Pediatric head trauma: an extensive review on imaging requisites and unique imaging findings

Acute Computer Tomography Findings in Pediatric Accidental Head Trauma-Review

Head trauma in paediatric patients is a worldwide and constant issue. It is the number one cause for childhood mortality and morbidity. Children of all ages are susceptible to sustaining head trauma and the anatomical characteristics of the region put them in a high-risk category for developing severe traumatic brain injuries. Boys are more frequently victims of accidental head traumas, and their injuries are more severe than those encountered in girls. The mechanisms of the trauma are a determining factor for the types of lesions we find. The traumatic injuries fall into two categories, primary and secondary. Primary traumatic injuries can be severe and life threatening, and their presence needs to be documented in order to set the correct therapeutic conduct. Due to their importance, this pictorial review focuses on them and the images used herein are selected from the database of our hospital. It is important to distinguish each of the different injuries that can be encountered. At the same time, radiologists are advised to remember that for children up to five years of age, some non-accidental imaging findings may appear to coincide with those found in accidental head trauma.

Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France

Importance

Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines.

Objectives

To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request.

Design, Setting, and Participants

This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022.

Exposure

All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines.

Main Outcomes and Measures

Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture.

Results

Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians.

Conclusion and Relevance

In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.

ACR Appropriateness Criteria® Head Trauma-Child

Head trauma is a frequent indication for cranial imaging in children. The majority of accidental pediatric head trauma is minor and sustained without intracranial injury. Well-validated pediatric-specific clinical decision guidelines should be used to identify very low-risk children who can safely forgo imaging. In those who require acute imaging, CT is considered the first-line imaging modality for suspected intracranial injury because of the short duration of the examination and its high sensitivity for acute hemorrhage. MRI can accurately detect traumatic complications, but often necessitates sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment. There is a paucity of literature regarding vascular injuries in pediatric blunt head trauma and imaging is typically guided by clinical suspicion. Advanced imaging techniques have the potential to identify changes that are not seen by standard imaging, but data are currently insufficient to support routine clinical use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Injury Causes and Severity in Pediatric Traumatic Brain Injury Patients Admitted to the Ward or Intensive Care Unit: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

Background: Traumatic brain injury (TBI) is the leading cause of death and disability in children. It includes a range of different pathologies that differ considerably from adult TBI. Analyzing and understanding injury patterns of pediatric TBI is essential to establishing new preventive efforts as well as to improve clinical management.

Methods: The multi-center, prospectively collected CENTER-TBI core and registry databases were screened and patients were included when younger than 18 years at enrollment and admitted to the regular ward (admission stratum) or intensive care unit (ICU stratum) following TBI. Patient demographics, injury causes, clinical findings, brain CT imaging details, and outcome (GOSE at 6 months follow-up) were retrieved and analyzed. Injury characteristics were compared between patients admitted to the regular ward and ICU and multivariate analysis of factors predicting an unfavorable outcome (GOSE 1-4) was performed. Results from the core study were compared to the registry dataset which includes larger patient numbers but no follow-up data.

Results: Two hundred and twenty seven patients in the core dataset and 687 patients in the registry dataset were included in this study. In the core dataset, road-traffic incidents were the most common cause of injury overall and in the ICU stratum, while incidental falls were most common in the admission stratum. Brain injury was considered serious to severe in the majority of patients and concurrent injuries in other body parts were very common. Intracranial abnormalities were detected in 60% of initial brain CTs. Intra- and extracranial surgical interventions were performed in one-fifth of patients. The overall mortality rate was 3% and the rate of unfavorable outcome 10%, with those numbers being considerably higher among ICU patients. GCS and the occurrence of secondary insults could be identified as independent predictors for an unfavorable outcome. Injury characteristics from the core study could be confirmed in the registry dataset.

Conclusion: Our study displays the most common injury causes and characteristics of pediatric TBI patients that are treated in the regular ward or ICU in Europe. Road-traffic incidents were especially common in ICU patients, indicating that preventive efforts could be effective in decreasing the incidence of severe TBI in children.