The use of repeated head computed tomography in pediatric blunt head trauma: Factors predicting new and worsening brain injury

Objective: Opinion is divided on the value of repeat head computed tomography for guiding clinical management of pediatric patients with blunt head trauma. This study describes the prevalence of worsening brain injury on repeat computed tomography, predictors of worsening computed tomography findings, and the frequency of neurosurgical intervention after the repeat computed tomography. Design: Retrospective cohort study. Setting: All patients were admitted to a level I pediatric trauma center between 1994 and 2003. Patients: Children < 15 yrs old with two or more head computed tomographies following hospital admission for blunt head trauma. Interventions: None. Measurements and Main Results: We reviewed the imaging reports to determine injury progression. Potential predictors of worsening computed tomography findings and neurosurgical intervention were recorded by chart review. Logistic regression and recursive partitioning were used to identify predictors. Twenty percent (50 of 257) of patients with mild head injury had worsening computed tomography findings, and three patients (1%) had subsequent neurosurgical intervention. Patients with moderate and severe head injuries were more likely to have worsening computed tomography findings (107 of 248; 43%) and to have neurosurgical intervention (15 of 248; 6%). In most surgical patients, repeat computed tomography was preceded by rapid decline in neurologic status or elevated intracranial pressure. Stratification based on four clinical factors (initial head injury severity, any intraparenchymal finding on initial computed tomography, normal findings on initial computed tomography, coagulopathy) identified 100% of the surgical patients and 89% of patents with worsening brain injuries on the repeat computed tomography. Conclusions: Repeat head computed tomography imaging is frequently used. About 30% of repeated computed tomographies showed new or worsening brain injury. However, worsening brain injury on repeat computed tomography rarely resulted in neurosurgical intervention. Patients with moderate or severe head injury and intraparenchymal injuries were more likely to show worsening brain injury and undergo neurosurgical intervention.