NON ACCIDENTAL HEAD INJURY in CHILDREN

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NON ACCIDENTAL HEAD INJURY in CHILDREN

• Various terms are used abusive head trauma,
  inflicted brain injury, non accidental injury
  and shaken baby syndrome
• Leading cause of infant death from injury
• Impact and non-impact (shaken)

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Non Accidental Head injury

• The Battered Child Syndrome Kempe et al 1962
• The whiplash shaken infant syndrome manual
  shaking by the extremities with whiplash induced
  intracranial and intraocular bleeding, linked
  with residual permanent brain damage and mental
  retardation John Caffey 1974

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EPIDEMIOLOGY

• Scottish study 25 cases/100,000 childrenlt1
• United Kingdom SDH 21/100,000lt1 year
• United Kingdom SDH 13/100,000lt2 year
• North Carolina incidence 17/100,000lt2 year with a
  fatality rate of 22 (3-4/100,000)

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NON ACCIDENTAL HEAD INJURY IN CHILDREN SYDNEY
EXPERIENCE

• J Neurosurgery (Paediatrics ) 103213-218, 2005
• Examined the demographics, clinical
  radiological features and clinical outcomes of
  presumed NAI of 65 consecutive cases

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Triad of shaken baby syndromeJohn Caffey

• Subdural haematomas
• Little signs of external trauma
• Retinal haemorrhages
• Other red flags might be changing history and
  incompatible history when there is no history
  of trauma or only minor trauma with subdural
  haematomas retinal haemorrhages the PPV for
  abuse is 0.92

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Diagnosis

• There is no diagnostic test for non accidental
  injury
• The diagnosis is made on a balance of probability
• Careful exclusion of other possible causes eg
  accidental injury and medical conditions ( rare
  metabolic disorders, coagulation disorders,
  infective encephalopathies etc)

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Diagnosis

• Established by a multidisciplinary team of CPU,
  neurosurgical, neurology, paediatric,
  ophthalmology and radiology staff
• Detailed family interviews
• Exclusion of underlying diseases and accidental
  injuries

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Total 65

• Range 0.5-46 months
• Age 8.2 months (mean)
• MF 3926

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Perpetrators

• Known in 41/65 cases and usually the male partner
  (70)
• Maternal age 22.6
• Male partner 24.5
• Risk factors family disruption, separation in 50
  cases
• History of abuse of the child or another family
  member in 24

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Family Dynamics

• There was a high incidence of family
  disruption, substance abuse and prematurity

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Seizures

• 35 patients out of the 65 had seizures on
  admission or a preceding history before admission
  and 17 had epilepsy on follow up

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Skull Fractures

• Were seen in 36.9 of cases

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Retinal Haemorrhages

• Seen in 60 of cases and most were bilateral

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Retinal Haemorrhages

• The subject of controversy. When associated with
  trauma almost always inflicted injury. But can be
  associated with increased ICP, coagulopathies,
  spontaneous SAH, retinal dysplasia, retinopathy
  of prematurity, galactosaemia, glutaric aciduria
  and hypertension as well as severe accidental
  head injury

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A History of Trauma

• Was given in 31 cases (50) but the mechanism
  of trauma was inconsistent with the childs
  development in the majority of cases (70)
• Scalp haematomas 30
• Facial bruising 40
• Truncal bruising limb bruising 20

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Presenting symptoms prior to admission for the 65
cases

• Seizures, irritability, breathing problems
  lethargy, apnoea, sleepy, arrest, poor feeding
  and failure to thrive, vomiting, a big head and
  coma.
• Apnoea (rib fractures) and retinal
  haemorrhages have a high odds ratio for
  association with inflicted head injury a
  systematic review 2009 (literature review
  1970-2008)

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Level of consciousness on admission
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Other Injuries

• Rib fractures collapsed lung
• Abdominal trauma (hepatic renal)
• Burns to forearm, limbs trunk
• Skeletal injuries gt 50
• ( often occult)

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Skeletal Injuries (60)

• gt 50 investigated found to have positive bone
  scans or skeletal survey, although clinical
  evidence for these injuries existed in only 20
• Multiple areas of skeletal injury in 30
• Limb fractures in 40
• Rib fractures 30
• Facial fractures
• Spinal fractures

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Admission to Non-accidental Injury

• Was made at some stage during the hospitalization
  in only 14 cases

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Hospital Stay

• The mean duration of stay was 18 days
• Range 1-127 days
• Ventilation required in 30 cases (46)

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Neuro Imaging

• CT Scan - all patients had at least one CT head
  scan
• MRI Scan - 37 patients (57) also had MRI scans
• MRI scanning picked up hypoxic changes,
  infarction, shearing injury, cerebral contusion
  haemorrhage, small subdural haematomas and
  subarachnoid haemorrhage not seen on CT

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MRI Scanning

• In summary MRI scans revealed additional
  pathological findings not visible on CT scanning
  in 18(49) of 37 children
• Investigation of choice

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CT and MRI

• Subdural haematoma 53
  
• Cerebral oedema or ischaemia 22
• Cerebral contusion
  21
• Skull fracture
  24
• Subarachnoid haemorrhage 12
• Extradural haematoma 1

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Characteristics of subdural haematoma

• Cerebral convexity 45
• Inter-hemispheric 23
• Posterior fossa 14
• Multiple locations 34
• Acute
  10
• Chronic
  16
• Differing ages 27

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Surgical Procedures

• A total of 35 operations were performed in 17
  children mainly for subdural and further subdural
  recollection

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Surgical Procedures

• Burr-hole drainage of subdural 21
• Insertion of subdural shunt 6
• Insertion of ventricular shunt 2
• External ventricular drain 1
• Removal of shunt 1
• Craniotomy
  4

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Glasgow Outcome Score

• 1 Dead
  4
• 2 Vegetative
  7
• 3 Severe Disability 17
• 4 Moderate Disability 12
• 5 Good
  25

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Care Arrangements

• After discharge were known for 59 cases and 29
  were placed into foster care, 16 to care of
  relatives and 14 to care of parent

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Statistical Analysis

• Patients were categorized as having a poor
  outcome if their GOS was 3 or less and a good
  outcome if 4 or 5 (for statistical analysis)
• The only statistically significant correlation
  was seen between CT or MRI findings of ischemia
  or oedema and outcome

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Poor Outcome

• If there were radiological findings of cerebral
  ischemia or oedema

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Discussion

• Risk factors included young parents, unstable
  family situations, low socioeconomic status and
  prematurity
• The epidemiological characteristics consistent
  with published data
• The most frequent perpetrators were the fathers
  and the maternal male partners

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Discussion

• In 24 of cases the families were already known
  to have a history of abuse
• The presentation of NAI or inflicted head injury
  can be subtle and non specific
• An association was seen between the radiological
  findings of ischemia or oedema and outcome

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Discussion

• Mortality 6 and severe disability or vegetative
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• The outcome in this study compares favourably
  with published data
• Recurrence of subdural collections occurs in
  nearly half of the cases treated with burr-hole
  drainage

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Conclusions

• Non specific clinical presentation
• Routine use of MRI to detect ischemia
• Routine screening of NAI with bone scans
• High rate of subclinical (occult) skeletal
  injuries
• Recurrence of subdural haematomas after surgery
• Families with history of abuse