Approach to Pediatric Brain

Radiographs

Skull radiographs have limited value in the pediatric patient. They may occasionally be obtained in the setting of trauma, but it should be recognized that they can be falsely reassuring. Pediatric patients can have significant intracranial injuries (including extraaxial hemorrhages & brain parenchymal contusions) without having skull fractures. Additionally, some fractures (particularly of the skull base) will not be readily seen by plain films. In these circumstances, there are typically mechanisms of injury & clinical manifestations that should lead to CT as the modality of choice. Occasionally radiographs of the skull are obtained in the setting of minor trauma for “parental reassurance,” yet these patients are the most likely group to have nondisplaced fractures that will be difficult to see on radiographs, particularly regarding the facial bones (other than the nasal bones).

Skull radiographs are regularly employed in certain circumstances, including the evaluation of ventricular shunt catheter continuity (when dysfunction is suspected), the detection of craniosynostosis, the work-up of a palpable bony abnormality or defect, & during skeletal surveys for nonaccidental trauma or multifocal bone lesions (such as Langerhans cell histiocytosis). In the setting of suspected nonaccidental trauma, the patient age & clinical appearance will guide the use of head CT over generalized bone screening in the plain film survey. Some institutions will still obtain radiographs even when a head CT is performed for suspected abusive head trauma, but centers using multiplanar & 3D reconstructions of the CT data may forgo skull plain films.