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Published on: August 16, 2019
Relationship Between Neonatal Brain Injury and Objective Measures of Head Trauma: A Case-Control Study
Mary Dunbar1, Abbey Norris1, Brandon T Craig1
1From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada.
Insights
Scalp swelling in newborns, often linked to birth trauma, was more frequent with difficult deliveries but not directly associated with increased risk of hypoxic-ischemic encephalopathy or stroke. This finding helps differentiate physical trauma from brain injury risk.
Area of Science:
- Neonatal neurology
- Pediatric imaging
- Obstetrics
Background:
- Neonatal brain injury presents significant lifelong challenges.
- The association between mechanical forces during birth (birth trauma) and neonatal brain injury lacks robust evidence.
- Scalp swelling is often considered a marker of mechanical forces applied to the head.
Purpose of the Study:
- To investigate the association between neonatal brain injury types and scalp swelling.
- To utilize a novel imaging method for objective quantification of scalp swelling as a proxy for mechanical forces.
- To determine if scalp swelling correlates with specific neonatal brain injury outcomes like hypoxic-ischemic encephalopathy (HIE) and stroke.
Main Methods:
- A case-control study utilizing population-based, prospectively collected tertiary care center databases and healthy controls.
- Infants born between 32-42 weeks gestational age with MRI within the first 9 days of life were included.
- Scalp swelling volume was objectively quantified using a novel imaging method, blinded to brain injury status. Statistical analyses included Kruskal-Wallis, chi-square, and logistic regression.
Main Results:
- Scalp swelling was observed in 40.8% of 309 infants, with no significant difference in proportion across outcome groups (healthy, HIE without injury, HIE with injury, stroke).
- Median scalp swelling volume was higher in infants with HIE (with or without brain injury) compared to healthy controls, but not significantly different for stroke groups.
- Scalp swelling was associated with instrumented delivery but not with increased odds of brain injury in infants with HIE.
Conclusions:
- Quantified scalp swelling, indicative of mechanical forces, was more prevalent in infants experiencing difficult deliveries.
- The study found no direct association between scalp swelling and increased odds of neonatal brain injury from hypoxia or stroke.
- These findings can help clinicians and parents distinguish between physical signs of trauma and the risk of brain injury in newborns.
Background And Objectives:
Neonatal brain injury is a common and devastating diagnosis conferring lifelong challenges for children and families. The role of mechanical forces applied to the head, often referred to as "birth trauma," are often considered although evidence for this association is lacking. The objective of this study was to investigate the association between common types of neonatal brain injury and scalp swelling using a novel method to quantify scalp swelling as an unbiased proxy for mechanical forces applied to the head.
Methods:
Case-control study using population-based, prospectively collected tertiary care center databases and healthy controls from the Human Connectome Development Project. Included were infants born 32-42 weeks gestational age and MRI in the first 9 days. Outcomes categories included healthy neonates, hypoxic ischemic encephalopathy (HIE) with or without brain injury, or stroke (ischemic or hemorrhagic). Volume of scalp swelling was objectively quantified by a novel imaging method blinded to brain injury. Variables included mode of delivery and use of instrumentation. Statistical tests included Kruskal-Wallis test, chi square, and multivariable and multinomial logistic regression.
Results:
There were 309 infants included (55% male): 72 healthy controls, 77 HIE without brain injury on MRI, 78 HIE with brain injury, and 82 with stroke (60 ischemic, 22 hemorrhagic). Scalp swelling was present in 126 (40.8%, 95% confidence interval [CI] 35.2%-46.5%) with no difference in proportions between outcome groups. Compared to healthy controls, median volume was higher in those with HIE without brain injury (17.5 mL, 95% CI 6.8-28.2), HIE with brain injury (12.1 mL, 95% CI 5.5-18.6), but not ischemic stroke (4.7 mL, 95% CI -1.2-10.6) nor hemorrhagic stroke (8.3 mL, 95% CI -2.2-18.8). Scalp swelling was associated with instrumented delivery (OR 2.1, 95% CI 1.0-4.1), but not associated with increased odds of brain injury in those with HIE (OR 1.5, 95% CI 0.76-3.30). Scalp swelling measures were highly reliable (ICC = 0.97).
Discussion:
"Birth trauma" quantified by scalp swelling volume was more common in infants with difficult deliveries, but not associated with greater odds of brain injury due to hypoxia or stroke. These results may help parents and practitioners to dissociate the appearance of trauma with the risk of brain injury.
