REVIEW ARTICLE
Clinical Decision Rules for Adults With Minor Head Injury:
A Systematic Review
Sue E. Harnan, MSc, Alastair Pickering, MD, Abdullah Pandor, MSc, and Steve W. Goodacre, PhD
Background: There are many clinical decision rules for adults with minor
head injury, but it is unclear how they compare in terms of diagnostic
accuracy. This study aimed to systematically identify clinical decision rules
for adults with minor head injury and compare the estimated diagnostic
accuracies for any intracranial injury and injury requiring neurosurgical
intervention.
Methods: Several electronic bibliographic databases covering biomedical,
scientific, and gray literature were searched from inception to March 2010.
At least two independent reviewers determined the eligibility of cohort
studies that described a clinical decision rule to identify adults with minor
head injury (Glasgow Coma Scale score, 13–15) at risk of intracranial injury
or injury requiring neurosurgical intervention.
Results: Twenty-two relevant studies were identified. Differences existed in
patient selection, outcome definition, and reference standards used. Nine
rules stratified patients into high- and moderate-risk categories (to identify
neurosurgical or nonsurgical intracranial lesions). The Canadian Computed
Tomography Head Rule (CCHR) high-risk criteria have sensitivity of 99%
to 100% with specificity of 48% to 77% for injury requiring neurosurgical
intervention. Other rules such as New Orleans criteria, National Emer-
gency X-Radiography Utilization Study II, Neurotraumatology Commit-
tee of the World Federation of Neurosurgical Societies, Scandinavian,
and Scottish Intercollegiate Guidelines Network produce similar sensi-
tivities for injury requiring neurosurgical intervention but with lower and
more variable specificity values.
Discussion: The most widely researched decision rule is the CCHR, which
has consistently shown high sensitivity for identifying injury requiring
neurosurgical intervention with an acceptable specificity to allow considered
use of cranial computed tomography. No other decision rule has been as
widely validated or demonstrated as acceptable results, but its exclusion
criteria make it difficult to apply universally.
Key Words: Craniocerebral trauma, Decision support techniques, System-
atic review, Clinical decision rules, Sensitivity and specificity.
(J Trauma. 2011;71: 245–251)
Submitted for publication June 23, 2010.
Accepted for publication December 23, 2010.
Copyright © 2011 by Lippincott Williams & Wilkins
From the School of Health and Related Research, University of Sheffield,
Sheffield, South Yorkshire, United Kingdom.
Supported by the NIHR Health Technology Assessment Programme (project
number 07/37/08) and will be published in full in the monograph series Health
Technology Assessment. See the HTA programme website for further project
information.
The views and opinions expressed therein are those of the authors and do not
necessarily reflect those of the Department of Health.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text, and links to the digital files are provided in the
HTML text of this article on the journal’s Web site (www.jtrauma.com).
Address for reprints: Sue E. Harnan, MSc, School of Health and Related Research,
The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1
4DA, United Kingdom; email: s.harnan@sheffield.ac.uk.
DOI: 10.1097/TA.0b013e31820d090f
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July 2011
I t is estimated that at least 1.7 million people sustain head
injury every year in the United States.1 Most head injuries
(90%) will be minor (Glasgow Coma Scale [GCS] score,
13–15) and do not require immediate neurosurgical interven-
tion or inpatient care. These patients have a small but important
risk of subsequent deterioration because of intracranial bleeding.
If these cases are recognized and treated early, then a full
recovery is likely; if not, severe disability or death may ensue.
Computed tomography (CT) of the head is the diagnos-
tic standard for identifying intracranial injury. Routine CT of
all minor head injury patients would result in a large number
of normal CT scans being performed with associated risks of
radiation exposure and waste of health care resources. There-
fore, researchers have attempted to derive clinical decision
rules to identify those at risk of intracranial injury based on
clinical characteristics at presentation to select them for
imaging. There are many such clinical decision rules for
adults with minor head injury, all of which vary in the
clinical criteria they use to identify those at risk of intra-
cranial injury. Table 1 (see Table, Supplemental Digital
Content 1, http://links.lww.com/TA/A66) outlines some com-
mon rules.
It is currently unclear how existing rules compare in
terms of diagnostic accuracy. This study aims to systemati-
cally identify clinical decision rules for adults with minor
head injury and compare the decision or prediction rules in
terms of estimated diagnostic accuracy for any intracranial
injury and injury requiring neurosurgical intervention.
METHODS
Search Strategy
Potentially relevant studies were identified through
electronic searches of key databases including MEDLINE,
EMBASE, CINAHL, and CENTRAL up to April 2009,
supplemented with an update from MEDLINE to March
2010. Search terms used free text and thesaurus terms (where
available) with Boolean operators and database-specific syn-
tax. Manual searches of reference lists in key publications
were used to identify addition studies. Experts in the field
were contacted for any additional literature.
Inclusion Criteria
Studies were included if they met the following criteria:
(a) a cohort study with minimum 20 patients at least half of
whom had GCS score of 1 to 15 at presentation, (b) they
evaluated a decision rule that used three or more clinical
criteria (such as history, physical examination, or a simple
245
Harnan et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July 2011
diagnostic test) to determine the risk of any intracranial injury
(defined as any intracranial abnormality detected on CT or
magnetic resonance imaging [MRI] scan because of trauma)
or injury requiring neurosurgical intervention (defined as any
