Factors associated with hemispheric hypodensity after subdural hematoma following abusive head trauma in children
Kimberly A Foster1, Matthew J Recker, Philip S Lee
11 Department of Neurological Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania.
Insights
Risk factors for hemispheric hypodensity (HH) in abusive head trauma (AHT) are not fully understood. Children with AHT who developed HH experienced higher intracranial pressure and more insults associated with ischemia.
Area of Science:
- Pediatric Neurology
- Neurotrauma
- Child Abuse Pediatrics
Background:
- Abusive head trauma (AHT) is a severe form of pediatric traumatic brain injury (TBI) with significant mortality and long-term neurological deficits.
- Hemispheric hypodensity (HH), a pattern of reduced density in the brain hemispheres, has been observed in association with subdural blood following AHT.
- The risk factors and underlying mechanisms contributing to the development of HH in pediatric TBI remain largely unknown.
Purpose of the Study:
- To investigate potential risk factors and clinical associations for hemispheric hypodensity (HH) in children suffering from abusive head trauma (AHT).
- To identify physiological and radiographic findings that may predict the development of HH in pediatric TBI patients.
Main Methods:
- A retrospective study enrolled 24 children under 5 years old diagnosed with TBI secondary to AHT, who had initial and follow-up brain imaging.
- Data collected included pre-arrival and in-hospital physiological parameters, intracranial pressure (ICP) monitoring, and radiographic findings.
- Hemispheric hypodensity (HH) was assessed by a blinded observer, and statistical analyses were performed to identify associated factors.
Main Results:
- Of the 24 children, 13 developed HH. HH was not significantly linked to age, initial Glasgow Coma Scale score, or mortality.
- Children with HH showed significantly higher Pediatric Intensity Level of Therapy (PILOT) scores and maximal intracranial pressure (ICPmax).
- Insults such as hypoxia, hypotension, cardiopulmonary arrest, and higher daily blood glucose levels were more prevalent in the HH group. Skull fracture was less common in children with HH.
Conclusions:
- The development of HH in abusive head trauma is associated with increased intracranial pressure and a greater burden of ischemic insults.
- While acute subdural hematoma was present in all HH cases, the presence of skull fracture was inversely associated with HH.
- Further research is needed to elucidate the mechanisms of HH development in AHT and to explore potential clinical interventions to mitigate its impact.
Abstract:
Abusive head trauma (AHT) is a unique form of pediatric TBI with increased mortality and neurologic sequelae. Hemispheric hypodensity (HH) in association with subdural blood after AHT has been described. Though risk factors for HH are not understood, we hypothesized that risk factors could be identified. We retrospectively enrolled children under 5 years with TBI secondary to AHT (child advocacy diagnosis) who had undergone initial and interval brain imaging. Records were interrogated for prearrival and in-hospital physiologic and radiographic findings. HH was determined by a blinded observer. Twenty-four children were enrolled and 13 developed HH. HH was not significantly associated with age, initial Glascow Coma Scale, or mortality. Pediatric Intensity Level of Therapy (PILOT) scores (p=0.01) and daily maximal intracranial pressure (ICPmax; p=0.037) were higher in HH. Hypoxia, hypotension, cardiopulmonary arrest, need for blood transfusion, and daily blood glucoses tended to be greater in HH. Whereas all children with HH had acute subdural hematoma (SBH), many children without HH also had subdural blood; the presence of skull fracture was more likely in the children who did not develop HH (p=0.04), but no other intracranial radiographic pattern of injury was associated with HH. Surgical intervention did not appear to protect against development of HH. A variety of insults associated with ischemia, including intracranial hypertension, ICP-directed therapies, hypoxia, hypotension, and cardiac arrest, occurred in the children who developed HH. Given the morbidity and mortality of this condition, larger studies to identify mechanisms leading to the development of HH and mitigating clinical approaches are warranted.
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