Indications for head computed tomography in children with mild traumatic brain injury

The “Evidence Based Telemedicine Trauma and Emergency Surgery” (TBE-CITE) performed a critical appraisal of the literature and selected the three most relevant and recent publications on the indications for head computed tomography (CT) scan in pediatric patients with mild traumatic brain injury (TBI). The first study identified patients with mild TBI, high and low risk factors for intracranial injuries detected on CT scan and the need for neurosurgical intervention. The second evaluated the guidelines of the National Institute of Clinical Excellence for pediatric patients with TBI. The outcome of this study was either performing a head CT scan or hospital admission. The last study identified and analyzed the patients in whom the CT scan is not necessary and consequently should not be routinely indicated. Based on the critical appraisal of the literature and expert discussion, the opinion of the TBE-CITE was to favor the adoption of the PECARN guidelines, proposing CT scans for children with GCS of 14, altered level of consciousness and palpable skull fracture, or when warranted by the physician experience, multiple findings or worsening

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INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION
T raumatic brain injury (TBI) is one of the most common indications for hospitalization among children, and is often associated with important morbidity and mortality 1 .In the United States, approximately 150-180 children per 100,000 people are hospitalized annually.Seventyfour to 80% of these children are classified as having mild TBI according to the Glasgow Coma Scale (GCS) scores, of 13-15 2 .The majority of children sustaining mild TBI are discharged home after a brief period of observation in emergency departments.However, a small proportion (0.5%) of these pediatric patients might progress to neurological deterioration, requiring neurosurgical interventions 3,4 .Timely detection and evacuation of intracranial hematomas are fundamental for favorable neurological outcomes in this population.Computed tomography (CT) is the diagnostic method of choice for early detection of traumatic intracranial hematomas 4 .
The liberal use of head CT for mild TBI may unnecessarily expose children to ionizing radiation, which in turn may increase the risk of developing leukemia and brain tumors by up to three-fold.In addition, the widespread use of head CT in mild TBI further increases health care costs 5,6 .Although guidelines for the use of head CT for adult patients with mild TBI are available, the indications for head CT in pediatric trauma patients remain controversial due to the limited evidence available to guide its use 7,8 .Due to the high prevalence of TBI in children and consequent widespread use of head CT, development of guidelines for its rational use is urgent.
The participants of the Evidence-based Telemedicine -Trauma and Acute Care Surgery (EBT-TACS) journal club conducted a literature review, and herein critically appraise the three most relevant multicenter studies Ghizoni Ghizoni Ghizoni Ghizoni Ghizoni Indications for head computed tomography in children with mild traumatic brain injury on recommendations for head CT in mild TBI in pediatric populations.These studies represent medical practice in North America and Europe 9,10,11 .
Based on the evidence reviewed, recommendations for head CT in children with mild TBI were generated.STUDY   1).
The presence of at least one high risk factor had 100% sensitivity and 70,2% specificity for predicting the need for neurosurgical intervention, which would require that 30.2% of patients undergo head CT.
The presence of at least one high and one low risk factors had 98,1% sensitivity and 50,1% specificity for identifying intracranial lesions, which would require that 51.9% of patients undergo head CT.
2. The clinical decision rule was developed based on high sensitivity, which is reassuring for the clinician that, if used, patients who really requires head CT would not be missed.
3. The study first outcome is a composite outcome that includes not only CT findings but also the need for neurosurgical interventions, which addresses in part the issue that not all children had a head CT performed.
4. Head CTs reviewed by an independent radiologist, and by a second radiologist or a neurosurgeon in uncertain cases.If uncertainty persisted, the CT was considered normal.
5. Well-established inclusion criteria and trained outcome assessors.

Limitations Limitations Limitations
Limitations Limitations 1.Not all children in the study underwent head CT.Therefore, it is unknown whether some children were asymptomatic, but with intracranial lesions.
2. It was unclear why some children were excluded from the study.
3. The clinical decision rule needs to be validated, and its economic impact evaluated.
4. Although with high sensitivity, the clinical decision tool has low specificity, indicating the need for head CT in only 51.9% of children with mild TBI.Among these children, only 0.5% will require neurosurgical intervention and 4-7% will have intracranial lesions.
5. The subgroup of children under 2 years of age is small (23 cases), which limits generazability and precision of estimates.STUDY

Strenghts Strenghts Strenghts
Strenghts Strenghts 1.The study addresses an important public health issue.Implementing the NICE guidelines has the potential to decrease admission rates, and thus to reduce health care costs in head injury management.
2. Large multicenter study, which allows more precision in estimates and generazability of findings.
3. The study first outcome is a composite outcome that includes not only CT findings but also the need for neurosurgical interventions, which addresses in part the issue that not all children had a head CT performed.

Limitations Limitations Limitations
Limitations Limitations 1.The study utilized data from a prospective multicenter study; thus, it retrospectively applied the guidelines based on simulation.
2. The outcomes were the need for head radiographs or CTs, and need for hospital admission.It  Children without any risk factors listed on the table can be classified as being low-risk, and do not require head CT (< 2 years -53.5%; 2 years or older -58.3%).In children under 2 years, the clinical rule both had a negative predictive value and a sensitivity of 100%; whilst in children 2 years or older, its negative predictive value and sensitivity were 99.95% and 96.8%, respectively.

Strenghts Strenghts Strenghts
Strenghts Strenghts 1. Patients with GCS < 14, where the risk of a positive head CT is 20%, were excluded, which prevented artificially improving the clinical decision rule performance.Similarly, asymptomatic patients and patients with nonsignificant mechanisms of trauma were excluded.
2. Large prospective multicenter study, which allowed the development of specific criteria for the subgroup of children less than 2 years of age.

Table 1 Table 1 -
Risk factors for the presence of intracranial lesion.
-Any signs of basal skull fracture -Large subgaleal hematoma -Significant mechanism of trauma (motor vehicle collision, fall from 1 m or 5 steps, bicycle collision without helmet)

Table 2 -Table 2 -Table 2 -Table 2 -Table 2 -
NICE guidelines for performing head CT in high-risk patients.