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Krishnan V, Jaganathan S, Choudhary AK, Ou X, Choudhary R, Choudhary A, Na X, Mankad K, Ramakrishnaiah R, Jayappa S. Birth-related subdural hemorrhage in asymptomatic neonates: evolution over time and differentiation from traumatic subdural hemorrhage. Pediatr Radiol 2024; 54:1631-1642. [PMID: 39037461 DOI: 10.1007/s00247-024-06003-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 07/07/2024] [Accepted: 07/09/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Intracranial birth-related subdural hemorrhage frequently occurs in asymptomatic newborns and has no adverse long-term sequelae. It is medically and medicolegally important to differentiate birth-related subdural hemorrhage from other pathological causes of intracranial hemorrhage. There is limited literature available on the incidence of birth-related subdural hemorrhage, its imaging features, and evolution over time, mainly because asymptomatic infants do not routinely undergo cranial MRI. OBJECTIVE To establish the incidence and distribution of birth-related subdural hemorrhage and evaluate their association with various modes of delivery, identify associated features, and evaluate the sequential evolution of signal changes of the birth-related hemorrhages on MRI. MATERIALS AND METHODS A total of 200 healthy term neonates and young infants were included in this retrospective review study. All infants underwent MRI of the brain and cervical spine at postnatal age of 0-2 months with acquisition of a 3D T1-weighted (T1W), 3D or 2D T2-weighted (T2W), and axial diffusion-weighted imaging (DWI) sequences. The scans were evaluated for the presence and distribution of subdural hemorrhages, other intracranial hemorrhages, and associated injuries. Prevalence of intracranial hemorrhage in various modes of delivery was analyzed. Relationship between the signal intensities of the bleeds on T1W, T2W, and DWI scans and the age of the infants was analyzed. Appropriate tests were applied to test for statistical significance of the data. RESULTS Out of 200 neonates, 66 (33%) had detectable intracranial hemorrhage on MRI with an age range of 11-25 days, including 31 (47%) males and 35 (53%) females. All of them had subdural hemorrhages, 54 (81.8%) of which were in the posterior fossa. Additional parenchymal hemorrhages were present in a few, but no subarachnoid hemorrhages, cervical spinal canal hemorrhages, cortical bridging vein injury, or cervical spinal ligamentous injury were identified within the limitations of the study. No detectable intracranial hemorrhage was found in subjects above 25 days of age. Overall incidence of subdural hemorrhage by mode of delivery was 8/68 (11.8%) in babies born by cesarean section and 58/132 (43.9%) in babies born by vaginal delivery. Among the vaginal deliveries, the highest incidence was observed in assisted vaginal delivery (19/30, 63.3%). Subjects with birth-related subdural hemorrhage were categorized into three age groups: <13 days, 13-21 days, and >21 days. All detected hemorrhages were T1W hyperintense. In the <13 days group, all bleeds were T2W hypointense. In the 13-21 days group, 73.1% were T2W hypointense, while 26.9% were T2W mixed. All bleeds in the >21 days group were T2W hypointense. All DWI hyperintense bleeds were found in the 13-21 days group. CONCLUSION Birth-related subdural hemorrhage occurs in over a third of normal deliveries and has a characteristic distribution, predominantly in the posterior fossa. Associated cervical spinal subdural hemorrhages, cervical spinal ligamentous injury, or cortical bridging vein injury, which are concerning for traumatic etiology, were not identified. Birth-related subdural hemorrhages follow a characteristic pattern of signal changes on MRI. Although not completely reliable, this can help in differentiating them from traumatic intracranial hemorrhages which usually occur postnatally. No birth-related subdural hemorrhages were seen after 25 days of age in our cohort.
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Affiliation(s)
- Venkatram Krishnan
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA.
| | - Sriram Jaganathan
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Arabinda K Choudhary
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Xiawei Ou
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Rhea Choudhary
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Anya Choudhary
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Xiaoxu Na
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Kshitij Mankad
- Department of Pediatric Radiology, Great Ormond Street Hospital, London, UK
| | - Raghu Ramakrishnaiah
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Sateesh Jayappa
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
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Ahmad D, Small A, Gibson A, Kissoon N. Developmental outcomes in abusive head trauma. Semin Pediatr Neurol 2024; 50:101142. [PMID: 38964813 DOI: 10.1016/j.spen.2024.101142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/25/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
Abusive head trauma (AHT) is associated with high mortality and poorer outcomes compared to accidental head injuries. The short and long-term developmental outcomes for AHT are not well identified. Variability in outcome measures, small sample sizes, difficulty in measuring domain-specific developmental skills, co-existence of comorbidities, genetic and environmental factors and high attrition rates all contribute to the challenges on providing data in this area. The objective of this article is to review the scientific literature on the developmental outcomes of AHT, highlighting factors that affect outcomes, the available assessment tools, and short and long-term developmental outcomes, recommended follow up, societal costs, and future opportunities for research. Authors searched OVID Medline and PubMed for articles published between 2013 and 2023 using the terms "abuse", "craniocerebral trauma" and "development". Fifty-five records were included for this review. The data shows that injuries sustained from AHT result in a spectrum of outcomes ranging from normal development to death. There are more than 100 outcome assessment tools limiting the ability to compare studies. More than half of patients are left with disabilities post discharge. Gross motor and cognition/academics are the 2 most common domains studied. Advancement in surgical and neurocritical care management has influenced AHT outcomes. Close long-term follow up is recommended to maximize each child's developmental potential, irrespective of the presence of disability at discharge. We suggest that future research should focus on adopting a consistent diagnostic and assessment approach and explore the social environmental factors that can affect recovery.
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Affiliation(s)
- Dina Ahmad
- UTHealth Houston (The University of Texas Health Science Center at Houston), USA.
| | | | - Ashley Gibson
- UTHealth Houston (The University of Texas Health Science Center at Houston), USA
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Nomakuchi TT, Alves CAP, Beslow LA, Zarnow D, Goyal N, Zackai EH, Reynoso Santos FJ. Subdural Hemorrhage as an Early Presentation in a Case of Sotos Syndrome. Neuropediatrics 2024; 55:71-74. [PMID: 36914163 DOI: 10.1055/a-2052-8750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Subdural hemorrhages (SDHs) in the pediatric population are associated with a high mortality and morbidity and may present in the context of abusive head trauma. Diagnostic investigations for such cases often include evaluation for rare genetic and metabolic disorders that can have associated SDH. Sotos syndrome is an overgrowth syndrome associated with macrocephaly and increased subarachnoid spaces and rarely with neurovascular complications. Here, we report two cases of Sotos syndrome, one with SDH during infancy who underwent repeated evaluation for suspected child abuse prior to the Sotos syndrome diagnosis and the other with enlarged extra-axial cerebrospinal fluid spaces, demonstrating a possible mechanism for SDH development in this setting. These cases suggest that some individuals with Sotos syndrome may be at elevated risk of developing SDH in infancy and that Sotos syndrome should be on the differential diagnosis during a medical genetics evaluation in cases of unexplained SDH, especially in the setting of macrocephaly.
