Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes.

OBJECT: Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions.

METHODS: A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores.

RESULTS: There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13-15 (OR 6.95), and the patients with NATs with of GCS scores 9-12 (OR 6.83) and 3-8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up.

CONCLUSIONS: Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.