Clinical indicators of intracranial injury in head-injured infants

Objectives. 1) To determine whether clinical signs of brain injury are sens itive indicators of intracranial injury (ICI) in head-injured infants. 2) T o determine whether radiographic imaging of otherwise asymptomatic infants with scalp hematoma is a useful means of detecting cases of ICI. 3) To dete rmine whether head-injured infants without signs of brain injury or scalp h ematoma may be safely managed without radiographic imaging. Methods. We performed a 1-year prospective study of all infants younger tha n 2 years of age presenting to a pediatric emergency department with head t rauma. Data were collected on historical features, physical findings, radio graphic findings, and hospital course. Follow-up telephone calls were made 2 weeks after discharge to assess for any late deterioration. Results. Of 608 study subjects, 30 (5%) had ICI; 12/92 (13%) infants 0 to 2 months of age had ICI, compared with 13/224 (6%) infants 3 to 11 months of age, and 5/292 (2%) infants 12 months of age or older. Only 16/30 (52%) subjects with ICI had at least one of the following clinic al symptoms or signs of brain injury: loss of consciousness, history of beh avior change, seizures, emesis, depressed mental status, irritability, bulg ing fontanel, focal neurologic findings, or vital signs indicating increase d intracranial pressure. Of the 14 asymptomatic subjects with ICI, 13 (93%) had significant scalp he matoma. Among subjects who had head computed tomography, significant scalp hematoma had an odds ratio of 2.78 (95% confidence interval: 1.15,6.70) for association with ICI. A total of 265 subjects (43%) were asymptomatic and had no significant scal p hematoma. None (95% confidence interval: 0,1.2%) required specific therap y or had any subsequent clinical deterioration. Conclusions. Clinical signs of brain injury are insensitive indicators of I CI in infants. A substantial fraction of infants with ICI will be detected through radiographic imaging of otherwise asymptomatic infants with signifi cant scalp hematomas. Asymptomatic infants older than 3 months of age who h ave no significant scalp hematoma may be safely managed without radiographi c imaging.