Robert A. Minns

Annual incidence of shaken impact syndrome in young children

We looked at the incidence and demography of nonaccidental head injury in children in a prospective population-based study of paediatric units in Scotland during 1998-99. Shaken impact syndrome occurs with an annual incidence of 24.6 per 100000 children younger than 1 year (95% CI 14.9-38.5). Cases are more common in urban regions, and during autumn and winter months. The risk of a child suffering non-accidental head injury by age 1 year is one in 4065. These brain injuries occur almost exclusively in young infants (median age 2.2 months).

Late Neurologic and Cognitive Sequelae of Inflicted Traumatic Brain Injury in Infancy

Objective. There is limited information regarding the long-term outcome of inflicted traumatic brain injury (TBI), including shaken infant syndrome. The purpose of this study was to describe the long-term neurologic, behavioral, and cognitive sequelae seen in this population. Methods. A cross-sectional and prospective longitudinal study was conducted of 25 children with inflicted TBI in Scotland between 1980 and 1999. After consent was obtained, neurologic and cognitive examinations were performed on all participants and sequentially in the prospective cohort. Two global outcome measures were used: Glasgow Outcome Score (GOS) and Seshia’s outcome score. Cognitive outcome was assessed using the Bayley Scales of Infant Development, British Ability Scales, and the Vineland Adaptive Behavior Scales. Results. The mean length of follow-up was 59 months. A total of 68% of survivors were abnormal on follow-up, 36% had severe difficulties and were totally dependant, 16% had moderate difficulties, and 16% had mild difficulties on follow-up. A wide range of neurologic sequelae were seen, including motor deficits (60%), visual deficits (48%), epilepsy (20%), speech and language abnormalities (64%), and behavioral problems (52%). There was a wide range of cognitive abilities: the mean psychomotor index, 69.9 (SD: ±25.73); and mean mental development index, 74.53 (SD: ±28.55). Adaptive functioning showed a wide range of difficulties across all domains: communication domain (mean: 76.1; SD: ±25.4), Daily living skills domain (mean: 76.9; SD: ±24.3), and socialization domain (mean: 79.1; SD: ±23.1). Outcome was found to correlate with the Pediatric Trauma Score and the Glasgow Coma Score but did not correlate with age at injury or mechanism of injury. Conclusions. Inflicted TBI has a very poor prognosis and correlates with severity of injury. Extended follow-up is necessary so as not to underestimate problems such as specific learning difficulties and attentional and memory problems that may become apparent only once the child is in school. Behavioral problems are present in 52% and begin to manifest clinically between the second and third years of life, although the consequences of frontal lobe injury may be underestimated unless follow-up is extended into adolescence and early adulthood.

Critical thresholds of intracranial pressure and cerebral perfusion pressure related to age in paediatric head injury

Background: The principal strategy for managing head injury is to reduce the frequency and severity of secondary brain insults from intracranial pressure (ICP) and cerebral perfusion pressure (CPP), and hence improve outcome. Precise critical threshold levels have not been determined in head injured children. Objective: To create a novel pressure–time index (PTI) measuring both duration and amplitude of insult, and then employ it to determine critical insult thresholds of ICP and CPP in children. Methods: Prospective, observational, physiologically based study from Edinburgh and Newcastle, using patient monitored blood pressure, ICP, and CPP time series data. The PTI for ICP and CPP for 81 children, using theoretical values derived from physiological norms, was varied systematically to derive critical insult thresholds which delineate Glasgow outcome scale categories. Results: The PTI for CPP had a very high predictive value for outcome (receiver operating characteristic analyses: area under curve = 0.957 and 0.890 for mortality and favourable outcome, respectively) and was more predictive than for ICP. Initial physiological values most accurately predicted favourable outcome. The CPP critical threshold values determined for children aged 2–6, 7–10, and 11–15 years were 48, 54, and 58 mm Hg. respectively. Conclusions: The PTI is the first substantive paediatric index of total ICP and CPP following head injury. The insult thresholds generated are identical to age related physiological values. Management guidelines for paediatric head injuries should take account of these CPP thresholds to titrate appropriate pressor therapy.

Temporal and spatial parameters of gait in children. I: Normal control data.

A study of the spatial and temporal parameters of gait was performed on 134 normal children, 68 boys and 66 girls, aged between three and 18 years. Normal gait showed a clear asymmetry; gait was considered to be abnormally asymmetrical if differences between left and right measurements exceeded 8 to 10 per cent. In addition, there was a definite bias corirparing left and right sides, which may relate to individual laterality.

Cerebrospinal fluid pressure in pyogenic meningitis.

The pressure of cerebrospinal fluid taken at lumbar puncture was recorded objectively by strain gauge pressure measurement in 35 infants and children with pyogenic meningitis. Raised pressures were found in 33 children. The median pressure was 15 mm Hg (range 4-70 mm Hg) in all age groups. The pressure level varied throughout the infection, but a higher median pressure (19 mm Hg) was found when this was measured on the day of admission. The clinical features of the meningitis in these patients suggest that many of the presenting symptoms and signs are those of pressure. These results show that high pressure is frequently present in childhood meningitis, not just in those who die from cones or who have radiological evidence of hydrocephalus. We conclude that raised cerebrospinal fluid pressure is a frequent accompaniment of childhood meningitis and may need treatment in its own right and is therefore one further important factor influencing the course and outcome of childhood meningitis.

