What is the next best step for a young boy who fell from a tree, hit his head, had a brief loss of consciousness followed by a seizure, and is now arousable in a post-ictal state with equal and reactive pupils and no focal neurological deficits?

Urgent Non-Contrast CT is the Next Best Step

This child requires immediate non-contrast head CT imaging due to the presence of post-traumatic seizure following head trauma with loss of consciousness, which places him at high risk for clinically important traumatic brain injury requiring urgent neurosurgical intervention. 1, 2

Clinical Rationale

Post-Traumatic Seizure as a High-Risk Feature

• Post-traumatic seizures are specifically identified as a high-risk criterion requiring immediate CT imaging in pediatric head trauma 1
• The American College of Radiology explicitly recommends CT head without IV contrast for children with post-traumatic seizures (excluding abusive head trauma) as initial imaging 1
• Seizures following head trauma indicate potential intracranial injury with reported incidence ranging from 2.4% in mild traumatic brain injury to 28-83% in severe traumatic brain injury 1
• The presence of seizure activity is one of the specific situations where CT should be used to evaluate for structural lesions 1

Loss of Consciousness as Additional Risk Factor

• Brief loss of consciousness combined with seizure activity substantially elevates the risk profile beyond isolated minor head trauma 2
• Children with altered mental status (even if now arousable) have approximately 4.3% risk of clinically important traumatic brain injury 2
• Loss of consciousness is a validated predictor across multiple clinical decision rules (PECARN, CATCH, CHALICE) for obtaining head CT 1, 3

Why CT Over Observation Alone

• CT provides rapid acquisition and excellent sensitivity for acute intracranial hemorrhage, skull fractures, and mass effect requiring neurosurgical intervention 1, 2
• The post-ictal state does not negate the need for imaging when seizure has occurred post-trauma 1
• Clinical observation alone is inadequate to rule out potentially dangerous intracranial lesions when loss of consciousness has occurred 4
• Among children requiring neurosurgical intervention for head trauma, 23 of 58 had no skull fractures, emphasizing that clinical examination alone cannot exclude serious injury 4

Critical Pitfalls to Avoid

• Do not delay imaging for prolonged observation when high-risk features (seizure + loss of consciousness) are present, as this represents a clear indication for immediate CT 1, 2
• Do not rely on the current normal neurological examination to exclude serious injury, as the post-ictal state may temporarily mask evolving intracranial pathology 4
• Do not obtain skull radiographs instead of CT, as they miss up to 50% of intracranial injuries and provide no information about brain parenchyma 1, 2
• Do not use MRI in the acute setting, as it requires longer examination times, potential sedation, and is impractical for emergency evaluation despite superior sensitivity for certain injuries 1, 2

Imaging Protocol Specifications

• Perform non-contrast CT head using dedicated pediatric protocols tailored to patient size to minimize radiation exposure while maintaining diagnostic quality 1, 2
• Multiplanar and 3D-reconstructed images should ideally be performed to increase sensitivity for fractures and small hemorrhages 1
• IV contrast is not indicated initially as it may obscure subtle hemorrhages 1

Post-Imaging Management

• If CT reveals intracranial injury, neurosurgical consultation and admission are indicated 2, 4
• If CT is negative and patient remains neurologically stable, discharge with detailed return precautions is appropriate 5
• Return precautions should include instructions to return immediately for worsening headache, repeated vomiting, altered consciousness, seizures, or focal neurological deficits 5