Skull radiographs and computed tomography scans in children and adolescents with mild head trauma

OBJECTIVE: To identify which pediatric patients with mild head trauma are candidates for skull radiographs or cranial computed tomography (CCT) scans. METHOD: Patients with mild head trauma aged from 0 to 19 years presenting to the Emergency
of 3
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Related Documents
  Arq Neurpsiquiatr 2008;66(3-B):708-710708 Skull radiographS and computed tomography ScanS in children and adoleScentS with mild head trauma  José Roberto Tude Melo 1  , Rodolfo Casimiro Reis  2  , Laudenor Pereira Lemos-Júnior   2  ,  Assuero Azevedo-Neto  2  , Dalton Willy Santos Oliveira  2  , Felipe René F. Cruz Garcia  2  ,  Joelson Oliveira Ribeiro  2  , Muryllo de Brito Santos-Neto  2  , Jamary Oliveira-Filho 3 Abstract – Objective: T identif wic pediatric patients wit mid ead trauma are candidates fr sku radigraps r crania cmputed tmgrap (CCT) scans. Method: Patients wit mid ead trauma aged frm 0 t 19 ears presenting t te Emergenc Department f a trauma centre frm Saadr Cit, Brazi, between Ma 2007 and Ma 2008. Results: A tta f 1888 mid ead trauma patients were admitted; mean age was 7.4 ( ± 5.5) ears. A tta f 1956 sku radigraps and 734 CCT scans were perfrmed. Abut 44.4% patients wit Gasgw cma scre (GCS) 13 and 55.4% wit GCS 14 ad abnrma CCT scans. In patients wit mutipe traumas, 16% ad abnrma findings n CCT scans. Conclusion: We strng recmmend rutine CCT studies t patients wit GCS f 13 and 14 r t mutipe trauma ictims, independent f scre. Rutine screening sku radigraps were nt usefu in te eauatin f mid ead trauma patients in tis stud.KEy WoRDS: tmgrap, radigrap, traumatic injur brain, cid, adescent. radiogafia simples e tomogafia computadoizada do cânio em cianças e adolescentes vítimas de taumatismo caniano leve Resumo – Objetivo: Identificar quais s pacientes na faixa pediátrica cm trauma craniencefáic ee sã candidats para a reaizaçã de radigrafia simpes u tmgrafia cmputadrizada d crâni (TCC). Método: Pacientes cm trauma cranian ee, entre 0 e 19 ans, admitids em um centr de referência em traumatgia, na cidade d Saadr, Brasi, entre mai 2007 e mai 2008. Resultados: Fram atendids 1888 pacientes cm trauma cranian ee, cm idade média de 7,4 ( ± 5,5) ans. Um tta de 1956 radigrafias simpes e 734 TCC fram reaizadas. Em 44,4% ds pacientes cm escaa de cma de Gasgw (GCS) 13 e 55.4% cm GCS 14, tieram TCC cm acads anrmais. Em pacientes cm mútips traumas, 16% pssuíam aterações na TCC. Conclusão: Recmendams TCC em pacientes cm GCS 13 e 14 u naquees cm traumas mútips, independente d GCS. Radigrafias simpes d crâni cm rtina, nã fram identificadas cm úteis, n presente estud.PAlAvRAS-ChAvE: tmgrafia, radigrafia, trauma craniencefáic, criança, adescência. 1 Pst-Graduatin Prgram in Medicine and heat frm Federa University f Baia, Savadr BA, Brazi (PPgMS-UFBA), Neursurgen, PD Candidate in Medicine (PPgMS-UFBA); 2 Medica student f te head Trauma Researc Grup (UFBA); 3 Neurgist, PD in Neurgy (University f Sã Pau)., Sã Pau SP, Brazi.Received 31 Marc 2008, received in na frm 20 June 2008. Accepted 18 Juy 2008. Dr. José Roberto Tude Melo – Hospital São Rafael 2152 - 41253-900 Salvador BA - Brasil. E-mail: Mid ead trauma is dened as a nn-penetrating ead esin in tse wit a nrma r minimay atered neur-gic examinatin, at times assciated wit a istry f ss f cnsciusness and pst-traumatic amnesia 1-6 . Cmpica-tins f mid ead trauma are unusua, but in rare cases it can be ife-treatening and require neursurgica interventin (0.4%–1.0%). Crania cmputed tmgrapy (CCT) scan is te imaging study f cice, atug sme cnsideratins abut cst, medica staff, patient sedatin and prper de-vices imit its rutine use in cidren and adescents 7-11 . Tere are sme divergences regarding CCT scan and sku radigrap indicatins in pediatric ppuatin 4,6,7,10,11 . Due t tis ack f cnsensus abut imaging evaua-tin f cidren and adescents wit mid ead trauma, in te present study we aimed t identify wic pediatric patients wit mid ead injury are te mst prper can-didates fr sku radigraps and CCT scans in an Emer-gency Department. method Patients and study design We cnsidered cidren wit mid ead trauma a tse w ad a Gasgw cma scre (GCS) 12  scre f 13, 14 r 15, in agree-ment wit te Braziian Sciety f Neursurgery 4 .  