[Assessment and treatment of minor cranio-cerebral injuries]

Despite the usually uncomplicated course, minor head injury has a major economic impact because of its high frequency. The traditional evaluation and management using plain skull x-rays and subsequent surveillance has recently been questioned due to the wide-spread availability of CT and MRI. Indication and value of these diagnostic methods, however, are still ill-defined. The resulting uncertainty leads to increasing pressure on the smaller hospitals to transfer patients with minor head injury to specialized centres. This trend causes further financial escalation and the capacity of the specialized centres is not large enough to admit all minor injuries. The present review is focused on the initial risk estimation after minor head injury with the aim to derive guidelines for safe and efficient patient management. Adequately communicating patients without history of loss of consciousness have only a minimum risk of an intracranial haemorrhage and need not routinely be submitted to x-ray studies or in-hospital surveillance. Patients with a history of change of consciousness carry a risk of a few percent to develop intracranial haemorrhage and need therefore be admitted for 24 hours. A skull fracture increases the risk of haemorrhage to approximately 10%. An initially unsuspicious CT-scan is no absolute guarantee against subsequent intracranial haemorrhage. Patients who are disoriented and/or somnolent upon emergency room admission or who display a focal neurological deficit have a high risk of intracranial haemorrhage and emergency CT-scan is therefore recommended. The expensive MRI technique is not justified for initial diagnostic work up of head injuries. However, this technique represents a sensitive means to define organic lesions in cases of persistent neurological or neuropsychological deficits.