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Narang SK, Haney S, Duhaime AC, Martin J, Binenbaum G, de Alba Campomanes AG, Barth R, Bertocci G, Care M, McGuone D. Abusive Head Trauma in Infants and Children: Technical Report. Pediatrics 2025; 155:e2024070457. [PMID: 39992695 DOI: 10.1542/peds.2024-070457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2025] Open
Affiliation(s)
- Sandeep K Narang
- Professor of Pediatrics, Medical College of Wisconsin; Chief, Section of Child Advocacy and Protection, Child Advocacy and Protection Services, Children's Wisconsin, Milwaukee, Wisconsin
| | - Suzanne Haney
- Children's Nebraska and University of Nebraska Medical Center, Omaha, Nebraska
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jonathan Martin
- Division Head, Neurosurgery, Connecticut Children's; Professor, Surgery and Pediatrics, UConn School of Medicine, Farmington, Connecticut
| | - Gil Binenbaum
- Division of Ophthalmology at Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Rich Barth
- Department of Radiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Gina Bertocci
- Department of Bioengineering, University of Louisville, Louisville, Kentucky
| | - Margarite Care
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine; Associate Medical Examiner, Connecticut Office of the Chief Medical Examiner, New Haven, Connecticut
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2
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Franklin D, Tiwari C, Zamora C, Barnett R, Woolard A, Hung SC, Berkoff M, Quinsey C. Combined rapid sequence MRI protocol and skull radiography as an alternative to head CT in the evaluation of abusive head trauma in children: a pilot study. Neurosurg Rev 2023; 46:175. [PMID: 37450200 DOI: 10.1007/s10143-023-02084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/21/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
The aim of our pilot study was to compare the performance of the RS-MRI protocol combined with skull radiography versus CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage in patients with abusive head trauma (AHT). Additionally, our study aimed to determine whether the presence of scalp hematoma predicts concurrent skull fracture. We conducted a pilot study through retrospective chart review of 24 patients between ages 0 and 15 months who experienced AHT and who received CT, MRI, and skull radiography between May 2020 and August 2021. Two blinded board certified neuroradiologists reviewed the skull radiographs alongside the rapid trauma MRI. Their impressions were documented and compared with findings derived from CT. Combination imaging detected ten out of the 12 skull fractures noted on CT (sensitivity 83.3%, specificity 100%, p=0.48). RS-MRI detected 15 out of the 16 intracranial hemorrhages detected by CT (sensitivity 93.75%, p >0.9). When scalp hematoma was detected on RS-MRI, nine out of the 12 had associated skull fractures when reviewed by radiologist 1 (sensitivity 75%, specificity 100%, p=0.22), and seven out of the 12 had associated skull fractures when reviewed by radiologist 2 (sensitivity 58%, specificity 92%, p=0.25). In pediatric patients with suspected AHT, we found that RS-MRI combined with skull radiographs was not significantly different than CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage. This combination has the potential to replace the use of CT as a screening tool for abusive head trauma, while avoiding the risks of sedation often required for routine MRI.
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Affiliation(s)
- Deveney Franklin
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.
- University of North Carolina Department of Neurosurgery, Chapel Hill, NC, USA.
| | - Chhitij Tiwari
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- University of North Carolina Department of Neurosurgery, Chapel Hill, NC, USA
| | - Carlos Zamora
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- University of North Carolina Department of Radiology, Chapel Hill, NC, USA
| | - Randaline Barnett
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- University of North Carolina Department of Neurosurgery, Chapel Hill, NC, USA
| | - Alice Woolard
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Curriculum of Bioinformatics and Computational Biology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sheng-Che Hung
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- University of North Carolina Department of Radiology, Chapel Hill, NC, USA
| | - Molly Berkoff
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- University of North Carolina Department of Pediatrics, Chapel Hill, NC, USA
| | - Carolyn Quinsey
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- University of North Carolina Department of Neurosurgery, Chapel Hill, NC, USA
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3
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Branson HM, Martinez-Rios C. Conventional MR Imaging in Trauma Management in Pediatrics. Neuroimaging Clin N Am 2023; 33:251-260. [PMID: 36965943 DOI: 10.1016/j.nic.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability in children across the world. The aim of initial brain trauma management of pediatric patients is to diagnose the extent of TBI and to determine if immediate neurosurgical intervention is required. A noncontrast computed tomography is the recommended diagnostic imaging choice for all patients with acute moderate to severe TBI. This article outlines the current use of conventional MR imaging in the management of pediatric head trauma and discusses potential future recommendations.
