Scalp Hematoma Characteristics Associated With Intracranial Injury in Pediatric Minor Head Injury

Abstract

Objectives: Minor head trauma accounts for a significant proportion of pediatric emergency department (ED) visits. In children younger than 24 months, scalp hematomas are thought to be associated with the presence of intracranial injury (ICI). We investigated which scalp hematoma characteristics were associated with increased odds of ICI in children less than 17 years who presented to the ED following minor head injury and whether an underlying linear skull fracture may explain this relationship.Methods: This was a secondary analysis of 3,866 patients enrolled in the Canadian Assessment of Tomography of Childhood Head Injury (CATCH) study. Information about scalp hematoma presence (yes/no), location (frontal, temporal/parietal, occipital), and size (small and localized, large and boggy) was collected by emergency physicians using a structured data collection form. ICI was defined as the presence of an acute brain lesion on computed tomography. Logistic regression analyses were adjusted for age, sex, dangerous injury mechanism, irritability on examination, suspected open or depressed skull fracture, and clinical signs of basal skull fracture.Results: ICI was present in 159 (4.1%) patients. The presence of a scalp hematoma (n = 1,189) in any location was associated with significantly greater odds of ICI (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 3.06 to 6.02), particularly for those located in temporal/parietal (OR = 6.0, 95% CI = 3.9 to 9.3) and occipital regions (OR = 5.6, 95% CI = 3.5 to 8.9). Both small and localized and large and boggy hematomas were significantly associated with ICI, although larger hematomas conferred larger odds (OR = 9.9, 95% CI = 6.3 to 15.5). Although the presence of a scalp hematoma was associated with greater odds of ICI in all age groups, odds were greatest in children aged 0 to 6 months (OR = 13.5, 95% CI = 1.5 to 119.3). Linear skull fractures were present in 156 (4.0%) patients. Of the 111 patients with scalp hematoma and ICI, 57 (51%) patients had a linear skull fracture and 54 (49%) did not. The association between scalp hematoma and ICI attenuated but remained significant after excluding patients with linear skull fracture (OR = 3.3, 95% CI = 2.1 to 5.1).

Traumatic brain injury in young children with isolated scalp haematoma

“…In addition, the CHALICE definition includes a large SH size (>5 cm) and a younger age (<1 year), which have been shown to be independently associated with intracranial injury. The PECARN subanalysis, consistent with other studies, found that younger patient age, increased SH size, non-frontal SH location and severe injury mechanism were independently associated with TBI on CT 6 21–23. In children meeting the CHALICE definition of isolated SH, the frequency of ciTBI/csII clearly supports the performance of CT scan.…”

“…While previous guidelines recommended skull X-rays in children with isolated SH, based on evidence showing the association between skull fracture and TBI, other studies have shown that up to 50% of TBI can occur in the absence of a skull fracture 9 22 25–28. Point-of-care ultrasound is increasingly replacing skull X-rays for the identification of skull fractures in children with traumatic SHs, showing good accuracy for fractures identification compared with CT scan 29 30.…”

Trial of life: Well infants presenting more than 24 h after head injury with a scalp haematoma: A 10‐year review

“…Scalp haematomas were frequently characterised as ‘boggy’. This term has been used in some studies as an indicator of larger size and increased risk of skull fracture . However, there is no consensus of what constitutes a ‘boggy’ swelling.…”

“…Scalp haematoma may be the only sign of an acute brain lesion in infants but is most frequently associated with isolated linear skull fractures, the majority of which do not require neurosurgical intervention . More recent research has suggested that patients with an isolated scalp haematoma have a negligible risk of requiring neurosurgical intervention …”

A Experiência duma Norma de Atuação no Traumatismo Crânio-Encefálico Ligeiro em Idade Pediátrica: Estudo Longitudinal de Três Anos

“…Vários estudos afirmam que hematomas volumosos e noção de afundamento ósseo são fatores de risco para fratura e/ou LIC. 3,13,19,35 Na verdade, estes sinais são considerados de alarme pelos três algoritmos de decisão clínica mais utilizados internacionalmente na abordagem dos TCE ligeiros em idade pediátrica (PECARN, CHA-LICE e CATCH). 11,19,25 Não podemos deixar de comentar que duas crianças com perda de conhecimento superior a cinco minutos e uma criança com sinais focais à admissão não realizaram TC-CE, não se respeitando o protocolo em vigor na nossa instituição.…”