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Are incidental brain MRI findings of concern in children?

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Incidental findings on brain magnetic resonance imaging (MRI) scans are seen in a significant minority of children, although most of these findings are benign and do not require immediate action, according to a study released online June 14 and to be published in the July issue of Pediatrics.

“Clinicians should be prepared to address these (incidental) findings,” senior investigator Dr. John J. Strouse from Johns Hopkins University School of Medicine in Baltimore wrote in an email to Reuters Health. “We do not know the best way to do this, but it may be useful to discuss the possibility before the child has the MRI.”

The most common reasons for brain MRI in children are seizures and headaches or as a prerequisite for entering a clinical trial.

Dr. Strouse and colleagues investigated the frequency and type of incidental intracranial abnormalities seen on brain MRI in 953 school-age children with sickle cell disease who underwent MRI as part of routine screening for enrollment in the Silent Infarct Transfusion Trial.

Two study neuroradiologists confirmed 68 incidental intracranial MRI findings (unrelated to sickle cell disease) in 63 of the 953 children (6.6%). The researchers excluded ischemic and vascular lesions because these were central to the major aims of the study that the children were enrolling in and therefore were not considered incidental.

No child had MRI findings that were considered to merit immediate attention (i.e., referral to an emergency department) and MRI findings requiring urgent referral were seen in only six children (0.6%). Two of them had Chiari I malformations with spinal cord syrinx and had surgery in the subsequent six months, and four had lesions suggestive of low-grade brain tumors.

MRI brain findings requiring routine referral were seen in 25 children (2.6%); these included spinal cord anomalies or a less serious subtype of Chiari malformation with minimal brain tissue protrusion into the spinal canal, cortical dysplasia, and various types of cysts.

Insignificant findings, most commonly cavum abnormalities not requiring any referral, were seen in 32 children (3.4%). Other insignificant abnormalities included gray matter heterotopia and cysts.

“Information from this study should assist neurologists and hematologists in the interpretation of incidental MRI findings for children with sickle cell disease and may be applicable to children in general,” the study team says.

Dr. Strouse reiterated that point. “These findings occur in both children with sickle cell disease and those having MRIs for other reasons,” he said.

“Helpful as it is, imaging technology can open a Pandora’s box, sometimes showing us things we didn’t expect and are not sure how to interpret,” lead investigator Dr. Lori Jordan, a pediatric neurologist at Hopkins Children’s, added in a university-issued statement.

The researchers hope the current data will help clinicians navigate relatively common clinical situations — for example, the child who undergoes brain MRI for uncomplicated headache and is found to have an MRI abnormality unrelated to the headache.

“Frequently, the child is then subjected to multiple ‘follow-up’ studies to confirm that the incidental MRI finding is indeed benign. It is hoped that studies such as this one will aid clinicians as they counsel families,” Dr. Strouse and colleagues write.

The investigators do recommend routine referral to a pediatric neurologist for findings that are of “uncertain significance.”

Pediatrics 2010;126:53-61.