Imaging of nonaccidental head trauma in childern

Abstract

Editor: I enjoyed the article on magnetic resonance and computed tomographic (CT) imaging of nonaccidental head trauma in children by Drs Petitti and Williams (1) in the March issue of Academic Radiology. Their review is a major contribution to the care of abused children. The authors note that although CT is the diagnostic imaging procedure of choice for detecting acute head injury, fractures that are in the same plane as the CT section may be undetectable. It is therefore to inspect the scout image that is obtained with the CT study for a skull They then show such a scout view in their Figure 4; the published image shows the faint line of what must be a parietal skull fracture. I suspect that skull radiographs would have shown this fracture, and perhaps other fractures, much more satisfactorily. We have had several cases in which skull fractures were seen on plain radiographs but were not detected either on the CT sections or on the scout view. Negative CT scans and a negative scout view do not exclude fracture. If it is important to demonstrate a fracture, standard skull radiography should be used. Dr Ferzli and colleagues, Drs Pisano, Braeuning, and Cance noted that patients with breast lesions considered to be category 2 (probably benign) according to the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) (2) should undergo 6month follow-up rather than open or core biopsy. According to the BI-RADS lexicon, category 2 lesions are termed and require annual mammography. Category 3 lesions, however, are defined as benign and short-interval follow-up is suggested. In general, patients with category 3 lesions undergo 6-month follow-up mammography to document stability of the lesion. It is unusual for patients with BIRADS category 2 lesions to undergo biopsy (2). The reviewers noted that patients with category 2 lesions who have high levels of anxiety may find the results of core biopsy reassuring. I think the reviewers may have actually meant category 3 lesions rather than category 2 lesions. According to the BI-RADS lexicon, the lesions that should be sampled for biopsy are category 4 and category 5 lesions. For category 1 and category 2 lesions, biopsy is not required because the results are considered either negative (for category 1 lesions) or negative with benign findings (for category 2 lesions). Category 3 includes probably benign findings, and shortinterval follow-up is suggested. Usually the short-interval follow-up is mammography at 6 months to document stability of the findings. Classification of a lesion as category 3 should not prompt a biopsy, and I imagine that patients with category 3 lesions and high levels of anxiety constitute a small subset for whom biopsy may be appropriate.