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Affiliation(s)
- Tomoki T Nomakuchi
- Division of Human Genetics, Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Cesar Augusto P Alves
- Division of Neuroradiology, Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Pennsylvania, United States
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, United States
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, United States
| | - Deborah Zarnow
- Division of Neuroradiology, Children's Hospital of Philadelphia, Pennsylvania, United States
- Department of Radiology Perelman School of Medicine, University of Pennsylvania, Pennsylvania, United States
| | - Neera Goyal
- Department of Pediatrics, Nemours Children's Health and Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Elaine H Zackai
- Division of Human Genetics, Children's Hospital of Philadelphia, Pennsylvania, United States
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, United States
| | - Francis Jeshira Reynoso Santos
- Division of Human Genetics, Children's Hospital of Philadelphia, Pennsylvania, United States
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, United States
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Lai CD, Marret MJ, Jayanath S, Azanan MS. Abusive head trauma in infants: An observational single centre study comparing developmental and functional outcome between 18 months and 5 years. CHILD ABUSE & NEGLECT 2023; 145:106434. [PMID: 37657172 DOI: 10.1016/j.chiabu.2023.106434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/08/2023] [Accepted: 08/25/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) is a major cause of traumatic brain injury in infancy. This exploratory study compared standardized developmental assessment versus functional outcome assessment between 18 months and 5 years of age following AHT in infancy. METHODS Observational cross-sectional study after surviving AHT in infancy. Seventeen children between 18 months and 5 years of age underwent clinical examination, developmental assessment using the Schedule of Growing Skills II (SGS II) and functional assessment using the Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds). Additional clinical information was extracted from medical records. RESULTS Age at assessment ranged from 19 to 53 months (median 26 months). Most (n = 14) were delayed in at least 1 domain, even without neurological or visual impairment or visible cortical injury on neuroimaging, including 8 children with favourable GOS-E Peds scores. The most affected domain was hearing and language. Delay in the manipulative domain (n = 6) was associated with visual and/or neurological impairment and greater severity of delay across multiple domains. Eleven (64.7 %) had GOS-E Peds scores indicating good recovery, with positive correlation between GOS-Peds scores and number of domains delayed (r = 0.805, p < 0.05). CONCLUSION The SGS-II detects behavioural and cognitive deficits not picked up by the GOS-E Peds. Combining both tools for assessment of AHT survivors under 5 years of age provides a comprehensive profile which addresses multiple domains of development and function, facilitating targeted intervention. Detection of developmental problems in the majority of survivors makes AHT prevention a public health priority.
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Affiliation(s)
- Charles Dekun Lai
- Department of Paediatrics, University of Malaya, 50603 Kuala Lumpur, Malaysia; Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300 Kota Samarahan, Sarawak.
| | - Mary J Marret
- Department of Paediatrics, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Subhashini Jayanath
- Department of Paediatrics, University of Malaya, 50603 Kuala Lumpur, Malaysia.
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Sarmiento CA, Wyrwa JM, Chambliss AV, Stearns-Yoder KA, Hoffberg AS, Appel A, Brenner BO, Brenner LA. Developmental Outcomes Following Abusive Head Trauma in Infancy: A Systematic Review. J Head Trauma Rehabil 2023; 38:283-293. [PMID: 36730957 DOI: 10.1097/htr.0000000000000808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A systematic review of the literature was conducted to identify measures used to evaluate developmental outcomes after abusive head trauma (AHT), as well as describe outcomes among those with AHT, and explore factors and interventions influencing such outcomes. DESIGN This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The protocol is in PROSPERO, registration number CRD42020179592. On April 17, 2020, OVID Medline, Embase, OVID PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were searched (since inception). Inclusion criteria included original, peer-reviewed study data; AHT exposure; infants younger than 24 months at time of AHT; and evaluation of developmental outcomes. Reviewers independently evaluated studies for inclusion and assessed risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. A descriptive synthesis approach was utilized as variability of study designs, follow-up periods, and outcome assessment tools precluded a meta-analytic approach. RESULTS Fifty-nine studies were included; 115 assessment tools were used to evaluate developmental outcomes; and 42 studies examined factors influencing outcomes. Two studies evaluated interventions. Five percent of studies ( n = 3) were rated low risk of bias. CONCLUSIONS Notable variation was observed in terms of case ascertainment criteria. Developmental outcomes after AHT have been assessed in a manner that limits understanding of how AHT impacts development, as well as the efficacy of interventions intended to improve outcomes. Researchers and clinicians are encouraged to adopt consistent diagnostic and assessment approaches.
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Affiliation(s)
- Cristina A Sarmiento
- Departments of Pediatric Rehabilitation Medicine (Drs Sarmiento, Wyrwa, Chambliss, and Appel) and Pediatrics (Drs Chambliss and Appel), Children's Hospital Colorado, Aurora; Departments of Physical Medicine and Rehabilitation (Drs Sarmiento, Wyrwa, Chambliss, Appel, and Brenner and Ms Stearns-Yoder) and Psychiatry and Neurology (Dr Brenner), University of Colorado Anschutz School of Medicine, Aurora; Veterans Health Administration Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado (Ms Stearns-Yoder, Mr Hoffberg, and Dr Brenner); and Brandeis University, Waltham, Massachusetts (Mr Brenner)
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6
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Primalani NK, Chan YH, Ng ZM, Chong SL, Seow WT, Loh LE, Mok YH, Low SYY. Abusive head injury in the very young: outcomes from a Singapore children's hospital. Childs Nerv Syst 2022; 38:2397-2407. [PMID: 35851614 DOI: 10.1007/s00381-022-05572-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is a serious problem in children. The aims of this study are to identify risk factors that correlate with outcomes for those requiring neurosurgical intervention for very young children with AHT, assessment of variables associated with outcomes, and corroboration of our results with literature. METHODS This is an ethics-approved, retrospective study. Inclusion criteria consisted of patients aged 2 years old or less with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. Logistic regression was applied to statistically significant variables for the risk prediction model. RESULTS From 2000 to 2020, 24 patients required surgery for AHT. Timepoint was set at 12 months post-diagnosis. Univariate analyses demonstrated that patients with mild TBI were likely to have a favourable GOS-E Peds (p = 0.01), whereas radiological presence of cerebral oedema (p < .001), development of scar epilepsy (p = 0.021), and progression to cerebral palsy (p = 0.001) were associated with unfavourable GOS-E Peds. CONCLUSION This is the first study focused on neurosurgical outcomes for very young children with AHT in Singapore. We advocate multidisciplinary efforts to improve outcomes for this devastating condition.
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Affiliation(s)
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, Clinical Research Centre, #02-03 (c/o CBmE Office), 10 Medical Drive, Singapore, 117597, Singapore
| | - Zhi Min Ng
- Neurology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore. .,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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7
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Snelling PJ, Aruljoe Thanasingam A, Jones P, Connors J. Comparison of abusive head trauma versus non-inflicted subdural haematoma in infants: A retrospective cohort study. Emerg Med Australas 2022; 34:968-975. [PMID: 35661408 PMCID: PMC9796578 DOI: 10.1111/1742-6723.14028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To compare the characteristics of subdural haematoma (SDH) in children under the age of 2 years, between inflicted, otherwise known as abusive head trauma (AHT), and non-inflicted aetiologies. METHODS This was a retrospective cohort study of 37 cases of SDH in children under the age of 2 years presenting to the ED at an Australian tertiary children's hospital between January 2009 and December 2012 and been assessed by the Child Protection Unit. SDH aetiology was classified into AHT and non-inflicted groups, based on child protection interagency outcome. These groups were compared to determine clinical associations with AHT. RESULTS Of the 37 infants with SDH, 20 cases were deemed due to AHT, whereas 17 cases were determined to be non-inflicted SDH (15 cases due to accidental trauma and two cases due to congenital benign enlargement of the subarachnoid space). SDH due to AHT was associated with antenatal maternal drug use, previous Department of Child Safety involvement, delayed presentation, history of seizures, floppiness or altered level of consciousness; extracranial findings of fractures, bruising or retinal haemorrhages; radiological findings of >5 mm depth, bilateral, inter-hemispheric blood, posterior fossa blood and diffusion restriction; and outcomes of death or permanent disability. Non-inflicted SDH was associated with witnessed injury, falls and scalp haematoma on imaging. CONCLUSIONS Infant SDH due to AHT accounts for high mortality and morbidity. Early identification of these patients in the ED with referral to specialised units that investigate for potential child abuse is essential.
