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Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?
Clinical Radiology xxx (2017) e1ee7
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?q S. Zaman*, P.H. Logan, C. Landes, S. Harave Department of Radiology, Alder Hey Children’s NHS Foundation Trust, 1 Eaton Road, Liverpool L12 2AP, UK
art icl e i nformat ion Article history: Received 27 June 2016 Received in revised form 2 November 2016 Accepted 19 December 2016
AIM: To determine whether it is justified to undertake a computed tomography (CT) examination of the head in children under 1 year of age who present with a bruise, swelling, or laceration of >5 cm following head injury in children presenting to a paediatric accident and emergency (A&E) department in the northwest of England. Further aims were to determine whether there was any justification for performing a CT head examination for children with soft-tissue injuries measuring <5 cm, or for children >1 year with evidence of soft-tissue injury, but without any other concerning feature. MATERIALS AND METHODS: Children <3 years of age presenting with soft-tissue evidence of head injury between May 2011 and Oct 2014 and who subsequently underwent head CT were retrospectively identified from radiology requests. The CT images and clinical notes were used to identify those with skull fracture or intracranial haemorrhage and to determine whether the child was subsequently admitted or discharged from A&E. RESULTS: Eighty-five CT head examinations met the criteria for inclusion. Of these, 45 examinations demonstrated skull fractures and four examinations identified intracranial haemorrhage. Thirty-eight requests included soft-tissue evidence of head injury as the sole reason indicated for CT head examination. Of these, 22 examinations demonstrated skull fractures and one examination identified intracranial haemorrhage. CONCLUSION: Soft-tissue evidence of head injury as the sole reason for CT head examination appears to be justified in the present patient population. Furthermore, this study suggests that CT head examination should also be considered for children with soft-tissue injuries of <5 cm and for children aged between 1 and 3 years if identification of a skull fracture would alter the child’s management. Ó 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction
q This work was presented at the European Society of Emergency Radiology meeting in Antalya, Turkey in 2015.
* Guarantor and correspondent: S. Zaman, Department of Radiology, Alder Hey Children’s NHS Foundation Trust, 1 Eaton Road, Liverpool L12 2AP, UK. Tel.: þ44 151 252 5432. E-mail address: [email protected] (S. Zaman).
Paediatric head injury is a common presentation to paediatric emergency departments and a major cause of morbidity and mortality in the paediatric population.1,2 Although it is important to identify and then manage clinically important head injuries, this should be balanced against the relative risks of radiation exposure, particularly in infants.3
http://dx.doi.org/10.1016/j.crad.2016.12.012 0009-9260/Ó 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Zaman S, et al., Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?, Clinical Radiology (2017), http://dx.doi.org/10.1016/j.crad.2016.12.012
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In January 2014, the National Institute for Health and Care Excellence (NICE) in the UK issued updated guidelines on the management of head injury in children, young people, and adults.4 The NICE recommendations 2014 now advise that a CT head examination should be performed within 1 hour for infants under the age of 1 year with a bruise, swelling, or laceration of >5 cm following head injury, and that a provisional written radiology report should be made available within 1 hour of the scan being performed. This is an update on the 2007 guidelines only in terms of timing. The 2007 guidelines also recommended CT head examination for children aged <1 year who had sustained a head injury and had a bruise, swelling, or laceration >5 cm on the head. The criterion related to soft-tissue evidence of head injury is taken verbatim from the work of Dunning et al.,5 also known as the children’s head injury algorithm for the prediction of clinically important events or CHALICE study. This was a large well-designed prospective study, involving over 22,000 children aged <16 years, which aimed to provide rules for the selection of children for CT head examination following head injury. The CHALICE study reported a positive predictive value for death as an outcome of head injury of 0.12 for the presence of bruising, swelling, or laceration of >5 cm in the <1-year-old age group; however, as discussed in the NICE 2014 guidelines, the CHALICE study does have some limitations: firstly, the parameters determined by the CHALICE study have not been prospectively validated. Furthermore, the NICE 2014 head injury guideline development group (GDG) commented that the method of patient selection used for CHALICE was not clear, and therefore, there is a potential selection bias within the study. The GDG also noted that the length of follow-up in CHALICE was not clearly stated. The GDG considered a follow-up of 2 weeks would be appropriate for children due to the very small risk of delayed diagnosis of intracranial haemorrhage in children as compared to adults. The aim of this retrospective review was to determine whether CT head examination for infants with bruising, swelling, or laceration >5 cm following head injury was justified in the present patient population. Further aims were to determine whether there is any justification for performing CT head examination for bruising, swelling, or laceration of <5 cm in the context of head injury, and whether there is justification for performing CT head examination for children over the age of 1 year with bruising, swelling, or laceration in the present patient population. These questions were relevant because the authors were aware of a few cases where children in these two categories had undergone a CT head examination due to clinical concern following discussion of individual cases with the on-call paediatric radiologist.
and October 2014 were identified using an in-built audit search function within the computerised radiology information system (CRIS) used by our radiology department. The audit search function was used to identify the search terms “bruise, swelling, bump, haematoma, laceration or abrasion” within the clinical details entered by the clinicians at the time of CT head examination request. Those examinations that had been carried out following a clear history of head injury were then identified by manually checking the clinical request details and by crossreferencing with the clinical notes. CT head examinations carried out in cases where there was a documented suspicion of non-accidental injury or where a skeletal survey was carried out within 28 days were excluded. At least one random day per week throughout the study period was chosen and CT day lists examined to doublecheck that the in-built audit function within CRIS identified all of the relevant CT examinations. During this check, no CT head examinations that met the search criteria were identified and that had not been identified by the audit search function (in fact, on the random days checked the audit search function identified all of the CT heads performed for children in the relevant age range, regardless of clinical details). The manual check of the request history was the most important factor in identifying relevant examinations. CT images were reviewed for each case to determine whether there was any radiological evidence of soft-tissue injury. Where this was present, the maximal width on the axial images was measured and recorded to the nearest 0.5 cm (Fig 1). It was hypothesised that this measurement would be a surrogate marker for the size of soft-tissue evidence of head injury as assessed clinically. In addition, this measurement would possibly be more objective than the clinical assessment due to the obvious difficulties of accurately assessing the size of a three-dimensional (3D) swelling with overlying hair in the clinical setting. Furthermore, this measurement would have the added
Materials and methods Children under the age of 3 years with head injury and who subsequently underwent head CT between May 2011
Figure 1 Schematic representation of measurement of radiologically evident soft-tissue injury.
