• Kelly A Foks, Crispijn L van den Brand, Hester F Lingsma, Joukje van der Naalt, Bram Jacobs, Eline de Jong, Hugo F den Boogert, Özcan Sir, Peter Patka, Suzanne Polinder, Menno I Gaakeer, Charlotte E Schutte, Kim E Jie, Huib F Visee, Hunink Myriam G M MGM Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands. , Eef Reijners, Meriam Braaksma, Guus G Schoonman, Ewout W Steyerberg, Korné Jellema, and Dippel Diederik W J DWJ Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands..
• Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands k.foks@erasmusmc.nl.
• BMJ. 2018 Aug 24; 362: k3527.

ObjectiveTo externally validate four commonly used rules in computed tomography (CT) for minor head injury.DesignProspective, multicentre cohort study.SettingThree university and six non-university hospitals in the Netherlands.ParticipantsConsecutive adult patients aged 16 years and over who presented with minor head injury at the emergency department with a Glasgow coma scale score of 13-15 between March 2015 and December 2016.Main Outcome MeasuresThe primary outcome was any intracranial traumatic finding on CT; the secondary outcome was a potential neurosurgical lesion on CT, which was defined as an intracranial traumatic finding on CT that could lead to a neurosurgical intervention or death. The sensitivity, specificity, and clinical usefulness (defined as net proportional benefit, a weighted sum of true positive classifications) of the four CT decision rules. The rules included the CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and National Institute for Health and Care Excellence (NICE) guideline for head injury.ResultsFor the primary analysis, only six centres that included patients with and without CT were selected. Of 4557 eligible patients who presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for performing CT scanning: the NOC rule was preferable at a low threshold, the NICE rule was preferable at a higher threshold, whereas the CHIP rule was preferable for an intermediate threshold.ConclusionsApplication of the CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT scanning among patients with minor head injury, resulting in many unnecessary CT scans and some missed intracranial traumatic findings. Until an existing decision rule has been updated, any of the four rules can be used for patients presenting minor head injuries at the emergency department. Use of the CHIP rule is recommended because it leads to a substantial reduction in CT scans while missing few potential neurosurgical lesions.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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