Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury

Unequal Cerebral Magnetic Resonance Imaging Changes in Perinatal Hypoxic Ischemic Injury of Term Neonates

BACKGROUND

Perinatal hypoxic ischemic injury (HII) has a higher prevalence in the developing world. One of the primary concepts for suggesting that an imaging pattern reflects a global insult to the brain is when the injury is noted to be bilateral and symmetric in distribution. In the context of HII in term neonates, this is either bilateral symmetric ( a ) peripheral/watershed (WS) injury or ( b ) bilateral symmetric basal-ganglia-thalamus (BGT) pattern, often with the peri-Rolandic and hippocampal injury. Unilateral, asymmetric, or unequal distribution of injury may therefore be misdiagnosed as perinatal arterial ischemic stroke.

OBJECTIVES

We aimed to determine the prevalence of unequal cerebral injury in HII, identify patterns, and determine their relationship with existing classification of HII.

MATERIALS AND METHODS

Review of brain magnetic resonance imaging from a database of children with HII. Reports with any unequal pattern of injury were included and further classified as a unilateral, bilateral asymmetric, or symmetric but unequal degree pattern of HII.

RESULTS

A total of 1213 MRI scans in patients with a diagnosis of HII revealed 156 (13%) with unequal involvement of the hemispheres: unilateral in 2 of 1213 (0.2%) (involvement only in the WS), asymmetric in 48 of 1213 (4%) (WS in 6 [0.5%], BGT in 4 [0.3%], and combined BGT and WS in 38 [3.1%]), and bilateral symmetric but unequal degree in 106 of 1213 (8.7%) (WS in 20 [1.6%], BGT in 17 [1.4%], and combined BGT and WS in 69 [5.7%]).

CONCLUSIONS

The majority of children with cerebral palsy due to HII demonstrate a characteristic bilateral symmetric pattern of injury. In our study, 13% demonstrated an unequal pattern. Differentiation from perinatal arterial ischemic stroke, which is mostly unilateral and distributed typically in the middle cerebral artery territory, should be possible and recognition of the typical BGT or WS magnetic resonance imaging patterns should add confidence to the diagnosis, in such scenarios.

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.

Electrodeposited Ni/TiN-SiC Nanocomposites on the Dumbbell: Reducing Sport Injuries

Sports are becoming an important part of everyday life. In this study, an excellent Ni-SiC nanocomposite was prepared on the dumbbell surface using the pulse electrodeposition (PE) method to improve the durability of sports equipment and prevent sports injuries. Transmission electron microscopy (TEM), scanning electron microscopy (SEM), abrasion testing, triboindentry, and X-ray diffraction (XRD) were used to evaluate the impact of plating conditions upon the microhardness, microstructure, morphology, and wear behavior of the fabricated coatings. The obtained results showed that several SiC and TiN nanoparticles were incorporated into Ni/TiN-SiC nanocomposites obtained at 4 A/dm2. SiC and TiN nanoparticles had mean diameters of 37.5 and 45.6 nm, respectively. The Ni/TiN-SiC nanocomposite produced at 4 A/dm2 showed an excellent mean microhardness value of 848.5 HV, compared to the nanocomposites produced at 2 and 6 A/dm2. The rate of wear for Ni/TiN-SiC nanocomposite produced at 4 A/dm2 was 13.8 mg/min, demonstrating outstanding wearing resistance. Hence, it has been suggested that the Ni/TiN-SiC nanocomposite can effectively reduce sports injuries.

Abusive head trauma in India: imaging raises the curtain

The purpose of the study was to identify children at our institute who possibly suffered abusive head trauma (AHT). A retrospective study of CT imaging of children between one month to three years of age between January 2013 and May 2021 was carried out at a dedicated neurocentre in Southern India. We identified 48 cases of possible AHT. The demographics, clinical features at presentation, imaging and fundus findings were analyzed. Imaging revealed subdural hemorrhage (SDH) in 42 and sub dural effusion (SDE) in 5 cases, one case had only hypoxia. The location of SDH was studied as was hypoxia underlying SDH, global hypoxia and ischemia. Cases of subarachnoid hemorrhage (SAH), parenchymal hematoma & intraventricular hemorrhage (IVH) were also noted. Skeletal survey, chest X-ray and CT spine were reviewed. AHT needs to be paid attention to in the Indian scenario. An extensive work up is required to substantiate the claim and to work on prevention & management of these cases subsequently.

