A 28-year-old man is brought to the emergency department following a road traffic accident. On arrival, he is alert and oriented, GCS 15/15. He complains of severe frontal headache and mild neck pain. On examination, there is a small laceration on the forehead but no focal neurological deficit. Which investigation is most appropriate as the next step to rule out intracranial injury?

Question

Accepted Answer

A. Non-contrast CT head. ## Investigation of Choice in Head Injury with GCS 15

**Key Point:** Non-contrast CT head is the gold standard first-line imaging in acute head injury, regardless of GCS score, to detect acute intracranial pathology (epidural hematoma, subdural hematoma, subarachnoid hemorrhage, contusion, diffuse axonal injury).

### Why CT is Superior in Acute Trauma

| Feature | CT Head | MRI Brain | Skull X-ray | LP |
|---------|---------|-----------|-------------|----|
| **Speed** | <5 min | 30–45 min | <2 min | Invasive |
| **Detects acute bleed** | Yes (hyperdense) | Yes but slower | No | Yes but late |
| **Bone fractures** | Excellent | Poor | Limited | No |
| **Availability** | Always available | Limited in trauma | Outdated | Contraindicated |
| **Radiation** | Yes | No | Yes | N/A |
| **Acute phase use** | **Gold standard** | Delayed imaging | Not recommended | Contraindicated |

**High-Yield:** In ATLS protocol, non-contrast CT head is the standard of care for any head injury with mechanism of injury, loss of consciousness, or persistent symptoms—even with normal GCS.

### Clinical Pearl

A GCS of 15 does **not** exclude intracranial injury. Up to 5–10% of patients with GCS 15 may have significant intracranial pathology on CT. Headache and neck pain in the context of trauma mandate imaging.

**Warning:** Do not delay CT imaging based on normal GCS or lack of focal signs. Epidural hematomas can present with lucid intervals and normal initial exam.

### Timing

CT should be performed **immediately** in the trauma bay or resuscitation area as part of the secondary survey (ATLS protocol).

![Head Injury — GCS and Management diagram](https://mmcphlazjonnzmdysowq.supabase.co/storage/v1/object/public/blog-images/explanation/4246.webp)

Answer

B. Skull X-ray

Answer

C. MRI brain with contrast

Answer

D. Lumbar puncture

Explanation

Investigation of Choice in Head Injury with GCS 15

Why CT is Superior in Acute Trauma

Clinical Pearl

Timing

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Feature	CT Head	MRI Brain	Skull X-ray	LP
Speed	<5 min	30–45 min	<2 min	Invasive
Detects acute bleed	Yes (hyperdense)	Yes but slower	No	Yes but late
Bone fractures	Excellent	Poor	Limited	No
Availability	Always available	Limited in trauma	Outdated	Contraindicated
Radiation	Yes	No	Yes	N/A
Acute phase use	Gold standard	Delayed imaging	Not recommended	Contraindicated