Common Data Elements for Neuroimaging
of Traumatic Brain Injury: Pediatric Considerations
Ann-Christine Duhaime,1Barbara Holshouser,2Jill V. Hunter,3and Karen Tong4
As part of the Traumatic Brain Injury Common Data Elements project, a large-scale effort to define common data
elements across a variety of domains, including neuroimaging, special considerations for pediatric patients were
introduced. This article is an extension of that initial work, in which pediatric-specific pathoanatomical entities,
technical considerations, interpretation paradigms, and safety considerationswerereviewed.Thegoal of this review
was to outline differences and specific information relevant to optimal performance and proper interpretation of
neuroimaging in pediatricpatientswithtraumatic brain injury.The long-range goalof this projectis tofacilitate data
sharing as well as to provide critical infrastructure for potential clinical trials in this major public health area.
Key words: CT; common data elements; MRI; pediatrics; traumatic brain injury
Overview and Rationale
project was designed to standardize data collection and
facilitate data sharing across a wide range of patient and injury
variables and at varying intervals after injury (Thurmond et al.,
2010). This large-scale initiative provided recommendations for
common data elements (CDE) for traumatic brain injury (TBI)
phase of the initiative, recommendations for TBI neuroimaging
CDE were formulated by a by a multidisciplinary panel of ex-
perts through an iterative process of scientific review. In the
second phase of the initiative, a multidisciplinary review of
those CDE was conducted with a focus on identification of
elements that are appropriate to the pediatric population. The
pediatric neuroimaging work group included professionals
with expertise in basic imaging research and physics, clinical
neuroradiology, and neurosurgery. Further information re-
garding the background of the TBI CDE initiative and the
methods used by all workgroups to arrive at CDE recommen-
dations is detailed by Hicks and associates (Hicks et al., 2011).
To optimally characterize neuroimaging elements for chil-
dren, age-dependent features must be considered across a
number of realms within neurotrauma. These include differ-
ences in injury mechanisms and injury types typical for each
age; specific technical considerations based on differences
in size, physiology, and other relevant parameters; age-
dependent differences in image characteristics of normal
he Traumatic Brain Injury Common Data Elements
children, which must be understood for accurate interpreta-
tion of images in the setting of trauma; and age-specific im-
pediatric neuroimaging CDE need to include appropriate
diagnostic entities, imaging protocols, and interpretation
schemes for infants and children of different ages.
In the recently published article on Common Data Ele-
ments for Neuroimaging, and posted on the NIH/NINDS
Common Data Elements web site, two sets of elements are
provided as Appendices (Duhaime et al., 2010). (http:/ /www
.commondataelements.ninds.nih.gov/TBI.aspx). The first
(Appendix I) is a list of the pathoanatomical entities present
in patients withTBI, from the acute stage to the more chronic
stage, with standardized operational definitions based on
objective findings and descriptions. The second cluster of el-
ements (Appendix II) involves technical parameters for ac-
quiring standard images, using CT and MRI. Although care
was taken to include basic pediatric entities within those el-
ements, in this article we provide an overview of the various
additional considerations for CDE and optimal implementa-
tion in neuroimaging of TBI in the pediatric population.
Pediatric Traumatic Pathoantomical Entities
Children may incur injury from different mechanisms than
adults, including non-accidental trauma in infancy, crush in-
juries from static loading in toddlers and young children
(most often being run over by vehicles, or pulling heavy
1Pediatric Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts.
2Department of Radiology, Loma Linda University School of Medicine, Loma Linda, California.
3Department of Neuroradiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas.
4Loma Linda University Medical Center, Loma Linda, California.
JOURNAL OF NEUROTRAUMA 29:629–633 (March 1, 2012)
ª Mary Ann Liebert, Inc.
objects onto the head), and various age-related sports and
recreational injuries. In addition, because the pediatric skull is
more malleable, and the mechanical properties of the head,
neck, and other anatomic structures differ from those of
adults, the resultant injuries from a given scenario reflect the
unique interplay of the mechanism and the host response. For
example, infants and toddlers may sustain so-called ‘‘ping
impact but not fractured through both bony tables. Similarly,
brain lacerations may occur underlying a linear skull fracture
line, even if the fracture edges are not significantly displaced
on imaging, because the malleable bone deforms transiently
and then returns to its prior form. Finally, differences in ce-
rebral physiology, such as higher cerebral blood flow, ongo-
ing rapid growth, and changes in myelination all may affect
the brain’s response to injury and how it evolves and appears
on imaging. All of these differences may result in pathoana-
tomical entities that are unique or at least more common in
children than in adults.