Please cite this article in press as: Zaman S, et al., Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?, Clinical Radiology (2017), http://dx.doi.org/10.1016/j.crad.2016.12.012
S. Zaman et al. / Clinical Radiology xxx (2017) e1ee7
advantage of being reproducible. The absence or presence of skull fracture and of intracranial haemorrhage on CT was also recorded. The documented size of any soft-tissue evidence of head injury as recorded by the accident and emergency (A&E) doctor assessing the child was taken from the clinical notes. The timing of the injury in relation to presentation to A&E and the decision to admit or discharge the child home from A&E was also taken from the clinical notes. This study was designed as an audit of local practice and is not considered research by the NHS Health Research Authority criteria. It was registered and approved as a retrospective audit by the trust’s Clinical Audit Department. The CT examinations were only performed based on clinical need as evaluated by the A&E department clinicians and as justified by a consultant paediatric radiologist or senior paediatric radiology trainee. NHS research ethics committee approval was therefore not required.
Results Ninety-one cases were identified where a child under the age of 3 years underwent a CT examination following head injury. Corresponding clinical notes were available for 85 of these patients. Of the 85 cases, 44 CT head examinations demonstrated skull fracture and four examinations demonstrated intracranial haemorrhage of any size (Fig 2). Of the four children with intracranial haemorrhage, all of whom also had a skull fracture, all had an extra-axial haemorrhage. None of the patients had any parenchymal haemorrhage. One child required neurosurgical intervention (evacuation of an extradural haematoma). None of the patients with intracranial haemorrhage required long-term follow-up. There were no deaths from head injury in the patient group identified.
Figure 2 CT findings.
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Sixty-eight cases had soft-tissue evidence of head injury (bruising, swelling, bump, haematoma, laceration, or abrasion) documented in the clinical notes or entered into the radiology request clinical details section. In 38 cases, softtissue evidence of head injury was the sole justification documented in the clinical notes and provided in the clinical details for CT head examination. Of these examinations, 22 demonstrated skull fracture and one examination demonstrated intracranial haemorrhage (Fig 3). In 47 cases, one or more NICE criteria for CT head examination other than soft tissue swelling (Table 1) with or without soft-tissue evidence of head injury was documented. Of these examinations, 22 demonstrated skull fracture and three demonstrated intracranial haemorrhage (Fig 3).
Results by age Forty-five CT examinations occurred in children < 1 year. Of these, 34 examinations demonstrated skull fracture and four demonstrated intracranial haemorrhage. Twenty-five examinations were performed in children aged between 1e2 years of age, of which five demonstrated skull fractures. None demonstrated intracranial haemorrhage. Eighteen examinations were performed in children aged between 2e3 years of age, of which five demonstrated skull fracture. None demonstrated intracranial haemorrhage (Fig 4). Of those examinations performed where soft-tissue evidence of head injury was the sole justification stated for imaging, 27 examinations were performed in children <1year old with 20 of these examinations demonstrating skull fracture and one demonstrating intracranial haemorrhage. Nine examinations were performed in children aged between 1 and 2 years with two demonstrating skull fracture and none demonstrating intracranial haemorrhage. Of note, one of the examinations performed in this age group in which a fracture was identified was due to soft-tissue swelling measuring just 2 cm in maximal trans-axial width on CT. Four examinations were performed for children aged between 2 and 3 years with none demonstrating skull fracture or intracranial haemorrhage.
Figure 3 Clinical soft-tissue evidence of head injury and positive CT findings.
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Table 1 NICE criteria for CT head, other than suspicion of non-accidental injury or presence of bruising, swelling, or laceration of >5 cm with no. of patients meeting each criterion.a Criteria
No. of patients
Post-traumatic seizure but no history of epilepsy4 On initial emergency department assessment, GCS <14, or for children under 1 year GCS (paediatric) <154 or at 2 h after the injury, GCS <154 or abnormal drowsiness Suspected open or depressed skull fracture or tense fontanelle4 Any sign of basal skull fracture (haemotympanum, “panda” eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)4 Focal neurological deficit4 Loss of consciousness lasting more than 5 min (witnessed)4 Three or more discrete episodes of vomiting4 Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist, or vehicle occupant, fall from a height of >3 m, high-speed injury from a projectile or other object)4 Amnesia (antegrade or retrograde) lasting more than 5 min4
1 10
3
Table 2 Contingency table of NICE soft-tissue swelling and skull fracture and/or intracranial haemorrhage. Meets NICE criteria for CT head based on soft tissue swelling?
CT head shows fracture or intracranial haemorrhage?
Yes No
Yes
No
21 6
10 16
NICE, National Institute for Health and Care Excellence; CT, computed tomography.
2
0 3 20 13
0
NICE, National Institute for Health and Care Excellence; CT, computed tomography; GCS, Glasgow Coma Scale. a Several patients met more than one criterion.
