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Results of a new study presented here suggest that a "significant" number of children with neurologic complaints who undergo computed tomography ( CT ) scans of the head in the emergency department (ED) do not appear to have clinical justification for the procedure. Moreover, the study found that abnormalities on head CT scans are almost always predicted by history and physical examination findings.

Child neurologist Tarannum M. Lateef, MD, of The George Washington University School of Medicine and Children's National Medical Center in Washington, DC, reported these findings here during the Child Neurology Society 39th Annual Meeting.

"The availability and use of advanced imaging techniques such CT has exploded; however, the true value of CT in medical decision-making and its impact on final outcome are unclear," Dr. Lateef told Medscape Medical News. CT scans are also costly and pose a risk for radiation exposure, especially in young children, she added.

In a retrospective study, Dr. Lateef and colleagues studied utilization patterns of head CT scans performed on children aged 1 month to 6 years (mean age, 28 months) at a large suburban ED during a 7-month period in 2008. Their aim, according to Dr. Lateef, was to "examine to what extent head CT contributes to the diagnosis of neurological disorders in these children."

A total of 394 children underwent head CT during the study period. The most common indications were trauma (58%); seizure (11%), with 25% of patients having a previous diagnosis of epilepsy, 57% an afebrile seizure, and 18% a febrile seizure; nonaccidental trauma (7%); and headache (6%). Less common indications included altered mental status, preexisting neurologic diagnoses (eg, ventriculoperitoneal [VP] shunt), ataxia, syncope, and motor delay.

Red Flags vs Head CT Results

Red flags predicting intracranial disease were identified using evidence-based literature. For head trauma, red flags were loss of consciousness, altered mental status, abnormal neurologic examination findings, and signs of fracture and hematoma. For seizure, red flags were prolonged postictal state and seizure after head injury. For headache, red flags were pain on awakening from sleep, occipital pain, and abnormal neurologic examination findings. Other red flags were major trauma, bleeding diathesis, ataxia, suspected nonaccidental trauma, suspected VP shunt malformation, and signs of increased intracranial pressure.

Abnormalities on CT were found in 158 children (40.1%). There were 104 incidental findings, 22 preexisting abnormalities, and 32 significant findings. Of note, according to the researchers, 29 of the 32 children (90.6%) with significant head CT findings had red flags on the history and physical examination. Only 3 did not.

Moreover, only 3 of all 394 children (0.76%) required immediate neurosurgical intervention, all of whom had had red flags in the history and physical examination; 2 had VP shunt malfunctions and 1 had cerebrospinal fluid leakage from a recent craniotomy site whose wound was closed in the ED and the patient was sent home.

"The percentage of patients with no red flags who required acute intervention was zero," Dr. Lateef told Medscape Medical News. "For a child in the ED with no red flags on history or physical exam, a head CT is unlikely to show an abnormality requiring acute intervention," the researcher concluded, adding, "Physicians can rely on history and physical exam to rule out serious intracranial pathology requiring acute intervention."

A "Pioneer" Study

Commenting on this research, John R. Crawford, MD, MS, assistant professor of neurosciences and pediatrics at the University of California at San Diego, who was not involved in the study, said, "This is a bit of a pioneer paper because for the first time it really lets us know what are the clinical factors that are predictive for finding an abnormality and really in the end it allows the clinician to trust their neurological exam and to trust the history to really determine whether or not a head CT scan is warranted or not.

"What we don't want, however, is clinicians not ordering scans if they have a strong clinical suspicion. I think that is really the point, that if there are warning signs, then that is the time to order the CT scan. At the end of the day, it's really all about trusting your medical judgment," Dr. Crawford said.

Source: Medscape

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