Incidental Findings of Brain MRI in Children Generate Disclosure Predicaments for Physicians and Patients

Pediatricians whose patients undergo routine brain magnetic resonance imaging (MRI) scanning need a plan to deal with findings that commonly reveal unexpected-but-benign anomalies that are unlikely to cause any problem.

"Doctors need to figure out what, if anything, they want to share with patients about such findings because they seldom require urgent follow-up,” said senior investigator John Strouse, M.D., Ph.D., a hematologist at Johns Hopkins Children's Center (Baltimore, MD, USA). In a report published online June 14, 2010, in the journal Pediatrics, Dr. Strouse and team described the findings of what they believe is the largest study to date of the frequency and type of unexpected brain findings in children who get MRI tests for reasons unrelated to these benign anomalies.

The most typical reasons for MRI testing in children are seizures and headaches or as a prerequisite for enrolling in certain studies. The patients in the Hopkins study, all of whom had sickle cell disease and were predominantly African-American, had brain MRI scans before enrolling in a research study about their condition. The investigators stressed that none of the brain anomalies discovered in the study were related to the patients' underlying condition, meaning the findings may apply to healthy children in general.

Of the 953 children, ages 5 to 14, in the study, 63 (6.6%) had a total of 68 abnormal brain findings. None of the children required emergency treatment or follow-up, and only six children (0.6%) needed urgent follow-ups. The urgent findings involved changes suggestive of slow-growing tumors and a structural defect called Chiari malformation type 1, in which brain tissue extends into the spinal canal. None of the six children with urgent findings had any clinical symptoms suggestive of the anomalies.

Because findings such unexpected findings--particularly ones of unclear clinical importance--can lead to more, often unnecessary, tests and fear, the Hopkins study highlights the need for pediatricians to prepare for such discussions, according to Dr. Strouse. Moreover, in the absence of guidelines on how to deal with such findings, many pediatricians, Dr. Strouse added, feel so unprepared that they may forego the discussion altogether and simply refer the patient to a neurologist or a neurosurgeon for consultation. "Helpful as it is, imaging technology can open a Pandora's box, sometimes showing us things we didn't expect to see and are not sure how to interpret,” said lead investigator Lori Jordan, M.D., Ph.D., a pediatric neurologist at Hopkins Children's.

Twenty-five children (2.6%) required only routine follow-up for spinal cord anomalies or another, less serious subtype of Chiari malformation with minimal brain tissue protrusion into the spinal canal. Thirty-two children (3.4%) required no follow-up at all for a benign anatomical anomaly called cavum septum pellucidum, marked by the presence of a thin membrane separating the lateral ventricles of the brain, which along with Chari malformation were the most common anomalies in the study. Other abnormalities included brain cysts and cortical dysplasia, a disorder in which specific nerve cells form abnormally in the wrong part of the brain and can lead to seizures.

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