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.

What Do Confessions Reveal About Abusive Head Trauma? A Systematic Review

Although confessions related to abusive head trauma (AHT) are reported, no detailed analysis exists. Therefore, we systematically reviewed studies of AHT confessions and examined the details, including country of origin, mechanisms and perpetrators' characteristics [PUBLISHER - THE PRECEDING UNDERLINED TEXT IS FOR THE MARGIN]. Employing 36 search terms across three search engines, we searched Medline and CINAHL from 1963 to 2018. All relevant studies underwent two independent reviews and data extraction. Descriptive statistics were used to characterise the sample; chi square and Fisher's exact tests were used to assess differences in demographic and clinical characteristics. Of 6759 identified studies, 157 full texts were reviewed and 55 articles from 15 countries spanning four continents were included. Included articles contained 434 confessions. The mechanisms of abuse included shaking alone (64.1%), impact alone (17.1%), shaking plus impact (18.0%) and other (0.9%). There was no statistically significant difference in the percentage of confessions reporting shaking alone when comparing continents: North America (64.0%), Europe (64.2%) and Oceania (60.0%; P=.92), or when comparing circumstances in which the confession was obtained: medical evaluation (74.6%) vs police or judicial investigations (63.4%; P=.11). Of 119 cases with identified perpetrators, 67.2 per cent were cases with males alone. Confessions reveal striking similarities in the mechanism of AHT (predominantly shaking) and occur across the globe.

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.

Clinico-radiological approach to cerebral hemiatrophy

INTRODUCTION

Cerebral hemiatrophy is an uncommon neuroimaging finding of diverse etiologies, conventionally classified into two broad categories: congenital and acquired. The authors propose an alternative pragmatic clinical approach to cerebral hemiatrophy, classifying its diverse etiologies into a single event insult such as an in utero stroke, or a progressive disorder from an inflammatory or neoplastic process, the latter of which needs urgent intervention and will be the focus of our review paper. Illustrative cases will also be presented to facilitate the understanding of the discussed disorders.

CONCLUSION

A systematic approach, linking both clinical and neuroimaging features, is important to facilitate the diagnostic workup of cerebral hemiatrophy. This may potentially help avoid large-scale investigations. Determining the underlying aetiology of cerebral hemiatrophy may impact treatment and prognostication as some conditions such as Rasmussen encephalitis and Parry-Romberg syndrome may benefit from timely implementation of immunomodulatory therapy.

Prevalence, Patterns, and Clinical Relevance of Hypoxic-Ischemic Injuries in Children Exposed to Abusive Head Trauma

BACKGROUND AND PURPOSE

Hypoxic-ischemic injuries (HIIs) are a scarcely investigated but important cause of morbidity and mortality in children who suffered abusive head trauma (AHT). The purpose of this study is to determine: (a) prevalence, types, and clinical relevance of cytotoxic edema compatible with HII in nonpenetrating AHT, (b) their relationship to other classic neuroimaging findings of AHT, and (c) their correlation with clinical outcomes.

METHODS

Diffusion-weighted imaging sequences of magnetic resonance imagings performed on children under 5 years diagnosed with AHT were reviewed to detect the most common patterns of acute parenchymal damage. Patterns of cytotoxic edema were described, and HII-compatible ones divided in subtypes. Correlation between HII, fractures, and subdural hemorrhages (SDHs) and with clinical outcomes was determined using imaging and available follow-up data.

RESULTS

Out of 57 patients, 36.8% showed lesions compatible with HII. A predominantly asymmetric cortical distribution was observed in 66.7% of cases, while 33.3% had diffused both cortical and deep gray/white matter distribution injury. Traumatic axonal injuries and focal contusions were less common. There was no significant correlation between the presence of SDH (P = .6) or skull fractures (P = .53) and HII. HII was the most severe form of parenchymal damage in terms of in-hospital mortality and morbidity at follow-up.

