Is MRI imaging an alternative to computed tomography for head injuries in children and adolescents in acute situations? An analysis of the TraumaRegister DGU ®

Is MRI imaging an alternative to computed tomography for head injuries in children and adolescents in acute situations? 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An analysis of the TraumaRegister DGU ® Jonas Alexander Strohm, Rolf Lefering, Peter C. Strohm, Hagen Schmal, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7918533/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Although head injuries are one of the most common causes of emergency room admissions in childhood and adolescence, severe traumatic brain injuries are rare. For acute diagnosis in the emergency department, (cranial) computed tomography (CT or cCT) is the gold standard, but magnetic resonance imaging (MRI) has become an increasingly valid alternative recently due to optimized protocols. This also applies to the recommendations in the current guidelines. The aim of this study was to use the national database of the TraumaRegister DGU ® to determine the current status of MRI diagnostics for pediatric traumatic brain injury (TBI) in European trauma centers. Material and method The TraumaRegister DGU ® (TR-DGU) data sets were analyzed from 2015 to 2022. All children up to the age of 15 with a relevant injury (AIS 2+) and primary admission to a European trauma center who were registered in the TraumaRegister DGU ® between 2015 and 2022 were included. In a further step, relevant predictors were determined by multivariate analysis. Results A total of 5000 children were included, 205 MRI images (4.1%) and 4002 CT images (79.8%) were documented. MRI diagnosis was performed more frequently in the 0-to-1-year age group (5.2%) than in the 14-to-17-year age group (3.5%). In conjunction with initial CT imaging, the median total time in the emergency room was 59 min, with a median time to CT of 19 min. When carrying out MRI imaging, the average total time in the emergency room was 85 min, with a median time to MRI of 49 min. Of the prehospital-intubated children (mean ISS 26.3), 91.6% had a CT scan in the acute diagnostic phase and 2.4% an MRI scan. The strongest positive predictor for MRI imaging was a concomitant cervical spine injury (OR=3.63, p<0.001) and the strongest negative predictor was prehospital intubation (OR = 0.54, p=0.007). Discussion CT imaging remains the gold standard in national comparison especially for severely injured children, partly due to its faster and wider availability after the patient arrives in the emergency room. However, in addition to radiation hygiene, the superior assessibility of the cervical spine in case of concomitant (ligamentous/soft tissue) injuries also speaks in favor of MRI imaging, particularly in young patients. If the necessary structural procedures and accessibility are at hand and when the patient's condition permits, MRI diagnostics should be considered as an alternative to CT imaging for childhood head injuries. The two procedures are nearly equivalent in terms of sensitivity. Figures Figure 1 Figure 2 Introduction In a traumatic brain injury (TBI), external violence results in impaired function or injury to the brain. Vessels and the arachnoid, the dura or the brain may be injured in addition to surrounding soft tissue or the bony skull itself. A head injury without brain involvement is referred to as a skull contusion. The severity of a traumatic brain injury is classified as "mild", "moderate" or "severe" according to the Glasgow Coma Scale (GCS). A GCS of 13–15 points indicates a mild, 9–12 a moderate, and 3–8 points a severe traumatic brain injury ( 1 ). Overall, head injuries in childhood and adolescence are one of the most common causes for presentation to an emergency room ( 2 – 4 ). Fortunately, however, "serious" injuries actually occur in only the rarest of cases. According to data from the Federal Statistical Office from 2015, the proportion of children and adolescents under age 15 with an ICD diagnosis of "traumatic brain injury" with mild TBI was the highest at 91-97.3%, while the proportion of moderate (1.7-4%) and severe (1–5%) injuries was fortunately low in almost equal proportions. However, this can differ in level I trauma centers, where the proportion of moderate and severe head injuries is higher ( 4 ). In terms of the patients’ ages, we identified almost identical collectives in preschool and school age. Native CT imaging is the current standard for diagnosing possible intracranial trauma sequelae and injuries to the bony skull and cervical spine in all age groups. However, despite special pediatric protocols, it remains associated with increased radiation exposure for (young) patients and the associated higher risk of malignant diseases during the disease course ( 5 , 6 ). In contrast, MRI imaging appears to be a promising alternative because, in addition to the lack of radiation exposure, it is possible to precisely visualize the soft tissues and potential ligamentous or cartilaginous injuries in the cervical spine. However, this capacity must be available promptly in an acute situation and quickly accessible from the emergency room, moreover, the patient must also lie still for a longer time during MRI imaging and therefore be sedated/intubated if necessary, depending on age and compliance ( 7 ). However, constant progress has been made in recent years with regard to the duration of imaging. Special protocols can now reliably image the child's brain in 3–4 minutes, and some authors even describe short protocols with special sequences only requiring approximately 30 seconds for imaging ( 5 , 8 ). Earlier imaging protocols, on the other hand, took considerably longer, averaging 3–7 minutes ( 5 ). The aim of this study was therefore to use the international database of the TraumaRegister DGU® to determine the current use of MRI imaging in pediatric traumatic brain injury in European trauma centers and to identify corresponding positive and negative predictors. Material and Methods The TraumaRegister DGU ® of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) was founded in 1993. The aim of this multi-center database is the pseudonymized and standardized documentation of severely injured patients. Data are collected prospectively in four consecutive time phases from the site of the accident until discharge from hospital: A) the pre-hospital phase, B) emergency room and initial surgery, C) intensive care unit and D) discharge. Documentation includes detailed information on demographics, injury pattern, comorbidities, pre- and in-hospital management, course on intensive care unit, relevant laboratory findings including data on transfusion and outcome of each individual. The inclusion criterion is admission to hospital via an emergency room with subsequent ICU/ICM care or reaching the hospital with vital signs and dying before ICU admission. The infrastructure for documentation, data management and data analysis is provided by AUC – Academy for Trauma Surgery (AUC - Akademie der Unfallchirurgie GmbH), a company affiliated with the German Trauma Society. Scientific leadership is provided by the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society. The participating hospitals submit their data pseudonymized into a central database via a web-based application. Scientific data analysis is approved according to a peer review procedure laid down in the publication guideline of TraumaRegister DGU ® . The participating hospitals are primarily located in Germany (90%), but a rising number of hospitals of other countries contribute data as well (at the moment from Austria, Belgium, China, Finland, Luxembourg, Slovenia, Switzerland, The Netherlands, and the United Arab Emirates). More than 38,000 cases from almost 700 hospitals are now being entered into the database per year. Participation in TraumaRegister DGU ® is voluntary. For hospitals associated with TraumaNetzwerk DGU ® , however, the entry of at least one basic data set is obligatory for reasons of quality assurance. This study complies with the publication guidelines of the TraumaRegister DGU ® and is registered under the TR-DGU project ID 2022-012. We conducted a retrospective evaluation of the available data sets from the TraumaRegister DGU ® in the period from 2015 to 2022. All patients up to age 15 with primary admission to a European trauma center were included. Slightly injured children were excluded (all injured patients with a maximum AIS 1; an AIS 2 was only included if the injured child received intensive medical care). We also carried out a descriptive evaluation and presentation of epidemiological data of the patient collective, the accident’s course and the severity of injured body regions. In addition, multivariate logistic regression was used to examine factors that speak for or against performing MRI imaging (dependent variable). The following characteristics were used as predictors: