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054. Substitution of Head CT with Rapid Sequence MRI and Skull X-ray in the Evaluation of Non-Accidental Trauma in Children: A Validation Study

Authors: Randaline Barnett, MD

Introduction:
Head CT (HCT) is historically the most common imaging modality in identifying skull fractures and intracranial hemorrhage in suspected non-accidental trauma (NAT) in children. Given risks of ionizing radiation, particularly in young infants, we sought to validate a proposal to image with a rapid sequence MRI and skull x-ray to identify all injuries compared to CT.Methods: We conducted a retrospective analysis of infants who had been suspected of NAT at an academic pediatric hospital from 5/2020 to 8/2021. We identified 27 infants (ages 0-15 months) who had undergone HCT, skull x-ray, and MRI. A neurosurgeon was blinded from all clinical data and radiology interpretations of the skull x-ray and rapid sequences of MRI (T2, SWI, DWI) as they interpreted imaging to identify skull fractures, intracranial hemorrhage, and scalp swelling.
Results:
Fracture detection was different for HCT vs MRI with only 7% of infants having a detectable skull fracture on MRI (p=0.0004), but it did not differ between HCT vs x-ray (71%, p=0.9997) or HCT vs x-ray combined with MRI (79%, p=0.9874). Intracranial hemorrhage was better detected on MRI than CT (p= < 0.0001). 100% of infants who had an intracranial hemorrhage on CT had hemorrhage on MRI while 33% without hemorrhage on CT had an intracranial hemorrhage on MRI. When a scalp hematoma was present on MRI, 79% had an associated skull fracture (11/14) (p= < 0.001), and in infants who did not have a skull fracture on CT, 0% had a scalp hematoma on MRI (p= < 0.001).
Conclusion:
While skull fractures are better detected on CT, there is no difference between their detection on CT vs x-ray or CT vs x-ray/MRI, and MRI provides superior detection of intracranial hemorrhage, suggesting the use of skull x-ray combined with MRI is an acceptable alternative for detection of NAT related injuries without additional HCT radiation.