Use of magnetic resonance imaging in severe pediatric traumatic brain injury: assessment of current practice

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There is no consensus on the optimal timing and specific brain MRI sequences in the evaluation and management of severe pediatric traumatic brain injury (TBI), and information on current practices is lacking. The authors performed a survey of MRI practices among sites participating in a multicenter study of severe pediatric TBI to provide information for designing future clinical trials using MRI to assess brain injury after severe pediatric TBI.


Information on current imaging practices and resources was collected from 27 institutions participating in the Approaches and Decisions after Pediatric TBI Trial. Multiple-choice questions addressed the percentage of patients with TBI who have MRI studies, timing of MRI, MRI sequences used to investigate TBI, as well as the magnetic field strength of MR scanners used at the participating institutions and use of standardized MRI protocols for imaging after severe pediatric TBI.


Overall, the reported use of MRI in pediatric patients with severe TBI at participating sites was high, with 40% of sites indicating that they obtain MRI studies in > 95% of this patient population. Differences were observed in the frequency of MRI use between US and international sites, with the US sites obtaining MRI in a higher proportion of their pediatric patients with severe TBI (94% of US vs 44% of international sites reported MRI in at least 70% of patients with severe TBI). The reported timing and composition of MRI studies was highly variable across sites. Sixty percent of sites reported typically obtaining an MRI study within the first 7 days postinjury, with the remainder of responses distributed throughout the first 30-day postinjury period. Responses indicated that MRI sequences sensitive for diffuse axonal injury and ischemia are frequently obtained in patients with TBI, whereas perfusion imaging and spectroscopy techniques are less common.


Results from this survey suggest that despite the lack of consensus or guidelines, MRI is commonly obtained during the acute clinical setting after severe pediatric TBI. The variation in MRI practices highlights the need for additional studies to determine the utility, optimal timing, and composition of clinical MRI studies after TBI. The information in this survey describes current clinical MRI practices in children with severe TBI and identifies important challenges and objectives that should be considered when designing future studies.

ABBREVIATIONS ACR = American College of Radiology; ADAPT = Approaches and Decisions after Pediatric TBI; DAI = diffuse axonal injury; DTI = diffusion tensor imaging; DWI = diffusion-weighted imaging; GCS = Glasgow Coma Scale; GOS-E Peds = Pediatric Glasgow Outcome Scale–Extended; GRE = gradient recalled echo; ICP = intracranial pressure; MRS = MR spectroscopy; PICU = pediatric intensive care unit; PWI = perfusion-weighted imaging; SWI = susceptibility-weighted imaging; TBI = traumatic brain injury.

Article Information

Correspondence Peter Ferrazzano: University of Wisconsin School of Medicine and Public Health, Madison, WI.

INCLUDE WHEN CITING Published online February 8, 2019; DOI: 10.3171/2018.10.PEDS18374.

Disclosures Dr. Alexander is a cofounder and scientific advisor for both Thervoyant, Inc., and Goal Line Imaging, LLC. Neither entity provided support or materials for the published work.

© AANS, except where prohibited by US copyright law.



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    Bar graphs showing the proportion of patients with severe TBI who undergo MRI. Sites were asked to select which of the 5 shown percentages best represents the proportion of their population with severe TBI that undergoes MRI during the acute hospitalization. A: The percentage of sites that selected each option. B: The distribution of responses among US and international sites. C: Freestanding children’s hospitals and nonfreestanding children’s hospitals.

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    Bar graphs showing the timing of MRI post-TBI. Sites were asked to select which option best represents the time point at which an MRI study is typically obtained in children with severe TBI at their institution. Percentage of sites selecting each response is shown for all sites (A), for US and international sites (B), and for freestanding and nonfreestanding children’s hospitals (C).

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    MR sequences used in acute clinical MRI studies. Sites were asked how often each MR sequence is included when MRI is performed in children with severe TBI at their institution. Available responses were: Always, Often, Sometimes, and Never. The percentage of all sites responding “always” or “often” is shown for each MR sequence (A). The distribution of responses is compared between US and international sites (B), and between freestanding and nonfreestanding children’s hospitals (C). MR sequences shown: T1-weighted MRI (T1-W), T2-weighted (T2-W), T2* GRE, SWI, DWI, PWI, DTI, and MRS.


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