From the Guidelines
Imaging is necessary for children with head trauma when there are concerning signs or symptoms that suggest a possible intracranial injury, and the PECARN criteria can guide decision-making, recommending observation for low-risk patients and imaging for higher-risk patients. The decision to image a child with head trauma should be based on the risk of clinically important traumatic brain injury, which can be estimated using the PECARN criteria 1. Children who should undergo head CT imaging include those with:
- Altered mental status
- Loss of consciousness lasting more than a few seconds
- Severe headache
- Persistent vomiting
- Seizures
- Signs of basilar skull fracture (such as raccoon eyes or Battle's sign)
- Large scalp hematomas (especially in infants)
- Focal neurological deficits For children under 2 years, additional concerns include fontanelle bulging, irritability, or behavior changes. The CT scan is the preferred initial imaging modality due to its speed and sensitivity for detecting acute bleeding, fractures, and mass effect 1. MRI may be used for follow-up or in cases where radiation exposure is a significant concern. Minimizing unnecessary imaging is important because children are more sensitive to radiation effects than adults, with potential long-term cancer risks. Clinical observation for 4-6 hours is a reasonable alternative for children with minor head trauma who are at low risk for clinically important traumatic brain injury 1.
Some key points to consider when deciding whether to image a child with head trauma include:
- The risk of clinically important intracranial injury in children with minor head trauma is low, but not negligible 1
- The PECARN criteria can help identify children who are at high risk for clinically important traumatic brain injury and who may benefit from imaging 1
- CT scan is the preferred initial imaging modality, but MRI may be used in certain cases, such as follow-up or when radiation exposure is a concern 1
- Minimizing unnecessary imaging is important to reduce the risk of radiation-induced cancer and other potential harms 1
From the Research
Imaging Modalities
- Computed Tomography (CT) scan is the standard for immediate imaging of head-injured children, but it uses radiation that predisposes to malignancy 2
- Magnetic Resonance Imaging (MRI) is more sensitive for all posttraumatic lesions other than skull fracture and subarachnoid hemorrhage, and can demonstrate parenchymal spinal cord injury 3
Indications for Imaging
- Headache, vomiting, loss of consciousness (LOC) or amnesia, and alcohol intoxication are associated with abnormal brain CT scans in minor head injury patients 4
- Loss of consciousness or amnesia, even with a normal physical examination, warrants a head computed tomography scan to avoid missing an intracranial injury 5
- Seizures, reduced level of consciousness, headache, and suspected ventriculoperitoneal shunt (VPS) malfunction are common indications for head CT scans in children with acute medical illness 6
Imaging Practices
- Almost all respondents (97.7%) reported that radiation concerns influence clinical management of children and adolescents with head trauma 2
- Head CT use is more frequently reported than MRI (55.3% vs 1.5% reported use in more than 10% of patients, respectively) 2
- Limited scanner availability, patient intolerance of MRI, and longer acquisition times are obstacles to increased use of MRI for head-injured children 2
Clinical Decision-Making
- A normal physical examination does not rule out the possibility of an intracranial injury, and a head computed tomography scan should be considered in patients with loss of consciousness or amnesia 5
- Evidence-based guidelines are required to guide the best use of head CT in the management of children without head trauma 6