Imaging for Concussion, When to Image the Brain – Closing the Clinical Knowledge Gap

Paul Griner, MD, MACPEmergency Medicine, Family Medicine, Internal Medicine, Nurse Practitioner, Nursing RN/PN, Pediatric Emergency Medicine, Pediatric Medicine, Personal Education, Physician Assistant, Urgent Care

imaging for concussion - using the glasgow coma score to know when to image the brain

Imaging for Concussion - Clinical Knowledge Gaps

When to Image the Brain in Cases of Head Injury or Suspected Concussion

Clinical guidelines should never be followed so rigidly that unique, medically important information of an individual patient is ignored in order to retrofit the patient to the guidelines.

However, it is helpful to be aware of the more common and less substantiated gaps between evidence-supported recommendations and usual clinical practice.

For example, it is common practice to obtain a Computerized Tomography (CT) of the head after someone has suffered a head injury.

This occurs despite guidelines clearly stating that most patients who have suffered an acute concussion do not require any brain imaging.

The correct next step after evaluating the patient with a concussion is observation.

Loss of consciousness (LOC) is not, per se, an indication for acute imaging; one or more of the following findings needs to co-exist with the LOC:

  1. Glasgow score <15
  2. Short term memory loss
  3. Drug or alcohol intoxication
  4. Age > 60
  5. Focal neurologic deficits
  6. Seizure
  7. Coagulopathy

The Glasgow Coma score should be routinely performed on patients after every head injury and is consistent with good medical practice.

It is determined by grading the best responses to motor, eye, and verbal functions as follows:

imaging for concussion - when to image the brain - glasgow coma score

A Glasgow coma score of < 15 is a clear indication for brain imaging.

When a scan is indicated, CT is preferred over MRI since it is quick, accurate, easy to perform, and it can identify lesions that might be considered in the differential diagnosis, such as epidural or subdural hematoma, subarachnoid hemorrhage, and skull fracture.

A repeat Glasgow Coma scale is indicated only in persons whose eye, motor, or verbal functions appear to decline.

CT scan is thus appropriate to look for and hopefully exclude the injuries that may accompany a concussion such as a skull fracture, subdural epidural, or subarachnoid hemorrhage.

However, there will be clinical signs of these conditions; guidelines recommend against obtaining a scan in patients with a concussion without the signs discussed above.

Since the above mentioned, grave complications are uncommon after a sports related head injury, the vast majority of head CTs routinely obtained after a concussion are normal.

Following concussion guidelines will avoid the majority of these ultimately unnecessary scans in the vast majority of patients with concussions who do not have any of the imaging indications discussed above.

Patients should understand that imaging not being necessary is NOT synonymous to them not having a concussion.

They might have a concussion that will take much time to heal; they just don’t have a concussion that with the few grave complications that require imaging prior to possible admission and surgical intervention.

Appropriate sleep is absolutely essential to the maintenance of normal neurochemistry.

Papa L, Goldberg SA. Head Trauma. Rosen’s Emergency Medicine: Concepts and Clinical Practice ,2018; 34: 301-329.e5
Bazarian JJ, Ling GSF. Traumatic Brain Injury and Spinal Cord Injury. Goldman-Cecil Medicine, 2020; 371: 2324-2329.e1

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