intracranial injury seen on CT or MRI that required neuro-
surgical intervention), (c) some or all patients were assessed
with CT scan or MRI for intracranial injury, or followed up
to determine need for neurosurgical intervention, and (d)
provided data that allowed true positive, true negative, false
positive, and false negative numbers to be extracted or
calculated.
Study Selection
Articles were considered for inclusion in three stages.
First, titles were sifted to exclude obviously irrelevant articles
(A. Pandor and S.E.H.). Second, abstracts of the remaining
studies were split between two teams of reviewers (A. Pandor
and A. Pickering, S.E.H. and S.W.G.) and assessed for
relevance to produce a list of potentially relevant articles.
Finally, all studies on this list were obtained and studied in
detail to generate a final list of included studies (S.E.H. and
A. Pandor, checked by S.W.G. and A. Pickering). When
discrepancies between reviewers occurred, these were re-
solved through discussion.
Assessment of Methodological Quality
The QUality Assessment of Diagnostic Accuracy Stud-
ies checklist was used to assess study quality.2 Two questions
were omitted; the disease progression bias item was ad-
dressed through definition of an adequate reference standard
(CT within 24 hours), and the incorporation bias item was
omitted, as the reference standard (CT/MRI scan or need for
neurosurgical intervention) was always independent of the
index test. As a different reference standard was required for
each outcome, items relating to the reference standard were
included twice, once for each outcome.
Data Abstraction
Data were extracted by one reviewer (S.E.H.) and
checked by a second (A. Pandor). Data were extracted only
from articles written in English. Variables relating to study
design, patient characteristics, study quality, and diagnostic
accuracy were extracted. When discrepancies occurred, these
were resolved through discussion. When differences were
unresolved, a third reviewer’s opinion was sought (S.W.G. or
A. Pickering). When a study presented several different
versions of a rule produced during derivation, all versions
were extracted but only one version of the rule (either that
endorsed by the authors or that with the most appropriate
outcome definition) was considered in further analysis.
Data Synthesis
A meta-analysis of any rule that had been indepen-
dently validated in multiple, relatively homogeneous cohorts
was planned. During data extraction, it became clear that no
rule had been evaluated to this extent. Instead, a narrative
synthesis was performed, comparing diagnostic accuracy es-
timates across cohorts to determine which (if any) of the
decision rules were supported by consistent estimates of
sensitivity and specificity in multiple validation cohorts.
246
RESULTS
A total of 8,003 citations were sifted from which 222
articles were selected for full-text review and 22 articles3–24
met the inclusion criteria (Fig. 1).
Study and Patient Characteristics
Some 223–24 articles, representing 19 studies, were
identified. Multiple publications from the same study were
found in two cases; an American publication23 which drew
on data from an Italian study,6 and three publications from
one study from the Netherlands.19 –21 Eight studies were
from the United States4,7–9,12,13,15; two each from Italy,3,6,23
Canada,22,24 and Iran17,18; and one from each of The Nether-
lands,19 –21 Australia,16 Japan,14 Spain,10 and Denmark.5
Six were multicenter studies.13,17–22,24 Cohorts ranged in size
from 16814 to 13,728.13 Fourteen studies derived a new
rule.3–5,8,10 –15,17,18,20,24 Four studies6,10,19 –23 reported validation
results for more than one rule in the same cohort. Of the 19
studies, three reported both a derivation and a validation co-
hort.8,11,14 All studies reported intracranial injury as an outcome,
eight studies also reported need for neurosurgical intervention as
an outcome.3,6,9,12,16,19 –24 Median prevalence of intracranial in-
jury was 7.2% (interquartile range, 6.3– 8.5%). Median preva-
lence of injury requiring neurosurgical intervention was 0.95%
(interquartile range, 0.31–1.5%). Outcome definitions varied
across studies. The main difference for intracranial injury in-
volved the perception of clinical significance; four co-
horts13,16,22,24 used a precise definition for significant injury,
whereas the others defined this broadly as any acute lesion on
CT, often excluding isolated skull fracture. Definitions of surgi-
cal lesions also varied but most included hematoma evacuation,
elevation of depressed skull fracture, and intracranial pressure
monitoring. Variations in reference standards are discussed below.
Quality Assessment
The methodological quality assessment of each in-
cluded study is summarized in Figure 2. No study scored well
on all the quality assessment criteria. However, studies were
usually reported well and satisfied the majority of the quality
assessment items, with notable exceptions.3– 6,23 The main
source of variation was for patient spectrum, with only one
study17 reporting an unselected, prospective cohort of adults
presenting within 48 hours of head injury. Studies used varied
patient selection criteria. These included age restrictions
(inclusion ages ranged from older than 3 years,4 to adults
aged 17 and older,4 and to all ages5,12,13), recruitment only of
those who had a CT scan4,9,11–13,15,16 and of those presenting
to the ED with clinical characteristics.4,7–9,12,16,19 –22,24 Five
studies defined minor head injury as GCS score of 14 to
156,7,10,14,23 and only included patients presenting within this
range. Four studies included only those with GCS score of
15,8,12,16,18 one study collected data on GCS score of 14 only,9
two studies11,13 included data from all GCS categories and
two did not report GCS status.5,15 Only 10 stud-
ies6,8,9,12,14,17–24 stated that they enrolled people who pre-
sented within 24 hours or 48 hours of injury. These variations
in patient spectrum are likely to affect comparability across
cohorts and application of conclusions with practice. They
may also affect estimates of sensitivity and specificity, as
© 2011 Lippincott Williams & Wilkins
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July 2011 Decision Rules for Adults With Minor Head Injury

