Correspondence

Incidental Findings on Brain Imaging in the General Pediatric Population

To the Editor:

Table 1. Table 1. Incidental Findings in the Generation R Study Population (3966 Children).

Incidentally discovered findings on brain magnetic resonance imaging (MRI) in healthy persons pose medical and ethical considerations regarding management.1 The prevalence of incidental findings on brain MRI has been described in adult populations,2 but less is known about incidental findings in children. We report the prevalence of incidental findings on brain MRI in a large, single-center neuroimaging study involving a general pediatric population. From April 2013 through November 2015, a total of 3966 children (mean age, 10.1 years; range, 8.6 to 11.9) in the population-based Generation R Study3 — designed to prospectively identify early environmental and genetic influences on normal and abnormal growth, development, and health during fetal life, childhood, and young adulthood — underwent MRI scanning of the brain on a single 3-Tesla scanner. Scans were systematically reviewed by trained researchers and neuroradiologists for the presence of incidental findings (Table 1).

At least one incidental finding was present in 25.6% of the children (95% confidence interval [CI], 24.2 to 27.0), although the prevalence of findings requiring clinical follow-up was only 0.43% (95% CI, 0.26 to 0.70). The most common findings were cysts of the pineal gland (in 665 children; 16.8%; 95% CI, 15.6 to 18.0), arachnoid cysts (in 86; 2.17%; 95% CI, 1.75 to 2.68), and developmental venous anomalies (in 63; 1.59%; 95% CI, 0.12 to 2.04). Among less frequent findings were Chiari I malformations (in 25 children; 0.63%; 95% CI, 0.42 to 0.94), subependymal heterotopia (in 19; 0.48%; 95% CI, 0.30 to 0.76), and partial agenesis of the corpus callosum (in 2; 0.05%; 95% CI, 0.01 to 0.20). A total of 17 children (0.43%) were referred to a pediatric neurologist for clinical imaging and follow-up; 7 of these children (0.18%) had suspected primary brain tumors, of whom 2 underwent neurosurgical treatment, with the diagnoses confirmed by histopathological examination. The prevalence of asymptomatic brain tumors in our population-based cohort was higher than estimates from cancer registries, which have shown a prevalence in the United States of approximately 35 in 100,000 (0.04%) among persons younger than 20 years of age.4 However, no reliable statistics are available to estimate the frequency of asymptomatic brain tumors among children.5

Our results emphasize the need for careful evaluation of incidental findings on brain scans of asymptomatic children. In addition, it may be prudent to use standardized protocols for managing incidental findings in children, including reporting, disclosure to parents, and subsequent follow-up when necessary.

Philip R. Jansen, M.D.
Marjolein Dremmen, M.D.
Aaike van den Berg, M.D.
Erasmus University Medical Center, Rotterdam, the Netherlands

Ilona A. Dekkers, M.D.
Leiden University Medical Center, Leiden, the Netherlands

Laura M.E. Blanken, M.D., Ph.D.
Ryan L. Muetzel, Ph.D.
Koen Bolhuis, M.D.
Rosa M. Mulder, M.Sc.
Desana Kocevska, M.D.
Toyah A. Jansen, M.Sc.
Marie-Claire Y. de Wit, M.D., Ph.D.
Rinze F. Neuteboom, M.D., Ph.D.
Erasmus University Medical Center, Rotterdam, the Netherlands

Tinca J.C. Polderman, Ph.D.
VU University, Amsterdam, the Netherlands

Danielle Posthuma, Ph.D.
VU University Medical Center, Amsterdam, the Netherlands

Vincent W.V. Jaddoe, M.D., Ph.D.
Frank C. Verhulst, M.D., Ph.D.
Henning Tiemeier, M.D., Ph.D.
Aad van der Lugt, M.D., Ph.D.
Tonya J.H. White, M.D., Ph.D.
Erasmus University Medical Center, Rotterdam, the Netherlands

Supported by the Sophia Children’s Hospital Research Foundation (project S14-27) and the Netherlands Organization for Health Research and Development (TOP project 91211021).

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

  1. 1. Illes J, Kirschen MP, Edwards E, et al. Incidental findings in brain imaging research. Science 2006;311:783-784

  2. 2. Morris Z, Whiteley WN, Longstreth WT Jr, et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009;339:b3016-b3016

  3. 3. Jaddoe VW, van Duijn CM, van der Heijden AJ, et al. The Generation R Study: design and cohort update 2010. Eur J Epidemiol 2010;25:823-841

  4. 4. Porter KR, McCarthy BJ, Freels S, Kim Y, Davis FG. Prevalence estimates for primary brain tumors in the United States by age, gender, behavior, and histology. Neuro Oncol 2010;12:520-527

  5. 5. Maher CO, Piatt JH Jr, Section on Neurologic Surgery. . Incidental findings on brain and spine imaging in children. Pediatrics 2015;135:e1084-e1096

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