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Published on: April 13, 2013
Clinical significance of scalp abnormalities in asymptomatic head-injured infants
1Division of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. greens@a1.tch.harvard.edu
Insights
Asymptomatic head-injured infants with large or parietal scalp hematomas are at high risk for skull fracture (SF) and intracranial injury (ICI). A new clinical decision rule can identify most cases needing imaging, reducing unnecessary scans.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Radiology
Background:
- Head injuries in infants can lead to serious complications like skull fractures (SF) and intracranial injuries (ICI).
- Identifying high-risk infants who require imaging is crucial for timely diagnosis and treatment.
- Current guidelines may lead to over-imaging in asymptomatic infants.
Purpose of the Study:
- To identify clinical predictors of SF and ICI in asymptomatic head-injured infants.
- To develop a clinical decision rule for imaging selection in this population.
Main Methods:
- Prospective cohort study of 422 infants (0-24 months) with head injuries.
- Asymptomatic infants were defined as those without clinical signs of brain injury or specific skull fractures.
- Analysis of scalp hematoma size and location, and patient age for predicting SF and ICI.
Main Results:
- 11% of infants had SF, and 3% had ICI.
- Large and parietal scalp hematomas were strongly associated with SF and ICI.
- A clinical decision rule was developed, achieving 98% sensitivity for SF and detecting all ICI cases, while recommending imaging for only 35% of infants.
Conclusions:
- Scalp hematoma size and location are key predictors of SF and ICI in asymptomatic infants.
- A validated clinical decision rule can accurately identify infants needing head imaging, potentially reducing unnecessary procedures.
- Further validation of the proposed rule in diverse populations is recommended.
Objectives:
1) To identify clinical features indicating a high risk of skull fracture (SF) and associated intracranial injury (ICI) in asymptomatic head-injured infants. 2) To develop a clinical decision rule to determine which asymptomatic head-injured infants require head imaging.
Methods:
We performed a prospective cohort study of all asymptomatic head-injured infants 0-24 months of age presenting to the emergency department of an urban children's hospital. Infants were considered asymptomatic if they had no clinical signs of brain injury, or of basilar or depressed SF. Among subjects who had head imaging, we assessed the utility of age, scalp hematoma size, and scalp hematoma location for predicting SF and ICI.
Results:
Of 422 study patients, 45 (11 %) were diagnosed with SF and 13 (3%) with ICI. In the 172 subjects who had head imaging, there was a stepwise relationship between hematoma size and likelihood of SF. Parietal and temporal hematomas were highly associated with SF; frontal hematomas were not. There was a trend toward higher rates of SF in younger patients. Both large scalp hematoma and parietal hematoma were associated with ICI. Using these data, we developed a clinical decision rule to determine which asymptomatic infants need head imaging. In our study population, this rule has a sensitivity of 0.98 and specificity of 0.49 for SF, and it detects all 13 cases of ICI. The clinical rule calls for imaging in 146/422 (35%) study subjects.
Conclusions:
Among asymptomatic head-injured infants, the risk of SF and associated ICI is correlated with scalp hematoma size, hematoma location, and weakly with patient age. We propose a clinical decision rule that could identify most cases of SF and ICI while not requiring head imaging for most patients. This decision rule should be validated in other study populations.
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