1. Aims- Evaluate practice variation in comparison with best practice

for brain imaging children with headache who present to the emergency department.

- American College of Radiology's Appropriateness Criteria guideline by Hayes LL et al1 stratifies low risk (usually not appropriate) and high risk (usually appropriate) groups

- Brain imaging here is defined as computed tomography (CT) or magnetic resonance imaging (MRI) scan.

Audit of Appropriateness for Brain Scan Use for Paediatric Headache at the Emergency DepartmentLyndon Woytuck, Meghan Linsdell, Lawrence Richer

As part of the Brain AttACKs project and St George’s, University of London MBBS programme

3. Methods- Data retrospectively collected from emergency department patient

records at the Stollery Children’s Hospital for a one year period (February 1st 2014 - January 30th 2015). Best standards used for chart review, with standardized form, training, and second party proofing.

- Records sampled using “Headache” criterion returned 635 visit results. Each visit was treated as separate, even for multiples with a single patient. 635 records were found, retrieved, de-identified on an encrypted computer, and data entered into a database using REDCap software5. Data was analysed with Microsoft Excel.

- ACR Criteria was assigned for brain imaging (regardless of contrast) and translated into three categories: “Usually not appropriate”, “May be appropriate” or “Usually appropriate”.

- Excluded 35 records with trauma occurring in previous 7 days

Table 1. Number of cases sent for neuroimaging acquisition and relevant findings according to appropriateness rating. Number (n) and 95% confidence intervals (CI) included.

2. Introduction- American College of Radiology Appropriateness Criteria

(ACRAC)1 gives guidance for imaging in children (paediatric) with headache.

- Notable other guidance and reviews by the American Association of Paediatrics, International Headache Society3 and American Academy of Neurology are less comprehensive and encompassed by ACRAC.

- ACRAC is designed to minimise unnecessary scans in low risk patients to reduce cost and x-ray exposure and maximizes scan use in high risk patients to catch underlying medical causes. ACRAC uses parameters like progressive headache history or abnormal neurologic examination to decide score.

- This audit studied how the local practice in an emergency department was different from the practice standard set by the Appropriateness Criteria. There was no local paediatric brain imaging guidance in place at this hospital.

- Similarly, Kan EY et al2 in Tuen Mun Hospital, Hong Kong found many CT scans were done for patients who did not meet ACRAC level for recommended scans (low risk group). Most of these low risk cases had normal findings and the remainder had sinusitis. The only abnormal CT findings were in high risk cases with underlying disease or fever.

- Current trends suggest brain imaging in North American (US) emergency departments (ED) is increasing4, while prevalence of severe intracranial conditions remains stable. 1.16% of all neurological presentations to the ED are imaged and much more in headache, according to Alberta Health Services.

- We asked: Are there differences in a North American centre as compared to an Asian centre? What might affect scan rate in this setting? Does scanning change diagnosis? Does MRI usage differ from CT compared to ACRAC for headache in paediatrics?

4. Results- 600 patient visits sampled; 251 male and 349 female. Average age at

time of presentation was 12 years with a standard deviation of 3.9 years.

- 41 patient visits had emergency services transport. 15 of these were imaged, 5 imaged by MRI and 13 imaged by CT.

- 146 had history of migraine (52 met imaging criteria, 20 were imaged) and 72 had a history of recurring headache (36 met criteria, 17 imaged).

- Patients were imaged more commonly by CT (88) than MRI (22).

- Inappropriate scanning was done more often by CT (Figure 1).

- Final diagnosis was headache in 255, migraine in 266, intracerebral haemorrhage in 2, brain or meningeal infection in 2, neoplasm (brain cancer) in 3, hydrocephalus in 2, and metabolic disease in 2.

- 36 patients imaged did not meet any appropriateness criteria (Table 1).

- 39 patients were not imaged for “usually appropriate” criteria. (Table 1).

Figure 1. Comparison across groups for those imaged by CT or MRI, not imaged and total imaged in each appropriateness category

5. Discussion- In comparison with the Tuen Mun study2, we found 36 cases of inappropriate imaging with

CT according to ACR guidance. This may be due to demanding parents, defensive medicine or unclear diagnosis. “Usually not appropriate” appreciates that not all high risk cases may be properly considered and it highly values expert opinion.

- Imaging was not used in all “usually appropriate”; this may reflect hesitancy to consider some symptoms as serious and not merely atypical migraine. The “may be appropriate category” best reflects ACRAC guidance, as only some of these patients were imaged.

- There was less inappropriate CT imaging here than Tuen Mun Hospital and each case involved previous conditions, which may be due to local practice and individual judgment, as found by Prevedello L, et al6. This would be more similar if both hospitals instituted the same guidance.

- Limitations: small sample of those imaged, missing imaging conclusions in 17 records, single centre bias, possible missing examination or history details

- In future: a prospective study with ACRAC and physician decision making may reveal more adherence or justification for imaging.

6. Conclusions- Most paediatric patients that presented to the emergency department with headache did not

receive neuroimaging. There is some variability in the application of the American College of Radiology’s Appropriateness Criteria, although most cases were found to be handled appropriately in this study. Accordingly, CT scans were done more often than recommended and not all patients who met criteria always received brain imaging.

- Future study will be based on eliciting effective screening tools based on the ACR criteria

References1. Hayes LL, Coley BD, Karmazyn B et al. American College of Radiology. ACR Appropriateness Criteria. Headache—child. Reston (VA):

ACR [Internet]. 2012[cited 2015 Jun 25]; 8. Available from: https://acsearch.acr.org/docs/69439/Narrative/2. Kan EY, Wong IY and Lau SP. Audit of Appropriateness and Outcome of Computed Tomography Brain Scanning for Headaches in

Paediatric Patients. J HK Coll Radiol. 2005; 8:202-206.3. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache

Disorders. 3rd ed. (beta version). Cephalalgia. 2013; 33(9) 629–808.4. Gilbert J, Johnson K, Larkin G, at al. Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and

factors associated with severe intracranial pathology. EMJ. 2012; 29(7):576-581. 5. Harris PA, Taylor R, Thielke R et al. (2009). Research electronic data capture (REDCap)--a metadata-driven methodology and

workflow process for providing translational research informatics support. J Biomed Inform, 42(2), 377-381. doi:10.1016/j.jbi.2008.08.010

6. Prevedello L, Raja A, Zane R, et al. Variation in use of head computed tomography by emergency physicians. Am. J. Med. 2012; 125(4):356-364.

AcknowledgementsI wish to acknowledge my supervisor, Dr. Lawrence Richer, and his research coordinator, Meghan Linsdell, who helped me very much throughout this project.

Appropriateness Rating Category

Number of Cases

Proportion Imaged

Important Abnormalities

Incidental Abnormalities

Usually not appropriate

412 9.7% n=40, CI 9.3-10%

1.7% n=7, CI 1.2-2.2%

1.5% n=6, CI 1.0-1.9%

May be appropriate 156 28% n=44, CI 27-29%

2.6% n=4, CI 1.3-3.8%

1.3% n=2, CI 0.0-2.5%

Usually appropriate 77 56% n=43, CI 55-57%

30% n=23, CI 28-32%

5.2% n=4, CI 2.8-7.6%

Imaged by CT Imaged by MRI Total imaged0

10

20

30

40

50

Usually not appropriate May be appropriate Usually appropriate

Type of imaging doneNum

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