When creating a list of the various pathoanatomical en-
tities associated with TBI, the authors of the recently posted
appendices to the article cited previously
ments that commonly occur in pediatric patients. These
radiologic data elements are described and defined opera-
tionally so that a researcher entering data should be able to
find the relevant neuroimaging findings seen in children of
all ages on conventional CT or MRI. Patterns of acute
subdural hematoma with associated hemispheric hypo-
density, as occur most commonly in infants and toddlers,
were included, as were indeterminate and mixed extra-ax-
ial collections, diastatic skull fractures, and ping-pong
fractures. Enlarged extra-axial cerebrospinal fluid (CSF)
spaces, the need for head circumference percentiles in in-
terpreting images, and age-dependent differences in normal
cisternal appearance were discussed. Injuries to the cervi-
comedullary junction, which may occur from distracting
forces in vehicular crush injuries in preschool-aged chil-
dren, were described.
With respect to using CDE for studies involving patients
in the more chronic stages of recovery, researchers may need
to take into account a potentially different and more pro-
longed time course of these processes in children compared
to adults (Alberico et al., 1987; Filley et al., 1987; Kriel
et al., 1988; Luerssen et al., 1988; Mahoney et al., 1983).
Therefore, the timing of both follow-up imaging and func-
tional outcome measures might need to take these differ-
ences into account.
Different Technical Considerations
the Pediatric Neuroimaging working group recommends that
the previously published list of general pathoanatomical en-
tities be used, as these were specifically designed to include
entities encountered throughout the entire age spectrum. In
contrast, with respect to pediatric considerations in imaging
acquisition, separate protocols specific to children of different
ages are appropriate for CT and MRI.
For CT, radiation dose is of particular importance in the
pediatric population, as mentioned in the subsequent Safety
and Procedural Considerations section. Dose reductions for
head CT examinations can be achieved by age-specific or
weight-specific guidelines. The Alliance for Radiation Safety
in Pediatric Imaging has sponsored the ‘‘Image Gently’’
campaign, which has a web site that provides general infor-
mation about how to lower radiation dose when imaging
children (www.imagegently.org). Calculating accurate radi-
ation doses usually requires the skills of a radiation physicist,
who can work with theradiologists and technologists totailor
imaging parameters to the age or size of the child. CT scanner
manufacturers (of which there are several) have developed
automated dose-modulation techniques to assist in the se-
lection of appropriate parameters. These can be used to dy-
namically control the tube current (mA) during scanning,
on the scanogram. Unfortunately, the modulation tech-
nique and settings used differ considerably among vendors
(Nievelstein et al., 2010), such as Smart Scan (GE Healthcare,
Waukesha, WI), Dose Right (Phillips Medical Systems,
Cleveland, OH), CARE Dose 4D (Siemens Medical Solutions,
Forchheim, Germany), and Sure Exposure (Toshiba Medical
Systems, Otawara-Chi, Japan).
As a guideline, we have included in Appendix II (technical
parameter information) of the CDE web site examples of
pediatric head CT imaging protocols, which are categorized
by age (http:/ /www.commondataelements.ninds.nih.gov/
TBI.aspx). The tube voltage (kVp) and tube current (mA) are
lower in the younger/smaller patients and gradually increase
with age/size. If iodinated contrast is required for CT angi-
ography or CT perfusion, the doses are calculated by weight,
which is the same as for adults. However, the injection rate is
slower, to account for smaller veins (and resulting smaller
intravenous cannulas). In addition, the delay between injec-
tion and scanning is shorter, to account for faster circulation
times in children.
With respect to MRI in the pediatric population, there is no
risk of radiation, and the protocols generally do not have to
change, unless there is a need to shorten the scan time. Most
current conventional MRI sequences already incorporate
methods for shortening the time needed for MRI data acqui-
sition, such as ‘‘fast’’ or ‘‘turbo’’ techniques. Advanced se-
quences, such as diffusion-weighted imaging, also use ultra-
fast methods such as echo-planar imaging (EPI). However, in
an unsedated or poorly sedated patient, MRI parameters can
be significantly modified to reduce scan time. Rapid MR se-
quences that have been developed in fetal imaging of the
brain and spine can be used in these situations (Glenn and
Barkovich, 2006). Some MRI sequences are specifically de-
signed to be rapid, sacrificing some degree of resolution, such
as the half-Fourier single-shot turbo spin-echo (HASTE)
technique. This is a very rapid T2-weighted sequence that can
be used in children to replace a conventional T2-weighted
sequence (Penzkofer et al., 2002).
Certain MR sequences, such as diffusion-weighted or ten-
sor imaging, may need to be adjusted to account for higher
water content in the less myelinated, developing/maturing
brain (Miller et al., 2003; Mukherjee and McKinstry, 2006;
Mukherjee et al.,2001, 2002). For example, diffusion weighted
imaging in infants <1 year of age may be best with a maxi-
mum b value of 800sec/mm2. In addition, analysis of diffu-
sion parameters or brain metabolites in MR spectroscopy
requires knowledge of age-related changes as the pediatric
brain develops (Girard et al., 2007; Schneider et al., 2004).
