Approach to neuroimaging for children with minor blunt head trauma^[1-7]

Emergency department neuroimaging decision for infants and children with mild traumatic brain injury (GCS 13 to 15) after minor blunt head trauma and a nonfocal neurologic examination
Clinical finding	Estimated risk of clinically important traumatic brain injury*	Decision
Any one of the following: GCS score ≤14 Other altered mental status^¶ Palpable skull fracture Signs of basilar skull fracture (eg, raccoon eyes, Battle sign, hemotympanum, or CSF rhinorrhea) Post-traumatic seizure Bulging fontanelle Concern for abuse	High risk (most >3%)	Perform neuroimaging^Δ
Children (≥2 years), GCS 15, and one or more of the following:^◊ History of loss of consciousness History of vomiting Severe mechanism of injury (eg, MVC with death of occupant, ejection of patient, or rollover; or fall from >1.5 m [5 feet] height) Severe headache	Intermediate risk (variable %^§)	Observe for 4 to 6 hours or perform neuroimaging depending upon additional factors:^¥ Presence of multiple findings Severity of symptoms Clinical course during observation Physician experience Parental preference
Infants (<2 years), GCS 15, and one or more of the following:^◊ Loss of consciousness >5 seconds Severe mechanism of injury (eg, MVC as above or fall from >0.9 m [3 feet] height) Occipital, parietal, or temporal scalp hematoma Not acting normally per routine caregiver History of lethargy or irritability, now resolved Age <3 months with nontrivial trauma Vomiting	Intermediate risk (variable %^§)	Observe for 4 to 6 hours or perform neuroimaging depending upon additional factors:^¥ Younger age Presence of multiple findings Severity of symptoms Clinical course during observation Physician experience Parental preference
Absence of any of the above risk factors and age ≥3 months	Low risk (<0.05%)	Do not perform neuroimaging Discharge home with anticipatory guidance

Minor blunt head trauma occurs commonly in infants and children and is typically not associated with brain injury or long-term sequelae. However, a small number of infants and children who appear to be at low risk after minor head trauma may have a clinically important traumatic brain injury (ciTBI) that requires acute intervention such as intensive supportive care or neurosurgery. Refer to UpToDate topics on minor blunt head trauma in infants and children.

GCS: Glasgow Coma Scale; CSF: cerebrospinal fluid; MVC: motor vehicle collision.

* Clinically important traumatic brain injury refers to brain injury that requires acute intervention such as hospitalization for 2 days or longer directly related to the head injury, endotracheal intubation to manage head injury, or neurosurgery or causes death. Types of injury includes epidural hematoma, subdural hematoma, or cerebral contusion on neuroimaging; depressed skull fracture warranting operative elevation (ie, depressed past the inner table of the skull), or clinical findings of a basilar skull fracture.

¶ Includes agitation (irritability in infants), somnolence, or, in older patients, repetitive questioning or slow response to verbal communication.

Δ Both unenhanced computed tomography (CT) of the head or magnetic resonance imaging (MRI) of the brain have the necessary sensitivity to identify clinically important traumatic brain injury (ciTBI). Although MRI has been shown to be feasible for the evaluation of children with mild blunt head trauma, it is not as widely available. Head CT identifies essentially all ciTBI.

◊ For children, the estimated risk of ciTBI if a single clinical finding is the only concerning feature is approximately 0.5% for loss of consciousness, 0.7% for vomiting, 0.5% for severe mechanism of injury, and 1.4% for severe and worsening headache. For infants, the estimated risk of ciTBI if a single clinical finding is the only concerning feature is approximately 0.6% for loss of consciousness, 0.3 % for severe mechanism, 0.5% for nonfrontal scalp hematoma, and 0.2% for not acting normally per routine caregiver.

§ The clinician should have a lower threshold for neuroimaging if symptoms are multiple, worsening or severe, if vomiting is persistent, and for infants younger than 3 months of age with nontrivial mechanism of injury. Physicians performing observation of these patients should have appropriate pediatric experience.

¥ Observation permits a more selective approach for patients with these clinical findings, which can reduce unnecessary neuroimaging but prevent missed ciTBI. Patients with multiple or worsening signs and symptoms during the observation period have a >1% risk of ciTBI and typically warrant neuroimaging.

References:

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009; 374:1160.
Nigrovic LE, Lee LK, Hoyle J, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch Pediatr Adolesc Med 2012; 166:356.
Dayan PS, Holmes JF, Atabaki S, et al. Association of traumatic brain injuries with vomiting in children with blunt head trauma. Ann Emerg Med 2014; 63:657.
Lee LK, Monroe D, Bachman MC, et al. Isolated loss of consciousness in children with minor blunt head trauma. JAMA Pediatr 2014; 168:837.
Dayan PS, Holmes JF, Schutzman S, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med 2014; 64:153.
Nishijima DK, Holmes JF, Dayan PS, Kuppermann N. Association of a Guardian's Report of a Child Acting Abnormally With Traumatic Brain Injury After Minor Blunt Head Trauma. JAMA Pediatr 2015; 169:1141.
Nigrovic LE, Kuppermann N. Children with minor blunt head trauma presenting to the emergency department. Pediatrics 2019; 144:e20191495.

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Approach to neuroimaging for children with minor blunt head trauma[1-7]

Approach to neuroimaging for children with minor blunt head trauma^[1-7]