Patient age (in 3 groups) ISS ≥ 16 Isolated head injury Polytrauma Patient admission on the weekend Patient admission at night Care level of the hospital Concomitant injury to the cervical spine Pre-hospital intubation of the patient Change over time (2015-2018 versus 2019-2022) A suspected TBI (by prehospital emergency doctor or GCS ≤13) Relevant scores AIS/ISS: There are various scoring systems for estimating the prognosis of polytrauma patients and, above all, uniformly assessing the degree of severity. The Abbreviated Injury Scale (AIS) can be used to describe and classify the severity of each injury: AIS 1 = mild AIS 2 = moderate AIS 3 = serious, but not life-threatening AIS 4 = severe, life-threatening AIS 5 = critical, survival uncertain AIS 6 = fatal / untreatable The Injury Severity Score (ISS) indicates the overall severity of injury in polytrauma. The injury severity of the three most injured regions (head, face, thorax, abdomen, extremities, soft tissue) is squared and totaled according to the following formula: ISS = (AIS region1 ) 2 + (AIS region2 ) 2 + (AIS region3 ) 2 . The maximum ISS is 75, which is also fulfilled in case of an AIS 6 injury (9, 10). GCS: The Glasgow Coma Scale (GCS) can be used to assess the level of consciousness or quantify impaired consciousness. Here, eye opening (1-4 points), the best possible verbal reaction (1-5 points) and the best possible motoric reaction (1-6 points) are assessed and scored, after which the corresponding classification into mild (13-15 points), moderate (9-12 points) or severe (3-8 points) traumatic brain injury is made (1). Statistics Categorical variables were presents with number and percentage per category, and metric data were presents as mean with standard deviation (SD) is distribution was not rather skewed. Observed differences were evaluated with Fisher’s exact test (2x2 table), chi-squared test, or Mann-Whitney U-test, respectively. In case of ordered categories, a trend was analyzed with the Mantel-Haenzel test (chi-squared test for trend). A p-value <0.05 was considered significant. Potential predictors for a MRT were analyzed by a multivariate logistic regression analysis was applied with MRT as dependent variable. The list of independent predictors is given in Table 2. Results are presented as adjusted odds ratios (OR) with their respective 95% confidence intervals. All analyses were performed with SPSS statistical software (version 29, IBM Inc., Armonk, NY, USA). Results Epidemiological data 5000 children were included. Data sets from a total of 240 clinics were used (1 - 194 patients per clinic). 159 of the 240 clinics did not perform MRI imaging. Broken down according to patient age, we observed similar percentage distributions in the group of 0-5-year-olds (29.6%; n=1479) and 6-10-year-olds (25.2%; n=1258), while the group of 11-15-year-old children made up the largest proportion at 45.3% (n=2263). Almost 2/3 of the patients were male (62.9%; n=3144). Regarding the cause of the accident, falls from a height > 3m (18%; n=885) or low height (16%, n=780), accidents as a pedestrian (17%; n=830) and other causes of accidents (17%; n=876) accounted for the largest proportion. Table 1 provides a complete overview of the epidemiological data collected, broken down according to the imaging performed in each case. Among the 5000 included children (age 0-15), 205 underwent initial MRI imaging (4.1%). In 2015-2021, the rate of MRI imaging varied between 3 and 4%, rising to 6.3% in 2022 (p=0.14; chi-square test for trend). Broken down by age group, MRI imaging was performed in 5.2% of 0-1-year-olds and in 3.5% of 14-17-year-olds. This trend is not significant (p=0.45). Figure 1 shows the exact distribution of imaging procedures performed in the different age groups. Among the documented cases, 793 children (15.9%) underwent no form of cross-sectional imaging, 4002 underwent cranial or whole-body CT imaging and 205 underwent MRI imaging (4.1%). Both CT and MRI imaging was performed in 79 children, with CT imaging done first in 96% of cases. 126 children (2.5%) underwent MRI imaging only. After CT, 63.6% presented AIS 2+ head injuries. After MRI, 62.4% showed AIS 2+ head injuries. In the 128 patients with only MRI diagnostics, 64.1% presented a head injury. If a CT was performed, median time in the emergency room was 59 minutes, with a median time to CT of 19 minutes. In contrast, if an MRI was performed, the median total time in the emergency room was 85 minutes, with a median time to MRI of 49 minutes (Figure 2). 3277 (65.5%) children arrived not intubated at the hospital (mean ISS 12.6), 531 (10.6%) children were intubated after arrival or during their stay in the emergency room (mean ISS 20.0). 1192 (23.8%) children were intubated prehospital (mean ISS 26.3) (see Table 3). Of the prehospital intubated children, 91.7% were given a CT scan after arrival in the emergency room and 2.4% of the children had an MRI scan. Table 2 shows the results of our multivariate logistic regression analysis with MRI screening as dependent variable. The following predictors had a positive association with performing an MRI: - Supra-regional trauma center (level 1 hospital) - (Concomitant) injury of the cervical spine - Isolated traumatic brain injury - Admission at day In contrast, the factors speaking against performing an MRI were: - Polytrauma or ISS ≥ 16 - Preclinical intubation - Admission at night However, the following variables had little or no effect: - Age of the child - Trend over time - Weekend admission - Suspected TBI Discussion The available data clearly show that CT is still performed much more often than MRI in acute diagnostics in the emergency room, especially in children who are presumably more seriously injured. In the group of children intubated prehospital and thus most likely already classified as critically injured by the prehospital emergency doctor, 91.6% underwent CT imaging as part of the initial emergency room diagnosis, compared to only 2.4% who underwent a sole, initial MRI imaging. Among those intubated prehospital, the severity of injury according to the ISS was also correspondingly high, with a mean value of over 26. These figures are also in line with the current recommendations in the guidelines, which recommend prompt CT for severe TBI to enable any critical injury sequelae to be identified immediately. Potential bleeding as intracranial trauma sequelae can thus be detected as quickly as possible and, if necessary, promptly resolved ( 11 ). However, in addition to the severity of injury, the time factor also seems to seems to be relevant in the choice of imaging. Here, our data evaluation showed that the average time from the young patient’s arrival in the emergency room to the performance of cross-sectional imaging was approximately 30 minutes shorter (19 min vs. 49 min) for CT than MRI. We detected similar differences in the total time in the emergency room (median 59 min for CT, 85 min for MRI). On the one hand, this time difference may be due to CT’s wider availability and faster accessibility and the significantly shorter examination time it takes for accurate images. On the other hand, as discussed above, our evaluation’s results reveal a correlation between the severity of injury and indication for CT imaging. With such very different times, we can therefore also assume that faster and more focused diagnosis and treatment were carried out in the emergency room due to a child’s presumably more severe injury than in the case of a potentially less severely injured child. Nevertheless, our data also show that, overall, more MRIs are performed in children than in adults (on average 4.1% vs. 1.5%), and that the total number of MRIs performed in children has risen trend-wise in recent years (from 3% in 2015 to 6.3% in 2022), while it has remained relatively constant in adults. It remains to be seen how this trend will develop in the coming years. The lack of radiation exposure and thus lower risk of malignant secondary diseases in adulthood speaks in favor of MRI imaging, particularly in young patients ( 12 ). Especially in infants and young children who have not yet reached the age of two, the lifelong risk of cancer, including brain tumors and leukemia, is significantly higher because of their greater sensitivity to ionizing radiation ( 6 , 13 ). Thanks to specially adapted pediatric protocols, the radiation exposure from necessary CT imaging in accordance with the ALARA principles (as low as reasonably achievable) has already been significantly reduced in recent years, as shown in particular in studies comparing centers with a pediatric trauma department to those without a specialized pediatric department ( 14 , 15 ). Nevertheless, the indication for CT must always be critically questioned and, if possible, replaced by a lower radiation alternative ( 16 ). Fortunately, the growing awareness of this problem is also reflected in our evaluation results: the group of 0-1-year-olds