Accuracy, Timing, and Clinical Utility of Early Neuroimaging and Decision Rules in Pediatric Traumatic Brain Injury: A Systematic Review

Background Pediatric traumatic brain injury (TBI) is a major cause of morbidity and mortality. Early neuroimaging—particularly computed tomography (CT)—enables timely detection of life-threatening intracranial injuries, but overuse may expose children to unnecessary radiation. Clinical decision rules (CDRs) such as PECARN, and newer modalities like rapid MRI, ultrasound, and near-infrared spectroscopy (NIRS), may refine decision-making. Methods This PRISMA-compliant systematic review included studies (2018–2024) evaluating early neuroimaging or CDRs in children < 18 years with acute TBI. Databases searched included PubMed, Embase, Scopus, and Web of Science. Outcomes included diagnostic accuracy for clinically important TBI (ciTBI), CT use, neurosurgical intervention, and missed injury. Risk of bias was assessed using QUADAS-2, RoB2, and ROBINS-I. Results Thirty studies involving > 25,000 children were included. PECARN showed near-perfect sensitivity (99–100%) for ciTBI in multiple validations [1–4]. CATCH and CHALICE had lower sensitivity but slightly higher specificity [5]. PECARN implementation led to 20–30% reductions in CT usage without missed injuries [6–7]. Rapid MRI demonstrated high sensitivity (~ 90–100%) for intracranial hemorrhage, with > 90% completion rates without sedation [8–10]. Skull ultrasound (POCUS) had pooled sensitivity of 91% and specificity of 96% for detecting fractures [11]. NIRS demonstrated high negative predictive value (> 98%) but only moderate sensitivity (58–81%) for hematomas > 3.5 mL [12–13]. Conclusion Validated CDRs—especially PECARN—enable safe reduction in CT use. Rapid MRI is a promising radiation-free alternative in stable patients. POCUS and NIRS are useful adjuncts but not replacements for CT. Integration of decision tools with imaging pathways can improve safety and efficiency in pediatric TBI care.