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The authors present the case of a 5-year-old boy who developed a unilateral internuclear ophthalmoplegia (INO) following mild head trauma with supporting magnetic resonance imaging (MRI) findings of damage to the medial longitudinal fasciculus. At 2 months of follow-up, the patient had resolution of diplopia and only minimal residual nystagmus. Although rare in the children, INO can develop following head trauma. Management should include work-up to exclude etiologies beyond trauma (specifically with MRI, which is superior to computed tomography imaging in evaluating INO) followed by observation and, if needed, comanagement of any amblyogenic potential from ocular misalignment. [ J Pediatr Ophthalmol Strabismus . 2024;61(6):e75-e77.] .

Early neurobehavioral outcomes among infants with abusive head trauma (AHT) have not been well characterized. Though there are standardized measures for assessing infants, the ability of these measures to detect deficits may be limited. The Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale, Second Edition (NNNS-II) has been correlated with neurobehavioral outcomes as early as birth but has not been used with this clinical group. There is no strong evidence of the concurrent validity of this measure. The primary goal was to examine the concurrent validity of the NNNS-II in patients with suspected AHT by comparing it to the Mullen Scales of Early Learning, American Guidance Service (AGS) Edition (Mullen). A secondary goal was to characterize early neurobehavioral outcomes among infants with suspected AHT across two measures. This retrospective study included 11 infants who sustained a traumatic brain injury (TBI) around 40 days of age. The sample's performance was variable and ranged from average to below average across measures. Participants experienced the most difficulty with visuospatial processing, attentional abilities, physiologic regulation, and asymmetric reflexes, and data suggested the NNNS-II may be more sensitive to deficits. There was evidence of concurrent validity of the NNNS-II based on strong to moderate correlations with the Mullen. Use of the NNNS-II shortly after the injury is more likely to showcase deficits, which may increase the likelihood that patients receive early intervention. Establishing concurrent validity of the NNNS-II further contributes to the evidence base regarding its criterion related validity, which may promote its more regular use.

Head injury is a potentially lethal and frequently occurring condition in the emergency department (ED). Reliable and fast diagnosis is important both for patients and flow in the ED. Circulating S100B is used to rule out the need for head computer tomography in low-risk patients with mild head injury. The flow of these patients through the ED would benefit from shorter turn-around time. Standard serum clotting tubes require 30-60 min clotting time, followed by an analysis time of 45 min. Here, we evaluated the performance of two alternative blood collection tubes; a rapid serum tube (RST) with a recommend clotting time of 5 min and a hirudin tube (HIR) for instant anticoagulation. S100B measurement was performed on paired blood samples from 221 subjects using a Roche Cobas 602 analyser. The performances of the alternative tubes were evaluated by method comparison to the standard serum clotting tube, repeatability and agreement of results obtained from alternative tubes compared with the standard clotting tube. Both alternative tubes had a minor positive bias (RST = 0.011 µg/L, HIR = 0.008 µg/L). The repeatability was 2% for RST and 10% for HIR, while being 4% for the standard clotting tube. In the agreement analysis, the positive and negative predictive values for RST were 62% and 100% while being 73% and 99% for HIR respectively. Our study suggests that RST is a feasible alternative to reduce laboratory turn-around time in S100b analysis.

Questionnaire-based symptom validity tests (SVTs) are an indispensable diagnostic tool for evaluating the credibility of patients' claimed symptomatology, both in forensic and in clinical assessment contexts. In 2019, the comprehensive professional manual of a new SVT, the Self-Report Symptom Inventory (SRSI), was published in German. Its English-language version was first tested in the UK. This experimental analogue study investigated 20 adults simulating minor head injury symptoms and 21 honestly responding participants. The effect sizes of differences between the two groups were large, with the simulating group endorsing a higher number of pseudosymptoms, both on the SRSI and the Structured Inventory of Malingered Symptomatology, and scoring lower on the Reliable Digit Span than the control group. The results are similar to those obtained in previous research of different SRSI language versions, supporting the effort to validate the English-language SRSI version.

