The importance of recognizing abusive head trauma in the neurosurgical setting

Abusive head trauma (AHT) occurs due to an intentional abrupt impact and/or violent shaking leading to an injury to the skull or intracranial contents of a baby or child, usually younger than 2 years of age. Without impact, there may be no external signs of head trauma. It is the leading cause of mortality in children who have suffered intentional physical abuse. It is more likely to occur in very young children with an estimated prevalence of 1 per 3000 in infants under 6 months of age. Studies have highlighted that distressed and exhausted parents can sometimes shake their infant in desperation and parental education has been shown to decrease the incidence of AHT. Clinicians dealing with children who presents with traumatic brain injury (TBI) should always consider the possibility of AHT. AHT is classically characterized by a triad of signs; subdural hematoma, brain edema, and retinal hemorrhage, however, non-specific features may also be seen in clinical practice both acutely or subsequently. Certain neuroradiological findings (subdural hemorrhages, multiple interhemispheric convexity and posterior fossa hemorrhages, hypoxic-ischemic injury and cerebral edema) are suggestive of AHT in young children. Associated spinal injuries can be easily missed and it is important to investigate for this. This review article includes 2 illustrative case studies and gives a comprehensive overview of AHT in children which we hope will be useful for neurosurgeons in their clinical practice. Child protection is everyone's responsibility and is best achieved when different specialties and professionals work together.