Cerebral contusional tears as a marker of child abuse--detection by cranial sonography

A lucid interval in a victim of abusive head trauma with multiple parenchymal lacerations

Abusive head trauma (AHT) is a leading cause of abusive deaths in children under age one. AHT can include intracranial hemorrhages, hypoxic ischemic injury, or parenchymal lacerations. Most infants with parenchymal lacerations present with acute neurological symptoms. There has been some published literature on lucid intervals in cases of AHT; however, there has not been a described lucid interval with parenchymal lacerations. Parenchymal lacerations typically present with acute symptomatology such as seizures, alteration in mental status, or increased fussiness/lethargy given the damage to neurons and brain structure. We present a case of a healthy 2-month-old who ultimately was diagnosed with AHT and three parenchymal lacerations and had a 2.5 hour period of normal neurological status prior to acute decompensation.

Imaging of Abusive Head Trauma in Children

In this article, we describe relevant anatomy, mechanisms of injury, and imaging findings of abusive head trauma (AHT). We also briefly address certain mimics of AHT, controversies, pearls, and pitfalls. Concepts of injury, its evolution, and complex nature of certain cases are highlighted with the help of case vignettes.

Parenchymal Insults in Abuse—A Potential Key to Diagnosis

Subdural hemorrhage is a key imaging finding in cases of abusive head trauma and one that many radiologists and radiology trainees become familiar with during their years of training. Although it may prove to be a marker of trauma in a young child or infant that presents without a history of injury, the parenchymal insults in these young patients more often lead to the debilitating and sometimes devastating outcomes observed in this young population. It is important to recognize these patterns of parenchymal injuries and how they may differ from the imaging findings in other cases of traumatic injury in young children. In addition, these parenchymal insults may serve as another significant, distinguishing feature when making the medical diagnosis of abusive head injury while still considering alternative diagnoses, including accidental injury. Therefore, as radiologists, we must strive to look beyond the potential cranial injury or subdural hemorrhage for the sometimes more subtle but significant parenchymal insults in abuse.

An In-Depth Analysis of Brain and Spine Neuroimaging in Children with Abusive Head Trauma: Beyond the Classic Imaging Findings

BACKGROUND AND PURPOSE

Abusive head trauma is the leading cause of morbidity and mortality in young children. Radiology provides valuable information for this challenging diagnosis, but no single neuroimaging finding is independently diagnostic of abusive head trauma. Our purposes were to describe the prevalence of brain and spine neuroimaging findings and to analyze the association of neuroimaging findings with clinical factors to determine which neuroimaging findings may be used as prognostic indicators.

MATERIALS AND METHODS

Children with a confirmed abusive head trauma diagnosis between January 2018 to February 2021 were included in this single-center retrospective study. Patient demographics, survival, Glasgow Coma Scale score on admission, length of hospital stay, and intensive care unit stay were examined. Brain neuroimaging findings were categorized as classic and nonclassic findings. Spine MRIs were also assessed for spinal ligamentous injury, compression fracture, and hemorrhage. The χ² test or the Wilcoxon rank-sum test was used for the analysis.

RESULTS

One hundred two children (male/female ratio: 75:27; average age, 9.49; range, 0.27-53.8 months) were included. Subdural hematoma was the most common (83.3%) classic neuroimaging finding. Bridging vein thrombosis was the most common (30.4%) nonclassic neuroimaging finding. Spinal ligamentous injury was seen in 23/49 patients. Hypoxic-ischemic injury was significantly higher in deceased children (P = .0001). The Glasgow Coma Scale score was lower if hypoxic-ischemic injury (P < .0001) or spinal ligamentous injury were present (P = .017). The length of hospital stay was longer if intraventricular hemorrhage (P = .04), diffuse axonal injury (P = .017), hypoxic-ischemic injury (P = .001), or arterial stroke (P = .0003) was present. The intensive care unit stay was longer if intraventricular hemorrhage (P = .02), diffuse axonal injury (P = .01), hypoxic-ischemic injury (P < .0001), or spinal ligamentous injury (P = .03) was present.

CONCLUSIONS

Our results may suggest that a combination of intraventricular hemorrhage, diffuse axonal injury, hypoxic-ischemic injury, arterial stroke, and/or spinal ligamentous injury on neuroimaging at presentation may be used as potential poor prognostic indicators in children with abusive head trauma.

