Clinical predictors of abnormal computed tomography scan in minor head trauma in children under 2 years old

Introduction: Minor blunt head trauma is a common reason for children to present to the emergency department (ED). Crania computed tomography (CT) is the choice for evaluating children with blunt head trauma in the ED, but few shows abnormal findings. In this study, we aim to evaluate CT findings in children with blunt head trauma and clinical symptoms to identify clinical predictors of abnormal CT scans. Methods: In this prospective study, 218 children under 2 years of age (121 male and 97 female with mean age of 11.24 ± 4.31 months) with compliant of minor blunt head trauma visiting the ED between April 2011 and April 2014 were included. Physical examination and clinical symptoms, as well as CT findings and patients’ outcome were evaluated. Results: Physical examinations were normal in 95.9%, and clinical symptoms were present only in 25.7% including vomiting in 16.1%, loss of consciousness (LOC) in 8.3%, ear/nose bleeding in 4.1% and seizure in 5.5%. CT scan was requested in 189 cases (86.7%) of which, 7.9% were abnormal including linear fracture in 5.3%, subgaleal hematoma in 1.1% and depressed fracture, subcutaneous hematoma and intracranial hemorrhage (ICH) each in 0.5%. Among all cases, 89.0% were discharged from ED with no further observation, 6.0% discharged after 48 h observation and 5.0% were hospitalized. There was a significant correlation between abnormal CT findings and having any clinical symptoms, vomiting and Ear/nose bleeding. Conclusion: In children under 2 years old with minor blunt head trauma, most CT scans are unnecessary. Considering clinical symptoms as predictors of abnormal CT scans we can reduce unnecessary ones. Article info

of children with minor head trauma.][13][14] Although avoiding unnecessary CT scans should be mentioned as a fact, brain CT scan is needed to minimize the risk of missing potentially dangerous TBIs with clinical symptoms. 15,16][19] The goal of this study is to identify some clinical symptoms as risk factors that could predict potentially dangerous TBI after minor head trauma that lead to decrease unnecessary CT scans.
In this prospective study, 218 children under 2 years of age with compliant of minor blunt head trauma visiting the ED of Imam Reza Hospital, Tabriz, Iran between April 2011 and April 2014 were included.Children with minor blunt head trauma, defined by a Glasgow coma scale score of 14 or 15, who were seen at the ED within 24 h of the traumatic event, were included.Patients with trivial injury mechanisms, defined a priori as ground level falls or as walking or running into stationary objects, and with no signs or symptoms of head trauma other than scalp abrasions or lacerations were excluded.Also, patients with penetrating trauma, comorbidities (ventricular shunts or bleeding disorders), or previous neuroimaging, as well as those who left the ED against medical advice were excluded from the study.The study protocol was approved by the Ethics Committee of Tabriz University of Medical Sciences and parents of all subjects gave written informed consent.
A standardized data collection survey was completed by an emergency medicine-trained attending or fellow physicians before cranial CT.Information about age, gender, type of trauma, physical and neurological examination findings, CT result, and last status (discharge, hospitalization, or referral) was obtained from patients' hospital case notes.An experienced radiologist interpreted cranial CT images who did not know the clinical data.Also, investigators conducted telephone surveys of a parent or guardian of children to get patients' outcome information within 30 days after their ED visits.Finally, all information was reviewed by an emergency physician to assess the CT results and blunt trauma outcome.
All data were analyzed using the SPSS software for Windows (version 17, SPSS Inc., Chicago, IL, USA).Baseline data are reported as means ± standard deviation (SD) (continuous data) or percentages (categorical data), depending on the data level.The correlation between clinical symptoms and CT findings were evaluated using Pearson's correlation.A P < 0.050 was considered as statistically significant.
In this study, 218 children under 2 years old with blunt head trauma were evaluated.Table 1 demonstrates demographic profile of patients.Most of the children were male.The most common cause of an accident falls.Normal physical examination and negative clinical symptoms were seen in most cases.Vomiting was the most common clinical symptom.There was no black eye and raccoon sign in any cases.Neurological findings also were present only in 2 cases (0.9%).Abnormal findings in CT scan were seen in 7.9% including linear fracture in 10 cases (5.3%), subgaleal hematoma in 2 cases (1.1%) and depressed fracture, subcutaneous hematoma and intracranial hemorrhage (ICH) each in 1 case (0.5%) (Figure 1).Among all cases, 194 (89.0%) were discharged from ED with no further observation, 13 (6.0%)were discharged after 48 h observation and 11 (5.0%) were hospitalized.All 29 cases (13.3%) with normal findings for which CT scan was not requested were discharged from ED.Among patients with available CT scans, 158 cases (90.8%) with normal CT scans and 7 cases (46.7%) with abnormal CT findings were discharged with no observation, 11 cases (6.3%) with normal and 2 cases (13.3%) with abnormal CT findings were discharged after 48 h observation and 5 cases (2.9%) with normal and 6 cases (40.0%) with abnormal CT findings were hospitalized.In 30 day follow-up, there were no deaths or worsening of patients' condition in need of hospitalization or intensive care.
