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Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs
K S Quayle1, D M Jaffe, N Kuppermann
1Department of Pediatrics, St Louis Children's Hospital, Washington University, St Louis, MO 63110-1077, USA.
Insights
Head injuries in children can have subtle signs, especially in infants. Skull fractures increase intracranial injury risk, but absence of fracture does not rule out injury.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Radiology
Background:
- Clinical screening criteria for imaging in pediatric head trauma are not standardized.
- Acute head trauma is common in children, necessitating clear guidelines for diagnostic imaging.
Purpose of the Study:
- To inform the selection of appropriate imaging modalities for children with acute head trauma.
- To identify clinical indicators for imaging in pediatric head injury cases.
Main Methods:
- Prospective cohort study of 322 children with nontrivial head injury.
- Data collected included injury mechanism, symptoms, physical findings, skull radiographs, and head computed tomography scans.
Main Results:
- 8% of children had intracranial injury, and 16% had skull fractures.
- Intracranial injury occurred even with normal mental status, particularly in infants under 1 year.
- Skull fracture, basilar skull fracture signs, prolonged loss of consciousness, altered mental status, and focal neurologic deficits were associated with intracranial injury.
Conclusions:
- Intracranial injury in children can present with subtle or few signs, especially in infants.
- Skull fractures significantly increase the risk of intracranial injury but do not exclude it if absent.
- Further research is needed on the implications of non-surgical intracranial injuries in neurologically normal children.
Objective:
Despite the frequent occurrence of head injury in children, there is no agreement about clinical screening criteria that indicate the need for imaging studies. This study was undertaken to provide information relevant to the choice of imaging modalities in children with acute head trauma.
Methodology:
A prospective cohort of 322 children seeking care consecutively in an urban pediatric emergency department for nontrivial head injury was assembled. Skull radiographs, head computed tomography, and data forms including mechanism of injury, symptoms, and physical findings were completed for each child.
Results:
Intracranial injury occurred in 27 children (8%), whereas 50 (16%) had skull fractures. Of those with intracranial injury, 16 (59%) had normal mental status and no focal abnormalities, and 1 of those 16 required surgery for evacuation of an epidural hematoma. Six (38%) of the 16 were younger than 1 year, 5 of whom had scalp contusion or hematoma without other symptoms. Findings not significantly associated with intracranial injury were scalp contusion, laceration, hematoma, abrasion, headache, vomiting, seizure, drowsiness, amnesia, and loss of consciousness for less than 5 minutes. Findings associated with intracranial injury were skull fracture, signs of a basilar skull fracture, loss of consciousness for more than 5 minutes, altered mental status, and focal neurologic abnormality.
Conclusions:
Intracranial injury may occur with few or subtle signs and symptoms, especially in infants younger than 1 year. The relative risk for intracranial injury is increased almost fourfold in the presence of a skull fracture, although the absence of a skull fracture does not rule out intracranial injury. The significance of nonsurgical intracranial injury in neurologically normal children needs further study.