendations
Focus the history on how and when the injury happened, the mechanism of injury, and the presence of symptoms since the injury.
A dangerous mechanism of injury (e.g., in adults: a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of more than 1 m or 5 stairs) is a risk factor for an intracranial complication.[42]
Symptoms may include headache, disturbed gait/balance or dizziness, depersonalisation, feeling foggy/slow, memory difficulties or amnesia, vomiting, headache, and neck pain.
Other important history findings include recent alcohol or drug intake and current anticoagulant medication (e.g., warfarin).
Perform a brief neurological examination and check the skull for possible fractures.
Use the Glasgow Coma Scale score (serial). [ Glasgow Coma Scale Opens in new window ]
Most people (95%) with a head injury present with a normal or minimally impaired conscious level (GCS score 13-15).[42]
The National Institute for Health and Care Excellence (NICE) recommends using the paediatric GCS in children under 1 year old.[42] In practice, the paediatric GCS is typically used until age 18-24 months since the standard GCS requires assessment of a verbal response as 'orientated' which is typically not possible in younger children and infants. BPNA: Child’s Glasgow Coma Scale Opens in new window
In the paediatric version of the GCS, include a 'grimace' alternative to the verbal score to enable scoring in children who are preverbal.[42]
Check pupils for size and reactivity and limbs for tone, power, reflexes, co-ordination, sensation, and gait. Perform a bedside cognitive assessment.
Also use the GCS/paediatric GCS for subsequent monitoring to help guide management decisions.
Check pupils for size and reactivity and limbs for tone, power, reflexes, co-ordination, sensation, and gait. Perform a bedside cognitive assessment.
Request a CT head scan within 8 hours of the head injury in:[42]
Adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
Age ≥65 years
Current bleeding or clotting disorders (liver failure, haemophilia)
Dangerous mechanism of injury
More than 30 minutes of retrograde amnesia of events immediately before the head injury
Consider a CT scan within 8 hours of the head injury in adults and children on anticoagulant treatment or antiplatelet treatment (excluding aspirin monotherapy), who have no other indications for a CT head scan.[42] Consider a CT scan within the hour if they present more than 8 hours after the injury.[42]
Take an Airway, Breathing, Circulation (ABC) approach to assessing and stabilising a patient with a traumatic brain injury (TBI).[42]
If you suspect a cervical spine injury, ensure full cervical spine immobilisation (before transfer of the patient to hospital, if presenting in the community).[42] See Acute cervical spine trauma in adults.
Be vigilant for symptoms and signs of an intracranial haemorrhage, which may include:
Deteriorating consciousness
Confusion
Severe or increasing headache
Repeated vomiting
Seizures
Double or blurred vision.
Assess all patients presenting with a head injury within 15 minutes of arrival at hospital for the presence of any risk factors for brain injury.[42] Aim to rapidly identify patients at risk for serious acute intracranial complications and establish the need for computed tomographic (CT) head scanning. See Imaging, below, for the criteria for performing a CT head scan.
Adults with a Glasgow Coma Scale (GCS) score 9 to 12 (moderate TBI) or a GCS score ≤8 (severe TBI) on the initial assessment should undergo an urgent (i.e., within 1 hour) CT head scan.[42] Moderate and severe TBI are not covered in this topic. See Assessment of traumatic brain injury, acute for more information.
Involve a clinician with training in safeguarding in the initial assessment of all patients.[42]
Clinical criteria for identifying a mild traumatic brain injury (TBI) in a patient with a history of blunt trauma to the head or acceleration/deceleration forces are:
A Glasgow Coma Scale (GCS) score of 13 to 15 thirty minutes or later post injury, and ≥1 of the following:[18]
Confusion or disorientation
Loss of consciousness for ≤30 minutes
Post-traumatic amnesia for <24 hours
Other transient neurological abnormalities (e.g., seizure, focal signs, intracranial lesion not requiring surgery).
Symptoms may include:
Headache
Although headache is often felt immediately, it can worsen the day after the injury is sustained.