Objective: To examine agreement between parental reports of head injury and evidence of head injury in medical records and to compare these two measures in predicting early conduct disorder (CD)., Design and Setting: Parent survey data was compared with records of child head injury from the National Health Services Register (Régie de l'assurance maladie du Québec, RAMQ) administrative database., Participants: Children ( N  = 685) ages 6-9 with and without CD. There were 147 children with RAMQ recorded head injury and 39 children with parent-reported head injury., Main Measures: Indication of one or more head injury before 6 years of age as reported by parents and/or as noted in medical data. Early CD (present by age 9) according to parents and/or teachers., Results: Results indicated poor agreement between the two forms of reporting κ = .161 (95% CI, .083 to .239), p  < 0.001. Medical data significantly predicted the presence of CD in children, with a RAMQ coded head injury suggesting a child was 1.88 times more likely to have CD. Parent reports of head injuries did not significantly predict CD. Conclusion: Medical data should be prioritized in research addressing pediatric head injury, given that parent reports may fail to capture incidence of injury and therefore may be less predictive of other known correlates of head injury.

A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient's symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Abusive head trauma (AHT) is a criminal offence that is prosecuted ex officio, following report to the police from physicians or child protection services. The aim of this study was to assess whether the judicial outcome (dismissal vs indictment) was influenced by the quality of the medical documentation and/or the time span between AHT diagnosis and reporting child abuse to the police. The cohort was divided in two groups: 13/23 dismissals (57%) and 10/23 indictments (43%). The diagnostic probability of the AHT cases was certain for both groups. Nonetheless, in fraction of dismissed cases, alternative explanations for the observed lesions seemed plausible to the public prosecutor. Legal files of only 3/12 dismissed cases had a forensic report, while 6/10 cases that were indicted included a forensic report. Further, the legal file of several dismissed cases entirely lacked medical documentation (3/12), which was not the cases for indicted cases. The period between AHT diagnosis and reporting to the police was not different for dismissals (29 ± 19 days) and indictments (7 ± 4 days) (p = 0.32). Physicians filed reports more rapidly (6 ± 1 days) compared to childhood protection service (70 ± 46 days) (p = 0.01) and that may increase the rate of indictments (9/18) compared to reporting via the childhood protection service (1/5). Despite diagnostic certainty, other causes for the lesions were considered as plausible alternative explanations to judicial professionals in several dismissed cases. These seemed to have less medical documentation and forensic evaluations. In addition, more rapid reporting to the police by physicians seems to increase the likelihood of indictments., (© 2024. The Author(s).)

Background: The PediBIRN-7 clinical prediction rule incorporates the (positive or negative) predictive contributions of completed abuse evaluations to estimate abusive head trauma (AHT) probability after abuse evaluation. Applying definitional criteria as proxies for AHT and non-AHT ground truth, it performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.88 (95 % CI: 0.85-0.92) in its derivation study., Objective: To validate the PediBIRN-7's AHT prediction performance in a novel, equivalent, patient population., Participants and Settings: Consecutive, acutely head-injured children <3 years hospitalized for intensive care across eight sites between 2017 and 2020 with completed skeletal surveys and retinal exams (N = 342)., Methods: Secondary analysis of an existing, cross-sectional, prospective dataset, including assignment of patient-specific estimates of AHT probability, calculation of AHT prediction performance measures (ROC-AUC, sensitivity, specificity, predictive values), and completion of sensitivity analyses to estimate best- and worst-case prediction performances., Results: Applying the same definitional criteria, the PediBIRN-7 performed with sensitivity 0.74 (95 % CI: 0.66-0.81), specificity 0.77 (95 % CI: 0.70-0.83), and ROC-AUC 0.83 (95 % CI: 0.78-0.88). The reduction in ROC-AUC was statistically insignificant (p = .07). Applying physicians' final consensus diagnoses as proxies for AHT and non-AHT ground truth, the PediBIRN-7 performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.90 (95 % CI: 0.87-0.94). Sensitivity analyses demonstrated minimal changes in rule performance., Conclusion: The PediBIRN-7's overall AHT prediction performance has been validated in a novel, equivalent, patient population. Its patient-specific estimates of AHT probability can inform physicians' AHT-related diagnostic reasoning after abuse evaluation., Competing Interests: Declaration of competing interest The authors have no personal or financial conflicts of interest relevant to this article to disclose., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children., Methods: Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old., Results: We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%)., Conclusions: The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population., (Copyright © 2024 by the American Academy of Pediatrics.)

