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Pediatric Head Trauma

Pediatric Head Trauma

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Pediatric Head Trauma

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  1. Pediatric Head Trauma Glenn D. Sandberg, M.D. Neuropathologist Harris County Institute of Forensic Sciences Presented by Jennifer L. Ross, M.D. Neuropathology Fellow The Methodist Hospital

  2. Objectives • Review the epidemiology of pediatric head trauma • Provide an introduction to major subtypes of head injuries observed in pediatric head trauma • Show examples of typical head injuries • Discuss challenges specific to the investigation of fatal, non-accidental pediatric head trauma

  3. Pediatric Head Trauma • 80% of all significant head injury under the age of 2 years is due to abuse • 75-80% of child abuse fatalities are due to head injury • Majority are infants <1 year • Percentage of deaths due to head trauma decreases with age as abdominal trauma becomes more prevalent

  4. Sequelae of Head Injury • 7-30% of children with abusive head injuries die • 30-50% live, but have significant cognitive or neurological deficits • Mental retardation, learning disabilities, seizures, and blindness • 30% recover

  5. Types of Head Injuries • Focal injuries • Epidural hematomas • Subdural hematomas • Subarachnoid hemorrhages • Contusions • Parenchymal hemorrhages • Diffuse injuries • Axonal • Traumatic • Concussion • Vascular • Vascular

  6. Epidural Hematoma • Bleeding between skull and dura • Occurs in approximately 2% of head injury • 5-15% of fatal head injuries • Almost always associated with skull fracture • Usually thin squamous portion of temporal bone • May occur in children without fracture • Laceration of arteries or veins • Middle meningeal artery-up to 50% • Middle meningeal veins-30%

  7. Epidural Hematoma • Clinical • Classical lucid interval sequence • Features: • Brief period of unconsciousness after injury • Conscious, lucid interval of variable duration • Coma • Occurs in 13-43% of EDH • Might be no more frequent in EDH than SDH

  8. EPIDURAL HEMATOMA Trauma ‑> fracture & concussion Tearing/stripping of dura away from inner table Laceration of meningeal vessels Blood between naked bone and dura NORMAL arterial pressure continues to dissect

  9. Epidural Hematoma • Blood cannot cross suture lines • Often causes significant mass effect • Acutely can tolerate up to 40 mL • Rarely survive if > 150 mL

  10. Subdural Hematoma • Accumulation of blood between dura and brain • Blood free to diffuse throughout subdural space • Evident in ~95% of abusive head trauma • May be small (<5 ml), bilateral and non-compressive • May be associated with skull fracture • May be present in open or closed head injury

  11. Subdural Hematoma • Commonly occur in • Falls • Assaults • MVA: 24% • Child abuse • Sports 72%

  12. Subdural Hematoma • Result of torn bridging veins • Some are secondary to ruptured cortical arteries • Sudden, rapidly applied angular acceleration/deceleration of the moveable head • High strain stretches and snaps bridging veins • Span between cerebral hemispheres and superior sagittal sinus • Subdural portions have a thin, irregular collagenous wall • Subarachnoid portions are covered by arachnoid trabeculae

  13. Subdural Hematoma • Characteristically form over the frontoparietal regions • Bilateral • Adults: 18.5% • Children: 76.7% • Posterior fossa • Rare: <1 % • Particularly rare in a neonate • Fracture to occiput present in 20-80% • Spinal cord • Rare; usually not compressive

  14. Subdural Hematoma • Gross: • Loosely adherent dark red blood: 3-5 days. • Well-formed outer membrane: 1 week. • Well-formed inner membrane: 3-4 weeks.

  15. Subdural Hematoma • Associated findings • 25% who undergo removal of acute subdural have underlying cerebral edema • >80% of these patients die • Ischemia • May be due to local compression of the microcirculation or effects of vasoactive substances released from the SDH • Excitotoxic neuronal injury

  16. Subarachnoid Hemorrhage • Trauma most frequent cause • Associated with contusions and lacerations • Fatal traumatic SAH should be suspected in • Ear injuries • Parotid region injuries • Upper neck injuries

  17. Contusion • “Bruise” of cerebral cortex • Focal type of brain injury occurring at the moment of impact • Caused primarily by the surface of the brain striking the skull or being impacted by it • Overlying dura usually remains intact • Injury patterns differ whether head is stationary or in motion at moment of impact • Freely mobile head motionless at impact • Coup injury • Freely mobile head accelerated in a fall prior to impact • Contrecoup injury

  18. Contusion • Do not occur in infancy • Contusional tears • Tears at cortex-white matter junction • Occur before 6 months of age • Especially in frontal and temporal lobes • Not usually hemorrhagic

  19. Contusion • Gliding • Head is in motion at the time of impact • Hematoma confined to the parasagittal white matter of the frontal lobes • Each hemisphere is firmly tethered to dura by arachnoid granulations • Subcortical white matter glides more than cortex • Deep basal ganglia hematomas and DAI often present • Forces sufficient to cause both axonal and vascular damage

  20. Contusion • Fracture • Occur at site of fracture, related to displaced bone against cortex, may not be at site of impact

  21. Contusion • Patients usually make good recovery • In absence of DAI • Remote contusion • Common incidental finding at autopsy • Cavitary lesion • Destruction involving full thickness of cortex • Hemosiderin deposition

  22. Diffuse Primary Head Injuries • Diffuse injuries • Concussion • Diffuse axonal injury

  23. Concussion • Temporary, reversible neurological deficit caused by trauma • Velocity r necessary • Consciousness can be retained in crush injury of fixed head • Results in immediate temporary loss of consciousness • Both retrograde and post-traumatic amnesia always accompanies concussion • Length of amnesia is indicative of severity of concussion

  24. Diffuse Axonal Injury • First recognized as an essential component of post-traumatic dementia in 1956 by Strich • Caused by inertial forces • Angular or rotational acceleration • Produced by long acceleration loading • Common in MVA • Falls have shorter acceleration loading • Injury attributed to shear and tensile strains • Occurs at moment of injury • Do not experience lucid interval in severe cases • Most common cause of coma and severe disability in absence of intracranial hemorrhage

  25. Diffuse Axonal Injury • Occurred in: • 34% of all fatal head injuries • 53% of deaths that occurred after at least 12 hour survival • For equivalent levels of angular acceleration • Lateral most severe • Sagittal best tolerated • Horizontal intermediate

  26. Diffuse Axonal Injury • Low incidence of: • Surface contusions • Skull fracture • Intracranial hemorrhages • Increased ICP • Increased incidence of: • Gliding contusions • Deep intracerebral hematomas

  27. Diffuse Axonal Injury • Location • Corpus callosum • Cerebral lobar white matter • Dorsolateral quadrant of rostral brainstem adjacent to the superior cerebellar peduncles • “Shearing injury triad”

  28. Diffuse Axonal Injury • Primary axotomy • Rare • Secondary axotomy • Calcium hypothesis • Physical stretch of axon • Disrupts axons ability to regulate ions • Influx of Ca2+ , K +,& Cl – • Activation of neutral proteases • Disruption of axonal cytoarchitecture • Mechanical disruption • Neurofilament subunits disrupted • Axonal transport impaired

  29. Axonal Spheroids • H&E • Need at least 18-24 hour survival • BAPP • Need at least 2-4 hour survival

  30. Retinal Hemorrhages • 80% of inflicted head trauma • Multifocal • Involve multiple retinal layers • Extend to the ora serrata • Optic nerve sheath hemorrhage is frequent

  31. Causes of Retinal Hemorrhages • Severe head injuries (not limited to abuse) • Birth trauma - 30% are resolved by 1 month • Bleeding disorders • Sepsis • Vasculopathies • Sudden changes in intracranial pressure • Terson’s syndrome • CPR – Rarely • Purtscher’s retinopathy-head or chest trauma

  32. Pediatric Head Trauma • “Lucid interval” concept • Vast majority of children who sustain fatal head trauma show an immediate decrease in consciousness (i.e. no lucid interval) • An infant or young child who has sustained an ultimately fatal head injury is not likely to act normally • Has important implications in criminal investigation of cases of fatal inflicted blunt head trauma

  33. Shaken Baby Syndrome (SBS) • Caffey, 1972 • Retinal, subdural, and/or subarachnoid hemorrhages caused by violent shaking • Whiplash action of head associated with weak neck muscles resulting in acceleration-deceleration injuries • Immature, partial membranous skull • Relatively large subarachnoid space • Soft, immature brain

  34. Shaken Baby Syndrome (SBS) • Controversies • SBS injuries (retinal, subdural, subarachnoid hemorrhage) can also be seen in impact head injury • Impact site may not be recognized by treating physicians • Even if no impact site is identified at autopsy, the possibility of impact against a broad, superficially soft surface cannot be excluded • In addition, the specificity of retinal hemorrhages for abuse has been questioned • Conflicting research models

  35. Shaken Baby Syndrome (SBS) • Diagnosis of SBS should not be made when evidence of direct impact is present • Most cases of fatal head injury have evidence of direct impact (facial or scalp contusions, skull fractures) • Even without identifiable impact site, impact cannot be ruled out • Therefore, SBS is rarely listed as a cause of death

  36. Infant Death Investigation • Age, date of birth, birth weight, race, sex • Normal delivery vs C-section; any complications • Last known alive - by whom, date, time • Found dead - by whom, date, time • Place of death - crib, bed, floor • Position of infant when found - supine, prone • Resuscitation - method and by whom • Recent injuries/illnesses and medical history • Change in behavior or appearance; last time child was behaving “normally” • Prior infant deaths in the family

  37. Investigative Challenges • Caregivers are often perpetrators • Reliable witness accounts are often lacking • Confessions may be unreliable • Determining mechanism of injury from autopsy findings alone may be impossible • Estimating age of injuries may be critical, but is unreliable and further complicated by medical treatment and hospital survival

  38. Investigation – Red Flags • Reported history is inconsistent with physical findings • Injuries that occur during the course of normal daily activities (including playing and short falls) do not usually result in fatal injuries • Delay in seeking treatment • Prior history of child abuse in household