Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients With Minor Head Injury

• Published in: JAMA : the journal of the American Medical Association Vol. 294; no. 12; pp. 1511 - 1518
• Main Authors: Stiell, Ian G, Clement, Catherine M, Rowe, Brian H, Schull, Michael J, Brison, Robert, Cass, Daniel, Eisenhauer, Mary A, McKnight, R. Douglas, Bandiera, Glen, Holroyd, Brian, Lee, Jacques S, Dreyer, Jonathan, Worthington, James R, Reardon, Mark, Greenberg, Gary, Lesiuk, Howard, MacPhail, Iain, Wells, George A
• Format: Journal Article
• Language: English
• Published: Chicago, IL American Medical Association 28-09-2005
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Biological and medical sciences; Brain Injuries - diagnostic imaging; Canada; Cohort Studies; Comparative analysis; Craniocerebral Trauma - diagnostic imaging; Decision Support Systems, Clinical; Female; General aspects; Glasgow Coma Scale; Head injuries; Humans; Injuries of the nervous system and the skull. Diseases due to physical agents; Male; Medical imaging; Medical sciences; Middle Aged; Prospective Studies; Sensitivity and Specificity; Tomography; Tomography, X-Ray Computed - standards; Traumas. Diseases due to physical agents; United States; Canada; North America; America; New Orleans Louisiana; United States > US; Human; Nervous system diseases; Head; Radiodiagnosis; Craniocerebral; Medicine; Criterion; Medical imagery; Computerized axial tomography; Minor; Head trauma; Rule; Comparative study
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.294.12.1511

CONTEXT Current use of cranial computed tomography (CT) for minor head injury
is increasing rapidly, highly variable, and inefficient. The Canadian CT Head
Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical
decision rules to guide CT use for patients with minor head injury and with
Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15
for the NOC. However, uncertainty about the clinical performance of these
rules exists. OBJECTIVE To compare the clinical performance of these 2 decision rules for detecting
the need for neurosurgical intervention and clinically important brain injury. DESIGN, SETTING, AND PATIENTS In a prospective cohort study (June 2000-December 2002) that included
9 emergency departments in large Canadian community and university hospitals,
the CCHR was evaluated in a convenience sample of 2707 adults who presented
to the emergency department with blunt head trauma resulting in witnessed
loss of consciousness, disorientation, or definite amnesia and a GCS score
of 13 to 15. The CCHR and NOC were compared in a subgroup of 1822 adults with
minor head injury and GCS score of 15. MAIN OUTCOME MEASURES Neurosurgical intervention and clinically important brain injury evaluated
by CT and a structured follow-up telephone interview. RESULTS Among 1822 patients with GCS score of 15, 8 (0.4%) required neurosurgical
intervention and 97 (5.3%) had clinically important brain injury. The NOC
and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3%
vs 12.1%, P<.001) for predicting need for neurosurgical
intervention. For clinically important brain injury, the CCHR and the NOC
had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%)
but the CCHR was more specific (50.6% vs 12.7%, P<.001),
and would result in lower CT rates (52.1% vs 88.0%, P<.001).
The κ values for physician interpretation of the rules, CCHR vs NOC,
were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging
for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13
to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients
requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients
with clinically important brain injury. CONCLUSION For patients with minor head injury and GCS score of 15, the CCHR and
the NOC have equivalent high sensitivities for need for neurosurgical intervention
and clinically important brain injury, but the CCHR has higher specificity
for important clinical outcomes than does the NOC, and its use may result
in reduced imaging rates.