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Affiliation(s)
- Helen M Branson
- Department of Diagnostic Imaging, SickKids, University of Toronto, 555 University Avenue, Toronto, Ontario M5G1X8, Canada.
| | - Claudia Martinez-Rios
- Department of Diagnostic Imaging, SickKids, University of Toronto, 555 University Avenue, Toronto, Ontario M5G1X8, Canada; Department of Medical Imaging, CHEO, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
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Cicogna A, Minca G, Posocco F, Corno F, Basile C, Da Dalt L, Bressan S. Non-ionizing Imaging for the Emergency Department Assessment of Pediatric Minor Head Trauma. Front Pediatr 2022; 10:881461. [PMID: 35633980 PMCID: PMC9132372 DOI: 10.3389/fped.2022.881461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians' decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.
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Affiliation(s)
| | | | | | | | | | | | - Silvia Bressan
- Division of Pediatric Emergency Medicine, Department of Women’s and Children’s Health, University of Padova, Padua, Italy
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5
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Abstract
Clinicians often miss making the diagnosis of abusive head injury in infants and toddlers who present with mild, non-specific symptoms such as vomiting, fussiness, irritability, trouble sleeping and eating, and seizure. If abusive head injury is missed, the child is likely to go on to experience more severe injury. An extensive review of the medical literature was done to summarize what is known about missed abusive head injury and about how these injuries can be recognized and appropriately evaluated. The following issues will be addressed: the definition of mild head injury, problems encountered when clinicians evaluated mildly ill young children with non-specific symptoms, the risk of missing the diagnosis of mild abusive head trauma, the risks involved in subjecting infants and young children to radiation and/or sedation required for neuroimaging studies, imaging options for suspected neurotrauma in children, clinical prediction rules for evaluating mild head injury in children, laboratory tests than can be helpful in diagnosing mild abusive head injury, history and physical examination when diagnosing or ruling out mild abusive head injury, social and family factors that could be associated with abusive injuries, and interventions that could improve our recognition of mild abusive head injuries. Relevant literature is described and evaluated. The conclusion is that abusive head trauma remains a difficult diagnosis to identify in mildly symptomatic young children.
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Kabakus IM, Spampinato MV, Knipfing M, Cervantes G, Patel A, Eskandari R, Yazdani M. Fast Brain Magnetic Resonance Imaging With Half-Fourier Acquisition With Single-Shot Turbo Spin Echo Sequence in Detection of Intracranial Hemorrhage and Skull Fracture in General Pediatric Patients: Preliminary Results. Pediatr Emerg Care 2021; 37:e1168-e1172. [PMID: 31804431 DOI: 10.1097/pec.0000000000001949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the accuracy of fast brain magnetic resonance imaging (MRI) in the detection of intra- and extra-axial intracranial hemorrhage compared with standard-of-care computed tomography (CT) or MRI in pediatric patients. Unlike previous studies, we did not focus exclusively on patients with head trauma. We evaluated the fast brain MRI findings in a general pediatric population referred for indications other than evaluation of ventricular size. METHODS We retrospectively reviewed 48 pediatric patients with indications other than hydrocephalus and shunt follow-up, who underwent a standard head CT or standard MRI within 15 days of the fast brain MRI. All fast brain MRI scans included half-Fourier acquisition with single-shot turbo spin echo (HASTE) sequences in the axial, coronal, and sagittal plane. Two neuroradiologists blinded to patient information and study indications reviewed the fast brain MRI studies independently and then concurrently. RESULTS A total of 48 patients met the inclusion and exclusion criteria. The median and mean time interval between the standard and fast imaging were 2 and 3.9 days, respectively. The sensitivity and specificity of fast brain MRI to detect intraparenchymal hemorrhage were 100% and 97%, respectively. The sensitivity and specificity of fast brain MRI in the detection of extra-axial hemorrhage (subdural and/or epidural) were 86% and 96%, respectively. The sensitivity and specificity of fast brain MRI were, respectively, 10% and 100% for subarachnoid hemorrhage, 50% and 100% for intraventricular hemorrhage, and 47% and 97% for skull fracture, respectively. CONCLUSIONS Our results show that fast brain MRI with HASTE sequence is as sensitive as CT and standard MRI in the detection of intra-axial hemorrhage and has moderate sensitivity in the detection of extra-axial hemorrhage. Our preliminary results show that T2-weighted HASTE imaging may be suitable for the follow-up of intraparenchymal and extra-axial (subdural and/or epidural) hemorrhages.