Arq Neurpsiquiatr 2008;66(3-B) 709 head trauma: CT Me et a. A patients wit mid ead trauma aged frm 0 t 19 years presenting t te Emergency Department f a trauma centre frm Savadr City, Baia, Brazi, between May 2007 and May 2008, were prspectivey enred in te study.Te study was apprved by te hspita Etics Cmmit-tee (n°06/07), and eiter patients r famiy members signed in-frmed cnsent befre participating. Data collection A questinnaire was appied n eac patient admissin and fued unti spita discarge. We assessed te mecanisms f injury, assciatin wit mutipe trauma, sku radigrap and CCT scan resuts.   Te pediatricians w assisted te cidren in te emergency rm dened wic radigica exam was nec-essary. Te reprts f sku radigraps r CCT scans were pr-vided by neurgists, neursurgens r radigists. Data analyses Statistica anaysis was dne by using SSPS 12.0 fr Windows (Statically Package for Social Sciences) . Categrica data were an-ayzed by using χ 2  anaysis. reSultS A tta f 2600 patients aged frm 0 t 19 years wit a istry f ead trauma presented t te Emergency De-partment in te study perid; 1888 (72.6%) ad mid ead trauma. Regarding GCS cassicatin, 1.9% f patients ad a GCS 13, 4.4% ad a GCS 14 and 93.7% ad a GCS 15 n admis-sin. Mean age was 7.4 years ( ± 5.5) and te majrity f cas-es (27.9%) invved patients between 03 and 06 years, f-wed by patients aged frm 11 t 19 years (27.4%). We b-served tat 437 (23.1%) patients ad ess tan 2 years f age.Patients wit mid ead trauma were submitted t 978 sku radigraps studies (a tta f 1956, incuding ater-a and frnta views) and 734 CCT scans. We registered abnrma sku radigraps in 2.5% f tese patients and simpe inear sku fracture was te mst frequent nding (2.1%). In reference t cidren ess tan 2 years f age (437 patients), ny 11 (2.5%) ad fractures n sku radigraps. Amng tese eeven patients, 09 were victims f fa frm a eigt and tw suffered mutipe trauma and were sub-mitted t a CCT scan. ony tw patients ess tan 2 years-d underwent a neursurgica prcedure and tey were victims f isated ead trauma. Cnsidering CCT scan as te gd-standard imaging study in mid ead trauma victims, sku radigraps ad a sensitivity f 60% (Tabe 1).Reviewing 734 CCT scans, abut 10.9% ad abnrma-ities and te main findings were fractures (6.2%), brain sweing (3.3%) and extradura ematmas (2.0%) (Tabe 2). Amng tse patients w ad abnrma ndings n CCT scans, 40.5% ad a istry f fa frm a eigt, 37.1% were victims f trafc accidents and 6.3% ad a grund-eve fa istry. ony 48 (2.5%) f a patients underwent a neursurgica prcedure.Cncerning GCS cassificatin, 44.4% f patients wit GCS 13 ad abnrma ndings n CCT scan ( χ 2 =12.2, ρ =0.01); amng tse wit GCS 14, 55.4% ad atered CCT scan ( χ 2 =48.9, ρ =0.01), and ny 8.1% f patients wit GCS 15 ad abnrma CCT scan. We as evauated if mutipe trauma was assciated wit a iger frequency f abnrma CCT scans. Amng patients wit isated mid ead trauma, 8.8% ad abnr-ma ndings n CCT scans, against 16% f patients wit mutipe trauma ( χ 2 =13.4; ρ =0.05). one patient wit mid ead trauma died during te study. Table 1. Comparison* between 135 cranial computed tomography (CCT) and skull radiograph in the diagnosis of brain lesions in mild head trauma pediatric patients (Salvador City, Bahia, Brazil,  2007/2008). CCT