274 Characteristics of Intracranial Injury in Pediatric Patients in the National Emergency X-Radiography Utilization Study

Abstract

Blunt head trauma remains an important and costly mechanism of injury in the pediatric population. This study aimed to investigate the characteristics of pediatric patients presenting to National Emergency X-Radiography Utilization Study (NEXUS) study centers with blunt head trauma and acute cranial injury, as well as determine the screening performance characteristics of physical exam for the detection of skull fracture. We performed a secondary analysis of pediatric computed tomography (CT) data from a previous NEXUS cohort. Demographic data, criteria for two well-established CT imaging decision instruments, and whether patients received neurosurgical interventions were analyzed for the 1018 enrolled patients under the age of 18 years. Radiologist interpretations of CT head results including classification of injury type, location of injury, mass effect, and associated injuries were abstracted for 128 injured patients. Provider detection of skull fractures was determined by response to a specific question on the decision instruments inquiring about signs of these injuries. Contingency tables were used to evaluate provider sensitivity to detect skull fracture. Between April 2006 and December 2015, 1018 pediatric patients were enrolled as part of the NEXUS validation study. 128 (12.5%) of children had a notable injury reported on CT head, 49 (4.8%) were deemed to have a significant injury, and 27 (2.7%) patients received neurosurgical intervention. The median age for injured patients was 9.96 (IQR 3.27 – 15.22) years old. Midline shift was observed in 7 children (5.4% of injuries), and none were observed to have herniation. The most common intracranial injuries were subdural hematomas (28.9%) and subarachnoid hemorrhage (29.7%). The majority of injuries were superior to the tentorium; 3 cerebellar injuries and no brainstem injuries were observed. Incidence of subarachnoid hemorrhage and parenchymal injuries was greater in teenage children (44% and 24%, respectively) than in school age (22.9% and 14.6%) and in infants and toddlers (16.7% and 6.7%). Patients with subarachnoid hemorrhage and parenchymal injuries more frequently presented with abnormal alertness or abnormal behavior. Skull fracture was present in the majority (66.4%) of children with intracranial injuries. The sensitivity and specificity of provider physical exam to detect skull fractures was 18.5% and 96.6%, respectively. Sensitivity and specificity for the detection of basilar or depressed skull fractures was 11.1% and 96.6%. These data suggest that while few pediatric patients presenting with blunt head trauma have a significant intracranial injury or require neurosurgical intervention, skull fracture may be present in a large proportion of children with intracranial hemorrhage. Despite its integration into head injury decision instruments, providers have poor sensitivity for detecting skull fractures in pediatric patients.