Introduction: The Glasgow Coma Scale (GCS) is an assessment tool commonly used by emergency department (ED) clinicians to objectively describe level of consciousness, especially in trauma patients. This study aims to assess the effect of drug and alcohol intoxication on GCS scores in cases of traumatic head injury., Methods: In this retrospective chart review study, data were extracted from The Pennsylvania Trauma Systems Foundation Data Base Collection System. Eligible subjects included trauma patients aged 18 years and older, with head trauma, who presented between January 2019 and August 2023. Subjects were matched to controls who did not test positive for drugs or alcohol, matched by Injury Severity Score (ISS) category., Results: Among 1088 subjects, the mean age was 63 (95% CI 62-64). The mean Injury Severity Score was 21 (95% CI 21-22). The median GCS among all subjects was 14 (IQR 6-15). Cases with alcohol or drug use were matched to controls without alcohol or drug use, and were matched by categories of Injury Severity Score. Cases with alcohol or drug use had lower GCS (median 13; IQR 3-15), compared to cases without alcohol or drug use (median 15; IQR 13-15) (p < 0.0001, Wilcoxon Rank Sum Test)., Conclusions: Among patients with head trauma, intoxicated patients had statistically significant lower GCS scores as compared to matched patients with similar Injury Severity Scores., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

When stroke occurs in pediatric age, it might be mistakenly interpreted as non-accidental head injury (NAHI). In these situations, a multidisciplinary approach is fundamental, including a thorough personal and familial history, along with accurate physical examination and additional investigations. Especially when the clinical picture is uncertain, it is important to remember that certain genetic conditions can cause bleeding inside the brain, which may resemble NAHI. Pediatric strokes occurring around the time of birth can also be an initial sign of undiagnosed genetic disorders. Hence, it is crucial to conduct a thorough evaluation, including genetic testing, when there is a suspicion of NAHI but the symptoms are unclear. In these cases, a characteristic set of symptoms is often observed. This study aims to summarize some of the genetic causes of hemorrhagic stroke in the pediatric population, thus mimicking non-accidental head injury, considering elements that can be useful in characterizing pathologies. A systematic review of genetic disorders that may cause ICH in children was carried out according to the Preferred Reporting Item for Systematic Review (PRISMA) standards. We selected 10 articles regarding the main genetic diseases in stroke; we additionally selected 11 papers concerning patients with pediatric stroke and genetic diseases, or studies outlining the characteristics of stroke in these patients. The disorders we identified were Moyamoya disease (MMD), COL4A1 , COL4A2 pathogenic variant, Ehlers-Danlos syndrome (E-D), neurofibromatosis type 1 (Nf1), sickle cell disease (SCD), cerebral cavernous malformations (CCM), hereditary hemorrhagic telangiectasia (HHT) and Marfan syndrome. In conclusion, this paper provides a comprehensive overview of the genetic disorders that could be tested in children when there is a suspicion of NAHI but an unclear picture.

