Crush head injuries in infants and young children neurologic and neuropsychologic sequelae

Neuroimaging considerations in abusive head trauma

This focused review on abusive head trauma describes the injuries to the head, brain and/or spine of an infant or young child from inflicted trauma and their neuroimaging correlates. Accurate recognition and diagnosis of abusive head trauma is paramount to prevent repeated injury, provide timely treatment, and ensure that accidental or underlying medical contributors have been considered. In this article, we aim to discuss the various findings on neuroimaging that have been associated with AHT, compared to those that are more consistent with accidental injuries or with underlying medical causes that may also be on the differential.

A baby carrier fall leading to intracranial bleeding and multilayered retinal hemorrhages

Significant intracranial and retinal hemorrhages are often seen in infants with abusive head trauma, although accidental injury and previously undiagnosed medical disorders are important considerations in the differential diagnosis. We present the case of an infant with confirmed accidental trauma sustained from an adult-worn baby carrier fall with superimposed head crush injury, which resulted in significant cranial, intracranial, and retinal findings.

What About the Little Ones? Systematic Review of Cognitive and Behavioral Outcomes Following Early TBI

There is increasing empirical focus on the effects of early traumatic brain injuries (TBI; i.e., before the age of six years) on child development, but this literature has never been synthetized comprehensively. This systematic review aimed to document the cognitive, academic, behavioral, socio-affective, and adaptive consequences of early TBI. Four databases (Medline, PsycNET, CINAHL, PubMed) were systematically searched from 1990 to 2019 using key terms pertaining to TBI and early childhood. Of 12, 153 articles identified in the initial search, 43 were included. Children who sustain early TBI are at-risk for a range of difficulties, which are generally worse when injury is sustained at a younger age, injury severity is moderate to severe, and injury mechanisms are non-accidental. Early childhood is a sensitive period for the emergence and development of new skills and behaviors, and brain disruption during this time is not benign. Research, clinical management, intervention, and prevention efforts should be further developed with consideration of the unique characteristics of the early childhood period.

3 Cases of Inflicted Skull Crush Injuries in Infants

ABSTRACT

We describe 3 infants with skull fractures that involved more than 1 skull bone. On further evaluation, 2 of the 3 infants had additional fractures at other sites of the body and the third infant had concerning bruising of the face. Although an accidental mechanism of injury was initially given as the history in each case, law enforcement investigations led all 3 fathers to confess to crushing their infants' skulls out of frustration. These crushes were caused by their arms or hands. Bilateral skull fractures or those involving more than 1 skull bone can be seen in falls as well as in crush injuries. A crush-like pattern of injury, in the absence of a clear and plausible accidental mechanism, should raise concerns for possible physical abuse especially in nonambulatory infants.

Children and youth with 'unspecified injury to the head': implications for traumatic brain injury research and surveillance

Background

The case definition for traumatic brain injury (TBI) often includes ‘unspecified injury to the head’ diagnostic codes. However, research has shown that the inclusion of these codes leads to false positives. As such, it is important to determine the degree to which inclusion of these codes affect the overall numbers and profiles of the TBI population. The objective of this paper was to profile and compare the demographic and clinical characteristics, intention and mechanism of injury, and discharge disposition of hospitalized children and youth aged 19 years and under using (1) an inclusive TBI case definition that included ‘unspecified injury to the head’ diagnostic codes, (2) a restricted TBI case definition that excluded ‘unspecified injury to the head ‘diagnostic codes, and (3) the ‘unspecified injury to the head’ only case definition.

Methods

The National Ambulatory Care Reporting System and the Discharge Abstract Database from Ontario, Canada, were used to identify cases between fiscal years 2003/04 and 2009/10.

Results

The rate of TBI episodes of care using the inclusive case definition for TBI (2,667.2 per 100,000) was 1.65 times higher than that of the restricted case definition (1,613.3 per 100,000). ‘Unspecified injury to the head’ diagnostic codes made up of 39.5 % of all cases identified with the inclusive case definition. Exclusion of ‘unspecified injury to the head’ diagnostic code in the TBI case definition resulted in a significantly higher proportion of patients in the intensive care units (p < .0001; 18.5 % vs. 22.2 %) and discharged to a non-home setting (p < .0001; 9.9 % vs. 11.6 %).

