Pediatric mild head trauma: is outpatient follow-up imaging necessary or beneficial?

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  • 1 Institute for Brain Protection Sciences, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida;
  • | 2 Morsani College of Medicine, Department of Neurosurgery, Tampa, Florida;
  • | 3 Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
  • | 4 Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
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OBJECTIVE

Pediatric traumatic brain injury (TBI) is the leading cause of death among children and is a significant cause of morbidity. However, the majority of injuries are mild (Glasgow Coma Scale score 13–15) without any need for neurosurgical intervention, and clinically significant neurological decline rarely occurs. Although the question of repeat imaging within the first 24 hours has been discussed in the past, the yield of short-term follow-up imaging has never been thoroughly described. In this paper, the authors focus on the yield of routine repeat imaging for pediatric mild TBI (mTBI) at the first clinic visit following hospital discharge.

METHODS

The authors conducted a retrospective review of patients with pediatric brain trauma who had been admitted to Johns Hopkins All Children’s Hospital (JHACH). Patients with mTBI were identified, and their presentation, hospital course, and imaging results were reviewed. Those pediatric patients with mTBI who had undergone no procedure during their initial admission (only conservative treatment) were eligible for inclusion in the study. Two distinct groups were identified: patients who underwent repeated imaging at their follow-up clinic visit and those who underwent only clinical evaluation. Each case was assessed on whether the follow-up imaging had changed the follow-up course.

RESULTS

Between 2010 and 2015, 725 patients with TBI were admitted to JHACH. Of those, 548 patients qualified for analysis (i.e., those with mTBI who received conservative treatment without any procedure and were seen in the clinic for follow-up evaluation within 8 weeks after the trauma). A total of 392 patients had only clinic follow-up, without any diagnostic imaging study conducted as part of their clinic visit, whereas the other 156 patients underwent repeat MRI. Only 1 patient had a symptomatic change and was admitted after undergoing imaging. For 30 patients (19.2%), it was decided after imaging to continue the neurosurgical follow-up, which is a change from the institutional paradigm after mTBI. None of these patients had a change in neurological status, and all had a good functional status. All of these patients had one more follow-up in the clinic with new MRI, and none of them required further follow-up.

CONCLUSIONS

Children with mTBI are commonly followed up in the ambulatory clinic setting. The authors believe that for children with mTBI, normal clinical examination, and no new symptoms, there is no need for routine ambulatory imaging since the clinical yield of such is relatively low.

ABBREVIATIONS

EDH = epidural hemorrhage; GCS = Glasgow Coma Scale; GOS-E = Glasgow Outcome Scale–Extended; ICH = intracerebral hematoma; JHACH = Johns Hopkins All Children’s Hospital; LOS = length of stay; mTBI = mild TBI; PICU = pediatric ICU; SAH = subarachnoid hemorrhage; SDH = subdural hemorrhage; TBI = traumatic brain injury.

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Contributor Notes

Correspondence Nir Shimony: Geisinger Medical Center, Danville, PA. nshimony@geisinger.edu.

INCLUDE WHEN CITING Published online May 7, 2021; DOI: 10.3171/2020.11.PEDS20588.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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