CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury

We read with interest the study “CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury” by Osmond et al. [1]. Recent studies have tried to identify children at low or high risk to develop brain injuries after blunt head trauma [2]. In addition to imaging studies the use of protein biomarkers for detection of injury or prognostication has emerged as an area of clinical and research interest [3]. However, despite these advances, there is valid concern that CT scans are overused and that they may be detecting a number of clinically inconsequential findings that require no intervention [2, 4, 5]. The authors are to be congratulated for their efforts to clarify the role and potential benefits of computed tomography in children with minor head injuries (GCS: 13-15) [1].

In addition to imaging studies, clinicians and researchers have used EEG to evaluate changes in the electrical activity of the brain following mild traumatic brain injury (MTBI). Standard clinical EEG analyses are often provided in acute care facilities to detect the presence of focal or generalized slowing as well as to detect the presence of epileptiform activity related to brain injury. We would like to report the results of a retrospective study done in our hospital to assess the role of standard EEG recordings in children with MTBI (GCS: 13-15).

In our retrospective analysis from 01/2006 to 12/2007, 150 children with MTBI (age 0-16 years), who were admitted to the Children's Hospital of the University of Saarland, were enrolled. Mean age was 4.3 (SD 3.6) years: 55.3% were boys. The most common mechanisms of injury were: Minor fall <1m of height (60%) and fall >1.5m of height (10%). The most common symptoms were: one or more episodes of vomiting (60%), somnolence (26.7%) and headache (12.7%). On 118 patients an EEG was performed; 106 (89.8%) were normal, 11 (9.3%) pathological and 1 (0.9%) invalid because of artefacts. The pathological EEGs showed focal findings with localized slowing in 9 cases, spike-wave complexes in 1 case and general slowing in 1 case. Of the 11 patients with pathological EEG 2 had a cerebral CT scan, 2 a cerebral MRI and 2 a cranial sonography; all neuro-imaging procedures were normal. None of the children required neurosurgical intervention, had a negative outcome or showed persistent symptoms. Based on the findings of our study we concluded that the routine performance of an EEG after MTBI in children is not indicated because in most of the cases it is unrevealing, and may lead to unnecessary diagnostic procedures. Notwithstanding the fact that the study by Osmond et al. needs to be confirmed in a prospective study, their results may prove an important basis for deriving a decision rule for the management in the emergency department of children with MTBI.

References 1. Osmond MH, Klassen TP, Wells GA, Correl R, Jarvis A, Joubert G, Bailey B, Chauvin-Kimoff, Pusic M,McConnell D, Nijssen-Jordan C, Silver N, Taylor B, Stiell IG; for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. 2. Palchak MJ, Holmes JF, Vance CW, Gelber RE, Schauer BA, Harrison MJ, Willis-Shore J, Wootton-Gorges SL, Derlet RW, Kuppermann N. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 2003; 42:492-506 3. Meyer S, Gottschling S, Baghai A, Polcher T, Strittmatter M, Gortner L. The role of S100B-protein in neonatology, pediatric intensive care, and pediatrics. Klin Padiatr 2006, 218:49-56 4. Oman JA, Cooper RJ, Holmes JF, Viccellio P, Nyce A, Ross SE, Hoffman JR, Mower WR. NEXUS II Investigators. Performance of a decision rule to predict need for computed tomography among children with blunt head trauma. Pediatrics 2006; 117:e238-246 5. Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A; Canadian CT Head and C-Spine Study Group. The Canadian CT head rule study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med 2001; 38:160-169

With kindest regards

Dr Sascha Meyer, Dr. Ghiath Mohammed Shamdeen, Professor Dr. Ludwig Gortner, Isabelle Oster

University Hospital of Saarland, Department of Pediatric Intensive Care Medicine, Neonatology, and Neuropediatrics, Homburg, Germany