Conclusion

Inclusion of ‘unspecified injury to the head’ diagnostic codes resulted in significant changes in numbers, healthcare use, and causes of TBI. Careful consideration of the inclusion of ‘unspecified injury to the head’ diagnostic codes in the case definition of TBI for the children and youth population is important, as it has implications for the numbers used for policy, resource allocation, prevention, and planning of healthcare services. This paper can inform future work on reaching consensus on the diagnostic codes for defining TBI in children and youth.

Defining pediatric traumatic brain injury using International Classification of Diseases Version 10 Codes: a systematic review

BACKGROUND

Although healthcare administrative data are commonly used for traumatic brain injury (TBI) research, there is currently no consensus or consistency on the International Classification of Diseases Version 10 (ICD-10) codes used to define TBI among children and youth internationally. This study systematically reviewed the literature to explore the range of ICD-10 codes that are used to define TBI in this population. The identification of the range of ICD-10 codes to define this population in administrative data is crucial, as it has implications for policy, resource allocation, planning of healthcare services, and prevention strategies.

METHODS

The databases MEDLINE, MEDLINE In-Process, Embase, PsychINFO, CINAHL, SPORTDiscus, and Cochrane Database of Systematic Reviews were systematically searched. Grey literature was searched using Grey Matters and Google. Reference lists of included articles were also searched for relevant studies. Two reviewers independently screened all titles and abstracts using pre-defined inclusion and exclusion criteria. A full text screen was conducted on articles that met the first screen inclusion criteria. All full text articles that met the pre-defined inclusion criteria were included for analysis in this systematic review.

RESULTS

A total of 1,326 publications were identified through the predetermined search strategy and 32 articles/reports met all eligibility criteria for inclusion in this review. Five articles specifically examined children and youth aged 19 years or under with TBI. ICD-10 case definitions ranged from the broad injuries to the head codes (ICD-10 S00 to S09) to concussion only (S06.0). There was overwhelming consensus on the inclusion of ICD-10 code S06, intracranial injury, while codes S00 (superficial injury of the head), S03 (dislocation, sprain, and strain of joints and ligaments of head), and S05 (injury of eye and orbit) were only used by articles that examined head injury, none of which specifically examined children and youth.

CONCLUSION

This review provides evidence for discussion on how best to use ICD codes for different goals. This is an important first step in reaching an appropriate definition and can inform future work on reaching consensus on the ICD-10 codes to define TBI for this vulnerable population.

Distinguishing accidental from inflicted head trauma at autopsy

This article will discuss accidental and inflicted head injuries in infants and young children and how forensic pathologists distinguish between these types of injuries. The article begins with a consideration of the special and unique features of the anatomy and development of the child's head and neck and then relates these features to the mechanisms of traumatic brain injury and how these unique features influence the mechanisms of injury. The article very specifically notes that accidental head injuries in young children that occur in and around the home are focal head injuries in distinction to inflicted head injuries, which are diffuse brain injuries. The article discusses the mechanisms by which traumatic brain injury causes loss of consciousness and relates those mechanisms to the differences in the clinical features that occur in both accidental and inflicted head injury. The article discusses and illustrates the pathological findings in accidental head injuries consisting of the crushing head injuries and the head injuries sustained in short falls including epidural hemorrhage and focal subdural hemorrhage. The article discusses and illustrates the pathological findings that occur in inflicted head trauma, including subdural and subarachnoid hemorrhages and retinal and optic nerve sheath hemorrhages.

Pediatric crushing head injury: biomechanics and clinical features of an uncommon type of craniocerebral trauma

BACKGROUND

Head injuries constitute one of the leading causes of pediatric morbidity and mortality. Most injuries result from accidents involving an acceleration/deceleration mechanism. However, a special type of head injury occurs when the children sustain a traumatism whose main component is a static load in relation to a crushing mechanism with the head relatively immobile.

PATIENTS AND METHODS

We report a series of children who sustained a craniocerebral injury of variable severity produced by head crushing. We also analyze epidemiological and clinical data, and biomechanics in these injuries.

RESULTS

Mean age of the group (13 boys/6 girls) was 4.1 years. All patients showed external lesions (scalp wounds or hemorrhage from the nose, ears, or throat). Eleven children were initially unconscious. Six children presented cranial nerve deficits in addition to impaired hearing. Skull base fractures were seen in most cases with extension to the vault in 11 instances. Fourteen patients had an associated intracranial lesion, including two with diffuse axonal injury. Surgery was performed in three instances. Only seven patients were left with sequelae.

