R. Appelbaum1, S. Azari1, M. Li4, M. Eischen3, M. Browne2 1Lehigh Valley Health Network,Allentown, PA, USA 2Lehigh Valley Health Network,Lehigh Valley Children’s Hospital And Pediatric Surgery,Allentown, PA, USA 3Lehigh Valley Health Network,LVPG General, Bariatric And Trauma Surgery,Allentown, PA, USA 4Lehigh Valley Health Network,LVPG Neurosurgery,Allentown, PA, USA
Introduction: Traumatic brain injury is the leading cause of morbidity and mortality for children in the United States. The modality of choice to evaluate closed head injuries in the acute care setting is computed tomography (CT); however, due to the radiation exposure, this imaging modality does not come without long term risks. Advances in imaging to include limited radiation alternatives have emerged with promising results, including rapid brain T2 weighted MRI (rbMRI). The aim of our study was to establish a guideline to decrease radiation exposure by identifying the patient population who had repeat head CT imaging due to an initial abnormal head CT scan; and identify if a rbMRI could have been used as an effective alternative.
Methods: We performed a retrospective chart review of all pediatric trauma patients from January 2013 to June 2018 at our institution. Our exclusion criteria included patients who did not sustain a head injury; had no initial head imaging or imaging was from an outside hospital; and children who were primary burns or drownings. This group was then narrowed to patients who obtained initial and repeat CT head imaging within the first 48 hours of injury. Demographics including age, gender, race, and mechanism of injury were reviewed. Additionally, GCS, number of total head CT scans during initial hospital course, clinical appropriateness of initial and repeat head CT scans; and the possible use of rbMRI imaging were analyzed. Clinical appropriateness of the initial CT scan was based on PECARN criteria; repeat scans were considered indicated for any child with a GCS <13 or altered mental exam with a subarachnoid, epidural, subdural or intraparenchymal hematoma. Possible rbMRI utilization was determined in children who received repeat imaging and did not meet rbMRI guideline contraindications, including patients with rapid neurologic decline, unstable ICPs, recent craniotomy, and retained metal or catheters.
Results: A total of 416 patients met initial inclusion criteria and 142/416 (34.1%) had an abnormal finding on the initial head CT; 100% following PECARN criteria. At least one repeat head CT scan was performed in 64/142 (45.1%) patients for re-evaluation of their initial findings. The average number of repeat head CT scans was 2.1; ranging from 1 to 10. Based on our clinical criteria, 51/64 (79.7%) patients met criteria for re-imaging. However, 38/51 (74.5%) of these patients could have had a rapid T2 weighted MRI instead of a CT scan to re-evaluate their intracranial process.
Conclusion: CT head imaging is invaluable in the initial trauma evaluation of pediatric patients; however, it is often over utilized and the radiation exposure may lead to long term deleterious effects. The ability of using other imaging modalities such as rbMRI, does appear to be a possible option and should be considered when developing a radiation reduction guideline for pediatric closed head injury.