30% of patients with mild TBI continue to report headache at 3 months post-trauma.[45]
Medication overuse, neck injuries, sleep disturbance and psychological comorbidity may all contribute to headache after mild TB.[46][47]
Disturbed gait/balance or dizziness
When occurring after a head injury, dizziness and balance problems are typically related to benign paroxysmal positional vertigo (BPPV).[46] BPPV is a common, and easily treatable, cause of dizziness.[46] These symptoms may be alarming to patients if they do not settle quickly. Explaining that they are due to debris dislodged into the inner ear by the injury can help to alleviate patients’ concerns about ‘brain damage’.[46]
Vestibular migraine is another cause of dizziness in patients with mild TBI.
Central vestibular disorders can occur but are more typical after moderate or severe brain injury.[46] See Benign paroxysmal positional vertigo.
Depersonalisation is another common cause of dizziness, and is also highly alarming to patients.[46] Patients describe feeling ‘zoned out’, ‘not quite there’, or that their arms or legs are ‘not their own’.
Fatigue
Tiredness is a common symptom.[5]
Feeling ‘foggy/slow’
Memory difficulties or amnesia
These can be centered on the injury incident itself or generalised to include difficulty in day-to-day situations, and typically co-occur with other cognitive and/or physical symptoms, such as headaches. Memory lapses are common in the general population and are not specific to mild TBI.[46]
Vomiting/nausea
Less typical in adults, occurring much more frequently in adolescents and children. When vomiting is the only symptom of head injury in children, TBI on CT is uncommon and clinically important traumatic brain injury is very uncommon.[48] TBI is more frequent in children when vomiting is accompanied by other signs or symptoms suggestive of TBI.[48] However, request an urgent (i.e., within 1 hour) CT scan for any children with ≥3 discrete episodes of vomiting together with any one or more of the following risk factors:[42]
Witnessed loss of consciousness lasting more than 5 minutes
Abnormal drowsiness
A dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist, or vehicle occupant, fall from a height of more than 3 m, high-speed injury from a projectile or other object)
Amnesia (antegrade or retrograde) lasting more than 5 minutes
Any current bleeding or clotting disorder (liver failure, haemophilia, taking anticoagulants or antiplatelets).
Neck pain
More commonly associated with motor vehicle collisions than with other mechanisms of injury.[49] If present, assess the patient for a cervical spine injury. See Acute cervical spine trauma in adults.
Practical tip
Some of the symptoms and signs of mild TBI may seem to indicate ‘brain damage’ but rather arise through vestibular (e.g., benign paroxysmal positional vertigo), psychological (e.g., depersonalisation), or other neurological mechanisms (e.g., post-traumatic migraine).[46]
Take a focused history. Ask about:
The mechanism of injury
A dangerous mechanism of injury in adults is defined as:[42]
A pedestrian or cyclist struck by a motor vehicle
An occupant ejected from a motor vehicle
A fall from a height of >1 metre or 5 stairs
A dangerous mechanism of injury in children is defined as:[42]
A high-speed road traffic accident either as a pedestrian, cyclist, or vehicle occupant
A fall from a height >3 metres
A high-speed injury from a projectile or other object
How and when the head injury occurred
Establish whether the impact was directly to the head or transmitted to the head by the acceleration or deceleration of the body on impact
Corroborate with a witness if possible
Symptoms/signs since the injury
Ask whether the patient has any headache, dizziness, loss of consciousness, amnesia, vomiting, neck pain
Key risk factors for traumatic brain injury, which include:
Recent head injury
Previous brain trauma
Recent alcohol or drug misuse
Many mild traumatic brain injuries occur in the context of alcohol consumption, which can make the assessment difficult, particularly if the patient is aggressive. Consider screening patients for alcohol misuse using a breathalyser or a blood alcohol test.[46] Consider imaging if any doubt
Do not assume a person’s abnormal behaviour or ataxia is due to alcohol or drugs until you have ruled out a significant brain injury.[42]
Current anticoagulant medication or antiplatelet therapy
Patients who have no other risk factors for brain injury but are taking anticoagulants have an increased risk of bleeding after a head injury.[50]
Consider a CT head scan within 8 hours of the head injury for patients on anticoagulants or antiplatelet treatment (excluding aspirin monotherapy) with no other indications for a CT head scan, for example, if it is difficult to do a risk assessment or if the person might not return to the emergency department if they have signs of deterioration).[42] Consider a CT scan within the hour if they present more than 8 hours after the injury.[42]
Neurological disorders, including dementia, which increase falls risk.[46]
Perform a brief neurological examination. Patients with mild traumatic brain injury (TBI) generally have a normal physical examination and no neurological signs other than those typical of mild TBI.[42] [ Glasgow Coma Scale Opens in new window ]
Use the paediatric version in children under one year old.[42] BPNA: Child’s Glasgow Coma Scale Opens in new window In practice, the paediatric GCS is used until age 18-24 months since the standard GCS requires assessment of a verbal response as 'orientated' which is typically not possible in younger children and infants. Also use the GCS/paediatric GCS for subsequent monitoring to help guide management decisions.