Discovering a body displaying signs of multiple head trauma requires a thorough examination by the forensic pathologist, and a multidisciplinary approach is recommended. However, determining the manner of death is not always possible. We present a case in which the body of a 60-year-old man was discovered lying face down on the floor of his apartment, partially unclothed, surrounded by blood and vomit, and presenting numerous head injuries. The autopsy concluded that the cause of death was a result of post-traumatic brain injury. Nevertheless, applying current criteria made it challenging to ascertain whether the trauma stemmed from an accidental event or an assault., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: Mild traumatic brain injury is common in children and it can be challenging to accurately identify those in need of urgent medical intervention. The Scandinavian guidelines for management of minor and moderate head trauma in children, the Scandinavian Neurotrauma Committee guideline 2016 (SNC16), were developed to aid in risk stratification and decision-making in Scandinavian emergency departments (EDs). This guideline has been validated externally with encouraging results, but internal validation in the intended healthcare system is warranted prior to broad clinical implementation., Objective: We aim to validate the diagnostic accuracy of the SNC16 to predict clinically important intracranial injuries (CIII) in paediatric patients suffering from blunt head trauma, assessed in EDs in Sweden and Norway., Methods and Analysis: This is a prospective, pragmatic, observational cohort study. Children (aged 0-17 years) with blunt head trauma, presenting with a Glasgow Coma Scale of 9-15 within 24 hours postinjury at an ED in 1 of the 16 participating hospitals, are eligible for inclusion. Included patients are assessed and managed according to the clinical management routines of each hospital. Data elements for risk stratification are collected in an electronic case report form by the examining doctor. The primary outcome is defined as CIII within 1 week of injury. Secondary outcomes of importance include traumatic CT findings, neurosurgery and 3-month outcome. Diagnostic accuracy of the SNC16 to predict endpoints will be assessed by point estimate and 95% CIs for sensitivity, specificity, likelihood ratio, negative predictive value and positive predictive value., Ethics and Dissemination: The study is approved by the ethical board in both Sweden and Norway. Results from this validation will be published in scientific journals, and a tailored development and implementation process will follow if the SNC16 is found safe and effective., Trial Registration Number: NCT05964764., Competing Interests: Competing interests: JU, NM and OC are members of the SNC committee, a non-profit organisation independent from financial company support, who are responsible for the SNC16 guidelines. None of the authors have any financial competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT., Methods: We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT., Results: 47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT., Conclusions: AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT., Type of Study: Observational cohort study., Level of Evidence: III., Competing Interests: Conflicts of interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Compare follow-up optical coherence tomography with visual function in children with abusive head trauma (shaken baby syndrome)., Methods: Retrospective follow-up studies of three children who were victims of abusive head trauma within the first year of life., Results: Optical coherence tomography showed disrupted retinal layering, thick detached internal limiting membrane, focal posterior vitreous separation, and multilayered tractional retinoschisis. Significant vision loss occurred in three of four eyes with a history of traumatic retinoschisis. Normal visual acuity and low-normal visual-evoked potentials were measured in a child with foveal distortion, reduced global nerve fiber layer thickness, detached internal limiting membrane, and history of vitreous hemorrhage., Conclusion: Significant abnormalities of retinal anatomy can be detected on optical coherence tomography years after abusive head trauma. Optical coherence tomographies and assessment of visual pathways help to elucidate causes of visual dysfunction in children with abusive head trauma., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

For infants that present with intracranial hemorrhage in the setting of suspected abusive head trauma (AHT), the standard recommendation is to perform an evaluation for a bleeding disorder. Factor XIII (FXIII) deficiency is a rare congenital bleeding disorder associated with intracranial hemorrhages in infancy, though testing for FXIII is not commonly included in the initial hemostatic evaluation. The current pediatric literature recognizes that trauma, especially traumatic brain injury, may induce coagulopathy in children, though FXIII is often overlooked as having a role in pediatric trauma-induced coagulopathy. We report an infant that presented with suspected AHT in whom laboratory workup revealed a decreased FXIII level, which was later determined to be caused by consumption in the setting of trauma induced coagulopathy, rather than a congenital disorder. Within the Child Abuse Pediatrics Research Network (CAPNET) database, 85 out of 569 (15 %) children had FXIII testing, 3 of those tested (3.5 %) had absent FXIII activity on qualitative testing, and 2 (2.4 %) children had activity levels below 30 % on quantitative testing. In this article we review the literature on the pathophysiology and treatment of low FXIII in the setting of trauma. This case and literature review demonstrate that FXIII consumption should be considered in the setting of pediatric AHT., Competing Interests: Declaration of competing interest AAL has no conflicts of interest. CTC declares conflicts of interest of participation on an advisory board for Bayer Pharmaceuticals and as a consultant for Oliver Wyman. AS has no conflicts of interest. FWL has no conflicts of interest. ANB has no conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable. WHAT THIS PAPER ADDS: There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken. Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage. Patterns of retinal haemorrhage cannot distinguish abuse. Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking. Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot. The shaking hypothesis and the literature on which it depends do not meet the standards of evidence-based medicine., (© 2023 Mac Keith Press.)

