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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a 4 year old child in significant distress due to a headache, which he has had for 2 days. It is bilateral, frontotemporal, not sudden onset, never had before. No associated fever, vomiting, neurologic abnormalities, relevant past medical history. Do you image?
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March 26, 2019 at 1:32 am
Deciding when to perform a CT in a child is always a balance between the risks of missing a serious abnormality vs the risks of radiation associated with the CT. Head CT in a young child is estimated to result in 1 in 1400 to 1 in 3000 excess cancers (as per http://www.xrayrisk.com/calculator/calculator.php).
One study showed that ED CTs done on children with headaches identified an abnormality in 10%. However, significant lesions are uncommon (0.37% of 815 children with headache in one series), and non-emergent abnormalities such as Chiari I malformation, sinusitis, arachnoid cysts, and vascular malformations are more frequently found.
Red flags for significant lesions can be recalled by the SNOOPY mnemonic: systemic symptoms (fever, ALOC, seizure, cancer, HIV), neurologic abnormalities, onset sudden/thunderclap, occipital location, pattern (progressive, early AM, positional, precipitated by Valsalva), and years < 6yo.
Reference: Trofimova A et al, Imaging of Children with Nontraumatic Headaches. AJR 2018;210:8-17.