Indication for brain CT in children with mild head injury (2011 UPDATE)

November 7, 2011

October 8, 2012

Matt Rotheram, Paediatric Emergency Medicine Trainee (Bristol Royal Hospital for Children)

Mark Lyttle, Bristol Royal Hospital for Children

In [children who have sustained a mild or minor head injury with a GCS of 14-15] do [clinical findings] predict [intra-cranial injury on computerised tomography]?

A 6-year-old girl presents to the emergency department with a teacher. She was missing at the end of the lunch break and was found dazed at the base of a climbing frame, and can’t remember what happened. Her examination is normal other than a scalp haematoma, with no evidence of an underlying skull fracture. You are aware of the adverse effects of radiation on the developing brain, but wonder if the history and clinical findings warrant performing a head CT despite the potential risks.

The previous BestBet (Andrew Munro, Ian Maconochie 2008, search until October 2007) was used as a starting point and the same search strategy used from October 2007-November 2011.
Medline and Embase: 2007 – November 2011.

[(head AND trauma) OR exp brain injuries OR exp craniocerebral trauma OR exp head injuries, closed OR (head AND injur*)] AND [(exp adolescent OR exp child OR exp child, preschool OR exp child, hospitalized OR exp child, institutionalized, OR exp infant OR exp pediatrics) OR (pediatric* OR paediatric* OR adolescen*)] AND [(exp tomography OR exp tomography scanners, x-ray computed OR exp tomography, x-ray computed) OR (ct AND scan)] AND (exp prospective studies OR prospectiv*). Limited to [Abstracts and Humans and (Age Groups All Child 0 to 18 years)].

The 2008 search found 347 papers, ten of which were considered relevant and of sufficient quality to address the question. In 2011, 235 additional papers were found which had been published since the previous update. Eight papers were considered relevant and were available in the English language. All eighteen are summarised in the table.
In addition, 2 good quality systematic reviews were identified, along with a comparison of clinical decision rules.

Cranial computed tomography (CT) of children with minor HI needs to balance the benefits of the resultant data with the risks associated with the test. Minor HI can be associated with intracranial injury requiring neurosurgery, and cranial CT may be more cost effective than inpatient observation (Oman et al. 2006; Da Dalt et al. 2006). However, the long-term clinical significance of minor intracranial changes on CT following acute HI is unknown, and ionising radiation in the developing brain carries an increased lifetime risk of neoplastic change.
Recent studies have concentrated on identifying clinically important traumatic brain injury (ciTBI) rather than any traumatic change on CT. However, there is no widely agreed definition of what is a ciTBI.
Clinical decision rules (CDRs) use clinical variables to identify children who are either high or low risk for ciTBI, and may guide a clinician’s decision regarding a CT scan. The number of CDRs for paediatric HI has increased markedly since the last BestBet and a systematic review from the same time period (Maguire et al., Pediatrics 2009;124:e145–e154). However, a further systematic review (Pickering et al., Arch Dis Child 2011;96:414-421), and a comparison of the CATCH, CHALICE and PECARN CDRs (Lyttle et al., Emerg Med J 2012;29:785-794) have identified that the CDR derivation studies vary widely in their inclusion/exclusion criteria, outcomes, and predictor variables. For example, when considering CHALICE, CATCH and PECARN, GCS is a variable in all three, but whereas PECARN and CATCH use GCS<15, CHALICE uses GCS<14. PECARN includes a ‘history of vomiting’, whereas CHALICE specifies 3 discrete episodes of vomiting. For brevity, we have not included a full description of the CDRs in the table above, though references are supplied below. Economic analysis (Pandor et al., Health Technol Assess. 2011;15(27):1-202) shows that a selective CT policy is the most cost-effective and that admission is only cost-effective for those with an abnormal CT head. CDRs would therefore seem to be a cost-effective tool in managing paediatric HI. However, the use of some tools would likely increase CT rates if applied verbatim to the UK population, and there is insufficient data validating their use in different populations.
Further studies validating and comparing the performance accuracy and cost-effectiveness of CDRs directly in new populations are required. Further research may focus on identifying TBI associated with adverse long-term neurological outcome. Current research investigating the role of biomarkers (Castellani et al., Acta Paediatrica 2009;98:1607-1612) suggests they may be of use in identifying patients who do not need a CT and future CDRs may incorporate such markers. However, there is insufficient evidence for their use in the management of paediatric HI at present.

