Abstract
ObjectivesTo assess whether head CT with 3D reconstruction can replace skull radiographs (SXR) in the imaging investigation of suspected physical abuse (SPA)/abusive head trauma (AHT).MethodsPACS was interrogated for antemortem skeletal surveys performed for SPA, patients younger than 2 years, SXR and CT performed within 4 days of each other. Paired SXR and CT were independently reviewed. One reviewer analysed CT without and (3 months later) with 3D reconstructions. SXR and CT expert consensus review formed the gold standard. Observer reliability was calculated.ResultsA total of 104 SXR/CT examination pairs were identified, mean age 6.75 months (range 4 days to 2 years); 21 (20%) had skull fractures; two fractures on CT were missed on SXR. There were no fractures on SXR that were not seen on CT. For SXR and CT, respectively: PPV reviewer 1, 95% confidence interval (CI) 48–82% and 85–100%; reviewer 2, 67–98% and 82–100%; and NPV reviewer 1, 95%, CI 88–98% and 96–100%; reviewer 2, 88–97% and 88–98%. Inter- and intra-observer reliability were respectively the following: SXR, excellent (kappa = 0.831) and good (kappa = 0.694); CT, excellent (kappa = 0.831) and perfect (kappa = 1). All results were statistically significant (p < 0.001).ConclusionsCT has greater diagnostic accuracy than SXR in detecting skull fractures which is increased on concurrent review of 3D reconstructions and should be performed in every case of SPA/AHT. SXR does not add further diagnostic information and can be omitted from the skeletal survey when CT with 3D reconstruction is going to be, or has been, performed.Key Points• Head CT with 3D reconstruction is more sensitive and specific for the diagnosis of skull fractures.• Skull radiographs can be safely omitted from the initial skeletal survey performed for suspected physical abuse when head CT with 3D reconstruction is going to be, or has been, performed.
Highlights
Materials and methodsAbusive head trauma (AHT) is defined as an injury to the skull or intracranial contents from a blunt impact or violent shaking in those children aged under 2 years of age [1]: injuries due to accidental trauma are not included
Skull radiographs can be safely omitted from the initial skeletal survey performed for suspected physical abuse when head computed tomography (CT)
104 eligible initial skeletal surveys and head CT examination pairs performed for suspected physical abuse (SPA) within 0 to 4 days of each other were identified
Summary
Materials and methodsAbusive head trauma (AHT) is defined as an injury to the skull or intracranial contents from a blunt impact or violent shaking in those children aged under 2 years of age [1]: injuries due to accidental trauma are not included. The European Society of Paediatric Radiology (ESPR) has endorsed the previous [6], current [5], and all future versions of this document as the European standard [7] in the investigation of suspected physical abuse (SPA) in infants and young children. The recently updated guidelines state that all children under the age of 1 year should have multi-slice computed tomography (CT) imaging of the head, in addition to anteroposterior (AP) and lateral skull radiographs (SXR) performed as part of the initial skeletal survey in the investigation of SPA. In children over 1 year of age, a head CT examination is only recommended if there are clinical features suggestive of neurological injury (external evidence of head trauma, abnormal neurological signs and symptoms, or haemorrhagic retinopathy). The guidelines state that three-dimensional (3D) surface reconstruction of head CT should be performed routinely to better assess for skull fractures and associated soft tissue scalp injury given that head CT with 3D reconstruction is superior to both head CT without 3D reconstruction and SXR [8, 9]
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