CONCLUSIONS

HII is the most common type of parenchymal damage in children victim of AHT, being present in 1/3 of patients with this condition, and correlates with more severe outcomes. Its presence is independent from other classic traumatic findings such as SDH and fractures.

Unilateral anoxic brain injury secondary to strangulation identified on conventional and arterial spin-labeled perfusion imaging

Anoxic brain injury on magnetic resonance imaging classically demonstrates symmetric diffusion restriction involving the highly metabolic structures including the basal ganglia and cortex and global hyperperfusion on arterial spin labeling perfusion. The pattern of injury is classically diffuse and bilateral owing to global oxygen deprivation from systemic causes, most commonly cardiac arrest. In cases of suspected nonaccidental trauma presenting with a unilateral anoxic injury pattern, strangulation with temporary occlusion of a unilateral carotid artery should be considered. We present 2 cases of unilateral anoxic brain injury due to strangulation identified on magnetic resonance imaging and arterial spin labeling perfusion.

The Big Black Brain: Subdural Hemorrhage with Hemispheric Swelling and Low Attenuation

The term "Big Black Brain" was first coined in 1993 to describe cases of abusive head trauma associated with subdural hematoma(s), brain swelling, and uni- or bilateral hypo-density involving the entire supratentorial compartment on CT scan imaging. This constellation of findings was invariably followed by extensive cerebral parenchymal destruction and a dismal neurological outcome or death. We describe two such cases and review the pathophysiology and differential diagnosis of this entity.

Seizure Severity Is Correlated With Severity of Hypoxic-Ischemic Injury in Abusive Head Trauma

BACKGROUND

The objective of this study was to characterize hypoxic-ischemic injury and seizures in abusive head trauma.

METHODS

We studied 58 children with moderate or severe traumatic brain injury due to abusive head trauma. Continuous electroencephalograms and magnetic resonance images were scored.

RESULTS

Electrographic seizures (51.2%) and hypoxic-ischemic injury (77.4%) were common in our cohort. Younger age was associated with electrographic seizures (no seizures: median age 13.5 months, interquartile range five to 25 months, versus seizures: 4.5 months, interquartile range 3 to 9.5 months; P = 0.001). Severity of hypoxic-ischemic injury was also associated with seizures (no seizures: median injury score 1.0, interquartile range 0 to 3, versus seizures: 4.5, interquartile range 3 to 8; P = 0.01), but traumatic injury severity was not associated with seizures (no seizures: mean injury score 3.78 ± 1.68 versus seizures: mean injury score 3.83 ± 0.95, P = 0.89). There was a correlation between hypoxic-ischemic injury severity and seizure burden when controlling for patient age (r_s=0.61, P < 0.001). The ratio of restricted diffusion volume to total brain volume (restricted diffusion ratio) was smaller on magnetic resonance imaging done early (median restricted diffusion ratio 0.03, interquartile range 0 to 0.23 on magnetic resonance imaging done within two days versus median restricted diffusion ratio 0.13, interquartile range 0.01 to 0.43 on magnetic resonance imaging done after two days, P = 0.03).

CONCLUSIONS

Electrographic seizures are common in children with moderate to severe traumatic brain injury from abusive head trauma, and therefore children with suspected abusive head trauma should be monitored with continuous electroencephalogram. Severity of hypoxic-ischemic brain injury is correlated with severity of seizures, and evidence of hypoxic-ischemic injury on magnetic resonance imaging may evolve over time. Therefore children with a high seizure burden should be reimaged to evaluate for evolving hypoxic-ischemic injury.

Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern

AIM

The purpose of this study was to document the incidence and pattern of cervical spine (c-spine) injuries in children below 36months with inflicted trauma.

METHODS

An IRB approved, prospective cohort study was performed between July 2011 and January 2016. Inclusion criteria were: age below 36months, loss of consciousness after inflicted trauma, and one initial head computed tomography finding: a subdural, intraventricular, intraparenchymal, subarachnoid hemorrhage, diffuse axonal injury, hypoxic injury, or cerebral edema. A protocol of brain and neck magnetic resonance imaging and angiography was obtained within 48h. Variables were compared by t-test and Fisher-exact test.

