Evidence-Based Neuroimaging for Traumatic brain injury in children

Key Points: □ Head injury is not a homogeneous phenomenon and has a complex clinical course. There are different mechanisms, varying severity, diversity of injuries, secondary injuries, and effects of age or underlying disease. A highly sensitive clinical decision rule in more than 20,000 children has been derived for the identification of children who should undergo CT imaging after head trauma (moderate evidence). □ The important CHALICE (Children's Head injury Algorithm for the prediction of Important Clinical Events) prediction rule (Fig. 7.1) has the potential to improve and standardize the care of pediatric patients with head injuries (strong evidence). □ Calvarial plain radiographs have a poor sensitivity for identifying pediatric patients with intracranial pathology (moderate to strong evidence) and hence are not recommended unless for highly selected patients with suspected non-accidental trauma. (See Chapters 12 and 13 on non-accidental head injury and non-CNS non-accidental injury, respectively.) □ CT is the mainstay of imaging in the acute period. The majority of evidence relates to the use of CT for detecting injuries that may require immediate treatment or surgery. Speed, availability, ease of exam, and lesser expense of CT studies remain important factors for using this modality in the acute setting (Table 7.1). Sensitivity of detection also increases with repeat scans in the acute period (strong evidence). □ It is safe to discharge children with TBI home after a negative CT study (moderate to strong evidence). □ The sensitivity and specificity of MRI for brain injury is generally superior to CT, although most studies have been retrospective and few direct comparisons have been performed in the recent decade. CT is clearly superior to MRI for the detection of fractures. MRI outperforms CT in detection of most other lesions (limited to moderate evidence), particularly diffuse axonal injury (DAI). MRI allows more detailed analysis of injuries, including metabolic and physiologic measures, but further evidence-based research is needed. There are few pediatric studies regarding the use of imaging and outcome predictions. □ Accurate prognostic information is important for determining management, but there are different needs for different populations. In severe TBI, information is important for acute patient management, long-term rehabilitation, and family counseling. In mild or moderate TBI, patients with subtle impairments may benefit from counseling and education.