Results by size of soft-tissue evidence of head injury The size of the soft-tissue evidence of head injury was documented in the A&E notes in 53 of the 85 cases. For these cases, the odds ratio of skull fracture with clinically assessed soft-tissue evidence of head injury measuring >5 cm compared with clinically assessed soft-tissue evidence of head injury measuring 5 cm is 8.23 (p¼0.0106); however, the clinical assessment of soft-tissue swelling large enough to meet the NICE criteria for CT head examination did not include all cases where a skull fracture or
Figure 4 Age and Identification of skull fracture and intracranial haemorrhage on CT.
intra-cranial haemorrhage was subsequently identified (Table 2). In five cases, there was no identifiable CT evidence of soft-tissue injury. Of these, two demonstrated skull fracture and one demonstrated an intracranial haemorrhage. In five cases, there was radiological evidence of soft-tissue injury measuring 0.5, 1, 1.5, 2, or 2.5 cm in maximal width to the nearest 0.5 cm on axial images. Of these, two examinations demonstrated skull fracture. In 40 cases, there was radiological soft-tissue evidence of head injury measuring 3, 3.5, 4, 4.5, or 5 cm in maximal width to the nearest 0.5 cm. Of these, 15 examinations demonstrated skull fracture and two demonstrated an intracranial haemorrhage. In 29 cases, there was radiological soft-tissue evidence of head injury measuring 5.5, 6, 6.5, 7, or 7.5 cm to the nearest 0.5 cm. Of these, 16 demonstrated skull fracture and one demonstrated an intracranial haemorrhage. In 10 cases, there was radiological soft-tissue injury measuring 8 cm to the nearest 0.5 cm (max. 10.5 cm). Of these, nine had an underlying skull fracture with no underlying intracranial haemorrhages identified (Fig 5).
Figure 5 Size of radiological soft tissue evidence of head injury (RSTEHI) in maximal trans-axial diameter and identification of skull fracture on CT.
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The odds ratio of skull fracture with radiological evidence of soft-tissue evidence of head injury measuring >5 cm (to the nearest 0.5 cm) compared with radiologically assessed soft-tissue evidence of head injury measuring 5 cm is 2.91 (p¼0.0158). In the 53 cases where clinical size of soft-tissue evidence was documented there was a moderate positive correlation (Spearman’s rank correlation coefficient ¼ 0.636) between these values and the width of soft-tissue swelling measured on trans-axial CT images. There was no statistically significant correlation between size of the soft-tissue evidence of head injury on CT and the timing of the injury (Spearman’s correlation coefficient ¼ 0.1131).
examination despite not meeting the NICE CT head criteria due to clinical concern and following discussion with the on-call paediatric radiology consultant or senior paediatric radiology trainee. Finally, the present data suggest that large radiologically evident soft-tissue swelling on CT should raise the suspicion of underlying skull vault fracture. The odds of having an underlying skull fracture were 2.91 times greater when there was radiologically evident swelling of >5 cm compared to cases where the radiologically evident swelling measured 5 cm.
Admission rates
This study concentrates upon one key criterion from the NICE head injury guidelines that was identified as being a potential source of unnecessary radiation exposure to young infants and children and provides reassurance that children are not being unnecessarily exposed to radiation in the authors’ institution. It also provides evidence that prompt examination as advised by the 2014 guidelines is justified in the present patient population.
Of 45 cases where skull fractures were identified, 35 were admitted to hospital for a period of observation. This includes the four cases where there was also intracranial haemorrhage. Ten patients with simple skull fractures identified on CT were discharged home from the A&E department.
Discussion In the present study, the use of soft-tissue evidence of head injury as the sole criterion for CT head examination is justified in the present patient population. Of the 38 patients identified with soft-tissue evidence of head injury as the sole NICE head injury guidance criterion for CT head examination, 57.9% had an underlying skull fracture and there was one underlying intracranial haemorrhage. This finding adds further evidence to support the inclusion of significant bruising, swelling, or laceration in the <1-year age group in the NICE head injury criteria for performing CT head examination. This study has also shown that the 5 cm lower cut-off in the size of bruising, swelling, or laceration, fails to identify all children with an underlying skull fracture that present with soft-tissue evidence of head injury and no other concerning feature following blunt head injury in the present patient population. In patients with soft-tissue evidence of head injury and no other concerning feature, four skull fractures (but no intracranial haemorrhages) were identified in children with clinical evidence of soft-tissue injury measuring <5 cm, as documented in the clinical notes, and seven skull fractures (but no intracranial haemorrhages) were identified in children with radiological soft-tissue evidence of injury of <5 cm in maximal width on CT head examination. In addition, this study has also shown that the upper age limit of 1 year for performing CT head examination in children with soft-tissue evidence of head injury and with no other concerning feature, does not identify all children with underlying skull fracture in the present patient population. Two skull fractures (and no intracranial haemorrhages) were identified in children aged between 1 and 3 years with soft-tissue evidence of head injury and no other concerning features. These children underwent CT head
Strengths of the study
Limitations of the study This is a retrospective study based upon CT examinations that have been carried out. No attempt has been made to identify infants or children with small swelling, haematoma, or laceration following head injury for whom CT head examination was not performed. The CT examinations were initially identified using the in-built audit search function within the CRIS system used in the Department of Radiology, Alder Hey Children’s NHS Foundation, Liverpool. It was apparent from an early stage that this search function identified more CT examinations than met the search criteria. This may have introduced an element of artificial selection into the data. An attempt was made to counteract this by manually reading through the radiology requests identified in order to determine which CT examinations were performed following head injury and by cross-referencing with the clinical notes. The initial audit function search also relied upon correct details being entered into the clinical details section of the radiology request form by the clinicians assessing the child. Documentation with regard to the size of any clinical soft-tissue evidence of head injury was inconsistent. In addition, in many cases, it was not possible to determine in retrospect whether the clinical soft-tissue evidence of head injury had been accurately measured or rather estimated. Finally, it is not clear to what extent the findings of this study would be applicable to a wider patient population; however, the methods used are likely to be of interest to other departments that manage the care of infants and young children following head injury.
