ACR Appropriateness Criteria Head Trauma—Child Maura E. Ryan, MDa, Susan Palasis, MDb, Gaurav Saigal, MDc, Adam D. Singer, MDd, Boaz Karmazyn, MDe, Molly E. Dempsey, MDf, Jonathan R. Dillman, MDg, Christopher E. Dory, MDh, Matthew Garber, MDi,j, Laura L. Hayes, MDk, Ramesh S. Iyer, MDl, Catherine A. Mazzola, MDm,n, Molly E. Raske, MDo, Henry E. Rice, MDp,q, Cynthia K. Rigsby, MDr, Paul R. Sierzenski, MDs, Peter J. Strouse, MDg, Sjirk J. Westra, MDt, Sandra L. Wootton-Gorges, MDu, Brian D. Coley, MDv
Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a wellestablished consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Key Words: Appropriateness criteria, head trauma, nonaccidental injury, pediatric, CT, MRI J Am Coll Radiol 2014;11:939-947. Copyright © 2014 American College of Radiology
a
Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois.
b
Children’s Hospital of Atlanta, Atlanta, Georgia.
c
University of Miami Health System, Miami, Florida.
r
Children’s Memorial Hospital, Chicago, Illinois.
s
Christiana Care Health System, Newark, Delaware; American College of Emergency Physicians, Irving, Texas.
d
t
e
u
f
v
University of Miami Jackson Memorial Hospital, Miami, Florida.
Riley Hospital for Children, Indiana University, Indianapolis, Indiana.
Texas Scottish Rite Hospital, Dallas, Texas.
g
C. S. Mott Children’s Hospital, Ann Arbor, Michigan. Children’s Hospitals, San Diego, California.
h i
Division of General and Hospital Pediatrics, Columbia, South Carolina.
j
American Academy of Pediatrics, Elk Grove Village, Illinois.
k
Children’s Healthcare of Atlanta, Atlanta, Georgia.
l
Seattle Children’s Hospital, Seattle, Washington.
m
New Jersey Pediatric Neuroscience Institute, Morristown, New Jersey.
n
American Association of Neurological Surgeons, Rolling Meadows, Illinois/ Congress of Neurological Surgeons, Schaumburg, Illinois.
o
St. Paul Radiology PA, St. Paul, Minnesota.
p
Duke University Medical Center, Durham, North Carolina.
q
American Pediatric Surgical Association, Deerfield, Illinois.
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.07.017
Massachusetts General Hospital, Boston, Massachusetts. University of California Davis, Sacramento, California. Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
Corresponding Author: Maura E. Ryan, MD, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave. Chicago, Illinois 60611; e-mail:
[email protected]. Reprint requests to:
[email protected]. The ACR seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Boaz K Karmazyn, MD, receives grant funding for research into CT dose and dose reduction techniques from Siemens Medical, but does not have any ownership in or receive any direct compensation from Siemens Medical.
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940 Journal of the American College of Radiology/Vol. 11 No. 10 October 2014
SUMMARY OF LITERATURE REVIEW Introduction/Background
Head trauma is a common indication for cranial imaging in children. Although the vast majority of head injuries are mild and do not require intervention [1], traumatic brain injury (TBI) remains a leading cause of death and disability in children [2]. As in adults, the necessity of identifying significant, potentially treatable injury must be weighed against appropriate resource utilization and the risks of performing imaging studies. However, several aspects of head trauma in the pediatric population deserve special attention. Children are more sensitive to ionizing radiation than adults, heightening concern for the effects of CT, which traditionally has been the primary imaging study for suspected TBI. MRI can detect traumatic lesions without radiation but often requires sedation in children, owing to the examination length and motion sensitivity. Clinical evaluation can be more difficult, particularly in preverbal children, and some indicators of adult injury, such as emesis, may not be as reliable in children [3,4]. Imaging assessment may also be more challenging in very young children because of the higher water content of incompletely myelinated white matter. Patterns of injury are different in this population as well. Children are more likely to sustain calvarial fractures due to a larger craniofacial ratio and thinner skull. Abused children may present with trauma from mechanisms not typically encountered in adults, such as repeated rotational forces. Furthermore, radiologic documentation, in addition to identification of injuries, presents a uniquely important challenge in evaluating children with suspected nonaccidental trauma. Minor Head Injury
The precise criteria for minor head injury are not consistent in the literature, but this usually refers to a patient with normal or near-normal postevent mental status; in pediatric studies, minor is often defined by a Glasgow Coma Score (GCS) of >13 [5]. Approximately 3%-5% of children with minor head trauma have abnormalities identifiable by imaging, and typically 2 years by the Pediatric Emergency Care Applied Research Network (PECARN) is the only very large, prospective study conducted exclusively in young patients. This study demonstrated a 99.9% negative predictive value and a 96.8% sensitivity for clinically important injury using the criteria of normal mental status and no loss of consciousness, vomiting, severe injury mechanism, signs of basilar skull fracture, or severe headache. [7]. See Variant 1 regarding head injury in patients age 2 years. Several other clinical algorithms for minor pediatric head trauma have been proposed from retrospective reviews, including the National Institute for Health and Care Excellence guidelines, Children’s Head Injury Algorithm for the Prediction of Important Clinical Events, and Canadian Assessment of Tomography for Childhood Head injury, among others [23-26]. These algorithms provide high sensitivity and negative predictive value but with variable specificity. Evidence is conflicting regarding the importance of several clinical risk factors. There are contradictory reports concerning the probability of traumatic head injury in children with headache, vomiting, loss of consciousness, and severe mechanisms of injury [10,27,28]. Kupperman et al determined a 13) at 2 years of age without neurologic signs or high-risk factors (eg, altered mental status, clinical evidence of basilar skull fracture). Excluding nonaccidental trauma Radiologic Procedure Rating Comments CT head without contrast
3
MRI head without contrast X-ray head CT head without and with contrast CT head with contrast CTA head with contrast MRI head without and with contrast MRA head without contrast MRA head without and with contrast Arteriography cerebral Ultrasound head FDG-PET/CT head Tc-99m HMPAO SPECT head
2 1 1
This is a known low-yield procedure.
1 1 1 1 1 1 1 1 1
Note: Rating scale: 1, 2, and 3 ¼ usually not appropriate; 4, 5, and 6 ¼ may be appropriate; 7, 8, and 9 ¼ usually appropriate. CTA ¼ CT angiography; FDG ¼ 18-fluoro-deoxyglucose; GCS ¼ Glasgow Coma Score; MRA ¼ MR angiography; SPECT ¼ single-positron emission CT.
[3,24,26,29]. The discrepancies are likely due to differences in the degree or duration of headache, number of emesis episodes, and definitions of severe mechanisms. The inconsistencies in the parameters evaluated complicate meta-analysis of these risk factors and likely contribute to the significant variability in CT rates among institutions [29,30]. In the PECARN study, CT imaging or observation was suggested in patients with risk factors other than altered mental status or basilar skull fracture based on physician experience, difficulty of examination, or worsening symptoms. No prediction model can completely replace clinical assessment, and physician judgment still plays a significant role in determining the imaging workup. Minor Head Injury in Patients Age
