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Hot Topic 3: Pediatric Abusive Head Trauma

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HOT TOPIC: Pediatric Abusive Head Trauma

Review: (R. Miller) Often children evaluated for abusive head trauma (AHT) in emergency departments have acute subdural hemorrhage (SDH), chronic SDH, or both. In cases in which both acute and chronic SDH are present, the question often arises whether the acute SDH is new abusive trauma or rebleeding into an area of chronic SDH, either spontaneously and/or from minor trauma. There is little literature regarding clinical presentations for children with acute or chronic SDH.

Title: Initial clinical presentation of children with acute and chronic versus acute subdural hemorrhage resulting from abusive head trauma

Authors: Kenneth W. Feldman, MD, Naomi F. Sugar, MD, and Samuel R. Browd, MD, PhD2

Author Affiliations: Department of Pediatrics, Children's Protection Program, and Department of Neurological Surgery, Seattle Children's and Harborview Medical Center, University of Washington, Seattle, Washington

Downloaded From: Journal of Neurosurgery: Pediatrics Aug 2015 / Vol. 16 / No. 2 / Pages 177-185

Why This Article is Relevant or Important: This article is the largest study to compare presenting clinical and radiological findings of abused, head-injured children with documented acute SDH with findings of children with acute or chronic SDH.

Very Brief Review:

With initial presentation, pediatric patients who have experienced AHT frequently have SDH which is acute, chronic, or both. There has been debate whether the acute SDH associated with chronic SDH results from trauma or from spontaneous rebleeding. The authors compared the clinical presentations of children with AHT and acute SDH with those having acute and chronic SDH.

Data was collected through retrospective review from four participating hospitals. Each of the hospitals had a multidisciplinary team including at least child abuse practitioners and social workers providing consultation and case review to the treating team. The authors compared the clinical and radiological characteristics of children with acute SDH to those of children with acute/chronic SDH. Clinical data included the chief complaint/reason for presentation as provided in the caretaker's history and whether caretakers provided any history of trauma before cranial imaging. Classification of types and locations of intracranial hemorrhage was based on neuroimaging (CT and MRI) accompanied by clinical information. The initial CT scan, which was usually obtained shortly after the child's presentation to medical care, and initial MRI images were used.

The study involved 383 children with AHT and either acute SDH (n = 291) or acute/chronic SDH (n = 92). The children with acute/chronic SDH were younger, had higher initial Glasgow Coma Scale scores, fewer deaths, fewer skull fractures, less parenchymal brain injury, and fewer acute non-cranial fractures than did children with acute SDH. No differences were found for the proportion with retinal hemorrhages, healing non-cranial fractures, or acute abusive bruises. Approximately 80% of children with acute/chronic SDH and with acute SDH had retinal hemorrhages or acute or healing extracranial injures. Of children with acute/chronic SDH, 20% were neurologically asymptomatic at presentation; almost half of these children were seen for macrocephaly and for all of them, the acute SDH was completely within the area of the chronic SDH.

In general, the presenting clinical and radiological characteristics of children with acute SDH and acute/chronic SDH caused by AHT did not differ. These findings suggest repeated abuse, rather than spontaneous rebleeding, is the etiology of most acute SDH in children with chronic SDH. However, the most severe neurological symptoms were more common among children with acute SDH. Children with acute/chronic SDH and asymptomatic macrocephaly have unique risks and distinct radiological and clinical characteristics.

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