DISCUSSION AND CONCLUSIONS

The observed skull, brain, and cranial nerve lesions corresponded to a mechanism of bilateral compression of the children's heads mainly occasioned by a static load, although an associated component of dynamic forces was also involved. The skull and its covering and the cranial nerves were the most severely affected structures while the brain seemed to be relatively well preserved. Most crush injuries appear to be preventable by the appropriate supervision of the children.

Recommendations for the use of common outcome measures in pediatric traumatic brain injury research

This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroup's recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Defining neurotrauma in administrative data using the International Classification of Diseases Tenth Revision

Background

It is essential to use a definition that is precise and accurate for the surveillance of traumatic brain injuries (TBI) and spinal cord injuries (SCI). This paper reviews the International Classification of Diseases 10^th revision (ICD-10) definitions used internationally to inform the definition for neurotrauma surveillance using administrative data in Ontario, Canada.

Methods

PubMed, Web of Science, Medline and the grey literature were searched for keywords "spinal cord injuries" or "brain injuries" and "international classification of diseases". All papers and reports that used an ICD-10 definition were included. To determine the ICD-10 codes for inclusion consensus across papers and additional evidence were sought to look at the correlation between the condition and brain or spinal injuries.

Results

Twenty-four articles and reports were identified; 15 unique definitions for TBI and 7 for SCI were found. The definitions recommended for use in Ontario by this paper are F07.2, S02.0, S02.1, S02.3, S02.7, S02.8, S02.9, S06, S07.1, T90.2, and T90.5 for traumatic brain injuries and S14.0, S14.1, S24.0, S24.1, S34.1, S34.0, S34.3, T06.0, T06.1 and T91.3 for spinal cord injuries.

Conclusions

Internationally, inconsistent definitions are used to define brain and spinal cord injuries. An abstraction study of data would be an asset in understanding the effects of inclusion and exclusion of codes in the definition. This paper offers a definition of neurotrauma for surveillance in Ontario, but the definition could be applied to other countries that have mandated administrative data collection.

Crush injuries and crush syndrome — a review. Part 1: the systemic injury

Crush injuries can occur in large numbers following natural disasters or acts of war and terrorism. They can also occur sporadically after industrial accidents or following periods of unconsciousness from drug intoxication, anaesthesia, trauma or cerebral events. A common pathophysiological pathway has been elucidated over the last century describing traumatic rhabdomyolysis leading to myoglobinuric acute renal failure and a systemic ‘crush syndrome’ affecting many organ systems. If left unrecognised or untreated, then mortality rates are high. If treatment is commenced early and the systemic effects are minimised then patients are often faced with significant morbidity from the crushed limbs themselves. We have performed a thorough review of the English language literature from 1940 to 2009 investigating crush injuries and crush syndrome and present a comprehensive, two-part summary. Part 1: The systemic injury: In this part we concentrate on the systemic crush syndrome. We determine the pathophysiology, clinical and prognostic indicators and treatment options such as forced alkaline diuresis, mannitol therapy, dialysis and haemofiltration. We discuss more controversial treatment options such as allopurinol, potassium binders, calcium therapy and other diuretics. We also discuss the specific management issues of the secondary ‘renal disaster’ that can occur following earthquakes and other mass disasters. Part 2: The local injury: Here we look in more detail at the pathophysiology of skeletal muscle damage following crush injuries and discuss how to minimise morbidity by salvaging limb function. In particular we discuss the controversies surrounding fasciotomy of crushed limbs and compare surgical management with conservative techniques such as mannitol therapy, hyperbaric oxygen therapy, topical negative pressure therapy and a novel topical treatment called gastric pentadecapeptide BPC 157.

Accidental traumatic head injury in infants and young children

This article will discuss accidental head injuries in infants and young children. The first category of injury is the crushing head injury. Static forces applied slowly to the head result in multiple fractures of the skull and contusions and lacerations of the brain resulting from the bone fragments striking the brain. This article will discuss the subject of short falls in young children and the resulting head injuries. Because falls are frequent events in early life, many cases have been collected and many papers written on the subject. Study of these cases is informative about the injuries likely to occur in these falls. Most often, only a minor contact injury such as scalp bruise or laceration results. In a 2 to 3% of falls, a simple linear skull fracture occurs and the majority of these are uneventful in terms of neurological deficit or intracranial bleeding. In about 1% of the fractures, an epidural or subdural hemorrhage occurs. Each of these forms of contact hemorrhages will be discussed and illustrated. While these are relatively rare injuries, it is essential that they can be identified as consistent with an accidental mechanism so that an erroneous diagnosis of inflicted injury is not made.

Clinical analysis of seven patients of crushing head injury

BACKGROUND

Crushing head injuries (CHI) are caused by static loading. This static force slowly deforms a cranium and damages some intracranial components. Severe CHI is usually fetal but substantial brain damage may not be recognized in some patients. In this article, we report seven patients who sustained CHI and analyzed clinical and radiological findings.

METHODS

In seven patients who sustained CHI, the following factors were analyzed: epidemiological features, neurological findings, and neuroradiological findings.

RESULTS

The present series included three males and four females. Mean age was 5.9 years. Six patients had the heads run over by automobiles. One patient had the head crushed by press machine. Epistaxis in six patients and otorrhagia in five patients was recognized. Mean Glasgow coma scale at admission was 8.1. Multiple linear fractures were recognized in four patients and skull base fractures in six patients. Pneumocephalus in five patients and cerebrospinal fluid leakage in seven patients was recognized. One patient underwent evacuation of ASDH and dural plasty. Four patients died and three survived and had only cranial nerve palsies, which recovered completely.

CONCLUSION

This injury actually has seldom been countered in daily practice and clinical manifestation and neuroimaging have characteristic features. The prognosis of CHI may be polarized to fatal or excellent, and depends on whether the cranium and brain itself can tolerate the applied force.

Ocular manifestations of crush head injury in children

AIMS

To review the ocular manifestations of crush head injuries in children.

METHODS

Retrospective clinical and pathological reviews. Group 1: A total of 16 children admitted with crush head injuries from television tip over. Group 2: Nine autopsy findings in crush head injury.

RESULTS

Group 1: A total of 11 children had fundus examination: three by neurosurgeons, eight by ophthalmologists. Scattered posterior pole preretinal and blot haemorrhages extending to mid equator region observed in one child. No evidence of traumatic retinoschisis or retinal folds in any patient. Group 2: All with multiple skull fractures and six with subdural haemorrhage. Posterior pole retinal haemorrhages in four children, extending to the ora serrata in one after motor vehicle accident. No child had retinal folds. Subinternal limiting membrane haemorrhages in three children. Optic nerve sheath haemorrhage in three children.

CONCLUSIONS

Intraretinal and preretinal haemorrhages, predominantly in the posterior pole, can occur in crush injury to the paediatric head. Haemorrhage under the internal limiting membrane or extending to the ora serrata were only seen in situations where crush injury was part of a fatal trauma scenario related to motor vehicles. Retinal folds and the typical macular retinoschisis associated with abusive head injury were not observed.

Bitemporal head crush injuries: clinical and radiological features of a distinctive type of head injury

OBJECT

Most craniocerebral injuries are caused by mechanisms of acceleration and/or deceleration. Traumatic injuries following progressive compression to the head are certainly unusual. The authors reviewed clinical and radiological features in a series of patients who had sustained a special type of cranial crush injury produced by the bilateral application of rather static forces to the temporal region. Their aim was to define the characteristic clinical features in this group of patients and to assess the mechanisms involved in the production of the cranial injuries and those of the associated cerebral and endocrine lesions found in this peculiar type of head injury.

METHODS

Clinical records of 11 patients were analyzed with regard to the state of consciousness, cranial nerve involvement, findings on neuroimaging studies, endocrine symptoms, and outcome. Furthermore, an experimental model of bitemporal crush injury was developed by compressing a dried skull with a carpenter's vice. Seven of the 11 patients were 16 years old or younger. All patients presented with a characteristic clinical picture consisting of no loss of consciousness (six patients), epistaxis (nine patients), otorrhagia (11 patients), peripheral paralysis of the sixth and/or seventh cranial nerves (10 patients), hearing loss (five patients), skull base fractures (11 patients), pneumocephalus (11 patients), and diabetes insipidus (seven patients). Ten patients survived the injury and most recovered neurological function.

CONCLUSIONS

Static forces applied to the head in a transverse axis produce fractures in the skull base that cross the midline structures without producing significant cerebral damage. Stretching of cranial nerves at the skull base explains the nearly universal finding of paralysis of these structures, whereas an increase in the vertical diameter of the skull accounts for the occurrence of diabetes insipidus in the presence of an intact function of the anterior pituitary lobe. The association of clinical, endocrine, and neuroimaging findings encountered in this peculiar type of head injury supports the idea that this subset of injured patients has a distinctive clinical condition, namely the syndrome of bitemporal crush injury to the head.