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Routine repeat brain computed tomography in all children with mild traumatic brain injury may result in unnecessary radiation exposure

Howe, Jarett MD; Fitzpatrick, Colleen M. MD; LaKam, Dana Rachel MD; Gleisner, Ana MD, PhD; Vane, Dennis W. MD, MBA

Journal of Trauma and Acute Care Surgery: February 2014 - Volume 76 - Issue 2 - p 292–296
doi: 10.1097/TA.0000000000000119
AAST 2013 Plenary Papers

BACKGROUND Computed tomography (CT) for pediatric traumatic brain injury (TBI) is common. Evidence suggests that 1 in 1,200 children undergoing CT will die of malignancy from radiation exposure. Presently, there is no protocol for surveying children with mild TBI; repeat CT (rCT) is often performed. We hypothesized that rCT could be avoided. Outcomes of similar patients who underwent rCT were compared with those of patients followed by clinical examination alone.

METHODS An 8-year retrospective review was performed of patients admitted to a Level I pediatric trauma center with TBI, CT evidence of TBI, and Glasgow Coma Scale (GCS) score of 14 to 15. There were two groups, those who underwent rCT (rCT+) and those who did not (rCT−). Data included age, Injury Severity Score (ISS), mechanism of injury, type of TBI, and outcome. Patients with coagulopathies, ventriculoperitoneal shunts, developmental disabilities, nonaccidental trauma, concomitant injuries, or medical problems resulting in intubation or sedation not attributed to TBI were excluded.

RESULTS Of 391 patients admitted with TBI, 120 were included in the study. A total of 106 patients were rCT+, and 14 were rCT−. rCT+ children were older (mean, 98.7 ± 7.3 vs. 35.3 ± 11.5 months; p = 0.0025) and more likely to have epidural hematoma (EDH) (100% rCT with EDH vs. 76% rCT all other TBI, p = 0.044). Mechanism of injury and mean ISS (15.2 ± 0.6 vs. 13.0 ± 1.1, p = 0.195) were not different between the groups. There were no worsening neurologic symptoms or need for surgery in rCT− children. rCT identified seven patients (6.6%) with CT progression of their injury. Five had an EDH, and two had a subarachnoid hemorrhage. Two children with EDH underwent operation.

CONCLUSION Our study indicates that routine rCT without evidence of clinical deterioration is not indicated in children with admission GCS score of 14 to 15 and TBI on CT scan. Children with EDH seem to have a higher potential for progression, and rCT seems to be indicated in this subgroup.

Level of evidence Therapeutic study, level IV.

From the Cardinal Glennon Children’s Medical Center (J.H., D.R.L., A.G., D.W.V.), St. Louis, Missouri; and St. Louis CSTARS (C.M.F.), St. Louis University, St. Louis, Missouri.

Submitted: July 31, 2013, Revised: November 4, 2013, Accepted: November 6, 2013.

This study was presented at the 72nd annual meeting of the American Association for the Surgery of Trauma, September 18–21, 2013, in San Francisco, California.

The opinions expressed are solely those of the authors and do not represent an endorsement by or the views of the US Air Force, the Department of Defense, or the US Government.

Address for reprints: Dennis W. Vane, MD, MBA, Cardinal Glennon Children’s Medical Center, 1465 S. Grand Blvd, St. Louis, MO 63104; email: dvane@slu.edu.

© 2014 Lippincott Williams & Wilkins, Inc.