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Avoiding skull radiographs in infants with suspected inflicted injury who also undergo head CT: "a no-brainer?"
Andrew Martin1, Michael Paddock2,3, Christopher S Johns4
1Department of Neuroradiology, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
Insights
Head CT with 3D reconstruction offers superior accuracy for detecting skull fractures in suspected physical abuse cases. Skull radiographs can be omitted when CT is performed, improving diagnostic efficiency.
Area of Science:
- Medical Imaging
- Radiology
- Pediatric Imaging
Background:
- Abusive head trauma (AHT) and suspected physical abuse (SPA) require accurate skeletal imaging.
- Skull radiographs (SXR) have been a traditional tool for evaluating skull fractures in infants and young children.
- The diagnostic performance of advanced imaging techniques like CT with 3D reconstruction needs evaluation against SXR.
Purpose of the Study:
- To determine if head CT with 3D reconstruction can replace SXR in the imaging workup of SPA/AHT.
- To compare the diagnostic accuracy of SXR and head CT with 3D reconstruction for detecting skull fractures.
Main Methods:
- A retrospective review of paired SXR and CT scans from patients under two years old with suspected SPA was conducted.
- CT scans were analyzed with and without 3D reconstructions by independent reviewers.
- Expert consensus review of SXR and CT served as the gold standard; observer reliability was calculated.
Main Results:
- Head CT with 3D reconstruction demonstrated higher sensitivity and specificity for detecting skull fractures compared to SXR.
- Two fractures were identified on CT that were missed on SXR; no fractures were seen on SXR but not on CT.
- High inter- and intra-observer reliability was achieved for CT analysis, particularly with 3D reconstructions.
Conclusions:
- Head CT with 3D reconstruction is more accurate than SXR for diagnosing skull fractures in SPA/AHT.
- SXR provides no additional diagnostic value when head CT with 3D reconstruction is performed and can be omitted from the skeletal survey.
Objectives:
To assess whether head CT with 3D reconstruction can replace skull radiographs (SXR) in the imaging investigation of suspected physical abuse (SPA)/abusive head trauma (AHT).
Methods:
PACS was interrogated for antemortem skeletal surveys performed for SPA, patients younger than 2 years, SXR and CT performed within 4 days of each other. Paired SXR and CT were independently reviewed. One reviewer analysed CT without and (3 months later) with 3D reconstructions. SXR and CT expert consensus review formed the gold standard. Observer reliability was calculated.
Results:
A total of 104 SXR/CT examination pairs were identified, mean age 6.75 months (range 4 days to 2 years); 21 (20%) had skull fractures; two fractures on CT were missed on SXR. There were no fractures on SXR that were not seen on CT. For SXR and CT, respectively: PPV reviewer 1, 95% confidence interval (CI) 48-82% and 85-100%; reviewer 2, 67-98% and 82-100%; and NPV reviewer 1, 95%, CI 88-98% and 96-100%; reviewer 2, 88-97% and 88-98%. Inter- and intra-observer reliability were respectively the following: SXR, excellent (kappa = 0.831) and good (kappa = 0.694); CT, excellent (kappa = 0.831) and perfect (kappa = 1). All results were statistically significant (p < 0.001).
Conclusions:
CT has greater diagnostic accuracy than SXR in detecting skull fractures which is increased on concurrent review of 3D reconstructions and should be performed in every case of SPA/AHT. SXR does not add further diagnostic information and can be omitted from the skeletal survey when CT with 3D reconstruction is going to be, or has been, performed.
Key Points:
• Head CT with 3D reconstruction is more sensitive and specific for the diagnosis of skull fractures. • Skull radiographs can be safely omitted from the initial skeletal survey performed for suspected physical abuse when head CT with 3D reconstruction is going to be, or has been, performed.
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