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Repeat head imaging in blunt pediatric trauma patients: Is it necessary?

Hill, E. Patricia MD; Stiles, P.J. MD; Reyes, Jared MEd; Nold, R. Joseph MD; Helmer, Stephen D. PhD; Haan, James M. MD

Journal of Trauma and Acute Care Surgery: May 2017 - Volume 82 - Issue 5 - p 896–900
doi: 10.1097/TA.0000000000001406
WTA 2016 Plenary Paper

BACKGROUND: Children with confirmed brain injury usually undergo follow-up computed tomography (CT) scan of the head within 24 hours of admission. To date, no evidence exists to validate the diagnostic or therapeutic value of these repeat CTs. The purpose of this study was to (1) evaluate progression of traumatic brain injuries, (2) determine if routine repeat imaging changes management, and (3) compare the efficacy of recognizing worsening hemorrhage with serial neurological examination versus repeat imaging.

METHODS: A 5-year retrospective review was conducted of all patients aged under 18 years with blunt traumatic head injury (n = 95). Data included demographics, type and size of intracranial hemorrhage, exam findings, diagnostic and management changes, and hospital outcomes.

RESULTS: Most patients (68.4%) had at least one repeat CT; of these, 67.7% (n = 44) showed no change or reduced hemorrhage. In only one patient did a repeat CT scan result in a surgical procedure; however, that CT scan was prompted by a change in neurological status. Among patients with more than two repeat head CTs, 42.9% led to a change in management, most frequently an additional CT scan. Presence of neurological symptoms was associated with having repeat CT scans (p = 0.025). Changes in Glasgow Coma Scale score were associated with increased hemorrhage (p = 0.012) but not repeat scans (p = 0.496). In the majority of cases, increased hemorrhage only resulted in an additional head CT and prolonged intensive care unit stay. Excluding patients who arrived with brain death, there was no difference in mortality between patients with and without repeat imaging.

CONCLUSION: Findings from this study support a selective approach for repeating head CTs with emphasis on changes in neurological symptoms and Glasgow Coma Scale score. Prospective studies on timing and indications for repeat CT scans are needed to support development of clinical guidelines.

LEVEL OF EVIDENCE: Therapeutic study, level III.

From the Department of Surgery (E.P.H., P.J.S., J.R., R.J.N., S.D.H., J.M.H.), The University of Kansas School of Medicine-Wichita; and Departments of Trauma Services (R.J.N., J.M.H.) and Medical Education (S.D.H.), Via Christi Hospital St. Francis, Wichita, Kansas.

Submitted: February 15, 2016, Revised: August 31, 2016, Accepted: February 8, 2017, Published online: February 28, 2017.

This study was presented at the 46th Annual Meeting of the Western Trauma Association, February 28 to March 4, 2016, in Lake Tahoe, California.

Address for reprints: James M. Haan, MD, Department of Trauma Services, Room 2514, Via Christi Hospital St. Francis, 929 N. Saint Francis St., Wichita, KS 67214; email: James.Haan.Research@viachristi.org.

© 2017 Lippincott Williams & Wilkins, Inc.