title: Clinical features of head injury patients presenting with a Glasgow Coma Scale score of 15 and who require neurosurgical intervention.
abstract: OBJECTIVE
  Emergency physicians are concerned about minor head injury patients who present with a Glasgow Coma Scale (GCS) score of 15 yet require neurosurgical intervention. Our objectives are to determine the accuracy of the Canadian CT Head Rule (CCHR) in this important subset, the prevalence of patients requiring urgent intervention, and their clinical course and possible warning signs.
  
  
  METHODS
  We conducted a secondary data analysis of the CCHR study cohorts from 10 hospital emergency departments (EDs). We included head trauma patients with witnessed loss of consciousness, disorientation, or definite amnesia and who presented with an initial GCS score of 15. Records were reviewed and specific variables added to the database. The primary outcome was need for urgent neurosurgical intervention.
  
  
  RESULTS
  Among the 4,551 study patients, only 26 (0.6%; 95% confidence interval [CI] 0 to 1.0%) required neurosurgical intervention, and the CCHR identified all 26 cases with 100% sensitivity. Eleven patients required "urgent" craniotomy within 7 days, and of those, 2 patients deteriorated precipitously. These 11 (0.2%; 95% CI 0.1% to 0.3%) cases had additional signs: GCS score decrease within 6 hours (82%), GCS score decrease within 3 hours (73%), confusion (64%), any vomiting (36%), focal temporal blow (36%), restlessness (36%), and severe headache (45%).
  
  
  CONCLUSIONS
  For patients with minor head injury and GCS score of 15, urgent neurosurgical intervention and precipitous deterioration are rare. The CCHR accurately identified all patients requiring neurosurgical intervention. Warning signs that may portend need for urgent intervention include any vomiting, restlessness, any GCS score decrease, severe headache, confusion, and focal temporal blow.
authors.affiliation: Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario, Canada. cclement@ohri.ca
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Clement
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Schull
authors.forename: Brian H
authors.initials: BH
authors.lastname: Rowe
authors.forename: Robert
authors.initials: R
authors.lastname: Brison
authors.forename: Jacques S
authors.initials: JS
authors.lastname: Lee
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Perry
authors.forename: George A
authors.initials: GA
authors.lastname: Wells
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006259:Craniocerebral Trauma / Q000503:physiopathology* / Q000601:surgery*; D004636:Emergency Service, Hospital; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D017063:Outcome Assessment, Health Care