In a patient with a normal neurologic examination (Glasgow Coma Scale 15, no focal deficits, no signs of increased intracranial pressure) and a negative non‑contrast head CT, should I still refer them to a neurologist?

Neurologist Referral After Normal Exam and Negative CT

In a patient with mild traumatic brain injury (GCS 15, normal neurologic examination, and negative head CT), routine neurologist referral is not necessary—these patients can be safely discharged from the emergency department with appropriate discharge instructions about postconcussive symptoms. 1

Evidence-Based Discharge Safety

The 2008 ACEP Clinical Policy provides Level B evidence that patients with mild TBI who have a negative head CT are at minimal risk for developing intracranial lesions and may be safely discharged from the ED 1. This recommendation is supported by:

• Negative predictive value of 99.7% for deterioration when both neurologic exam and CT are normal 1
• A comprehensive Swedish Class I randomized trial of 1,292 patients with GCS 15 showed zero patients with negative CT developed complications requiring hospitalization or surgery at 3-month follow-up 1
• Multiple prospective studies demonstrate that no patient with normal neurologic examination and negative CT deteriorated during observation periods 2

When Neurologist Referral IS Indicated

You should refer to neurology or neurosurgery if:

• Any abnormality on CT scan, even if clinically "minor" (small contusions, skull fractures, any intracranial hemorrhage) 3
• GCS < 15 at any point, even if it normalizes 3
• Neurologic deterioration develops after initial assessment 3
• Persistent or worsening symptoms beyond expected postconcussive syndrome timeline
• Special populations with inadequate safety data:
  • Patients on anticoagulation or antiplatelet therapy 1
  • Bleeding disorders 1
  • Previous neurosurgical procedures (VP shunts) 1
  • Significant pre-existing neurologic disease 1

Critical Discharge Requirements

Before discharge without neurology referral, ensure:

1. GCS remains 15 throughout ED observation
2. Completely normal neurologic examination (no focal deficits, normal cranial nerves, normal strength/sensation) 4
3. Negative non-contrast head CT (no acute intracranial findings) 1
4. Responsible adult available for home observation 5
5. Clear discharge instructions about postconcussive symptoms (Level C recommendation) 1

Common Pitfalls to Avoid

Do not be falsely reassured by:

• Normal initial GCS if patient later develops confusion, vomiting, or GCS decline 6
• Negative CT in anticoagulated patients—these require individualized assessment as safety data is limited 1, 3
• Patient's subjective feeling of being "fine"—provide written instructions about warning signs

Warning signs requiring return (include in discharge instructions): 6

• Worsening or severe headache
• Repeated vomiting
• Increasing confusion or disorientation
• Unusual drowsiness or difficulty awakening
• Seizures
• Weakness or numbness
• Any GCS decline

The Evidence Hierarchy

The ACR Appropriateness Criteria (2021) confirms that imaging is "usually not appropriate" when clinical decision rules don't indicate it, and that patients with normal exams and negative imaging don't require routine follow-up imaging 3. The 2023 ACEP Clinical Policy reinforces that validated decision instruments (Canadian CT Head Rule, New Orleans Criteria) effectively identify patients who need imaging, and by extension, those who don't need specialist referral 4.

The key distinction: Your question asks about neurologist referral, not about discharge safety. These are different questions. Safe discharge without neurology referral is well-supported for the population you describe. However, ensure primary care follow-up is arranged for symptom monitoring, as this represents good clinical practice even though it's not specialist-level care.