RESULTS

There were 53 children (median age: five months; range: 1-35months), 38 males (71.7%), of which seven died (13.2%). C-spine injury was identified in 8 (15.1%): ligamentous injury (2), vertebral artery shear injury (1), atlantooccipital dissociation (AOD) (1), cord injury with cord epidural hematoma (2), and isolated cord epidural hematoma (2). Retinal hemorrhages (p=0.02), shaking (p=0.04), lower Glasgow coma score (GCS) (p=0.01), brain infarcts (p=0.01), and hypoxic/ischemic injury (p=0.01) were associated with c-spine injury. One with AOD died. Six had significant disability.

CONCLUSION

For small children with inflicted trauma, the c-spine injury incidence is 15.1%. The injury pattern includes retinal hemorrhages, shaking, lower GCS, and brain injury. Evaluation of shaken infants should include c-spine imaging.

LEVEL OF EVIDENCE

Level 2 A- This is a prospective cohort study with complete follow-up to hospital discharge or death. In all cases, inflicted trauma was confirmed. Owing to the nature of child abuse, the precise time of injury is not known. All children underwent a strict imaging protocol on arrival to hospital that was supervised on a prospective basis.

Early diffusion restriction of white matter in infants with small subdural hematomas is associated with delayed atrophy

BACKGROUND

Traumatic brain injury (TBI) is a major cause of infant morbidity and mortality. In these patients, magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) is the test of choice to describe the extent of microstructural injury.

CASE PRESENTATION AND DISCUSSION

In this case series, we describe novel acute and chronic MRI findings in four infants (6-19 months) with small, unilateral subdural hematomas in whom the etiology of head injury was suspicious for non-accidental trauma (NAT). Acute (<1-week post-injury) DWI revealed extensive areas of restricted diffusion isolated to the cerebral white matter predominantly ipsilateral to the subdural hematoma. After prolonged pediatric intensive care treatment including subdural evacuation (n = 2) or decompressive craniectomy (n = 1), all patients survived albeit with significant motor and cognitive deficits. Delayed structural MRI (6-9-year post-injury) demonstrated cortical and subcortical atrophy well-correlated with areas of acute restricted diffusion.

CONCLUSION

These four cases highlight that relatively small subdural hematomas can be associated with extensive white matter injury-detectable only by early DWI-which have long-term structural and functional consequences.

Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma

BACKGROUND

In the evaluation of children younger than 3 years with intracranial hemorrhage it can be difficult to determine whether the cause of hemorrhage was traumatic, and if so, whether abusive head trauma (AHT) is a possibility. Cervical spine MRI is not a routine part of the nationally recommended imaging workup for children with suspected abusive head trauma. There is increasing evidence that spinal injuries are found at autopsy or MRI in abused children. However the prevalence of cervical spine injuries in children evaluated for abusive head trauma is unknown. We sought to determine both the incidence and the spectrum of cervical spine and brain injuries in children being evaluated for possible abusive head trauma. We also examined the relationship between cervical and brain MRI findings and selected study outcome categories.

MATERIALS AND METHODS

This study is a 3-year retrospective review of children evaluated for abusive head trauma. Inclusion criteria were: children with head trauma seen at our institution between 2008 and 2010, age younger than 36 months, availability of diagnostic-quality brain and cervical spine MRI, and child abuse team involvement because abusive head trauma was a possibility. A child abuse pediatrician and pediatric radiologists, all with board certification, were involved in data collection, image interpretation and data analysis. Statistical analysis was performed using Stata v12.1.

RESULTS

The study included 74 children (43 boys, 31 girls) with a mean age of 164 days (range, 20-679 days). Study outcomes were categorized as: n = 26 children with accidental head trauma, n = 38 with abusive head trauma (n = 18 presumptive AHT, n = 20 suspicious for AHT), and n = 10 with undefined head trauma. We found cervical spine injuries in 27/74 (36%) children. Most cervical spine injuries were ligamentous injuries. One child had intrathecal spinal blood and two had spinal cord edema; all three of these children had ligamentous injury. MRI signs of cervical injury did not show a statistically significant relationship with a study outcome of abusive head trauma or help discriminate between accidental and abusive head trauma. Of the 30 children with supratentorial brain injury, 16 (53%) had a bilateral hypoxic-ischemic pattern. There was a statistically significant relationship between bilateral hypoxic-ischemic brain injury pattern and abusive head trauma (P < 0.05). In addition, the majority (81%) of children with bilateral hypoxic-ischemic brain injuries had cervical injuries.