Clinical findings in the form of a clinical decision rule are useful in helping to predict which children have intra-cranial injury on CT scan after minor head injury. A number of such clinical rules exist. Each has differing advantages, and different rules may be more effective in different healthcare systems. Current UK guidance is in the form of the NICE guideline, based on the CHALICE CDR. In the absence of comparative validation studies of clinical decision rules, there appears to be insufficient evidence to support deviating from current practice in the UK. The NICE guidance is in the early stages of revision.

1. Dietrich, A M, M J Bowman, M E Ginn-Pease, E Kosnik, and D R King. . Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography?
2. Quayle, Kimberly S., David M. Jaffe, Nathan Kuppermann, Bruce A. Kaufman, Benjamin C. P. Lee, T. S. Park, and William H. McAlister. . Diagnostic Testing for Acute Head Injury in Children: When Are Head Computed Tomography and Skull Radiographs Indicated?
3. Wang, M Y, P Griffith, J Sterling, J G McComb, and M L Levy.. A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow Coma Scale score of 13-14)
4. Greenes, D S, and S A Schutzman.. Clinical significance of scalp abnormalities in asymptomatic head-injured infants.
5. Murgio, A, P D Patrick, F A Andrade, S Boetto, K M Leung, and M A Muñoz Sanchez.. International study of emergency department care for pediatric traumatic brain injury and the role of CT scanning.
6. Palchak, Michael J., James F. Holmes, Cheryl W. Vance, Rebecca E. Gelber, Bobbie A. Schauer, Mathew J. Harrison, Jason Willis-Shore, Sandra L. Wootton-Gorges, Robert W. Derlet, and Nathan Kuppermann.. A decision rule for identifying children at low risk for brain injuries after blunt head trauma.
7. Palchak, Michael J, James F Holmes, Cheryl W Vance, Rebecca E Gelber, Bobbie A Schauer, Mathew J Harrison, Jason Willis-Shore, Sandra L Wootton-Gorges, Robert W Derlet, and Nathan Kuppermann.. Does an isolated history of loss of consciousness or amnesia predict brain injuries in children after blunt head trauma?
8. Boran, Burak O, Perran Boran, Nehir Barut, Cem Akgun, Erhan Celikoglu, and Mustafa Bozbuga. . Evaluation of mild head injury in a pediatric population.
9. Dunning, J, J Patrick Daly, J-P Lomas, F Lecky, J Batchelor, and K Mackway-Jones.. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children.
10. Da Dalt, Liviana, Alberto G Marchi, Lorenzo Laudizi, Giovanni Crichiutti, Gianni Messi, Lucia Pavanello, Francesca Valent, and Fabio Barbone.. Predictors of intracranial injuries in children after blunt head trauma.
11. Oman, Jennifer A., Richelle J. Cooper, James F. Holmes, Peter Viccellio, Andrew Nyce, Steven E. Ross, Jerome R. Hoffman, William R. Mower, and for the NEXUS II Investigators.. Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma.
12. Atabaki, Shireen M., Ian G. Stiell, Jeffrey J. Bazarian, Karin E. Sadow, Tien T. Vu, Mary A. Camarca, Scott Berns, and James M. Chamberlain. . A Clinical Decision Rule for Cranial Computed Tomography in Minor Pediatric Head Trauma.
13. Turedi, S., A. Hasanbasoglu, A. Gunduz, and M. Yandi.. Clinical Decision Instruments for CT Scan in Minor Head Trauma.
14. Kuppermann, Nathan, James F Holmes, Peter S Dayan, John D Hoyle, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, et al.. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
15. Osmond, Martin H., Terry P. Klassen, George A. Wells, Rhonda Correll, Anna Jarvis, Gary Joubert, Benoit Bailey, et al.. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury.
16. Bin, S.S., S.A. Schutzman, and D.S. Greenes.. Validation of a clinical score to predict skull fracture in head-injured infants.
17. Nigrovic, Lise E., Jeff E. Schunk, Adele Foerster, Arthur Cooper, Michelle Miskin, Shireen M. Atabaki, John Hoyle, et al.. The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt Head Trauma.
18. Fabbri, A., F. Servadei, G. Marchesini, A. Raggi, and A. Vandelli. . Analysis of different decision aids for clinical use in pediatric head injury in an emergency department of a general hospital.