Rapid brain MRI protocols reduce head computerized tomography use in the pediatric emergency department

Abstract

Background: Rapid magnetic resonance imaging (MRI) protocols may be effective in the emergency department (ED) to evaluate nontraumatic neurologic complaints. We evaluate neuroimaging (rapid MRI [rMRI]), head computerized tomography [HCT], and full MRI) use following widespread implementation of rMRI protocols in a pediatric emergency department (ED). Methods:We conducted a retrospective study in a tertiary care pediatric ED of encounters with neuroimaging during two 9-month periods: one prior to (control period) and one after generalized availability of 4 rMRI protocols (rMRI period). The primary outcome was differences in neuroimaging rates between the two periods. Secondary outcomes included ED process measures, unsuccessful imaging, and undetected pathology, with full MRI within 14 days as the reference standard.Results: There were 1052 encounters with neuroimaging during the control and 1308 during the rMRI periods. Differences in neuroimaging between periods were 27.7% for rMRI (95% CI, 24.4, 31.0), − 21.5% for HCT (95% CI, − 25.5, − 17.5), and − 6.2% for full MRI (95% CI, − 9.3, − 3.1%.) Time to imaging (182 [IQR 138-255] versus 86 [IQR 52-137] minutes) as well as ED length of stay (396 [IQR 304-484] versus 257 [IQR 196-334] minutes) was longer for rMRI versus HCT (p < 0.01). Between the control and rMRI periods, there were differences in types of neuroimaging performed for patients with altered mental status, headache, seizure, shunt dysfunction, stroke, syncope, trauma, vomiting, infection, and other neurologic complaints (p < 0.05). rMRI studies were unsuccessful in 3.6% of studies versus 0.0% of HCTs (p < 0.01). The 22 unsuccessful rMRI studies were unsuccessful due to artifacts from dental hardware (n = 2) and patient motion (n = 20). None of the rMRI studies with full MRI follow-up imaging had undetected pathology; the false negative rate for the HCT exams was as high as 25%.Conclusions: After routine ED use of 4 rMRI protocols, there was a more than 20% decrease in HCT use without missed diagnoses. Time to neuroimaging and length of stay were longer for rMRI than HCT, with higher rates of unsuccessful imaging. Despite these limitations, rMRI may be an alternative to HCT for nontraumatic complaints in the ED.

Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache

“…6 Patients who need imaging may benefit from rapid MRI as an alternative to head CT, though research on this topic has been limited to date. 48 -50 Third, our study demonstrates that efforts are needed to reduce narcotic use among children and young adults with headache, particularly given the addictive nature of these medications, in addition to risks of rebound and medication overuse. 51…”

Replacing Computed Tomography with “Rapid” Magnetic Resonance Imaging for Ventricular Shunt Imaging

“…Our ED uses 3 additional rMRI protocols for various conditions in the ED (stroke, abusive head trauma, and nonspecific neurologic symptoms), which has led to an increase in demand for MRI imaging. 11 This may have contributed to the apparent MRI ordering threshold we observed in the last year of the study below which further improvements are unlikely to be made. Nonetheless, the goal is to continue to identify residual barriers beyond MRI availability that may be contributing to continued reliance on CT. For example, the treating team often consults neurosurgery residents early in the ED evaluation process.…”

Accuracy of Brain MRI Interpretation of Emergency Medicine Specialists Versus Radiologist and Neurologist in Suspected Acute Ischemic Stroke Patients; a Diagnostic Accuracy Study

“…Besides what has mentioned above, transient ischemic attach (TIA) triage in ED, its usefulness for assessing traumatic brain injury in young children, reducing the number of CT scan use in the pediatric emergency department are among other possible brain MRI applications in EDs (11)(12)(13)(14).…”