Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma

Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma

“…44 However, the abusive head injury population differs clinically from the accidental head injury population in that they have higher mortality rates 1-3 and worse neurologic outcomes. 1,[4][5][6][7] It is now widely theorized that the pathophysiology of brain damage in AHT does not result from a direct traumatic mechanism but instead from a hypoxic-ischemic insult that occurs after trauma-induced apnea. [44][45][46][47] Hyperextension injury to the neck caused by violent shaking has been implicated in damaging the central pattern generator of respiration in the brain stem.…”

“…Neurologic, cognitive, and behavioral deficits have been observed in victims of AHT in the immediate postinjury period as well as decades later. [4][5][6][7] AHT preferentially affects young children. Presentation to care for abused patients peaks around 2 months to 3 months of age, and the majority of children are 2 years or younger.…”

Severe neurological impairment: a review of the definition

“…. .expected to last at least 12 months (unless death intervenes) Involves either several different organ systems or one organ system severely enough to require specialty paediatric care Medically fragile children 51 Dependent on technology for survival Neuromuscular disorders 52 Disorders that involve injury or dysfunction of peripheral nerves or muscle Children with severe global developmental delay 47 Significant intellectual disability and severe motor impairment Extremely limited functional movement Dependent upon others for all activities of daily living Bakke et al 7 Neurological disorders but no significant mental deficiencies Buratti et al 10 Severe psychomotor and mental retardation Danielson and Emmens 13 Non-ambulatory Severe psychomotor and mental impairment Elliott 14 Profoundly, irreversibly neurologically damaged Will never be able to speak, walk, sit up, or feed themselves Intellectual abilities extremely limited Hauer 17 Non-verbal Severe impairment of the CNS Hauer and Solodiuk 18 Severe global impairment of the CNS Khoshoo et al 22 Profound developmental delay Neuromuscular impairment Non-verbal and wheelchair-bound Lind et al 24 GOS score III and IV Mahant et al 26 GMFCS level III-V McCrea et al 29 Profound developmental impairment Requires constant care Cannot mobilize Very limited possibilities for communication Mergler et al 31,32 Moderate or severe intellectual disability (IQ <55) GMFCS level IV or V Orel et al 35 GMFCS level V Pinnington and Hegarty 36,37 Quadriplegic distribution of athetosis and/or spasticity Associated impairments in visual perception and learning Roka et al, 38 Sun et al 44 from chronic disorders. Thirty-three of the articles referred to patients with CNS disorders only, while five included both patients with disorders of the CNS and PNS.…”

Abusive Head Trauma and Mortality–An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury

“…Keenan and colleagues found children with AHT had worse outcomes at 1 year post-injury (12) and that children with AHT (i) were younger, (ii) had extracranial fractures, (iii) retinal hemorrhages, (iv) older injuries, (v) subdural hemorrhage, (vi) seizures and (vii) cerebral edema (13). In another study, only 15% of AHT patients had a good outcome at a mean of 8 years after injury whereas 40% had severe neurological impairment (14). Among children with AHT, risk factors for mortality include low initial GCS score, retinal hemorrhage, intraparenchymal hemorrhage, and cerebral edema (15).…”

“…The average hospital costs for AHT in the U.S. was $69.6 million (16). This estimate did not consider ongoing medical needs which Lind and colleagues found that 83% of AHT children required at median follow-up of 8 y after injury (14). Survivors are estimated to exceed 24 disability adjusted life years (DALY), defined as years lost due to disability/death, while even mild AHT exceeds the burden estimated for children with severe burn injuries (17).…”