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Affiliation(s)
| | | | | | | | | | - Ramin Eskandari
- Neurosurgery, Medical University of South Carolina, Charleston, SC
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Kessler BA, Goh JL, Pajer HB, Asher AM, Northam WT, Hung SC, Selden NR, Quinsey CS. Rapid-sequence MRI for evaluation of pediatric traumatic brain injury: a systematic review. J Neurosurg Pediatr 2021; 28:278-286. [PMID: 34171833 DOI: 10.3171/2021.2.peds20852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rapid-sequence MRI (RSMRI) of the brain is a limited-sequence MRI protocol that eliminates ionizing radiation exposure and reduces imaging time. This systematic review sought to examine studies of clinical RSMRI use for pediatric traumatic brain injury (TBI) and to evaluate various RSMRI protocols used, including their reported accuracy as well as clinical and systems-based limitations to implementation. METHODS PubMed, EMBASE, and Web of Science databases were searched, and clinical articles reporting the use of a limited brain MRI protocol in the setting of pediatric head trauma were identified. RESULTS Of the 1639 articles initially identified and reviewed, 13 studies were included. An additional article that was in press at the time was provided by its authors. The average RSMRI study completion time was variable, spanning from 1 minute to 16 minutes. RSMRI with "blood-sensitive" sequences was more sensitive for detection of hemorrhage compared with head CT (HCT), but less sensitive for detection of skull fractures. Compared with standard MRI, RSMRI had decreased sensitivity for all evidence of trauma. CONCLUSIONS Protocols and uses of RSMRI for pediatric TBI were variable among the included studies. While traumatic pathology missed by RSMRI, such as small hemorrhages and linear, nondisplaced skull fractures, was frequently described as clinically insignificant, in some cases these findings may be prognostically and/or forensically significant. Institutions should integrate RSMRI into pediatric TBI management judiciously, relying on clinical context and institutional capabilities.
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Affiliation(s)
| | - Jo Ling Goh
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Hengameh B Pajer
- 3Campbell University School of Osteopathic Medicine, Buies Creek, North Carolina and
| | | | | | - Sheng-Che Hung
- 5Division of Neuroradiology, Department of Radiology
- 6Biomedical Research Imaging Center, University of North Carolina, Chapel Hill
| | - Nathan R Selden
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Abstract
Mild traumatic brain injury accounts for an estimated 4.8 million cases of pediatric traumatic brain injuries worldwide every year. In the United States, 70% of mild traumatic brain injury cases are due to sports and recreational injuries. Early diagnosis, especially in active children, is critical to preventing recurrent injuries. Management is guided by graded protocols for returning to school and activity. Ninety percent of children recover within 1 month of injury. Promising research has shown that early referral to specialty concussion care and multidisciplinary treatment with physical and occupational therapy may shorten recovery time and improve neurologic outcomes.
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Affiliation(s)
- Aaron M Yengo-Kahn
- Department of Neurosurgery, Vanderbilt University Medical Center, Medical Center North, Suite T-4224, 1161 21st Avenue South, Nashville, TN 37232, USA
| | - Rebecca A Reynolds
- Department of Neurosurgery, Vanderbilt University Medical Center, Medical Center North, Suite T-4224, 1161 21st Avenue South, Nashville, TN 37232, USA
| | - Christopher M Bonfield
- Department of Neurosurgery, Vanderbilt University Medical Center, Medical Center North, Suite T-4224, 1161 21st Avenue South, Nashville, TN 37232, USA.
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9
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Lawson M, Tully J, Ditchfield M, Metcalfe P, Qi Y, Kuganesan A, Badawy MK. A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury. J Med Imaging Radiat Oncol 2021; 66:68-78. [PMID: 34176229 DOI: 10.1111/1754-9485.13270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.