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Affiliation(s)
- Peter J Snelling
- Emergency DepartmentGold Coast University HospitalGold CoastQueenslandAustralia,Child Protection UnitMater Children's HospitalBrisbaneQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Child Health Research CentreThe University of QueenslandBrisbaneQueenslandAustralia
| | | | - Philip Jones
- Emergency DepartmentGold Coast University HospitalGold CoastQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Emergency and Trauma CentreRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Jan Connors
- Child Protection UnitMater Children's HospitalBrisbaneQueenslandAustralia,Child Protection and Forensic Medical ServiceQueensland Children's HospitalBrisbaneQueenslandAustralia
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Souter J, Behbahani M, Sharma S, Cantrell D, Alden TD. Middle meningeal artery embolization in pediatric patient. Childs Nerv Syst 2022; 38:1861-1866. [PMID: 35962222 DOI: 10.1007/s00381-022-05639-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE There is paucity of data in management of recurrent and expanding subdural hematomas (SDH) within the pediatric population, who are otherwise not surgical candidates. Middle meningeal artery (MMA) embolization has been utilized minimally in this population and here, we explore the utility of this procedure in a 15-month-old-child, along with review of the literature. METHODS A case report of a 15-month-old child who underwent MMA embolization for recurrent and expanding SDH in the setting of anticoagulation for cardiac condition. A literature review of MMA embolization in pediatric patients was conducted. RESULTS Initially stabilization of SDH was noted on serial imaging; however, recurrent hemorrhages were noted with subsequent boluses of antiplatelet and anticoagulating agents. There are only 5 total reported cases, included ours, of MMA embolization in pediatrics with an overall success rate of 80%. CONCLUSION Treatment of chronic or recurrent subdural hematoma by MMA embolization in the pediatric population is understudied. Our case notes limitation of this procedure and impact on long-term success, specifically in patients with systemic illness and ongoing anticoagulation.
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Affiliation(s)
- John Souter
- Department of Neurological Surgery, University of Illinois Chicago, Chicago, IL, USA
| | - Mandana Behbahani
- Division of Neurological Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Shelly Sharma
- Division of Neurological Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Donald Cantrell
- Division of Interventional Radiology, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Tord D Alden
- Division of Neurological Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA.
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL, USA.
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Regeffe F, Chevignard M, Millet A, Bellier A, Wroblewski I, Patural H, Javouhey E, Mortamet G. Factors associated with poor neurological outcome in children after abusive head trauma: A multicenter retrospective study. CHILD ABUSE & NEGLECT 2022; 131:105779. [PMID: 35816903 DOI: 10.1016/j.chiabu.2022.105779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/18/2022] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Abusive Head Trauma (AHT) remains the leading cause of brain injury in infants. OBJECTIVE This study aims to describe a cohort of patients with AHT and identify early risk factors associated with poor neurological outcome. PARTICIPANTS AND SETTING Children under one year old admitted to a Pediatric Intensive Care Unit (PICU) with a suspected or confirmed diagnosis of AHT were included. Neurological outcome was assessed by the Pediatric Overall Performance Category score (POPC) at discharge from the hospital and at two years of follow-up. METHODS A multicentre retrospective study was conducted over 8 years (from January 2012 to December 2020). RESULTS A total of 117 patients (mean age 4.3 (+/- 2.5) months, 61 % boys) from three PICUs were included. A total of 99 (85 %) patients completed a 2-year follow-up. Sixty-one (52 %) and 47 (40 %) children with AHT had a POPC (pediatric overall performance category) score ≥ 2 at discharge from ICU and discharge from hospital, respectively (meaning they had at least a moderate disability). Fifty-one (44 %) had a POPC score ≥ 2 at 2-year follow-up, including 19 patients (19 %) with severe disabilities. The main neurological disabilities were neurodevelopmental (n = 38, 35 %), hyperactivity disorder (n = 36, 33 %) and epilepsy (n = 34, 31 %). After analysis according to the hierarchical model, the occurrence of a cardiorespiratory arrest and a low Glasgow Coma Score at admission stand out as factors of poor neurological outcome. CONCLUSION This study highlights the wide range of neurological disabilities in children with AHT. Early and multidisciplinary follow-up is crucial to limit the impact of neurological disability.
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Affiliation(s)
- Fanny Regeffe
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France; Sorbonne Université, Laboratoire d'Imagerie Biomédicale, LIB, CNRS, INSERM, F-75006 Paris, France; Sorbonne Université, GRC 24 Handicap Moteur et Cognitif et Réadaptation (HaMCRe), Paris, France
| | - Anne Millet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Alexandre Bellier
- Department of medical Evaluation, Grenoble-Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, Grenoble, France
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Hugues Patural
- Pediatric Intensive Care Unit, Saint-Etienne Hospital, Saint-Etienne, France
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Lyon University Hospital, Bron, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, Grenoble, France.
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Aydın SO, Etli MU, Köylü RC, Varol E, Yaltırık CK, Ramazanoğlu AF. Factors Associated with Nontraumatic Spontaneous Subdural Hematomas in Pediatric Patients. Neuropediatrics 2022. [PMID: 35793697 DOI: 10.1055/a-1893-2559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE In our study, we aimed to summarize the etiology of subdural hematoma that was not traumatic and required operation in pediatric patients. The subdural hematoma characteristics, possible etiologies, and treatment, as well as the patient outcomes, were analyzed. METHODS A retrospective examination was made of pediatric patients with subdural hematoma who were operated on at Ümraniye Training and Research Hospital. Patients with a history of trauma were excluded. Data on patient sex, age, bleeding location, type of hematoma based on computed tomography imaging, surgical treatment, presenting symptoms, presence of comorbidities, Glasgow Coma Scale, thrombocyte counts, and international normalized ratio values were recorded. RESULTS Of the 19 patients included in the study, 4 were female and 15 were male. Their ages ranged between 0 and 15 (mean = 5.84) years. In 57.8% of the patients, comorbidities, including acute myeloid leukemia, a history of shunt operation, epilepsy, mucopolysaccharidosis, known subdural effusion, autism, coagulopathy, ventricular septal defect/tetralogy of Fallot, cerebrospinal fluid leakage after baclofen pump administration, Marfan's syndrome, and late neonatal sepsis were present, while 21% had arachnoid cysts and 21% had no reported comorbidities. CONCLUSION This study suggests that, in pediatric patients with subdural hematoma with an amount of bleeding requiring surgical management, any underlying comorbidities should be investigated regardless of the presence of a history of trauma. While investigating systemic diseases, special attention should be paid to the presence of arachnoid cysts or disruption in cerebrospinal fluid dynamics along with a history of hematologic diseases.
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Affiliation(s)
- Serdar Onur Aydın
- Department of Neurosurgery, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Umut Etli
- Department of Neurosurgery, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Reha Can Köylü
- Department of Neurosurgery, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Eyüp Varol
- Department of Neurosurgery, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Cumhur Kaan Yaltırık
- Department of Neurosurgery, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Ali Fatih Ramazanoğlu
- Department of Neurosurgery, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Turkey
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Weiss R, He CH, Khan S, Parsikia A, Mbekeani JN. Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma. Pediatr Neurol 2022; 127:11-18. [PMID: 34922138 DOI: 10.1016/j.pediatrneurol.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.
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Affiliation(s)
- Rebecca Weiss
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | | | - Sabine Khan
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York; Research Services, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce N Mbekeani
- Albert Einstein College of Medicine, Bronx, New York; Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York.
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Burns J, Rohl S, Marth D, Proctor D, Amin R, Sekhon C. Which Clinical Features of Children on Initial Presentation to the Emergency Department With Head Injury Are Associated With Clinically Important Traumatic Brain Injury, Classification as Abuse, and Poor Prognosis? Pediatr Emerg Care 2022; 38:e254-e258. [PMID: 32925700 DOI: 10.1097/pec.0000000000002239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are leading causes of morbidity and mortality. Clinicians may not be aware of AHT at presentation to the emergency department (ED). OBJECTIVE The objective of this study was to determine which clinical features associated with head injury in children on initial presentation to the ED trauma bay predict 3 outcomes including clinically important TBI (CiTBI), classification as confirmed abuse by Child Protection Team (CPT), and poor neurologic status on hospital discharge. PARTICIPANTS AND SETTING Inclusion for this study were children 3 years or younger, presenting to the ED with significant TBI. In addition, presentations where the mechanism of injury was not verifiable such as with falls, being struck by object, or no mechanism of injury reported by caregiver were included. METHODS Researchers used 3 sources of information for this analysis: a regional trauma registry, hospital records, and the CPT database. Clinical features included demographics, mechanisms of injury, physical, radiological findings, and CPT classification. RESULTS On pairwise analysis, seizures, apnea, and no mechanism of injury reported by caregiver were the only clinical features related to all 3 outcomes (P < 0.001). Rib fractures (relative risk [RR], 3.3; P < 0.001), long bone fractures (RR, 3.1; P < 0.001), retinal hemorrhages (RR, 3.0; P < 0.001), seizures (RR, 3.6; P < 0.001), apnea (RR, 4.4; P < 0.001), and younger than 6 months (RR, 1.8; P < 0.001) were related to AHT. On multivariable logistic regression, no mechanism of injury reported by caregiver and seizures remained significantly related to CiTBI; seizures and retinal hemorrhage remained significantly related to classification as abuse by CPT, and no mechanism of injury by the caregiver, apnea, and seizures were significantly related to poor outcome on hospital discharge. CONCLUSIONS No mechanism of injury reported by the caregiver, seizures, and apnea at the time of presentation to the ED are important features associated with CiTBI, classification as AHT, and poor prognosis. In addition, younger age, retinal hemorrhage, rib, and long bone fractures were found to be important clinical features associated with AHT.
