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Investigating the necessity of computed tomographic scans in children with headaches: a retrospective review

Published online by Cambridge University Press:  01 April 2015

Rohit Gandhi ,
Evan Cole Lewis ,
Jeanette W. Evans  and
Erick Sell
Rohit Gandhi*
Affiliation:
Department of Pediatric Neurology, Children’s Hospital of Eastern Ontario Faculty of Medicine, University of Ottawa, Ottawa, ON
Evan Cole Lewis
Affiliation:
Department of Pediatric Neurology, Children’s Hospital of Eastern Ontario
Jeanette W. Evans
Affiliation:
Department of Pediatric Neurology, Children’s Hospital of Eastern Ontario Faculty of Medicine, University of Ottawa, Ottawa, ON
Erick Sell
Affiliation:
Department of Pediatric Neurology, Children’s Hospital of Eastern Ontario
*
Correspondence to: Mr. Rohit Gandhi, 55 Hyannis Avenue, Ottawa, ON K2J 2W9; rohit.gandhi@uottawa.ca.

Abstract

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Objective: Headaches are a common problem in the pediatric population. In 2002, the American Academy of Neurology (AAN) developed guidelines on neuroimaging for patients presenting with headache. Our objective was to determine the frequency of computed tomographic (CT) scanning ordered by a range of medical practitioners for pediatric patients presenting with primary headache.

Methods: A retrospective chart review was conducted at the Children’s Hospital of Eastern Ontario (CHEO), a tertiary care centre in Ontario. One hundred fifty-one records of patients referred to the outpatient neurology clinic at CHEO with ‘‘headache’’ or ‘‘migraine’’ as the primary complaint from 2004 to 2009 were randomly selected. Ninety-nine patients with normal neurologic examinations were ultimately included.

Results: Thirty-four patients (34%; 95% CI 25–45) had undergone CT scanning. None of the 34 CT scans (0%; 95% CI 0–10) showed significant findings, and none changed the headache diagnosis or management. Eleven (32%) of the CT scans were ordered by CHEO neurologists, 15 (44%) by community physicians, and 8 (24%) by CHEO emergency physicians.

Conclusion: A high proportion of children presenting with primary headaches and a normal neurologic examination undergo CT scanning, despite well-established AAN guidelines regarding neuroimaging. Most of these CT scans do not appear to alter diagnosis and management. A variety of non–evidencebased factors may be encouraging physicians to overinvestigate this population and, as a result, increasing the risk of adverse events due to radiation exposure. Implementing initiatives at a site-based level that promote the use of established guidelines before performing CT scanning in this population may be beneficial.

Résumé

Objectif: Les céphalé es sont un problème fréquent chez les enfants. En 2002, l’American Academy of Neurology (AAN) a élaboré des lignes de conduite sur la neuro-imagerie chez les patients souffrant de céphalées. L’étude visait a` dé terminer la fréquence des demandes de tomodensitomé trie (TDM) faites par différents types de médecins praticiens en pédiatrie chez les enfants souffrant de céphalées primitives.

Méthode: Nous avons procédé à un examen rétrospectif de dossiers au Centre hospitalier pour enfants de l’est de l’Ontario (CHEO), un centre de soins tertiaires, en Ontario. Cent cinquante et un dossiers de patients dirigés au service de consultation externe en neurologie, au CHEO, de 2004 à 2009, pour des «céphalées» ou des «migraines» qui constituaient le principal motif de consultation, ont été choisis au hasard. À cela se sont ajoutés 99 patients ayant un examen neurologique normal.

Résultats: Trente-quatre patients (34%; IC à 95%: 25–45) ont subi une TDM. Dans aucun cas (0%; IC à 95%: 0–10), l’examen n’a révélé d’anomalies importantes ni changé le diagnostic de céphalée ou la prise en charge. Onze (32%) examens par TDM ont été demandés par des neurologues, au CHEO; 15 (44%), par des médecins de ville; et 8 (24%) par des urgentologues, au CHEO.

Conclusions: Une forte proportion d’enfants souffrant de céphalées primitives et ayant un examen neurologique normal sont soumis à un examen par TDM, malgré les lignes de conduite bien établies de l’AAN en ce qui concerne le recours à la neuro-imagerie. Dans la plupart des cas, la TDM ne semble pas changer le diagnostic ou la prise en charge. Différents facteurs non fondés sur des données probantes peuvent inciter les médecins à explorer à l’excès la population en question, ce qui a pour effet d’accroître le risque d’événement indésirable lié à l’exposition au rayonnement. La mise en oeuvre d’initiatives, dans les hôpitaux mêmes, favorisant l’application des lignes de conduite déjà établies avant le recours à la TDM dans cette population pourrait se révéler avantageuse.

Type
Original Research
Information
Canadian Journal of Emergency Medicine , Volume 17 , Issue 2 , March 2015 , pp. 148 - 153
Copyright
Copyright © Canadian Association of Emergency Physicians 2015 

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