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Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joanna Tully
- Victorian Forensic Paediatric Medical Service, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Ditchfield
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Metcalfe
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Yujin Qi
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Mohamed K Badawy
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Jaimes C, Robson CD, Machado-Rivas F, Yang E, Mahan K, Bixby SD, Robertson RL. Success of Nonsedated Neuroradiologic MRI in Children 1-7 Years Old. AJR Am J Roentgenol 2021; 216:1370-1377. [PMID: 32783551 DOI: 10.2214/ajr.20.23654] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND. MRI use and the need for monitored anesthesia care (MAC) in children have increased. However, MAC is associated with examination delays, increased cost, and safety concerns. OBJECTIVE. The purpose of this study was to evaluate the success rate of nonsedated neuroradiologic MRI studies in children 1-7 years old and to investigate factors associated with success. METHODS. We retrospectively reviewed data from our institutional nonsedated MRI program. Inclusion criteria were outpatient nonsedated MRI referral, age 1-7 years old, and neuroradiologic indication. Exclusion criteria were MRI examinations for ventricular checks and contrast material use. Success was determined by reviewing the clinical MRI report. We recorded patient age and sex, type of MRI examination (brain, spine, craniospinal, head and neck, and brain with MRA), protocol length, presence of child life specialist, video goggle use, and MRI appointment time (routine daytime appointment or evening appointment). We used descriptive statistics to summarize patient demographics and clinical data and logistic regression models to evaluate predictors of success in the entire sample. Subset analyses were performed for children from 1 to < 3 years old and 3 to 7 years old. RESULTS. We analyzed 217 patients who underwent nonsedated MRI examinations (median age, 5.1 years). Overall success rate was 82.0% (n = 178). The success rates were 81.4% (n = 127) for brain, 90.3% (n = 28) for spine, 71.4% (n = 10) for craniospinal, 66.7% (n = 6) for head and neck, and 100% (n = 7) for brain with MRA. Age was significantly associated with success (odds ratio [OR], 1.33; p = .009). In children 1 to < 3 years old, none of the factors analyzed were significant predictors of success (all, p > .48). In children 3-7 years old, protocol duration (OR, 0.96; 95% CI, 0.93-0.99; p = .02) and video goggle use (OR, 6.38; 95% CI, 2.16-18.84; p = .001) were significantly associated with success. CONCLUSION. A multidisciplinary approach with age-appropriate resources enables a high success rate for nonsedated neuroradiologic MRI in children 1-7 years old. CLINICAL IMPACT. Using age as the primary criterion to determine the need for MAC may lead to overuse of these services. Dissemination of information regarding nonsedated MRI practice could reduce the rate of sedated MRI in young children.
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Affiliation(s)
- Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02215
- Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Caroline D Robson
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02215
- Harvard Medical School, Boston, MA
| | - Fedel Machado-Rivas
- Harvard Medical School, Boston, MA
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02215
- Harvard Medical School, Boston, MA
| | - Kellyn Mahan
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02215
| | - Sarah D Bixby
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02215
- Harvard Medical School, Boston, MA
| | - Richard L Robertson
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02215
- Harvard Medical School, Boston, MA
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Shope C, Alshareef M, Larrew T, Bolling C, Reagan J, Yazdani M, Spampinato M, Eskandari R. Utility of a pediatric fast magnetic resonance imaging protocol as surveillance scanning for traumatic brain injury. J Neurosurg Pediatr 2021; 27:475-481. [PMID: 33545669 DOI: 10.3171/2020.8.peds20496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a prevalent pediatric pathology in the modern emergency department. Computed tomography (CT) is utilized for detection of TBI and can result in cumulatively high radiation exposure. Recently, a fast brain magnetic resonance imaging (fbMRI) protocol has been employed for rapid imaging of hydrocephalus in pediatric patients. The authors investigate the utility of a modified trauma-focused fbMRI (t-fbMRI) protocol as an alternative to surveillance CT in the setting of acute TBI in pediatric patients, thus reducing radiation exposure while improving diagnostic yield. METHODS A retrospective review was performed at the authors' institution for all pediatric patients who had undergone t-fbMRI within 72 hours of an initial CT scan, using a 1.5- or 3-T MR scanner for trauma indications. Forty patients met the study inclusion criteria. The authors performed a comparison of findings on the reads of CT and fbMRI, and a board-certified neuroradiologist conducted an independent review of both modalities. RESULTS T-fbMRI outperformed CT in specificity, sensitivity, and negative predictive value for all injury pathologies measured, except for skull fractures. T-fbMRI demonstrated a sensitivity of 100% in the detection of extraaxial bleed, intraventricular hemorrhage, and subarachnoid hemorrhage and had a sensitivity of 78% or greater for epidural hematoma, subdural hematoma, and intraparenchymal hemorrhage. T-fbMRI yielded a specificity of 100% for all types of intracranial hemorrhages, with a corresponding negative predictive value that exceeded that for CT. CONCLUSIONS In pediatric populations, the t-fbMRI protocol provides a valid alternative to CT in the surveillance of TBI and intracranial hemorrhage. Although not as sensitive in the detection of isolated skull fractures, t-fbMRI can be used to monitor pathologies implicated in TBI patients while minimizing radiation exposure from traditional surveillance imaging.