underwent MRI significantly more often than did the group of 14-17-year-olds. The cervical spine’s improved assessibility with regard to concomitant ligamentous injuries during MRI should also be considered when choosing the diagnostic procedure ( 17 ). Infants and small children under the age of 2 years tend to have a proportionally larger, heavier head, as well as significantly softer and less developed neck muscles ( 18 ). These young patients are therefore particularly susceptible to acceleration-deceleration traumas causing consecutive damage to highly sensitive structures such as the medulla oblongata or the cervical myelon, and additional imaging of the craniocervical junction is urgently recommended to rule out such serious injuries ( 19 , 20 ). In addition to possible concomitant injuries to the cervical spine, the available data also show a more frequent indication for performing an MRI in the (suspected) presence of an isolated head injury. Note of course in this context that not every trauma center is capable of performing MRI imaging around the clock. According to our multivariate logistic regression data, such a capacity appears to be reserved for supra-regional trauma centers or is more feasible during the day. If the structural procedures and accessibility in the emergency department are a given or if they can be optimized in terms of time and imaging quality together with specially adapted (pediatric) protocols, MRI diagnostics should always be considered as an alternative to CT imaging for pediatric head injuries - especially in stable patients and those with a mild to moderate TBI. Both methods can be considered at least equivalent in terms of their sensitivity in detecting hemorrhages and parenchymal lesions, as several recent studies have shown ( 21 – 25 ). Some authors even consider MRI to be superior to CT in terms of sensitivity and specificity, particularly for detecting minor (intracranial) head injuries ( 26 , 27 ). CT appears to be superior to MRI only with regard to the detection of fresh fractures in children under 6 years of age ( 28 ). The current guidelines also recommend that MRI imaging should always be the preferred diagnostic procedure for cross-sectional imaging in case of follow-up imaging ( 11 ). Conclusion We have identified various factors and predictors concerning MRI imaging for pediatric head injuries. The frequency of emergency room MRIs decreases significantly in conjunction with increasing injury severity or polytraumatization, correlating with a higher ISS and often accompanied by the young patient’s prehospital intubation. Furthermore, the time factor, which includes preparing the patient (necessary intubation/sedation) as well as structural conditions and accessibility appear to be arguments for the initial performance of a CT. On the other hand, the lack of radiation exposure during MRI imaging reduces the risk of malignant secondary diseases, especially in infants and young children. In addition, MRI’s superior soft tissue imaging allows ligamentous (concomitant) injuries of the cervical spine or injuries in the craniocervical junction to be detected faster and more reliably. Provided that age-appropriate protocols and structural conditions are in place, MRI imaging should always be considered in stable patients, and especially for follow-up diagnostics. Study limitations Despite this study’s large patient population, there are some limitations that should be noted and mentioned. Firstly, the group of children who underwent MRI imaging is significantly smaller than the group of children who underwent CT imaging, which creates limitations with regard to the significance of our results. In addition, experience has shown that the data quality is lower and the documented parameters in registries are less complete compared to prospective clinical studies. A further relevant limitation is the fact that the TraumaRegister DGU ® can only show that MRI imaging has been performed, but currently no dedicated differentiation is possible with regard to the body region examined (in particular cranial MRI). It can only be assumed that the primary MRI imaging is a cranial imaging based on the defined inclusion criteria (shock room/severity of injury), in combination with the analyzed predictors and considering the results, particularly with regard to the proportion of relevant head injuries after CT/MRI imaging has been performed. The registry data also is not capable of showing if (after initial CT imaging in the emergency room) an additional MRI imaging was performed in the further (inpatient) course. Nevertheless, we identified an encouraging tendency among the initial diagnostics now being carried out in emergency rooms especially in view of the severity and location of the injury. The last few years also seem to indicate a trend towards low-radiation diagnostics in children. Declarations Ethical approval and consent to participate Ethical approval was not applicable. Informed consent to participate was obtained from all of the participants in the study respectively in the TraumaRegister DGU ® . Consent for publication Not applicable. Competing interests The authors have no conflicts of interests to disclose. Funding No funding was received. Author Contribution Writing - original draft: JS; Data acquisition: RL; Writing – review & editing: KMP and HS; Supervision: PS and IS; All authors reviewed the manuscript. Acknowledgements We appreciate the support of the DGU in conducting this research. Data Availability The data used in this study were provided by the TraumaRegister DGU® of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU). References Heim C, Schoettker P, Spahn DR. [Glasgow Coma Scale in traumatic brain injury]. Anaesthesist. 2004;53(12):1245-55; quiz 56. Schulz-Drost S, Finkbeiner R, Lefering R, Grosso M, Krinner S, Langenbach A, TraumaRegister DGU. Lung Contusion in Polytrauma: An Analysis of the TraumaRegister DGU. Thorac Cardiovasc Surg. 2021;69(8):735-48. 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Magnetic resonance imaging as an alternative to computed tomography in select patients with traumatic brain injury: a retrospective comparison. J Neurosurg Pediatr. 2015;15(5):529-34. Tables Table 1: Comparison of children with CT or MRI (plus maybe CT) Statistical tests for CT versus MRI imaging: Fisher’s Exact test or chi-squared test for categorical data; Mann-Whitney U-test for metric data CT imaging N=4002 MRI imaging N=205 p-value No CT/MRI imaging N=793 Age 9.1 (4.9) 8.6 (4.8) .131 8.0 (4.9) Sex (m) 2531 (63.2%) 128 (62.4%) .824 485 (61.2% Recent years (2019-22) 2109 (52.7%) 111 (54.1%) .720 370 (46.7%) Injury Severity Score (ISS) 17.5 (11.4) 15.1 (11.4) <.001 12.7 (11.8) ISS ≥ 16 2034 (50.8%) 82 (40.0%) .003 201 (25.3%) Polytrauma 532 (13.3%) 12 (5.9%) .001 38 (4.8%) Level 1 hospital 3273 (81.8%) 182 (88.8%) .011 626 (78.9%) Cause of accident traffic high fall low fall other 2180 (54.5%) 765 (19.1%) 597 (14.9%) 460 (11.5%) 87 (42.4%) 46 (22.4%) 50 (24.4%) 22 (10.7%) <.001 344 (43.4%) 74 (9.3%) 133 (16.8%) 242 (30.5%) Prehospital intubation 1050 (26.2%) 29 (14.1%) <.001 90 (11.3%) Admission during the night (18-6) 1633 (40.8%) 66 (32.2%) .014 290 (36.6%) Admission on weekends (Fr-Su) 1819 (45.5%) 96 (46.8%) .720 343 (43.3%) Relevant injuries (AIS 3+) head 1903 (47.6%) 99 (48.3%) .886 96 (12.1%) thorax 916 (22.9%) 41 (20.0%) .393 86 (10.8%) abdomen 457 (11.4%) 15 (7.3%) .070 89 (11.2%) extremities 802 (20.0%) 15 (7.3%) <.001 244 (30.8%) Suspected head injury (prehospital) 2247 (56.1%) 103 (50.2%) .097 182 (23.0%) Isolated head injury 809 (20.2%) 58 (28.3%) .008 50 (6.3) Cervical spine injured 253 (6.3%) 36 (17.6%) <.001 33 (4.2%) Cranial CT 3913 (97.8%) 77 (37.6%) <.001 --- Sonography 3216 (80.4%) 188 (91.7%) <.001 605 (76.3%) X-ray* 1070 (26.7%) 51 (24.9%) .627 307 (38.7%) Intensive care treatment 3583 (89.5%) 189 (92.2%) .241 574 (72.4%) Died within 6 hours 68 (1.7%) 0 (0%) .079 53 (6.7%) Died in hospital 244 (6.1%) 3 (1.5%) .003 61 (7.7) * x-ray of thorax, pelvis, or spinal cord (x-ray of extremities is not documented) Table 2: Results of logistic regression analysis with MRT as dependent variable. All 4207 children with CT and/or MRT diagnostic were included; Nagelkerke’s R² was 0.055 Predictor Reference Odds Ratio (OR) 95% CI for OR P value Level 1 hospital Level 2/3 2.04 1.30 – 3.20 = 16 <16 0.75 0.55 – 1.03 .077 Polytrauma no 0.70 0.36 – 1.35 .28 Cervical spine injured no 3.63 2.45 – 5.37 <.001 Isolated head injury no 1.61 1.14 – 2.26 .007 Prehospital intubation no 0.54 0.35 – 0.84 .007 Admission during night day 0.68 0.50 – 0.92 .011 Admission on weekend weekday 1.09 0.82 – 1.45 .55 Suspected head injury* no 0.84 0.62 – 1.15 .28 * suspected if GCS ≤13, or relevant head injury assumed by emergency physician Table 3 – time of intubation in relation to ISS number of patients Mean ISS (SD) MRI performed Not intubated 3277 (65.5%) 12.6 (7.2) 151 (4,6%) Prehospital intubation 1192 (23.8%) 26.3 (15.0) 29 (2,4%) Intubation in the ER 531 (10.6%) 20.0 (11.2) 25 (4,7%) Additional Declarations No competing interests reported. 