Objectives: Data in literature indicate that in patients suffering a minor head injury (MHI), biomarkers serum levels could be effective to predict the absence of intracranial injury (ICI) on head CT scan. Use of these biomarkers in case of patients taking oral anticoagulants who experience MHI is very limited. We investigated biomarkers as predictors of ICI in anticoagulated patients managed in an ED., Methods: We conducted a single-cohort, prospective, observational study in an ED. Our structured clinical pathway included a first head CT scan, 24 h observation and a second CT scan. The outcome was delayed ICI (dICI), defined as ICI on the second CT scan after a first negative CT scan. We assessed the sensitivity (SE), specificity (SP), negative predictive value (NNV) and positive predictive value (PPV) of the biomarkers S100B, NSE, GFAP, UCH-L1 and Alinity TBI in order to identify dICI., Results: Our study population was of 234 patients with a negative first CT scan who underwent a second CT scan. The rate of dICI was 4.7 %. The NPV for the detection of dICI were respectively (IC 95 %): S100B 92.7 % (86.0-96.8 %,); ubiquitin C-terminal hydrolase-L1 (UCH-L1) 91.8 % (83.8-96.6 %); glial fibrillary protein (GFP) 100 % (83.2-100 %); TBI 100 % (66.4-100 %). The AUC for the detection of dICI was 0.407 for S100B, 0.563 for neuron-specific enolase (NSE), 0.510 for UCH-L1 and 0.720 for glial fibrillary acidic protein (GFAP), respectively., Conclusions: The NPV of the analyzed biomarkers were high and they potentially could limit the number of head CT scan for detecting dICI in anticoagulated patients suffering MHI. GFAP and Alinity TBI seem to be effective to rule out a dCI, but future trials are needed., (© 2024 Walter de Gruyter GmbH, Berlin/Boston.)

Healthcare demand from falls in older adults is increasing, but guidance from the literature is lacking on the value of neuroimaging, particularly for those who have fallen but have no head injury or an unclear history. We carried out retrospective analysis of data from Emergency Department attendances at a large English hospital to assess compliance with guidelines and explore utility of CT scans for those not covered by existing guidance. Following a fall, 49% (577) of older adults received a cranial CT scan, 4.9% (28) of whom had an intracranial haemorrhage and only 2 received neurosurgical intervention. Only 59% who had a CT had a clear history of head injury, unwitnessed falls were common (71%) and there was a high prevalence of dementia (23%); those scanned without a clear history of head injury were significantly more frail, but not older. There was some indication that seizure, reduced GCS and neurological signs are predictive of intracranial haemorrhage regardless of head injury history, but further research is recommended to provide clarity on which groups stand to benefit most and how clinicians can be supported in decision making that balances diagnostic yield, patient benefit and imaging demand., Competing Interests: On behalf of all authors, the corresponding author states that there is no conflict of interest.

Purpose: We explored the application of a machine learning algorithm for the timely detection of potential abusive head trauma (AHT) using the first free-text note of an encounter and demographic information., Methods: First free-text physician notes and demographic information were collected for children under 5 years of age at a Level 1 Trauma Center. The control group, which included patients with head/neck injury, was compared to those with AHT diagnosed by the Child Protective Team. Differential scores accounted for words overrepresented in AHT patient vs. control notes. Sentiment scores were reflective of note positivity/negativity and subjectivity scores accounted for note subjectivity/objectivity. The composite scores reflected the patient's differential score modified by the subjectivity score. Composite, sentiment, and subjectivity scores combined with demographic information trained a Random Forest (RF) machine learning algorithm to predict AHT., Results: Final composite scores with demographic information were highly associated with AHT in a test dataset. The control group included 587 patients and the test group included 193 patients. Combining composite scores with demographic information into the RF model improved AHT classification area under the curve (AUC) from 0.68 to 0.78, with an overall accuracy of 84%. Feature importance analysis of our RF model revealed that composite score, sentiment, age, and subjectivity were the most impactful predictors of AHT. The sentiment was not significantly different between control and AHT notes (p = 0.87), while subjectivity trended higher for AHT notes (p = 0.081)., Conclusion: We conclude that a machine learning algorithm can recognize patterns within free-text notes and demographic information that aid in AHT detection in children., Level of Evidence: III., Competing Interests: Conflict of interest The authors report no conflict of interest. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Abusive Head Trauma (AHT) results in more child fatalities than any other form of physical abuse and is associated with significant risk of morbidity for survivors. The diagnosis of AHT is made like any other complex medical condition and is based on a constellation of findings within the context of a reported history provided by the patient's caregiver(s). A standardized process with careful consideration of a differential diagnosis and utilization of a multidisciplinary team is essential. This article explores the history of the diagnosis of AHT, reviews the scientific basis for potential mechanisms, references the recommended medical evaluation, describes common findings, and the importance of early and accurate diagnosis.

