Background <p>Pediatric traumatic brain injury (TBI) accounts for a significant proportion of emergency department (ED) visits, with an estimated global incidence of up to 200 cases per 100,000 children each year. Despite clinical guidelines, imaging is often overused, particularly in mild cases, exposing children to unnecessary radiation. In Latin America, evidence regarding the appropriateness of imaging requests (AIR) and their diagnostic value remains scarce.</p> Objective <p>To assess the association between the AIR and final radiologic findings in traumatic brain injury, and to explore predictors through multivariable analysis.</p> Methods <p>This retrospective, multicentric, cross-sectional study included 719 neuroimaging studies (CT and skull radiography -SR-) performed in 2023 at two high-complexity private hospitals in Santiago, Chile. AIR was classified using the ACR Appropriateness Criteria® and the PECARN algorithm. Confirmatory findings included hemorrhages, skull fractures, and other traumatic lesions. Exploratory multivariable models were applied to evaluate factors associated with final diagnosis.</p> Results <p>Only 2.9% of imaging requests were deemed appropriate. Among CTs (<i>n</i> = 317), the adjusted probability of a confirmatory result was 48.0% (95% CI: 26.3–69.8) for appropriate requests versus 7.0% (95% CI: 4.1–9.9) for inappropriate ones, an absolute difference of 41 percentage points (<i>p</i> &lt; 0.01). Inappropriate requests were associated with a 13-fold lower relative probability of identifying clinically relevant findings. All SRs were considered inappropriate and had a diagnostic yield of only 1%.</p> Conclusion <p>A significant gap exists between clinical practice and guideline-based imaging for pediatric TBI in Chile. Reinforcing validated decision tools may help optimize imaging use and minimize unnecessary radiation exposure.</p> Graphical Abstract <p></p>