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Infant Scalp Hematoma Score – Maybe Some Don’t Need CT

August 26, 2020

Written by Vivian Lei

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The Infant Scalp Score refines TBI risk stratification recommendations for infants with isolated scalp hematoma after head injury to guide clinicians on which infants require CT imaging.

Why does this matter?
Physicians evaluating infants with head trauma have to parse out those with clinically important traumatic brain injury (ciTBI) while limiting use of unnecessary radiation exposure from CT imaging. Although a scalp hematoma may be the only sign of TBI in head-injured infants, most infants with a scalp hematoma do not have a ciTBI. A simple risk stratification tool in this young patient group is especially important as young infants are the most challenging to assess while also being most sensitive to the effects of ionizing radiation.

Not every scalp hematoma gets a scan?
Using the Pediatric Emergency Care Applied Research Network (PECARN) TBI dataset, researchers identified infants under 1 year of age with a finding of isolated scalp hematoma (ISH). A total of 1,289 infants met criteria for definition of ISH and 462 (36%) of those had a head CT performed. Of these, 12 had a ciTBI, defined as death, need for neurosurgical intervention, intubation for at least 24 hours or hospitalization for two or more nights for TBI. A total of 59 had a positive CT, defined as presence of any intracranial bleeding, pneumocephalus, cerebral edema, skull fracture, or diastasis of the skull. The researchers found that no infant with an ISH and an infant scalp score <5 had a ciTBI and no infant with an ISH and an infant scalp score < 4 had TBI found on CT. They suggest a cutoff infant scalp score of 5 or greater for obtaining head CT in infants with ISH. This cutoff would have missed 3 infants with TBI on CT, none of whom required any intervention.

This is a helpful risk stratification tool for infants under 1 year of age with ISH who are otherwise asymptomatic, well-appearing, but may still be getting head CTs when guided by existing clinical decision aids. Of note, the infant scalp score was not designed for use in those for whom non-accidental trauma is suspected.

Here is the Infant Scalp Score.

Infant Scalp Score – adapted from cited article

The Infant Scalp Score: a validated tool to stratify risk of traumatic brain injury in infants with isolated scalp hematoma. Acad Emerg Med. 2020 Jul 16. doi: 10.1111/acem.14087. [Epub ahead of print] 

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2 thoughts on “Infant Scalp Hematoma Score – Maybe Some Don’t Need CT

  • This looks like a >12 month old would never reach the threshold for a scan, as their max possible score is 5. Am I missing something? Or should it say the threshold is 5 or greater, not >5?

What are your thoughts?