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07:39:53","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":113802,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7918533/v1/b6cb7aeda07338528ec75a34.html"},{"id":96203361,"identity":"683b6de3-1b5f-4e67-b895-71fd809cab79","added_by":"auto","created_at":"2025-11-18 16:52:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":16222,"visible":true,"origin":"","legend":"\u003cp\u003eAge distribution of the patient collective with imaging performed\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7918533/v1/6f41e529b1d63089a549d462.png"},{"id":96203362,"identity":"9f034d9d-890c-49d7-ad3f-1f52565c6d8c","added_by":"auto","created_at":"2025-11-18 16:52:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13166,"visible":true,"origin":"","legend":"\u003cp\u003ecomparison of CT/MRI in relation to the time needed\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7918533/v1/cd56f6ed0ecfddc6a5b21a7f.png"},{"id":102295942,"identity":"ce3e597a-c882-4e49-965e-97896b4e72c4","added_by":"auto","created_at":"2026-02-10 10:16:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":702574,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7918533/v1/95d28681-a7d7-4e6c-98c5-48a59cc1495e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is MRI imaging an alternative to computed tomography for head injuries in children and adolescents in acute situations? An analysis of the TraumaRegister DGU ®","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn a traumatic brain injury (TBI), external violence results in impaired function or injury to the brain. Vessels and the arachnoid, the dura or the brain may be injured in addition to surrounding soft tissue or the bony skull itself. A head injury without brain involvement is referred to as a skull contusion. The severity of a traumatic brain injury is classified as \"mild\", \"moderate\" or \"severe\" according to the Glasgow Coma Scale (GCS). A GCS of 13\u0026ndash;15 points indicates a mild, 9\u0026ndash;12 a moderate, and 3\u0026ndash;8 points a severe traumatic brain injury (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOverall, head injuries in childhood and adolescence are one of the most common causes for presentation to an emergency room (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Fortunately, however, \"serious\" injuries actually occur in only the rarest of cases.\u003c/p\u003e\u003cp\u003eAccording to data from the Federal Statistical Office from 2015, the proportion of children and adolescents under age 15 with an ICD diagnosis of \"traumatic brain injury\" with mild TBI was the highest at 91-97.3%, while the proportion of moderate (1.7-4%) and severe (1\u0026ndash;5%) injuries was fortunately low in almost equal proportions. However, this can differ in level I trauma centers, where the proportion of moderate and severe head injuries is higher (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn terms of the patients\u0026rsquo; ages, we identified almost identical collectives in preschool and school age.\u003c/p\u003e\u003cp\u003eNative CT imaging is the current standard for diagnosing possible intracranial trauma sequelae and injuries to the bony skull and cervical spine in all age groups. However, despite special pediatric protocols, it remains associated with increased radiation exposure for (young) patients and the associated higher risk of malignant diseases during the disease course (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In contrast, MRI imaging appears to be a promising alternative because, in addition to the lack of radiation exposure, it is possible to precisely visualize the soft tissues and potential ligamentous or cartilaginous injuries in the cervical spine. However, this capacity must be available promptly in an acute situation and quickly accessible from the emergency room, moreover, the patient must also lie still for a longer time during MRI imaging and therefore be sedated/intubated if necessary, depending on age and compliance (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, constant progress has been made in recent years with regard to the duration of imaging. Special protocols can now reliably image the child's brain in 3\u0026ndash;4 minutes, and some authors even describe short protocols with special sequences only requiring approximately 30 seconds for imaging (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Earlier imaging protocols, on the other hand, took considerably longer, averaging 3\u0026ndash;7 minutes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe aim of this study was therefore to use the international database of the TraumaRegister DGU\u0026reg; to determine the current use of MRI imaging in pediatric traumatic brain injury in European trauma centers and to identify corresponding positive and negative predictors.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThe TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e of the German Trauma Society (Deutsche Gesellschaft f\u0026uuml;r Unfallchirurgie, DGU) was founded in 1993. The aim of this multi-center database is the pseudonymized and standardized documentation of severely injured patients.\u003c/p\u003e\n\u003cp\u003eData are collected prospectively in four consecutive time phases from the site of the accident until discharge from hospital: A) the pre-hospital phase, B) emergency room and initial surgery, C) intensive care unit and D) discharge. Documentation includes detailed information on demographics, injury pattern, comorbidities, pre- and in-hospital management, course on intensive care unit, relevant laboratory findings including data on transfusion and outcome of each individual. The inclusion criterion is admission to hospital via an emergency room with subsequent ICU/ICM care or reaching the hospital with vital signs and dying before ICU admission.\u003c/p\u003e\n\u003cp\u003eThe infrastructure for documentation, data management and data analysis is provided by AUC \u0026ndash; Academy for Trauma Surgery (AUC - Akademie der Unfallchirurgie GmbH), a company affiliated with the German Trauma Society. Scientific leadership is provided by the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society. The participating hospitals submit their data pseudonymized into a central database via a web-based application. Scientific data analysis is approved according to a peer review procedure laid down in the publication guideline of TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe participating hospitals are primarily located in Germany (90%), but a rising number of hospitals of other countries contribute data as well (at the moment from Austria, Belgium, China, Finland, Luxembourg, Slovenia, Switzerland, The Netherlands, and the United Arab Emirates). More than 38,000 cases from almost 700 hospitals are now being entered into the database per year.\u003c/p\u003e\n\u003cp\u003eParticipation in TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e is voluntary. For hospitals associated with TraumaNetzwerk DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e, however, the entry of at least one basic data set is obligatory for reasons of quality assurance.\u003c/p\u003e\n\u003cp\u003eThis study complies with the publication guidelines of the TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e and is registered under the TR-DGU project ID 2022-012.\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective evaluation of the available data sets from the TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e in the period from 2015 to 2022. All patients up to age 15 with primary admission to a European trauma center were included. Slightly injured children were excluded (all injured patients with a maximum AIS 1; an AIS 2 was only included if the injured child received intensive medical care).\u003c/p\u003e\n\u003cp\u003eWe also carried out a descriptive evaluation and presentation of epidemiological data of the patient collective, the accident\u0026rsquo;s course and the severity of injured body regions.