I recently gave an interview for an article in Radiology Today discussing the opportunities and challenges in the use of imaging technologies like CT and MRI for the evaluation and treatment recommendations in children who are suspected to have sustained head trauma. It is an important topic and one that neurologists are heavily weighing the merits of. The reasons for that are many, but perhaps the largest issue at play is how we medical experts manage technological advancement with its appropriate clinical applications. In other words, just because technology can reveal to us MORE than it ever has before, we must still assess that information in the context of what we know to be scientifically TRUE and clinically APPROPRIATE regarding how we use that information to influence our treatment decisions.
It’s not an easy answer. And one of the largest factors involved in providing that answer is that it is generally agreed at present time that there is no clear indication for the use of some imaging modalities, most notably CT in the majority of circumstances related to concussion. In addition to the fact that CT contains radiation which includes potential for complications and side effects, especially in children, it is unlikely that this imaging modality will reveal any abnormality that would otherwise change a neurologist’s treatment recommendations. Of course, there are instances where “red flags” would indicate the appropriateness of CT including prolonged loss of consciousness, clinical evidence of skull fracture, frequent/repetitive vomiting and others.
One frequently used imaging modality with regard to concussion diagnosis is MRI. As this technology has improved over the years, these scans have become much more revealing. These revelations are now able to show us structural brain changes that weren’t previously appreciated. Though most “official” protocols don’t acknowledge a role for imaging in concussion assessment, many neurologists order MRI with certain sequences and techniques in cases of sports-related head trauma. These types of MRI can assess for subtle changes and abnormalities that can influence our treatment recommendations.
Part of the reason this subject is so sensitive involves the parent(s) of the injured child. Understandably so, they often want “hard proof” to rule out potentially catastrophic complications of a head injury, like bleeding in the brain. When this happens, it is tough for the treating physician because his or her clinical judgement (based on extensive research and approved guidelines) that a catastrophic abnormality (like bleeding) is very unlikely may seem insufficient to the loved one looking for tangible evidence. Adding to that dilemma is the fact that we cannot yet use these imaging examinations to extrapolate future predictions about concussion recurrence, prolonged symptoms or functional consequences. The brightest minds in the field are working diligently to provide this type of information but we aren’t quite there yet.
For parents and coaches of youngsters, my best advice is to find a highly qualified neurologist in whom you explicitly trust. When he or she gives you treatment recommendations and you have questions, ask them. But if those questions involve “pushing” for deeper imaging studies when your physician hasn’t already recommended them, please know that this isn’t out of ignorance or an unwillingness to give you a complete picture. It is simply because we have yet to clinically “prove” that such studies offer more than what has already been proven and is working in the management of young people who have suffered a head injury. I am confident we will get to a place where safe and contextually accurate imaging technology becomes part of the solution to these important concerns – and not something that just adds more questions.