From the Guidelines
For a female workers' compensation patient with head bruising after being hit by a metal door who is now experiencing headaches without other concerning symptoms, a non-contrast CT scan of the head is indicated to rule out intracranial hemorrhage, as per the 2008 Clinical Policy from the American College of Emergency Physicians (ACEP) 1. Given the mechanism of injury and persistent headaches, this diagnostic approach is appropriate, although the likelihood of significant findings is low without altered mental status or focal neurological findings. The patient's presentation should be evaluated using a validated clinical decision rule, such as the New Orleans Criteria or the Canadian CT Head Rule, to determine the need for imaging 1. In this case, since the patient has headaches, a noncontrast head CT is indicated according to the Level A recommendation of the ACEP Clinical Policy 1. Key considerations in the diagnostic workup include:
- A thorough neurological examination to assess for any subtle deficits
- Basic cognitive testing to establish a baseline and monitor for post-concussive syndrome
- Detailed documentation of the work-related nature of the injury, mechanism, timing, and symptom progression for workers' compensation claims
- Patient education on typical post-concussive headache patterns and return-to-work guidelines based on her specific job duties and symptom severity. If the CT is negative but symptoms persist beyond 1-2 weeks, consider further evaluation with MRI imaging to assess for subtle brain injury not visible on CT 1.
From the Research
Diagnostics for Head Bruising and Headaches
- The patient presents with head bruising after being hit by a metal door and is now experiencing headaches with no other concerning symptoms.
- According to the study by 2, noncontrast CT of the head is a widely used noninvasive investigation for acute and chronic neurological conditions, and can be used to detect subtle vascular changes.
- However, the study by 3 suggests that imaging is generally not warranted for headaches, and diagnosis is made by a careful history and physical examination.
- The study by 4 found that the pre-test probability of significant intracranial abnormalities in persons with chronic headaches and normal neurological exam is 0.9%, and that CT and MRI scans have a low yield in detecting significant abnormalities in this population.
- The study by 5 found that noncontrast CT scans of the head are not useful for altered mental status presentations, except in cases of symptoms concerning for stroke or sudden onset of impaired consciousness.
- Considering the patient's presentation, a noncontrast CT scan of the head may be considered to rule out any significant intracranial abnormalities, but the yield is likely to be low given the patient's normal neurological exam and lack of other concerning symptoms.
Considerations for Imaging
- The study by 6 highlights the importance of radiation dose optimization in CT imaging, and discusses techniques for reducing radiation dose without compromising diagnostic value.
- The patient's age and sex should be taken into account when considering imaging, as the study by 5 found that older patients and females were more likely to undergo CT scans.
- The patient's clinical condition and symptoms should be carefully evaluated to determine the need for imaging, and alternative diagnostic approaches should be considered if possible.