CT Head Criteria for Pediatric Patients
CT head scans in pediatric patients should be ordered based on validated clinical decision rules such as the PECARN criteria, which stratify children into risk categories based on specific clinical findings rather than routine imaging for all head trauma cases.
PECARN Criteria for Pediatric Head CT
The Pediatric Emergency Care Applied Research Network (PECARN) criteria provide the most widely validated framework for determining the need for head CT in pediatric trauma patients 1. These criteria divide children into two age groups with specific risk factors:
For Children <2 Years Old
High risk (CT recommended - ~4.4% risk of clinically significant injury):
- GCS score of 14 or other signs of altered mental status
- Palpable skull fracture
Intermediate risk (Observation vs. CT based on other factors):
- Occipital/parietal/temporal scalp hematoma
- Loss of consciousness ≥5 seconds
- Severe mechanism of injury
- Not acting normally per parent
- Consider CT if multiple factors present, worsening symptoms during observation, or parental preference
Very low risk (CT generally not necessary):
- None of the above risk factors present
For Children ≥2 Years Old
High risk (CT recommended - ~4.3% risk of clinically significant injury):
- GCS score of 14 or other signs of altered mental status
- Signs of basilar skull fracture
Intermediate risk (Observation vs. CT based on other factors):
- History of loss of consciousness
- History of vomiting
- Severe mechanism of injury
- Severe headache
- Consider CT if multiple factors present, worsening symptoms during observation, or parental preference
Very low risk (CT generally not necessary):
- None of the above risk factors present
Special Considerations
Suspected Non-Accidental Trauma
- Different criteria apply - refer to ACR Appropriateness Criteria on "Suspected Physical Abuse-Child" 1
Coagulopathy
- Most clinical practice guidelines recommend CT in all pediatric patients with head trauma and coagulopathy, including medication-induced coagulopathy 1
Imaging Modality Selection
- Non-contrast CT is the first-line imaging modality for acute pediatric head trauma due to its rapid acquisition time and excellent sensitivity for acute hemorrhage and fractures 1
- MRI has higher sensitivity for small bleeds and non-hemorrhagic injuries but is impractical in emergency settings due to longer acquisition time and frequent need for sedation in young children 1
- Skull radiographs are not sufficient for evaluation of traumatic brain injury as up to 50% of intracranial injuries occur without fracture 1
Radiation Concerns
- Dedicated pediatric head CT parameters with protocols tailored to patient size should always be used to minimize radiation exposure 1
- Multiplanar and 3D-reconstructed CT images increase sensitivity for fractures and small hemorrhages 1
Follow-up Imaging
- Routine repeat head CT within 24-36 hours in pediatric patients with moderate to severe head trauma is unlikely to yield changes in therapy unless there is clinical deterioration or changes in intracranial pressure 2
- For patients with epidural hemorrhage >10 cc or severe head trauma (GCS 3-8), repeat head CT may be warranted even without clinical deterioration 3
Pitfalls to Avoid
- Over-imaging children with very low risk of clinically significant injury
- Under-imaging high-risk patients, particularly those with altered mental status
- Failing to recognize signs of non-accidental trauma that require different evaluation approaches
- Using adult head trauma criteria for pediatric patients
- Not using age-appropriate CT protocols that minimize radiation exposure
By following these evidence-based criteria, clinicians can appropriately identify pediatric patients who would benefit from head CT while avoiding unnecessary radiation exposure in those at very low risk for clinically significant traumatic brain injury.