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Affiliation(s)
- Chelsea Shope
- 1College of Medicine, Medical University of South Carolina; and
| | | | | | - Christopher Bolling
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Justin Reagan
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Milad Yazdani
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Maria Spampinato
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
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Cartocci G, Fineschi V, Padovano M, Scopetti M, Rossi-Espagnet MC, Giannì C. Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma. Brain Sci 2021; 11:179. [PMID: 33535601 PMCID: PMC7912837 DOI: 10.3390/brainsci11020179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/10/2023] Open
Abstract
In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration-deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice.
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Affiliation(s)
- Gaia Cartocci
- Emergency Radiology Unit, Department of Radiological, Oncological and Pathological Sciences, Umberto I University Hospital, Sapienza University of Rome, 00198 Rome, Italy;
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Maria Camilla Rossi-Espagnet
- Neuroradiology Unit, NESMOS Department, Sapienza University, 00185 Rome, Italy;
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Costanza Giannì
- Department of Human Neurosciences, Sapienza University of Rome, 00198 Rome, Italy;
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13
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Abstract
Emergent imaging of the brain is often required to diagnose and manage serious and life-threatening conditions for children presenting to the emergency department. In an effort to reduce children's exposure to ionizing radiation, the use of magnetic resonance imaging (MRI) as an alternative to computed tomography (CT) is increasing. In some conditions, an urgent MRI rather than CT is critical for making management decisions. The purpose of this review is to highlight 3 emergency medical conditions-acute stroke, traumatic brain injury, and hydrocephalus-in which timely MRI of the brain is required for diagnosis and management. Another aim will be to guide providers in determining when and what limited MRI sequences of the brain can be used in lieu of CT in these emergency medical conditions.
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14
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Lindberg DM. Abusive and Nonabusive Traumatic Brain Injury: Different Diseases, Not Just Different Intent. J Pediatr 2020; 227:15-16. [PMID: 32828884 DOI: 10.1016/j.jpeds.2020.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado.
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15
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Lumba‐Brown A, Lee MO, Brown I, Cornwell J, Dannenberg B, Fang A, Ghazi‐Askar M, Grant G, Imler D, Khanna K, Lowe J, Wang E, Wintermark M. Emergency department implementation of abbreviated magnetic resonance imaging for pediatric traumatic brain injury. J Am Coll Emerg Physicians Open 2020; 1:994-999. [PMID: 33145550 PMCID: PMC7593499 DOI: 10.1002/emp2.12055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/19/2020] [Accepted: 03/05/2020] [Indexed: 12/26/2022] Open
Abstract
Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.
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Affiliation(s)
| | - Moon O. Lee
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | - Ian Brown
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | - Jordan Cornwell
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | | | - Andrea Fang
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | | | - Gerald Grant
- Department of NeurosurgeryStanford UniversityStanfordCalifornia
| | - Daniel Imler
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | - Kajal Khanna
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | - Jason Lowe
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | - Ewen Wang
- Department of Emergency MedicineStanford UniversityStanfordCalifornia
| | - Max Wintermark
- Department of RadiologyStanford UniversityStanfordCalifornia
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16
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Torres ER, Tumey TA, Dean DC, Kassahun-Yimer W, Lopez-Lambert ED, Hitchcock ME. Non-pharmacological strategies to obtain usable magnetic resonance images in non-sedated infants: Systematic review and meta-analysis. Int J Nurs Stud 2020; 106:103551. [PMID: 32294563 DOI: 10.1016/j.ijnurstu.2020.103551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although the use of sedation is commonly practiced to keep infants still while receiving magnetic resonance imaging, non-pharmacological strategies are a potential alternative. OBJECTIVES The purpose of this study was to determine the success rate of obtaining usable magnetic resonance images in infants with the sole use of non-pharmacological strategies. DESIGN Systematic literature review and meta-analysis SETTING: A search was conducted in PubMed, CINAHL and Cochrane Library. PARTICIPANTS Human infants from birth to 24 months of age who did not receive any sedation or anesthesia during magnetic resonance imaging METHOD: Articles that reported the success rate of obtaining usable images were included. RESULTS Of the 521 non-duplicate articles found, 58 articles were included in the systematic review with sample sizes ranging from 2-457, an average success rate of 87.8%, and an average scan time of 30 min. The most common non-pharmacological technique included feeding and swaddling infants before imaging to encourage infants to sleep during the scan. Meta-analysis performed on 53 articles comprising 3,410 infants found a success rate of 87%, but significant heterogeneity was found (I2 = 98.30%). It was more difficult to obtain usable images solely with non-pharmacological techniques if infants were critically ill or a structural magnetic resonance imaging of the brain was required. CONCLUSION Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most but not all infants. Tweetable abstract: Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most infants.