\u003c/p\u003e\n\u003cp\u003eIn addition, multivariate logistic regression was used to examine factors that speak for or against performing MRI imaging (dependent variable). The following characteristics were used as predictors:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePatient age (in 3 groups)\u003c/li\u003e\n \u003cli\u003eISS \u0026ge; 16\u003c/li\u003e\n \u003cli\u003eIsolated head injury\u003c/li\u003e\n \u003cli\u003ePolytrauma\u003c/li\u003e\n \u003cli\u003ePatient admission on the weekend\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePatient admission at night\u003c/li\u003e\n \u003cli\u003eCare level of the hospital\u003c/li\u003e\n \u003cli\u003eConcomitant injury to the cervical spine\u003c/li\u003e\n \u003cli\u003ePre-hospital intubation of the patient\u003c/li\u003e\n \u003cli\u003eChange over time (2015-2018 versus 2019-2022)\u003c/li\u003e\n \u003cli\u003eA suspected TBI (by prehospital emergency doctor or GCS \u0026le;13)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cu\u003eRelevant scores\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAIS/ISS:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere are various scoring systems for estimating the prognosis of polytrauma patients and, above all, uniformly assessing the degree of severity. The Abbreviated Injury Scale (AIS) can be used to describe and classify the severity of each injury:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAIS 1 = mild\u003c/li\u003e\n \u003cli\u003eAIS 2 = moderate\u003c/li\u003e\n \u003cli\u003eAIS 3 = serious, but not life-threatening\u003c/li\u003e\n \u003cli\u003eAIS 4 = severe, life-threatening\u003c/li\u003e\n \u003cli\u003eAIS 5 = critical, survival uncertain\u003c/li\u003e\n \u003cli\u003eAIS 6 = fatal / untreatable\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe Injury Severity Score (ISS) indicates the overall severity of injury in polytrauma. The injury severity of the three most injured regions (head, face, thorax, abdomen, extremities, soft tissue) is squared and totaled according to the following formula:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eISS = (AIS\u003csub\u003eregion1\u003c/sub\u003e)\u003csup\u003e2\u003c/sup\u003e + (AIS\u003csub\u003eregion2\u003c/sub\u003e)\u003csup\u003e2\u003c/sup\u003e + (AIS\u003csub\u003eregion3\u003c/sub\u003e)\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe maximum ISS is 75, which is also fulfilled in case of an AIS 6 injury (9, 10).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGCS:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Glasgow Coma Scale (GCS) can be used to assess the level of consciousness or quantify impaired consciousness. Here, eye opening (1-4 points), the best possible verbal reaction (1-5 points) and the best possible motoric reaction (1-6 points) are assessed and scored, after which the corresponding classification into mild (13-15 points), moderate (9-12 points) or severe (3-8 points) traumatic brain injury is made (1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistics\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eCategorical variables were presents with number and percentage per category, and metric data were presents as mean with standard deviation (SD) is distribution was not rather skewed. Observed differences were evaluated with Fisher\u0026rsquo;s exact test (2x2 table), chi-squared test, or Mann-Whitney U-test, respectively. In case of ordered categories, a trend was analyzed with the Mantel-Haenzel test (chi-squared test for trend). A p-value \u0026lt;0.05 was considered significant.\u003c/p\u003e\n\u003cp\u003ePotential predictors for a MRT were analyzed by a multivariate logistic regression analysis was applied with MRT as dependent variable. The list of independent predictors is given in Table 2. Results are presented as adjusted odds ratios (OR) with their respective 95% confidence intervals.\u003c/p\u003e\n\u003cp\u003eAll analyses were performed with SPSS statistical software (version 29, IBM Inc., Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cu\u003eEpidemiological data\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e5000 children were included. Data sets from a total of 240 clinics were used (1 - 194 patients per clinic). 159 of the 240 clinics did not perform MRI imaging. Broken down according to patient age, we observed similar percentage distributions in the group of 0-5-year-olds (29.6%; n=1479) and 6-10-year-olds (25.2%; n=1258), while the group of 11-15-year-old children made up the largest proportion at 45.3% (n=2263). Almost 2/3 of the patients were male (62.9%; n=3144).\u003c/p\u003e\n\u003cp\u003eRegarding the cause of the accident, falls from a height \u0026gt; 3m (18%; n=885) or low height (16%, n=780), accidents as a pedestrian (17%; n=830) and other causes of accidents (17%; n=876) accounted for the largest proportion.\u003c/p\u003e\n\u003cp\u003eTable 1 provides a complete overview of the epidemiological data collected, broken down according to the imaging performed in each case.\u003c/p\u003e\n\u003cp\u003eAmong the 5000 included children (age 0-15), 205 underwent initial MRI imaging (4.1%). In 2015-2021, the rate of MRI imaging varied between 3 and 4%, rising to 6.3% in 2022 (p=0.14; chi-square test for trend).\u003c/p\u003e\n\u003cp\u003eBroken down by age group, MRI imaging was performed in 5.2% of 0-1-year-olds and in 3.5% of 14-17-year-olds. This trend is not significant (p=0.45). Figure 1 shows the exact distribution of imaging procedures performed in the different age groups.\u003c/p\u003e\n\u003cp\u003eAmong the documented cases, 793 children (15.9%) underwent no form of cross-sectional imaging, 4002 underwent cranial or whole-body CT imaging and 205 underwent MRI imaging (4.1%). Both CT and MRI imaging was performed in 79 children, with CT imaging done first in 96% of cases. 126 children (2.5%) underwent MRI imaging only.\u003c/p\u003e\n\u003cp\u003eAfter CT, 63.6% presented AIS 2+ head injuries.\u003c/p\u003e\n\u003cp\u003eAfter MRI, 62.4% showed AIS 2+ head injuries.\u003c/p\u003e\n\u003cp\u003eIn the 128 patients with only MRI diagnostics, 64.1% presented a head injury.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIf a CT was performed, median time in the emergency room was 59 minutes, with a median time to CT of 19 minutes.\u003c/p\u003e\n\u003cp\u003eIn contrast, if an MRI was performed, the median total time in the emergency room was 85 minutes, with a median time to MRI of 49 minutes (Figure 2).\u003c/p\u003e\n\u003cp\u003e3277 (65.5%) children arrived not intubated at the hospital (mean ISS 12.6),\u003c/p\u003e\n\u003cp\u003e531 (10.6%) children were intubated after arrival or during their stay in the emergency room (mean ISS 20.0). 1192 (23.8%) children were intubated prehospital (mean ISS 26.3) (see Table 3).\u003c/p\u003e\n\u003cp\u003eOf the prehospital intubated children, 91.7% were given a CT scan after arrival in the emergency room and 2.4% of the children had an MRI scan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 shows the results of our multivariate logistic regression analysis with MRI screening as dependent variable. The following predictors had a positive association with performing an MRI:\u003c/p\u003e\n\u003cp\u003e- Supra-regional trauma center (level 1 hospital)\u003c/p\u003e\n\u003cp\u003e- (Concomitant) injury of the cervical spine\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Isolated traumatic brain injury\u003c/p\u003e\n\u003cp\u003e- Admission at day\u003c/p\u003e\n\u003cp\u003eIn contrast, the factors speaking against performing an MRI were:\u003c/p\u003e\n\u003cp\u003e- Polytrauma or ISS \u0026ge; 16\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Preclinical intubation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Admission at night\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the following variables had little or no effect:\u003c/p\u003e\n\u003cp\u003e- Age of the child\u003c/p\u003e\n\u003cp\u003e- Trend over time\u003c/p\u003e\n\u003cp\u003e- Weekend admission\u003c/p\u003e\n\u003cp\u003e- Suspected TBI\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe available data clearly show that CT is still performed much more often than MRI in acute diagnostics in the emergency room, especially in children who are presumably more seriously injured. In the group of children intubated prehospital and thus most likely already classified as critically injured by the prehospital emergency doctor, 91.6% underwent CT imaging as part of the initial emergency room diagnosis, compared to only 2.4% who underwent a sole, initial MRI imaging. Among those intubated prehospital, the severity of injury according to the ISS was also correspondingly high, with a mean value of over 26. These figures are also in line with the current recommendations in the guidelines, which recommend prompt CT for severe TBI to enable any critical injury sequelae to be identified immediately. Potential bleeding as intracranial trauma sequelae can thus be detected as quickly as possible and, if necessary, promptly resolved (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, in addition to the severity of injury, the time factor also seems to seems to be relevant in the choice of imaging. Here, our data evaluation showed that the average time from the young patient\u0026rsquo;s arrival in the emergency room to the performance of cross-sectional imaging was approximately 30 minutes shorter (19 min vs. 49 min) for CT than MRI. We detected similar differences in the total time in the emergency room (median 59 min for CT, 85 min for MRI).