Emergent Neuroimaging Research Articles

Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit

Background: Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.Case Report: An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital.Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol

IntroductionHeadache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%–1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than...

First-Time Seizure Patients have High Rate of Abnormalities on Emergency Department Performed Brain Computed Tomography: A Prospective Study

BackgroundFirst-time seizures comprise 15% to 35% of all seizure-related complaints in the emergency department (ED). Emergent neuroimaging of first-time seizure patients is recommended by both the American Academy of Neurology and American College of Emergency Physicians. However, most of these studies are over 10 years old and included both adults and children. ObjectivesThe goal of this investigation is to determine the rate of abnormal neuroimaging in adults with first-time seizures presenting to the ED during the current era. MethodsThis was a prospective observational study of patients presenting to three urban EDs with a chief complaint of seizure over 18 months. Abnormal neuroimaging findings were defined a priori and were dichotomized into acute and subacute/chronic categories. ResultsOf the 2505 patients who presented with a seizure, 242 patients (9.7%) presented with a first-time seizure. The most common etiologies for first-time seizures were drug intoxication and drug withdrawal. Of those 242 patients, 29 (11.9%) patients had abnormal findings on brain computed tomography (CT). Brain CT demonstrated an acute finding in 13 (45%) patients and a subacute/chronic finding in 16 (55%) patients. The most common abnormality overall and the most common chronic finding was ischemic changes. The most common acute findings were traumatic intracranial hemorrhage and intracranial metastases. ConclusionsThis study demonstrated that 11.9% of first-time seizure patients presenting to the ED had abnormal findings on neuroimaging. Our findings support current recommendations to obtain emergent neuroimaging for adult patients with first-time seizures.

Clinically important intracranial abnormalities in children presenting with first focal seizure.

Management of pediatric patients presenting with first seizure is challenging, especially with regards to emergent neuroimaging. The rate of abnormal neuroimaging findings is known to be higher in focal seizures than in generalized seizures, but those intracranial abnormalities are not always clinically emergent. In this study, we aimed to determine the rate and indicators for clinically important intracranial abnormalities that change acute management in children presenting with a first focal seizure to the pediatric emergency department (PED). This study was conducted retrospectively in the PED at a University Children`s Hospital setting. The study population consisted of patients aged between 30 days and 18 years with first focal seizure and who had emergent neuroimaging at the PED between the years 2001 and 2012. There were 65 eligible patients meeting the study criteria. Clinically important intracranial abnormalities requiring emergent neurosurgical or medical intervention were detected in 18 patients (27.7%) at the PED. Four patients (6.1%) underwent emergent surgical procedures. Seizure recurrence and the need for acute seizure treatment in the PED were significantly associated with clinically important intracranial abnormalities. Neuroimaging study yielding of 27.7% shows that first focal seizure must be evaluated meticulously. From the emergency department`s point of view; we suggest that first focal seizures in children should be evaluated with emergent neuroimaging, if possible with magnetic resonance imaging. Especially patients with recurrent seizures at presentation requires more careful evaluation.

Head computed tomography for elderly patients with acute altered mental status in the emergency setting: value for decision-making and predictors of abnormal findings.

This study evaluated the impact of head computed tomography (CT) on clinical decision-making about older adults with acute altered mental status (AMS) in the emergency department in terms of CT's diagnostic yield, emergency department length of stay, and changes in medical strategy. It also attempted to find predictors of an acute imaging abnormality. This was a 1-year, retrospective, single-center observational study of patients aged ≥75 years who underwent noncontrast head CT because of an isolated episode of AMS. The acute positive CT findings were ischemic strokes, hemorrhages, tumors, demyelinating lesions, hydrocephalus, and intracranial infections. A total of 594 CTs were performed, of which 38 (6.4%) were positive. The main etiology of AMS was sepsis (29.1%). Changes in medical strategy were more common in patients with a positive CT, and the major changes were ordering additional neuro exams (odds ratio [OR], 95.3; 95% confidence interval [CI], 38.4-233.8; P<0.001), adjusting treatments (OR, 12.2; 95% CI, 5.0-29.5; P<0.001), and referral to a neurologic unit (OR, 7.3; 95% CI, 3.0-17.5; P<0.01). Three factors were significantly associated with a positive outcome: Glasgow Coma Scale <13 (OR, 8.5; 95% CI, 2.3-28.9; P<0.001), head wound (OR, 3.1; 95% CI, 1.1-8.2; P=0.025), and dehydration (OR, 0.3; 95% CI, 0.1-0.4; P=0.021). For elderly patients with a Glasgow Coma Scale ≥13 and no head wound or clinical dehydration, the probability of a positive CT was 0.02 (95% CI, 0.01-0.04). Considering only those patients, the diagnostic yield fell to 1.7%. In elderly patients, the causes of AMS are primarily extracerebral. Randomized clinical trials are needed to validate a clinical pathway for selecting patients who require emergent neuroimaging.