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Affiliation(s)
- Elisa R Torres
- School of Nursing, University of Mississippi Medical Center, 2500 North State Street, Jackson 39216, MS, United States.
| | - Tyler A Tumey
- Burrell College of Osteopathic Medicine, 3501 Arrowhead Dr Las Cruces, NM 88001, United States.
| | - Douglas C Dean
- Waisman Center, University of Wisconsin-Madison, 1500 Highland Ave, Madison WI 53705, United States.
| | - Wondwosen Kassahun-Yimer
- Department of Data Science, University of Mississippi Medical Center, School of Population Health,2500 North State Street, Jackson, MS 39216, United States.
| | - Eloise D Lopez-Lambert
- School of Nursing, University of Mississippi Medical Center, 2500 North State Street, Jackson 39216, MS, United States
| | - Mary E Hitchcock
- Ebling Library, University of Wisconsin-Madison, 750 Highland Ave, Madison WI 53705, United States.
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17
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Berger RP, Furtado AD, Flom LL, Fromkin JB, Panigrahy A. Implementation of a brain injury screen MRI for infants at risk for abusive head trauma. Pediatr Radiol 2020; 50:75-82. [PMID: 31901990 DOI: 10.1007/s00247-019-04506-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/19/2019] [Accepted: 08/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Head computed tomography (CT) is the current standard of care for evaluating infants at high risk of abusive head trauma. OBJECTIVE To both assess the feasibility of using a previously developed magnetic resonance imaging (MRI) brain injury screen (MRBRscreen) in the acute care setting in place of head CT to identify intracranial hemorrhage in high-risk infants and to compare the accuracy of a rapid imaging pulse sequence (single-shot T2 fast spin echo [ssT2FSE]) to a conventional pulse sequence (conventional T2 fast spin echo [conT2FSE]). MATERIALS AND METHODS This was a quality improvement initiative to evaluate infants <12 months of age who were screened for intracranial hemorrhage using an MRBRscreen as part of clinical care. The MRBRscreen included axial conT2FSE, axial gradient recalled echo, coronal T1-weighted inversion recovery, axial diffusion-weighted image and an axial ssT2FSE. A comparison of ssT2FSE to conT2FSE with respect to lesion detection was also performed. RESULTS Of 158 subjects, the MRBRscreen was able to be completed in 155 (98%); 9% (14/155) were abnormal. Ninety-four percent (137/145) of subjects underwent only an MRBRscreen and avoided both radiation from head CT and sedation from MRI. The axial ssT2FSE and conT2FSE results were congruent 99% of the time. CONCLUSION An MRBRscreen in place of a head CT is feasible and potentially could decrease head CT use by more than 90% in this population. Using a rapid ssT2FSE in place of a conT2FSE can reduce total scan time without losing lesion detection. If an MRBRscreen is readily available, physicians' threshold to perform neuroimaging may be lowered and lead to earlier detection of abusive head trauma.
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Affiliation(s)
- Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4117 Penn Ave., Pittsburgh, PA, 15224, USA.
| | - Andre D Furtado
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lynda L Flom
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Janet B Fromkin
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4117 Penn Ave., Pittsburgh, PA, 15224, USA
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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18
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Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. J Neurosurg Pediatr 2019; 24:481-488. [PMID: 31675688 DOI: 10.3171/2019.7.peds18394] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
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Affiliation(s)
- Ann-Christine Duhaime
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Cindy W Christian
- 2Department of Pediatrics, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Lindberg DM, Stence NV, Grubenhoff JA, Lewis T, Mirsky DM, Miller AL, O'Neill BR, Grice K, Mourani PM, Runyan DK. Feasibility and Accuracy of Fast MRI Versus CT for Traumatic Brain Injury in Young Children. Pediatrics 2019; 144:peds.2019-0419. [PMID: 31533974 DOI: 10.1542/peds.2019-0419] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Computed tomography (CT) is commonly used for children when there is concern for traumatic brain injury (TBI) and is a significant source of ionizing radiation. Our objective was to determine the feasibility and accuracy of fast MRI (motion-tolerant MRI sequences performed without sedation) in young children. METHODS In this prospective cohort study, we attempted fast MRI in children <6 years old who had head CT performed and were seen in the emergency department of a single, level 1 pediatric trauma center. Fast MRI sequences included 3T axial and sagittal T2 single-shot turbo spin echo, axial T1 turbo field echo, axial fluid-attenuated inversion recovery, axial gradient echo, and axial diffusion-weighted single-shot turbo spin echo planar imaging. 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 Among 299 participants, fast MRI was available and attempted in 225 (75%) and completed in 223 (99%). Median imaging time was 59 seconds (interquartile range 52-78) for CT and 365 seconds (interquartile range 340-392) for fast MRI. TBI was identified by CT in 111 (50%) participants, including 81 skull fractures, 27 subdural hematomas, 24 subarachnoid hemorrhages, and 35 other injuries. Fast MRI identified TBI in 103 of these (sensitivity 92.8%; 95% confidence interval 86.3-96.8), missing 6 participants with isolated skull fractures and 2 with subarachnoid hemorrhage. CONCLUSIONS Fast MRI is feasible and accurate relative to CT in clinically stable children with concern for TBI.