\u003c/p\u003e\u003cp\u003eOn the one hand, this time difference may be due to CT\u0026rsquo;s wider availability and faster accessibility and the significantly shorter examination time it takes for accurate images. On the other hand, as discussed above, our evaluation\u0026rsquo;s results reveal a correlation between the severity of injury and indication for CT imaging. With such very different times, we can therefore also assume that faster and more focused diagnosis and treatment were carried out in the emergency room due to a child\u0026rsquo;s presumably more severe injury than in the case of a potentially less severely injured child.\u003c/p\u003e\u003cp\u003eNevertheless, our data also show that, overall, more MRIs are performed in children than in adults (on average 4.1% vs. 1.5%), and that the total number of MRIs performed in children has risen trend-wise in recent years (from 3% in 2015 to 6.3% in 2022), while it has remained relatively constant in adults. It remains to be seen how this trend will develop in the coming years.\u003c/p\u003e\u003cp\u003eThe lack of radiation exposure and thus lower risk of malignant secondary diseases in adulthood speaks in favor of MRI imaging, particularly in young patients (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Especially in infants and young children who have not yet reached the age of two, the lifelong risk of cancer, including brain tumors and leukemia, is significantly higher because of their greater sensitivity to ionizing radiation (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThanks to specially adapted pediatric protocols, the radiation exposure from necessary CT imaging in accordance with the ALARA principles (as low as reasonably achievable) has already been significantly reduced in recent years, as shown in particular in studies comparing centers with a pediatric trauma department to those without a specialized pediatric department (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Nevertheless, the indication for CT must always be critically questioned and, if possible, replaced by a lower radiation alternative (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Fortunately, the growing awareness of this problem is also reflected in our evaluation results: the group of 0-1-year-olds underwent MRI significantly more often than did the group of 14-17-year-olds.\u003c/p\u003e\u003cp\u003eThe cervical spine\u0026rsquo;s improved assessibility with regard to concomitant ligamentous injuries during MRI should also be considered when choosing the diagnostic procedure (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Infants and small children under the age of 2 years tend to have a proportionally larger, heavier head, as well as significantly softer and less developed neck muscles (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These young patients are therefore particularly susceptible to acceleration-deceleration traumas causing consecutive damage to highly sensitive structures such as the medulla oblongata or the cervical myelon, and additional imaging of the craniocervical junction is urgently recommended to rule out such serious injuries (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition to possible concomitant injuries to the cervical spine, the available data also show a more frequent indication for performing an MRI in the (suspected) presence of an isolated head injury. Note of course in this context that not every trauma center is capable of performing MRI imaging around the clock. According to our multivariate logistic regression data, such a capacity appears to be reserved for supra-regional trauma centers or is more feasible during the day.\u003c/p\u003e\u003cp\u003eIf the structural procedures and accessibility in the emergency department are a given or if they can be optimized in terms of time and imaging quality together with specially adapted (pediatric) protocols, MRI diagnostics should always be considered as an alternative to CT imaging for pediatric head injuries - especially in stable patients and those with a mild to moderate TBI.\u003c/p\u003e\u003cp\u003eBoth methods can be considered at least equivalent in terms of their sensitivity in detecting hemorrhages and parenchymal lesions, as several recent studies have shown (\u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Some authors even consider MRI to be superior to CT in terms of sensitivity and specificity, particularly for detecting minor (intracranial) head injuries (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). CT appears to be superior to MRI only with regard to the detection of fresh fractures in children under 6 years of age (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe current guidelines also recommend that MRI imaging should always be the preferred diagnostic procedure for cross-sectional imaging in case of follow-up imaging (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe have identified various factors and predictors concerning MRI imaging for pediatric head injuries.\u003c/p\u003e\n\u003cp\u003eThe frequency of emergency room MRIs decreases significantly in conjunction with increasing injury severity or polytraumatization, correlating with a higher ISS and often accompanied by the young patient\u0026rsquo;s prehospital intubation.\u003c/p\u003e\n\u003cp\u003eFurthermore, the time factor, which includes preparing the patient (necessary intubation/sedation) as well as structural conditions and accessibility appear to be arguments for the initial performance of a CT.\u003c/p\u003e\n\u003cp\u003eOn the other hand, the lack of radiation exposure during MRI imaging reduces the risk of malignant secondary diseases, especially in infants and young children.\u003c/p\u003e\n\u003cp\u003eIn addition, MRI\u0026rsquo;s superior soft tissue imaging allows ligamentous (concomitant) injuries of the cervical spine or injuries in the craniocervical junction to be detected faster and more reliably.\u003c/p\u003e\n\u003cp\u003eProvided that age-appropriate protocols and structural conditions are in place, MRI imaging should always be considered in stable patients, and especially for follow-up diagnostics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy limitations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite this study\u0026rsquo;s large patient population, there are some limitations that should be noted and mentioned.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirstly, the group of children who underwent MRI imaging is significantly smaller than the group of children who underwent CT imaging, which creates limitations with regard to the significance of our results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, experience has shown that the data quality is lower and the documented parameters in registries are less complete compared to prospective clinical studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA further relevant limitation is the fact that the TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e can only show that MRI imaging has been performed, but currently no dedicated differentiation is possible with regard to the body region examined (in particular cranial MRI). It can only be assumed that the primary MRI imaging is a cranial imaging based on the defined inclusion criteria (shock room/severity of injury), in combination with the analyzed predictors and considering the results, particularly with regard to the proportion of relevant head injuries after CT/MRI imaging has been performed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe registry data also is not capable of showing if (after initial CT imaging in the emergency room) an additional MRI imaging was performed in the further (inpatient) course.\u003c/p\u003e\n\u003cp\u003eNevertheless, we identified an encouraging tendency among the initial diagnostics now being carried out in emergency rooms especially in view of the severity and location of the injury. The last few years also seem to indicate a trend towards low-radiation diagnostics in children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003cp\u003eEthical approval was not applicable. Informed consent to participate was obtained from all of the participants in the study respectively in the TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors have no conflicts of interests to disclose.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo funding was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWriting - original draft: JS; Data acquisition: RL; Writing \u0026ndash; review \u0026amp; editing: KMP and HS; Supervision: PS and IS; All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe appreciate the support of the DGU in conducting this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used in this study were provided by the TraumaRegister DGU\u0026reg; of the German Trauma Society (Deutsche Gesellschaft f\u0026uuml;r Unfallchirurgie, DGU).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHeim C, Schoettker P, Spahn DR. 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[Clinical evaluation of evidence-based criteria for CT diagnostics in the treatment of mild traumatic brain injury]. Z Orthop Unfall. 