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David I. Levy, Harold L. Rekate, W. Bruce Cherny, Kim Manwaring, S. David Moss and Hillel Z. Baldwin

hematoma evacuation, with mild mass effect. Lower: Lower cuts of postoperative CT scan obtained before drain placement showing open cisterns. Brain edema is evident in left frontal region. Fig. 7. Case 14. Graph showing intracranial pressure at time of lumbar drain placement. Results Of the 16 patients, 14 had an admission GCS score lower than 8, whereas all patients at 24 hours had a GCS score lower than 8. There were seven pedestrian/bicyclists struck by automobiles; two motor vehicle accidents; two suspected nonaccidental traumas; two all

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John David Morenski, Joseph D. Tobias and David F. Jimenez

given rFVIIa after repeated doses of FFP failed to correct the coagulopathy, whereas the other two patients received rFVIIa as the initial therapy. Treatment with rFVIIa consisted of a bolus of 90 µg/kg. We based this dose on mean doses reported in the literature for successful rFVIIa treatment of CNS hemorrhages. 9, 17, 37 Case 1 This 20-month-old infant girl suffered nonaccidental trauma with brain injury. The infant presented to the pediatric ICU unresponsive; her pupils were fixed and dilated and she was experiencing respiratory failure. At presentation her

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Priya Prabhakaran, Alyssa T. Reddy, W. Jerry Oakes, William D. King, Margaret K. Winkler and Timothy G. Givens

) ventriculostomy placement; and 4) trauma that was accidental in nature. Patients in whom clinical brain death (absent brainstem reflexes in normothermic and metabolically stable patients in the absence of sedation or muscle relaxation) was evident on admission were excluded from the study. Patients for whom death was imminent (brain injury in the setting of refractory hypoxemia or hypotension despite aggressive resuscitation) were also excluded as were patients who were suspected to be the victims of nonaccidental trauma/abuse. Prior to their arrival at our institution

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Saadi Ghatan, David W. Newell, M. Sean Grady, Sohail K. Mirza, Jens R. Chapman, Frederick A. Mann and Richard G. Ellenbogen

quadriparesis 4 days normal 72 2 MVA vs ped quadriparesis, 10 & 12 CN palsies 1 hr slight lt 12 CN palsy 72 3 NAT obtunded, flaccid, quadriparesis 2 mos developmental delay, Grade 4/5 LUE, paresis 32 * CN = cranial nerve; LUE = left upper extremity; MVA =motor vehicle accident; NAT = nonaccidental trauma; ped = pedestrian. Discussion Craniocervical stability is provided by a complex arrangement of ligaments. Traumatic disruption of these vital soft tissues, as seen in high-energy blunt trauma, can have

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Matthieu Vinchon, Sabine Defoort-Dhellemmes, Marie Desurmont and Patrick Dhellemmes

better characterize the distinctive features associated with child abuse, we have prospectively collected all cases of accidental as well as nonaccidental traumas occurring in infants treated at our institution to study their clinical, radiological, and ophthalmological findings and clinical outcome. Clinical Material and Methods Our institution, serving a population area of four million, is the only referral center for neurosurgical emergencies occurring in neonates and children. We prospectively collected cases of children younger than 24 months of age who were

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Ali Ghahreman, Vishal Bhasin, Raymond Chaseling, Bronwyn Andrews and Erhard W. Lang

Object

The purpose of this study was to evaluate the demographics, clinical and radiological features, and clinical outcomes of nonaccidental pediatric head injury.

Methods

The authors reviewed 65 consecutive cases of nonaccidental head injury in a single pediatric neurosurgical unit during a period of 7 years. The mean patient age was 8.2 months (range 0.5–46 months). There were 39 boys and 26 girls. A history of abuse was present in 24% of families. There was a high incidence of family disruption, substance abuse, and premature birth. Fathers were the most common perpetrators. Fifteen patients had a Glasgow Coma Scale score of less than 10. Thirty-five patients had seizures on or preceding admission. Subdural hematoma was the most common finding (81.5%). Skull fractures were present in 36.9% of patients, skeletal injuries in 50% (of which 67% were subclinical), and retinal hemorrhages in 59%. The radiological finding of ischemia or edema had a significant correlation with a poor outcome. Magnetic resonance imaging revealed additional pathological findings not visible on computerized tomography scanning in 18 (49%) of 37 cases. Surgery was performed in 17 patients; recurrence of the subdural collection occurred in 46% of them. In this group, reevacuations were followed by further recurrences, and a subdural—peritoneal shunt was eventually required. Four patients died. Of the 56 surviving patients reviewed on a long-term basis, 19 made a full recovery, and epilepsy was reported in 17%.

Conclusions

Magnetic resonance imaging should be routinely used in depicting ischemia, which is associated with a poor outcome. The high incidence of subclinical skeletal injuries stresses the importance of assessment of suspected cases of nonaccidental trauma with skeletal surveys and bone scans. Recurrence of subdural collection following burr hole drainage is common and is best treated with a subdural—peritoneal shunt.

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Patrick Graupman

blood. Case Report History and Examination. This 2-week-old male infant was transferred from an outside facility with head injuries and long bone fractures. The patient’s history and examination findings were suspicious for nonaccidental trauma. Peripheral lines had been inserted and one interosseous line was in place. Ongoing blood loss was obvious due to a large expanding cephalohematoma. Treatment. Shortly after the infant arrived at our facility, we lost all venous access. The left interosseous line no longer functioned, and an attempt at inserting

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Patrick Graupman and Ken R. Winston

At autopsy, Hadley, et al., 13 found hemorrhages and contusions within the high cervical spinal cord in five of 13 patients with nonaccidental trauma. Geddes, et al., 11 found localized axonal injury in the craniovertebral junction or the cervical spinal cord in 11 of 53 patients. Johnson, et al., 18 found significant pathological conditions in the cervical spine of three of four children whose bodies underwent autopsy (atlantooccipital dislocation in the first patient, spinal cord contusion and laceration in the second, and cervical and thoracic subdural in the

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Zachary N. Litvack, Matthew A. Hunt, Jason S. Weinstein and G. Alexander West

for injury prevention. In this cohort, 783 accidental injuries were reported. One involved a penetrating wound to the orbit, but none involved penetrating wounds of the cranium. 17 In contrast, a review of the medical literature reveals numerous case reports of penetrating wounds of the cranium from nail-gun misuse. 6 , 17–19 , 23–25 , 27–29 , 31–33 , 35 , 36 , 38 The extremely low prevalence of intracranial trauma as an accidental occurrence in the industrial setting (< 0.1%) should alert the admitting physician to be highly suspicious of nonaccidental trauma

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Peter Kan, Aminullah Amini, Kristine Hansen, George L. White Jr., Douglas L. Brockmeyer, Marion L. Walker and John R. W. Kestle

Object

Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution.

Methods

Children with severe TBI who underwent decompressive craniectomy at the Primary Children’s Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King’s Outcome Scale for Closed Head Injury (KOSCHI).

Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months.

Conclusions

Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.