Computed Tomographic Scan in Head Trauma: What is the Rational in Children?

Abstract

Traumatic brain injury (TBI) is the consequence of external forces that traumatically injure the brain. Closed head injury is common in children and is estimated to result in 650,000 to 1 million emergency department visits annually with approximately 7,400 deaths in the United States. Mild TBI is the most common form of closed head injury and constitutes 80 to 90% of all the TBI. Cranial computed tomography (cCT) is performed in usually more than 50% of the patients, thus, resulting in an extreme overuse with the inherent risk for inducing malignancies. The purpose of this article is to review current approaches, recommendations, and guidelines on pediatric head trauma with special emphasis on cCT. Therefore, after an overview on classification and TBI scores, diagnostic imaging, and management rules for clinical important TBI, as well as own experience including remarks on cCT technique will be discussed.

Keywords

brain injuries - computed tomography - children

• References

• 1 Klig JE, Kaplan CP. Minor head injury in children. Curr Opin Pediatr 2010; 22 (3) 257-261
• 2 Kuppermann N. Pediatric head trauma: the evidence regarding indications for emergent neuroimaging. Pediatr Radiol 2008; 38 (Suppl. 04) S670-S674
• 3 Atabaki SM, Stiell IG, Bazarian JJ , et al. A clinical decision rule for cranial computed tomography in minor pediatric head trauma. Arch Pediatr Adolesc Med 2008; 162 (5) 439-445
• 4 Fachgesellschaften AdWM. S2K Guideline: Das Schädel-Hirn-Trauma im Kindesalter. In. 2011. http://www.awmf.org/uploads/tx_szleitlinien/024-018l_S2k_Schaedel-Hirn-Trauma_im_Kindesalter-2011-03.pdf Last accessed November 19, 2013
• 5 Doezema D, King JN, Tandberg D, Espinosa MC, Orrison WW. Magnetic resonance imaging in minor head injury. Ann Emerg Med 1991; 20 (12) 1281-1285
• 6 Abdel-Dayem HM, Abu-Judeh H, Kumar M , et al. SPECT brain perfusion abnormalities in mild or moderate traumatic brain injury. Clin Nucl Med 1998; 23 (5) 309-317
• 7 Mettler Jr FA, Wiest PW, Locken JA, Kelsey CA. CT scanning: patterns of use and dose. J Radiol Prot 2000; 20 (4) 353-359
• 8 Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics 2009; 124 (1) e145-e154
• 9 Slovis TL. Where we were, what has changed, what needs doing: a decade of progress. Pediatr Radiol 2011; 41 (Suppl. 02) 456-460
• 10 Klassen TP, Reed MH, Stiell IG , et al. Variation in utilization of computed tomography scanning for the investigation of minor head trauma in children: a Canadian experience. Acad Emerg Med 2000; 7 (7) 739-744
• 11 Jagoda AS, Cantrill SV, Wears RL , et al; American College of Emergency Physicians. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2002; 40 (2) 231-249
• 12 Pearce MS, Salotti JA, Little MP , et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380 (9840) 499-505
• 13 Mathews JD, Forsythe AV, Brady Z , et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013; 346: f2360
• 14 Kuppermann N, Holmes JF, Dayan PS , et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374 (9696) 1160-1170
• 15 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872) 81-84
• 16 Durham SR, Clancy RR, Leuthardt E , et al. CHOP Infant Coma Scale (“Infant Face Scale”): a novel coma scale for children less than two years of age. J Neurotrauma 2000; 17 (9) 729-737
• 17 Ong L, Selladurai BM, Dhillon MK, Atan M, Lye MS. The prognostic value of the Glasgow Coma Scale, hypoxia and computerised tomography in outcome prediction of pediatric head injury. Pediatr Neurosurg 1996; 24 (6) 285-291
• 18 Duncan CC, Ment LR, Smith B, Ehrenkranz RA. A scale for the assessment of neonatal neurologic status. Childs Brain 1981; 8 (4) 299-306
• 19 Gordon NS, Fois A, Jacobi G, Minns RA, Seshia SS. The management of the comatose child. Neuropediatrics 1983; 14 (1) 3-5
• 20 Hahn YS, Chyung C, Barthel MJ, Bailes J, Flannery AM, McLone DG. Head injuries in children under 36 months of age. Demography and outcome. Childs Nerv Syst 1988; 4 (1) 34-40
• 21 Morray JP, Tyler DC, Jones TK, Stuntz JT, Lemire RJ. Coma scale for use in brain-injured children. Crit Care Med 1984; 12 (12) 1018-1020
• 22 Raimondi AJ, Hirschauer J. Head injury in the infant and toddler. Coma scoring and outcome scale. Childs Brain 1984; 11 (1) 12-35
• 23 Simpson D, Reilly P. Pediatric coma scale. Lancet 1982; 2 (8295) 450
• 24 Seshia SS, Seshia MM, Sachdeva RK. Coma in childhood. Dev Med Child Neurol 1977; 19 (5) 614-628
