Incidental Intracranial Findings in Pediatric Brain Magnetic Resonance Imaging: Prevalence, Radiological Spectrum, and Evidence-Based Management in a Neurology Referral Cohort

A bstract Background: Incidental intracranial findings (IIFs) are frequently detected on pediatric brain magnetic resonance imaging (MRI), particularly with the increasing use of neuroimaging for common neurological complaints. While many of these findings represent benign developmental variants, a subset may carry clinical significance, leading to variability in reporting, follow-up, and management. Objectives: This study aimed to determine the prevalence, radiological spectrum, and clinical relevance of IIFs in children undergoing brain MRI for neurological indications, and to inform evidence-based management strategies. Materials and Methods: This retrospective cross-sectional study included 350 children (0–18 years) who underwent brain MRI at a tertiary pediatric neurology center between January 2019 and December 2023. MRIs performed for nonacute neurological indications were reviewed using a standardized pediatric imaging protocol. IIFs were defined as previously unknown abnormalities unrelated to the presenting complaint and were categorized based on predefined radiological criteria. Prevalence estimates were calculated with 95% confidence intervals, and findings were stratified by clinical significance and follow-up requirements. Results: IIFs were identified in 70 out of 350 children, yielding an overall prevalence of 20.0%. Clinically insignificant findings accounted for 12.9% of the cohort, whereas clinically significant findings were observed in 7.1%. The most common lesions included arachnoid cysts (21.4%), pineal cysts (14.3%), nonspecific white matter hyperintensities (11.4%), and Chiari I malformation (7.1%). No follow-up was required in 40.0% of cases, routine surveillance in 24.3%, specialist referral in 28.6%, and surgical intervention in 7.1%. Conclusions: IIFs are more common in pediatric brain MRI, yet the majority are benign and do not necessitate intervention. Standardized classification, risk-stratified follow-up, and clear counseling frameworks are crucial for reducing unnecessary investigations while ensuring the timely identification of clinically relevant abnormalities.”