Identification
Records identified through database Additional records identified
searching through other sources
(n = 7987) (n =16)

Records screened by title

(n = 8003)
Screening

Excluded by title
(n = 4578)

Record screened by
abstract
(n = 3425)
Excluded by abstract
(n = 3203)

Full-text articles assessed

Eligibility

for eligibility
(n = 222)
Full-text articles excluded,
with reasons
(n =200)

Full text articles included (review or not cohort study

(n =22) n=11; not all or
predominantly minor head
injury n=9; foreign
language n=18; no data on,
or new or usable
Studies included in narrative
diagnostic data for adult
synthesis
Included

decision rules n=129;

patients selected on basis
22 articles representing 19 of prior imaging or
studies outcome n=25; inadequate
reference standard n=1;
cohort <20 n=1; unable to
obtain n=3; wrong
outcome n=3)

Figure 1. PRISMA flow chart (adapted from www.prisma-statement.org).

selection of patients on these criteria may result in a cohort
with more severe injury.
Only three studies scored well for the intracranial
injury reference standard.12,17,19 Problems with the refer-
ence standard for intracranial injury included variation in
methods, a lack of clarity about whether CT was per-
formed within 24 hours (rather than CT not being used at
all),4,7–11,13–16,18 and use of telephone follow-up and/or
review of hospital records where CT was not performed for
all. It is unlikely that follow-up would accurately identify
all intracranial injuries and could affect estimates of sen-
sitivity and specificity.25 Problems with the reference stan-
dard for injuries requiring neurosurgical intervention were
usually because not all patients were followed-up or the
length of follow-up was sooner than 30 days after injury.
Both of these factors are likely to affect estimates of
diagnostic accuracy. For intracranial injury, partial verifi-
cation bias and differential verification bias were generally
avoided but may be a problem in two large cohorts6,23 as
participants received different reference standards depen-
dent on their initial presentation. Less than half the studies
scored well for blinding, and studies were of mixed quality
for clinical review bias, which may limit external validity
of results.