Spinal ligamentous injury in abusive head trauma: a pictorial review

There is growing evidence of spine injury in abusive head trauma (AHT). Historically, spine injury was considered rare in AHT because of a lack of attributable clinical symptoms or signs and a lack of advanced imaging. Increased use of MRI in AHT has been instrumental in helping identify evidence of ligamentous injuries of the spine. These findings can be difficult to identify on autopsy because of the size and location of the ligaments. Because spinal injury in AHT mostly involves ligamentous and soft tissues and only rarely involves bony fractures, more than 90% of the injury findings are missed on CT or radiography of the spine. Investigation of these findings and the injury patterns should lead to a better understanding of the mechanism of spinal injury. In this pictorial review, we describe the various manifestations of spinal ligamentous injury in AHT, as seen on MRI, in children younger than 48 months.

Parenchymal brain injuries in abusive head trauma

The consequences of abusive head trauma (AHT) can be devastating for both the individual child and for wider society. Death is undoubtedly a very real possibility, but even for those children who survive, there is often very significant morbidity with the potential for gross motor and cognitive impairment, behavioural problems, blindness and epilepsy, which can greatly affect their quality of life. Caring for such children places a vast financial and infrastructural burden on society that frequently extends well into adulthood. While few struggle to have any sympathy for the perpetrator, frequently the infant's father, it should be noted that a single solitary and momentary loss of complete control can have horrific and unforeseen consequences. A number of papers within this edition describe features of AHT and include descriptions of skull fractures and extra-axial haemorrhage, along with mimics of such phenomena. However, in this review we concentrate our attention on the myriad of parenchymal findings that can occur. Such parenchymal injuries include hypoxic-ischaemic damage, clefts, contusion and focal haemorrhage. We offer our perspectives on current thinking on these entities and put them in the context of the immensely important question - how do we recognise abusive head trauma?

Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma

In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration–deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice.

Medical findings and symptoms in infants exposed to witnessed or admitted abusive shaking: A nationwide registry study

BACKGROUND

Many physicians regard the combination of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhage (RH), rib fractures, and classical metaphyseal lesions (CML) as highly specific for abusive head trauma (AHT). However, without observed abuse or other criteria that are independent of these findings, bias risk is high.

METHODS

Infants subjected for examination under the suspicion of maltreatment during the period 1997-2014 were identified in the National Patient Registry, International Classification of Diseases (ICD-10 SE). The medical records were scrutinized for identification of cases of witnessed or admitted physical abuse by shaking. The main outcome measures were occurrence of SDH, RH, fractures and skin lesions.

RESULTS

All identified 36 infants had been shaken, and for 6, there was information indicating blunt force impact immediately after shaking. In 30 cases, there were no findings of SDH or RH, rib fractures, or CMLs. Six infants had finding(s) suggestive of physical abuse, two with possible acute intracranial pathology. One infant with combined shaking and impact trauma had hyperdense SDH, hyperdense subarachnoid haemorrhage, suspected cortical vein thrombosis, RH, and bruises. Another infant abused by shaking had solely an acute subarachnoid haemorrhage. Both had pre-existing vulnerability. The first was born preterm and had non-specific frontal subcortical changes. The other had bilateral chronic SDH/hygroma.

CONCLUSIONS

The present findings do not support the hypothesis that acute SDH or RH can be caused by isolated shaking of a healthy infant. However, they do suggest that abuse by shaking may cause acute intracranial haemorrhage with RH in infants with certain risk factors.

Cerebral white matter lacerations in children caused by repetitive head trauma

It has been known that infants less than 1 year develop cerebral white matter (WM) lacerations associated with head trauma, however, there has been no report of similar WM lesions over 1 year. We report three teenage boys (11, 12, and 18 years at final MRI studies) with acquired WM lacerations associated with recurrent head trauma who developed neurologic symptoms such as spastic paralysis, afebrile convulsions, and cognitive impairment. Two of them (patients 1 and 2) were given a diagnosis of autism spectrum disorder and had a history of repeated severe self-inflicted head trauma from preschool age. Patient 3, who practiced karate and boxing from preschool age, showed gradual declining intellectual ability. Brain MRI of the three patients revealed severe lacerations in the bilateral cerebral WM. Previous neuroimaging showed no WM lacerations at 4 and 5 years in patients 1 and 2, or mild WM lacerations at 17 years in patient 3, indicating the WM lacerations could have been acquired in childhood. It is suggested that repetition of head trauma in children can cause cerebral WM lacerations and brain dysfunction.