Examples of imaging protocols that are specific for children of
630DUHAIME ET AL.
different ages can be found on the CDE website at (http:/ /
Interpretation of Pediatric MRI
‘‘children are not little adults’’ holds true for imaging. Because
of rapid changes in brain anatomy and physiology, age-
matched normative data are necessary for accurate interpre-
tation of MRI for any diagnostic category. To this end, the
National Institutes of Health (NIH) has sponsored a project to
collect and provide data on age-related normative changes on
MRI (https:/ /nihpd.crbs.ucsd.edu/nihpd/info/index.htm).
Several specific instances of brain maturational differences
are relevant to MRI findings in trauma. In infants <1 year of
age there is a very wide range of normal extra-axial CSF space
should not be ascribed to atrophy unless there is proof posi-
tive of brain volume loss on serial imaging, or a positive his-
tory of known causes of atrophy such as congenital HIV or a
definitive history of prior head trauma. Serial measurements
of head circumference, as a surrogate for brain growth, can be
extremely helpful in confirming or refuting the presence of
volume loss. The presence of macro- or microcephaly is a
valuable piece of information as it will guide the neuroradi-
ologist toward two very different diagnostic pathways.
Because of the lack of myelination of the cerebrum, even in a
full-term neonate, certain T2-weighted sequences such as fluid-
attenuated inversion recovery (FLAIR) may be less helpful in
the newborn period; therefore, a balanced or proton density
sequence may be better able to detect white matter abnormali-
white matter injury in a young infant, and because of the small
head size, three-dimensional (3D) imaging may be beneficial in
improving the visuospatial resolution in the neonate. Greater
care may need to taken in the interpretation of diffusion–
weighted imaging (DWI) in the newborn, as there have been
reports of restricted diffusion changes, resulting from an is-
newborns. Normal myelination, in the corticospinal tracts for
example, may show as T2 bright signal change with ‘‘shine-
through’’ on DWI and, as in older children and adults, it be-
comes important to correlate with the apparent diffusion coef-
ficient (ADC) maps (see Appendix II for a list of abbreviations,
definitions, and moredetail on these varioussequences, http:/ /
MR spectroscopy demonstrates a different pattern of metab-
olites in early infancy compared to the adult brain. Whereas
creatine tends to be fairly stable, the N-acetyl aspartate (NAA)
peak in normal infants starts lower than that of choline but rises
rapidly with myelination during the first 6 months of life,
whereas the choline peak demonstrates a relative diminution in
the first 24h after delivery, but the presence of a measurable
lactate peak after the first day of life is abnormal and other eti-
ologies such as hypoxic-ischemic injury should be sought.
Hemorrhage in the newborn period maybe related to the
trauma of a normal birthing process if subdural blood is re-
stricted to the posterior fossa. This typically resolves by 1
month of life. In a similar fashion the presence of fluid within
the mastoid air cells and middle ear clefts may be a normal
finding up to 1 month of life but should be cleared thereafter.
age-matched normative data are necessary for accurate in-
terpretation of MRI. To this end, the NIH has sponsored a
project to collect and provide data on age-related normative
changes on MRI (https:/ /nihpd.crbs.ucsd.edu/nihpd/info/
Safety and Procedural Considerations
Although safety is a consideration with all patients under-
going CT and MR imaging examinations, special consider-
ations must be made when pediatric patients are going to be
the emergency department will often involve radiation expo-
sure including CT and plain radiographs. CT provides the
accounting for * 67% of radiation exposure in only 11% of the
of particular importance in the pediatric population, because
children’s maturing organ systems are more radiosensitive
than those of an adult; therefore, the potential for expression of
radiation-induced biological effects later in life is a primary
concern (Brenner and Hall, 2007). Asa result, reduction in dose
while maintaining diagnostic image quality is an increased
(Goske et al.,2010;Strausset al.,2010),theAmericanCollegeof
Radiology (ACR), the American Association of Physicists in
Medicine as well as CT manufacturers (Strauss et al., 2009).