• 25 Marcoux KK. Management of increased intracranial pressure in the critically ill child with an acute neurological injury. AACN Clin Issues 2005; 16 (2) 212-231 , quiz 270–271
• 26 Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol 2008; 7 (8) 728-741
• 27 Parikh S, Koch M, Narayan RK. Traumatic brain injury. Int Anesthesiol Clin 2007; 45 (3) 119-135
• 28 Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT ; Workshop Scientific Team and Advisory Panel Members. Classification of traumatic brain injury for targeted therapies. J Neurotrauma 2008; 25 (7) 719-738
• 29 Jennett B. Epidemiology of head injury. Arch Dis Child 1998; 78 (5) 403-406
• 30 Johnson AR, DeMatt E, Salorio CF. Predictors of outcome following acquired brain injury in children. Dev Disabil Res Rev 2009; 15 (2) 124-132
• 31 Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006; 21 (5) 375-378
• 32 Dacey Jr RG, Alves WM, Rimel RW, Winn HR, Jane JA. Neurosurgical complications after apparently minor head injury. Assessment of risk in a series of 610 patients. J Neurosurg 1986; 65 (2) 203-210
• 33 Ghajar J, Hariri RJ. Management of pediatric head injury. Pediatr Clin North Am 1992; 39 (5) 1093-1125
• 34 Thiessen ML, Woolridge DP. Pediatric minor closed head injury. Pediatr Clin North Am 2006; 53 (1) 1-26 , v
• 35 Schutzman SA, Greenes DS. Pediatric minor head trauma. Ann Emerg Med 2001; 37 (1) 65-74
• 36 Jaffe KM, Fay GC, Polissar NL , et al. Severity of pediatric traumatic brain injury and neurobehavioral recovery at one year—a cohort study. Arch Phys Med Rehabil 1993; 74 (6) 587-595
• 37 Roncadin C, Guger S, Archibald J, Barnes M, Dennis M. Working memory after mild, moderate, or severe childhood closed head injury. Dev Neuropsychol 2004; 25 (1-2) 21-36
• 38 Yeates KO, Swift E, Taylor HG , et al. Short- and long-term social outcomes following pediatric traumatic brain injury. J Int Neuropsychol Soc 2004; 10 (3) 412-426
• 39 Schnadower D, Vazquez H, Lee J, Dayan P, Roskind CG. Controversies in the evaluation and management of minor blunt head trauma in children. Curr Opin Pediatr 2007; 19 (3) 258-264
• 40 Quayle KS, Jaffe DM, Kuppermann N , et al. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?. Pediatrics 1997; 99 (5) E11
• 41 Greenes DS, Schutzman SA. Clinical indicators of intracranial injury in head-injured infants. Pediatrics 1999; 104 (4 Pt 1) 861-867
• 42 Greenes DS, Schutzman SA. Occult intracranial injury in infants. Ann Emerg Med 1998; 32 (6) 680-686
• 43 Boulis ZF, Dick R, Barnes NR. Head injuries in children—aetiology, symptoms, physical findings and x-ray wastage. Br J Radiol 1978; 51 (611) 851-854
• 44 Leonidas JC, Ting W, Binkiewicz A, Vaz R, Scott RM, Pauker SG. Mild head trauma in children: When is a roentgenogram Necessary. Pediatrics 1982; 69 (2) 139-143
• 45 Berney J, Favier J, Froidevaux AC. Paediatric head trauma: influence of age and sex. I. Epidemiology. Childs Nerv Syst 1994; 10 (8) 509-516
• 46 Mann KS, Chan KH, Yue CP. Skull fractures in children: their assessment in relation to developmental skull changes and acute intracranial hematomas. Childs Nerv Syst 1986; 2 (5) 258-261
• 47 Dietrich AM, Bowman MJ, Ginn-Pease ME, Kosnik E, King DR. Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography?. Ann Emerg Med 1993; 22 (10) 1535-1540
• 48 Rivara FP. Childhood injuries. III: Epidemiology of non-motor vehicle head trauma. Dev Med Child Neurol 1984; 26 (1) 81-87
• 49 Gabriel EJ, Ghajar J, Jagoda A, Pons PT, Scalea T, Walters BC ; Brain Trauma Foundation. Guidelines for prehospital management of traumatic brain injury. J Neurotrauma 2002; 19 (1) 111-174
• 50 Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K ; Children's head injury algorithm for the prediction of important clinical events study group. 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) 885-891
• 51 Osmond MH, Klassen TP, Wells GA , et al; Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010; 182 (4) 341-348
• 52 Greenes DS. Decisionmaking in pediatric minor head trauma. Ann Emerg Med 2003; 42 (4) 515-518
• 53 Palchak MJ, Holmes JF, Vance CW , 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
• 54 Homer CJ, Kleinman L. Technical report: minor head injury in children. Pediatrics 1999; 104 (6) e78
• 55 Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatr Emerg Care 1996; 12 (3) 160-165
• 56 Bailey PL, Pace NL, Ashburn MA, Moll JW, East KA, Stanley TH. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 1990; 73 (5) 826-830