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Affiliation(s)
- Daniel M Lindberg
- School of Medicine, University of Colorado, Denver, Colorado .,Departments of Pediatrics.,Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, and.,Emergency Medicine
| | - Nicholas V Stence
- School of Medicine, University of Colorado, Denver, Colorado.,Radiology, and
| | - Joseph A Grubenhoff
- School of Medicine, University of Colorado, Denver, Colorado.,Departments of Pediatrics
| | - Terri Lewis
- School of Medicine, University of Colorado, Denver, Colorado.,Departments of Pediatrics.,Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, and
| | - David M Mirsky
- School of Medicine, University of Colorado, Denver, Colorado.,Radiology, and
| | - Angie L Miller
- School of Medicine, University of Colorado, Denver, Colorado.,Radiology, and
| | - Brent R O'Neill
- School of Medicine, University of Colorado, Denver, Colorado.,Neurosurgery
| | - Kathleen Grice
- School of Medicine, University of Colorado, Denver, Colorado.,Departments of Pediatrics
| | - Peter M Mourani
- School of Medicine, University of Colorado, Denver, Colorado.,Departments of Pediatrics.,Section of Critical Care
| | - Desmond K Runyan
- School of Medicine, University of Colorado, Denver, Colorado.,Departments of Pediatrics.,Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, and
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20
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Burstein B, Saint-Martin C. The Feasibility of Fast MRI to Reduce CT Radiation Exposure With Acute Traumatic Head Injuries. Pediatrics 2019; 144:peds.2019-2387. [PMID: 31533973 DOI: 10.1542/peds.2019-2387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Brett Burstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics and
| | - Christine Saint-Martin
- Division of Pediatric Medical Imaging, Department of Diagnostic Radiology, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
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21
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Janos S, Schooler GR, Ngo JS, Davis JT. Free-breathing unsedated MRI in children: Justification and techniques. J Magn Reson Imaging 2019; 50:365-376. [DOI: 10.1002/jmri.26644] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 12/16/2022] Open
Affiliation(s)
- Sara Janos
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
| | - Gary R. Schooler
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
| | - Jennifer S. Ngo
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
| | - Joseph T. Davis
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
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22
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Greenberg JK, Yan Y, Carpenter CR, Lumba-Brown A, Keller MS, Pineda JA, Brownson RC, Limbrick DD. Development of the CIDSS 2 Score for Children with Mild Head Trauma without Intracranial Injury. J Neurotrauma 2018; 35:2699-2707. [PMID: 29882466 DOI: 10.1089/neu.2017.5324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
While most children with mild traumatic brain injury (mTBI) without intracranial injury (ICI) can be safely discharged home from the emergency department, many are admitted to the hospital. To support evidence-based practice, we developed a decision tool to help guide hospital admission decisions. This study was a secondary analysis of a prospective study conducted in 25 emergency departments. We included children under 18 years who had Glasgow Coma Scale score 13-15 head injuries and normal computed tomography scans or skull fractures without significant depression. We developed a multi-variable model that identified risk factors for extended inpatient management (EIM; defined as hospitalization for 2 or more nights) for TBI, and used this model to create a clinical risk score. Among 14,323 children with mTBI without ICI, 20% were admitted to the hospital but only 0.76% required EIM for TBI. Key risk factors for EIM included Glasgow Coma Scale score less than 15 (odds ratio [OR] = 8.1; 95% confidence interval [CI] 4.0-16.4 for 13 vs. 15), drug/alcohol Intoxication (OR = 5.1; 95% CI 2.4-10.7), neurological Deficit (OR = 3.1; 95% CI 1.4-6.9), Seizure (OR = 3.7; 95% CI 1.8-7.8), and Skull fracture (odds ratio [OR] 24.5; 95% CI 16.0-37.3). Based on these results, the CIDSS2 risk score was created. The model C-statistic was 0.86 and performed similarly in children less than (C = 0.86) and greater than or equal to 2 years (C = 0.86). The CIDSS2 score is a novel tool to help physicians identify the minority of children with mTBI without ICI at increased risk for EIM, thereby potentially aiding hospital admission decisions.