Comparison with NICE head injury guidelines The NICE criteria use the presence of bruising, swelling, or laceration as a criterion for CT head examination only if the bruising, swelling, or laceration is >5 cm and the child is
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under 1 year of age. In practice at Alder Hey Children’s NHS Foundation, clinicians ask for CT examinations for infants and young children outside of these parameters, for example, when the bruising, swelling, or laceration is <5 cm in diameter or when a child older than 1 year is deemed to have a “significant” bruising, swelling, or laceration by the examining clinician or overseeing A&E consultant. The study findings provide some justification to the clinicians for these approaches. The arbitrary 5 cm cut-off criterion used in the NICE head injury guidelines is taken word-for-word from the CHALICE study. It is not clear from the CHALICE study why this value was chosen. Dunning et al.6 carried out a meta-analysis of variables that could predict clinically significant head injury prior to carrying out the CHALICE study. This had identified soft-tissue evidence of head injury as a possible independent variable for clinically significant head injury based on the work of Greenes and Shutzman7 in Boston, MA, USA. Greenes and Shutzman noted that scalp swelling was the only indicator of clinically significant brain injury in a number of children aged <1 year in their study of 608 patients aged <2 years, and suggested that scalp haematoma in the under 1-year age group should be a criterion for CT head examination. Of note is the fact that Greenes and Shutzman used a grading system of “small (barely perceptible), moderate [and] large (obvious swelling and/or boggy consistency)” for scalp swelling in their study and that they included small haematomas in their analysis for the under 1 year age group. Another clinical decision making tool derived by Osmond et al.,8 known as the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) study, uses the presence of “large, boggy haematoma of the scalp” as a criterion for CT head examination but does not specifically give a size cut-off. The present study shows that a skull fracture is seen almost three times as often when there is radiologically evident swelling, haematoma, or laceration measuring >5 cm in maximal width on transaxial images compared to radiologically evident softtissue swelling measuring 5 cm (Fig 5); however, the study also shows that there is no lower cut-off in the size of swelling, haematoma, or laceration that would allow identification of all children with skull fracture or intracranial bleed following head injury when soft-tissue evidence of head injury is the sole criterion for further investigation. It was hypothesised that there may be a relationship between swelling or haematoma formation with time, i.e., in children who present almost immediately to A&E following their head injury, there may not have been sufficient time for a significant or clinically obvious swelling haematoma to develop, whereas children with a longer journey time to hospital or those that present within a few hours of head injury, may have larger evidence of soft-tissue injury on presentation; however, in the present patient group, there was only a very weak relationship between these variables. The incidence of skull fracture in the present population was 51.7%, higher than might have been expected from previous studies; however, the CHALICE study for example, looked only at “marked abnormalities on
computerised tomography”5 and did not include the presence of simple skull fracture within this definition. Earlier studies such as Greenes and Schutzman7 relied partly on plain radiograph imaging of the skull and only on selective CT examination. It is therefore likely that the true incidence of non-depressed skull fracture is underestimated in the literature. In addition, it is recognised that the use of spiral CT head examination and the viewing of 3D reformatted images increases the pick-up rate of simple non-displaced skull fractures, particularly in infants and young children.9 This is routine practice in the authors’ institution and may partly explain the high incidence of isolated non-depressed skull fractures in the present study.
Clinical implications of identifying skull fracture The importance of swelling, haematoma, or laceration as a criterion for CT head examination is because of its nature as a marker for underlying pathology, such as skull fracture and/or intracranial haemorrhage. In the present study, the skull fractures identified on CT examination were almost exclusively simple or non-depressed skull fractures and most were not associated with any underlying intracranial haemorrhage. As previously mentioned, many authors of larger studies such as CHALICE, CATCH and the paediatric emergency care applied research network (PECARN)10 study do not include such fractures in their outcome measures11; however, the NICE head injury guidance includes the presence of new, clinically significant abnormalities on imaging as a criterion for admission. Whether or not the presence of a simple non-displaced fracture constitutes a clinically significant abnormality may be open to interpretation by clinicians and, as the present data show, in the authors’ institution, the A&E team commonly admit infants and young children with simple, non-displaced skull fractures to hospital for a period of observation, usually under the care of the neurosurgical team. Therefore, there is a service provision and economic impact for the hospital following the identification of simple skull fractures in infants and young children. Metzger et al.,12 implemented guidelines designed to reduce admission of children with simple skull fracture following blunt head trauma and reduced admission rates from 75% to 57% in their study in Salt Lake City, UT. Metzger et al. also noted that young age combined with the presence of skull fracture was a concerning feature for clinicians and that this often prompted hospital admission despite this not being indicated by their guidelines. Although there is little information in the published literature about current practice in the UK, it seems likely that many infants and young children with simple skull fracture identified following head CT examination are admitted for a period of observation as occurs in the authors’ institution. There is therefore a service provision requirement for the NHS following the identification of simple skull fractures in young children.
Please cite this article in press as: Zaman S, et al., Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?, Clinical Radiology (2017), http://dx.doi.org/10.1016/j.crad.2016.12.012
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Recommendations Given the findings of this study, and until further prospective studies could provide more evidence, it is advised that A&E clinicians should have a low threshold for requesting CT head examination for children under 1 year of age with any size of swelling, haematoma, or laceration following head injury, and that radiologists should have a low threshold for accepting these requests, provided that the identification of an abnormality, such as simple skull fracture, would alter the child’s management, e.g., admission for observation. In addition, clinicians and radiologists should have a relatively low threshold for performing CT head examination for children aged 1e3 years with large swelling, haematoma, or laceration.
Acknowledgements The authors wish to thank Dr G. Burnside, Department of Translational Medicine at the University of Liverpool for his expert advice on statistical analysis.
References 1. Hawley C, Wilson J, Hickson C, et al. Epidemiology of paediatric minor head injury: comparison of injury characteristics with indices of multiple deprivation. Injury 2013 Dec;44(12):1855e61. 2. Phang I, Mathieson C, Sexton I, et al. Paediatric head injury admissions over a 10-year period in a regional neurosurgical unit. Scott Med J 2012 Aug;57(3):152e6.