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Affiliation(s)
- James Burns
- From the Pediatric Trauma Research Team, Studer Family Children's Hospital at Ascension Sacred Heart
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13
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Jackson JE, Beres AL, Theodorou CM, Ugiliweneza B, Boakye M, Nuño M. Long-term impact of abusive head trauma in young children: Outcomes at 5 and 11 years old. J Pediatr Surg 2021; 56:2318-2325. [PMID: 33714452 PMCID: PMC8374003 DOI: 10.1016/j.jpedsurg.2021.02.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is a leading cause of morbidity and mortality among young children. We aimed to evaluate the long-term impact of AHT. METHODS Using administrative claims from 2000-2018, children <3 years old with documented AHT who had follow-up through ages 5 and 11 years were identified. The primary outcome was incidence of neurodevelopmental disability and the secondary outcome was the effect of age at time of AHT on long-term outcomes. RESULTS 1,165 children were identified with follow-up through age 5; 358 also had follow-up through age 11. The incidence of neurodevelopmental disability was 68.0% (792/1165) at 5 years of age and 81.6% (292/358) at 11 years of age. The incidence of disability significantly increased for the 358 children followed from 5 to 11 years old (+14.3 percentage points, p<0.0001). Children <1 year old at the time of AHT were more likely to develop disabilities when compared to 2 year olds. CONCLUSIONS AHT is associated with significant long-term disability by age 5 and the incidence increased by age 11 years. There is an association between age at time of AHT and long-term outcomes. Efforts to improve comprehensive follow-up as children continue to age is important. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jordan E Jackson
- Department of Surgery, Division of Pediatric Surgery, University of California, Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, United States.
| | - Alana L Beres
- Department of Surgery, Division of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Christina M Theodorou
- Department of Surgery, Division of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, CA
| | | | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, KY
| | - Miriam Nuño
- Department of Surgery, Division of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, CA.,Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, CA
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14
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Johnson BL, Gerzina EA, Naik-Mathuria B, Wesson DE, Vogel AM, Niedzwecki CM, Fallon SC. What happens after the hospital? An analysis of longitudinal care needs in children treated for child physical abuse. J Pediatr Surg 2021; 56:1696-1700. [PMID: 34167802 DOI: 10.1016/j.jpedsurg.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/10/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Victims of child physical abuse (CPA) undergo stabilization and social evaluation during initial management. Current data guides the initial hospital course, but few studies evaluate post-hospital care. The aim of this study was to evaluate compliance with recommended post-discharge visits. METHODS A retrospective review of our trauma database at a Level I pediatric trauma center from 2014-2018 was performed. Data included demographics, injuries, and longitudinal outcomes. Descriptive statistics and univariate analyses were performed. RESULTS There were 401 patients (409 unique presentations). Median age was 7 months. Mortality was 6%. Ninety-five percent (358/377) had recommended appointments with multiple specialty services. Compliance with all recommended visits during the first year after injury was 88%. Patients with complex injuries were as likely to comply with recommended follow-up [72% vs. 67%, p = 0.4]; however, they were more likely to still be receiving care at 1 year (58% vs. 14%, p = 0.0001). Those discharged to CPS custody were more likely to be compliant with their follow-up (90% vs. 82%, p = 0.03). CONCLUSION Patients significantly injured due to CPA require more post-hospital care over time. CPA management guidelines should include a mechanism to provide resources to these patients and manage multiple coordinating consultants .
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Affiliation(s)
- Brittany L Johnson
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.
| | - Elizabeth A Gerzina
- Department of Medical Education, Baylor College of Medicine, Houston, Texas, USA
| | - Bindi Naik-Mathuria
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - David E Wesson
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Adam M Vogel
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Christian M Niedzwecki
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sara C Fallon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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Binder H, Majdan M, Leitgeb J, Payr S, Breuer R, Hajdu S, Tiefenboeck TM. Management and Outcome of Traumatic Intracerebral Hemorrhage in 79 Infants and Children from a Single Level 1 Trauma Center. CHILDREN (BASEL, SWITZERLAND) 2021; 8:854. [PMID: 34682119 PMCID: PMC8534601 DOI: 10.3390/children8100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traumatic brain injury is a leading form of pediatric trauma and a frequent cause of mortality and acquired neurological impairment in children. The aim of this study was to present the severity and outcomes of traumatic intracerebral bleeding in children and adolescence. METHODS Seventy-nine infants and children with intracerebral bleedings were treated between 1992 and 2020 at a single level 1 trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. The Glasgow Outcome Scale was used to classify the outcome at hospital discharge and at follow-up visits. CT scans of the brain were classified according to the Rotterdam score. RESULTS In total, 41 (52%) patients with intracerebral bleedings were treated surgically, and 38 (48%) patients were treated conservatively; in 15% of the included patients, delayed surgery was necessary. Patients presenting multiple trauma (p < 0.04), higher ISS (p < 0.01), poor initial neurological status (p < 0.001) and a higher Rotterdamscore (p = 0.038) were significantly more often treated surgically. Eighty-three percent of patients were able to leave the hospital, and out of these patients, about 60% showed good recovery at the latest follow-up visit. Overall, 11 patients (14%) died. CONCLUSION The findings in this study verified intracerebral bleeding as a rare but serious condition. Patients presenting with multiple traumas, higher initial ISS, poor initial neurological status and a higher Rotterdamscore were more likely treated by surgery. TRIAL REGISTRATION (researchregistry 2686).
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Affiliation(s)
- Harald Binder
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Johannes Leitgeb
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Stephan Payr
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Robert Breuer
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Stefan Hajdu
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Thomas M. Tiefenboeck
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
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16
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Copley PC, Dean B, Davidson AL, Jackson M, Sokol D. Spontaneous subdural haematoma in a neonate requiring urgent surgical evacuation. Acta Neurochir (Wien) 2021; 163:1743-1749. [PMID: 32920661 PMCID: PMC8116277 DOI: 10.1007/s00701-020-04570-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/03/2020] [Indexed: 11/29/2022]
Abstract
We describe the unusual case of a clinically significant subdural haematoma without any underlying cause in a term baby delivered by an elective caesarean section, which required surgical evacuation. We review the literature and describe the presentation, investigation and management options in infants with this infrequent condition.
