Clinical use and indications for head computed tomography in children presenting with acute medical illness in a low- and middle-income setting.

Abstract

Computed tomography (CT) imaging is an indispensable tool in the management of acute paediatric neurological illness providing rapid answers that facilitate timely decisions and interventions that may be lifesaving. While clear guidelines exist for use of CT in trauma to maximise individual benefits against the risk of radiation exposure and the cost to the healthcare system, the same is not the case for medical emergency. The study primarily aimed to retrospectively describe indications for non-trauma head CT and the findings at a tertiary paediatric hospital. Records of children presenting with acute illness to the medical emergency unit of Red Cross War Children's Hospital, Cape Town, over one year (2013) were retrospectively reviewed. Participants were included if they underwent head CT scan within 24 hours of presentation with a non-trauma event. Clinical data and reports of CT findings were extracted. Inclusion criteria were met by 311 patients; 188 (60.5%) were boys. The median age was 39.2 (IQR 12.6-84.0) months. Most common indications for head CT were seizures (n = 169; 54.3%), reduced level of consciousness (n = 140;45.0%), headache (n = 74;23.8%) and suspected ventriculoperitoneal shunt (VPS) malfunction (n = 61;19.7%). In 217 (69.8%) patients CT showed no abnormal findings. In the 94 (30.2%) with abnormal CT results the predominant findings were hydrocephalus (n = 54;57.4%) and cerebral oedema (n = 29;30.9%). Papilloedema was more common in patients with abnormal CT (3/56; 5.4%) compared with none in those with normal CT; P = 0.015; while long tract signs were found in 42/169 (24.9%) and 23/56 (41.1%) of patients with normal and abnormal CT findings, respectively; P = 0.020. Post-CT surgery was required by 47(15.1%) of which 40 (85.1%) needed a ventricular drainage. A larger proportion of patients with VPS (25/62; 40.3%) required surgery compared to patients without VPS (22/249; 8.8%; P<0.001). A majority of head CT scans in children with medical emergency with acute neurological illness were normal. Patients with VPS constituted the majority of patients with abnormal CT scans that required subsequent neurosurgical intervention. Evidence-based guidelines are required to guide the best use of head CT in the management of children without head trauma.