Occult Intracranial Injury in Infants,☆☆,

Presented at the Joint Emergency Medicine Poster Symposium of the Ambulatory Pediatric Association and the Society for Pediatric Research, Washington DC, May 1997.
https://doi.org/10.1016/S0196-0644(98)70067-8Get rights and content

Abstract

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 6½-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. [Greenes DS, Schutzman SA: Occult intracranial injury in infants. Ann Emerg Med December 1998;32:680-686.]

Section snippets

INTRODUCTION

Several authors recommend using clinical symptoms and signs as a screen for determining which patients need radiographic imaging after head trauma.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 For several reasons, however, many of these recommendations specifically exclude infants younger than 2 years of age.1, 2, 11 First, it has been recognized that infants are at increased risk of intracranial injury (ICI), and that infants may suffer ICI even after more minor mechanisms of injury.1, 12 Second, some authors

MATERIALS AND METHODS

We performed a retrospective analysis of all patients younger than 2 years of age admitted to Children’s Hospital in Boston with an acute ICI between January 1, 1990, and June 30, 1996. Patients were identified through a search of the hospital’s medical records database. Initially, all patients younger than 2 years of age with a discharge diagnosis indicating any form of head injury were identified. The medical record was reviewed for each of these patients, and all patients who had an acute

RESULTS

Three hundred fifty-seven subjects younger than 2 years of age were admitted to Children’s Hospital with a discharge diagnosis related to head trauma over the study period. Of these, 182 subjects were excluded because they had skull fracture but no intracranial injury. Another 74 subjects were excluded because they had no acute radiographic abnormalities noted, or because they had preexisting intracranial lesions or bleeding diathesis. The remaining 101 subjects constituted the study sample

DISCUSSION

We found clinical signs and symptoms to be insensitive indicators of ICI in infants admitted after head injury; only 81% of the infants in our sample had any of the symptoms or signs we studied. Occult ICIs were most common among the youngest infants, with 27% of the infants younger than 6 months of age being asymptomatic.

These findings suggest that infants need to be evaluated in a different manner than older children or adults after head trauma. Increasingly in recent years, researchers have

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From the Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital, Harvard Medical School, Boston, MA.

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Address for reprints: David S Greenes, MD, Emergency Department, Children’s Hospital,300 Longwood Avenue, Boston, MA 02115; 617-355-6624, fax 617-355-6625,E-mail [email protected].

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