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Affiliation(s)
- Phillip Correia Copley
- Department of Neurosurgery, Royal Infirmary of Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK.
| | - Bethan Dean
- Department of Neonatology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Angela L Davidson
- Department of Neonatology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Michael Jackson
- Department of Pediatric Radiology, Royal Hospital for Sick Children, 9 Sciennes Rd, Edinburgh, EH9 1LF, UK
| | - Drahoslav Sokol
- Department of Neurosurgery, Royal Infirmary of Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
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17
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Nikam RM, Kandula VV, Yue X, Krishnan V, Kumbhar SS, Averill LW, Paudyal B, Choudhary AK. Birth-related subdural hemorrhage: prevalence and imaging morphology. Pediatr Radiol 2021; 51:939-946. [PMID: 33830289 DOI: 10.1007/s00247-021-05060-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 02/13/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Birth trauma accounts for 1-2% of the mortality in newborns with significant intracranial injuries presenting in the immediate postnatal period. However, a significant number of asymptomatic neonates harbor birth-related intracranial hemorrhage (ICH), with birth-related subdural hemorrhage (SDH) being a common occurrence on infant brain CT and MRI studies performed as a standard of care for a variety of reasons. Although clinically insignificant, birth-related SDH is frequently brought up in courts as an alternative explanation for SDH in suspected abusive head trauma. OBJECTIVE The aim of this study was to determine prevalence, imaging morphology and distribution of birth-related SDHs on brain CT and MRI studies obtained as a standard of care in infants up to 1 month old. We further tried to ascertain the relationship of birth-related SDHs with mode of delivery and birth weight. MATERIALS AND METHODS Infants up to the age of 1 month who had CT or MRI of the brain performed between Jan. 1, 2018, and March 29, 2020, were included in this retrospective observational study. In addition to the imaging data, we reviewed clinical history, birth history including birth weight and mode of delivery, and final diagnoses. RESULTS Two hundred six infants younger than 30 days (range 0-29 days, mean 11.9 days, median 11 days and standard deviation [SD] 8.4 days) had a CT or MRI study during the study period. Among these, 58 infants were excluded as per the exclusion criteria. Among the included 148 infants, 88 (59.5%) had no imaging evidence of SDH. An additional 56 (37.8%) infants were assessed as having birth-related SDH based on review of clinical data. Within the birth-related SDH cohort (56 infants), only supratentorial SDH was identified in 5 (8.9%), only infratentorial SDH was identified in 14 (25%), while SDHs within both compartments were identified in 37 (66.1%) infants. The most common location for supratentorial birth-related SDH was along the occipital lobes (31/42, 73.8%), with other common locations being along the posterior interhemispheric fissure (30/42, 71.4%) and fronto-parietal convexity (9/42, 21.4%). The distribution of posterior fossa SDH was along the tentorium (38/51, 74.5%), along the cerebellum (38/51, 74.5%) and in both the locations (25/51, 49.0%). The rate of SDH was significantly higher in vaginal delivery group (46/84, 54.7%) as compared to caesarean section group (10/57, 17.5%) (P<0.05). We did not find any statistically significant difference between the birth weights of normal and birth-related SDH cohorts (P>0.05). CONCLUSION Birth-related SDH is a common occurrence, with our study suggesting a prevalence of 37.8%. The most common distribution of birth-related SDH is within both the supra- and infratentorial compartments (66.1%) followed by infratentorial compartment (25%). The rate of birth-related SDH was significantly higher in vaginal delivery group as compared to caesarean section group.
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Affiliation(s)
- Rahul M Nikam
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Vinay V Kandula
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Xuyi Yue
- Katzin Diagnostic & Research PET/MR Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Vijay Krishnan
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Sachin S Kumbhar
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lauren W Averill
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Bishnuhari Paudyal
- Katzin Diagnostic & Research PET/MR Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Arabinda K Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR, USA
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18
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Binder H, Tiefenboeck TM, Majdan M, Komjati M, Schuster R, Hajdu S, Leitgeb J. Management and outcome of traumatic subdural hematoma in 47 infants and children from a single center. Wien Klin Wochenschr 2020; 132:499-505. [PMID: 32333270 PMCID: PMC7518988 DOI: 10.1007/s00508-020-01648-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 03/27/2020] [Indexed: 11/28/2022]
Abstract
Background Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children. It is hypothesized, that with the adequate treatment of SDH in children and adolescence, excellent clinical and functional outcomes can be achieved. The aim of this study was to present the severity and outcome of traumatic SDH in children and adolescence as well as to analyze differences between patients treated surgically and conservatively. Methods In this study 47 infants and children with a subdural hematoma (SDH) were treated between 1992 and 2010 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow outcome scale (GOS) scores at hospital discharge and at follow-up visits were used. Severity of SDH was classified according to the Rotterdam score. Results In total, 47 cases were treated (21 surgically, 26 conservatively), with 10 patients needing delayed surgery. Overall, 89% of the patients were able to leave hospital, 5 patients died, 2 patients (5%) within 24 h, another 2 (5%) after 48 h and 1 (2%) within 7 days. In 25 patients (53%) a good recovery was recorded at the last follow-up visit. Outcome was mainly influenced by the following factors: age, severity of TBI, and neurological status. Overall, in 70% good clinical and neurological outcomes could be achieved. Conclusion The results of this study confirmed that pediatric SDH is a rare, but serious condition. Despite a poor prognosis, most patients could be treated with good outcomes, given that the choice of treatment is correct. Trial registration Research registry 2686 Electronic supplementary material The online version of this article (10.1007/s00508-020-01648-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harald Binder
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas M Tiefenboeck
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Marek Majdan
- International Neurotrauma Research Organization, Vienna, Austria
| | - Micha Komjati
- Department of Orthopaedics, Sacred Heart Hospital of Jesus, Vienna, Austria
| | - Rupert Schuster
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Johannes Leitgeb
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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The medical and social outcome in 2016 of infants who were victims of shaken baby syndrome between 2005 and 2013. Arch Pediatr 2018; 26:21-29. [PMID: 30554853 DOI: 10.1016/j.arcped.2018.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/02/2018] [Accepted: 10/14/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION There are few studies that have investigated the long-term outcome of children who have been victims of shaken baby syndrome (SBS). However, the consequences appear to be significant and the data available from a social point of view are scarce. The main objective of this study was to define the medical and social outcome in 2016 of the infants who were victims of SBS and admitted to one of the Marseille university hospitals. The number of patients followed by a specialized team was evaluated along with their clinical state, living conditions, and whether a social support system such as the Child welfare system had been put into place. METHOD The study was retrospective and descriptive. Patients under 1 year of age who were hospitalized between January 2005 and December 2013 and manifested clinical and paraclinical characteristics enabling the diagnosis of SBS were included in the study. The diagnosis was certain, probable, or possible according to the definitions given by the consensus of the 2011 shaken baby health authority conference (HAS). RESULTS Eighty babies qualified for the study, three of whom died in intensive care. Only ten of these patients (12.9%) had regular (annual) neuropediatric check-up during the whole study period. Thirty-seven patients (48%) had an annual neuropediatric check-up during the first 2 years only following the diagnosis. Only 12 of the children (15.6%) were still being followed after the age of 6. The children were followed up on average for 2.5 years (29.6 months). In 24 cases (31%), the last medical visit revealed an abnormal neurological examination including multiple disabilities due to spastic quadriplegia and severe intellectual deficit, which led to total dependency in half of these cases. Forty-four patients (57%) had a normal neurological examination. Concerning the babies' social outcome, 50 patients (64.9%) had returned home, 12 (15.6%) benefited, from educational assistance at the patient's home (AEMO) following the ruling of a children's judge, and 19 (24.7%) were still placed in foster care (ASE). The average foster care placement lasted 34.7 months. DISCUSSION AND CONCLUSION Long-term medical follow-up for children having sustained serious head injury as a result of abuse is inadequate. Sequelae such as multiple disabilities are less frequent than described in the literature. According to this study, a longer-term follow-up is necessary for children suffering from sequelae such as learning disabilities than what is actually possible in our center.
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Pfeiffer H, Crowe L, Kemp AM, Cowley LE, Smith AS, Babl FE. Clinical prediction rules for abusive head trauma: a systematic review. Arch Dis Child 2018; 103:776-783. [PMID: 29622594 DOI: 10.1136/archdischild-2017-313748] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 02/14/2018] [Accepted: 02/20/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Misdiagnosis of abusive head trauma (AHT) has serious consequences for children and families. This systematic review identifies and compares clinical prediction rules (CPredRs) assisting clinicians in assessing suspected AHT. DESIGN We searched MEDLINE, Embase, PubMed and Cochrane databases (January 1996 to August 2016). Externally validated CPredRs focusing on the detection of AHT in the clinical setting were included. RESULTS Of 110 potential articles identified, three studies met the inclusion criteria: the Pediatric Brain Injury Research Network (PediBIRN) 4-Variable AHT CPredR, the Predicting Abusive Head Trauma (PredAHT) tool and the Pittsburgh Infant Brain Injury Score (PIBIS). The CPredRs were designed for different populations and purposes: PediBIRN: intensive care unit admissions (<3 years) with head injury, to inform early decisions to launch or forego an evaluation for abuse (sensitivity 0.96); PredAHT: hospital admissions (<3 years) with intracranial injury, to assist clinicians in discussions with child abuse specialists (sensitivity 0.72); and PIBIS: well-appearing children (<1 year) in the emergency department with no history of trauma, temperature <38.3°C, and ≥1 symptom associated with high risk of AHT, to determine the need for a head CT scan (sensitivity 0.93). There was little overlap between the predictive variables. CONCLUSION Three CPredRs for AHT were relevant at different stages in the diagnostic process. None of the CPredRs aimed to diagnose AHT but to act as aids/prompts to clinicians to seek further clinical, social or forensic information. None were widely validated in multiple settings. To assess safety and effectiveness in clinical practice, impact analyses are required and recommended.
