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ACR Appropriateness Criteria head trauma--child
Maura E Ryan1, Susan Palasis2, Gaurav Saigal3
1Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
Insights
Computed tomography (CT) is the first-line imaging for pediatric head trauma, but radiation risks necessitate careful consideration for mild injuries. Magnetic resonance imaging (MRI) offers a radiation-free alternative, though sedation and length can be drawbacks.
Area of Science:
- Pediatric Radiology
- Neuroradiology
- Medical Imaging
Background:
- Head trauma is a common reason for cranial imaging in children.
- Computed tomography (CT) is the primary choice for suspected intracranial injury due to availability and speed in detecting hemorrhage.
- The risks of ionizing radiation in pediatric patients, especially with mild head trauma, warrant careful consideration.
Purpose of the Study:
- To review the appropriateness of cranial imaging in children with head trauma.
- To evaluate the benefits and risks of CT versus MRI in pediatric head injury.
- To provide evidence-based guidelines for imaging decisions in pediatric head trauma.
Main Methods:
- Review of current medical literature from peer-reviewed journals.
- Application of a modified Delphi consensus methodology by a multidisciplinary expert panel.
- Development of evidence-based guidelines (ACR Appropriateness Criteria) for imaging procedures.
Main Results:
- CT is widely available and rapid for acute hemorrhage detection in pediatric head trauma.
- MRI provides radiation-free assessment but may require sedation and is less rapid.
- Advanced techniques like diffusion tensor imaging show potential but lack sufficient data for routine use.
Conclusions:
- Imaging decisions for pediatric head trauma should balance the benefits of detection against radiation risks.
- MRI is valuable for suspected nonaccidental trauma and when CT findings are discordant with clinical status.
- Expert opinion guides recommendations when evidence is not definitive, emphasizing judicious use of imaging.
Abstract:
Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.