What are the indications for computed tomography (CT) scans in pediatric patients with head injuries?

Indications for CT Scan in Pediatric Head Trauma

CT scans should not be routinely obtained for mild head injuries in pediatric patients but are strongly recommended for children with specific high-risk clinical features that indicate potential clinically important traumatic brain injury. 1, 2

Risk Stratification for CT Imaging

High-Risk Features (CT Recommended)

• Children ≥2 years of age:

  • Glasgow Coma Scale (GCS) score of 14 or other signs of altered mental status 1, 2
  • Signs of basilar skull fracture 1, 2
  • Risk of clinically important traumatic brain injury approximately 4.3% 1

• Children <2 years of age:

  • GCS score of 14 or other signs of altered mental status 1
  • Any palpable skull fracture 1
  • Risk of clinically important traumatic brain injury approximately 4.4% 1

• All pediatric patients:

  • Moderate to severe head trauma (GCS ≤13) 1
  • Focal neurologic deficits 2
  • Suspected vascular injury (especially with basilar fracture through vascular canal) 1

Intermediate-Risk Features (CT May Be Considered)

• Vomiting (especially persistent) 2, 3
• Severe headache 2, 3
• Loss of consciousness 2
• Severe mechanism of injury 2
• Visual disturbances (representing focal neurologic deficit) 2
• Risk of clinically important traumatic brain injury approximately 0.8% 2

Low-Risk Features (CT Not Recommended)

• GCS score of 15 2, 3
• Normal mental status 2, 3
• No clinical signs of basilar skull fracture 2, 3
• No loss of consciousness 3
• No vomiting 2, 3
• No severe injury mechanism 2, 3
• No severe headache 2, 3
• Risk of clinically important traumatic brain injury <0.05% 3

Special Considerations

Clinical Observation

• Clinical observation before deciding on CT imaging can be an effective strategy to reduce unnecessary radiation exposure 1
• Every additional hour of ED observation is associated with decreased CT utilization without delay in diagnosis of significant traumatic brain injury 1

Imaging Modality Selection

• CT remains the imaging modality of choice in acute pediatric head trauma due to:

  • Rapid acquisition time 1, 2
  • Excellent sensitivity for acute intracranial hemorrhage and fractures 1, 2
  • No need for sedation 1

• Skull radiographs are insufficient for evaluation as:

  • Up to 50% of intracranial injuries occur without fracture 1, 2
  • Not all skull fractures are evident on radiographs 1

• MRI, while more sensitive for certain injuries, is often impractical in emergency settings due to:

  • Longer examination times 1, 2
  • Need for safety screening 1
  • Potential requirement for sedation in younger children 1, 2

Radiation Concerns

• CT scans expose children to ionizing radiation with potential long-term risks 3
• Facilities should implement pediatric-specific, reduced-dose CT protocols following the ALARA principle ("as low as reasonably achievable") 1
• Nearly 25% of emergency departments do not have reduced-dose radiation protocols for CT imaging 1

Common Pitfalls and Caveats

• Relying solely on loss of consciousness as an indicator for CT is unreliable, as studies show it is not strongly associated with intracranial injury 4, 5
• Skull fractures have poor negative predictive value for intracranial injury, as 45% of patients with intracranial injuries do not have fractures 4
• Normal neurologic examination does not preclude significant rates of intracranial injury in pediatric trauma patients 4
• Post-traumatic headache alone, without other neurological symptoms, is not an indication for CT imaging in the subacute phase 3
• Clinical deterioration in a patient with initially normal examination warrants immediate CT imaging 1, 3

By following these evidence-based guidelines for CT imaging in pediatric head trauma, clinicians can appropriately identify children at risk for clinically important traumatic brain injury while minimizing unnecessary radiation exposure.