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. 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 Department
Lyndon 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
References
1. 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.
Acknowledgements
I 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%
0
10
20
30
40
50
Imaged by CT Imaged by MRI Total imaged
Numberofpatientvisits
Type of imaging done
Usually not appropriate May be appropriate Usually appropriate