Epidural Hematoma in an Infant: Abuse or Accident?
The parents of an 8-month-old boy brought him to the emergency department (ED) after a change in his mental status. The parents reported that the father and the patient had been sitting on a hardwood floor. The father was facing the child, supporting him from a seated position, when the boy suddenly swung his head backward, hitting it on the floor. The boy cried, fell asleep briefly, and then awoke at his neurologic baseline. He was given a bottle and fell asleep again. Approximately 1 hour later, he awoke vomiting, and then lost consciousness.
In the ED, the patient was obtunded, with a Glasgow Coma Scale score of 3, and was intubated. Physical examination findings were significant for a boggy area on his left scalp; no other injuries were identified. A noncontrast computed tomography (CT) scan of the head was performed the results of which are shown in Figures 1 and 2.
Do you suspect that the infant’s injuries are accidental trauma or signs of abuse?
(Answer and discussion on next page)
Answer: The infant’s head injury was accidental
CT scan results (Figures 1 and 2) showed a left parietal skull fracture, along with an underlying massive epidural hematoma causing an 11-mm left-to-right midline shift, left lateral ventricular effacement, early uncal herniation, and left hemispheric cerebral edema with evolving infarcts in the left temporal and occipital lobes.
The boy was taken to the operating room, where a neurosurgical team evacuated the hematoma. Ophthalmologic examination findings were negative for retinal hemorrhages. Ultimately, he was discharged home with his parents.
Discussion
Most head injuries in children younger than 2 years of age result from falls. Such injuries are both age- and mechanism-dependent.1 The mechanism is determined by the type of applied forces. In cases of falls, this correlates to fall height. Falls from low heights (1 m or less) primarily produce linear or translational impact forces,1 where the head predominately moves in a straight line. Linear or translational impact forces are associated with contact injuries such as scalp swelling and bruising, skull fractures, epidural hematomas, and contact subdural hemorrhages. Rotational forces, where the head rotates around the neck, are associated with injuries such as noncontact subdural hemorrhages, diffuse axonal or sheer injury, and contusional white matter tears.2 When retinal hemorrhages are numerous, involve multiple retinal layers, and extend beyond the posterior pole to the peripheral retina, they are similarly associated with rotational forces that have been applied to the brain.
Contact subdural hemorrhages occur in cases of direct cranial impact that usually result in a skull fracture with an associated small underlying subdural hemorrhage.3 In contrast, falcotentorial (interhemispheric or tentorial) subdural hemorrhages and subdural hemorrhages along a convexity (frontal, temporal, parietal, occipital) usually are the result of rotational forces and are highly concerning for child physical abuse in the absence of a history of a significant mechanism (eg, motor vehicle accident).3
Epidural hematomas typically arise from a direct impact that disrupts the middle meningeal arterial branches or dural venous sinuses. An overlying fracture also may be present.4
A history of a short fall often is provided by a caretaker to explain a child’s injuries in cases of physical abuse.5 The crucial distinction is that in cases of abuse, the explanation is inconsistent with the pattern, age, or severity of the injuries.6 In the case described here, it might appear as though physical abuse was the cause of the child’s injury, given the minimal mechanism described, the severe and acute change in the child’s mental status, and the large intracranial hematoma. The critical point in differentiating accidental from nonaccidental trauma is the clinical history paired with a solid understanding of mechanisms of injury. The described history of a short fall and a direct impact onto a hard surface with an initial loss of consciousness, a lucid interval, and an abrupt onset of coma is consistent with the boy’s skull fracture and epidural hematoma and, therefore, is consistent with an accident.
Dana M. Kaplan, MD, is a child abuse pediatrics fellow at the Lawrence A. Aubin, Sr. Child Protection Center at Hasbro Children’s Hospital, the Warren Alpert Medical School of Brown University, in Providence, Rhode Island.
Amy Goldberg, MD, is an attending physician at the Lawrence A. Aubin, Sr. Child Protection Center at Hasbro Children’s Hospital, and an associate professor of pediatrics (clinical) at the Warren Alpert Medical School of Brown University, in Providence, Rhode Island.
Christine Barron, MD, is the program director of the Fellowship in Child Abuse, Pediatrics, at the Lawrence A. Aubin, Sr. Child Protection Center at Hasbro Children’s Hospital, the Warren Alpert Medical School of Brown University, in Providence, Rhode Island.
References
1. Ibrahim NG, Wood J, Margulies SS, Christian CW. Influence of age and fall type on head injuries in infants and toddlers. Int J Dev Neurosci. 2012;30(3):201-206.
2. Tung GA, Kumar M, Richardson RC, Jenny C, Brown WD. Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. Pediatrics. 2006;118(2):626-633.
3. Hymel KP, Rumack CM, Hay TC, Strain JD, Jenny C. Comparison of intracranial computed tomographic findings in pediatric abusive and accidental head trauma. Pediatr Radiol. 1997;27(9):743-747.
4. Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics. 1992;90(2 pt 1):179-185.
5. Piteau SJ, Ward MGK, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130(2):315-323.
6. Thompson AK, Bertocci G, Rice W, Pierce MC. Pediatric short-distance household falls: biomechanics and associated injury severity. Accid Anal Prev. 2011;43(1):143-150.