Traumatismes crâniens accidentels ou non du nourrisson: Étude prospective de 88 cas

doi:10.1016/S0755-4982(04)98886-0

La Presse Médicale

Volume 33, Issue 17, October 2004, Pages 1174-1179

https://doi.org/10.1016/S0755-4982(04)98886-0 Get rights and content

Résumé

Objectif

Étudier l’épidémiologie des traumatismes crâniens (TC) du nourrisson, les facteurs favorisant la survenue d’un hématome sous-dural (HSD), la prévalence des hémorragies rétiniennes (HR) et les facteurs pronostiques, en comparant les TC accidentels (TA) et non accidentels (TNA). Les HR, en particulier, ont une valeur fondamentale pour le diagnostic de TNA, mais en l’absence d’étude systématique, leur sensibilité et leur spécificité pour le diagnostic de TNA restent mal évaluées.

Méthode

Les données cliniques, ophtalmoscopiques et radiologiques des TC survenant chez des enfants de moins de 24 mois ont été recueillies en distinguant notamment la macrocrânie essentielle et la macrocrânie symptomatique d’un HSD, et en gradant les HR suivant leur gravité.

Résultats

88 cas ont été observés pendant une période de 22 mois. Il s’agissait d’un TNA dans 28 cas, d’un TA dans les 60 autres cas. L’HSD était souvent corrélé avec la présence d’hémorragies rétiniennes et l’absence de signes d’impact crânien, mais pas avec la maltraitance, ni avec la macrocrânie essentielle. Les HR avaient une importance majeure pour le diagnostic de TNA, des HR peu sévères étaient cependant trouvées dans 4 cas de TA. Le pronostic neurologique était essentiellement corrélé avec la gravité clinique initiale.

Conclusion

Bien que représentant seulement 33 % des cas, la maltraitance était responsable de 2/3 des décès et de la totalité de la morbidité lourde. Les enfants ayant des antécédents périnatals représentent un groupe à risque important de maltraitance, qui justifie un suivi médico-social rapproché.

Summary

Objective

To study the epidemiology of head injury (HI) in infants, the factors favouring the occurrence of a subdural haematoma (SDH), the prevalence of retinal haemorrhages (RH) and the prognostic factors, by comparing the non-accidental (NAHI) and accidental (AHI) head injuries. RH, in particular, are of fundamental value in the diagnosis of NAHI but, in the absence of systematic studies, their sensitivity and specificity for the diagnosis of the NAHI have rarely been assessed.

Method

We prospectively collected the clinical, ophthalmologic and radiological data of HI occurring in children under 24 months old, notably by distinguishing essential macrocrania and symptomatic macrocrania of an SDH, by classifying the HI according to its severity.

Results

We observed 88 cases over a period of 22 months. It 28 cases it was NAHI and in the 60 others, AHI. The SDH was often correlated with the presence of retinal haemorrhages and the absence of signs of cranial impact, but not with child abuse or with essential macrocrania. The RH were of great importance in the diagnosis of NAHI; however, non-severe RH was noted in 4 cases of AHI. The neurological prognosis was essentially correlated with the initial clinical severity.

Conclusion

Although only representing 33% of cases, child abuse was responsible for 2/3 of the deaths and for the totality of the severe morbidity in our series. The infants exhibiting perinatal problems represented an important group at risk of abuse, which justified their regular medical-social follow-up.

Section snippets

Glossaire

AVP: accident de la voie publique
BSS: bosse séro-sanguine
DS: déviation standard
EB: enfant battu
ES: enfant secoué
FO: fond d’oeil
GOS: Glasgow Outcome Score
HED: hématome extradural
HR: hémorragie rétinienne
HSD: hématome sous-dural
IRM: imagerie par résonance magnétique
LED: lésions encéphaliques diffuses
PC: périmètre crânien
TA: traumatisme accidentel
TC: traumatisme crânien
TNA: traumatisme non accidentel

Références (23)

C. Christian et al.
Retinal hemorrhages caused by accidental household trauma
J Pediatr
(1999)
A.C. Duhaime et al.
Non-incidental head injuries in infants - The “shaken baby syndrome”
N Engl J Med
(1998)
J.F. Kraus et al.
Pediatric brain injuries: the nature, clinical course, and early outcomes in a defined United States’ population
Pediatrics
(1987)
A.C. Duhaime et al.
Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age
Pediatrics
(1992)
L. Ewing-Cobbs et al.
Acute neuroradiological findings in young children with inflicted or noninflicted traumatic brain injury
Child's Nerv Syst
(2000)
M. Vinchon et al.
Infantile subdural hematomas due to traffic accident
Pediatr Neurosurg
(2002)
D.L. Johnson et al.
Accidental head trauma and retinal hemorrhage
Neurosurgery
(1993)
M. Vinchon et al.
Subduroperitoneal drainage for traumatic subdural hematoma in infants: results with 244 cases
J Neurosurg
(2001)
K. Mori et al.
Subarachnoid fluid collection in infants complicated with subdural hematoma
Child's Nerv Syst
(1993)
A. Ikeda et al.
Infantile acute subdural hematoma
Child's Nerv Syst
(1987)

N.C. Papasian et al.

