Prior Head Circumference Measurements in Infants With Older Subdural Hematomas: Did We Miss It?

To establish whether infants with macrocephaly and non-acute subdural hematomas (SDHs) had missed opportunities for measuring fronto-occipital circumference (FOC) and obtaining neuroimaging prior to diagnosis. Macrocephaly due to SDH in infancy is initially detected by FOC measurements and/or neuroimaging, as neurologic symptoms may be subtle or missed.

Retrospective chart review of infants with macrocephaly and non-acute SDHs referred to child abuse pediatricians for suspected abusive head trauma (AHT) over an 8-year period. A study sample of 35 infants met inclusion criteria and had complete prior medical records which were reviewed for missed opportunities for earlier SDH diagnosis. Four types of missed opportunities were identified: not initiating a workup for nonaccidental trauma (NAT) with a history or exam finding of a sentinel injury, not obtaining FOC when presenting with nonspecific neurologic symptoms, no neuroimaging for macrocephalic infants, and incomplete or delayed workup for macrocephaly.

Most (91%) infants had missed opportunities for earlier diagnosis of macrocephaly and/or SDH. The most common missed opportunity was no neuroimaging when macrocephalic (N = 28; 54%). Other missed opportunities included not obtaining FOC on a symptomatic infant (N = 10), macrocephaly with incomplete or delayed workup (N = 9), and no NAT workup with a sentinel injury (N = 5). Most of these 35 infants (77%) were diagnosed with concerns for abuse and 43% required surgery upon diagnosis with SDH.

Measuring and reviewing FOC, especially in infants with nonspecific neurologic symptoms or infants with sentinel injuries, may facilitate earlier assessment for AHT. An earlier diagnosis of AHT will assist in developing appropriate safety and treatment interventions.