scanAbnrmaNrmaSku radigrap**Abnrma257Nrma1786 *here we incuded ny te patients w were submitted t bt sku radigrap and CCT scan; **Sku radigrap ad a sensitivity f 60% and a specicity f 92% wen cmpared t CCT scan. Table 2. Imaging studies* in children and adolescents with mild head trauma at Salvador, Bahia, Brazil, 2007/2008. Imaging studyn%**Sku radigrap Nrma Simpe inear fracture Depressed fracture Tta93140797849.32.10.451.8Crania cmputed tmgrapy (CCT) scan Nrma Abnrma*** Simpe inear fracture Brain sweing Acute extradura ematma Depressed fracture Cntusin oters**** Tta529205118623736284773428. *A tta f 1956 sku radigraps (wic incuded frnta and atera views) and 734 crania cmputed tmgrapy (CCT) scans were perfrmed; **Percent f a admitted patients; ***93 patients ad at east tw abnrma ndings n CCT scans; ****Subaracnid emrrage and/r acute subdura ematma and/r pneumencepaus.  Arq Neurpsiquiatr 2008;66(3-B)710 head trauma: CT Me et a. diScuSSion Sme previus studies reprted cidren and ades-cents as te main victims f ead trauma 13 , as we as te predminance f mid cases amng patients wit ead trauma 2,10,13,14 . Te ratina use f imaging studies in te evauatin f mid ead trauma victims is nt we estab-ised and a cnsensus regarding sku radigraps and CCT scan use n patients wit a GCS f 15 is acking 2,4,14-17 . As a resut, sme imaging studies are dne wit n indica-tin, eevating spita csts.Sme autrs suc as Scutzman et a. 15  and hayde et a. 18  nticed tat, amng victims f mid ead trauma, 3-7% ad abnrma CCT scans. We swed ere a rate f 10.9%, wic raise te need f a better identicatin f candidates fr CCT scans. It is imprtant t ntice, tere-fre, tat patients wit GCS 13 r 14 must aways be sub-mitted t a CCT study, since radigica abnrmaities are mre frequent in tis grup f patients. Sku radigraps were abnrma in a wer frequency (2.5%) wen cmpared t CCT scans and ad a w sensi-tivity, wic is in agreement wit sme studies tat sw its ack f imprtance as a rutine screening study in pa-tients wit mid ead trauma 17,19-21 . lyd et a. 17  bserved tat neurgica examinatin as a iger sensitivity tan sku radigraps wit respect t te investigatin f in-tracrania esins. Subdivisin f mid ead trauma in categries, suc as ig, midde and w risk f deveping intracrania e-sins, is imprtant t better guide te evauatin f tese patients 4,15,16 , aviding unnecessary expsure t inizing ra-diatin, famiy anxiety, patient emtina stress and ig spita csts 17 .We swed tat fa frm a eigt was te mst im-prtant mecanism f injury assciated wit abnrma ndings n CCT scans; wever, we cud nt specify w eigt te patients fe. Scutzman et a. 15  reprted tat tere is a w risk f intracrania esin in te subgrup f patients tat fa frm a eigt ess tan 3 feet, w ave n signs r symptms at east 2 urs after te injury and tat are der tan 6 mnts f age. Te iger incidence f abnrma CCT scans in mu-tipe trauma patients is prbaby due t mre severe mecanisms f injury invved in tese accidents wen cmpared t isated ead trauma nes. Tis tendency was bserved by ter autrs as we 4,15-17,19 . Te imitatins f tis study sud be nted. First f a, tis was a singe-center study, and s te resuts swn ere may nt necessariy be generaized t a centers and ppuatins. Secnd, te imaging studies resuts were giv-en nt ny by radigists, but as by neurgists and neursurgens, and tus sme image misinterpretatin may ave ad ccurred. In cncusin, prper identicatin f patients wit w, midde r ig risk f deveping intracrania esin is cru-cia t a better evauatin and management f patients wit mid ead trauma, terefre aviding unnecessary imaging studies. here we swed tat te subgrup f mid ead trauma patients wit iger risk f deveping intracrania esins incude mutipe trauma victims (independenty f GCS ), patients tat ad a istry f fa frm a eigt r trafc accidents and tse wit GCS 13 and 14; ence, we strngy recmmend CCT scans fr tese patients. Screen-ing sku radigraps were nt usefu in te evauatin f mid ead trauma patients in tis study, atug teir re is sti t be determined in patients ess tan 2 years-d. referenceS  1. Smits M, Dippel DW, de Haan GG, et al. External validation of the Ca-nadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA 2005; 294:1519-1525. 