Early posttraumatic seizures in non-accidental head injury: relation to outcome

To document the characteristics of early posttraumatic seizures (EPTS) in non‐accidental head injury (NAHI), and examine their relation with outcome, a retrospective study was carried out. All children with NAHI admitted to the Royal Hospital for Sick Children, Edinburgh, since 1981 were identified. The characteristics of EPTS, EEG, and outcome were noted. Forty‐four cases were identified. The average age of children at presentation was 5.9 months. Thirty‐two of these children had EPTS. The median length of follow‐up was 3 years. The mortality rate was six in 44 (14%). The neurodevelopmental outcome correlated significantly with the presence and severity of EPTS (Tau=0.317,p=0.017). Of survivors, 22% developed late posttraumatic epilepsy; the outcome in those with epilepsy was significantly worse than those without (p<0.0001). It was concluded that the severity of the primary brain injury dictates the severity of the EPTS and neurodevelopmental status at follow‐up.

The neurological outcome of non-accidental head injury

Purpose: The literature regarding the outcome of non-accidental head injury (NAHI) is scarce and lacks specific detail even though it is generally considered to be poor. The purpose of this study is to review the literature to date and report the neurological outcome of these children in detail. Methods: A cross-sectional and prospective study of children admitted to hospital with NAHI in Scotland. Results: Twenty-five children were enrolled and 68% of children were neurologically abnormal at an average follow-up of 59 months. A wide range of abnormalities and outcomes was seen. Speech and language difficulties were present in 64% including autistic spectrum disorder. Cranial nerve abnormalities were present in 20%. Visual deficits and epilepsy compounded learning difficulties in 25% of survivors. Consent for follow-up was more likely to be obtained where the perpetrator was known. Conclusions: The spectrum and degree of severity of neurological abnormalities in survivors of NAHI is extremely variable, with the majority of these children being moderate or severely abnormal. These children require the support of a multi-disciplinary team in the community. Further study regarding the process of follow-up, where complex medicolegal issues exist, are needed in order to facilitate maximum neurological development.

Incidence and Demography of Non-Accidental Head Injury in Southeast Scotland from a National Database

BACKGROUND This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland. METHODS This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period. RESULTS The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services. CONCLUSIONS The incidence rates from this prospective study for NAHI are considerably higher than other published UK surveys and are not considered to reflect a cluster effect. The perpetrators in this study fit a strongly skewed profile aggregating to the lowest socioeconomic groups in the community.

Magnetic resonance imaging in acute non-accidental head injury.

Making the diagnosis of non‐accidental head injury, particularly in the acute illness, can be difficult. The aim of this retrospective study was to evaluate the use of magnetic resonance imaging in the acute presentation of non‐accidental head injury. Twelve cases admitted to the Royal Hospital for Sick Children, Edinburgh with a diagnosis of non‐accidental head injury, and who had magnetic resonance imaging in the acute illness, were identified. The average age was 5.7 mo (range 1 to 34 mo). The mechanism of the primary injury was whiplash‐shaking injury syndrome with impact in four cases and without evidence of impact in seven; in one case there was a compression injury. The magnetic resonance imaging findings reflected the pathological consequences of rotational acceleration‐deceleration injury and did not differ between those cases with evidence of impact and those without. Subdural haematomas were identified in all cases; the commonest location for subdural blood was the subtemporal region. It is surprising and important that the most frequent location of subdural blood was in the subtemporal area. This is an area difficult to assess by computerized tomography. Evidence of repeated injuries was found in two cases. These findings confirm the value of magnetic resonance imaging in the acute phase of non‐accidental head injury. □Child abuse, magnetic resonance imaging, non‐accidental head injury, whiplash shaking injury

The relation between intracranial pressure and outcome in non-accidental head injury

The aim of this retrospective study was to ascertain whether physiological derangement and potential secondary brain insult from raised intracranial pressure (ICP) or reduced cerebral perfusion pressure (CPP) in non‐accidental head injury (NAHI) influences outcome. Any child who had a diagnosis of NAHI and had ICP monitoring or measurements during the acute illness was entered in the study. Seventeen children with an average age 5.1 months (range 1 to 20 months) were identified. Details of the acute encephalopathy, lowest mean arterial blood pressure (MAP), mean of maximum ICP measured, lowest CPP, and neurodevelopmental outcome at follow up were obtained from the hospital case notes. Seshias (1994) outcome classification scale was used. The lowest CPP was very significantly related to outcome (P=0.0047, τ=–0.544). Mean of maximum ICP did not correlate with outcome. The lowest MAP was significantly related to outcome (P=0.039). It was concluded that the degree of secondary brain insult from reduced CPP influences outcome. Developmental Medicine & Child Neurology 1999, 41: 220–225