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Affiliation(s)
- Helena Pfeiffer
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Louise Crowe
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Alison Mary Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Anne S Smith
- Victorian Forensic Paediatric Medical Service, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Congenital Dysfibrinogenemia, An Unusual Cause for Subdural Hematoma in an Infant. J Neurosurg Anesthesiol 2017; 28:439-40. [PMID: 26524418 DOI: 10.1097/ana.0000000000000244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Arterial spin-labeling perfusion imaging of children with subdural hemorrhage: Perfusion abnormalities in abusive head trauma. J Neuroradiol 2017; 44:281-287. [DOI: 10.1016/j.neurad.2017.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/09/2016] [Accepted: 02/12/2017] [Indexed: 11/17/2022]
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Letson MM, Cooper JN, Deans KJ, Scribano PV, Makoroff KL, Feldman KW, Berger RP. Prior opportunities to identify abuse in children with abusive head trauma. CHILD ABUSE & NEGLECT 2016; 60:36-45. [PMID: 27680755 DOI: 10.1016/j.chiabu.2016.09.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 06/06/2023]
Abstract
Infants with minor abusive injuries are at risk for more serious abusive injury, including abusive head trauma (AHT). Our study objective was to determine if children with AHT had prior opportunities to detect abuse and to describe the opportunities. All AHT cases from 7/1/2009 to 12/31/2011 at four tertiary care children's hospitals were included. A prior opportunity was defined as prior evaluation by either a medical or child protective services (CPS) professional when the symptoms and/or referral could be consistent with abuse but the diagnosis was not made and/or an alternate explanation was given and accepted. Two-hundred-thirty-two children with AHT were identified; median age (IQR) was 5.40 (3.30, 14.60) months. Ten percent (22/232) died. Of the 232 patients diagnosed with AHT, 31% (n=73) had a total of 120 prior opportunities. Fifty-nine children (25%) had at least one prior opportunity to identify abuse in a medical setting, representing 98 prior opportunities. An additional 14 (6%) children had 22 prior opportunities through previous CPS involvement. There were no differences between those with and without a prior opportunity based on age, gender, race, insurance, mortality, or institution. Children with prior opportunities in a medical setting were more likely to have chronic subdural hemorrhage (48 vs. 17%, p<0.01) and healing fractures (31 vs. 19%, p=0.05). The most common prior opportunities included vomiting 31.6% (38/120), prior CPS contact 20% (24/120), and bruising 11.7% (14/120). Improvements in earlier recognition of AHT and subsequent intervention might prevent additional injuries and reduce mortality.
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Affiliation(s)
- Megan M Letson
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; The Ohio State University College of Medicine, 370 W. 9th Ave., Columbus, OH 43210, USA.
| | - Jennifer N Cooper
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Katherine J Deans
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; The Ohio State University College of Medicine, 370 W. 9th Ave., Columbus, OH 43210, USA
| | - Philip V Scribano
- The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Building 421, Philadelphia, PA 19104, USA
| | - Kathi L Makoroff
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 3230 Eden Ave., Cincinnati, OH 45267, USA
| | - Kenneth W Feldman
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; University of Washington School of Medicine, 4333 Brooklyn Ave. NE, Seattle, WA 98105, USA
| | - Rachel P Berger
- Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave., Pittsburgh, PA 15224, USA; Safar Center for Resuscitation Research, 3434 Fifth Ave., University of Pittsburgh 15260, USA
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Wharewera-Mika J, Cooper E, Kool B, Pereira S, Kelly P. Caregivers' voices: The experiences of caregivers of children who sustained serious accidental and non-accidental head injury in early childhood. Clin Child Psychol Psychiatry 2016; 21:268-86. [PMID: 26088208 DOI: 10.1177/1359104515589636] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Head injury is a leading cause of mortality and acquired neurological impairment in children. Head-injured children may have neurobehavioural deficits that persist for years following injury. Head injury can result in significant and persistent caregiver burden, including mental health issues, family stress and disorganisation, and unmet social and healthcare service needs. Few studies have examined the healthcare and social service needs of children and their families following head injury sustained at an early age. This qualitative study aims to describe the experiences of caregivers of children who sustained a serious head injury (particularly non-accidental head injury) before the age of 2 years. Caregivers were interviewed up to 15 years following the initial injury. Semi-structured interviews with 21 caregivers of 15 children (aged 3-15 years at the time of interview) were completed. Thematic analysis of interview data generated three key themes: impact, support and information. The study's findings reveal the broad impact of serious childhood head injury on caregivers, specifically the significant distress and burden brought about through lack of information, challenges in accessing support and inconsistent care. Recommendations for developing a quality 'model of care' and improving ease of access to supports for caregivers are provided.
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Affiliation(s)
| | - Erana Cooper
- The Flying Doctors - Ngā Manu Ārahi, Auckland, New Zealand
| | - Bridget Kool
- Section of Epidemiology and Biostatistics, School of Population Health, The University of Auckland, New Zealand
| | - Susana Pereira
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, New Zealand
| | - Patrick Kelly
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, New Zealand Department of Paediatrics, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
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Affiliation(s)
- Jill C Glick
- Department of Pediatrics, University of Chicago; Medical Director, Child Advocacy and Protective Services, University of Chicago Comer Children's Hospital, Chicago, IL
| | - Michele A Lorand
- Division of Child Protective Services, Department of Pediatrics; Medical Director, Chicago Children's Advocacy Center, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL
| | - Kristen R Bilka
- Department of Pediatrics, University of Chicago; Physician Assistant, Child Advocacy and Protective Services, University of Chicago Comer Children's Hospital, Chicago, IL
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McDougall RJ, Barnes R, Danks RA, Ditchfield M. Subdural haematoma following infant spinal anaesthesia. Childs Nerv Syst 2016; 32:579-81. [PMID: 26255150 DOI: 10.1007/s00381-015-2862-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 07/28/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Subdural haematoma (SDH) is rare following spinal anaesthesia and has not been reported previously in an infant. Non-accidental injury is the commonest cause of subdural haematoma in infants. METHODS We describe two cases of SDH following spinal anaesthesia in infants. RESULTS In both cases, forensic investigation was commenced and no evidence of child abuse was found. Both children are well 2 years after diagnosis. CONCLUSION Paediatric health workers should be aware of the possibility of SDH after spinal anaesthesia and consider this as a differential diagnosis when investigating possible non-accidental injury in an infant.
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Affiliation(s)
- Robert J McDougall
- Department of Paediatrics, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Australia.
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, VIC, Australia.
| | | | - R Andrew Danks
- Department of Surgery, Monash University, Clayton, Australia
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Abstract
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
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Hinds T, Shalaby-Rana E, Jackson AM, Khademian Z. Aspects of abuse: abusive head trauma. Curr Probl Pediatr Adolesc Health Care 2015; 45:71-9. [PMID: 25771265 DOI: 10.1016/j.cppeds.2015.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abusive Head Trauma (AHT) is a form of child physical abuse that involves inflicted injury to the brain and its associated structures. Abusive Head Trauma, colloquially called Shaken Baby Syndrome, is the most common cause of serious or fatal brain injuries in children aged 2 years and younger. The American Academy of Pediatrics recommends the term Abusive Head Trauma, as opposed to Shaken Baby Syndrome, as the former term encompasses multiple forms of inflicted head injury (inertial, contact, and hypoxic-ischemic) and a range of clinical presentations and radiologic findings and their sequelae. Children diagnosed with AHT are 5 times more likely to die compared with accidentally head-injured children, yet signs and symptoms are not always obvious, and therefore the diagnosis can be overlooked. Therefore, the American Academy of Pediatrics has tasked pediatricians with knowing how and when to begin an evaluation of children with signs and symptoms that could possibly be due to AHT. Overall, a detailed history of present illness and medical history, recognition of physical and radiological findings, and careful interpretation of retinal pathology are important aspects of formulating the differential diagnoses and increasing or decreasing the index of suspicion for AHT.
