Normal Head Computed Tomography Research Articles

Pediatric Head Injury

1. Jeff E. Schunk, MD* 2. Sara A. Schutzman, MD† 1. *Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Medical Center, Salt Lake City, UT. 2. †Assistant Professor, Department of Pediatrics, Harvard Medical School, Senior Associate Physician in Medicine, Division of Emergency Medicine, Department of Medicine, Children’s Hospital Boston, Boston, MA. * Abbreviations: BSF: : basilar skull fracture CSF: : cerebrospinal fluid CT: : computed tomography EDH: : epidural hemorrhage GCS: : Glasgow Coma Scale ICI: : intracranial injury ICP: : intracranial pressure PECARN: : Pediatric Emergency Care Applied Research Network SAH: : subarachnoid hemorrhage SDH: : subdural hemorrhage TBI: : traumatic brain injury Recent studies have provided updated guidelines for the diagnosis of head injury and the management of patients who experience concussions. A multidisciplinary panel has recently issued new guidelines for return to play after head injury. After reading this article, readers should be able to: 1. Understand the anatomy and pathophysiology relevant to pediatric head injuries. 2. Take an appropriate history, perform an appropriate physical examination, and decide what imaging, if any, is warranted in the case of a child with a head injury. 3. Know the characteristics of the various types of intracranial injuries. 4. Understand the proper management of both minor and severe head injuries in children. Pediatric head injury is extremely common. Although the vast majority of children with head trauma have minor injuries, a small number, even among well-appearing children, will have more serious injuries with the potential for deterioration and significant sequelae. The clinician is challenged to discern which few among the many injured are at high risk for intracranial complications. Clinical symptoms are neither completely sensitive nor specific for significant injury: vomiting may be associated with intracranial injury (ICI), but most children who experience vomiting do not have a complication. Computed tomography (CT) accurately identifies ICIs requiring intervention, but also identifies minor lesions with unclear clinical importance (ie, not requiring intervention) and exposes developing brains to ionizing radiation with the associated risks. Although clinical decision rules determine which children are at highest risk and provide a useful clinical framework, they may not necessarily direct care. Additionally, in this era of reliance on imaging, it is important to remember what the clinical examination tells us regarding brain function, information that …

Monitoring and prediction of intracranial hypertension in pediatric traumatic brain injury

Control of intracranial hypertension (ICH) in patients with traumatic brain injury (TBI) is standard care. However, predicting risk for ICH is essential to balance risks and benefits of intracranial pressure (ICP) monitoring. Current recommendations for ICP monitoring in pediatric trauma patients are extrapolated from adult studies. This retrospective study evaluated 299 children admitted to Primary Children's Medical Center with moderate to severe TBI. ICP monitors were used in 120. Demographic, injury, and admission computed tomography (CT) scan characteristics were compared with determine factors associated with monitoring among those with less severe head CT findings. Among all monitored patients, clinical and radiographic features were compared for early ICH defined as any sustained ICP ≥20 mm Hg in the first 24 hours. Factors independently associated with monitoring children with Marshall I or II scores included presence of intraventricular hemorrhage (odds ratio [OR], 21.4; 95% confidence interval [CI], 4.0-114.7) and greater injury severity scores (ISS) (OR, 9.5 [95% CI, 2.9-31.1] for ISS 21 to 29 and OR, 14.3 [95% CI, 4.3-50.5] for ISS >29 compared with ISS <21). Among those with a normal head CT, 9 of 68 had an ICP monitor placed because of the inability to localize pain. Of these, 78% (7 of 9) had early ICH. Among monitored patients radiologic and clinical features of injury severity were not useful to distinguish risk for early ICH. Among children with severe TBI, a normal head CT does not exclude ICH. Need for ICP monitoring should be determined by depth of coma in addition to radiographic imaging.

Repeat Computed Tomography Not Needed After Mild Head Injury in Patients on Warfarin

Do anticoagulated patients with minor closed-head injury require repeat head computed tomography (CT) after in-hospital observation for 24 hours? Researchers prospectively studied 137 consecutive patients (mean age, 76) at a single hospital in Spain who were taking warfarin and had normal initial head CT scans after minor closed-head injury (defined as documented …

Head CT is of limited diagnostic value in critically ill patients who remain unresponsive after discontinuation of sedation

BackgroundProlonged sedation is common in mechanically ventilated patients and is associated with increased morbidity and mortality. We sought to determine the diagnostic value of head computed tomography (CT) in mechanically ventilated patients who remain unresponsive after discontinuation of sedation.MethodsA retrospective review of adult (age >18 years of age) patients consecutively admitted to the medical intensive care unit of a tertiary care medical center. Patients requiring mechanical ventilation for management of respiratory failure for longer than 72 hours were included in the study group. A group that did not have difficulty with awakening was included as a control.ResultsThe median time after sedation was discontinued until a head CT was performed was 2 days (interquartile range 1.375–2 days). Majority (80%) of patients underwent head CT evaluation within the first 48 hours after discontinuation of sedation. Head CT was non-diagnostic in all but one patient who had a small subarachnoid hemorrhage. Twenty-five patients (60%) had a normal head CT. Head CT findings did not alter the management of any of the patients. The control group was similar to the experimental group with respect to demographics, etiology of respiratory failure and type of sedation used. However, while 37% of subjects in the control group had daily interruption of sedation, only 19% in the patient group had daily interruption of sedation (p < 0.05).ConclusionIn patients on mechanical ventilation for at least 72 hours and who remain unresponsive after sedative discontinuation and with a non-focal neurologic examination, head CT is performed early and is of very limited diagnostic utility. Routine use of daily interruption of sedation is used in a minority of patients outside of a clinical trial setting though it may decrease the frequency of unresponsiveness from prolonged sedation and the need for head CT in patients mechanically ventilated for a prolonged period.