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3. Arthurs OJ, Bjørkum AA. Safety in pediatric imaging: an update. Acta Radiol 2013 Nov;54(9):983e90. 4. Head injury: triage, assessment, investigation and early management of head injury in children, young people and adults. National Clinical Guideline Centre (UK). London: National Institute for Health and Care Excellence (UK); 2014 Jan. 5. Dunning J, Patrick Daly J, Lomas J-P, et al, on behalf of the children’s head injury algorithm for the prediction of important clinical events (CHALICE) study group. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 2006 Nov;91(11):885e91. 6. Dunning J, Batchelor J, Stratford-Smith P, et al. A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child 2004 Jul;89(7):653e9. 7. Greenes DS, Schutzman SA. Clinical indicators of intracranial injury in head-injured infants. Pediatrics 1999;104:861e7. 8. Osmond MH, Klassen TP, Wells GA, et al, Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010 Mar 9;182(4):341e8. 9. Orman G, Wagner MW, Seeburg D, et al. Pediatric skull fracture diagnosis: should 3D CT reconstructions be added as routine imaging? J Neurosurg Pediatr 2015 Oct;16(4):426e31. 10. 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;374:1160e70. 11. Lyttle MD, Crowe L, Oakley E, et al. CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J 2012 Oct;29(10):785e94. 12. Metzger RR, Smith J, Wells M, et al. Impact of newly adopted guidelines for management of children with isolated skull fracture. J Pediatr Surg 2014 Dec;49(12):1856e60.
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Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?q S. Zaman*, P.H. Logan, C. Landes, S. Harave Department of Radiology, Alder Hey Children’s NHS Foundation Trust, 1 Eaton Road, Liverpool L12 2AP, UK
art icl e i nformat ion Article history: Received 27 June 2016 Received in revised form 2 November 2016 Accepted 19 December 2016
AIM: To determine whether it is justified to undertake a computed tomography (CT) examination of the head in children under 1 year of age who present with a bruise, swelling, or laceration of >5 cm following head injury in children presenting to a paediatric accident and emergency (A&E) department in the northwest of England. Further aims were to determine whether there was any justification for performing a CT head examination for children with soft-tissue injuries measuring <5 cm, or for children >1 year with evidence of soft-tissue injury, but without any other concerning feature. MATERIALS AND METHODS: Children <3 years of age presenting with soft-tissue evidence of head injury between May 2011 and Oct 2014 and who subsequently underwent head CT were retrospectively identified from radiology requests. The CT images and clinical notes were used to identify those with skull fracture or intracranial haemorrhage and to determine whether the child was subsequently admitted or discharged from A&E. RESULTS: Eighty-five CT head examinations met the criteria for inclusion. Of these, 45 examinations demonstrated skull fractures and four examinations identified intracranial haemorrhage. Thirty-eight requests included soft-tissue evidence of head injury as the sole reason indicated for CT head examination. Of these, 22 examinations demonstrated skull fractures and one examination identified intracranial haemorrhage. CONCLUSION: Soft-tissue evidence of head injury as the sole reason for CT head examination appears to be justified in the present patient population. Furthermore, this study suggests that CT head examination should also be considered for children with soft-tissue injuries of <5 cm and for children aged between 1 and 3 years if identification of a skull fracture would alter the child’s management. Ó 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction
q This work was presented at the European Society of Emergency Radiology meeting in Antalya, Turkey in 2015.
* Guarantor and correspondent: S. Zaman, Department of Radiology, Alder Hey Children’s NHS Foundation Trust, 1 Eaton Road, Liverpool L12 2AP, UK. Tel.: þ44 151 252 5432. E-mail address: [email protected] (S. Zaman).
Paediatric head injury is a common presentation to paediatric emergency departments and a major cause of morbidity and mortality in the paediatric population.1,2 Although it is important to identify and then manage clinically important head injuries, this should be balanced against the relative risks of radiation exposure, particularly in infants.3
http://dx.doi.org/10.1016/j.crad.2016.12.012 0009-9260/Ó 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Zaman S, et al., Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?, Clinical Radiology (2017), http://dx.doi.org/10.1016/j.crad.2016.12.012
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In January 2014, the National Institute for Health and Care Excellence (NICE) in the UK issued updated guidelines on the management of head injury in children, young people, and adults.4 The NICE recommendations 2014 now advise that a CT head examination should be performed within 1 hour for infants under the age of 1 year with a bruise, swelling, or laceration of >5 cm following head injury, and that a provisional written radiology report should be made available within 1 hour of the scan being performed. This is an update on the 2007 guidelines only in terms of timing. The 2007 guidelines also recommended CT head examination for children aged <1 year who had sustained a head injury and had a bruise, swelling, or laceration >5 cm on the head. The criterion related to soft-tissue evidence of head injury is taken verbatim from the work of Dunning et al.,5 also known as the children’s head injury algorithm for the prediction of clinically important events or CHALICE study. This was a large well-designed prospective study, involving over 22,000 children aged <16 years, which aimed to provide rules for the selection of children for CT head examination following head injury. The CHALICE study reported a positive predictive value for death as an outcome of head injury of 0.12 for the presence of bruising, swelling, or laceration of >5 cm in the <1-year-old age group; however, as discussed in the NICE 2014 guidelines, the CHALICE study does have some limitations: firstly, the parameters determined by the CHALICE study have not been prospectively validated. Furthermore, the NICE 2014 head injury guideline development group (GDG) commented that the method of patient selection used for CHALICE was not clear, and therefore, there is a potential selection bias within the study. The GDG also noted that the length of follow-up in CHALICE was not clearly stated. The GDG considered a follow-up of 2 weeks would be appropriate for children due to the very small risk of delayed diagnosis of intracranial haemorrhage in children as compared to adults. The aim of this retrospective review was to determine whether CT head examination for infants with bruising, swelling, or laceration >5 cm following head injury was justified in the present patient population. Further aims were to determine whether there is any justification for performing CT head examination for bruising, swelling, or laceration of <5 cm in the context of head injury, and whether there is justification for performing CT head examination for children over the age of 1 year with bruising, swelling, or laceration in the present patient population. These questions were relevant because the authors were aware of a few cases where children in these two categories had undergone a CT head examination due to clinical concern following discussion of individual cases with the on-call paediatric radiologist.