Most people with a head injury present with a normal or minimally impaired conscious level (GCS score 13-15) (i.e, mild traumatic brain injury).[18]
Severity of traumatic brain injury[18] | GCS score |
|---|---|
Mild | 13 to 15 |
Moderate | 9 to 12 |
Severe | 8 or less |
Check cranial nerves including pupil size and reactivity, and limbs for tone, power, reflexes, co-ordination, sensation, and gait.
Focal neurological deficit, if present, may be a sign of a more severe brain injury. Request an urgent (i.e., within 1 hour) computed tomographic scan in these patients.[42]
Practical tip
Focal neurological deficit may be defined as problems restricted to a particular part of the body or a particular activity, for example:
Difficulties with understanding, speaking, reading, or writing
Decreased sensation
Loss of balance
Weakness of ≥1 limbs
Visual changes
Abnormal reflexes
Problems walking.
Perform a bedside cognitive assessment to judge orientation, short term memory, attention and concentration.
Attention deficits, planning and problem-solving deficits, and difficulties with visual and verbal memory are common. However, cognitive symptoms usually resolve quickly after mild TBI; a minority of patients have memory and concentration problems within 3 months of injury.[46] Routine referral for cognitive (psychometric) assessment is not recommended after mild TBI.[46][51]
Check for a suspected basal skull fracture, which may present with:[42]
Clear fluid (possible cerebrospinal fluid) leaking from the ear(s) or nose
Periorbital haematoma(s) with no associated damage around the eyes (‘panda’ [‘raccoon’] eyes)
Bleeding from 1 or both ears, blood behind the ear drum (haemotympanum), new deafness in 1 or both ears
Battle's sign – bruising behind 1 or both ears over the mastoid process, suggesting fracture of the middle cranial fossa.
Practical tip
Be aware that in some patients (e.g.,those with dementia, underlying chronic neurological disorders, or learning disabilities) the pre-injury baseline GCS score may be below 15. Establish this where possible, and take it into account during assessment.[42]
Practical tip
The assessment of children with a head injury is more complex than the assessment of adults due to anatomical, physiological, cognitive, and psychological differences. Young children are more likely to experience a higher number of isolated head injuries than older children. However, the basic principles of trauma care (airway, breathing, and circulation) remain the same, regardless of the age of the patient. When assessing a child, consider:
Using 'head, shoulders, knees, and toes' to help assess their motor function
Checking the fontanelles in younger children for any bulging spots.
Refer any adult or child with a head injury to the accident and emergency department if you identify any of the following risk factors (which may indicate an intracranial complication or cervical spine injury):[42]
A Glasgow Coma Scale (GCS) score <15 on initial assessment
Any loss of consciousness as a result of the injury
Any focal neurological deficit since the injury
Any suspicion of a complex skull fracture or penetrating head injury since the injury
Amnesia for events before or after the injury
Persistent headache since the injury
Any vomiting episodes since the injury (use clinical judgement regarding the cause of vomiting in those aged 12 years or younger and the need for referral)
Any seizure since the injury
Any previous brain surgery
A high-energy head injury
Current bleeding or clotting disorders (liver failure, haemophilia)
Current anticoagulant or antiplatelet therapy
Current drug or alcohol intoxication
Any safeguarding concerns (e.g., possible non-accidental injury or a vulnerable person is affected)
Continuing concern about the diagnosis.