Emergent Neuroimaging Findings for Written Expression in Children: A Scoping Review.

Background: There is currently a dearth of research on the neural framework of writing tasks in children, as measured by neuroimaging techniques. Objective: This paper provides an overview of the current literature examining the neurological underpinnings of written expression in children. Design: Using a scoping review approach, with thorough searches of key databases, this paper presents the available literature comprising 13 different studies using both structural and functional neuroimaging techniques with the 0–18 English speaking population. Results: Studies largely presented small sample sizes, with most studies utilizing elementary or middle school-aged children. Emergent findings revealed a complex network of neural contributions to the writing process in children. There were associations between the left fusiform gyrus and orthographic coding (i.e., handwriting), and spelling and written composition measures were significantly correlated with activity in the left posterior cingulate, left precuneus, and right precuneus regions. Additionally, results revealed that good versus poor writers manifested differential brain activation patterns during many tasks associated with written expression, with good writers performing more efficiently than poor writers with respect to brain regions activated during a writing task across handwriting, spelling, and idea generation. Conclusions: The findings from this scoping review lay the foundation for future studies examining the interface between writing skills in children and underlying neural pathways that support the various components of the writing process. It will be important for future research to examine the neurological bases of the various components of written expression in children and adolescents.

Epidemiology, investigation, management, and outcomeofheadache in emergency departments (HEADstudy)-A multinational observational study.

To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. We enrolled 4536 patients (67hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

Validation of a clinical decision instrument for emergent neuroimaging after a seizure: Let's image malignancy, intracranial hemorrhage, and trauma (LIMIT).

Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. However, a CT exposes patients to 100 times more radiation than a chest radiograph. Previously, we developed a four-item clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) do not require emergent neuroimaging. In this study, we seek to prospectively validate our CDI in patients with a history of seizures with both SE and generalized tonic-clonic seizures. This was a prospective observational study of 1,739 consecutive patients who were recruited from two urban hospitals in Philadelphia, Pennsylvania. All patients, 18years and older, who presented with a chief complaint of seizure and had emergency neuroimaging performed were eligible for inclusion. Patients were excluded from analysis if this was a first-time seizure, had a ventriculoperitoneal shunt, or had focal neurologic deficits. A total of 376 patients were in the final analysis. Of the 376 patients, 10 patients (3%) had positive CTs. Nine of the 10 of the patients were identified by our CDI, resulting in a negative predictive value (NPV) of 99.5%. On secondary analysis, we refined our CDI from four to three criteria: 1) history of intracranial hemorrhage (ICH), 2) active malignancy, and 3) trauma. These criteria also had a NPV of >99% when applied to patients in SE. The validation of our CDI showed improved NPV when compared to the derivation set. Use of the criteria of history of ICH, active malignancy, and trauma could have reduced the use of emergent neuroimaging in our cohort by up to 49%. This CDI should be validated in a larger subset of patients and in multiple centers prior to widespread adoption.

Emergent neuroimaging for seizures in epilepsy: A population study

We determined how often patients with epilepsy presented to the emergency department (ED) for seizure and the frequency and predictors for undergoing emergent neuroimaging during those visits. We conducted a retrospective population-based cohort study using administrative claims' data from 2007 to 2015. Adults with epilepsy were identified based on a diagnosis of epilepsy and an outpatient prescription for an antiepileptic medication. The Bonferroni corrected significance level was 0.0018. We identified 381,362 patients with a mean follow-up period of 1.99 years, of whom 35,015 (9.2%) patients presented to the ED for seizure at least once. Patients with at least one ED visit were younger, more likely to be male, had fewer comorbidities, and had longer follow-up as compared with those with no ED visit (all p < 0.001). Among the 35,015 patients presenting to the ED, 13.6% had neuroimaging, mostly commonly head computed tomography (CT; 95.5%). Patients undergoing neuroimaging were younger (46 versus 48 years) and with higher rates of psychosis (17.4% versus 13.8%) and depression (16.1% versus 12.2%; p < 0.001). This helps to quantify the burden of ED and emergent neuroimaging utilization for patients with epilepsy and can help inform efforts to curtail unnecessary neuroimaging.