2008;146(5):595-601.\u003c/li\u003e\n\u003cli\u003eCohen AR, Caruso P, Duhaime AC, Klig JE. Feasibility of \u0026quot;rapid\u0026quot; magnetic resonance imaging in pediatric acute head injury. Am J Emerg Med. 2015;33(7):887-90.\u003c/li\u003e\n\u003cli\u003ePearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de Gonzalez A. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499-505.\u003c/li\u003e\n\u003cli\u003eBurstein B, Saint-Martin C. The Feasibility of Fast MRI to Reduce CT Radiation Exposure With Acute Traumatic Head Injuries. Pediatrics. 2019;144(4).\u003c/li\u003e\n\u003cli\u003eSheridan DC, Newgard CD, Selden NR, Jafri MA, Hansen ML. 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J Neurosurg. 2015;123(6):1463-75.\u003c/li\u003e\n\u003cli\u003eRomanova AL, Nemeth AJ, Berman MD, Guth JC, Liotta EM, Naidech AM, Maas MB. Magnetic resonance imaging versus computed tomography for identification and quantification of intraventricular hemorrhage. J Stroke Cerebrovasc Dis. 2014;23(8):2036-40.\u003c/li\u003e\n\u003cli\u003eYoung JY, Duhaime AC, Caruso PA, Rincon SP. Comparison of non-sedated brain MRI and CT for the detection of acute traumatic injury in children 6 years of age or less. Emerg Radiol. 2016;23(4):325-31.\u003c/li\u003e\n\u003cli\u003eAshwal S, Holshouser BA, Tong KA. Use of advanced neuroimaging techniques in the evaluation of pediatric traumatic brain injury. Dev Neurosci. 2006;28(4-5):309-26.\u003c/li\u003e\n\u003cli\u003eSchaefer PW, Huisman TA, Sorensen AG, Gonzalez RG, Schwamm LH. Diffusion-weighted MR imaging in closed head injury: high correlation with initial glasgow coma scale score and score on modified Rankin scale at discharge. Radiology. 2004;233(1):58-66.\u003c/li\u003e\n\u003cli\u003eRoguski M, Morel B, Sweeney M, Talan J, Rideout L, Riesenburger RI, Madan N, Hwang S. Magnetic resonance imaging as an alternative to computed tomography in select patients with traumatic brain injury: a retrospective comparison. J Neurosurg Pediatr. 2015;15(5):529-34.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1:\u0026nbsp;Comparison of children with CT or MRI (plus maybe CT)\u003c/p\u003e\n\u003cp\u003eStatistical tests for CT versus MRI imaging: Fisher\u0026rsquo;s Exact test or chi-squared test for categorical data; Mann-Whitney U-test for metric data\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"597\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCT imaging\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN=4002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMRI imaging\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN=205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo CT/MRI imaging\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN=793\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e9.1 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e8.6 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e8.0 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eSex (m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e2531 (63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e128 (62.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.824\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e485 (61.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eRecent years (2019-22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e2109 (52.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e111 (54.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e370 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eInjury Severity Score (ISS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e17.5 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e15.1 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e12.7 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eISS \u0026ge; 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e2034 (50.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e82 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e201 (25.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003ePolytrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e532 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e12 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e38 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eLevel 1 hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e3273 (81.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e182 (88.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e626 (78.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eCause of accident\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; traffic\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; high fall\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; low fall\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2180 (54.5%)\u003cbr\u003e\u0026nbsp;765 (19.1%)\u003cbr\u003e\u0026nbsp;597 (14.9%)\u003cbr\u003e\u0026nbsp;460 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e87 (42.4%)\u003cbr\u003e\u0026nbsp;46 (22.4%)\u003cbr\u003e\u0026nbsp;50 (24.4%)\u003cbr\u003e\u0026nbsp;22 (10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e344 (43.4%)\u003cbr\u003e\u0026nbsp;74 (9.3%)\u003cbr\u003e\u0026nbsp;133 (16.8%)\u003cbr\u003e\u0026nbsp;242 (30.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003ePrehospital intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e1050 (26.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e29 (14.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e90 (11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eAdmission during the night (18-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e1633 (40.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e66 (32.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e290 (36.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eAdmission on weekends (Fr-Su)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e1819 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e96 (46.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e343 (43.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eRelevant injuries (AIS 3+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;head\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e1903 (47.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e99 (48.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.886\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e96 (12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;thorax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e916 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e41 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e86 (10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;abdomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e457 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e15 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e89 (11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;extremities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e802 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e15 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e244 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eSuspected head injury (prehospital)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e2247 (56.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e103 (50.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e182 (23.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eIsolated head injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e809 (20.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e58 (28.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e50 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eCervical spine injured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e253 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e36 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e33 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eCranial CT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e3913 (97.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e77 (37.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eSonography\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e3216 (80.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e188 (91.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e605 (76.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eX-ray*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e1070 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e51 (24.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.627\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e307 (38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eIntensive care treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e3583 (89.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e189 (92.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e574 (72.