Head trauma is a common neurosurgical complication. It is encountered daily at neurosurgical outpatient departments or after-hour emergency outpatient departments. In addition, most cases of patients with trauma transported by ambulance involve those with head trauma. Head trauma is a common and unavoidable neurosurgical injury. In case of a head injury, the neurosurgeon should verify the level of consciousness and perform a proper neurological examination. A head computed tomography should be performed immediately for any abnormalities. However, currently, severe trauma is often complicated by head trauma and various other injuries. When medical examinations and treatments focus only on head trauma, preventable trauma death cannot be avoided. Functional prognosis due to secondary brain injury may be exacerbated. This article presents a standardized procedure for the initial care of patients with multiple trauma and head injuries.

Previous studies demonstrate racial disparities in child abuse evaluations even after controlling for health insurance coverage. We conducted a cross-sectional study using the Military Health System Data Repository (MDR) of Military Health System (MHS) beneficiaries born between fiscal years 2016 and 2018 to evaluate racial disparities and other factors in the suspicion of child abuse. We observed beneficiaries for 2.5 years after birth and assessed the incidence of head injury using diagnostic codes. Among children with head injury codes, we performed a multivariable logistic regression analysis to measure the association between race and the concurrent use of the diagnostic code for suspected child abuse (SCA) or for the performance of a skeletal survey. There were 195,893 infants included and 45,269 (23.1%) underwent evaluations for head injury. Less than one percent ( n = 424) concurrently had the diagnostic code for SCA or a skeletal survey performed within 2 weeks of the head injury evaluation. When controlling for other factors, race was not associated with SCA. Higher military rank was independently associated with decreased odds of SCA. Racial disparities in SCA may be mitigated in the MHS, and further evaluation is needed. Military rank could be a factor in SCA disparities and warrants further study.

A considerable number of patients with mild traumatic brain injury have been known to "talk and die." Serial neurological examinations, however, have been the only method of determining the necessity of repeat computed tomography (CT), and no validated method has been available to predict early deterioration of minor head injury. This study aimed to evaluate the association between hypertension and bradycardia, a classic sign of raised intracranial pressure (Cushing reflex) on hospital arrival and determine the clinical consequences of minor head injury after blunt trauma. We created a new Cushing Index (CI) by dividing the systolic blood pressure by the heart rate (equaling the inverse number of the Shock Index, a score for hemodynamic stability) and hypothesized that a high CI would predict surgical intervention for deterioration and in-hospital death among patients with minor head injury. To test our hypothesis, a retrospective observational study was conducted using a nationwide trauma database. Accordingly, adult blunt trauma with minor head injury (defined as a Glasgow Coma Scale of 13-15 and Abbreviated Injury Scale score of ≥2 in the head) who were transported directly from the scene by ambulances were included. Among the 338,744 trauma patients identified in the database, 38,844 were eligible for inclusion. A restricted cubic spline regression curve for risks of in-hospital death was created using the CI. Thereafter, the thresholds were determined based on inflection points of the curve, and patients were divided into low-, intermediate-, and high-CI groups. Patients with high CI showed significantly higher in-hospital mortality rates compared with those with intermediate CI (351 [3.0%] vs. 373 [2.3%]; odds ratio [OR] = 1.32 [1.14-1.53]; p  < 0.001). Patients with high index also had a higher incidence of emergency cranial surgery within 24h after arrival than those with an intermediate CI (746 [6.4%] vs. 879 [5.4%]; OR = 1.20 [1.08-1.33]; p  < 0.001). In addition, patients with low CI (equal to high Shock Index, meaning hemodynamically unstable) showed higher in-hospital death compared with those with intermediate CI (360 [3.3%] vs. 373 [2.3%]; p  < 0.001). In conclusion, a high CI (high systolic blood pressure and low heart rate) on hospital arrival would be helpful in identifying patients with minor head injury who might experience deterioration and need close observation.