Complex Febrile Seizures: An Update

AbstractFebrile seizures are the most common seizures in childhood. Febrile seizures are divided into two groups: simple and complex. Simple febrile seizures (SFS) are generalized, short, and occur only once in 24 hours. Complex febrile seizures are prolonged, focal, or repeat more than once in 24 hours. Around 35% of children experience complex features as part of their initial seizure event. These children have more chances of complex recurrences than children with SFS. While the guidelines for SFS remain clear, there are no clear guidelines for the evaluation of children with complex febrile seizures. The conflicting results about electroencephalography (EEG) utilization preclude drawing meaningful conclusions. An EEG can be obtained in children with persistent alteration of consciousness after the seizure, and emergent neuroimaging is not required in most cases. Due to low incidence of bacterial meningitis in the post-vaccination era, it is reasonable to perform lumbar puncture (LP) only if there is clinical concern for central nervous system infection. LP should also be considered in children between 6 and 12 months of age with incomplete or unknown vaccination status or who have been previously treated with antibiotics. Further, antipyretics are used to make children more comfortable during the febrile process, but are ineffective in reducing the rate of seizure reoccurrence. Continuous antiepileptic therapy and intermittent oral diazepam are effective in the prevention of subsequent febrile seizures, but they do not reduce the risk of epilepsy and have potential unwanted side effects. In specific circumstances, the benefits of antiseizure medications may outweigh the risks. Treatment may be a consideration in cases of febrile status: patients with electroclinical features suggesting a specific epilepsy syndrome or children with limited access to health care services.

S-100β in chronic subdural haematoma: Prospective cohort study

Chronic subdural haematoma (CSDH) is invariably classified as ‘neurotrauma’. However, whilst a history of trauma/fall is frequent, it is usually distant, mild or even absent. Serum S-100β > 1.38 μg/L is associated with a 100% specificity for mortality/poor outcome acutely after moderate-severe neurotrauma. Serum S-100β > 0.10 μg/L is used to screen mild neurotrauma cases for emergent neuro-imaging. Serum S-100 in controls is 0.057 μg/L. S-100β in serum or CSDH fluid (CSDHf) has not been studied. No normal ‘subdural fluid’ exists to compare CSDHf. We measured serum and CSDHf S-100β at surgical drainage in a novel prospective single-centre cohort. Of n = 86/86 (100%, M65, age 73 ± 13yrs), n = 66 (76%) reported mild trauma/fall 31 ± 23 days previously. N = 54 (63%) presented with good clinical Markwalder Grade (MG: 0–1). Paired serum and CSDHf S-100β samples were obtained in n = 45. CSDHf S-100β (n = 80) was elevated (0.9 ± 0.6 μg/L), was significantly higher than serum S-100β (n = 51) (0.33 ± 0.05 μg/L, P = 0.002), and was significantly correlated with midline-shift (r = 0.43, P = 0.005) and CSDH volume (r = 0.225, P = 0.046). CSDHf S-100β was not significantly associated with any demographic factor, co-morbidity or outcome measure. ConclusionsDespite expectations, S-100β was elevated in serum CSDH, but was significantly higher in CSDHf. Indeed, CSDHf S-100β approached serum levels associated with a poor prognosis after acute-neurotrauma. However, CSDHf S-100β did not represent a biomarker for trauma nor functional outcome. Whilst the non-traumatic source for on-going S-100β release could not be determined, prolonged compression of an atrophic brain, subsequent CSF leakage, or ‘subdural-space’ meningeal disruption/proliferation, represent theoretical possibilities. Elevated S-100β may therefore not be specific for mild-moderate-severe acute neurotrauma. Alternative non-traumatic intra-cranial mechanisms evidently also exist.

