Diagnostic Values of Red Flags and a Clinical Prediction Score for Emergent Intracranial Lesions in Non-Traumatic Pediatric Headaches

Abstract

Introduction: Diagnosis of emergent intracranial lesions that require emergency treatment either medically or surgically in non-traumatic pediatric headaches is important. Red-flag signs and symptoms are commonly used as justification for neuroimaging; however, evidence on its diagnostic values is limited. The study aims to identify diagnostic values of red-flags and develop a clinical prediction score to help improve the diagnostic yield of neuroimaging. Methods: A retrospective review of 109 pediatric patients from 2006 to 2020 who presented with a non-traumatic headache was conducted. A clinical prediction score from red flags was developed using multivariate logistic regression. Discriminatory ability was examined using the area under the receiver operating characteristic curve. Results: A total of 51 patients were diagnosed with emergent intracranial lesions. Four potential clinical red flag predictors were identified: (1) acute onset (less than 3 months), (2) altered conscious state, (3) focal motor abnormality, and (4) and ocular/pupillary abnormality or squint. A clinical prediction score was developed with good discriminatory properties (0.84). Conclusions: Clinical predictor scores from these four red flags may play an important role in maximizing neuroimaging and proper management for pediatric patients with non-traumatic headaches. Future validation studies are needed and could guide referrals and optimize the use of neuroimaging for these patients.

Children under 6 years with acute headache in Pediatric Emergency Departments. A 2-year retrospective exploratory multicenter Italian study

“…Headache is a common symptom in children, even in preschoolers and represents one of the main neurological causes of access to the ED. Headache in children under six years of age is still considered a diagnostic challenge often requiring neuroimaging to exclude malignant causes (15,16,(23)(24)(25)(26)(27)(28). To date, there are few studies focused on this age group.…”

Pediatric Migraines: A Comprehensive Review and Perspectives on Diagnosis and Treatment

“…Among 109 children with nontraumatic headaches studied by Manoyana et al, 48 25.5% were diagnosed with brain tumor, 25.5% had intracranial infections, and 13.7% had intracranial hemorrhage. Among the children aged < 5 years, four out of six were diagnosed with brain cancer, albeit lacking statistical significance due to too few under-five-year-olds in the study.…”

“… 45 Rho et al, 47 observed that imaging for pediatric headaches, particularly recurring headaches, was quite common, with the most frequent group undergoing unnecessary imaging. Manoyana et al, 48 recently identified four red flag predictors for PM: an abrupt onset (< three months), altered consciousness, focal motor abnormality, and ocular/pupillary abnormality or squint. Children with nontraumatic headaches may benefit from clinical predictor scores based on these four red flags.…”

“… 49 Parents’ awareness and attention are crucial in identifying potential red flags such as changes in mood and personality prior to migraine episodes. 48 A sudden onset headache, commonly called a thunderclap headache, is a symptom of reversible cerebral vasoconstriction syndrome. In rare cases, colorful hallucinations as part of MA may also signal underlying epilepsy.…”

Pediatric headache: a narrative review

“…According to Medina et al [ 23 ], in a study of 315 children, the probability of brain tumors in patients with headaches for less than 6 months and at least one red flag was approximately 4% compared to 0.4% in those who had no red flag [ 23 ]. Red flags are presented in Table 3 [ 24 ].…”