When do you order a computed tomography (CT) brain scan in a baby?

From the Guidelines

A CT brain scan in a baby should be ordered when there are specific clinical concerns that warrant neuroimaging, such as suspected trauma, persistent or severe seizures, or signs of increased intracranial pressure, as indicated by the most recent guidelines 1. When considering a CT brain scan for a baby, it's essential to weigh the diagnostic benefits against the potential risks of radiation exposure to the developing brain. The decision to perform a CT scan should be based on specific clinical concerns that warrant neuroimaging. Some indications for a CT brain scan in a baby include:

• Suspected trauma, such as after falls or in cases of suspected abuse
• Persistent or severe seizures
• Abnormal head growth, such as macrocephaly or microcephaly
• Focal neurological deficits
• Signs of increased intracranial pressure, such as bulging fontanelle, persistent vomiting, or lethargy
• Congenital malformations or unexplained developmental delays

According to the American College of Radiology Appropriateness Criteria, CT is particularly useful in emergency situations because it's quick and readily available, making it valuable for detecting acute hemorrhage, hydrocephalus, or mass lesions requiring immediate intervention 1. However, MRI is generally preferred when time permits due to its superior soft tissue contrast and lack of radiation exposure.

In cases of suspected abusive head trauma, either noncontrast CT or MRI of the brain is recommended, with CT preferred for unstable patients and those with acute trauma and concern for skull fracture 1. The Pediatric Emergency Care Applied Research Network head injury clinical decision rule excluded children with concern for abuse, and therefore should not be applied to these patients.

When ordering a CT for an infant, it's crucial to use the lowest possible radiation dose protocol and consider sedation if the baby cannot remain still during the scan 1. The most recent guidelines emphasize the importance of optimizing advanced imaging of the pediatric patient in the emergency department, with a focus on minimizing radiation exposure while ensuring accurate diagnosis and treatment 1.

From the Research

Indications for CT Brain Scan in Babies

• The decision to order a computed tomography (CT) brain scan in a baby is based on several factors, including the mechanism of injury, consciousness level, neurological findings, and presence or absence of a history of abuse 2.
• The Pediatric Emergency Care Applied Research Network (PECARN) study provides reliable criteria for CT scans in infants with head trauma 2.
• Clinical findings and CT scan results are crucial in assessing traumatic brain injury (TBI) in children with minor head trauma, and a normal neurologic exam and maintenance of consciousness do not preclude significant rates of intracranial injury 3, 4.
• Risk factors for intracranial injury in pediatric patients include skull fractures, superficial craniofacial injury, loss of consciousness, and Glasgow Coma Scale (GCS) score less than 15 3, 4.

CT Scan Findings and Outcomes

• CT scan findings, such as sulcal obliteration, lateral ventricle compression, third ventricle compression, midline shift, and herniation, are associated with increased intracranial pressure (ICP) and poor outcomes in patients with traumatic brain injury 5.
• The presence of hemorrhage, particularly in the posterior fossa, basal ganglia, frontal lobe, subarachnoid, or intraventricular regions, is also associated with increased risk of death and poor functional outcome 5.
• Repeat head CT scans may not be necessary in patients with traumatic intracranial hemorrhage, unless there are changes in symptoms or neurological examination, emphasizing the importance of direct patient care and nursing assessment 6.

Clinical Decision-Making

• A liberal policy of CT scanning may be warranted for pediatric patients with a high-risk mechanism of injury, despite maintenance of normal neurologic status in the field and at hospital screening 3.
• Standard history and clinical examination are sufficient to identify high-risk cases of pediatric head injuries, and requesting a CT scan is not recommended without these risk factors 4.
• The decision to order a CT brain scan in a baby should be made on a case-by-case basis, taking into account the individual patient's clinical presentation, mechanism of injury, and other relevant factors 2, 3, 4.