Background: Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists., Objectives: To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs)., Participants and Setting: Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career., Methods: This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons., Results: There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example., Conclusions: Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Retinal hemorrhages (RHs) are suggestive of abusive head trauma (AHT). Even so, controversy persists about other possible causes, a fact that hinders the diagnosis of abuse., Objective: To determine the prevalence and patterns of RHs associated with increased intracranial pressure (ICP) in young children., Participants and Methods: Prospective, single center study of children aged 29 days-3 years undergoing a lumbar puncture with opening pressure (OP) measured during routine clinical care in the emergency department, over a 4-year period. Children with known causes of RHs were excluded. All the children underwent a detailed ophthalmological examination within 72 h of admission. For children with RHs, an in-depth investigation was carried out to rule out AHT., Results: Thirty-four patients were included: 20(58.8 %) were boys, median age 11.7 months (range 1-33 months). Overall, 29(85.3 %) had clinical findings of increased ICP. The duration of symptoms was ≤4 days in all patients except one, in whom it was 1.5 months. The median OP was 27cmH 2 O (range 20-60cmH2O). One of the children was found to have RHs, with evaluation resulting in a diagnosis of AHT. No RHs were found in any of the others studied. Using the Wilson method, we can be confident to an upper limit of 95 % that the probability of RHs occurring secondary to increased ICP alone is at most 0.1., Conclusions: RHs were not detected in patients with isolated nontraumatic increased ICP, measured via OP and diagnosed in the ED. Therefore, if RHs are detected, investigation into the possibility of AHT is warranted., Competing Interests: Declaration of competing interest The authors have no example conflicts of interest to disclose., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Toddlers face serious health hazards if they fall from relatively high places at home during everyday activities and are not swiftly rescued. Still, few effective, precise, and exhaustive solutions exist for such a task. This research aims to create a real-time assessment system for head injury from falls. Two phases are involved in processing the framework: In phase I, the data of joints is obtained by processing surveillance video with Open Pose. The long short-term memory (LSTM) network and 3D transform model are then used to integrate key spots' frame space and time information. In phase II, the head acceleration is derived and inserted into the HIC value calculation, and a classification model is developed to assess the injury. We collected 200 RGB-captured daily films of 13- to 30-month-old toddlers playing near furniture edges, guardrails, and upside-down falls. Five hundred video clips extracted from these are divided in an 8:2 ratio into a training and validation set. We prepared an additional collection of 300 video clips (test set) of toddlers' daily falling at home from their parents to evaluate the framework's performance. The experimental findings revealed a classification accuracy of 96.67%. The feasibility of a real-time AI technique for assessing head injuries in falls through monitoring was proven.

Purpose: Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures., Methods: Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR)., Results: Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping., Discussion: Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics., (© 2023. The Author(s).)

Objective: To develop a Modified Glasgow Coma Scale (MGCS) for use in raptors presenting with head trauma and assess the agreement of the MGCS scores between examiners with varying backgrounds, and to assess the prognostic value of the avian MGCS in raptors with head trauma., Animals: 156 native raptorial species., Methods: All raptors received an MGCS assessment within 8 hours of their presentation, between January 1, 2018, and December 31, 2019. For the first objective, the assessment was performed by a veterinary student, a wildlife veterinarian, and a board-certified or resident veterinary neurologist. Each animal received a score in 3 categories (motor activity, level of consciousness, and brain stem reflexes) and an overall score. For the second objective, the MGCS scoring was performed by the intaking clinical team member and survival after 48 hours was documented., Results: Agreement between the 3 individual scores was assessed via Cronbach α and intraclass correlation. There was excellent-good agreement in all 3 assessment categories as well as the overall score. Univariate associations between survival and demographic factors were determined using the χ2 test. Overall, raptors with a total MGCS of < 10 were less likely to survive than those with a score > 12., Clinical Relevance: An avian-specific MGCS demonstrated good-excellent agreement among raters of various backgrounds in assessing raptors with head trauma. Additionally, this study showed that an avian-specific MGCS may be correlated with the probability of survival within the first 48 hours after presentation to rehabilitation facilities in raptors with head trauma.

Head injuries are a common occurrence in sports and can involve injuries to the brain, skull, and superficial soft tissues. The most commonly discussed diagnosis is a concussion. Head and cervical spine injuries must be considered together at times, due to the overlapping nature of symptoms present during on-field evaluation. This article presents a range of head injuries, along with critical steps in evaluation and management., (Published by Elsevier Inc.)

