Clinical predictors of outcome following inflicted traumatic brain injury in children
ABSTRACT The study aimed to determine which acute injury variables were predictors of long-term functional outcome following inflicted traumatic brain injury (iTBI).
A retrospective case review of 35 children with iTBI was performed. After controlling for age at injury and time since injury, the generalized estimation equations method was used to identify acute injury variables that were significantly related to the Glasgow Outcome Scale scores at the initial follow-up assessments. When available, functional sequelae at these and longer-term follow-ups were also examined.
In bivariate generalized estimation equations analyses, a low Glasgow Coma Scale (GCS) eye component score, a low GCS motor component score, a low GCS verbal component score, need for neurosurgical intervention, seizures in the first week after injury, need for mechanical ventilation for more than 10 days, length of intensive care unit stay of more than 10 days, initial hyperglycemia, and neuroimaging findings of cerebral edema or loss of gray-white matter differentiation were significantly (p ≤ 0.05) related to having a poor outcome, as defined by their Glasgow Outcome Scale score at the initial follow-up. In multivariable analyses, considering the significant predictors while controlling for age at injury and time since injury, the presence of cerebral edema on neuroimaging (odds ratio, 27.21; 95% confidence interval, 4.40-168.22), and length of intensive care unit stay of more than 10 days (odds ratio, 21.57; 95% confidence interval, 3.09-150.48) were significantly related to having a poor outcome.
Early clinical data following iTBI help predict long-term functional outcome. Further research to support these findings may help delineate acutely after injury which children with iTBI are at risk for a poor prognosis and should be more closely followed up over time.
Prognostic study, level IV.
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ABSTRACT: Abusive head trauma (AHT) occurs due to an intentional abrupt impact and/or violent shaking leading to an injury to the skull or intracranial contents of a baby or child, usually younger than 2 years of age. Without impact, there may be no external signs of head trauma. It is the leading cause of mortality in children who have suffered intentional physical abuse. It is more likely to occur in very young children with an estimated prevalence of 1 per 3000 in infants under 6 months of age. Studies have highlighted that distressed and exhausted parents can sometimes shake their infant in desperation and parental education has been shown to decrease the incidence of AHT. Clinicians dealing with children who presents with traumatic brain injury (TBI) should always consider the possibility of AHT. AHT is classically characterized by a triad of signs; subdural hematoma, brain edema, and retinal hemorrhage, however, non-specific features may also be seen in clinical practice both acutely or subsequently. Certain neuroradiological findings (subdural hemorrhages, multiple interhemispheric convexity and posterior fossa hemorrhages, hypoxic-ischemic injury and cerebral edema) are suggestive of AHT in young children. Associated spinal injuries can be easily missed and it is important to investigate for this. This review article includes 2 illustrative case studies and gives a comprehensive overview of AHT in children which we hope will be useful for neurosurgeons in their clinical practice. Child protection is everyone's responsibility and is best achieved when different specialties and professionals work together.06/2014; DOI:10.1016/j.ijnt.2014.03.003
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ABSTRACT: To compare clinical features and functional outcomes of age- and sex-matched children with abusive and nonabusive head trauma receiving inpatient rehabilitation. Children with abusive head trauma (n = 28) and age- and sex-matched children with nonabusive head trauma (n = 20) admitted to an inpatient pediatric rehabilitation unit from 1995-2012 were studied. Acute hospitalization and inpatient rehabilitation records were retrospectively reviewed for pertinent clinical data: initial Glasgow Coma Scale score, signs of increased intracranial pressure, neuroimaging findings, and presence of associated injuries. Functional status at admission to and discharge from inpatient rehabilitation was assessed using the Functional Independence Measure for Children. Outcome at discharge and outpatient follow-up were described based on attainment of independent ambulation and expressive language. Children with abusive and nonabusive head trauma had similar levels of injury severity, although associated injuries were greater in those with abusive head trauma. Functional impairment upon admission to inpatient rehabilitation was comparable, and functional gains during inpatient rehabilitation were similar between groups. More children with nonabusive than with abusive head trauma attained independent ambulation and expressive language after discharge from rehabilitation; the difference was no longer significant when only children aged >12 months at injury were examined. There was variability in delay to obtain these skills and in the quality of gained skills in both groups. Despite more associated injuries, children with abusive head trauma make significant functional gains during inpatient rehabilitation, comparable with an age- and sex-matched sample with nonabusive head trauma. Key functional skills may be gained by children in both groups following discharge from inpatient rehabilitation.The Journal of pediatrics 12/2013; 164(3). DOI:10.1016/j.jpeds.2013.10.075 · 3.74 Impact Factor
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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.Pediatric Radiology 12/2014; 44(Supplement 4):548-558. DOI:10.1007/s00247-014-3169-8 · 1.65 Impact Factor