MRI Findings in Pediatric Abusive Head Trauma: A Review

Trauma is the most common cause of death and significant morbidity in childhood; abusive head trauma (AHT) is a prominent cause of significant morbidity and mortality in children younger than 2 years old. Correctly diagnosing AHT is challenging both clinically and radiologically. The primary diagnostic challenges are that the abused children are usually too young to provide an adequate history, perpetrators are unlikely to provide truthful account of trauma, and clinicians may be biased in their assessment of potentially abused children. The main radiological challenge is that there is no single imaging finding that is independently specific for or diagnostic of AHT. The radiological evaluation should be based on the multiplicity and severity of findings and an inconsistency with the provided mechanism of trauma. While the most common neuroimaging finding in AHT is subdural hemorrhage, other less well-known magnetic resonance imaging (MRI) findings such as the "lollipop sign" or "tadpole sign," parenchymal or cortical lacerations, subpial hemorrhage, cranio-cervical junction injuries including retroclival hematomas, as well as diffuse hypoxic brain injury have been identified and described in the recent literature. While AHT is ultimately a clinical diagnosis combining history, exam, and neuroimaging, familiarity with the typical as well as the less-well known MRI findings will improve recognition of AHT by radiologists.

The pathology and aetiology of subcortical clefts in infants

In infants, traumatic surface contusions of the brain are rare but subcortical clefts or cysts, variously labelled "contusional tears", "contusional clefts", "cortical tears" or "parenchymal lacerations" have been ascribed to trauma, and are even said to be characteristic of shaking and abuse. We describe the pathology of subcortical clefts or haemorrhages in seven infants. In none were the axonal swellings characteristic of traumatic axonal injury seen in relation to the clefts. Subpial bleeding was associated with clefts in all the cases of recent onset. We hypothesize that subcortical clefts are not due to direct mechanical forces of trauma but are part of a secondary cascade caused by impaired venous drainage which may or may not follow trauma. The finding of subcortical and subpial haemorrhages should prompt a search for CVT. We consider the term "contusion" is not accurate and is misleading.

Ocular and Intracranial MR Imaging Findings in Abusive Head Trauma

Abusive head trauma (AHT) is a form of inflicted head injury. AHT is more frequent in 2-year-old or younger children. It is an important cause of neurological impairment and the major cause of death from head trauma in this age group. Brain magnetic resonance imaging allows the depiction of retinal hemorrhages, injured bridging veins, and identifying and localizing extra- and intra-axial bleeds, contusions, lacerations, and strokes. The diagnosis of AHT is a multidisciplinary team effort which includes a careful evaluation of social, clinical, laboratory, and radiological findings. Notwithstanding, the introduction in the current clinical practice of high-resolution techniques is adding forensic evidence to the recognition of AHT.

Neonatal subcortical bruising

A specific type of acute brain injury can occur during birth, presenting on ultrasound examination with focal, unilateral, or asymmetrical change in the core of the superior frontal gyri. Ultrasound inspection of the superior gyri near the convexity of the frontal lobe is warranted following mechanically difficult delivery.

Pathophysiological and behavioral deficits in developing mice following rotational acceleration-deceleration traumatic brain injury

Abusive head trauma (AHT) is the leading cause of death from trauma in infants and young children. An AHT animal model was developed on 12-day-old mice subjected to 90° head extension-flexion sagittal shaking repeated 30, 60, 80 and 100 times. The mortality and time until return of consciousness were dependent on the number of repeats and severity of the injury. Following 60 episodes of repeated head shakings, the pups demonstrated apnea and/or bradycardia immediately after injury. Acute oxygen desaturation was observed by pulse oximetry during respiratory and cardiac suppression. The cerebral blood perfusion was assessed by laser speckle contrast analysis (LASCA) using a PeriCam PSI system. There was a severe reduction in cerebral blood perfusion immediately after the trauma that did not significantly improve within 24 h. The injured mice began to experience reversible sensorimotor function at 9 days postinjury (dpi), which had completely recovered at 28 dpi. However, cognitive deficits and anxiety-like behavior remained. Subdural/subarachnoid hemorrhage, damage to the brain-blood barrier and parenchymal edema were found in all pups subjected to 60 insults. Proinflammatory response and reactive gliosis were upregulated at 3 dpi. Degenerated neurons were found in the cerebral cortex and olfactory tubercles at 30 dpi. This mouse model of repetitive brain injury by rotational head acceleration-deceleration partially mimics the major pathophysiological and behavioral events that occur in children with AHT. The resultant hypoxia/ischemia suggests a potential mechanism underlying the secondary rotational acceleration-deceleration-induced brain injury in developing mice.