and October 2014 were identified using an in-built audit search function within the computerised radiology information system (CRIS) used by our radiology department. The audit search function was used to identify the search terms “bruise, swelling, bump, haematoma, laceration or abrasion” within the clinical details entered by the clinicians at the time of CT head examination request. Those examinations that had been carried out following a clear history of head injury were then identified by manually checking the clinical request details and by crossreferencing with the clinical notes. CT head examinations carried out in cases where there was a documented suspicion of non-accidental injury or where a skeletal survey was carried out within 28 days were excluded. At least one random day per week throughout the study period was chosen and CT day lists examined to doublecheck that the in-built audit function within CRIS identified all of the relevant CT examinations. During this check, no CT head examinations that met the search criteria were identified and that had not been identified by the audit search function (in fact, on the random days checked the audit search function identified all of the CT heads performed for children in the relevant age range, regardless of clinical details). The manual check of the request history was the most important factor in identifying relevant examinations. CT images were reviewed for each case to determine whether there was any radiological evidence of soft-tissue injury. Where this was present, the maximal width on the axial images was measured and recorded to the nearest 0.5 cm (Fig 1). It was hypothesised that this measurement would be a surrogate marker for the size of soft-tissue evidence of head injury as assessed clinically. In addition, this measurement would possibly be more objective than the clinical assessment due to the obvious difficulties of accurately assessing the size of a three-dimensional (3D) swelling with overlying hair in the clinical setting. Furthermore, this measurement would have the added
Materials and methods Children under the age of 3 years with head injury and who subsequently underwent head CT between May 2011
Figure 1 Schematic representation of measurement of radiologically evident soft-tissue injury.
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advantage of being reproducible. The absence or presence of skull fracture and of intracranial haemorrhage on CT was also recorded. The documented size of any soft-tissue evidence of head injury as recorded by the accident and emergency (A&E) doctor assessing the child was taken from the clinical notes. The timing of the injury in relation to presentation to A&E and the decision to admit or discharge the child home from A&E was also taken from the clinical notes. This study was designed as an audit of local practice and is not considered research by the NHS Health Research Authority criteria. It was registered and approved as a retrospective audit by the trust’s Clinical Audit Department. The CT examinations were only performed based on clinical need as evaluated by the A&E department clinicians and as justified by a consultant paediatric radiologist or senior paediatric radiology trainee. NHS research ethics committee approval was therefore not required.
Results Ninety-one cases were identified where a child under the age of 3 years underwent a CT examination following head injury. Corresponding clinical notes were available for 85 of these patients. Of the 85 cases, 44 CT head examinations demonstrated skull fracture and four examinations demonstrated intracranial haemorrhage of any size (Fig 2). Of the four children with intracranial haemorrhage, all of whom also had a skull fracture, all had an extra-axial haemorrhage. None of the patients had any parenchymal haemorrhage. One child required neurosurgical intervention (evacuation of an extradural haematoma). None of the patients with intracranial haemorrhage required long-term follow-up. There were no deaths from head injury in the patient group identified.
Figure 2 CT findings.
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Sixty-eight cases had soft-tissue evidence of head injury (bruising, swelling, bump, haematoma, laceration, or abrasion) documented in the clinical notes or entered into the radiology request clinical details section. In 38 cases, softtissue evidence of head injury was the sole justification documented in the clinical notes and provided in the clinical details for CT head examination. Of these examinations, 22 demonstrated skull fracture and one examination demonstrated intracranial haemorrhage (Fig 3). In 47 cases, one or more NICE criteria for CT head examination other than soft tissue swelling (Table 1) with or without soft-tissue evidence of head injury was documented. Of these examinations, 22 demonstrated skull fracture and three demonstrated intracranial haemorrhage (Fig 3).
Results by age Forty-five CT examinations occurred in children < 1 year. Of these, 34 examinations demonstrated skull fracture and four demonstrated intracranial haemorrhage. Twenty-five examinations were performed in children aged between 1e2 years of age, of which five demonstrated skull fractures. None demonstrated intracranial haemorrhage. Eighteen examinations were performed in children aged between 2e3 years of age, of which five demonstrated skull fracture. None demonstrated intracranial haemorrhage (Fig 4). Of those examinations performed where soft-tissue evidence of head injury was the sole justification stated for imaging, 27 examinations were performed in children <1year old with 20 of these examinations demonstrating skull fracture and one demonstrating intracranial haemorrhage. Nine examinations were performed in children aged between 1 and 2 years with two demonstrating skull fracture and none demonstrating intracranial haemorrhage. Of note, one of the examinations performed in this age group in which a fracture was identified was due to soft-tissue swelling measuring just 2 cm in maximal trans-axial width on CT. Four examinations were performed for children aged between 2 and 3 years with none demonstrating skull fracture or intracranial haemorrhage.
Figure 3 Clinical soft-tissue evidence of head injury and positive CT findings.
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Table 1 NICE criteria for CT head, other than suspicion of non-accidental injury or presence of bruising, swelling, or laceration of >5 cm with no. of patients meeting each criterion.a Criteria
No. of patients
Post-traumatic seizure but no history of epilepsy4 On initial emergency department assessment, GCS <14, or for children under 1 year GCS (paediatric) <154 or at 2 h after the injury, GCS <154 or abnormal drowsiness Suspected open or depressed skull fracture or tense fontanelle4 Any sign of basal skull fracture (haemotympanum, “panda” eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)4 Focal neurological deficit4 Loss of consciousness lasting more than 5 min (witnessed)4 Three or more discrete episodes of vomiting4 Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist, or vehicle occupant, fall from a height of >3 m, high-speed injury from a projectile or other object)4 Amnesia (antegrade or retrograde) lasting more than 5 min4
1 10
3
Table 2 Contingency table of NICE soft-tissue swelling and skull fracture and/or intracranial haemorrhage. Meets NICE criteria for CT head based on soft tissue swelling?
CT head shows fracture or intracranial haemorrhage?
