Management of Frontal Scalp Hematoma in Toddlers
Most toddlers with isolated frontal scalp hematomas and normal mental status do not require CT imaging and can be safely observed at home with return precautions, as the risk of clinically important traumatic brain injury is extremely low (<0.4%) and no child in this category has required neurosurgery. 1, 2
Risk Stratification Using PECARN Criteria
The American College of Radiology recommends using validated PECARN criteria to determine which children require imaging versus observation 3, 1:
Very Low Risk (No CT Needed)
Children ≥2 years old meet very low-risk criteria when ALL of the following are present 3, 1:
- Glasgow Coma Scale (GCS) = 15
- Normal mental status
- No signs of basilar skull fracture
- No loss of consciousness
- No vomiting
- No severe injury mechanism
- No severe headache
For children <2 years old, very low-risk criteria require GCS = 15, normal mental status, no palpable skull fracture, no nonfrontal scalp hematoma, loss of consciousness ≤5 seconds, no severe mechanism, and acting normally per parents, with a risk of clinically important traumatic brain injury <0.02%. 1, 4
High-Risk Features Requiring Immediate CT
Obtain non-contrast head CT immediately if ANY of the following are present 3, 1, 4:
- GCS ≤14 or altered mental status (4.3% risk of clinically important injury in children ≥2 years)
- Signs of basilar skull fracture (hemotympanum, Battle sign, raccoon eyes, CSF otorrhea/rhinorrhea)
- Palpable skull fracture (in children <2 years)
- Post-traumatic seizure
Intermediate-Risk Features (Consider CT vs Observation)
For children ≥2 years with GCS 15 and normal mental status but with 3, 1, 4:
- History of loss of consciousness
- Severe headache
- Vomiting
- Severe mechanism of injury (motor vehicle crash with ejection, death of another passenger, or rollover; pedestrian/bicyclist struck by vehicle; fall >5 feet for children ≥2 years or >3 feet for children <2 years; head struck by high-impact object)
The risk of clinically important traumatic brain injury in intermediate-risk patients is approximately 0.8%, and clinical observation for several hours can effectively reduce unnecessary CT scans without delaying diagnosis. 1, 4
Special Considerations for Frontal Location
Frontal scalp hematomas carry lower risk than nonfrontal (parietal, temporal, occipital) hematomas in children <2 years old. 1, 2 In a study of nearly 3,000 children with isolated scalp hematomas, nonfrontal location was independently associated with traumatic brain injury on CT, while frontal hematomas were not 2.
Management Approach for Delayed Presentation
Children presenting >24 hours after injury with isolated scalp swelling and no neurological symptoms have excellent outcomes without imaging, as none experienced neurological deterioration or required neurosurgical intervention in multiple studies. 5, 6
For delayed presentations (>24 hours), consider observation without CT if 5, 6:
- No neurological symptoms (persistent vomiting, excessive sleepiness, irritability, seizures)
- Normal neurological examination
- No severe mechanism of injury
- Child acting normally per parents
Home Observation Instructions
Provide written discharge instructions to return immediately if the child develops 1:
- Persistent or worsening vomiting
- Increasing drowsiness or difficulty arousing
- Seizure activity
- Worsening or severe headache
- Changes in behavior or irritability
- Unsteady walking or loss of balance
- Unequal pupil size
- Any new neurological symptoms
Critical Pitfalls to Avoid
Do not obtain skull radiographs, as they miss up to 50% of intracranial injuries and provide no information about brain parenchyma. 1, 4
Do not delay CT imaging when high-risk features are present—immediate imaging is indicated for altered mental status, GCS ≤14, basilar skull fracture signs, or post-traumatic seizures. 4
Maintain a low threshold for imaging in children <1 year old with any concerning findings, as this age group has higher risk. 1
Always consider non-accidental trauma in children with unexplained injuries, inconsistent history, or delayed presentation—these cases require different evaluation protocols including skeletal survey and may warrant CT or MRI regardless of PECARN criteria. 3, 1, 4, 5
When Surgical Drainage is Needed
Surgical drainage of scalp hematomas is rarely required but should be considered for large hematomas causing severe pain, signs of infection, airway compression, orbital compartment syndrome, or anemia requiring transfusion. 7 Most scalp hematomas resolve spontaneously with conservative management 8, 7.