Canadian Head CT Rule

The Canadian Head CT Rule was originally published in 2001¹ and validated in 2005². There have been multiple subsequent validation studies. It was designed to determine which patients with mild traumatic brain injury (mTBI) require imaging. 

Inclusion Criteria: 

GCS 13-15 AND at least one of the following

• Loss of consciousness
• Amnesia to the traumatic event
• Witnessed disorientation

Exclusion Criteria:

• Age <16 years old. 
• ANY anticoagulation (or antiplatelet agents)
• Seizure after injury

High Risk Criteria 

Yes to any of these, consider imaging. Patient at high risk. If negative, excludes need for neurosurgical intervention.

• GCS <15 at 2 hours post injury
• Suspected open or depressed skull fracture
• Any signs of basilar skull fracture (hemotympanum, raccoon eyes, battle’s sign, CSF otorrhea or rhinorrhea)
• >2 episodes of vomiting
• Age >65

Medium Risk Criteria 

Yes to any of these, consider imaging. Patient at medium risk for clinically important” brain injury. If negative, excludes positive CT findings usually resulting in admission, but not intervention.

• Retrograde amnesia to the event > 30 minutes
• “Dangerous” mechanism (Pedestrian struck by vehicle, ejected from vehicle, fall from >3 feet or >5 stairs)

Take Home Points: 

• Failing the rule means the medical provider should use his/her judgement to determine the need for imaging. It is not mandatory. 
• The rule was created and validated in Canada.^1,2 It has also been validated once in the US.³
• Interestingly, a retrospective application of the rule to a UK population found it would have increased the number of head CTs ordered.⁴
• There is debate about the need to identify all injuries vs clinically important injuries requiring intervention. 

MDCalc has a free calculator for this rule here.

Further Reading

Optimizing Imaging in the Pediatric Trauma Patient, Part 1: Head and Neck Trauma – Trauma EXTRA Supplement (Trauma CME) Date Release: Aug 2021 This Pediatric Trauma EXTRA CME supplement (free to Pediatric Emergency Medicine Practice subscribers) reviews imaging recommendations and interpretations in pediatric head and neck injuries.

Emergency Department Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion (Trauma CME) Date Release: Jun 2021 This issue reviews the most recent literature on mTBI and concussion and provides recommendations for the evaluation, diagnosis, and treatment of mTBI and concussion in the acute setting. Clinical decision rules and their utility in clinical practice will also be discussed.

Concussion in the Emergency Department: A Review of Current Guidelines – Trauma EXTRA Supplement (Trauma CME) Date Release: Sep 2019 This EXTRA Trauma CME supplement (free to Emergency Medicine Practice subscribers) provides evidence-based recommendations for concussion management in the ED and reviews consensus-based guidelines for the evaluation and management of sport-related concussion and mTBI.

References: 

1. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. PubMed
2. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005;294(12):1511-1518. PubMed
3. Papa L, Stiell IG, Clement CM, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center. Acad Emerg Med. 2012;19(1):2-10. PubMed
4. Boyle A, Santarius L, Maimaris C. Evaluation of the impact of the Canadian CT head rule on British practice. Emerg Med J. 2004;21(4):426-428. PubMed
5. Runde, Daniel, Calculated Decisions,Canadian CT Head Injury/Trauma Rule, EB Medicine. Sept, 2012. Link
6. Canadian CT Head Injury/Trauma Rule, MDCalc

Last Updated on January 24, 2023