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eDied within 6 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e68 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.079\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e53 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7114%;\"\u003e\n \u003cp\u003eDied in hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e244 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e3 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4094%;\"\u003e\n \u003cp\u003e.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9597%;\"\u003e\n \u003cp\u003e61 (7.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;* x-ray of thorax, pelvis, or spinal cord (x-ray of extremities is not documented)\u003c/p\u003e\n\u003cp\u003eTable 2: \u0026nbsp;Results of logistic regression analysis with MRT as dependent variable. All 4207 children with CT and/or MRT diagnostic were included; Nagelkerke\u0026rsquo;s R\u0026sup2; was 0.055\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI for OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eLevel 1 hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eLevel 2/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e1.30 \u0026ndash; 3.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eAge \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 6 - 10 years\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;11 - 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003e0-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e1.10\u003cbr\u003e\u0026nbsp;0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.76 \u0026ndash; 1.61\u003cbr\u003e\u0026nbsp;0.66 \u0026ndash; 1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.610\u003cbr\u003e\u0026nbsp;.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eRecent years (2019-22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003e2015-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.78 \u0026ndash; 1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eISS \u0026gt;= 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003e\u0026lt;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.55 \u0026ndash; 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.077\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003ePolytrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.36 \u0026ndash; 1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eCervical spine injured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e3.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e2.45 \u0026ndash; 5.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eIsolated head injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e1.14 \u0026ndash; 2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003ePrehospital intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.35 \u0026ndash; 0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eAdmission during night\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.50 \u0026ndash; 0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eAdmission on weekend\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eweekday\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.82 \u0026ndash; 1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2914%;\"\u003e\n \u003cp\u003eSuspected head injury*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0596%;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5232%;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e0.62 \u0026ndash; 1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7616%;\"\u003e\n \u003cp\u003e.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* suspected if GCS \u0026le;13, or relevant head injury assumed by emergency physician\u003c/p\u003e\n\u003cp\u003eTable 3 \u0026ndash; time of intubation in relation to ISS\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.3113%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1656%;\"\u003e\n \u003cp\u003enumber of patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5099%;\"\u003e\n \u003cp\u003eMean ISS (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0132%;\"\u003e\n \u003cp\u003eMRI performed\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.3113%;\"\u003e\n \u003cp\u003eNot intubated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1656%;\"\u003e\n \u003cp\u003e3277 (65.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5099%;\"\u003e\n \u003cp\u003e12.6 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0132%;\"\u003e\n \u003cp\u003e151 (4,6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.3113%;\"\u003e\n \u003cp\u003ePrehospital intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1656%;\"\u003e\n \u003cp\u003e1192 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5099%;\"\u003e\n \u003cp\u003e26.3 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0132%;\"\u003e\n \u003cp\u003e29 (2,4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.3113%;\"\u003e\n \u003cp\u003eIntubation in the ER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1656%;\"\u003e\n \u003cp\u003e531 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5099%;\"\u003e\n \u003cp\u003e20.0 (11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0132%;\"\u003e\n \u003cp\u003e25 (4,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7918533/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7918533/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough head injuries are one of the most common causes of emergency room admissions in childhood and adolescence, severe traumatic brain injuries are rare. For acute diagnosis in the emergency department, (cranial) computed tomography (CT or cCT) is the gold standard, but magnetic resonance imaging (MRI) has become an increasingly valid alternative recently due to optimized protocols. This also applies to the recommendations in the current guidelines. The aim of this study was to use the national database of the TraumaRegister DGU\u003csup\u003e®\u003c/sup\u003e to determine the current status of MRI diagnostics for pediatric traumatic brain injury (TBI) in European trauma centers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe TraumaRegister DGU\u003csup\u003e®\u003c/sup\u003e (TR-DGU) data sets were analyzed from 2015 to 2022. All children up to the age of 15 with a relevant injury (AIS 2+) and primary admission to a European trauma center who were registered in the TraumaRegister DGU\u003csup\u003e®\u003c/sup\u003e between 2015 and 2022 were included. In a further step, relevant predictors were determined by multivariate analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 5000 children were included, 205 MRI images (4.1%) and 4002 CT images (79.8%) were documented. MRI diagnosis was performed more frequently in the 0-to-1-year age group (5.2%) than in the 14-to-17-year age group (3.5%).\u003c/p\u003e\n\u003cp\u003eIn conjunction with initial CT imaging, the median total time in the emergency room was 59 min, with a median time to CT of 19 min.\u003c/p\u003e\n\u003cp\u003eWhen carrying out MRI imaging, the average total time in the emergency room was 85 min, with a median time to MRI of 49 min.\u003c/p\u003e\n\u003cp\u003eOf the prehospital-intubated children (mean ISS 26.3), 91.6% had a CT scan in the acute diagnostic phase and 2.4% an MRI scan.\u003c/p\u003e\n\u003cp\u003eThe strongest positive predictor for MRI imaging was a concomitant cervical spine injury (OR=3.63, p\u0026lt;0.001) and the strongest negative predictor was prehospital intubation (OR = 0.54, p=0.007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCT imaging remains the gold standard in national comparison especially for severely injured children, partly due to its faster and wider availability after the patient arrives in the emergency room. However, in addition to radiation hygiene, the superior assessibility of the cervical spine in case of concomitant (ligamentous/soft tissue) injuries also speaks in favor of MRI imaging, particularly in young patients. If the necessary structural procedures and accessibility are at hand and when the patient's condition permits, MRI diagnostics should be considered as an alternative to CT imaging for childhood head injuries. The two procedures are nearly equivalent in terms of sensitivity.\u003c/p\u003e","manuscriptTitle":"Is MRI imaging an alternative to computed tomography for head injuries in children and adolescents in acute situations? An analysis of the TraumaRegister DGU ®","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-18 16:52:25","doi":"10.21203/rs.3.rs-7918533/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8063c1b5-a719-4d27-9f84-cf3983602bf0","owner":[],"postedDate":"November 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-06T07:57:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-18 16:52:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7918533","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7918533","identity":"rs-7918533","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}