DOI: 10.5061/dryad.d51c5b014
title: Predictors of abnormal computed tomography findings for paediatric head injury: a retrospective cohort study

description: Objectives: Head injuries in children are common causes for visits to the
 emergency department (ED). Computed tomography (CT) scans are useful for
 confirming head injury diagnoses. However, radiation exposure from CT
 scans might cause lethal malignancies. We aimed to examine predictors for
 the indication of performing CT scans necessary for diagnosis. Design:
 Retrospective cohort study. Setting: Three EDs in Japan Participants:
 Patients aged &lt;16 years with head trauma who underwent CT. Primary
 and Secondary Outcome Measures: The primary outcome measure was abnormal
 CT findings that were evaluated using the area under the
 receiver-operating characteristic curve (AUC). We derived predictors from
 three existing CDRs: Canadian Assessment of Tomography for Childhood Head
 Injury (CATCH), Children’s Head Injury Algorithm for the Prediction of
 Important Clinical Events (CHALICE), and Paediatric Emergency Care Applied
 Research Network (PECARN). Results: Of 1,103 eligible patients, 410 were
 included in this study. There were 283 (68%) boys, and the median age was
 2 years. In total, 35 (9%) patients showed an abnormality, 73 (18%) were
 admitted, and 3 (0.7%) underwent neurosurgery. We developed a CDR
 consisting of 6 predictors for identifying children with abnormal CT
 findings: (1) severe or worsening headache; (2) GCS &lt;15; (3) signs
 of skull fracture; (4) hematoma; (5) loss of consciousness; and (6)
 altered mental status. Our CDR had a sensitivity of 74.3%, a specificity
 of 75.2%, a negative predictive value of 96.9%, and a positive predictive
 value of 21.8%. The AUC for our rule was not inferior to those for CATCH,
 CHALICE, and PECARN {0.75 (95% confidence interval [CI], 0.67-0.81) versus
 0.64 (95% CI, 0.56-0.73; p&lt;0.05), 0.68 (95% CI, 0.60–0.76; p=0.28),
 and 0.67 (95% CI, 0.60-0.74); p=0.10}. Conclusions: Our findings suggest
 that a CDR, which lowers the frequency of CT in children with head
 injuries, must be developed and validated.
description: <strong>Study Setting and
 Population</strong> We conducted a retrospective
 cohort study involving patients &lt;16 years of age with head trauma
 admitted to three EDs in Japan. The participating hospitals were district
 general hospitals with 13,000 to 18,000 emergency patients per year in
 each hospital. No established CDR is required to be used at any hospitals
 when assessing patients with head trauma; the decision regarding whether
 to perform CT scans is made by each physician based on the patient’s
 clinical characteristics and history. Inclusion
 criteria for this study were (1) age &lt;16 years, (2) a history of
 blunt head injury within 24 hours before admission to the ED, and (3)
 patients who underwent CT scans for the first time in the ED. Patients
 transferred from another hospital after undergoing neuroimaging were
 excluded from this study. Accordingly, 410 patients admitted to the EDs
 from April 2014 to March 2018 were included (Figure 1).
 The primary outcome measure was abnormal CT findings, such as
 skull fracture and any brain lesion attributed to acute head injury. Staff
 radiologists at each hospital interpreted the CT scans. If radiologists
 suggested an uncertainty regarding whether an abnormal finding existed,
 the scan was considered negative. <strong>Data
 Collection</strong> Data for demographic
 variables (age, sex), clinical characteristics (trauma mechanism, clinical
 history prior to the hospitalization, signs, management of the patient),
 and outcome information (CT findings) were collected from each patient’s
 medical record. Abnormal CT findings were defined as any skull fracture
 and acute brain lesion attributed to acute head injury. For predictive
 variables in this study, patients with altered mental status were defined
 as those with agitation, somnolence, or/and repetitive questioning during
 verbal communication. The person in charge of each
 hospital registered the data with the data centre, and then three authors
 (N.Y., M.G., and M.S.) independently reviewed all data, performed the
 patient selection, and established the dataset for this study.