© 2011 Lippincott Williams & Wilkins 247

Harnan et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July 2011
Figure 2. Methodological quality graph: review authors’ judgements about each quality item presented as percentages across
all included studies.
Narrative Synthesis
The 19 included studies reported test accuracy data
for a total of 25 decision rules3–5,7,8,10 –15,17,18,20,24,26 –35
(see Table, Supplemental Digital Content 2,
http://links.lww.com/TA/A67). Nine of the rules21,24,26,27,31–34
were reported as existing in two forms. These were often
intended to identify those at risk of injury requiring neurosurgi-
cal intervention (high risk) and those at risk of intracranial injury
(medium risk). Eleven rules3,8,11,13,14,24,26,27,29 –31,34 were evalu-
ated in more than one data set, and one further rule12 was
evaluated in two cohorts: one of GCS score of 15 (derivation
cohort)12 and one of GCS score of 14.9 Figure 3 shows
the diagnostic accuracy for identifying neurosurgical in-
jury by rules that have been evaluated in multiple cohorts.
Figure 4 (see Figure, Supplemental Digital Content 3,
http://links.lww.com/TA/A68) shows the corresponding
parameters for identifying intracranial injury. Further data
relating to rules that were evaluated in only one data set
are reported elsewhere.36
The Canadian CT Head Rule (CCHR) and the New
Orleans Criteria (NOC) have been most extensively tested. The
CCHR was developed for use in patients with GCS score of 13
to 15, with some specific exclusions, whereas the NOC were
developed for use in patients with GCS score of 15 only. Five
studies evaluated both rules,10,16,19,22,23 allowing direct compar-
ison. The CCHR24 high-risk criteria has sensitivity ranging from
99% to 100% and specificity from 48% to 77% for injuries
requiring neurosurgical intervention,16,22–24 and the CCHR high-
248
and medium-risk criteria had corresponding values of 99% to
100% and 37% to 48%,16,19,23 whereas NOC had similar sensi-
tivity of 99% to 100% but generally poorer specificity, ranging
from 3% to 31%.16,19,22,23 For the identification of those with
intracranial injury, the estimates of sensitivity range from 80% to
100%10,16,19,22–24 for CCHR high- and medium-risk criteria,
whereas for NOC, they range from 95% to 100%,8,10,16,19,22,23
which suggests NOC may have superior sensitivity. However,
this would seem to be at the expense of specificity, as CCHR
achieves specificities in the range 39% to 50%, whereas NOC
specificity ranges from 3% to 33%. In most cohorts, application
of NOC would have resulted in nearly all patients having a CT
scan, whereas for CCHR, specificity is adequate to allow a
meaningful proportion of patients to avoid a CT scan. CCHR
sensitivity for any intracranial injury is probably more modest
but the missed cases are unlikely to be clinically significant.
The National Institute for Health and Clinical Excel-
lence guidelines29,30 were developed from the CCHR high-
and medium-risk criteria. However, sensitivity and specificity
for injuries requiring neurosurgical intervention seemed
poorer generally, ranging from 88% to 98%6,21,23 and 29% to
67%, respectively. For intracranial injury, sensitivity seemed
poorer, and ranged from 67% to 99%,6,21,23 whereas speci-
ficity may be superior with a range from 31% to 70%. It
should be noted that two of these studies6,23 report data from
the same cohort but with different outcome definitions.
The National Emergency X-Radiography Utilization
Study II13 rule seems to have high sensitivity for both injuries
© 2011 Lippincott Williams & Wilkins
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July 2011 Decision Rules for Adults With Minor Head Injury

Figure 3. Sensitivity and specificity of decision rules for identifying injuries that require neurosurgical intervention: rules with
multiple cohorts of data.

requiring neurosurgical intervention and any injury but variable
specificity and limited validation. The Neurotraumatology Com-
mittee of the World Federation of Neurosurgical Societies31
guidelines and Scottish Intercollegiate Guidelines Network
guidelines both have sensitivities in a similar range to the CCHR
when lenient criteria are used, but results for specificity are
variable and generally much lower. The Scandinavian lenient
criteria27 have diagnostic parameters in the same range but with
more variation in sensitivity for injuries requiring neurosurgical
intervention (94 –99%)20,32 and specificity for injuries requir-
ing neurosurgical intervention (20 –50%) or any injury (21–
60%). Other rules have not been validated in sufficient
cohorts and settings to draw meaningful conclusions.
DISCUSSION
There are many clinical decision rules for minor head
injury but few have been adequately validated. The CCHR

