Fifty-three cases of non-accidental
head injury in children were subjected to detailed neuropathological study, which included immunocytochemistry for microscopic damage. Clinical details were available for all the cases. There were 37 infants, age at
head injury ranging from 20 days to 9 months, and 16 children (range 13 months to 8 years). The most common
injuries were
skull fractures (36% of cases), acute subdural
bleeding (72%) and
retinal haemorrhages (71%); the most usual cause of death was raised intracranial pressure secondary to
brain swelling (82%). On microscopy, severe
hypoxic brain damage was present in 77% of cases. While vascular axonal damage was found in 21 out of 53 cases, diffuse traumatic axonal injury was present in only three. Eleven additional cases, all of them infants, showed evidence of localized axonal injury to the craniocervical junction or the cervical cord. When the data were analysed by median age at
head injury, statistically significant patterns of age-related damage emerged. Our study shows that infants of 2-3 months typically present with a history of apnoea or other breathing abnormalities, show axonal damage at the craniocervical junction, and tend also to have a
skull fracture, a thin film of subdural haemorrhage, but lack extracranial injury. Children over 1 year are more likely to suffer severe extracranial, particularly
abdominal, injuries. They tend to have larger subdural haemorrhages, and where traumatic axonal injury is present, show patterns of hemispheric white matter damage more akin to those reported in adults.
Diffuse axonal injury is an uncommon sequel of inflicted
head injury in children.