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Affiliation(s)
- Tanya Hinds
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eglal Shalaby-Rana
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Allison M Jackson
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Zarir Khademian
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Long-term outcome of abusive head trauma. Pediatr Radiol 2014; 44 Suppl 4:S548-58. [PMID: 25501726 DOI: 10.1007/s00247-014-3169-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/22/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
Abusive head trauma is a severe inflicted traumatic brain injury, occurring under the age of 2 years, defined by an acute brain injury (mostly subdural or subarachnoidal haemorrhage), where no history or no compatible history with the clinical presentation is given. The mortality rate is estimated at 20-25% and outcome is extremely poor. High rates of impairments are reported in a number of domains, such as delayed psychomotor development; motor deficits (spastic hemiplegia or quadriplegia in 15-64%); epilepsy, often intractable (11-32%); microcephaly with corticosubcortical atrophy (61-100%); visual impairment (18-48%); language disorders (37-64%), and cognitive, behavioral and sleep disorders, including intellectual deficits, agitation, aggression, tantrums, attention deficits, memory, inhibition or initiation deficits (23-59%). Those combined deficits have obvious consequences on academic achievement, with high rates of special education in the long term. Factors associated with worse outcome include demographic factors (lower parental socioeconomic status), initial severe presentation (e.g., presence of a coma, seizures, extent of retinal hemorrhages, presence of an associated cranial fracture, extent of brain lesions, cerebral oedema and atrophy). Given the high risk of severe outcome, long-term comprehensive follow-up should be systematically performed to monitor development, detect any problem and implement timely adequate rehabilitation interventions, special education and/or support when necessary. Interventions should focus on children as well as families, providing help in dealing with the child's impairment and support with psychosocial issues. Unfortunately, follow-up of children with abusive head trauma has repeatedly been reported to be challenging, with very high attrition rates.
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McKeag H, Christian CW, Rubin D, Daymont C, Pollock AN, Wood J. Subdural hemorrhage in pediatric patients with enlargement of the subarachnoid spaces. J Neurosurg Pediatr 2013; 11:438-44. [PMID: 23394356 PMCID: PMC8502493 DOI: 10.3171/2012.12.peds12289] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Enlargement of the subarachnoid spaces has been theorized as a risk factor for the development of subdural hemorrhage (SDH). As the finding of unexplained SDH in children often raises suspicion for nonaccidental trauma, the possibility of increased risk of SDH in children with enlargement of the subarachnoid spaces has important clinical, social, and legal implications. Therefore, the authors evaluated the frequency of SDH in a cohort of children with enlargement of the subarachnoid spaces. METHODS The authors identified children younger than 2 years of age who were diagnosed with enlargement of the subarachnoid spaces on MRI or CT scanning in a large primary care network between July 2001 and January 2008. The authors excluded children who had enlargement of the subarachnoid spaces diagnosed on imaging performed for trauma or developmental delay, as well as children with a history of prematurity, diagnosis of intracranial pathology, or metabolic or genetic disorders. Chart review recovered the following data: patient demographics, head circumference, history of head trauma, and head imaging results. For the subset of children with SDH, information regarding evaluation for other injuries, including skeletal survey, ophthalmological examination, and child protection team evaluation, was abstracted. RESULTS There were 177 children with enlargement of the subarachnoid spaces who met the inclusion criteria. Subdural hemorrhage was identified in 4 (2.3%) of the 177 children. All of the children with SDH underwent evaluations for suspected nonaccidental trauma, which included consultation by the child protection team, skeletal survey, and ophthalmological examination. Additional injuries (healing rib fractures) were identified in 1 of 4 patients. None of the 4 children had retinal hemorrhages. Only the child with rib fractures was reported to child protective services due to concerns for abuse. CONCLUSIONS Only a small minority of the patients with enlargement of the subarachnoid spaces had SDH. Evidence of additional injuries concerning for physical abuse were identified in a quarter of the children with enlargement of the subarachnoid spaces and SDH, suggesting that an evaluation for suspected nonaccidental trauma including occult injury screening should be performed in cases of SDH with enlargement of the subarachnoid spaces. In the absence of additional injuries, however, the presence of an unexplained SDH in the setting of enlargement of the subarachnoid spaces may be insufficient to support a diagnosis of nonaccidental trauma.
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Affiliation(s)
- Heather McKeag
- Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts, USA.
| | - Cindy W. Christian
- Department of Pediatrics, The Children’s Hospital of Philadelphia;,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rubin
- Department of Pediatrics, The Children’s Hospital of Philadelphia;,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carrie Daymont
- Department of Pediatrics and Child Health, University of Manitoba;,The Manitoba Institute of Child Health, Winnipeg, Manitoba, Canada
| | - Avrum N. Pollock
- Department of Radiology, The Children’s Hospital of Philadelphia;,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joanne Wood
- Department of Pediatrics, The Children’s Hospital of Philadelphia;,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
The Shaken Baby Syndrome (SBS) is a severe inflicted brain injury due to an adult violently shaking an infant. Diagnostic guidelines have been recently published by the "Haute Autorité de santé". The mortality rate after SBS is 21.6 % and the long-term outcome is good for only 8 to 36 % patients followed over more than 5 years. The aim of this article is to describe sequelae after a SBS, their mechanisms, prognostic factors and recommendations for a better long-term care of the patients.
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Gürer B, Kertmen H, Yilmaz ER, Sekerci Z. The surgical outcome of traumatic extra-axial hematomas causing brain herniation in children. Pediatr Neurosurg 2013; 49:215-22. [PMID: 25073982 DOI: 10.1159/000363193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/20/2014] [Indexed: 11/19/2022]
Abstract
AIM The aim of this study was to assess the surgical outcome and prognostic importance of clinical and radiological data from children operated on under emergency conditions due to an extra-axial hematoma causing brain herniation. METHODS This retrospective study included 25 children operated on due to herniated traumatic extra-axial hematomas from January 2000 to December 2010. RESULTS Of those 25 children, 17 (68%) were diagnosed with subdural hematoma (SDH), 7 (28%) with epidural hematoma (EDH) and only 1 patient (4%) suffered from both SDH and EDH. Overall mortality from a herniated extra-axial hematoma was 44%. The mortality rate for herniated SDH patients was 52.9%, and only 1 patient died from a herniated EDH (14.2%). Low Glasgow coma scale scores at admission, high postoperative intracranial pressure (ICP) values, longer intervals from trauma to surgery, longer durations of brain herniation, the presence of intraoperative brain swelling, larger and thicker hematomas and more displacement of the midline structures and obliteration of the basal cisterns were all correlated with mortality and an unfavorable outcome. CONCLUSIONS Brain herniation is a serious consequence of traumatic extra-axial hematomas in children, and approximately one third of these patients have the potential for a favorable outcome. We recommend postoperative ICP monitoring to predict outcome and early decompressive surgery when possible for promising results.
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Affiliation(s)
- Bora Gürer
- Neurosurgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, Ministry of Health, Istanbul, Turkey
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Friedman J, Reed P, Sharplin P, Kelly P. Primary prevention of pediatric abusive head trauma: a cost audit and cost-utility analysis. CHILD ABUSE & NEGLECT 2012; 36:760-770. [PMID: 23141137 DOI: 10.1016/j.chiabu.2012.07.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/26/2012] [Accepted: 07/30/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost-benefit of a national primary prevention program. METHODS A 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs. RESULTS There were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes. CONCLUSIONS Pediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost-benefit analysis in the field of abusive head trauma prevention.
