Brain lesions in pediatric abusive head trauma: prevalence, pathophysiology, patterns, and a classification system

Area of Science:

• Pediatric neurology
• Forensic pathology
• Neuroradiology

Background:

• Abusive head trauma (AHT) is a significant cause of pediatric injury.
• Understanding extensive brain lesions (EBL) in AHT is crucial for differentiating it from other trauma types.
• Current data on AHT-associated EBL patterns, pathophysiology, and classification are limited.

Purpose of the Study:

• To investigate the prevalence and characteristics of AHT-associated EBL in neuroimaging.
• To develop a classification system for AHT-associated EBL.
• To differentiate AHT from other forms of trauma using EBL patterns.

Main Methods:

• Retrospective multicenter study of cranial CT and/or MRI in 61 medico-legally documented AHT cases.
• Analysis of lesions in the cerebrum, cerebellum, and brain stem.
• Development of a classification system by grouping EBLs into distinct patterns based on laterality, symmetry, distribution, and shape.

Main Results:

• Extensive brain lesions (EBL) were present in approximately one-third of AHT cases (n=20).
• Nine distinct EBL patterns were identified, some novel, in AHT cases.
• Brain stem lesions were rare (n=2); most lesions could be attributed to hypoxic-ischemic injury, but hypoglycemia and "second impact syndrome" were also considered.

Conclusions:

• Brain lesions in AHT by shaking exhibit categorizable patterns.
• The findings question the hypothesis of primary brain stem lesions causing initial respiratory insufficiency in AHT.
• Identified lesion patterns offer insights into pathomechanisms and support the clinical diagnosis of abusive head trauma.