Head CT Should Be Obtained First in Infants with Suspected Non-Accidental Trauma
In an infant with suspected non-accidental trauma, head CT takes priority over skeletal survey because head trauma is the leading cause of death in child abuse cases, with case fatality rates exceeding 20%, and requires immediate identification to guide urgent neurosurgical intervention. 1
The Critical Mortality Argument
The ACR Appropriateness Criteria (2017) explicitly states that although skeletal injuries are more frequent, most child abuse fatalities result from head trauma, and abusive head injury is the principal cause of death in children under 2 years of age 1. This mortality differential makes head imaging the urgent priority.
Clinical Decision Algorithm
Immediate Head CT is indicated when:
- Any neurologic signs or symptoms are present
- Skull fractures are suspected
- The infant is under 12 months of age (highest risk group)
- High-risk criteria exist: rib fractures, multiple fractures, facial injury, or age <6 months 1
Key Clinical Reality:
29% of abused infants without any clinical suspicion of intracranial injury had positive neuroimaging (subdural hematoma, epidural hematoma, or cerebral edema), and most had negative skeletal surveys 1. Additionally, 37% of children under 2 years with high-risk criteria but no overt head injury signs had occult intracranial injury on CT 1.
Why Head CT Must Come First
Time-Sensitive Pathology:
- Unenhanced head CT is the examination of choice for initial evaluation because it rapidly detects life-threatening intracranial injuries requiring immediate neurosurgical intervention 1
- Subdural hematomas, epidural hematomas, and cerebral edema can progress rapidly and cause death
- CT is fast and can be performed emergently with monitoring equipment in place
Occult Injury is Common:
Children under 12 months may have significant intracranial injury without signs or symptoms of head injury or retinal hemorrhage 1. You cannot rely on clinical examination alone in this age group.
The Skeletal Survey Follows
Once life-threatening intracranial pathology is excluded or managed, proceed immediately to skeletal survey, which remains essential because:
- Fractures occur in up to 55% of physically abused children 1
- 11-20% of infants have unsuspected fractures detected by skeletal survey 1
- Skeletal survey is the initial imaging modality of choice for detecting fractures and is recommended in all children under 2 years with suspected abuse 1
Common Pitfalls to Avoid
Don't wait for neurologic symptoms - Infants under 12 months can have severe intracranial injury with normal neurologic exams 1
Don't skip head imaging because skeletal survey is negative - Most children with occult head injury had negative skeletal surveys 1
Don't rely on skull radiographs - Significant traumatic intracranial pathology may occur without skull fractures 1
Don't delay for MRI in the acute setting - CT is faster and more sensitive for acute hemorrhage and fractures requiring immediate intervention; MRI can follow later for better characterization 1
Practical Implementation
Step 1: Obtain non-contrast head CT immediately upon suspicion of NAT in any infant
Step 2: While awaiting CT results or immediately after if negative, obtain complete skeletal survey
Step 3: Consider follow-up MRI brain (and cervical spine) within days for better detection of parenchymal injury, dating of injuries, and prognostication 1
Step 4: Repeat skeletal survey in 2 weeks to detect healing fractures not visible initially 1
The guideline evidence is unequivocal: clinicians should have a low threshold for performing head CT in young children with suspected abuse 1, and given that head trauma causes the deaths while skeletal injuries rarely do, head CT must be the first imaging obtained.