CONCLUSION

Although detection of cervical spine injuries by MRI does not discriminate between accidental and abusive head trauma, it can help to distinguish a traumatic from non-traumatic intracranial subdural hemorrhage. Cervical MRI should be considered in children with acute intracranial bleeds and otherwise non-contributory history, physical examination and ophthalmological findings. There is a statistically significant relationship between diffuse hypoxic-ischemic brain injury patterns and abusive head trauma. The high incidence of cervical injuries in children with hypoxic-ischemic injuries suggests a causal relationship. Overall, increased utilization of brain and spine MRI in children being evaluated for abusive head trauma can be helpful.

Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review

BACKGROUND AND OBJECTIVE

To systematically review the literature to determine which clinical and radiographic characteristics are associated with abusive head trauma (AHT) and nonabusive head trauma (nAHT) in children.

METHODS

We searched MEDLINE, EMBASE, PubMed, conference proceedings, and reference lists to identify relevant studies. Two reviewers independently selected studies that compared clinical and/or radiographic characteristics including historical features, physical exam and imaging findings, and presenting signs or symptoms in hospitalized children ≤ 6 years old with AHT and nAHT.

RESULTS

Twenty-four studies were included. Meta-analysis was complicated by inconsistencies in the reporting of characteristics and high statistical heterogeneity. Notwithstanding these limitations, there were 19 clinical and radiographic variables that could be meta-analyzed and odds ratios were determined for each variable. In examining only studies deemed to be high quality, we found that subdural hemorrhage(s), cerebral ischemia, retinal hemorrhage(s), skull fracture(s) plus intracranial injury, metaphyseal fracture(s), long bone fracture(s), rib fracture(s), seizure(s), apnea, and no adequate history given were significantly associated with AHT. Epidural hemorrhage(s), scalp swelling, and isolated skull fracture(s) were significantly associated with nAHT. Subarachnoid hemorrhage(s), diffuse axonal injury, cerebral edema, head and neck bruising, any bruising, and vomiting were not significantly associated with either type of trauma.

CONCLUSIONS

Clinical and radiographic characteristics associated with AHT and nAHT were identified, despite limitations in the literature. This systematic review also highlights the need for consistent criteria in identifying and reporting clinical and radiographic characteristics associated with AHT and nAHT.

Advanced neuromonitoring and imaging in pediatric traumatic brain injury

While the cornerstone of monitoring following severe pediatric traumatic brain injury is serial neurologic examinations, vital signs, and intracranial pressure monitoring, additional techniques may provide useful insight into early detection of evolving brain injury. This paper provides an overview of recent advances in neuromonitoring, neuroimaging, and biomarker analysis of pediatric patients following traumatic brain injury.

Neonatal ischemic brain injury: what every radiologist needs to know

We present a pictorial review of neonatal ischemic brain injury and look at its pathophysiology, imaging features and differential diagnoses from a radiologist's perspective. The concept of perinatal stroke is defined and its distinction from hypoxic-ischemic injury is emphasized. A brief review of recent imaging advances is included and a diagnostic approach to neonatal ischemic brain injury is suggested.

ACR Appropriateness Criteria(®) on suspected physical abuse-child

The appropriate imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and whether the injuries are discrepant with the clinical history. The clinical presentations reviewed consider these factors and provide evidence-based consensus recommendations by the ACR Appropriateness Criteria(®) Expert Panel on Pediatric Imaging.