• 57 Vade A, Sukhani R, Dolenga M, Habisohn-Schuck C. Chloral hydrate sedation of children undergoing CT and MR imaging: safety as judged by American Academy of Pediatrics guidelines. AJR Am J Roentgenol 1995; 165 (4) 905-909
• 58 Woolard DJ, Terndrup TE. Sedative-analgesic agent administration in children: analysis of use and complications in the emergency department. J Emerg Med 1994; 12 (4) 453-461
• 59 Rao PN, Faulkner K, Sweeney JK, Asbury DL, Sambrook P, Blacklock NJ. Radiation dose to patient and staff during percutaneous nephrostolithotomy. Br J Urol 1987; 59 (6) 508-512
• 60 Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007; 357 (22) 2277-2284
• 61 Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics 2003; 112 (4) 951-957
• 62 Perry JJ, Stiell IG, Sivilotti ML , et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011; 343: d4277
• 63 Radiopadia. Available at: http://radiopaedia.org/articles/subdural-haemorrhage Last accessed November 19, 2013
• 64 King MA, Kanal KM, Relyea-Chew A, Bittles M, Vavilala MS, Hollingworth W. Radiation exposure from pediatric head CT: a bi-institutional study. Pediatr Radiol 2009; 39 (10) 1059-1065
• 65 Suskauer SJ, Huisman TA. Neuroimaging in pediatric traumatic brain injury: current and future predictors of functional outcome. Dev Disabil Res Rev 2009; 15 (2) 117-123
• 66 Lee B, Newberg A. Neuroimaging in traumatic brain imaging. NeuroRx 2005; 2 (2) 372-383
• 67 Ashwal S, Holshouser BA, Tong KA. Use of advanced neuroimaging techniques in the evaluation of pediatric traumatic brain injury. Dev Neurosci 2006; 28 (4-5) 309-326
• 68 Lloyd DA, Carty H, Patterson M, Butcher CK, Roe D. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet 1997; 349 (9055) 821-824
• 69 Seidenbusch MC, Regulla D, Schneider K. [Radiation exposure of children in pediatric radiology—part 2: the PAEDOS algorithm for computer-assisted dose reconstruction in pediatric radiology and results for X-ray examinations of the skull]. Rofo 2008; 180 (6) 522-539
• 70 Sorantin E, Brader P, Thimary F. Neonatal trauma. Eur J Radiol 2006; 60 (2) 199-207
• 71 Rosenthal BW, Bergman I. Intracranial injury after moderate head trauma in children. J Pediatr 1989; 115 (3) 346-350
• 72 Dunning J, Daly JP, Malhotra R , et al; Children's Head injury Algorithm for the Identification of significant Clinical Events Study (CHALICE Study). The implications of NICE guidelines on the management of children presenting with head injury. Arch Dis Child 2004; 89 (8) 763-767
• 73 Da Dalt L, Marchi AG, Laudizi L , et al. Predictors of intracranial injuries in children after blunt head trauma. Eur J Pediatr 2006; 165 (3) 142-148
• 74 Levin HS, Eisenberg HM, Wigg NR, Kobayashi K. Memory and intellectual ability after head injury in children and adolescents. Neurosurgery 1982; 11 (5) 668-673
• 75 Ewing-Cobbs L, Levin HS, Fletcher JM, Miner ME, Eisenberg HM. The Children's Orientation and Amnesia Test: relationship to severity of acute head injury and to recovery of memory. Neurosurgery 1990; 27 (5) 683-691 , discussion 691
• 76 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) 507-514
• 77 Oman JA, Cooper RJ, Holmes JF , et al; NEXUS II Investigators. Performance of a decision rule to predict need for computed tomography among children with blunt head trauma. Pediatrics 2006; 117 (2) e238-e246
• 78 Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000; 343 (2) 100-105
• 79 Stiell IG, Wells GA, Vandemheen K , et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357 (9266) 1391-1396
• 80 Schachar JL, Zampolin RL, Miller TS, Farinhas JM, Freeman K, Taragin BH. External validation of the New Orleans Criteria (NOC), the Canadian CT Head Rule (CCHR) and the National Emergency X-Radiography Utilization Study II (NEXUS II) for CT scanning in pediatric patients with minor head injury in a non-trauma center. Pediatr Radiol 2011; 41 (8) 971-979
• 81 Zaupa PR, Ruttenstock E, Barounig A , et al. Isolierte, leichte Schädelhirntraumata bei Kindern - in welchen Fällen ist ein SChädelröntgen in der Primärdiagnostik notwendig?. Eur Surg 2008; 40 (Suppl. 224): 58
• 82 Commission USNR §20.1003 Definitions. Available at: http://www.nrc.gov/reading-rm/doc-collections/cfr/part020/part020-1003.html Last accessed November 19, 2013
• 83 Sorantin E, Weissensteiner S, Hasenburger G, Riccabona M. CT in children—dose protection and general considerations when planning a CT in a child. Eur J Radiol 2013; 82 (7) 1043-1049
• 84 Sorantin E, Robl T, Lindbichler F, Riccabona M. MRI of the neonatal and paediatric spine and spinal canal. Eur J Radiol 2008; 68 (2) 227-234