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Neuropathology of inflicted head injury in children. I. Patterns of brain damage
J F Geddes1, A K Hackshaw, G H Vowles
1Departments of Histopathology and Morbid Anatomy and Environmental and Preventative Medicine, Queen Mary, University of London and Department of Forensic Pathology, University of Sheffield, UK. j.f.geddes@mds.qmw.ac.uk
Insights
Non-accidental head injuries in children show age-related neuropathological differences. Infants often exhibit craniocervical axonal damage, while older children present with injuries similar to adults.
Area of Science:
- Pediatric Neuropathology
- Forensic Pathology
- Child Abuse Research
Background:
- Non-accidental head injury (NAHI) is a significant cause of morbidity and mortality in children.
- Understanding neuropathological patterns is crucial for diagnosis and prevention.
- Previous studies have highlighted various injury types, but age-specific neuropathological findings require further elucidation.
Purpose of the Study:
- To investigate age-related neuropathological differences in non-accidental head injuries in children.
- To correlate clinical presentations with specific microscopic findings.
- To differentiate injury patterns between infants and older children.
Main Methods:
- Detailed neuropathological examination of 53 pediatric cases of NAHI, including immunocytochemistry.
- Analysis of clinical data for all cases, including age at injury.
- Statistical analysis of age-related patterns in neuropathological damage.
Main Results:
- Common injuries included skull fractures, subdural bleeding, and retinal hemorrhages; brain swelling was the usual cause of death.
- Severe hypoxic brain damage was prevalent (77%).
- Age-specific patterns emerged: infants (2-3 months) showed craniocervical junction axonal injury, skull fractures, and thin subdural hemorrhages, often with breathing abnormalities and no extracranial injury. Older children (>1 year) had more severe extracranial/abdominal injuries, larger subdural hemorrhages, and hemispheric white matter damage patterns similar to adults.
Conclusions:
- NAHI in children exhibits distinct age-related neuropathological features.
- Infants and older children demonstrate different injury mechanisms and locations.
- Diffuse traumatic axonal injury is uncommon in inflicted pediatric head injuries.
Abstract:
Fifty-three cases of non-accidental head injury in children were subjected to detailed neuropathological study, which included immunocytochemistry for microscopic damage. Clinical details were available for all the cases. There were 37 infants, age at head injury ranging from 20 days to 9 months, and 16 children (range 13 months to 8 years). The most common injuries were skull fractures (36% of cases), acute subdural bleeding (72%) and retinal haemorrhages (71%); the most usual cause of death was raised intracranial pressure secondary to brain swelling (82%). On microscopy, severe hypoxic brain damage was present in 77% of cases. While vascular axonal damage was found in 21 out of 53 cases, diffuse traumatic axonal injury was present in only three. Eleven additional cases, all of them infants, showed evidence of localized axonal injury to the craniocervical junction or the cervical cord. When the data were analysed by median age at head injury, statistically significant patterns of age-related damage emerged. Our study shows that infants of 2-3 months typically present with a history of apnoea or other breathing abnormalities, show axonal damage at the craniocervical junction, and tend also to have a skull fracture, a thin film of subdural haemorrhage, but lack extracranial injury. Children over 1 year are more likely to suffer severe extracranial, particularly abdominal, injuries. They tend to have larger subdural haemorrhages, and where traumatic axonal injury is present, show patterns of hemispheric white matter damage more akin to those reported in adults. Diffuse axonal injury is an uncommon sequel of inflicted head injury in children.