© 2011 Lippincott Williams & Wilkins 249

Harnan et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July 2011
has been shown to be consistent across a number of studies
and to have diagnostic parameters that would allow CT
scanning to be avoided in a worthwhile proportion of patients
without an excessive risk of significant intracranial injury
being missed. The NOC seems to have higher sensitivity for
intracranial injury but at the expense of specificity. Other
rules may have comparable diagnostic performance with the
CCHR, when applied appropriately but have not been as
widely validated.
The CCHR has high sensitivity for detecting injuries
requiring neurosurgical intervention, whether high-risk or
high-and medium-risk criteria are used. This is a consistent
finding in the available data, and so clinicians can be reason-
ably assured that selecting patients for CT scanning on the
basis of the CCHR will carry a low risk of missing injuries
that require neurosurgical intervention. The sensitivity of the
CCHR medium-risk criteria for detecting any intracranial
lesion is less consistent, although the lower reported sensi-
tivity in some studies may reflect failure to detect injuries that
are of little clinical significance. Clinicians using the CCHR
should be aware that it may miss some nonneurosurgical
lesions of questionable clinical significance.
Some limitations of the available data should be con-
sidered when using the CCHR in practice. Patients with
coagulopathy, age ⬍16 years, pregnancy, seizure postinjury,
focal neurologic deficit, or injuries considered minimal were
excluded from developmental work, and so the rule may not
be applicable to these patients. However, diagnostic accuracy
was maintained in subsequent studies that included these
patients (see CCHR high and medium risk adapted to cohort,
Figs. 3 and 4).19 Whenever rules have been directly compared
in the same patient cohort, only marginal differences in
sensitivity have been identified, translating to little clinical
difference in injury detection. The primary advantage of the
CCHR over other decision rules is in its improved specificity,
leading to a reduction in the number of scans required to
identify the same number of injuries.
To the best of our knowledge, this study constitutes the
most extensive search of diagnostic test accuracy data relat-
ing to minor head injury decision rules performed to date.
However, as with all systematic reviews, our search strategy
may have missed some eligible cohorts and others may have
been excluded on the basis of non-English language. There is
a high degree of heterogeneity in minor head injury defini-
tion, patient spectrum, outcome definition (for both intracra-
nial injuries and injuries requiring neurosurgical intervention)
and reference standards used. These variations lead to signif-
icant differences in prevalence, selection bias, and quality
assessment and, as such, limited direct comparability of rules
with each other, and precluded meta-analysis. However, the
main purpose of data synthesis is to increase the precision of
estimates. The primary data included some large studies with
reasonably precise estimates of sensitivity and especially
specificity. The main limitation of the available primary data
are thus likely to be inaccuracy rather than imprecision.
Policy makers and clinicians must decide on their
underlying priorities. We feel that decision making in minor
head injury involves a trade-off between unnecessary CT
250
scanning and missed intracranial injury, as reflected in the
sensitivity and specificity estimates reported. The substantial
benefit of neurosurgical interventions for certain lesions
means that specificity should be sacrificed to optimize sensi-
tivity for injuries requiring neurosurgical intervention. How-
ever, the benefit of identifying and treating injuries that do
not require surgical intervention is less certain, and the
balance between unnecessary investigation and missed pa-
thology is less clear. This uncertainty is reflected in variations
in the definition of what constitutes a clinically significant
intracranial lesion; most studies considered any acute lesion
as a positive outcome. Consistently listed injuries include
extradural, subdural, subarachnoid, intracerebral, and intra-
parenchymal hemorrhage as well as cerebral contusion. Only
two authors13,24 predefined their clinically significant findings
on CT (which have been adopted for other cohorts). Stiell et
al.,24 more specifically, defines what was considered not
significant, after extensive consultation with expert contrib-
utors, but disagreement still exists between these definitions.
Further research is required to validate existing rules
and compare the performance of different rules in the same
population. Decision analysis and economic modeling is
required to explore the trade-off between sensitivity and
specificity in terms of the costs and benefits of missed
pathology and unnecessary investigation. Research into the
prognosis of nonneurosurgical intracranial injuries and the
effect of identification and treatment on prognosis is required
to allow better definition of what constitutes a clinically
significant injury and what benefits can be derived from
accurate identification. In addition, researchers should con-
sider how best to minimize bias and sources of inaccuracy in
their study design. In the face of practical and ethical diffi-
culties, researchers have to choose between a selected cohort
where all patients have CT (with the attendant risk of spec-
trum bias) and a relatively unselected cohort that uses
follow-up without CT in the reference standard (with the
attendant risk of verification bias). Where follow-up is used,
careful consideration of adequacy should be made.
The heterogeneity of these rules has highlighted the dif-
ficulties that exist with any research into minor head injury.
Definitions of injury and outcomes vary while patient selection
and reference standards are not uniform. To take minor head
injury research forward, agreed definitions and standard out-
come assessments must be adopted, along the lines of the
approach by Utstein37 in cardiopulmonary resuscitation re-
search. The call for unification of mild brain injury definitions
for the future development of patient management is not new.38
The current evidence base suggests that the CCHR has the
most consistent and acceptable sensitivity and specificity when
compared with other decision rules for adults with minor head
injury.
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