Parenchymal Brain Laceration as a Predictor of Abusive Head Trauma

BACKGROUND AND PURPOSE

Accurate differentiation of abusive head trauma and accidental head injury in infants and young children is critical and impacts clinical care, patient prognosis, forensic investigations, and medicolegal proceedings. No specific finding seen on cross-sectional brain imaging has been reported to distinguish abusive head trauma from accidental injury. Our study investigated whether a specific imaging finding, parenchymal brain laceration, is unique to children diagnosed with abusive head trauma.

MATERIALS AND METHODS

We retrospectively identified 137 patients with abusive head trauma and 28 patients who incurred moderate to severe accidental brain injury. Brain MR imaging represented the imaging standard for characterizing intracranial injuries.

RESULTS

Among the abusive head trauma cohort, parenchymal brain lacerations were identified in 18 patients, while none were identified in any patients with accidental injury.

CONCLUSIONS

Our findings are in concurrence with the existing forensic, pathology, and imaging literature, which suggests that parenchymal brain lacerations may be related to abusive injury mechanisms.

Mechanics of the brain: perspectives, challenges, and opportunities

The human brain is the continuous subject of extensive investigation aimed at understanding its behavior and function. Despite a clear evidence that mechanical factors play an important role in regulating brain activity, current research efforts focus mainly on the biochemical or electrophysiological activity of the brain. Here, we show that classical mechanical concepts including deformations, stretch, strain, strain rate, pressure, and stress play a crucial role in modulating both brain form and brain function. This opinion piece synthesizes expertise in applied mathematics, solid and fluid mechanics, biomechanics, experimentation, material sciences, neuropathology, and neurosurgery to address today’s open questions at the forefront of neuromechanics. We critically review the current literature and discuss challenges related to neurodevelopment, cerebral edema, lissencephaly, polymicrogyria, hydrocephaly, craniectomy, spinal cord injury, tumor growth, traumatic brain injury, and shaken baby syndrome. The multi-disciplinary analysis of these various phenomena and pathologies presents new opportunities and suggests that mechanical modeling is a central tool to bridge the scales by synthesizing information from the molecular via the cellular and tissue all the way to the organ level.

ACR Appropriateness Criteria head trauma--child

Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

The "Shaken Baby" syndrome: pathology and mechanisms

The "Shaken Baby" syndrome (SBS) is the subject of intense controversy; the diagnosis has in the past depended on the triad of subdural haemorrhage (SDH), retinal haemorrhage and encephalopathy. While there is no doubt that infants do suffer abusive injury at the hands of their carers and that impact can cause catastrophic intracranial damage, research has repeatedly undermined the hypothesis that shaking per se can cause this triad. The term non-accidental head injury has therefore been widely adopted. This review will focus on the pathology and mechanisms of the three physiologically associated findings which constitute the "triad" and are seen in infants suffering from a wide range of non-traumatic as well as traumatic conditions. "Sub" dural bleeding in fact originates within the deep layers of the dura. The potential sources of SDH include: the bridging veins, small vessels within the dura itself, a granulating haemorrhagic membrane and ruptured intracranial aneurysm. Most neuropathologists do not routinely examine eyes, but the significance of this second arm of the triad in the diagnosis of Shaken Baby syndrome is such that it merits consideration in the context of this review. While retinal haemorrhage can be seen clinically, dural and subarachnoid optic nerve sheath haemorrhage is usually seen exclusively by the pathologist and only rarely described by the neuroradiologist. The term encephalopathy is used loosely in the context of SBS. It may encompass anything from vomiting, irritability, feeding difficulties or floppiness to seizures, apnoea and fulminant brain swelling. The spectrum of brain pathology associated with retinal and subdural bleeding from a variety of causes is described. The most important cerebral pathology is swelling and hypoxic-ischaemic injury. Mechanical shearing injury is rare and contusions, the hallmark of adult traumatic brain damage, are vanishingly rare in infants under 1 year of age. Clefts and haemorrhages in the immediate subcortical white matter have been assumed to be due to trauma but factors specific to this age group offer other explanations. Finally, examples of the most common causes of the triad encountered in clinical diagnostic and forensic practice are briefly annotated.

