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

Abstract

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.

Shaken Baby Syndrome Manifesting as Chronic Subdural Hematoma: Importance of Single Photon Emission Computed Tomography for Treatment Indications-Case Report-

“…1,2,5,15) Cerebral hypoxia/ischemia in SBS may be explained by numerous factors, such as reactive vasospasm adjacent to hemorrhagic lesions, strangulation, cervicomedullary injuries, and persistent crying and apnea. 8,9) Diffusion-weighted MR imaging in our case showed no obvious ischemic lesions. We assumed that the delay between examinations (16 months from the first hospitalization) may have masked any injury.…”

“…7) Shaken baby syndrome (SBS) is a form of abuse that can cause severe injuries such as subdural hematoma (SDH), subarachnoid hemorrhage, hemorrhagic contusion, and/or diffuse axonal injury. 8,12,13) We describe a case of SBS manifesting as chronic SDH detected by magnetic resonance (MR) imaging, diffusionweighted MR imaging, and single photon emission computed tomography (SPECT).…”

Subdural Hemorrhage and Hypoxia in Infants With Congenital Heart Disease

“…2 The relationship between infantile SDH and trauma has been challenged in recent years. One series of neuropathological postmortem studies [3][4][5] concluded by speculating that in a susceptible infant, "subdural and retinal bleeding might result from any event that initiated apnoea or significant hypoxia, with brain swelling." 5 Thus, in some infants with unexplained SDH a presumptive diagnosis of AHT might be incorrect.…”

Serial neuroimaging in infants with abusive head trauma: timing abusive injuries

“…Geddes first suggested that the majority of diffuse axonal injuries in fatal cases of AHT are ischemic rather than traumatic based on beta-amyloid precursor protein (BAPP) staining patterns, traumatic axonal injuries being restricted to the cervicomedullary junction and upper spinal cord. 12 A number of other small case series have documented upper cervical spinal cord injuries in fatal cases of AHT. 15,20,26 In the largest study to date, Brennan and colleagues documented cervicomedullary and/or upper spinal cord injuries in 29 (71%) of 41 fatal cases of AHT.…”