When should a cranial computed tomography (CT) scan be performed in an 8‑year‑old boy who sustained a head injury after falling onto a cement floor while playing?

When to Perform Cranial CT in an 8-Year-Old with Head Injury from Fall onto Cement

Use the validated PECARN clinical decision rules to determine CT necessity—this child can safely avoid CT if he has a Glasgow Coma Scale (GCS) of 15, normal mental status, no signs of basilar skull fracture, no loss of consciousness, no vomiting, no severe headache, and no severe mechanism of injury. 1

Risk Stratification Framework

The American College of Radiology endorses the PECARN criteria as the gold standard for determining which children require CT imaging versus observation. 1, 2 For an 8-year-old boy (≥2 years age group), systematically assess the following:

Very Low Risk (CT NOT Needed)

Children meeting ALL of these criteria can safely forgo CT with a risk of clinically important traumatic brain injury <0.05%: 1, 2, 3

• GCS score of 15 1, 2
• Normal mental status (alert, oriented, appropriate for age) 1, 2
• No signs of basilar skull fracture (no Battle sign, raccoon eyes, hemotympanum, or CSF leak) 1, 2
• No loss of consciousness 2, 3
• No vomiting 1, 2
• No severe mechanism of injury (not struck by motor vehicle, fall >5 feet, or high-impact collision) 2, 3
• No severe headache 1, 2

If all these criteria are met, observation alone is appropriate with a negative predictive value of >99.9%. 2, 3

High Risk (CT Required Immediately)

Obtain non-contrast head CT urgently if ANY of the following are present, as the risk of clinically important injury is 4.3-16%: 1, 2, 3

• GCS score of 14 or less 1
• Any signs of altered mental status (confusion, agitation, somnolence, repetitive questioning) 1
• Signs of basilar skull fracture 1
• Post-traumatic seizure 2, 3
• Focal neurological deficits 2, 3

Intermediate Risk (Consider CT or Observation)

For children with GCS 15 and normal mental status but with ANY of these features, CT may be considered versus careful clinical observation, with a risk of clinically important injury of approximately 0.8%: 1, 3

• History of loss of consciousness 1, 2
• Severe mechanism of injury (fall onto cement from significant height, struck by vehicle, high-speed collision) 1
• Vomiting (especially multiple episodes) 1, 2
• Severe or worsening headache 1, 2

In intermediate-risk cases, CT may be considered based on parental preference, multiple risk factors present simultaneously, worsening symptoms during observation, or physician concern. 1

Clinical Observation as Alternative Strategy

For intermediate-risk patients, clinical observation in the emergency department is an effective strategy to reduce unnecessary CT scans without delaying diagnosis. 2 Every additional hour of observation is associated with decreased CT utilization across all risk groups. 2, 3 However, if the child demonstrates clinical deterioration during observation, proceed immediately to CT imaging. 2

Critical Pitfalls to Avoid

• Do NOT obtain skull radiographs instead of CT—they miss up to 50% of intracranial injuries and provide no information about brain parenchyma. 1, 4

• Do NOT delay CT when high-risk features are present—altered mental status, GCS ≤14, basilar skull fracture signs, or seizures require immediate imaging. 2, 3

• Do NOT routinely CT very low-risk patients—this exposes them to unnecessary radiation without clinical benefit. 2, 3

• Consider non-accidental trauma if the history is inconsistent with injuries, there is delayed presentation, or unexplained findings—these cases may warrant CT regardless of PECARN criteria. 1, 3, 4

Imaging Technical Specifications

When CT is indicated, use non-contrast head CT with dedicated pediatric protocols tailored to patient size following ALARA principles to minimize radiation exposure. 2, 3 Multiplanar and 3D reconstructions should be obtained to increase sensitivity for fractures and small hemorrhages. 2, 3 IV contrast is not indicated for acute trauma evaluation. 2, 3

Special Context for Falls onto Cement

A fall onto cement constitutes a potentially severe mechanism of injury depending on the height. 2, 3 Falls from >5 feet in children ≥2 years are considered severe mechanisms. 3 However, if the child meets all very low-risk criteria despite the cement surface, CT can still be safely avoided. 1, 2 The mechanism alone does not mandate CT—it must be considered in conjunction with all other clinical findings. 1