Can the addition of “Black Bone” sequence improve diagnosis of skull fractures after traumatic brain injury in children?

This study aimed to evaluate whether three-dimensional (3D) Black Bone imaging enhances diagnostic accuracy in detecting skull fractures in children with traumatic brain injury (TBI), using computed tomography (CT) as the reference standard. Data were collected between January 2022 and August 2024 from 50 pediatric TBI patients (27 boys, 23 girls; mean age: 4.76 ± 3.39 years) who underwent CT (gold standard) and conventional magnetic resonance imaging (MRI), with or without the Black Bone sequence, for fracture diagnosis. Patients were categorized by age (< 3 years, ≧3 years) and fracture type (linear, depressed, sutural disconnection, comminuted). The presence or absence of skull fracture was assessed using conventional MRI with and without Black Bone images. Conen’s kappa, McNemar’s test, area under curve (AUC), accuracy, sensitivity, negative predictive values (NPV) and positive predictive values (NPV) were employed to compare inter-reader agreement and fracture detection performance between image types. For all cases of skull fracture, conventional MRI with Black Bone images demonstrated an AUC of 0.947 (95% CI: 0.937–0.990) compared to 0.711 (95% CI: 0.650–0.766) for conventional MRI without Black Bone. In addition, conventional MRI with Black Bone images achieved a diagnostic accuracy of 76.0%, sensitivity of 94.7%, NPV of 85.7%, and agreement (ĸ) of 0.896, all higher than those obtained by conventional MRI without Black Bone. However, both imaging modalities showed lower accuracy, sensitivity, and agreement in detecting fractures among patients aged $$\:<$$ 3 years, as well as in cases of linear and sutural disconnection fractures, compared to patients aged $$\:\ge\:$$ 3 years and cases of depressed and comminuted fractures. Black Bone imaging could improve MRI detection of pediatric skull fractures in TBI, especially in children aged $$\:\ge\:$$ 3 years old.