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Occult intracranial injury in infants
1Division of Emergency Medicine, Department of Pediatrics, Children's Hospital, Harvard Medical School, Boston, MA, USA. greenes@al.tch.harvard.edu
Insights
Clinical symptoms are not reliable indicators of intracranial injury (ICI) in infants under one year old. Many infants with head trauma and occult ICI, often associated with skull fractures, do not show signs of brain injury and have favorable outcomes.
Area of Science:
- Pediatric Traumatology
- Neuroimaging in Pediatrics
- Infant Clinical Assessment
Background:
- Head trauma is a common cause of injury in infants.
- Intracranial injury (ICI) can occur in infants following head trauma.
- Clinical signs of brain injury may not always be present in infants with ICI.
Purpose of the Study:
- To evaluate the sensitivity of clinical symptoms and signs in detecting ICI in infants with head trauma.
- To characterize infants with ICI who present without symptoms or signs of brain injury (occult ICI).
- To determine the clinical significance and outcomes of occult ICI in infants.
Main Methods:
- Retrospective analysis of infants under 2 years old admitted with acute ICI.
- Classification of infants as symptomatic or asymptomatic (occult ICI) based on predefined clinical criteria.
- Review of clinical characteristics, associated injuries, and treatment for infants with occult ICI.
Main Results:
- 19% of infants with head trauma had clinically occult ICI.
- Occult ICI was more common in infants younger than 6 months.
- Infants with occult ICI frequently had scalp contusions/hematomas and skull fractures but rarely required surgery or management for increased intracranial pressure.
Conclusions:
- Clinical signs of brain injury are not sufficient to rule out ICI in infants under one year of age.
- Occult ICI in infants is often associated with skull fractures but typically has a benign clinical course.
- Further investigation may be warranted for infants under one year with head trauma, even in the absence of overt neurological signs.
Study Objectives:
The objectives of this study were as follows: (1) to determine whether clinical symptoms and signs of brain injury are sensitive indicators of intracranial injury (ICI) in infants admitted with head trauma, (2) to describe the clinical characteristics of infants who have ICI in the absence of symptoms and signs of brain injury, and (3) to determine the clinical significance of those ICIs diagnosed in asymptomatic infants.
Methods:
We conducted a retrospective analysis of all infants younger than 2 years of age admitted to a tertiary care pediatric hospital with acute ICI during a 6(1/2)-year period. Infants were considered symptomatic if they had loss of consciousness, history of behavior change, seizures, vomiting, bulging fontanel, retinal hemorrhages, abnormal neurologic examination, depressed mental status, or irritability. All others were considered to have occult ICI.
Results:
Of 101 infants studied, 19 (19%; 95% confidence interval [CI] 12%, 28%) had occult ICI. Fourteen of 52 (27%) infants younger than 6 months of age had occult ICI, compared with 5 of 34 (15%) infants 6 months to 1 year, and none of 15 (0%) infants older than 1 year. Eighteen (95%) infants with occult ICI had scalp contusion or hematoma, and 18 (95%) had skull fracture. Nine (47%) infants with occult ICI received therapy for the ICI. No infants with occult ICI (0%) (95% CI 0, 14%) required surgery or medical management for increased intracranial pressure. Only 1 subject (5%) with occult ICI had any late symptoms or complications: a brief, self-limited convulsion.
Conclusion:
We found that 19 of 101 ICIs in infants admitted with head trauma were clinically occult. All 19 occult ICIs occurred in infants younger than 12 months of age, and 18 of 19 had skull fractures. None experienced serious neurologic deterioration or required surgical intervention. Physicians cannot depend on the absence of clinical signs of brain injury to exclude ICI in infants younger than 1 year of age.