Skull Radiography

 Guidelines

Indications, Royal College of Radiologists Guidelines

Assess Risk of Intracranial Injury
Ref http://www.patient.co.uk/showdoc/40001571/

The risk of intracranial injury is the main consideration when planning further imaging of the skull.
The Royal College of Radiologists has defined four categories of risk for intracranial injury following head trauma as follows:4

  • Low risk: Glasgow Coma Scale (GCS) 15/15, no fracture.
  • Medium risk: GCS 15/15 , no fracture, but history of loss of consciousness.
  • High risk: GCS 13-14/15,or GCS 15/15 with a skull fracture.
  • Very high risk: GCS <13/15, or deterioration in clinical condition.
Indications for SXR after Trauma

If the risk of intracranial injury is sufficiently high to warrant the performance of an emergency CT scan, then plain skull films should not be routinely carried out in addition as they will not influence management further. If the GCS is 15/15 i.e. the patient is fully conscious, orientated and obeying commands and CT scanning is not going to be carried out, plain skull films should be carried out in the following situations:

  • The mechanism of the injury has not been trivial and/or has involved a fall from a significant height.
  • Consciousness has been lost
  • The patient has loss of memory
  • The patient has vomited since the event
  • The scalp has a full thickness laceration
  • A boggy haematoma or scalp bruise is evident
  • The child is under the age of 5 and non-accidental injury is suspected
  • The history is inadequate
Additional indications for Skull X-ray

The Royal College of Radiologists have collated the available evidence and made the following recommendations as to when the use of plain skull films may be the most appropriate investigation to aid diagnosis:

  • The presence of a palpable vault abnormality which feels bony
  • As part of an imaging protocol for specific clinical problems after discussion with radiologists e.g. skeletal survey for myeloma
  • Facial views are of use following trauma to facial skeleton or mandible
  • Facial views may be of use following trauma to the orbit, or possibility of metallic foreign body

Skull films are not indicated routinely for the following indications:

  • Headache
  • Possible pituitary problems - ( CT/MRI preferred)
  • Possible space occupying lesion
  • Epilepsy
  • Dementia or memory loss
  • Middle or inner ear problems
  • Nasal trauma - coned views may be requested by appropriate specialist
  • Sinus disease - mucosal thickening is a common incidental finding and not diagnostic
  • Temporal mandibular joint dysfunction - will not show disc abnormality which is the most common cause of dysfunction.

 

Taken from The Royal College Of Radiologists Publication Making The Best Of A Department Of Radiology, Guidelines For Doctors November 1993.

CIRCUMSTANCE

GUIDELINES

EXCEPTIONS

Cerebral symptoms with focal signs or symptoms,

 

Lateral only in most cases

Localisation of calcifications

Cerebral symptoms without focal signs or symptoms

 

Not recommended routinely

 

Head Injury

Not recommended routinely

Selective radiography of patients with the presence of any of the following

Suspected penetrating injury

CSF or blood loss via the nose

Blood discharge from the ear

Loss of consciousness

Head injury + major trauma

Possible head injury with difficult patient, stroke seizure or mental handicap.

Head injury with alcoholic intoxication which may prevent proper clinical examination.

 

X-Ray may be helpful if the patient’s condition allows the taking of diagnostic quality films.

 

Epilepsy (Children)

 

Not recommended routinely

 

Head injury children

 

Not recommended routinely

Selective use as per adults

Sinusitis

Sinuses are poorly developed under 6-9 years, radiography of limited use in this age group.

 

The Royal College of Radiologists have collated the available evidence and made the following recommendations as to when the use of plain skull films may be the most appropriate investigation to aid diagnosis:

Royal College of Radiologists .Making the best use of a department of clinical radiology. Guidelines for doctors, 4th ed.London:RCR;1998

The presence of a palpable vault abnormality which feels bony As part of an imaging protocol for specific clinical problems after discussion with radiologists e.g. skeletal survey for myeloma Facial views are of use following trauma to facial skeleton or mandible Facial views may be of use following trauma to the orbit, or possibility of metallic foreign body

Contra Indications:

There are few if any contra indications other than that alternative forms of imaging may be preferable or  the fact that X-Ray imaging may be considered inappropriate in some cases where treatment will not be affected by the result of X-Ray examination.

A contra indication to the use of ionising radiation is the use of imaging in order to reduce the possibility of  medico legal litigation and for psychological reassurance of the patient.