CT Indications for Pediatric Head Trauma
CT scans should not be routinely obtained for mild head injuries in pediatric patients but are strongly indicated for children with moderate to severe head trauma (GCS ≤13), signs of altered mental status, or high-risk clinical findings. 1
Risk Stratification for CT Decision-Making
High-Risk Factors (CT Strongly Recommended)
- GCS score ≤13 (moderate to severe head trauma)
- Altered mental status (including GCS of 14)
- Signs of basilar skull fracture
- Palpable skull fracture (especially in children <2 years)
- Focal neurologic deficits
- Post-traumatic seizure
- Persistent vomiting
- Severe mechanism of injury
Intermediate-Risk Factors (Consider CT vs. Observation)
- Loss of consciousness
- History of vomiting
- Severe headache
- Not acting normally per parent
- Scalp hematoma (especially in children ≤2 years)
- Multiple risk factors
Low-Risk Factors (Observation Typically Appropriate)
- Normal mental status
- No loss of consciousness
- No vomiting
- No severe headache
- Acting normally
- No scalp hematoma
- No signs of skull fracture
Age-Specific Considerations
Children <2 Years
- Higher risk for clinically important traumatic brain injury even with minimal symptoms
- Palpable skull fracture is a significant risk factor (approximately 4.4% risk of clinically important TBI) 1
- Scalp hematoma is an important predictor in this age group
- Clinical assessment is more challenging in pre-verbal children
Children ≥2 Years
- Signs of altered mental status or basilar skull fracture indicate approximately 4.3% risk of clinically important TBI 1
- More reliable clinical assessment possible
- Headache and vomiting carry more predictive value
Clinical Pearls and Pitfalls
Skull radiographs are not sufficient for evaluating traumatic brain injury, as up to 50% of intracranial injuries occur without fracture 1
Normal neurologic examination does not exclude intracranial injury - studies have shown significant rates of intracranial injury in pediatric patients with normal neurologic status 2
Radiation concerns - CT exposes children to ionizing radiation, which carries long-term risks. Follow the ALARA (as low as reasonably achievable) principle with weight- and size-based CT parameters 1
Serial imaging is rarely needed for children with mild head trauma who have normal initial CT findings and no neurological deterioration 3
MRI considerations - While more sensitive for parenchymal injuries, MRI is impractical in acute trauma settings due to longer scan times and potential need for sedation 1
Special Scenarios
Suspected Child Abuse
- Lower threshold for imaging
- CT is indicated for acute trauma or concern for skull fracture
- Consider MRI for more detailed evaluation 1
Subacute Head Trauma with Neurologic Signs
- CT can provide rapid assessment for progressive hemorrhage, herniation, and hydrocephalus
- MRI may be helpful for persistent, unexplained, or new neurological deficits 1
Vascular Injury Concerns
- CTA or MRA should be considered when there is clinical suspicion of vascular injury
- Particularly important with fractures extending through skull base vascular channels 1
By following these evidence-based guidelines, clinicians can appropriately identify children who require CT imaging while minimizing unnecessary radiation exposure in those who can be safely observed.