The density ratio of grey to white matter on computed tomography as an early predictor of vegetative state or death after cardiac arrest

Objectives:To evaluate whether the ratio (in Hounsfield units; HU) of grey matter (GM) to white matter (WM) on computed tomography (CT) scans taken within 24 h of resuscitation can be...

Cerebral lateral ventricular asymmetry on CT: how much asymmetry is representing pathology?

The purpose of this study was to evaluate the association of asymmetric lateral ventricle (ALV) with clinical and structural pathologies and assess its clinical importance. We analyzed 170 consecutive ALV cases on computed tomography (CT) and 170 control group patients with normal head CT. Patients who had apparent etiologic causes for ALV were excluded. The differential diagnosis of ALV and unilateral hydrocephalus (UH) was made by using three different ventricle-brain ratios (VBRs). The measurements of the ALV were made at the frontal horn level. Patients with asymmetry were divided into three subgroups including mild, moderate and severe groups to eloborate the grade of the ventricular asymmetry. Additional CT findings including septal deviation, diffuse enlargement, atrophy and the densities of constant sites were also recorded systematically for each patient. Clinical and handedness data were collected and analyzed. The prevalence of ALV in the study population was 6.1%. Headache was the most common reason for head CT examination and was significantly more common in the asymmetry group (61.7% in group A, 42.9% in group B, P = 0.001). Transient ischemic attack, focal neurologic findings, vertigo, ataxia, visual and hearing disturbances were similar in both groups (P > 0.5). There was no difference in smoking and alcohol habits in both patient groups. Ten (5.8%) patients in group A and 16 (9.4%) patients in group B had neuropsychiatric disorders, which did not achieve statistical significance. In group A patients, the larger ventricle was more common in the left side than in the right (left = 70.0%, right = 30.0%). Group A consisted of 57.0% mild (grade 1, n = 97), 26.5% moderate (grade II, n = 45) and 16.5% severe (grade III, n = 28) patients. There was no significant correlation between handedness and ALV. The density of different brain sites was found close similar on both sides in ALV and control group (P > 0.5). Choroidal cystic or solid neoplasm or periventricular dysplasia was detected in six ALV patients in group A (3.5%), on their additional MR examinations. The physician should not overlook an ALV finding on unenhanced CT, particularly in cases with severe degree of asymmetry or diffuse ventricular enlargement, and search for possible accompanying disorders.

Yield and utility of radiographic “shunt series” in the evaluation of ventriculo-peritoneal shunt malfunction in adult emergency patients

We examined the yield and utility of shunt series (SS) performed for suspected shunt malfunction and whether an abnormal SS lead to shunt revision when head computed tomography (CT) was normal or unchanged. We reviewed medical records for all adult emergency patients over a 34-month period with suspected shunt malfunction imaged with both SS and head CT to determine whether a shunt revision was performed contemporaneous with imaging. Nine (3.4%) abnormal SS were identified among 263 studies performed. Among the 192 cases in which CT was normal or unchanged, two patients with abnormal SS underwent contemporaneous shunt revision. Yield of SS is very low, and in the presence of a normal or unchanged head CT, SS provides the imaging basis for contemporaneous shunt revision in 1% (2/192) of cases.

Can we abolish skull x rays for head injury?

Objectives: To assess the effect of a change in skull x ray policy on the rate of admission, use of computed tomography (CT), radiation dose per head injury, and detection...

Predictors of Abnormal Findings of Computed Tomography of the Head in Pediatric Patients Presenting With Seizures

Study objective: To develop a preliminary clinical decision guideline, using characteristics of ED pediatric patients presenting with seizures, that successfully predicts all abnormal results of computed tomography (CT) of the head. Methods: We assembled a retrospective case series in the ED of a tertiary care children's hospital without trauma designation. The series comprised all patients who presented between January 1, 1992, and December 31, 1994, with seizures (febrile and afebrile) who underwent head CT as part of ED evaluation. Results: Our inclusion criteria were met by 203 patients. Of these patients, who had a median age of 3.1 years, 53% were boys; 18% had been transferred from another facility; 25% had received anticonvulsant medication in the field, at the referring facility, or both; 32% had a history of seizures before the presenting episode; 6% had sustained a closed-head injury (CHI); 15% had a cerebrospinal fluid (CSF) shunt; 4% had an underlying malignancy or neurocutaneous disorder (NCT); and 30% had a documented fever. CT findings were abnormal in 25 patients (12%). CT showed evidence of hemorrhage in eight patients (32%), small focal abnormalities in four (16%), cerebral edema in three (12%), and shunt obstruction in two (8%). χ 2 Recursive-partitioning analysis revealed that CT scan results were always normal when the patient did not have an underlying high-risk condition (malignancy, NCT, recent CHI, or recent CSF shunt revision), was older than 6 months, had sustained a seizure of 15 minutes or less, and did not have a history of a new-onset focal neurologic deficit. Retrospective application of these criteria revealed that 41% of the CT scans could have been deferred. Conclusion: In this case series, the absence of defined high-risk factors predicted normal head CT findings. The deferral of emergency CT in this population should be considered. [Warden CR, Brownstein DR, Del Beccaro MA: Predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures. Ann Emerg Med April 1997; 29:518-523.]