In the absence of any risk factors above, consider referral to the emergency department if any of these factors are present, depending on judgement of severity:[42]
Irritability or altered behaviour, particularly in babies and children aged under 5
Visible trauma to the head not covered in the recommendations above but still of concern to the professional
No one is able to observe the injured person at home
Continuing concern by the injured person, or their family or carer, about the diagnosis.
If you suspect a cervical spine injury, ensure full cervical spine immobilisation before transfer of the patient to hospital.[42] See Acute cervical spine trauma in adults.
CT head in adults
Request a computed tomographic (CT) head scan to exclude an intracranial complication (e.g., bleed) in patients deemed at risk following the initial assessment (see flowchart below).[42]
Most patients with a mild traumatic brain injury have a normal CT scan.
Selection of adults for CT head scan[Figure caption and citation for the preceding image starts]: Selection of adults for CT head scan; GCS = Glasgow Coma Scale; CT = computed tomography; A&E = accident and emergency departmentAdapted from Rajesh S et al. BMJ 2023;381:p1130 [Citation ends].
CT head in children
Selection of children for CT head scan[Figure caption and citation for the preceding image starts]: Selection of children for CT head scan; GCS = Glasgow Coma Scale; CT = computed tomography; A&E = accident and emergency departmentAdapted from Rajesh S et al. BMJ 2023;381:p1130 [Citation ends].
Evidence: CT head scan as choice of imaging
CT imaging of the head is the primary investigation recommended for the detection of acute clinically important brain injuries.
In 2003 the UK National Institute for Health and Care Excellence (NICE) produced one of the first guidelines internationally to move away from skull x-ray as the first-line investigation for mild traumatic brain injury and recommend CT imaging as the primary investigation.[52] This was based on:
General consensus that early CT in selected patients improves outcomes[53]
A meta-analysis that showed the sensitivity of skull x-ray in the diagnosis of intracranial haematoma is only 38%[54]
A prospective study (2152 people over 16 years with suspected blunt head trauma) that found patients with a negative CT scan and no other body system injuries or persistent neurological findings can be safely discharged (negative predictive power 99.7%).[55]
In its 2007 guideline update NICE did not find any new studies comparing CT with other imaging.
It did, however, emphasise that skull x-ray was not a suitable substitute for CT and therefore made a 'do not use' recommendation against skull x-ray for the diagnosis of significant brain injury (except as part of a skeletal survey for suspected non-accidental trauma in children).[52]
This was backed by the Royal College of Radiologists in the UK.[56]
In 2017, as part of evidence surveillance, NICE concluded there was no new evidence that would change the current guideline recommendations. This conclusion remained unchanged in the 2023 update.[42]
Due to safety, availability, and speed issues NICE does not recommend magnetic resonance imaging (MRI) scanning as the first-line investigation for mild traumatic brain injury.[52]
However, it recognises that additional information of importance to medical management and prognosis can sometimes be detected using MRI.[57]
Therefore, if these issues are resolved in the future the role of MRI could change.
Evidence: Decision rules for performing a CT scan in adults
There are multiple clinical decision rules to identify which adults should have a CT scan to determine whether they have clinically significant brain injury. The results of validation studies vary and there is no clear decision rule that should be used internationally. In the UK, follow the recommendations from the National Institute for Health and Care Excellence (NICE).
The NICE clinical decision rule for CT scanning adults with mild head injury combines patient selection for imaging with urgency and is based on the high- and medium-risk criteria of the Canadian CT Head Rule (CCHR).[42]
An update (2023) to the 2014 NICE guideline found no new evidence of sufficiently high quality to change the previous recommendation on clinical decision for CT scanning.[42]
NICE identified 33 diagnostic accuracy studies in adults, but no diagnostic randomised controlled trials. Most of the trials were in adults with mild traumatic brain injury, and the evidence for the majority of outcomes were assessed by GRADE as low to very low quality.
The updated evidence confirmed previous findings that the CCHR has good sensitivity ( ≥90%) when used as intended but in general has poor specificity (<60%).
The National Emergency X-Radiography Utilisation Study II (NEXUS II) decision rule performed similarly to CCHR, however the evidence was more limited. Other decision rules had a similar sensitivity but lower specificity.