Yes No
Yes
No
21 6
10 16
NICE, National Institute for Health and Care Excellence; CT, computed tomography.
2
0 3 20 13
0
NICE, National Institute for Health and Care Excellence; CT, computed tomography; GCS, Glasgow Coma Scale. a Several patients met more than one criterion.
Results by size of soft-tissue evidence of head injury The size of the soft-tissue evidence of head injury was documented in the A&E notes in 53 of the 85 cases. For these cases, the odds ratio of skull fracture with clinically assessed soft-tissue evidence of head injury measuring >5 cm compared with clinically assessed soft-tissue evidence of head injury measuring 5 cm is 8.23 (p¼0.0106); however, the clinical assessment of soft-tissue swelling large enough to meet the NICE criteria for CT head examination did not include all cases where a skull fracture or
Figure 4 Age and Identification of skull fracture and intracranial haemorrhage on CT.
intra-cranial haemorrhage was subsequently identified (Table 2). In five cases, there was no identifiable CT evidence of soft-tissue injury. Of these, two demonstrated skull fracture and one demonstrated an intracranial haemorrhage. In five cases, there was radiological evidence of soft-tissue injury measuring 0.5, 1, 1.5, 2, or 2.5 cm in maximal width to the nearest 0.5 cm on axial images. Of these, two examinations demonstrated skull fracture. In 40 cases, there was radiological soft-tissue evidence of head injury measuring 3, 3.5, 4, 4.5, or 5 cm in maximal width to the nearest 0.5 cm. Of these, 15 examinations demonstrated skull fracture and two demonstrated an intracranial haemorrhage. In 29 cases, there was radiological soft-tissue evidence of head injury measuring 5.5, 6, 6.5, 7, or 7.5 cm to the nearest 0.5 cm. Of these, 16 demonstrated skull fracture and one demonstrated an intracranial haemorrhage. In 10 cases, there was radiological soft-tissue injury measuring 8 cm to the nearest 0.5 cm (max. 10.5 cm). Of these, nine had an underlying skull fracture with no underlying intracranial haemorrhages identified (Fig 5).
Figure 5 Size of radiological soft tissue evidence of head injury (RSTEHI) in maximal trans-axial diameter and identification of skull fracture on CT.
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The odds ratio of skull fracture with radiological evidence of soft-tissue evidence of head injury measuring >5 cm (to the nearest 0.5 cm) compared with radiologically assessed soft-tissue evidence of head injury measuring 5 cm is 2.91 (p¼0.0158). In the 53 cases where clinical size of soft-tissue evidence was documented there was a moderate positive correlation (Spearman’s rank correlation coefficient ¼ 0.636) between these values and the width of soft-tissue swelling measured on trans-axial CT images. There was no statistically significant correlation between size of the soft-tissue evidence of head injury on CT and the timing of the injury (Spearman’s correlation coefficient ¼ 0.1131).
examination despite not meeting the NICE CT head criteria due to clinical concern and following discussion with the on-call paediatric radiology consultant or senior paediatric radiology trainee. Finally, the present data suggest that large radiologically evident soft-tissue swelling on CT should raise the suspicion of underlying skull vault fracture. The odds of having an underlying skull fracture were 2.91 times greater when there was radiologically evident swelling of >5 cm compared to cases where the radiologically evident swelling measured 5 cm.
Admission rates
This study concentrates upon one key criterion from the NICE head injury guidelines that was identified as being a potential source of unnecessary radiation exposure to young infants and children and provides reassurance that children are not being unnecessarily exposed to radiation in the authors’ institution. It also provides evidence that prompt examination as advised by the 2014 guidelines is justified in the present patient population.
Of 45 cases where skull fractures were identified, 35 were admitted to hospital for a period of observation. This includes the four cases where there was also intracranial haemorrhage. Ten patients with simple skull fractures identified on CT were discharged home from the A&E department.
Discussion In the present study, the use of soft-tissue evidence of head injury as the sole criterion for CT head examination is justified in the present patient population. Of the 38 patients identified with soft-tissue evidence of head injury as the sole NICE head injury guidance criterion for CT head examination, 57.9% had an underlying skull fracture and there was one underlying intracranial haemorrhage. This finding adds further evidence to support the inclusion of significant bruising, swelling, or laceration in the <1-year age group in the NICE head injury criteria for performing CT head examination. This study has also shown that the 5 cm lower cut-off in the size of bruising, swelling, or laceration, fails to identify all children with an underlying skull fracture that present with soft-tissue evidence of head injury and no other concerning feature following blunt head injury in the present patient population. In patients with soft-tissue evidence of head injury and no other concerning feature, four skull fractures (but no intracranial haemorrhages) were identified in children with clinical evidence of soft-tissue injury measuring <5 cm, as documented in the clinical notes, and seven skull fractures (but no intracranial haemorrhages) were identified in children with radiological soft-tissue evidence of injury of <5 cm in maximal width on CT head examination. In addition, this study has also shown that the upper age limit of 1 year for performing CT head examination in children with soft-tissue evidence of head injury and with no other concerning feature, does not identify all children with underlying skull fracture in the present patient population. Two skull fractures (and no intracranial haemorrhages) were identified in children aged between 1 and 3 years with soft-tissue evidence of head injury and no other concerning features. These children underwent CT head
Strengths of the study
Limitations of the study This is a retrospective study based upon CT examinations that have been carried out. No attempt has been made to identify infants or children with small swelling, haematoma, or laceration following head injury for whom CT head examination was not performed. The CT examinations were initially identified using the in-built audit search function within the CRIS system used in the Department of Radiology, Alder Hey Children’s NHS Foundation, Liverpool. It was apparent from an early stage that this search function identified more CT examinations than met the search criteria. This may have introduced an element of artificial selection into the data. An attempt was made to counteract this by manually reading through the radiology requests identified in order to determine which CT examinations were performed following head injury and by cross-referencing with the clinical notes. The initial audit function search also relied upon correct details being entered into the clinical details section of the radiology request form by the clinicians assessing the child. Documentation with regard to the size of any clinical soft-tissue evidence of head injury was inconsistent. In addition, in many cases, it was not possible to determine in retrospect whether the clinical soft-tissue evidence of head injury had been accurately measured or rather estimated. Finally, it is not clear to what extent the findings of this study would be applicable to a wider patient population; however, the methods used are likely to be of interest to other departments that manage the care of infants and young children following head injury.
