Headache Assessment of Children for Emergent Intracranial Abnormalities

项目摘要 每年有400,000多名儿童随院长一起前往美国的急诊科 对头痛的抱怨。这些儿童中有一小部分(0.5%-1%)会有异常，但意义重大 脑部的需要紧急识别的，如肿瘤、出血或中风。然而，一个更大的 在急诊室接受大脑成像的儿童比例高达三分之一的头痛儿童 不必要地暴露在与神经成像相关的风险中。这些风险中最突出的是致命的 由计算机断层扫描(CT)的辐射引起的恶性肿瘤。过度使用的主要原因是 ED的神经影像表现是缺乏关于哪些临床特征或“危险信号”发现的清晰程度， 准确识别患有头痛的儿童，这些儿童有可能出现紧急脑异常。当前 危险信号的发现是从方法有限和/或数量较少的研究中发现的 患者；事实上，频繁使用的危险信号表现(例如，头痛将患者从睡眠中唤醒)是常见的 而且不是特定的，某些发现发生在多达30%-40%的头痛儿童中。长的- 我们研究的长期目标是广泛实施决策支持工具，帮助临床医生进行平衡 以及基于对儿童突发脑异常风险的准确估计做出的明智决定 头痛。目前这项研究的目标是产生明确的证据，使临床医生能够 确定在其他方面健康的儿童出现急诊脑部异常的风险 头痛。我们当前研究的主要目标是派生和内部验证决策工具，该工具 对患有头痛的儿童向急诊室就诊的风险进行分层。该模型将使用临床上合理的和 可靠的因素，以近乎完美的准确度识别出现脑部紧急异常风险接近零的儿童。 我们将通过进行一项前瞻性的多中心研究来实现这一目标，我们将招募28,000人 2至17岁的儿童头痛，在儿科急诊室的18个急诊室之一就诊 应用研究网络(PECARN)我们将前瞻性地收集一份全面的历史和 这些患者的体检结果，并使用复杂的统计建模分析得出 风险分层模型。我们的目标是推导出一种在接近零的情况下高度准确地识别患者的模型。 突发脑部异常的风险。提供一种决策工具，用于识别患有近零分的儿童 基于特定头痛特征的紧急脑异常的风险和更高风险将 从根本上改善患有急性头痛的儿童的管理方式。这些信息将有助于优化 紧急神经成像的使用，包括安全地减少儿童不必要的神经成像。

Project Summary More than 400,000 children present annually to emergency departments (EDs) in the U.S. with chief complaints of headaches. A small but meaningful proportion (0.5-1%) of these children will have abnormalities in the brain requiring emergent identification, such as tumors, bleeding, or strokes. However, a much larger proportion undergo neuroimaging of the brain in the ED, with up to one-third of children with headaches being unnecessarily exposed to the risks associated with neuroimaging. The most prominent of these risks is a lethal malignancy due to radiation from computed tomography (CT) scanning. The primary reason for the overuse of neuroimaging in the ED is the lack of clarity regarding which clinical characteristics, or “red flag” findings, accurately identify children with headaches who are at risk of having emergent brain abnormalities. Current red flag findings were discovered from studies that were limited in their methods and/or had small numbers of patients; in fact, frequently used red flag findings (e.g. headache waking the patient from sleep) are common and non-specific, with certain findings occurring in as many as 30-40% of children with headaches. The long- term goal of our research is to widely implement a decision support tool that will help clinicians make balanced and informed decisions based on precise estimates of the risk of emergent brain abnormalities in children with headaches. The goal of the current study is to generate the definitive evidence that will allow clinicians to identify the risks of emergent brain abnormalities in otherwise healthy children presenting to EDs with headaches. The primary aim of our current study is to derive and internally validate a decision tool that stratifies the risk for children presenting to EDs with headaches. This model will use clinically sensible and reliable factors to identify children at near-zero risk of emergent brain abnormalities with near perfect accuracy. We will accomplish this aim by conducting a prospective multicenter research study in which we enroll 28,000 children 2 to 17-years-old with headaches presenting to one of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We will prospectively collect a comprehensive list of history and physical examination findings for these patients and use sophisticated statistical modeling analyses to derive a model to stratify risk. We aim to derive a model which is highly accurate for identifying patients at near-zero risk of emergent brain abnormalities. The availability of a decision tool which identifies children with near-zero risk and higher risk of emergent brain abnormalities based on specific headache characteristics will fundamentally improve how children with acute headaches are managed. This information will help optimize the use of emergent neuroimaging, including the safe reduction of unnecessary neuroimaging in children.