Diagnostic imaging of child abuse

The role of imaging in cases of child abuse is to identify the extent of physical injury when abuse is present and to elucidate all imaging findings that point to alternative diagnoses. Effective diagnostic imaging of child abuse rests on high-quality technology as well as a full appreciation of the clinical and pathologic alterations occurring in abused children. This statement is a revision of the previous policy published in 2000.

What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review

AIMS

To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI).

MATERIALS AND METHODS

A systematic review of studies published between 1970-2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI.

RESULTS

Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3-33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI.

CONCLUSIONS

In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.

Neuroimaging of nonaccidental head trauma: pitfalls and controversies

Although certain neuroimaging appearances are highly suggestive of abuse, radiological findings are often nonspecific. The objective of this review is to discuss pitfalls, controversies, and mimics occurring in neuroimaging of nonaccidental head trauma in order to allow the reader to establish an increased level of comfort in distinguishing between nonaccidental and accidental head trauma. Specific topics discussed include risk factors, general biomechanics and imaging strategies in nonaccidental head trauma, followed by the characteristics of skull fractures, normal prominent tentorium and falx versus subdural hematoma, birth trauma versus nonaccidental head trauma, hyperacute versus acute on chronic subdural hematomas, expanded subarachnoid space versus subdural hemorrhage, controversy regarding subdural hematomas associated with benign enlarged subarachnoid spaces, controversy regarding hypoxia as a cause of subdural hematoma and/or retinal hemorrhages without trauma, controversy regarding the significance of retinal hemorrhages related to nonaccidental head trauma, controversy regarding the significance of subdural hematomas in general, and pitfalls of glutaric aciduria type 1 and hemophagocytic lymphohistiocytosis mimicking nonaccidental head trauma.

Delayed white matter injury in a murine model of shaken baby syndrome

Shaken baby syndrome, a rotational acceleration injury, is most common between 3 and 6 months of age and causes death in about 10 to 40% of cases and permanent neurological abnormalities in survivors. We developed a mouse model of shaken baby syndrome to investigate the pathophysiological mechanisms underlying the brain damage. Eight-day-old mouse pups were shaken for 15 seconds on a rotating shaker. Animals were sacrificed at different ages after shaking and brains were processed for histology. In 31-day-old pups, mortality was 27%, and 75% of survivors had focal brain lesions consisting of hemorrhagic or cystic lesions of the periventricular white matter, corpus callosum, and brainstem and cerebellar white matter. Hemorrhagic lesions were evident from postnatal day 13, and cysts developed gradually between days 15 and 31. All shaken animals, with or without focal lesions, had thinning of the hemispheric white matter, which was significant on day 31 but not earlier. Fragmented DNA labeling revealed a significant increase in cell death in the periventricular white matter, on days 9 and 13. White matter damage was reduced by pre-treatment with the NMDA receptor antagonist MK-801. This study showed that shaking immature mice produced white matter injury mimicking several aspects of human shaken baby syndrome and provided evidence that excess release of glutamate plays a role in the pathophysiology of the lesions.

Neuroimaging in non-accidental head injury: if, when, why and how

Non-accidental head injury (NAHI) in infants is an important but difficult topic. To miss or misdiagnose NAHI potentially has important consequences. The evidence base upon which to base decisions is limited but growing. This article aims to summarise current literature and thinking in this difficult area.

Normal computerized tomography of brain in children with shaken baby syndrome

OBJECTIVE

To characterize the clinical presentation and clinical course of shaken baby syndrome (SBS) with normal cranial computerized tomography (CT) on admission and to suggest further diagnostic procedures in such circumstances.

METHODS

Using a worldwide listserv designed to facilitate discussion in the field of child abuse and neglect, we solicited case information for children hospitalized in different medical centers, who were diagnosed with SBS and had a normal CT scan on admission.