Table 2 demonstrates the correlation between clinical symptoms and CT findings.There was a significant correlation between showing abnormal CT findings and having any clinical symptoms, vomiting and ear/nose bleeding.But the correlation between abnormal CT findings and loss of consciousness (LOC) and seizure was not significant.
Minor head trauma is common among the pediatric population.Although it is a common presentation among children referred to ED, 3-5% of those have TBI, and only less than 1% of these children require neurosurgical intervention. 20,21Zhu et al. showed that minor head trauma in boys is likely more common than in girls [69.2% vs. 30.8% of total mild TBIs (MTBIs) cases]. 22A similar report from Peloso et al. showed that head injury with symptoms of concussion is twice more in boys than girls. 23Willer et al. also reported the same result in which boys suffer an MTBI more likely than girls. 24ccording to Elgmark et al. there is no significant difference between boys and girls in terms of what activities that caused a  MTBI. 25In this study, of the 218 children, 121 (55.5%) were male and 97 (44.5%) were female.Although cranial CT is the choice diagnostic modality for evaluation of children with blunt head trauma, it has its own disadvantages like increased risk of lethal malignancy and it's cost, studied by Brenner et al. 11 Palchak et al. 4 reported that 62.0% of children referred to ED with minor head trauma were evaluated with CT and only 7.7% of those reveal abnormal findings.Unlike these findings in another study by Zhu et al., they reported that 96.9% of children with minor head trauma were evaluated with CT scan, and 33.3% had abnormal CT findings. 228][19] It is important to identify predicating factors that could predict TBI that may help us to decrease unnecessary CT Scans.In this study, we observed 95.9% patients have normal physical examination.Clinical symptoms were seen in 25.7% of cases including: vomiting (16.1%),LOC (8.3%), ear/nose bleeding (4.1%), and seizure (5.5%).Post traumatic amnesia is an important predictor factor, however, it is difficult to evaluate, so we did not include this variable.There was a significant correlation between abnormal CT scan finding and clinical symptoms such as: vomiting, ear/nose bleeding, and no significant correlation with LOC and seizure.
In some of the previous studies, some clinical symptoms introduce as predicting factors of abnormal CT findings.Munivenkatappa et al. reported that in the presence of each symptoms such as vomiting, LOC, ear/nose bleeding and seizure patient should be evaluated by brain CT scan. 26ulsen et al. reported strong relationship between vomiting and presence of abnormal findings in brain CT scan. 27However, Dunning et al. reported that there is no significant relationship between post traumatic vomiting and TBI. 19Also Osmond et al. claimed that vomiting could not be considered as an indicator factor for performing CT scan. 5Da DL et al. claimed that post-traumatic vomiting (PTV) is highly related to personal or familial background rather than presence of intracranial lesions. 28OC is one of the clinical symptoms and may be presented in children with minor head trauma.Some previous studies have failed to show that history of LOC is predictor of TBI. 17,29-34Davis et al. 35 claimed that LOC is not predictive of significant brain injury in children with minor head trauma the same as Falimirski et al. 36 reported.][39][40][41][42][43] Dunning et al. also reported that there is a statistical relation between LOC and TBI. 19In our study, LOC was seen in 18 cases (8.3%) and correlation between LOC and abnormal CT findings was not significant.
In our study, we did not find a significant correlation between post traumatic seizure (PTS) and abnormal brain CT scan.Dias et al. also reported that children with simple PTS without any history of neurologic disorder and consumption of antiepileptic drugs had not abnormal CT scan. 44Saboori et al. identified PTS as predictor of having abnormal CT scan. 45Dunning et al. claimed that the presence of seizures showed a trend toward an association with brain injury after minor trauma but is not statistically significant correlation. 46t seems that some clinical symptoms as mentioned above (PTV, PTS, LOC, and ear/nose bleeding) could be considered as risk factors that could predict presence of abnormal CT findings in children under 2 years old with minor head trauma.These clinical risk factors could help us decide which patient needs brain CT scan as further evaluation and possibly neurosurgical intervention.
Although we could not just rely on clinical symptoms for decision-making about further radiologic assessment, but some of these clinical symptoms as mentioned above (PTV, PTS, LOC, and ear/nose bleeding) could be considered as clinical risk factors that help us to predict abnormal CT scans.
Authors have no conflict of interest.
The authors would like to appreciate all children participating in this research and their families for their cooperation.