J Neurol Neurosurg Psychiatry 68:416-422 doi:10.1136/jnnp.68.4.416
  • Paper

Value of radiological diagnosis of skull fracture in the management of mild head injury: meta-analysis

  1. P A M Hofmana,
  2. P Nelemansb,
  3. G J Kemerinka,
  4. J T Wilminka
  1. aDepartment of Radiology, University Hospital Maastricht and the University Maastricht, PO Box 5800, 6200 AZ, Maastricht, The Netherlands, bDepartment of Epidemiology
  1. Dr P A M Hofman, Department of Radiology, University Hospital Maastricht, PO Box 5800, 6200 AZ, Maastricht, The Netherlands email pho{at}
  • Received 26 April 1999
  • Revised 21 October 1999
  • Accepted 29 October 1999


OBJECTIVES Head injury is a common event. Most patients sustain a mild head injury (MHI), and management depends on the risk of an intracranial haemorrhage (ICH). The value of a plain skull radiograph as a screening tool for ICH is controversial. The aim of this meta-analysis was to estimate and explain differences in reported sensitivity and specificity of the finding of a skull fracture for the diagnosis of ICH, in order to assess the value of the plain skull radiograph in the investigation of patients with MHI, and to estimate the prevalence of ICH in these patients.

METHOD After a systematic literature search 20 studies were selected that reported data on the prevalence of ICH after MHI and/ or data on the diagnostic value of skull fracture for the diagnosis of ICH. The mean prevalence of ICH weighted for the sample size was determined. The sensitivity and specificity of different studies were combined using a summary receiver operator characteristic curve. Correlation analysis was used to determine factors that could explain the reported differences between studies.

RESULTS The weighted mean prevalence of ICH after MHI is 0.083. The potential for verification bias and the percentage of patients who had suffered loss of consciousness or post-traumatic amnesia were the most significant factors explaining interstudy differences in sensitivity and specificity. Based on studies wherein at least 50% of patients had a CT study of the brain, the estimated sensitivity of a radiographic finding of skull fracture for the diagnosis of ICH is 0.38 with a corresponding specificity of 0.95.

CONCLUSION The plain skull radiograph is of little value in the initial assessment of MHI patients.


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