Comparison with NICE head injury guidelines The NICE criteria use the presence of bruising, swelling, or laceration as a criterion for CT head examination only if the bruising, swelling, or laceration is >5 cm and the child is
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under 1 year of age. In practice at Alder Hey Children’s NHS Foundation, clinicians ask for CT examinations for infants and young children outside of these parameters, for example, when the bruising, swelling, or laceration is <5 cm in diameter or when a child older than 1 year is deemed to have a “significant” bruising, swelling, or laceration by the examining clinician or overseeing A&E consultant. The study findings provide some justification to the clinicians for these approaches. The arbitrary 5 cm cut-off criterion used in the NICE head injury guidelines is taken word-for-word from the CHALICE study. It is not clear from the CHALICE study why this value was chosen. Dunning et al.6 carried out a meta-analysis of variables that could predict clinically significant head injury prior to carrying out the CHALICE study. This had identified soft-tissue evidence of head injury as a possible independent variable for clinically significant head injury based on the work of Greenes and Shutzman7 in Boston, MA, USA. Greenes and Shutzman noted that scalp swelling was the only indicator of clinically significant brain injury in a number of children aged <1 year in their study of 608 patients aged <2 years, and suggested that scalp haematoma in the under 1-year age group should be a criterion for CT head examination. Of note is the fact that Greenes and Shutzman used a grading system of “small (barely perceptible), moderate [and] large (obvious swelling and/or boggy consistency)” for scalp swelling in their study and that they included small haematomas in their analysis for the under 1 year age group. Another clinical decision making tool derived by Osmond et al.,8 known as the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) study, uses the presence of “large, boggy haematoma of the scalp” as a criterion for CT head examination but does not specifically give a size cut-off. The present study shows that a skull fracture is seen almost three times as often when there is radiologically evident swelling, haematoma, or laceration measuring >5 cm in maximal width on transaxial images compared to radiologically evident softtissue swelling measuring 5 cm (Fig 5); however, the study also shows that there is no lower cut-off in the size of swelling, haematoma, or laceration that would allow identification of all children with skull fracture or intracranial bleed following head injury when soft-tissue evidence of head injury is the sole criterion for further investigation. It was hypothesised that there may be a relationship between swelling or haematoma formation with time, i.e., in children who present almost immediately to A&E following their head injury, there may not have been sufficient time for a significant or clinically obvious swelling haematoma to develop, whereas children with a longer journey time to hospital or those that present within a few hours of head injury, may have larger evidence of soft-tissue injury on presentation; however, in the present patient group, there was only a very weak relationship between these variables. The incidence of skull fracture in the present population was 51.7%, higher than might have been expected from previous studies; however, the CHALICE study for example, looked only at “marked abnormalities on
computerised tomography”5 and did not include the presence of simple skull fracture within this definition. Earlier studies such as Greenes and Schutzman7 relied partly on plain radiograph imaging of the skull and only on selective CT examination. It is therefore likely that the true incidence of non-depressed skull fracture is underestimated in the literature. In addition, it is recognised that the use of spiral CT head examination and the viewing of 3D reformatted images increases the pick-up rate of simple non-displaced skull fractures, particularly in infants and young children.9 This is routine practice in the authors’ institution and may partly explain the high incidence of isolated non-depressed skull fractures in the present study.
Clinical implications of identifying skull fracture The importance of swelling, haematoma, or laceration as a criterion for CT head examination is because of its nature as a marker for underlying pathology, such as skull fracture and/or intracranial haemorrhage. In the present study, the skull fractures identified on CT examination were almost exclusively simple or non-depressed skull fractures and most were not associated with any underlying intracranial haemorrhage. As previously mentioned, many authors of larger studies such as CHALICE, CATCH and the paediatric emergency care applied research network (PECARN)10 study do not include such fractures in their outcome measures11; however, the NICE head injury guidance includes the presence of new, clinically significant abnormalities on imaging as a criterion for admission. Whether or not the presence of a simple non-displaced fracture constitutes a clinically significant abnormality may be open to interpretation by clinicians and, as the present data show, in the authors’ institution, the A&E team commonly admit infants and young children with simple, non-displaced skull fractures to hospital for a period of observation, usually under the care of the neurosurgical team. Therefore, there is a service provision and economic impact for the hospital following the identification of simple skull fractures in infants and young children. Metzger et al.,12 implemented guidelines designed to reduce admission of children with simple skull fracture following blunt head trauma and reduced admission rates from 75% to 57% in their study in Salt Lake City, UT. Metzger et al. also noted that young age combined with the presence of skull fracture was a concerning feature for clinicians and that this often prompted hospital admission despite this not being indicated by their guidelines. Although there is little information in the published literature about current practice in the UK, it seems likely that many infants and young children with simple skull fracture identified following head CT examination are admitted for a period of observation as occurs in the authors’ institution. There is therefore a service provision requirement for the NHS following the identification of simple skull fractures in young children.
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Recommendations Given the findings of this study, and until further prospective studies could provide more evidence, it is advised that A&E clinicians should have a low threshold for requesting CT head examination for children under 1 year of age with any size of swelling, haematoma, or laceration following head injury, and that radiologists should have a low threshold for accepting these requests, provided that the identification of an abnormality, such as simple skull fracture, would alter the child’s management, e.g., admission for observation. In addition, clinicians and radiologists should have a relatively low threshold for performing CT head examination for children aged 1e3 years with large swelling, haematoma, or laceration.
Acknowledgements The authors wish to thank Dr G. Burnside, Department of Translational Medicine at the University of Liverpool for his expert advice on statistical analysis.
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