A theoretical model of benign external hydrocephalus that predicts a predisposition toward extra-axial hemorrhage after minor head trauma

Pediatr Neurosurg

(2000)

Cited by (9)

Intracranial injuries after accidental head trauma in children under 3 years of age
1970, Revue de Medecine Legale
Citation Excerpt :
In the same way, in scan reports, a description of injuries to the pericranial soft tissue is often absent, although this is also an argument which backs up direct impact. It is known that subdural hematomas are more frequent in cases of non-accidental trauma than in accidental trauma [14–18]. Recently, a meta-analysis has also confirmed a significant association between abusive head trauma, subdural hematoma, but also retinal hemorrhages [19].
A retrospective study of common points found between the circumstances of occurrence and the presence of intracranial injuries in accidental head trauma for children under 3 years of age.
All these children hospitalized at Angers University Hospital between 2002 and 2010 recovering from head trauma reported as accidental, having undergone a cerebral CT-scan were included. Conditions of occurrence were classified according to their mechanism. Cutaneous signs and fundus results were sought in medical files. Brain scans were reinterpreted according to a pre-determined grid.
Thirty-four files were included. The occurrence mechanism was high energy in 20 cases, including six domestic accidents. Cutaneous signs were only observed in 17 files. The intracranial injuries identified comprised 16 parenchymal contusions of which eight with subdural hematomas, two isolated subdural hematomas, six epidural hematomas, and two subarachnoid hemorrhages. Subdural hematomas and complex bone fractures were always the result of high-energy mechanisms even when the accidents were domestic, while epidural hematomas could occur when accidents were low-energy.
Subdural hematomas are always the result of high-energy mechanisms, as are complex fractures. This concept is important when a variation exists between a traumatic mechanism reported as apparently benign and severe injuries. Effects on soft tissue are insufficiently described where they show evidence of a direct shock. These items highlight the importance of comparing the anamnestic record with clinical and radiological items, and to include expert appraisals from forensic examiners in order to prevent a failure to recognize a suspected abusive situation.
Étude rétrospective des concordances entre les circonstances de survenue et les lésions intracrâniennes dans les traumatismes crâniens accidentels chez l’enfant de moins de trois ans.
Tous les enfants hospitalisés au CHU d’Angers de 2002 à 2010 au décours d’un traumatisme crânien évoqué comme accidentel et ayant bénéficié d’un scanner cérébral ont été inclus. Les conditions de survenue ont été classées en fonction de leur mécanisme ; les signes cutanés et les résultats de fonds d’œil recherchés ; les scanners cérébraux réinterprétés selon une grille préétablie.
Trente-quatre dossiers ont été inclus. Le mécanisme de survenue était à haute énergie dans 20 cas. Les signes cutanés n’étaient notés que dans 17 dossiers. Les lésions intracrâniennes retrouvées étaient 16 contusions parenchymateuses dont huit avec hématome sous-dural, deux hématomes sous-duraux isolés, six hématomes extraduraux, deux hémorragies méningées. Les hématomes sous-duraux et les fractures osseuses complexes résultaient toujours de mécanismes à haute énergie même lors d’accidents domestiques, alors que les hématomes extraduraux pouvaient survenir pour des accidents à basse énergie.
Les hématomes sous-duraux comme les fractures complexes résultent toujours de mécanismes à haute énergie. Cette notion est importante lorsque des lésions sévères sont associées à un mécanisme traumatique rapporté comme bénin. Les atteintes des parties molles sont insuffisamment décrites alors qu’elles témoignent d’un choc direct. Ces éléments mettent en avant l’importance de confronter le recueil anamnestique aux éléments cliniques et radiologiques, et d’y associer l’expertise des médecins légistes afin de ne pas méconnaître une situation suspecte de maltraitance.
Subdural Hematoma
2022, Pediatric Neurosurgery for Clinicians
Chronic subdural hematoma in the pediatric population
2021, Subdural Hematoma: Past to Present to Future Management
Update in child maltreatment
2018, Update in Pediatrics
Abusive head trauma: Clinical, biomechanical, and imaging considerations
2015, Diagnostic Imaging of Child Abuse
Abusive head trauma: Extra-axial hemorrhage and nonhemic collections
2015, Diagnostic Imaging of Child Abuse

View all citing articles on Scopus

View full text

Article originalTraumatismes crâniens accidentels ou non du nourrisson: Étude prospective de 88 casAccidental or non-accidental brain injury in infants: Prospective study of 88 cases

Résumé

Objectif

Méthode

Résultats

Conclusion

Summary

Objective

Method

Results

Conclusion

Section snippets

Glossaire

J Pediatr

Non-incidental head injuries in infants - The “shaken baby syndrome”

N Engl J Med

Pediatric brain injuries: the nature, clinical course, and early outcomes in a defined United States’ population

Pediatrics

Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age

Pediatrics

Acute neuroradiological findings in young children with inflicted or noninflicted traumatic brain injury

Child's Nerv Syst

Infantile subdural hematomas due to traffic accident

Pediatr Neurosurg

Accidental head trauma and retinal hemorrhage

Neurosurgery

Subduroperitoneal drainage for traumatic subdural hematoma in infants: results with 244 cases

J Neurosurg

Subarachnoid fluid collection in infants complicated with subdural hematoma

Child's Nerv Syst

Infantile acute subdural hematoma

Child's Nerv Syst

A theoretical model of benign external hydrocephalus that predicts a predisposition toward extra-axial hemorrhage after minor head trauma

Pediatr Neurosurg

Article original
Traumatismes crâniens accidentels ou non du nourrisson: Étude prospective de 88 casAccidental or non-accidental brain injury in infants: Prospective study of 88 cases