The purpose is to evaluate practice variation at the emergency department in comparison with best practice for brain imaging in children presenting with headache. The results of the study might be used to inform a clinical prediction rule in order to better stratify risk according to the American College of Radiology Appropriateness Criteria. I created a poster for presentation and am currently working on a paper for publication in a scholarly journal.

1. Audit of Appropriateness: Brain
Scan Use for Paediatric Headache
at the Emergency Department
Lyndon Woytuck1, Meghan Linsdell2, Lawrence Richer2,3
1St. George’s University of London medical programme delivered by the University of Nicosia
2Women’s and Children’s Health Research Institute, University of Alberta, Edmonton, AB, Canada
3Department of Pediatrics, Division of Neurology, University of Alberta, Edmonton, AB, Canada

2. 9 YEAR-OLD GIRL
SPLITTING HEADACHE

3. PURPOSE
• To evaluate appropriateness and outcomes at the emergency
department in comparison with best practice for brain imaging
in children presenting with headache.

4. YOU WILL LEARN
• How well the emergency department images children presenting with headache
• That we catch most important diagnoses (i.e. brain tumour)
• We overexpose children to radiation
• Studies suggest this is common worldwide
• We can improve

5. THE PROBLEM
• Guidance: American College of Radiology Appropriateness Criteria on headache
• low risk (usually not appropriate)
• high risk (usually appropriate)
• Are the criteria useful / do they match diagnosis?
• Can we learn from our mistakes?

6. METHODS
• Searched ED records: ICD “Headache”
• Excluded head trauma in last 7 days
• 645 patient visits over 1 year from Feb 1 2014 – Jan 30 2015
• Stollery Children’s Hospital, Edmonton, Canada
• Stratified –
“usually NOT appropriate”, “MAYBE appropriate”, “USUALLY appropriate”
• Compared imaging results

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

8. RESULTS
Most patients that presented to the ED with headache did not receive neuroimaging
o CT scans are overused
o Some high risk patients did not receive brain imaging
Most cases handled appropriately
Could make predictions as per Appropriateness Criteria

9. DISCUSSION
• Compared Hong Kong Study; the Stollery scanned less
• Compared to Pakistan Study: similar CT overuse in migraine
• Imaging all catches diagnoses, both important and benign pathology
• MRI underused –
no radiation risk + higher yield, BUT expensive + high demand
• Better record-keeping, guidance usage, clinical rules could help!
• “Better safe than sorry” + parental anxiety

10. MISTAKES CLINICIANS MAKE
• Missing warning signs: high risk patients
• CT imaging due to anxiety
• Not vetting “medium risk” patients
• Not referring to guidance

11. WHAT YOU CAN DO
• Use CT less, and MRI more
• Strongly consider past history and aetiology
• Primary or Secondary?
• Neuro signs / symptoms?
• Red flags?
• Use imaging criteria! ACRAC or local guideline
• Remember: imaging rarely changes diagnosis

12. THANK YOU!
‫רבה‬ ‫תודה‬!
QUESTIONS?
woytuck@ualberta.ca