Major reductions in dose can be achieved by tailoring the ex-
demand and government regulations have developed proto-
cols, and will provide information for pediatric dose reduction
appropriate for their scanners. In children, the possibility of
motion during the study must also be considered, as the radi-
Adequate immobilization and/or sedation are also consider-
ations before exposing a child to ionizing radiation. Sedation
providers must comply with protocols established by the in-
dividual state and institution with adherence to standards of
care mandates following the sedation guidelines developed by
organizations such as the American Academy of Pediatrics
With the increased use of higher field MR scanners, there is
also increased risk for all patients, healthcare professionals
working with the patients, and family members accompany-
cooperation of the parents or guardians if possible. Metal
detectors can be used to screen toys or stuffed animals that
children may want to take into the scanner. A recent featured
article from the Radiologic Society of North America (RSNA)
states that the 2008 Food and Drug Administration (FDA)
accident report data show a 310% increase in MRI-related
accidents since 2004 ( Radiologic Society of North America,
2010). Most accidents are a result of ‘‘projectile’’ injuries in
which ferromagnetic objects are strongly attracted to the
magnetic field and consequently accelerated toward the bore
of the magnet at a high speed, putting the patient, or anyone
standing near the bore of the magnet, at risk for being hit by
the resulting ‘‘missile’’. Burn injuries to patients are also
common, and result from conductive materials such as cables
NEUROIMAGING OF PEDIATRIC TBI631
or electrodes on radiofrequency coils, and physiological
monitoring equipment that can heat up during gradient
pulsing. MR-contraindicted implantable devices. such as
stimulators, although not as common in pediatric patients,
must be screened for in personnel or family members who
enter the MR suite. Vagus nerve stimulators require special
considerations as well, as transmit-receive coils are required,
the manufacturer. Cochlear implants historically have not
been considered MR compatible, but MR-compatible cochlear
implant devices are under development. Deep brain stimu-
lators are technically considered MRI incompatible, but some
experience has accrued in some centers with MRI at 1.5T for
the electrodes only, before they are attached to the generator;
for specifications, the manufacturer of the individual devices
should be contacted for guidance. Another commonly used
implantable device in children is the programmable shunt,
which may be unintentionally changed by the magnetic field
leading to over- or under-drainage of CSF. For these children,
a trained programmer or clinician must be available to verify
the correct setting, and reprogram the device if necessary
following an MR scan at any field strength. A resource that
can be used to aid MR personnel in determining whether
implants or devices are safe for MR imaging is the web site
(MRIsafety.com). In addition, many manufactures have MR
safety information posted online or will email or fax infor-
mation regarding the MR compatibility of their devices if
contacted. Toll- free numbers are usually available online. For
help in establishing a safety program for MR departments, an
American College of Radiology committee has published
useful guidelines for safe MR practices (Kanal et al., 2007). In
addition, a web site is available with MR safety information at
Sedation for the pediatric patient is more common for MRI
than for CT, because of the longer imaging times. Earplugs or
headphones to decrease acoustic noise should be used on all
pediatric patients even if sedated. For neonates and younger
equipment is available to prevent hypo- or hyperthermia
while in the MR scanner (Bryan et al., 2006). For toddlers and
older children, many hospitals have an MR safe system to
allow children to watch videos while being scanned. This is
appropriate depending upon the child’s age, ability to coop-
erate, and level of injury. Otherwise, sedation with appro-
priate monitoring using only MR-safe equipment is necessary
to obtain images without motion artifacts. Several manufac-
turers make FDA-approved, MR-safe, patient monitoring
equipment, anesthesia equipment, and ventilators. Care must
be taken to avoid taking non-MR safe equipment, including
smaller items such as scissors, stethoscopes, or clipboards,
into the magnet suite to avoid injury to the patient caused by
burns or projectiles. MR safety training for non-MR hospital
personnel such as nurses, respiratory therapists, or anesthesia
personnel working in the MR suite to monitor patients should
be mandatory. Posted signs, warnings, and metal detectors
should not be a substitute for MR safety education.
Neuroimaging for children with TBI can be performed
and interpreted optimally when attention is given to age-
dependent differences in injury type, use of appropriate im-
aging parameters, proper age-dependent interpretation, and
safety precautions. These considerations are necessary to
insure appropriate inclusion of patients of all ages in CDE
efforts, and should lead to improved data collection and re-
search in pediatric TBI. It is clear that as with all technologic
advances in medicine, changes will occur rapidly. Further
considerations regarding emerging technologies and pediat-
ric applications are provided by Hunter et al. (in press).
We gratefully acknowledge the valuable contributions of
Ramona Hicks for providing the impetus as well as the
organization and format for this project and for assistance
with manuscript preparation. This project was jointly sup-
ported by the National Institutes of Health (National In-
stitute of Neurological Disorders and Stroke; NIH/NINDS)
and the United States Department of Education/National
Institute on Disability and Rehabilitation Research (DOE/
Views expressed are those of the authors and do not
necessarily reflect those of the agencies or institutions with
which they are affiliated, including the United States De-
partment of Veterans Affairs, the United States Department
of Education, and the National Institutes of Health. This
work is not an official document, guidance, or policy of the
United States government, nor should any official endorse-
ment be inferred.
Author Disclosure Statement
No competing financial interests exist.
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Address orrespondence to:
Ann-Christine Duhaime, M.D.
Massachusetts General Hospital
15 Parkman Street, Wang 331
Boston, MA 02114
NEUROIMAGING OF PEDIATRIC TBI633