Initial neurologic presentation in young children sustaining inflicted and unintentional fatal head injuries - In reply

The Children's Hospital of Philadelphia, Filadelfia, Pennsylvania, United States
PEDIATRICS (Impact Factor: 5.47). 07/2005; 116(1):180-4. DOI: 10.1542/peds.2004-2671
Source: PubMed


It remains unclear if fatal brain injuries in young children are characterized by immediate rapid deterioration or can present after an initial period of lucidity. This issue has legal implications in child abuse, for which understanding the clinical course affects perpetrator identification.
To determine patterns of neurologic presentation on hospital admission in infants and toddlers who die of inflicted and unintentional injury.
Data on children <48 months of age who sustained a fatal head injury from 1986-2002 were extracted from the Pennsylvania Trauma Outcomes Study. Only those with external-causes-of-injury codes for inflicted injury, falls, and motor vehicle crashes (MVCs) with a recorded Glasgow Coma Scale (GCS) on admission were included. The GCS was compared across mechanisms and age groups (0-11, 12-23, 24-35, and 36-47 months).
Of the 314 fatally injured children, 37% sustained inflicted injury, 13% sustained a fall, and 49% sustained an MVC. At admission, 6.8% of all children had a GCS score of >7, and 1.9% presented with a GCS score of >12 (lucid). The incidence of admission a GCS score of >7 varied by mechanism. Overall, children with inflicted injury were 3 times more likely to present with a GCS score of >7 than those injured in MVCs (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.2-10.3), but incidence of a GCS score of >7 did not differ between inflicted injuries and falls. Similarly, when considering only those children >or=24 months old, a GCS score of >7 did not differ by mechanism. In contrast, in those <24 months old, children who died as a result of inflicted injury were >10 times more likely to have a GCS score of >7 than those who died as a result of a MVC (OR: 9.36; 95% CI: 1.3-80.9).
The data suggest an age- and mechanism-dependent presentation of neurologic status in children with fatal head injury. Although infrequent, young victims of fatal head trauma may present as lucid (GCS score: >12) before death. Furthermore, children <48 months old sustaining inflicted injury are 3 times more likely to be assessed with a moderate GCS score (>7) than those in MVCs. This effect is amplified in the youngest children (<24 months old): those with inflicted injury were 10 times more likely to present with moderate GCS scores than those in MVCs. In addition, this youngest age group seems to be overrepresented in those who present as lucid (GCS score: >12 [5 of 6]). It is unclear whether these differences are the result of inadequate tests to evaluate consciousness in younger children or differences in biomechanical mechanisms of inflicted trauma.

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    • "et al., 1991). Furthermore, it has been reported that young children with fatal TBI may present with an initial lucid period (no loss of consciousness), or a high GCS score (Arbogast et al., 2005). Compared to age-matched uninjured animals, 3-mm depth of impact did not affect acquisition in the first week postinjury , an observation similar to that reported following diffuse brain trauma in the immature rat, for which learning deficits at lower levels of injury severity were either not present (Adelson et al., 1997), or were transient (Gurkoff et al., 2006). "
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    ABSTRACT: Although diffuse brain damage has been suggested to be the predominant predictor of neurological morbidity following closed head injury in infants and children, the presence of contusions also predicts long-term neurobehavioral dysfunction. Contusive brain trauma in the 17-day-old rat resulted in neurodegeneration and caspase activation in the cortex at 1 day, and in the thalamus at 3 days post-injury, and to a greater extent following a deeper impact. Cortical tissue loss in the 4-mm impact group was significantly greater than that in the 3-mm impact group (p < 0.05), and exhibited a time-dependent increase over the first 3 weeks post-injury. Traumatic axonal injury was observed in the white matter tracts below the site of impact at 1 day, and in the corpus callosum at 3 days, to a greater extent following 4-mm impact. In contrast, cellular caspase-3 activation in these white matter tracts was only observed at 24 h post-injury and was not affected by impact depth. Similarly, neurodegeneration and caspase activation in the hippocampus was restricted to the dentate gyrus and occurred to a similar extent in both injured groups. Only the 4-mm impact group exhibited learning deficits in the first week (p < 0.0001) that was sustained until the third week post-injury (p < 0.0001), while deficits in the 3-mm impact group were seen only at 3 weeks post-injury (p < 0.02). These observations demonstrate that increasing severity of injury in immature animals does not uniformly increase the extent of cellular damage, and that the progression of tissue damage and behavioral deficits varies as a function of injury severity.
    Journal of neurotrauma 02/2011; 28(2):245-57. DOI:10.1089/neu.2010.1639 · 3.71 Impact Factor
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    • "For instance, head impact frequently produces focal contusions, whereas non-impact rotational head motion has been shown to produce more diffuse brain injuries (Adams, et al., 1985, Gennarelli, et al., 1982, Ommaya, 1985). Furthermore, falls are the most common cause of mild to moderate TBI in infants, whereas motor vehicle crashes and assault, which have a larger rotational component, more frequently produce severe or fatal TBI, suggesting the importance of rotational head motion in the most severe brain injuries (Arbogast, et al., 2005, Duhaime, et al., 1992). Direction of head motion may also be an important factor in TBI outcomes, and would therefore need to be considered when developing safety standards for automobiles and helmets. "
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    ABSTRACT: Rotational inertial forces are thought to be the underlying mechanism for most severe brain injuries. However, little is known about the effect of head rotation direction on injury outcomes, particularly in the pediatric population. Neonatal piglets were subjected to a single non-impact head rotation in the horizontal, coronal, or sagittal direction, and physiological and histopathological responses were observed. Sagittal rotation produced the longest duration of unconsciousness, highest incidence of apnea, and largest intracranial pressure increase, while coronal rotation produced little change, and horizontal rotation produced intermediate and variable derangements. Significant cerebral blood flow reductions were observed following sagittal but not coronal or horizontal injury compared to sham. Subarachnoid hemorrhage, ischemia, and brainstem pathology were observed in the sagittal and horizontal groups but not in a single coronal animal. Significant axonal injury occurred following both horizontal and sagittal rotations. For both groups, the distribution of injury was greater in the frontal and parietotemporal lobes than in the occipital lobes, frequently occurred in the absence of ischemia, and did not correlate with regional cerebral blood flow reductions. We postulate that these direction-dependent differences in injury outcomes are due to differences in tissue mechanical loading produced during head rotation.
    Experimental Neurology 09/2010; 227(1):79-88. DOI:10.1016/j.expneurol.2010.09.015 · 4.70 Impact Factor
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