The CCHR was also the most cost effective of the decision rules assessed, further supporting its use as the basis for the NICE recommendations. There was no cost effectiveness evidence directly assessing the NICE 2014 rule.
A separate recommendation for people on anticoagulant or antithrombotic therapy, introduced in 2014, also remained unchanged.
In the 2023 NICE guideline update, only one study was identified comparing the performance of different decision rules in the same population of adults. This was a prospective diagnostic accuracy study from 2018, and it compared four decision rules (including the NICE 2014 decision tool).[42]
This study included 4557 adults with mild traumatic brain injury (six centres in the Netherlands). It found the NICE decision tool had a higher specificity but lower sensitivity compared with the CT in head injury patients (CHIP) rule, New Orleans Criteria (NOC) or CCHR.
Sensitivity for any intracranial injury on CT ranged from NICE 73% to NOC 99%; specificity ranged from 4% with NOC to 61% with NICE.
Sensitivity for potential neurosurgical lesions ranged between NICE 85% and 100% NOC; specificity ranged from 4% with NOC to 59% with NICE.
Of note, the sensitivity of the CCHR in this study was considerably lower than in other studies (<90%).
As the NICE 2014 decision tool was largely based on the CCHR, the NICE guideline committee postulated that there may be some differences in this study population, affecting the sensitivity of both rules; and that the lower sensitivities of the NICE tool in this study did not match their clinical experience.
Evidence: Decision rules for performing a CT scan in children
Use the UK National Institute for Health and Care Excellence (NICE) criteria to identify which children and infants should have a CT scan to determine whether they have clinically significant brain injury. However, there is a paucity of externally validated studies and therefore NICE acknowledges that its recommendations should be used alongside clinical judgement.
The NICE clinical decision rule for CT scanning children and infants with mild traumatic brain injury is based on the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE).[42]
An update (2023) to the 2014 NICE guideline found no new evidence of sufficiently high quality to change the previous recommendation on clinical decision for CT scanning in children and infants.
NICE identified 42 diagnostic accuracy studies in children and infants, but no diagnostic randomised controlled trials. Most of the trials were in children and infants with mild traumatic brain injury, and the evidence for the majority of outcomes were assessed by GRADE as low to very low quality.
The updated evidence (n >40,000) for the CHALICE rule showed that it had >90% sensitivity and >80% specificity for clinically important injuries or neurosurgical outcomes.
There was some evidence that the Pediatric Emergency Care Applied Research Network (PECARN) and the Canadian Assessment of Tomography for Childhood Head Injury 7-item (CATCH‑7) rules may have slightly better sensitivity compared with CHALICE, especially for any severity of head injury, However, the specificity of CHALICE was better than for other rules the guideline panel did not feel any changes were required to the NICE 2014 criteria.
The committee also felt that the inclusion of timings in the NICE 2014 criteria, and their applicability to a more general population, made the NICE 2014 criteria more useful clinically than PECARN or CATCH-7.
Three studies assessed the National Emergency X-Radiography Utilisation Study II (NEXUS II) in children.[58][59][60] Sensitivity was >98% for any severity of injury, clinically important injuries and neurosurgery outcomes. However, specificity was <50% for all outcomes, and only the outcome of clinically important injuries was assessed in a sufficiently large population.[42]
One small study was identified which assessed the Pittsburgh Infant Brain Inventory Score (n=891; infants aged 30 days to 1 year).[61] Using a cut-off score of ≥2, sensitivity was 93% for any severity of injury, although specificity was only 53%.[42] The rule had not been externally validated at the time of publication of the NICE 2023 guideline.