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Affiliation(s)
- Jacob K Greenberg
- 1 Department of Neurological Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Yan Yan
- 2 Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Christopher R Carpenter
- 5 Division of Emergency Medicine, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Angela Lumba-Brown
- 8 Department of Emergency Medicine, Stanford University , Stanford, California
| | - Martin S Keller
- 2 Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Jose A Pineda
- 3 Department of Pediatrics, Washington University School of Medicine in St. Louis , St. Louis, Missouri.,4 Department of Neurology, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Ross C Brownson
- 2 Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri.,6 Alvin J. Siteman Cancer Center, Washington University School of Medicine in St. Louis , St. Louis, Missouri.,7 Prevention Research Center, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - David D Limbrick
- 1 Department of Neurological Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
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23
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Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018; 172:e182853. [PMID: 30193284 PMCID: PMC7006878 DOI: 10.1001/jamapediatrics.2018.2853] [Citation(s) in RCA: 311] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.
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Affiliation(s)
| | | | - Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Matthew J Breiding
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Gerard A Gioia
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | | | | | - Stacy J Suskauer
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Giza
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | | | - Catherine Broomand
- Center for Neuropsychological Services, Kaiser Permanente, Roseville, California
| | | | - Wayne Gordon
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Karen McAvoy
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Linda Ewing-Cobbs
- Children's Learning Institute, Department of Pediatrics, University of Texas (UT) Health Science Center at Houston
| | | | - Margot Putukian
- University Health Services, Princeton University, Princeton, New Jersey
| | | | | | - Shari L Wade
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Meeryo Choe
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | - Cindy W Christian
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - P B Raksin
- John H. Stroger, Jr Hospital of Cook County (formerly Cook County Hospital), Chicago, Illinois
| | - Andrew Gregory
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anne Mucha
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | - H Gerry Taylor
- Nationwide Children's Hospital Research Institute, Columbus, Ohio
| | - James M Callahan
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - John DeWitt
- Jameson Crane Sports Medicine Institute, School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | | | - John Ragheb
- Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Theodore J Spinks
- Department of Pediatric Neurosurgery, St Joseph's Children's Hospital, Tampa, Florida
| | | | | | | | | | - Tom Getchius
- American Academy of Neurology, Minneapolis, Minnesota
| | | | - Zoe Donnell
- Social Marketing Group, ICF, Rockville, Maryland
| | | | - Shelly D Timmons
- Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
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24
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MRI in mild pediatric traumatic brain injury: diagnostic overkill or useful tool? Childs Nerv Syst 2018; 34:1345-1352. [PMID: 29556697 DOI: 10.1007/s00381-018-3771-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 03/01/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE Magnetic resonance imaging (MRI) is a sensitive imaging tool which lacks the burden of ionizing radiation. It is not established as primary diagnostic tool in traumatic brain injury (TBI). The purpose of this study was to evaluate the usefulness of MRI as initial imaging modality in the emergency management of mild pediatric TBI. METHODS Children (0-18 years, sub-divided in four age-groups) with mild TBI who received MRI in the emergency department were identified. Clinical characteristics and trauma mechanisms were evaluated retrospectively. Univariate and multivariate logistic regression analyses were used to identify clinical factors that might be indicative for trauma sequelae on MRI scans. RESULTS An institutional case series of 569 patients (322 male/247 female; age < 18years; (GCS ≥ 13), who received MRI for mild TBI, was analyzed. Multi-sequence imaging (including T2, T2*, FLAIR, and diffusion-weighted sequences) was feasible without sedation in 96.8% of cases (sedation, 1.8%; general anesthesia, 1.4%). MRI revealed trauma-associated findings in 13% of all cases; incidental findings were detected in 4.7%. In our cohort, GCS deterioration, scalp hematoma, clinical signs of skull base fractures, and horseback riding accidents were related to structural trauma sequelae on MRI. CONCLUSIONS MRI is a practical primary imaging tool for evaluating children with mild TBI in the emergency department. The presented analyses demonstrated that in our institution, MRI imaging is performed frequently in the emergency department. It resulted mostly in normal findings. This may reflect uneasiness of when to perform imaging in mild TBI and appears retrospectively as an "overdo." There are clinical factors that are more likely associated with MRI-positive findings. Their reliability has to be evaluated in prospective studies in order to formulate further decision rules of when to perform MRI imaging or not.
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25
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Pediatric Emergency MRI: What You Need to Know to Make It Through the Night. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0248-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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