Yield of Emergent CT in Patients With Epilepsy Presenting With a Seizure

Studies of emergent neuroimaging in the management of patients presenting with a breakthrough seizure are lacking. We sought to determine how often emergent computed tomography (CT) scans are obtained in patients with known epilepsy presenting with a seizure and how often acute abnormalities are found. This multicenter retrospective cohort study was performed in the emergency department at 2 academic medical centers. The primary outcomes were percentage of visits where a CT scan was obtained, whether CT findings represented acute abnormalities, and whether these findings changed acute management. Of the 396 visits included, CT scans were obtained in 39%, and 8% of these scans demonstrated acute abnormalities. Patients who were older, had status epilepticus, a brain tumor, head trauma, or an abnormal examination were all significantly more likely to undergo acute neuroimaging (P < .05). In the multivariable model, only history of brain tumor (odds ratio [OR] 5.88, 95% confidence interval [CI], 1.33-26.1) and head trauma as a result of seizure (OR 3.92, 95% CI, 1.01-15.2) reached statistical significance in predicting an acutely abnormal scan. The likelihood of an acute imaging abnormality in visits for patients without a history of brain tumor or head trauma as a result of the seizure was 2.7% (2 visits). Both of these patients had abnormal neurological examinations. Obtaining an emergent CT scan for patients with epilepsy presenting with a seizure may be avoidable in most cases, but might be indicated for patients with a history of brain tumor or head trauma as a result of seizure.

Yield of Emergent Neuroimaging in Patients With Sturge-Weber Syndrome Presenting With Acute Neurologic Symptoms

Seizures, strokelike episodes, and headaches are common complications in patients with Sturge-Weber syndrome. Based on our experience, we hypothesized that patients with Sturge-Weber syndrome have frequent urgent neuroimaging studies when presenting acutely to the emergency department. In this study, we aimed to determine the incidence of acute imaging studies in this patient population and to evaluate the prevalence of findings such as acute intracranial hemorrhagic or ischemic strokes. To determine the frequency and yield of brain imaging, we conducted a retrospective chart analysis in patients with Sturge-Weber syndrome who presented to Boston Children's Hospital with acute neurologic symptoms between 1996 and 2016. We reviewed 136 encounters of patients with Sturge-Weber syndrome. In 73 of 136 encounters (53.7%), patients underwent a total of 89 imaging studies, consisting of 47 head computed tomographies (CTs) and 42 brain magnetic resonance images (MRIs). Twenty-two percent of patients imaged underwent both CT and MRI scanning of the brain. Patients with strokelike episodes or headaches were more likely to be imaged compared to patients presenting with seizures (89.7% and 100% vs 34.4%, respectively). None of the neuroimaging studies showed acute hemorrhagic or ischemic strokes. Acute neurologic manifestations of Sturge-Weber syndrome frequently lead to urgent neuroimaging. In our cohort, there was no imaging evidence of acute hemorrhagic or ischemic strokes. In addition, emergent imaging in patients presenting with breakthrough seizures did not result in meaningful changes in management.

Advanced Neuroimaging of Acute Ischemic Stroke: Penumbra and Collateral Assessment.

Acute ischemic stroke (AIS) occurs when there is a sudden loss in cerebral blood flow due to embolic or thromboembolic occlusion of a cerebral or cervical artery. Patients with AIS require emergent neuroimaging to guide treatment, which includes intravenous thrombolysis and endovascular mechanical thrombectomy (EMT). Recent advances in AIS treatment by EMT has been driven in part by advances in computed tomography (CT) and MR imaging neuroimaging evaluation of ischemic penumbra and pial collateral vessels. The authors review advanced noninvasive brain imaging by CT and MR imaging for the evaluation of AIS focusing on penumbral and collateral imaging.

Radiation Dose Considerations in Emergent Neuroimaging.

Computed tomography is often the first-line diagnostic imaging modality in the evaluation of patients with neurologic emergencies. A patient-centered approach to radiation dose management in emergent neuroimaging thus revolves around the appropriate use of computed tomography, including clinical decision support for ordering providers, thoughtful protocol design, the use of available technological advances in computed tomography, and radiation exposure monitoring at a population level. A multifaceted approach can help to minimize radiation exposure to individual patients while preserving diagnostic quality imaging.