2. Macedo KC. [Clinic and epidemiologic characteristics of children and adolescents with mild head trauma and factors associated with skull fracture and brain injury]. Belo Horizonte, 2006. Master dissertion – Federal University of Minas Gerais, Brazil. 3. American College of Surgeons Committee on Trauma. Initial assess-ment and management. In: Advanced trauma life support: reference manual. 4.Ed. Chicago: American College of Surgeons, 1994:17-37. 4. Brazilian Society of Neurosurgery. [Diagnosis and management of pa-tients with mild head trauma]. Guidelines Project, 2001. Available on-line at traumatismo_craniencefalico_leve.pdf. Accessed on January 29 th  , 2007. 5. Brazilian Society of Neurosurgery. [Diagnosis and management of pa-tients with moderate head trauma]. Guidelines Project, 2001. Available online at traumatismo_craniencefalico_leve.pdf. Accessed on January 29 th  , 2007. 6. American Academy of Pediatrics. Minor head injuries in children. Available online at Ac-cessed on August 12 th  , 2007. 7. Glauser J. Head injury: which patients need imaging? Which test is  best? Cleveland Clin J Med 2004;71:353-357. 8. Varela Hernandez A, Pardo Camacho G, Medrano García R, Rivero Gar- cia C. [Tomographic ndings in mild head trauma]. Rev Mex Neuroc 2005;6:120-123. 9. Lee B, Newber A. Neuroimaging in traumatic brain Imaging. J Am Soc Exp NeuroTherap 2005;2:372-383.10. American Academy of Pediatrics. The management of minor closed head injury in children. Committee on quality improvement, American Academy of pediatrics; Commission on clinical polices and research, American of Family Physicians. Pediatrics 1999;104:1407-1415.11. Blackwell CD, Gorelick M, Bandyopadhyay S, Kuppermann N. Pediatric head trauma: changes in use of computed tomography in emergency de-partments in the United States over time. Ann Emerg Med 2007;49: 320-324.12. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;13:81-83.13. Melo JRT, Santana DLP, Pereira JLB, Ribeiro TF. Traumatic brain injury in children and adolescents at Salvador City, Bahia, Brazil. Arq Neu-ropsiquiatr 2006;64:994-996.14. Aitken ME, Herrerias CT, Davis R, et al. Minor head injury in children: current management practices of pediatricians, emergency physicians, and family physicians. Arch Pediatr Adolesc Med. 1998;152:1176-1180.15. Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation and manage-ment of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 2001;107:983-993. 16. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391-1396.17. Lloyd DA, Carty H, Patterson M, Butcher CK, Roe D. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet 1997;349:821-824.18. Haydel, MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux, P. In-dications for computed tomography in patients with minor head inju-ry. N Engl J Med 2000;343:100-105.19. Hofman PAM, Nelemans P, Kemerink GJ, Wilmink JT. Value of radio-logical diagnosis of skull fracture in the management of mild head in- jury: meta-analysis. J Neurol Neurosurg Psychiatry 2000;68:416-422.20. Leonidas JC, Ting W, Binkiewicz A, Vaz R, Scott M, Pauker SG. Mild head trauma in children: when is a roentgenogram necessary? Pediatrics 1982;69:139-143. 21. Homer CJ, Kleinman L. Technical report: minor head injury in children. Pediatrics 1999;104:78.
Similar documents
View more...
Related Search
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks