Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes

Clinical article

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Object

Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions.

Methods

A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores.

Results

There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13–15 (OR 6.95), and the patients with NATs with of GCS scores 9–12 (OR 6.83) and 3–8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up.

Conclusions

Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.

Abbreviations used in this paper: CPS = Child Protective Services; GCS = Glasgow Coma Scale; KOSCHI = King's Outcome Scale for Childhood Head Injury; ICP = intracranial pressure; NAT = nonaccidental trauma; SDH = subdural hemorrhage; TBI = traumatic brain injury.

Article Information

Address correspondence to: Matthew A. Adamo, M.D., Department of Neurosurgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 3705 Fifth Avenue, 3rd Floor, Purple Building, Pittsburgh, Pennyslvania 15213. email:matthew.a.adamo@gmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graph demonstrating the percentage of infants and toddlers presenting with accidental (AT) and nonaccidental trauma represented in 6-month blocks for ages 0–36 months.

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    Pie graphs showing the percentage of infants and toddlers presenting with GCS scores of 13–15, 9–12, or 3–8. Upper: The breakdown of GCS scores among infants and toddlers who have sustained accidental trauma is shown. Lower: The breakdown of GCS scores among infants and toddlers who have sustained NAT is shown.

  • View in gallery

    Pie graphs showing the percentage of infants and toddlers presenting with hyperdense or hypodense subdural fluid collections. Upper: The breakdown of subdural collections among infants and toddlers who have sustained accidental trauma is shown. Lower: The breakdown of subdural collections among infants and toddlers who have sustained NAT is shown.

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