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In the paper by Wardlaw et al (this issue, pp 188–192)1 it is shown that the presence of subarachnoid blood and “overall appearance” of a CT scan could be added to the already established variables of age, Glasgow coma score, and pupil reaction to improve prediction of 1 year survival after head injury. This has been a thorough investigation and should be of practical benefit in improving the predictive model. A deficiency, which is recognised by the authors, is that the interrater variability in classifying the overall appearance of scans has still to be established. It remains to be seen whether or not this classification proves to be sufficiently robust for day to day application within increasingly busy neuroradiology departments.
Although this paper has focused on CT, MRI may be a better imaging modality for prognostic estimation, especially on account of its ability to detect brain stem lesions.2 If the current constraints around access for patients with acute head injury at the time of admission can be tackled then there could be a gradual shift towards MRI.
It is also clear that more subtle outcome measures are difficult to predict. Neurophychiatric status after mild head injury has been investigated3 and variables including CT failed to predict outcome.
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