Original Article

Occult Cranial Injuries Found with Neuroimaging in Clinically Asymptomatic Young Children Due to Abusive Compared to Accidental Head Trauma

Authors: Kristin A. Fickenscher, MD, Julianne S. Dean, DO, David C. Mena, MD, Brian A. Green, MD, Lisa H. Lowe, MD


Objective: To compare occult brain injuries on neuroimaging in clinically asymptomatic children under 20 months due to abusive versus accidental head trauma.

Subjects and Methods: A retrospective review of 58 children under 20 months who underwent neuroimaging for possible abusive trauma was performed. The data collected were demographics, neurological signs/symptoms, imaging findings, and disposition (abusive or accidental).

Results: The disposition of 31 subjects was abusive trauma and 27 were accidental. At presentation, 8/31(25.8%) children with abusive injury and 15/27(55.6%) with accidental injury were neurologically asymptomatic. Neuroimaging was abnormal in 6 of 8 (75.0%) asymptomatic children with abusive injury, and 13/15 (86.7%) children with accidental trauma. No significant (P = 0.59) difference in frequency of abnormal neuroimaging was seen between the asymptomatic abusive and accidental trauma groups.

Conclusions: Although victims of abusive trauma under 20 months of age are less often neurologically asymptomatic compared to accidental trauma victims, neuroimaging revealed a high rate of occult traumatic brain injury in both groups.

Key Points

* Infants and young children who are victims of accidental trauma are often screened more aggressively for occult head injuries than those who are victims of abusive trauma.

* This study shows that children <20 months of age who are victims of accidental, as well as abusive trauma have a similar rate of asymptomatic head injuries detected with neuroimaging.

* Because neuroimaging findings of head trauma may be used for evidentiary reasons, we suggest that screening neuroimaging be carefully considered during the evaluation of infants and young children who may have suffered abusive head injuries regardless of presence or absence of symptoms.

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1.Duus BR, Lind B, Christensen H, et al. The role of neuroimaging in the initial management of patients with minor head injury. Ann Emerg Med 1994;23:1279–1283.
2.Judkins AR, Hood IG, Mirchandani HG, et al. Technical communication: rationale and technique for examination of nervous system in suspected infant victims of abuse. Am J Forensic Med Pathol 2004;25:29–32.
3.Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics 2003;111:1382–1386.
4.Greenes DS, Schutzman SA. Occult intracranial injury in infants. Ann Emerg Med 1998;32:680–686.
5.Fernando S, Obaldo RE, Walsh IR, et al. Neuroimaging of nonaccidental head trauma: pitfalls and controversies. Pediatr Radiol 2008;38:827–838.
6.Berger RP, Kochanek PM, Pierce MC. Biochemical markers of brain injury: could they be used as diagnostic adjuncts in cases of inflicted traumatic brain injury? Child Abuse Negl 2004;28:739–754.
7.Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621–626.
8.Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med 2000;154:11–15.
9.Hymel KP, Makoroff KL, Laskey AL, et al. Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study. Pediatrics 2007;119:922–929.
10.Barnes RE. Reefer madness: legal & moral issues surrounding the medical prescription of marijuana. Bioethics 2000;14:16–41.
11.Hattar S, Kumar M, Park A, et al. Central projections of melanopsin-expressing retinal ganglion cells in the mouse. J Comp Neurol 2006;497:326–349.
12.Laskey AL, Holsti M, Runyan DK, et al. Occult head trauma in young suspected victims of physical abuse. J Pediatr 2004;144:719–722.
13.DiScala C, Sege R, Li G, et al. Child abuse and unintentional injuries: a 10-year retrospective. Arch Pediatr Adolesc Med 2000;154:16–22.
14.Levin AV. Ocular Manifestations of Child Abuse. Philadelphia, Lippincott Williams and Wilkins, 2001, ed 2.
15.Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 2004;114:165–168.