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Affiliation(s)
- Joshua Friedman
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Private Bag 92024, Auckland 1142, New Zealand
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Pearls and Pitfalls for the Pediatric Emergency Medical Provider in the Evaluation of Abusive Head Trauma. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Goldstein JL, Leonhardt D, Kmytyuk N, Kim F, Wang D, Wainwright MS. Abnormal neuroimaging is associated with early in-hospital seizures in pediatric abusive head trauma. Neurocrit Care 2012; 15:63-9. [PMID: 21042880 DOI: 10.1007/s12028-010-9468-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is a common condition in children. Little is known in this condition regarding the frequency of seizures, the factors associated with increased risk of seizures, or the association of seizures with outcome. We sought to determine frequency and risks for in-hospital seizures after AHT. METHODS This was a single-center, retrospective chart review study at a 270 bed tertiary care referral pediatric hospital. RESULTS A total of 54 cases of AHT were identified during the study period. During the first week following hospital admission, 33% of patients were observed to have clinical seizures. The occurrence of clinical seizures after admission was associated with findings on initial CT including midline shift, cerebral edema, and loss of gray white differentiation. MRI findings associated with clinical seizures after admission included midline shift, cerebral edema, infarction, and restricted diffusion. The presenting complaint of seizures or acute mental status changes well as a variety of abnormal imaging findings including gray white blurring, infarction, and edema were associated with short-term outcomes. CONCLUSIONS Specific neuroradiologic findings identify children at greater risk for seizures, both clinical and subclinical, following AHT. Clinical and subclinical seizures are common in the initial hospitalization for AHT.
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Affiliation(s)
- Joshua L Goldstein
- Division of Neurology no. 51, Department of Pediatrics, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, 2300 Children's Plaza, Chicago, IL 60614, USA.
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Alexiou GA, Sfakianos G, Prodromou N. Pediatric head trauma. J Emerg Trauma Shock 2011; 4:403-8. [PMID: 21887034 PMCID: PMC3162713 DOI: 10.4103/0974-2700.83872] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 11/04/2010] [Indexed: 11/12/2022] Open
Abstract
Head injury in children accounts for a large number of emergency department visits and hospital admissions. Falls are the most common type of injury, followed by motor-vehicle-related accidents. In the present study, we discuss the evaluation, neuroimaging and management of children with head trauma. Furthermore, we present the specific characteristics of each type of pediatric head injury.
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Affiliation(s)
- George A Alexiou
- Department of Neurosurgery, Children's Hospital "Agia Sofia", Athens, Greece
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Guddat SS, Ehrlich E, Martin H, Tsokos M. Fatal spontaneous subdural bleeding due to neonatal giant cell hepatitis: a rare differential diagnosis of shaken baby syndrome. Forensic Sci Med Pathol 2011; 7:294-7. [PMID: 21331818 DOI: 10.1007/s12024-011-9227-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2011] [Indexed: 12/30/2022]
Abstract
A 7-week-old girl showed vomiting after feeding, facial pallor, loss of muscle tone and respiratory depression. An emergency doctor performed successful resuscitation and after arrival in hospital, cranial ultrasound showed left-sided subdural hemorrhage, cerebral edema with a shift of the midline, and a decrease in cerebral perfusion. Ophthalmologic examination showed retinal hemorrhage. In view of this, the doctors suspected shaken baby syndrome and approached the parents with their suspicions, but they denied any shaking or trauma. Despite surgery for the subdural hemorrhage the girl died a few hours later with a severe coagulopathy. Autopsy verified subdural hemorrhage, cerebral edema and retinal hemorrhage, but also revealed intact bridging veins and a lack of optic nerve sheath hemorrhage, therefore shaken baby syndrome could not be proven by autopsy. Histological examination showed severe neonatal giant cell hepatitis as the cause of the severe coagulopathy and the associated spontaneous subdural bleeding. Neonatal giant cell hepatitis may be responsible for unexpected deaths in infancy and, although rarely associated with subdural bleeding, must be considered as a potential differential diagnosis of shaken baby syndrome.
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Affiliation(s)
- Saskia S Guddat
- Institute of Legal Medicine and Forensic Sciences, Charité-Universitätsmedizin Berlin, Turmstr. 21 (Haus L), 10559, Berlin, Germany
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Barnes PD. Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine. Radiol Clin North Am 2011; 49:205-29. [PMID: 21111136 DOI: 10.1016/j.rcl.2010.08.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Because of the controversy involving the determination of child abuse, or nonaccidental injury (NAI), radiologists must be familiar with the issues, literature, and principles of evidence-based medicine to understand the role of imaging. Children with suspected NAI must receive protective evaluation along with a timely and complete clinical and imaging work-up. Imaging findings cannot stand alone and must be correlated with clinical findings, laboratory testing, and pathologic and forensic examinations. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive clinical, imaging, biomechanical, or pathology findings.
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Affiliation(s)
- Patrick D Barnes
- Department of Radiology, Lucile Packard Children's Hospital, Stanford University Medical Center, 725 Welch Road, Palo Alto, CA 94304, USA.
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Adamo MA, Drazin D, Smith C, Waldman JB. Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes. J Neurosurg Pediatr 2009; 4:414-9. [PMID: 19877772 DOI: 10.3171/2009.6.peds0939] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions. METHODS A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores. RESULTS There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13-15 (OR 6.95), and the patients with NATs with of GCS scores 9-12 (OR 6.83) and 3-8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up. CONCLUSIONS Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.
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Affiliation(s)
- Matthew A Adamo
- Department of Neurosurgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennyslvania 15213, USA.
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Intrauterine subdural hemorrhage in a preterm neonate possibly associated with maternal low-molecular weight heparin treatment. J Perinatol 2009; 29:521-3. [PMID: 19556984 DOI: 10.1038/jp.2008.248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report intrauterine subdural hemorrhage in a preterm infant delivered by cesarean section at 32 weeks following vaginal bleeding of a mother treated with low-molecular weight heparin (LMWH) for deep vein thrombosis. The subdural hematomas were partially calcified, proving antenatal occurrence. Maternal trauma during pregnancy, intrauterine infection, cerebral vascular malformation and congenital coagulopathy as known etiologies of subdural hemorrhage could be ruled out. Intrauterine subdural hemorrhage may be an exceptional complication of maternal LMWH treatment.
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Long-term outcome of the shaken baby syndrome and medicolegal consequences: A case report. Ann Phys Rehabil Med 2009; 52:436-47. [DOI: 10.1016/j.rehab.2009.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 03/20/2009] [Indexed: 11/23/2022]
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Abstract
Child physical abuse that results in injury to the head or brain has been described using many terms, including battered child syndrome, whiplash injuries, shaken infant or shaken impact syndrome, and nonmechanistic terms such as abusive head trauma or nonaccidental trauma. These injuries sustained by child abuse victims are discussed in detail in this article, including information about diagnosis, management and outcomes. The use of forensics, the use imaging studies, and associated injuries are also detailed.
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Affiliation(s)
- Antonia Chiesa
- Department of Pediatrics, Kempe Child Protection Team, The Children's Hospital, 13123 E. 16th Avenue, Box 138, Denver, CO 80045, USA.
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Abstract
PURPOSE OF REVIEW The authors discuss the significance of studies published over the previous year regarding assessment and treatment and prevention of child maltreatment, including physical and sexual abuse, inflicted traumatic brain injury, and child neglect. RECENT FINDINGS The evidence base for many forms of child abuse is growing. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented. In response to a very public reprimand by the General Medical Council of two child abuse pediatricians, which was felt by many to be unwarranted, the UK government re-emphasized its commitment to the protection of children. In the US, this well-publicized set of events has renewed the medical community's commitment to the recognition of child abuse pediatrics as a formal subspecialty. Several authors detail the short-term and long-term outcome of varying forms of abuse for children as they grow into adults, reinforcing the importance of community efforts to prevent abuse and support families during times of heightened stress such as the current war in Iraq. SUMMARY The short-term and long-term impact of child maltreatment is significant not only for individuals, but for families and communities where abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children.
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Abstract
Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Abusive head injuries are among the most common causes of serious and lethal injuries in children. These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration/ deceleration movements, which may create inertial movement of the brain within the cranial compartment.
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