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Prior Head Circumference Measurements in Infants With Older Subdural Hematomas: Did We Miss It?
Maryann Alvarez Griffis1,2, Nancy D Kellogg3, Wouter Koek3
1CARE Team, Driscoll Children's Hospital, Corpus Christi, TX, USA.
Insights
Missed opportunities in measuring infant head circumference and obtaining neuroimaging delayed diagnoses of subdural hematomas (SDHs). Earlier assessment for abusive head trauma (AHT) is crucial for timely interventions.
Area of Science:
- Pediatrics
- Neurology
- Child Abuse Pediatrics
Background:
- Macrocephaly due to subdural hematomas (SDHs) in infants is often detected through fronto-occipital circumference (FOC) measurements or neuroimaging.
- Neurologic symptoms associated with SDH in infants can be subtle or overlooked, potentially delaying diagnosis.
Purpose of the Study:
- To determine if infants diagnosed with macrocephaly and non-acute SDHs experienced missed opportunities for earlier detection.
- To identify specific missed diagnostic steps, including FOC measurement and neuroimaging, prior to SDH diagnosis.
Main Methods:
- A retrospective chart review was conducted on 35 infants with macrocephaly and non-acute SDHs.
- Infants were referred for suspected abusive head trauma (AHT).
- Medical records were analyzed for missed opportunities in workup for nonaccidental trauma (NAT), FOC measurement, neuroimaging, and macrocephaly assessment.
Main Results:
- A high rate (91%) of missed diagnostic opportunities were identified in infants with macrocephaly and SDH.
- The most frequent missed opportunity was the absence of neuroimaging in macrocephalic infants (54%).
- Other missed opportunities included failure to measure FOC in symptomatic infants (19%), incomplete macrocephaly workup (17%), and lack of NAT workup despite sentinel injuries (9%).
Conclusions:
- Routine FOC measurement and review, particularly in infants with nonspecific symptoms or sentinel injuries, can aid early AHT detection.
- Earlier diagnosis of AHT is essential for implementing timely safety measures and treatment interventions.
Objective:
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.
Methods:
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.
Results:
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.
Conclusion:
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.
