title: Children presenting in delayed fashion after minor head trauma with scalp swelling: do they require further workup?
abstract: OBJECTIVE
  It is common to evaluate children who have sustained minor head trauma with computed tomography (CT) of the head. Scalp swelling, in particular, has been associated with intracranial injury. A subset of patients, however, present in delayed fashion, often days after the head trauma, as soft tissue edema progresses and their caregiver notices scalp swelling. We explore the value of further workup in this setting.
  
  
  METHODS
  We conducted a retrospective review of a prospectively collected cohort of children ≤24 months of age presenting to the Texas Children's Hospital with scalp swelling more than 24 h following a head trauma. Cases were collected over a 2-year study period from June 1, 2014 to May 31, 2016.
  
  
  RESULTS
  Seventy-six patients comprising 78 patient encounters were included in our study. The mean age at presentation was 8.8 months (range 3 days-24 months). All patients had noncontrast CT of the head as part of their evaluation by emergency medicine, as well as screening for nonaccidental trauma (NAT) by the Child Protection Team. The most common finding on CT head was a linear/nondisplaced skull fracture (SF) with associated extra-axial hemorrhage (epidural or subdural hematoma), which was found in 31/78 patient encounters (40%). Of all 78 patient encounters, 43 patients (55%) were discharged from the emergency room (ER), 17 patients (22%) were admitted for neurologic monitoring, and 18 patients (23%) were admitted solely to allow further NAT evaluation. Of those patients admitted, none experienced a neurologic decline and all had nonfocal neurologic exams on discharge. No patient returned to the ER in delayed fashion for a neurologic decline. Of all the patient encounters, no patient required surgery.
  
  
  CONCLUSIONS
  Pediatric patients ≤24 months of age presenting to the ER in delayed fashion with scalp swelling after minor head trauma-who were otherwise nonfocal on examination-did not require surgical intervention and did not experience any neurologic decline. Further radiographic investigation did not alter neurosurgical management in these patients; however, it should be noted that workup for child abuse and social care may have been influenced by CT findings, suggesting the need for the future development of a clinical decision-making tool to help safely avoid CT imaging in this setting.
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Jonathan N
authors.initials: JN
authors.lastname: Sellin
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Amee
authors.initials: A
authors.lastname: Moreno
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Sheila L
authors.initials: SL
authors.lastname: Ryan
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Sandi K
authors.initials: SK
authors.lastname: Lam
authors.affiliation: Department of Pediatrics, Baylor College of Medicine, Section of Public Health Pediatrics, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Marcella
authors.initials: M
authors.lastname: Donaruma-Kwoh
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Luerssen
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA. ajea@goodmancampbell.com.|Department of Neurosurgery, Section of Pediatric Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive #1134, Indianapolis, IN, 46202, USA. ajea@goodmancampbell.com.
authors.forename: Andrew
authors.initials: A
authors.lastname: Jea
mesh_terms: D002675:Child, Preschool; D006259:Craniocerebral Trauma / Q000150:complications* / Q000000981:diagnostic imaging / Q000523:psychology; D057210:Delayed Diagnosis; D004487:Edema / Q000209:etiology; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008137:Longitudinal Studies; D008279:Magnetic Resonance Imaging; D008297:Male; D011788:Quality of Life / Q000523:psychology; D012189:Retrospective Studies; D012535:Scalp / Q000000981:diagnostic imaging / Q000503:physiopathology*; D015898:Tomography Scanners, X-Ray Computed
keywords: Delayed presentation; Minor pediatric head trauma; Scalp swelling