What's the next step after ordering a Non-Contrast Computed Tomography (NCCT) scan for an unconscious child?

Management After Non-Contrast Computed Tomography (NCCT) for an Unconscious Child

After ordering a Non-Contrast Computed Tomography (NCCT) scan for an unconscious child, the next step should be to proceed with an MRI of the head and cervical spine if the NCCT shows abnormal findings or if neurological symptoms persist despite normal NCCT findings. 1

Interpreting NCCT Results

If NCCT Shows Abnormal Findings:

• Parenchymal hemorrhage/hematoma:

  • Proceed with MRI head without and with IV contrast (rated 9/9 for appropriateness) 1
  • Include MRI cervical spine without IV contrast (rated 8/9) 1
  • Consider CT angiography (CTA) head with IV contrast (rated 8/9) to evaluate for underlying vascular malformation 1

• Suspected vascular abnormality:

  • If NCCT suggests vascular injury, proceed with CTA head (rated 8/9) 1
  • Consider MR venography if there is concern for venous thrombosis 1

• Hydrocephalus or mass effect:

  • Urgent neurosurgical consultation
  • Consider repeat NCCT to follow hemorrhage evolution (rated 8/9) 1

If NCCT Shows No Abnormalities:

• With persistent neurological deficits:

  • Proceed with MRI head without IV contrast (rated 8/9) 1
  • Include MRI cervical spine without IV contrast (rated 8/9) 1
  • T2* and susceptibility-weighted imaging (SWI) sequences are particularly important as they can detect 30% more TBI-related lesions compared to NCCT 1

• Without persistent neurological deficits:

  • Clinical observation for 4-6 hours 2
  • Monitor for changes in mental status, development of vomiting, worsening headache, or abnormal behavior 2

Special Considerations

Age-Specific Approach:

• Children <2 years:

  • Lower threshold for MRI even with normal NCCT 1
  • Up to 50% of intracranial injuries occur without skull fracture 2
  • Infants <3 months are particularly vulnerable with small risk (0.4%) of traumatic brain injury despite normal NCCT 2

• Children >2 years:

  • Follow clinical status more reliably as they can better verbalize symptoms 1

Suspected Non-Accidental Trauma:

• Additional imaging needed:
  • Complete skeletal survey (rated 9/9) 1
  • MRI head without IV contrast (rated 8/9) 1
  • MRI cervical spine without IV contrast (rated 8/9) 1
  • SWI sequence is crucial as it can predict poor outcomes when combined with ischemic injury findings 1

Discharge Planning

• Discharge is appropriate after observation period if:

  • No deterioration in neurological status
  • No development of concerning symptoms
  • Normal behavior according to parents
  • Reliable caregivers who can monitor the child at home 2

• Provide clear discharge instructions to return if the child develops:

  • Persistent vomiting
  • Severe or worsening headache
  • Difficulty waking up or staying awake
  • Confusion or unusual behavior
  • Seizures
  • Weakness or numbness in arms or legs
  • Difficulty walking or talking 2

Important Pitfalls to Avoid

1. Don't rely solely on NCCT to rule out all intracranial injuries - Studies show that MRI can detect additional diagnostic information in about 25% of patients with normal NCCT 1

2. Don't delay MRI in cases with persistent neurological deficits - Even with a normal NCCT, significant brain injuries can be present 1, 3

3. Don't forget to image the cervical spine - Unsuspected cervical spine injuries can be present, especially in unconscious children 1

4. Don't underestimate normal neurological exam - Studies show that 14% of children with GCS 15 and no loss of consciousness can still have intracranial injury 4

5. Don't discharge without adequate observation - Each additional hour of observation is associated with decreased need for additional imaging without missing significant injuries 2