Pediatric abusive head trauma and stroke

Nickalus R. Khan Department of Neurosurgery and

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Brittany D. Fraser College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee;

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Vincent Nguyen Department of Neurosurgery and

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Kenneth Moore Department of Neurosurgery and

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Scott Boop University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas;

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Brandy N. Vaughn Department of Neurosurgery, Le Bonheur Children’s Hospital; and

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Paul Klimo Jr. Department of Neurosurgery and
Department of Neurosurgery, Le Bonheur Children’s Hospital; and
Semmes Murphey Clinic, Memphis, Tennessee

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OBJECTIVE

Despite established risk factors, abusive head trauma (AHT) continues to plague our communities. Cerebrovascular accident (CVA), depicted as areas of hypodensity on CT scans or diffusion restriction on MR images, is a well-known consequence of AHT, but its etiology remains elusive. The authors hypothesize that a CVA, in isolation or in conjunction with other intracranial injuries, compounds the severity of a child’s injury, which in turn leads to greater health care utilization, including surgical services, and an increased risk of death.

METHODS

The authors conducted a retrospective observational study to evaluate data obtained in all children with AHT who presented to Le Bonheur Children’s Hospital (LBCH) from January 2009 through August 2016. Demographic, hospital course, radiological, cost, and readmission information was collected. Children with one or more CVA were compared with those without a CVA.

RESULTS

The authors identified 282 children with AHT, of whom 79 (28%) had one or more CVA. Compared with individuals without a CVA, children with a stroke were of similar overall age (6 months), sex (61% male), and race (56% African-American) and had similar insurance status (81% public). Just under half of all children with a stroke (38/79, 48%) were between 1–6 months of age. Thirty-five stroke patients (44%) had a Grade II injury, and 44 (56%) had a Grade III injury. The majority of stroke cases were bilateral (78%), multifocal (85%), associated with an overlying subdural hematoma (86%), and were watershed/hypoperfusion in morphology (73%). Thirty-six children (46%) had a hemispheric stroke. There were a total of 48 neurosurgical procedures performed on 28 stroke patients. Overall median hospital length of stay (11 vs 3 days), total hospital charges ($13.8 vs $6.6 million), and mean charges per patient ($174,700 vs $32,500) were significantly higher in the stroke cohort as a whole, as well as by injury grade (II and III). Twenty children in the stroke cohort (25%) died as a direct result of their AHT, whereas only 2 children in the nonstroke cohort died (1%). There was a 30% readmission rate within the first 180-day postinjury period for patients in the stroke cohort, and of these, approximately 50% required additional neurosurgical intervention(s).

CONCLUSIONS

One or more strokes in a child with AHT indicate a particularly severe injury. These children have longer hospital stays, greater hospital charges, and a greater likelihood of needing a neurosurgical intervention (i.e., bedside procedure or surgery). Stroke is such an important predictor of health care utilization and outcome that it warrants a subcategory for both Grade II and Grade III injuries. It should be noted that the word “stroke” or “CVA” should not automatically imply arterial compromise in this population.

ABBREVIATIONS

ACA = anterior cerebral artery; ADC = apparent diffusion coefficient; AHT = abusive head trauma; AICA = anterior inferior cerebellar artery; CARES = Neurosurgery and the Child Advocacy Resource and Evaluation Services; CVA = cerebrovascular accident; DWI = diffusion-weighted imaging; LBCH = Le Bonheur Children’s Hospital; LOS = length of stay; MCA = middle cerebral artery; NAT = nonaccidental trauma; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; SCA = superior cerebellar artery.
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