From the Guidelines
A computed tomography (CT) head scan is indicated in a pediatric patient with suspected serious intracranial pathology, such as moderate to severe traumatic brain injury, persistent altered mental status, or signs of increased intracranial pressure, as evidenced by the most recent and highest quality study 1. When evaluating pediatric patients for head trauma, it is crucial to balance the need for prompt diagnosis of serious conditions against the long-term risks of radiation exposure in the developing brain.
- The PECARN criteria provide a framework for identifying children at low risk for clinically important traumatic brain injury, who may safely forgo CT evaluation 1.
- For children 2 years of age, CT head scans are indicated in those with a Glasgow Coma Scale (GCS) of 14 or less, other signs of altered mental status, or signs of a basilar skull fracture, as these factors increase the risk of clinically important intracranial injury to approximately 4.3% 1.
- In children under 2 years of age, high-risk factors for intracranial injury include a GCS of 14 or less, other signs of altered mental status, or signs of any palpable skull fracture, with an estimated risk of clinically significant intracranial injury of approximately 4.4% 1.
- The decision to order a CT head scan should be guided by the presence of high-risk features, such as loss of consciousness, severe mechanism of injury, persistent vomiting, severe headache, or concerning physical exam findings like a large scalp hematoma or palpable skull fracture.
- Alternative imaging modalities, such as MRI, should be considered for non-urgent cases when possible, as they avoid radiation exposure and can provide valuable diagnostic information.
- It is essential to weigh the benefits of CT imaging against the potential risks and to use CT scans judiciously in pediatric patients, as supported by the American College of Radiology Appropriateness Criteria 1.
From the Research
Indications for CT Head Scan in Pediatric Patients
- A computed tomography (CT) head scan is indicated in pediatric patients with head trauma, especially when there are signs of severe injury or abnormal neurological findings 2, 3, 4, 5
- The decision to perform a CT scan should be based on 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
- A normal neurologic exam and maintenance of consciousness do not preclude significant rates of intracranial injury in pediatric trauma patients, and a liberal policy of CT scanning may be warranted for pediatric patients with a high-risk mechanism of injury 3
- Repeated CT scans may be necessary for pediatric patients with traumatic brain injury, especially those with epidural hemorrhage (EDH) more than 10 cc or a Glasgow Coma Scale (GCS) score below 9 6
Risk Factors for Intracranial Injury
- Loss of consciousness (LOC) and mild altered mentation are not sensitive indicators for selecting patients for CT scanning 3
- Skull fractures and superficial craniofacial injury are also unreliable indicators for intracranial injury 3
- Epidural hemorrhage (EDH) more than 10 cc is a significant risk factor for delayed surgical intervention 6
- A GCS score below 9 is also a risk factor for delayed surgical intervention 6
Clinical Variables and CT Scan Results
- Commonly used clinical variables such as seizure, LOC, vomiting, headache, confusion, irritability, sleepiness, and amnesia are not associated with intracranial injury (ICI) in pediatric patients with normal neurologic examinations 5
- Abnormal head CT scans are noted in 28% of pediatric patients with normal neurologic examinations, with 25% being traumatic abnormalities involving the skull and/or contents 5
- Intracranial injuries (ICI) occur in less than 5% of pediatric head trauma patients with normal neurologic examinations, and neurosurgery is needed in 1% of the cases 5