RESULTS

Nine cases were identified. While all children had an abnormal neurologic examination on admission, eight had a normal CT, and one had "widening of cranial sutures." In four cases, subdural hemorrhage was diagnosed on magnetic resonance imaging (MRI) 3 to 7 days after admission. Five children had bone fractures. The neurological outcome was normal in four of nine cases. Five children had long-term neurologic damage. The diagnosis of SBS was supported by either perpetrator confession, characteristic evolution of brain abnormalities on CT or MRI, inconsistent or absent explanatory history, and/or other social risk factors.

CONCLUSION

The diagnosis of SBS can be established even when brain CT is normal on admission. The documentation of retinal hemorrhages is of primary importance in establishing the diagnosis of SBS in these cases.

The 'unified hypothesis' of Geddes et al. is not supported by the data

Inflicted head injury to the developing brain frequently results in serious disability. The pathogenesis of the neuraxial and ocular findings in infants believed to have suffered inflicted head injury remains the subject of considerable debate. Recent neuropathology studies of fatal cases of inflicted head injury and of a foetal/perinatal non-traumatic model have led to the proposal that there is a 'unified hypothesis', the essential feature of which is hypoxic brain swelling secondary to cervicomedullary injury. It has been suggested that less than violent forces may be involved and even that some cases may not be due to trauma at all. The purpose of this paper is to provide a critical review of the data upon which these suppositions are based on a background of what is already known. It is submitted that there are serious flaws in the methodology; the conclusions reached cannot logically be drawn from the data; and the 'unified hypothesis' is not supported by the evidence. On the basis of the data presented, it is also difficult to sustain the secondary hypothesis purporting to describe a minority cohort with 'infantile encephalopathy with subdural and retinal bleeding' of non-traumatic causation.

Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome

OBJECTIVE

Studies of long-term outcome on nonaccidental head injury (NAHI) in young children have shown severe neurodevelopmental sequelae in most cases. For improving the knowledge of outcome and for identifying prognostic factors, additional clinical and cerebral imaging data are needed. The aim of this study was to describe clinical and imaging features over time and to consider their value for predicting neurodevelopmental outcome.

METHODS

A retrospective medical record review was conducted of 23 children with confirmed NAHI, for whom an extended follow-up of 2.5 to 13 years (mean: 6 years) was contemplated. Glasgow Coma Scale scores, severity of retinal hemorrhages, presence of skull fractures, cranial growth deceleration, and sequential neuroimaging data (computed tomography and/or magnetic resonance imaging) were compared with patterns of clinical evolution assessed by the Glasgow Outcome Scale.

RESULTS

Clinical outcome showed that 14 (61%) children had severe disabilities, 8 (35%) had moderate disabilities, and 1 (4%) was normal. A low initial Glasgow Coma Scale score, severe retinal hemorrhages, presence of skull fracture, and cranial growth deceleration were significantly associated with poor developmental outcome. Eighteen of the 23 patients had abnormal magnetic resonance imaging scans. This examination disclosed atrophy when performed beyond 15 days of injury. Atrophy seemingly resulted from various brain lesions, namely, contusions, infarcts, and other lesions within the white matter. Presence of intraparenchymal brain lesions within the first 3 months was significantly associated with neurodevelopmental impairment. Severity of motor and cognitive dysfunctions was related to the extent of intraparenchymal lesions.

CONCLUSIONS

Early clinical and radiologic findings in NAHI are of prognostic value for neurodevelopmental outcome.

From the archives of the AFIP. Child abuse: radiologic-pathologic correlation

In the United States, roughly one of every 100 children is subjected to some form of neglect or abuse; inflicted injury is responsible for approximately 1,200 deaths per year. Child physical abuse may manifest as virtually any injury pattern known to medicine. Some of the injuries observed in battered children are relatively unique to this population (especially when observed in infants) and therefore are highly suggestive of nonaccidental, or inflicted, injury. Worrisome injuries include rib fracture, metaphyseal fracture, interhemispheric extraaxial hemorrhage, shear-type brain injury, vertebral compression fracture, and small bowel hematoma and laceration. As noted, however, virtually any injury may be inflicted; therefore, careful consideration of the nature of the injury, the developmental capabilities of the child, and the given history are crucial to determine the likelihood that an injury was inflicted. The majority of these injuries are readily detectable at imaging, and radiologic examination forms the mainstay of evaluation of child physical abuse. Detection of metaphyseal fracture (regarded as the most specific radiographically detectable injury in abuse) depends on high-quality, small field-of-view radiographs. The injury manifests radiographically as a lucent area within the subphyseal metaphysis, extending completely or partially across the metaphysis, roughly perpendicular to the long axis of the bone. Acute rib fractures (which in infants are strongly correlated with abuse) appear as linear lucent areas. They may be difficult to discern when acute; thus, follow-up radiography increases detection of these fractures. For skull injuries, radiography is best for detecting fractures, but computed tomography and magnetic resonance imaging best depict intracranial injury.