Emergent Neuroimaging During Pregnancy and the Postpartum Period.

Acute neurologic emergencies in pregnancy often require neuroimaging to guide diagnosis and treatment. Implementation of a patient-centered care model in radiology can alleviate a patient's stress, reinforce appropriate imaging workup, improve patient satisfaction, and lead to improved outcomes. The authors present the evaluation, differential diagnosis, and recommended imaging protocols for the three most common acute neurologic symptoms in pregnancy and the postpartum period: headache, seizure, and focal neurologic deficits. With the patient's symptoms as a reference point, the referring physician in consultation with the radiologist can effectively implement the optimal imaging procedures.

Emergent Neuroimaging in the Oncologic and Immunosuppressed Patient.

Neuroimaging in the emergency department increasingly involves patients at increased risk for acute neurologic complications from malignancy and immunosuppression, including patients with organ transplantation, diabetes mellitus, treatment of chronic disease, and HIV positivity. These patients are susceptible to the same infections and emergencies as immunocompetent patients, but may present differently with common illnesses and are susceptible to a variety of other diseases. This article reviews important patient risk factors, emergent central nervous system abnormalities, and their imaging findings. Detailed knowledge of risk factors and specific complications in these complex patients is essential for optimal image acquisition, interpretation, diagnosis, and treatment.

Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging.

Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the identification of red flag findings is associated with potentially unnecessary emergency department neuroimaging. We aimed to determine the prevalence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to determine the prevalence of emergent intracranial abnormalities in this population. A prospective cohort study of otherwise healthy children 2-17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neurological exam findings. Children who did not receive emergency department neuroimaging received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities. We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Several red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging. Red flag findings are common in children presenting with headaches to the emergency department. The presence of red flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiving unnecessary neuroimaging due to the high prevalence of non-specific red flag findings.

Emerging Trends in Emergent Stroke Neuroimaging

Various imaging techniques used in stroke evaluation have complementary, evolving roles. This article reviews recent updates in emergent stroke neuroimaging. Multiple recent randomized trials showing benefit of endovascular therapy in strokes with confirmed large-vessel occlusion emphasize need for vessel imaging, typically CTA, in addition to unenhanced head CT. In addition, because recent trials published in 2018 showed efficacy of mechanical thrombectomy at up to 24 h from symptom onset in stroke patients with favorable ischemic core and/or penumbra assessments, imaging techniques to define viable and infarcted tissue, such as DWI or CT/MR perfusion imaging, have an increasing role in emergent stroke assessment. Other studies contributing to new AHA/ASA stroke guidelines are also discussed. Neuroimaging remains crucial to emergent stroke evaluation, with CTA, MRI, and perfusion studies playing an increasing role in identifying patients likely to benefit from treatment.

Emergency Department Care of Young Children at Risk for Traumatic Brain Injury: What Are We Doing and Do Parents Understand?

The aims of the study were to describe emergency department (ED) management of young children with head injury and to assess parental comfort level and perceptions of ED care. This was a prospective observational study of children younger than 5 years who presented to a pediatric ED after head injury. Children were eligible if clinical observation was an appropriate ED management option per the Pediatric Emergency Care Academic Research Network's neuroimaging clinical decision rule. Demographics, injury variables, and ED clinician surveys explaining the care provided were collected at time of study enrollment. Parents were subsequently contacted to assess understanding of ED management and comfort with care. One hundred four children were enrolled with a mean (standard deviation) age of 1.19 (1.34) years. Thirty (29%) had emergent neuroimaging and 59 (57%) were placed into a period of observation per clinician report. A total of 37 children received a head computed tomography, of which 21 (57%) were normal. Eighty-four parents (81%) completed the phone follow-up. Of these children, there was a significant difference between whether parents and clinicians reported that the child had been clinically observed in the ED (P < 0.0001). Parents of children who did not receive a head CT were more likely to be uncomfortable with the decision to obtain neuroimaging compared with those who did receive a head CT (P = 0.003). Parents are not always comfortable with the medical care practices provided and are often unaware of clinical observation when it does occur. Better parent-clinician communication could improve parental understanding and reduce overall discomfort.