MRI head
Consider a magnetic resonance imaging (MRI) head scan in patients who after 24 hours of observation have not returned to a Glasgow Coma Scale score of 15 and who had a normal CT scan on initial assessment.[42] A further CT scan may also be considered in these patients.[42]
Consider susceptibility weighted imaging sequences as these are highly sensitive in detecting microbleeds, traumatic axonal injury and superficial contusions in traumatic brain injury.[2][62][63][64]
Standard T1/T2 MRI has been shown to be abnormal in 30% of patients with a normal head CT.[2][22][23][65]
Skull x-ray (children)
Consider a skull x-ray in children presenting with suspected non-accidental injury as part of the skeletal survey.[42]
Consider a computed tomographic (CT) head scan within 8 hours of the head injury in adults and children on anticoagulant treatment who have no other indications for a CT head scan (for example, if it is difficult to do a risk assessment or if the person might not return to the emergency department if they have signs of deterioration).[42] Consider a CT scan within the hour if they present more than 8 hours after the injury.[42]
Patients who have no other risk factors for brain injury but are taking anticoagulants have an increased risk of bleeding after a head injury.[50]
Consider a clotting screen (prothrombin time, partial thromboplastin time, and international normalised ratio [INR]) in these patients.
Evidence: CT head scan in patients on anticoagulant or antiplatelet medication with no other indications for CT
Observational evidence supports the recommendations made by the UK National Institute for Health and Care Excellence (NICE) to consider a CT scan in patients with mild head injury and no other risk factors for clinically significant brain injury but who are on anticoagulants or antiplatelets (other than aspirin monotherapy).
In the 2014 NICE head injury guideline, the guideline committee found no clinical decision rules for patients who have no history of amnesia or loss of consciousness who are on anticoagulant or antiplatelet therapy.[52] As part of the 2023 update, the guideline committee looked for prognostic evidence from cohort studies in people on anticoagulant treatment.[42]
Adults
NICE identified five cohort studies in adults on anticoagulants only, and five in adults on anticoagulants and antiplatelet therapy.[42]
There was conflicting evidence as to whether people on anticoagulant or antiplatelet therapy are at an increased risk of intracranial haemorrhage. The guideline committee decided that the recommendation should be changed from "request a CT scan" to "consider a CT scan" to allow for shared decision making and for selected patients to be discharged without a CT scan.[42]
When considering the risks of not requesting a scan in all patients with mild head injury on anticoagulant or antiplatelet therapy without any other indication, the committee noted that delayed recovery was more likely than death if an intracranial haemorrhage was missed at initial presentation.
Further, for patients aged >74 years the committee felt that risks of neurosurgical intervention may outweigh the benefits, and that this should also be taken into consideration when deciding whether to scan patients with no other risk factors.
The 2014 NICE guideline strategy of scanning all people on anticoagulants was not found to be cost effective in the base case analysis. However, sensitivity analyses found small changes in rates of admission or in assumptions about the effectiveness of immediate versus delayed neurosurgery meant it would be cost effective.[42][66]
In 2014, NICE made a research recommendation regarding people on antiplatelet therapy. At the 2023 update the decision was made, based on limited new evidence and clinical experience, to include patients on antiplatelet therapy in the same recommendation.[42]
The evidence for people on aspirin monotherapy was limited. Based on expert knowledge and clinical experience, the committee felt that the risk of intracranial haemorrhage in this population was low, therefore this population was excluded from the recommendation.
The guideline committee also discussed timing of imaging.
The evidence review in 2014 found that the median time in the study from injury to CT scan was 234 minutes (interquartile range 175 to 335 minutes) for patients diagnosed with an intracranial lesion at the first scan.[52]
Therefore, a timeframe of within 8 hours of injury (giving time to detect a possible slow bleed) was recommended.
At the 2023 update, the committee agreed that the 2014 recommendations could also be applicable to people presenting >8 hours post-injury based on their clinical experience and from extrapolating the data from <8 hours. The committee felt that in this situation the CT scan should be done within the hour.[42]
Children and infants
For children and infants the 2014 guideline group identified one prospective cohort study (43,904 children under 18 years) with non-trivial blunt head trauma.[67]
Only 15 children were taking anticoagulation therapy and only two children in the entire study population were diagnosed with an intracranial haemorrhage, of which one was taking warfarin.
No new evidence for children and infants was identified at the 2023 update.
Due to the very limited evidence in children the decision was made to extend the recommendation based on the evidence in adults to anyone on anticoagulants or antiplatelets.
Due to the lack of evidence on risk of intracranial haemorrhage in people with a pre-injury coagulopathy (including patients on anticoagulant or antiplatelet therapy) and no other risk factors, the guideline committee made a research recommendation in this area.[42]
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