Neuroimaging for non-accidental head injury in childhood: a proposed protocol

Non-accidental head injury (NAHI) is a major cause of neurological disability and death during infancy. Radiological imaging plays a crucial role in evaluating craniospinal injury, both for guiding medical management and the forensic aspects of abusive trauma. The damage sustained is varied, complex and may be accompanied by an evolving pattern of brain injury secondary to a cascade of metabolic and physiological derangements. Regrettably, many cases are poorly or incompletely evaluated leading to diagnostic errors and difficulties in executing subsequent child care or criminal proceedings. It is evident, from cases referred to the authors, that imaging protocols for NAHI are lacking (or only loosely adhered to, if present) in many centres throughout the U.K. Future research in this field will also be hampered if there is a lack of consistent and reliable radiological data. There is no nationally agreed protocol for imaging NAHI. We propose such a protocol, based upon a wide experience in the medical management of child abuse and extensive involvement in the medicolegal aspects of NAHI.

Neuropathological and biochemical features of traumatic injury in the developing brain

Trauma to the developing brain constitutes a poorly explored field. Some recent studies attempting to model and study pediatric head trauma, the leading cause of death and disability in the pediatric population, revealed interesting aspects and potential targets for future research. Trauma triggers both excitotoxic and apoptotic neurodegeneration in the developing rat brain. Excitotoxic neurodegeneration develops and subsides rapidly (within hours) whereas apoptotic cell death occurs in a delayed fashion over several days following the initial traumatic insult. Apoptotic neurodegeneration contributes in an age-dependent fashion to neuronal injury following head trauma, with the immature brain being exceedingly sensitive. In the most vulnerable ages the apoptosis contribution to the extent of traumatic brain damage far outweighs that of the excitotoxic component. Molecular and biochemical studies indicate that both extrinsic and intrinsic mechanisms are involved in pathogenesis of apoptotic cell death following trauma. Interestingly, in infant rats a pan-caspase inhibitor ameliorated apoptotic neurodegeneration with a therapeutic time window of up to 8 h after trauma. These results help explain unfavorable outcomes of very young pediatric head trauma patients and imply that regimens which target slow active forms of cell death may comprise a successful neuroprotective approach.

Diagnostic imaging of child abuse

The role of imaging in cases of child abuse is to identify the extent of physical injury when abuse occurs, as well as to elucidate all imaging findings that point to alternative diagnoses. Diagnostic imaging of child abuse is based on both advances in imaging technology, as well as a better understanding of the subject based on scientific data obtained during the past 10 years.(1-3) The initial recommendation was published in Pediatrics (1991;87:262-264).

Cerebral complications of nonaccidental head injury in childhood

Patterns of cerebral parenchymal injury and their relationship to outcome morbidity are evaluated in this retrospective study of 14 children with confirmed nonaccidental head injury (NAHI). The mean age at time of injury was 12 months 6 days, mean Children's Coma Score was 5.36, and mean postinjury follow-up was 17 months 12 days. All patients had acute subdural hematoma (interhemispheric or convexity) on initial CT imaging. Two major groups of children were identified from initial CT scans; those with diffuse cerebral hypoattenuation (n = 7) and those with focal cerebral hypoattenuation (n = 7). The two groups differed significantly by age (diffuse group, mean age 5 months 9 days +/- 36 days; focal group, mean age 19 months 3 days +/- 6 months 9 days; P < 0.01) and ultimate type and extent of parenchymal damage. Outcome was generally poor in both groups (mean Children's Outcome Score of III/IV). Cerebral infarction developed in all survivors. Most common were hemispheric necrosis after hemispheric swelling subjacent to an ipsilateral convexity acute subdural hematoma (n = 5); distribution of the posterior cerebral artery (n = 4) or callosomarginal branch of the anterior cerebral artery (n = 4); and borderzone infarctions (n = 4). Of 14 children, 11 (79%) had early posttraumatic seizures (EPTS). Clinical progression of symptoms was confirmed in nine patients (mean Childrens Coma Score was 4.0 +/- 0.33). None had a lucid interval. This is the first study using strict inclusion criteria that documents the range of infarction patterns and potential age-dependent differences in postinjury response cascades after nonaccidental head injury.

Chest physiotherapy may be associated with brain damage in extremely premature infants

OBJECTIVES

To determine whether a characteristic form of brain damage (encephaloclastic porencephaly) was associated with chest physiotherapy treatment in preterm babies.

METHODS

A retrospective case-control study was undertaken among 454 infants of birth weight less than 1500 gm cared for during the 3-year period of 1992 to 1994. Thirteen babies of 24 to 27 weeks of gestation who weighed 680 to 1090 gm at birth had encephaloclastic porencephaly. Twenty-six control subjects were matched for birth weight and gestation.

RESULTS

The patients received two to three times as many treatments with chest physiotherapy in the second, third, and fourth weeks of life as did control infants (median 79 vs 19 treatments in the first 4 weeks, p < 0.001). Patients also had more prolonged and severe hypotension in the first week than did control subjects (median duration of hypotension 4 vs 0.5 days, p < 0.01), and were less likely to have a cephalic presentation (31% vs 81%, p < 0.01). Since December 1994 no very low birth weight baby has received chest physiotherapy treatment in the first month of life in our nursery, and no further cases have occurred.

CONCLUSIONS

Encephaloclastic porencephaly may be a previously unrecognized complication of chest physiotherapy in vulnerable extremely preterm infants.

Advances in paediatric CNS ultrasound

Advanced paediatric ultrasound of the central nervous system (CNS) requires 7 MHz sector and linear transducers, equipment which is highly sensitive to flow velocity (Power Doppler) and additional transcranial axial, coronal and sagittal imaging. New diagnostic possibilities include recognition of subarachnoid hemorrhage (imaging of cisterns and/or CSF-flow); differentiation between subarachnoid and subdural fluid collections (colour flow imaging of traversing veins); additional criteria suggestive of spinal cord tethering (spinal cord pulsations); and grey-white matter differentiation in newborn infants. A meticulous examination technique is mandatory when investigating suspected brain death, sinus venous thrombosis, diffuse early ischemia or viral (herpes) encephalitis. Anatomical areas such as the cerebral aqueduct, tentorium, Foramina of Luschka or circle of Willis which are not usually regarded as accessible to cerebral echography can be visualized by advanced transcranial imaging technique. Indications for transcranial scanning; shortcomings of cerebral ultrasound; measures to overcome limitations; and requirements for present and future ultrasound equipment are given and discussed in tables.

Imaging of child abuse

Diagnostic imaging plays a fundamental role in the evaluation of suspected physical abuse. Judicious application of modern imaging techniques to cases of suspected abuse aids in early and accurate diagnosis, leading to appropriate measures to protect all family members at risk of serious injury.

The pathology of fatal child abuse

It is a sad indictment of human society that the abuse of children is such a prevalent and widespread problem. The acknowledgement that physical, emotional and sexual injury as well as intentional neglect can be inflicted upon the young by any person but especially by caregivers has been increasingly realised by the community. As a result, many professionals, especially in the medical sciences, are involved in the study and management of such cases with the ultimate goals of recognising children at risk, diagnosing those cases that have occurred, preventing initial or subsequent injury and bringing perpetrators to justice. The aim of this paper is to review recent published work on the pathology of abuse leading to death of the child. Particular reference is made to the patterns of observed physical damage as well as to the interpretation of those observations. Clearly many more children are abused than die directly as a result of that abuse, but pathologists are infrequently involved in the management of clinical abuse cases. Exceptions to this rule, of course, include assessment of biochemical changes in cases of Munchausen syndrome by proxy, diagnosis of infective lesions resulting from sexual assault as well as the interpretation of unexplained cutaneous lesions subsequently shown to be caused by physical assault (such as burns and bite marks). Cases of physical abuse are usually managed by pediatric specialists with assistance from radiologists, neurosurgeons and ophthalmologists, and it is important that effective communication be maintained by pathologists with these practitioners when investigating a case that has unfortunately culminated in death.