The association of subcortical brain injury and abusive head trauma

Background: Abusive head trauma (AHT) remains a major pediatric problem with diagnostic challenges. A small pilot study previously associated subcortical brain injury with AHT. Objectives: To investigate the association of subcortical injury on neuroimaging with the diagnosis of AHT. Participants and setting: Children <3 years with acute TBI admitted to 18 PICUs between 2011 and 2021. Methods: Secondary analysis of existing, combined, de-identified, cross-sectional dataset. Results: Deepest location of visible injury was characterized as scalp/skull/epidural (n = 170), subarachnoid/subdural (n = 386), cortical brain (n = 170), or subcortical brain (n = 247) (total n = 973). Subcortical injury was significantly associated with AHT using both physicians' diagnostic impression (OR: 8.41 [95 % CI: 5.82–12.44]) and a priori definitional criteria (OR: 5.99 [95 % CI: 4.31–8.43]). Caregiver reports consistent with the child's gross motor skills and historically consistent with repetition decreased as deepest location of injury increased, p < 0.001. Patients with subcortical injuries were significantly more likely to have traumatic extracranial injuries such as rib fractures (OR 3.36, 95 % CI 2.30–4.92) or retinal hemorrhages (OR 5.97, 95 % CI 4.35–8.24), respiratory compromise (OR 12.12, 95 % CI 8.49–17.62), circulatory compromise (OR 6.71, 95 % CI 4.87–9.29), seizures (OR 3.18, 95 % CI 2.35–4.29), and acute encephalopathy (OR 12.44, 95 % CI 8.16–19.68). Conclusions: Subcortical injury is associated with a diagnosis of AHT, historical inaccuracies concerning for abuse, traumatic extracranial injuries, and increased severity of illness including respiratory and circulatory compromise, seizures, and prolonged loss of consciousness. Presence of subcortical injury should be considered as one component of the complex AHT diagnostic process.