Objectives: To assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New Zealand., Design: A retrospective cohort study of hospital inpatient records., Setting: A tertiary children's hospital in Auckland, New Zealand., Participants: 1731 children less than 5 years of age who were discharged after a non-fatal head trauma event over a 10-year period from 1 January 2010 to 31 December 2019., Outcome Measures: The outcome of assessment by the hospital's multidisciplinary child protection team (CPT) was compared with the outcome of ICD, Tenth Revision (ICD-10) discharge coding for non-fatal abusive head trauma (AHT). The ICD-10 code definition of AHT was derived from an ICD, Ninth Revision, Clinical Modification definition developed by the Centers for Disease Control, Atlanta, Georgia, which requires both a clinical diagnosis code and a cause-of-injury code., Results: There were 1755 head trauma events with 117 determined as AHT by the CPT. The ICD-10 code definition had a sensitivity of 66.7% (95% CI 57.4 to 75.1) and specificity of 99.8% (95% CI 99.5 to 100). There were only three false positives but 39 false negatives, with 18 of the false negatives coded with X59 (exposure to unspecified factor)., Conclusions: The ICD-10 code broad definition of AHT is a reasonable epidemiological tool for passive surveillance of AHT in New Zealand but it underestimates the incidence. Its performance could be improved by clear documentation of child protection conclusions in clinical notes, clarifying coding practice and removing the exclusion criteria from the definition., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Concussion is a common ED complaint, but diagnosis is challenging as there are no validated objective measures. Use of concussion tools derived from sports medicine is common, but these tools are not well validated in ED settings. The aim of this study was to assess the ability of the Sport Concussion Assessment Tool 5th Edition (SCAT5) to identify concussion in ED patients presenting following head injury., Methods: We conducted a prospective observational study of head-injured adult patients presenting to ED between March and July 2021. ED diagnosis of concussion was used as the diagnostic standard, and we assessed the diagnostic performance of the SCAT5 test and its three subsections (Standardised Assessment of Concussion (SAC), Post-Concussion Symptom Scale (PCSS) and Modified Balance Error Scoring System (mBESS)) against this., Results: Thirty-two head-injured participants were enrolled, 19 of whom had a discharge diagnosis of concussion, alongside 17 controls. Median time for SCAT5 testing was 21 (interquartile range 16-27) min. Fifteen (30.6%) participants were interrupted during testing. Area under the curve (AUC) (95% confidence interval) for the SAC, PCSS and mBESS were 0.51 (0.34-0.68), 0.92 (0.84-0.99) and 0.66 (0.47-0.85), respectively. Sensitivity and specificity of sections were as follows: entire SCAT5 (100.0%, 20.0%), SAC (48.1%, 60.0%), PCSS (89.7%, 85.0%) and mBESS (83.3%, 58.8%). Using PCSS alone would have identified 17 of 19 concussions., Conclusion: The SCAT5 test had a low specificity, was long and was frequently interrupted. We suggest it is not an ideal assessment to use in ED. The PCSS score performed well and was easy to complete. It may be useful as a standalone tool to simplify ED concussion identification., (© 2022 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.)

Competing Interests: Competing interests: None declared.

Introduction: Substantial difference in mortality following severe traumatic brain injury (TBI) across international trauma centers has previously been demonstrated. This could be partly attributed to variability in the severity coding of the injuries. This study evaluated the inter-rater and intra-rater reliability of Abbreviated Injury Scale (AIS) scores of patients with severe TBI across three international level I trauma centers., Methods: A total 150 patients (50 per center) were randomly selected from each respective trauma registry: University Medical Center Utrecht (UMCU), the Netherlands; John Hunter Hospital (JHH), Australia; and Harborview Medical Center (HMC), the United States. Reliability between coders and trauma centers was measured with the intraclass correlation coefficient (ICC)., Results: The reliability between the coders and the original trauma registry scores was 0.50, 0.50, and 0.41 in, respectively, UMCU, JHH, and HMC. The AIS coders at UMCU scored the most AIS codes of ≥ 4. Reliability within the trauma centers was substantial in UMCU (ICC = 0.62) and HMC (ICC = 0.78) and almost perfect in JHH (ICC = 0.85). Reliability between trauma centers was 0.70 between UMCU and JHH, 0.70 between JHH and HMC, and 0.59 between UMCU and HMC., Conclusion: The results of this study demonstrated a substantial and almost perfect reliability of the AIS coders within the same trauma center, but variability across trauma centers. This indicates a need to improve inter-rater reliability in AIS coders and quality assessments of trauma registry data, specifically for patients with head injuries. Future research should study the effect of differences in AIS scoring on outcome predictions., (© 2022. The Author(s).)

Competing Interests: Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf):