Inflicted Head Injury Research Articles

Neuropathology of inflicted head injury in children: II. Microscopic brain injury in infants

There are very few reports in the literature dealing with the neuropathology of infant head injury, and the question of whether diffuse traumatic brain damage [diffuse axonal injury (DAI)] occurs in such children has not yet been reliably established by detailed neuropathological studies. We report the findings in the brains of a series of 37 infants aged 9 months or less, all of whom died from inflicted head injuries, and 14 control infants who died of other causes. Axonal damage was identified using immunohistochemistry for beta-amyloid precursor protein. Full clinical details were available for each case, the most constant of which in the study cohort was an episode of significant apnoea at presentation, found to have been recorded in 75% of cases. Global hypoxic damage was the most common histological finding. Widespread axonal damage, interpreted as vascular, was present in 13 cases, but widespread traumatic axonal injury was found in only two children, both of whom had severe head injuries with multiple skull fractures. Epidural cervical haemorrhage and focal axonal damage to the brainstem and the spinal nerve roots, found in 11 cases but not in controls, indicate that the craniocervical junction is vulnerable in infant head injury, the neuropathology being that of stretch injury from cervical hyperextension/flexion. Damage to this region could account for the observed apnoea, which could in turn lead to hypoxic damage and brain swelling. The observation that the predominant histological abnormality in cases of inflicted head injury in the very young is diffuse hypoxic brain damage, not DAI, can be explained in one of two ways: either the unmyelinated axon of the immature cerebral hemispheres is relatively resistant to traumatic damage, or in shaking-type injuries the brain is not exposed to the forces necessary to produce DAI.

Brain Damage Following Inflicted Head Injury

Detailed neuropathological studies, including immunocytochemistry for microscopic damage, are reported in 53 cases of non-accidental head injury in children examined by 2 neuropathologists at the Universities of London and Sheffield, UK.

Neuropathology of inflicted head injury in children. I. Patterns of brain damage.

Fifty-three cases of non-accidental head injury in children were subjected to detailed neuropathological study, which included immunocytochemistry for microscopic damage. Clinical details were available for all the cases. There were 37 infants, age at head injury ranging from 20 days to 9 months, and 16 children (range 13 months to 8 years). The most common injuries were skull fractures (36% of cases), acute subdural bleeding (72%) and retinal haemorrhages (71%); the most usual cause of death was raised intracranial pressure secondary to brain swelling (82%). On microscopy, severe hypoxic brain damage was present in 77% of cases. While vascular axonal damage was found in 21 out of 53 cases, diffuse traumatic axonal injury was present in only three. Eleven additional cases, all of them infants, showed evidence of localized axonal injury to the craniocervical junction or the cervical cord. When the data were analysed by median age at head injury, statistically significant patterns of age-related damage emerged. Our study shows that infants of 2-3 months typically present with a history of apnoea or other breathing abnormalities, show axonal damage at the craniocervical junction, and tend also to have a skull fracture, a thin film of subdural haemorrhage, but lack extracranial injury. Children over 1 year are more likely to suffer severe extracranial, particularly abdominal, injuries. They tend to have larger subdural haemorrhages, and where traumatic axonal injury is present, show patterns of hemispheric white matter damage more akin to those reported in adults. Diffuse axonal injury is an uncommon sequel of inflicted head injury in children.

Neurotrauma in Infants: Shaken Impact Syndrome (Inflicted Head Injury)

In summary, inflicted cerebral trauma is a devastating but ultimately preventable brain injury caused by unique physiologic mechanisms that result in a distinctive pattern of injury. Nurses in a variety of settings, from the clinic and emergency room to the pediatric intensive care unit, play a major role in the identification, documentation, diagnosis, treatment, and prevention of ICT. The nurse's unique training also promotes prevention education and nonjudgmental support of the family.

Fatal Physical Child Abuse in Two Children of a Family

Fatal Physical Child Abuse in Two Children of a Family

Nonaccidental head injury in infants--the "shaken-baby syndrome".

Trauma is the most common cause of death in childhood, and inflicted head injury is the most common cause of traumatic death in infancy.1–3 Beginning with the classic descriptions of Kempe et al.4 and Caffey5 and with subsequent clinical, biomechanical, and radiologic studies, the diagnostic features of nonaccidental head injury in infants and toddlers have become widely recognized. This review outlines the mechanisms, typical features, differential diagnosis, and acute management of the most frequently encountered form of infantile inflicted head injury, the so-called shaken-baby syndrome. Biomechanics and Terminology The names applied to the syndromes of inflicted head injury in . . .

Inflicted versus accidental head injury in critically injured children.

To assess the frequency of inflicted head injury in critically injured children; the severity of neurologic injury; the neurologic outcome; and the historical, socioeconomic, physical, and radiologic factors associated with inflicted head injury. Prospective clinical study. Multidisciplinary pediatric intensive care unit (ICU). Consecutive cases (n = 40) of severe head injury admitted to a pediatric ICU. None. Fourteen (35%) of 40 cases of head injury were due to inflicted head injury. Eleven (79%) of 14 inflicted head injury cases were due to child abuse and three (21%) were due to neglect. The severity of neurologic injury, as measured by the admission Glasgow Coma Scale, was worse in cases of inflicted head injury (7.1 +/- 0.7 [SE] [inflicted] vs. 9.9 +/- 0.8 [accidental]; p = .04). Glasgow Outcome Scores were worse after inflicted head injury (2 +/- 1 inflicted] vs. 4 +/- 1 [accidental]; p = .004). In victims of child abuse, we found the combination of any two of the following three factors was associated with inflicted head injury: an inconsistent history/physical examination; retinal hemorrhages; or parental risk factors (alcohol or drug abuse, previous social service intervention within the family, or a past history of child abuse or neglect). This study confirms that severity of neurologic injury and neurologic outcome in cases of inflicted head injury are worse than in any other type of childhood head injury. We believe that a combination of any two of the above three risk factors may prove to be a reliable marker of inflicted head injury in children admitted to a pediatric ICU and will lead to an early and definitive diagnosis.