Diagnostic Imaging Pathways - Paediatric, Head Trauma
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This pathway provides guidance on imaging for head trauma in a paediatric population.
Date reviewed: July 2017
Date of next review: July 2020
Published: October 2017
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The relative radiation level of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE | |
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None | 0 | |
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Minimal | < 1 millisieverts | |
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Low | 1-5 mSv | |
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Medium | 5-10 mSv | |
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High | >10 mSv |
Teaching Points
Teaching Points
- Traumatic brain injury is the leading cause of death and disability in accidental childhood trauma. A head CT is the modality of choice for assessing acute neurological presentations in this population
- Paediatric Glasgow Coma Scale (GCS) is used to stratify head injury severity in children 1
| Sign | PGCS | Score |
|---|---|---|
| Eye opening | Spontaneous | 4 |
| To sound | 3 | |
| To pain | 2 | |
| None | 1 | |
| Verbal response | Age-appropriate vocalisation, smile, or orientation to sound, interacts (coos, babbles), follows objects | 5 |
| Cries, irritable | 4 | |
| Cries to pain | 3 | |
| Moans to pain | 2 | |
| None | 1 | |
| Motor response | Spontaneous movements (obeys verbal command) | 6 |
| Withdraws to touch (localizes pain) | 5 | |
| Withdraws to pain | 4 | |
| Abnormal flexion to pain (decorticate posture) | 3 | |
| Abnormal extension to pain (decerebrate posture) | 2 | |
| None | 1 | |
| Best total score | 15 | |
- Moderate to severe head trauma is defined as a GCS of 9-12 (moderate) or 3-8 (severe) and should be investigated with a head CT
- Minor head trauma is defined as a GCS of 13 or greater. The prevalence of brain injury in this group is low (<5% with a GCS of 15) and the need for surgical intervention is even lower (1%). Missing a significant injury on CT, therefore, needs to be balanced against unnecessarily exposing children to the risks of ionising radiation and possible sedation for the exam
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Several clinical decision rules have been proposed to identify children who at risk of traumatic brain injury and who should therefore be investigated with a CT scan
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Common features to many of these clinical decision rules are that patients are unlikely to have a clinically significant intracranial injury if none of the following are present:
Child less than 2 years of age, altered mental status, clinical evidence of skull fracture, persistent vomiting, headache, dizziness, focal neurological deficit, seizure, amnesia, dangerous mechanism of injury (high speed motor vehicle accident, high speed projectile injury, fall from >3m)
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Paediatric Head Trauma
- Traumatic brain injury is the leading cause of death and disability in accidental childhood trauma 2
- The incidence of paediatric head trauma in Australia is estimated to be 765 per 100 000 per year. More children present to the emergency department with head injuries than any other age group 3
- Approximately 7 per 100 000 per year will sustain significant head injuries of which 40% will require neurosurgical intervention 3
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Minor Head Trauma
- Defined as a Glasgow Coma Scale (GCS) of 14 or greater 2, 4
- Although found in approximately 90% of children with head trauma, subtle or no neurological signs do not exclude the possibility of an acute brain injury. Half of all those with a traumatic brain injury seen on CT will have a GCS of 14 or more
- Nevertheless, the prevalence of brain injury in this group is low (<5% with a GCS of 15) and the need for surgical intervention, even lower (1%). 4, 5 Therefore, missing a significant injury on CT needs to be balanced against unnecessarily exposing children to the risks of ionising radiation and possible sedation for the exam 4
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Computed Tomography (CT)
- Modality of choice for assessing acute neurological presentations in children with trauma 6
- Useful for the rapid detection of acute or subacute haemorrhage and associated mass effects, skull fractures and scalp injury 7
- Advantages
- Can accommodate life support equipment, monitoring devices and traction devices
- Disadvantages
- May require sedation in paediatric populations
- Exposure to ionising radiation
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Clinical Decision Rule
- Several clinical decision rules have been proposed to identify children who are at risk of traumatic brain injury and who should therefore be investigated with a CT scan 1, 6
- The sensitivity of these range from 95 to 99% with negative predictive values of around 99%. (8-12) Many of these decision rules, however, are derived from studies lacking either sufficient accuracy, prospective validation or an adequate sampling size. Therefore, their appropriateness needs to be assessed for patients individually 13
- It is estimated that application of these clinical decision rules may reduce the number of CT scans by 14 to 23% 8-10
- A systematic review of the literature in 2011 found that the PECARN rule had the highest sensitivity and specificity for clinically significant intracranial injury 14
CATCH (Canadian Assessment of Tomography for Childhood Head injury)
- CATCH is a clinical decision rule developed for minor head injury (GCS 13-15) in children which classifies patients into high risk and medium risk groups in whom a CT scan of brain is helpful 6, 10
- High risk (need for neurologic intervention)
- GCS score < 15 at two hours after injury
- Suspected open or depressed skull fracture
- History of worsening headache
- Irritability on examination
- Medium risk (brain injury on CT scan)
- Any sign of basal skull fracture (e.g. hemotympanum, 'raccoon' eyes, otorrhea or rhinorrhea of the cerebrospinal fluid, Battle's sign)
- Large, boggy hematoma of the scalp
- Dangerous mechanism of injury (e.g. motor vehicle crash, fall from elevation ≥ 3 ft [≥ 91 cm] or 5 stairs, fall from bicycle with no helmet)
It is estimated that application of these clinical decision rules may reduce the number of CT scans by 14 to 23% 8-10
PECARN Paediatric Head CT Rule
- PECARN is a clinical decision rule developed to identify low risk clinically-important traumatic brain injury in children 15, 16
- Findings associated with very low risk of significant brain injury in children
- Age <2 years
- normal mental status
- normal behaviour per routine caregiver
- no loss of consciousness (LOC)
- no severe mechanism of injury
- no non-frontal scalp hematoma
- no evidence of skull fracture
- Age ≥2 to 18 years
- normal mental status
- no LOC
- no severe mechanism of injury
- no vomiting
- no severe headache
- no signs of basilar skull fracture
- Age <2 years
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Magnetic Resonance Imaging (MRI)
- CT scans are first line in acute head injury due to their speed, availability and capacity to detect surgically important lesions 7
- MRI in head injury has a role in prognostication and further evaluation for diffuse axonal injury and contusions 17
- Compared to CT scans, MRI is able to detect abnormalities such as intracranial haemorrhage and diffuse axonal injury more frequently. However MRI has poor sensitivity in the evaluation of skull fractures 17
References
References
Date of literature search: March 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Hebb MO, Clarke DB, Tallon JM. Development of a provincial guideline for the acute assessment and management of adult and pediatric patients with head injuries. Can J Surg. 2007;50(3):187-94. (Review article). View the reference
- Swaminathan A, Levy P, Legome E. Evaluation and management of moderate to severe pediatric head trauma. J Emerg Med. 2009;37(1):63-8. (Review article). View the reference
- Mitra B, Cameron P, Butt W. Population-based study of paediatric head injury. J Paediatr Child Health. 2007;43(3):154-9. ( Level III evidence). View the reference
- Greenberg JK, Stoev IT, Park TS, Smyth MD, Leonard JR, Leonard JC, et al. Management of Children with Mild Traumatic Brain Injury and Intracranial Hemorrhage. The journal of trauma and acute care surgery. 2014;76(4):1089-95. (Level III evidence). View the reference
- Quayle KS. Minor head injury in the pediatric patient. Pediatr Clin North Am. 1999;46(6):1189-99. (Review article). View the reference
- Thiam DW, Yap SH, Chong SL. Clinical Decision Rules for Paediatric Minor Head Injury: Are CT Scans a Necessary Evil? Ann Acad Med Singapore. 2015;44(9):335-41. (Level III evidence). View the reference
- Beauchamp MH, Ditchfield M, Babl FE, Kean M, Catroppa C, Yeates KO, et al. Detecting traumatic brain lesions in children: CT versus MRI versus susceptibility weighted imaging (SWI). J Neurotrauma. 2011;28(6):915-27. (Level III evidence). View the reference
- Haydel MJ, Shembekar AD. Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms. Ann Emerg Med. 2003;42(4):507-14. (Level III evidence). View the reference
- Oman JA, Cooper RJ, Holmes JF, Viccellio P, Nyce A, Ross SE, et al. Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma. Pediatrics. 2006;117(2):e238. (Level III evidence). View the reference
- Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ : Canadian Medical Association Journal. 2010;182(4):341-8. (Level II evidence). View the reference
- Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006;91(11):885-91. (Level III evidence). View the reference
- Palchak MJ, Holmes JF, Vance CW, Gelber RE, Schauer BA, Harrison MJ, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42(4):492-506. (Review Article). View the reference
- Kuppermann N. Pediatric head trauma: the evidence regarding indications for emergent neuroimaging. Pediatr Radiol. 2008;38 Suppl 4:S670-4. (Review article). View the reference
- Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S. Clinical decision rules for children with minor head injury: a systematic review. Arch Dis Child. 2011;96(5):414-21. (Level I evidence). View the reference
- Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Postgrad Med J. 2015;91(1081):634-8. (Level III evidence). View the reference
- Atabaki SM, Hoyle JD, Jr., Schunk JE, Monroe DJ, Alpern ER, Quayle KS, et al. Comparison of Prediction Rules and Clinician Suspicion for Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma. Acad Emerg Med. 2016;23(5):566-75. (Level III evidence). View the reference
- Roguski M, Morel B, Sweeney M, Talan J, Rideout L, Riesenburger RI, et al. Magnetic resonance imaging as an alternative to computed tomography in select patients with traumatic brain injury: a retrospective comparison. J Neurosurg Pediatr. 2015;15(5):529-34. (Level IV evidence). View the reference
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