What is the recommended imaging protocol for pediatric patients with traumatic head injury?

From the Guidelines

For pediatric traumatic head injury imaging, CT scan without contrast is the recommended first-line imaging modality, as it provides rapid acquisition and excellent sensitivity for acute intracranial hemorrhage and fractures, especially in high-risk patients as defined by PECARN criteria 1.

Key Considerations

• The decision to image should be guided by the patient's risk for clinically important brain injury, with those at high risk (e.g., GCS < 14, signs of altered mental status, or signs of basilar skull fracture) requiring immediate CT scanning 1.
• For patients with minor acute blunt head trauma and intermediate risk, careful clinical observation or CT head without IV contrast may be appropriate, while those with high risk should undergo CT head without IV contrast 1.
• MRI can be considered for follow-up or in cases where more detailed imaging is needed, but it's not typically used in the acute setting due to longer scan times and the need for sedation in young children 1.

Specific Indications for Imaging

• Immediate CT is indicated for:
  • Glasgow Coma Scale (GCS) < 14
  • Focal neurological deficits
  • Seizures
  • Persistent vomiting
  • Severe headache
  • Signs of skull fracture
• For very young infants (< 3 months), consider skull radiographs and/or ultrasound as initial screening tools due to their open fontanelles, but proceed to CT if there's any concern for intracranial injury.

Radiation Exposure and Patient Stabilization

• Minimize radiation exposure by using age-appropriate CT protocols and avoiding repeat scans unless clinically indicated, as the benefit of detecting a potentially life-threatening injury outweighs the small long-term risk from radiation exposure in these cases.
• Remember to stabilize the patient first, ensuring proper airway management and hemodynamic stability before imaging, and always correlate imaging findings with the clinical presentation for appropriate management decisions.

From the Research

Imaging Protocols for Pediatric Patients with Traumatic Head Injury

The recommended imaging protocol for pediatric patients with traumatic head injury is a topic of ongoing research and debate. Several studies have investigated the use of computed tomography (CT) and magnetic resonance imaging (MRI) in this context.

Computed Tomography (CT) Scanning

• CT scanning is commonly used in the evaluation of pediatric patients with traumatic head injury, particularly in cases of severe injury or abnormal neurological symptoms 2, 3.
• However, the use of CT scanning in minor head trauma remains a topic of debate, with some studies suggesting that it may be overused in this context 3, 4.
• A study published in 2001 found that 14% of pediatric patients with minor head trauma had intracranial injuries, despite having a normal neurological examination 2.
• Another study published in 2021 found that 1.9% of pediatric patients with minor head trauma had traumatic intracranial hemorrhage or skull fracture on CT, and that the use of CT scanning was associated with certain factors such as age, Glasgow Coma Scale score, and mechanism of injury 4.

Magnetic Resonance Imaging (MRI)

• MRI may be a useful alternative to CT scanning in select stable patients with mild traumatic head injury, particularly in cases where radiation exposure is a concern 5.
• A study published in 2015 found that MRI was as sensitive as CT scanning in detecting traumatic head injury, diffuse axonal injury, and intracranial hemorrhage, but missed skull fractures in some cases 5.

Repeat Head CT Scans

• The use of routine repeat head CT scans in pediatric patients with mild-to-moderate traumatic brain injury is not well established, and some studies suggest that it may not alter management in cases without clinical deterioration 6.
• A study published in 2022 found that routine repeat head CT scans did not change management in mild-to-moderate traumatic brain injury patients under 2 years old, and that clinical deterioration was a better indicator of the need for repeat imaging 6.

Recommendations

• The decision to use CT scanning or MRI in pediatric patients with traumatic head injury should be based on individual patient factors, such as age, mechanism of injury, and neurological symptoms 2, 5, 3, 4.
• Clinicians should be aware of the potential risks and benefits of imaging in this context, and use imaging judiciously to avoid unnecessary radiation exposure and minimize costs 3, 4.