Pediatric Head Trauma

Dr. Rich LaVeau

Overview

Between 800,000 and 1 million patients aged 17 and under present to ED for head injuries each year.
Approximately 32% of these patients receive neuroimaging with CT. Studies have estimated there is an increased lifetime risk of radiation induced cancers in ~1 in 10,000 pediatric patients who receive head CT, with more recent studies showing an even more frequent occurrence.
This has led to multiple movements to reduce unnecessary radiation exposure in pediatrics, most notably with clinical decision tools such as PECARN. Despite high quality evidence put forth in these clinical decision tools, there has not been a decrease in CT imaging in pediatric head trauma.
MRI technology has been improving and may offer a way to obtain high quality neuro-imaging without radiation exposure. This study aimed to determine two endpoints: whether or not fast MRI is a feasible alternative, and accuracy compared to CT.

Article

Feasibility and Accuracy of Fast MRI Versus CT for Traumatic Brain Injury in Young Children.

Lindberg DM1,2,3,4, Stence NV5,6, Grubenhoff JA5,2, Lewis T5,2,3, Mirsky DM5,6, Miller AL5,6, O’Neill BR5,7, Grice K5,2, Mourani PM5,2,8, Runyan DK5,2,3. https://www.ncbi.nlm.nih.gov/pubmed/31533974

The Study

This study was a single site prospective cohort study that attempted fast MRI in pediatric patients under 6 years old who had head CT performed. Feasibility was assessed by completion rate and imaging time. Fast MRI accuracy was measured against CT findings of TBI, including skull fracture, intracranial hemorrhage, or parenchymal injury.

Results

299 patients qualified, MRI was attempted in 225, and completed in 223. Mean imaging time was 59 seconds for CT and 365 seconds for fast MRI. TBI identified in 111 of these patients on CT. Fast MRI identified TBI in 103 of these patients (sensitivity 92.8; 95% CI), notably missing 2 subarachnoid hemorrhages and 6 isolated linear non-depressed skull fractures. However, fast MRI identified 6 TBIs in 5 patients missed on CT: 3 subdurals, 2 parenchymal contusions, and 1 subarachnoid hemorrhage

All fast MRIs were done without sedation and time to complete was ~6 mins versus 59 seconds for CT
Fast MRI and CT each missed findings apparent on the other modality
Serial imaging with fast MRI can be obtained for young children with mild TBI without concern for ionizing radiation

Conclusion

PECARN should be standard of care and utilized appropriately
Fast MRI can reliably be utilized in centers that have the capability in stable pediatric patients who meet imaging criteria

Application

References

https://pediatrics.aappublications.org/content/142/4/e20180814
https://www.jwatch.org/na50021/2019/10/01/fast-mri-instead-ct-traumatic-brain-injury-children
ttps://www.cancer.gov/about-cancer/diagnosis-staging/ct-scans-fact-sheet#what-are-the-risks-of-ct-scans-for-childrennbsp