A prospective study was performed on 4,262 consecutive patients who had had 
skull examinations for recent head trauma. Clinical signs and symptoms and 
patient history were correlated with skull fractures and intracranial sequelae 
as identified on CT studies, in order to evaluate the predictive value of each 
clinical finding and to identify high-yield referral criteria. Ninety-seven 
skull fractures (3%) and 32 intracranial sequelae (0.7%) were observed. All the 
intracranial complications were observed in patients with fractures and with 
altered consciousness of some degrees (Glasgow Coma Scale score less than 13). 
Most patients were asymptomatic (41%) or showed "low risk" symptoms (29%): among 
them, neither fractures nor complications were observed. High-risk clinical 
signs, mainly expressing basilar fractures (as rhinorrhea, otorrhea, focal 
neurologic signs, retroauricular hematoma) demonstrated high predictive value 
(100%) for intracranial sequelae. Other "moderate risk" findings for 
intracranial injury--i.e. loss of consciousness at any time, antegrade or 
retrograde amnesia, multiple trauma, and possible skull penetration--showed a 
high correlation with skull fractures and a slightly lower one with intracranial 
sequelae. The most predictive finding for brain injury was the depressed level 
of consciousness: brain injuries were never observed in fully conscious 
patients; in altered consciousness with GCS 15-13 we observed 4% of skull 
fractures with no sequelae; at GCS values 12-9, 61% of skull fractures and 20% 
of sequelae were present, whereas at GCS less than 8, 100% of complicated 
fracture were observed. The finding of skull fracture showed 33% of predictivity 
for brain damage, which was, however, always associated with "high or moderate 
risk" clinical signs. Therefore, the authors suggest some guidelines for the 
management of patients with recent head trauma, including referral criteria for 
X-rays or CT studies, based on signs and symptoms with high, intermediate and 
low risk of developing intracranial sequelae.