Advanced neuroimaging in children with nonaccidental trauma

Physical abuse associated with nonaccidental trauma (NAT) affects approximately 144,000 children per year in the USA and, frequently, these injuries affect the developing brain. Most infants with suspected NAT are initially evaluated by skull X-rays and computed tomography to determine whether fractures are present, the severity of the acute injury and the need for urgent neurosurgical intervention. Increasingly, magnetic resonance imaging (MRI) is conducted as it provides additional diagnostic and prognostic information about the extent and nature of the injury. In this review, we examine 4 MRI techniques as they apply to children who present acutely after NAT. Susceptibility-weighted imaging is a 3-D high-resolution MRI technique that is more sensitive than conventional imaging in detecting hemorrhagic lesions that are often associated with diffuse axonal injury (DAI). Magnetic resonance spectroscopy acquires metabolite information reflecting neuronal integrity and function from multiple brain regions and provides a sensitive, noninvasive assessment of neurochemical alterations that offers early prognostic information regarding outcome. Diffusion-weighted imaging (DWI) is based on differences in the diffusion of water molecules within the brain and has been shown to be very sensitive in the early detection of ischemic injury. It is now being used to study the direct effects of traumatic injury as well as those due to secondary ischemia. Diffusion tensor imaging is a form of DWI and allows better evaluation of white matter fiber tracts by taking advantage of the intrinsic directionality (anisotropy) of water diffusion in the human brain. It has been shown to be useful in identifying white matter abnormalities after DAI when conventional imaging appears normal. Although these imaging methods have been studied primarily in adults and children with accidental traumatic brain injury, it is clear that they have the potential to provide additional value in the imaging and clinical evaluation of children with NAT.

Pediatric central nervous system emergencies

This article summarizes current state-of-the-art techniques used in the management of pediatric neurologic emergencies. Solutions to challenges faced by the radiologist, including the selection of an appropriate modality for an individual patient, are discussed. Imaging appearances of specific entities are described with an emphasis on conditions unique to the pediatric population.

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.

Susceptibility-weighted imaging findings of cortical laminar necrosis in pediatric patients

BACKGROUND AND PURPOSE

MR susceptibility-weighted imaging (SWI) is a highly sensitive technique for detection of hemorrhage, but its utility in the evaluation of children with laminar necrosis is not yet known. We assessed whether cortical laminar necrosis in pediatric patients contains hemorrhage on SWI.

MATERIALS AND METHODS

"Cortical laminar necrosis" was defined as a hyperintense cortical lesion on T1-weighted imaging in the subacute or chronic phase of brain damage in some foci involving the cerebral cortex and white matter such as hypoxic-ischemic incidents and encephalopathy. Medical records, CT, and MR images were retrospectively analyzed. Fifteen patients (7 boys, 8 girls; age range, 0-13 years) were included. The areas of signal-intensity loss on SWI that were considered to be hemorrhage were correlated with the laminar necrosis. CT was assessed to correlate with the presence of calcification at the location of the signal-intensity loss on SWI. To assess appearance or signal-intensity changes of hemorrhage in the laminar necrosis, follow-up SWI was performed.

RESULTS

The causes of laminar necrosis included infarction in 4 patients, ischemic changes from Moyamoya disease in 2, meningoencephalitis in 2, hypoxic-ischemic encephalopathy in 2, shaken baby syndrome in 1, encephalopathy from severe infection in 1, status epilepticus in 1, citrullinemia in 1, and brain injury with posterior reversible encephalopathy syndrome in 1. T1-weighted imaging showed focal laminar necrosis in 8, multifocal laminar necrosis in 2, and diffuse laminar necrosis in 5. SWI findings correlated with laminar necrosis included the following: no hemorrhage in 13 patients (80.0%), dotted hemorrhage in 2 (13.3%), and laminar hemorrhage in 1 (6.7%). Follow-up SWI performed in 6 patients showed no additional hemorrhage.

CONCLUSION

Most areas of cortical laminar necrosis in pediatric patients showed no hemorrhage on SWI.

Update on child maltreatment

PURPOSE OF REVIEW

The authors discuss the significance of studies published over the previous year regarding assessment and treatment and prevention of child maltreatment, including physical and sexual abuse, inflicted traumatic brain injury, and child neglect.

RECENT FINDINGS

The evidence base for many forms of child abuse is growing. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented. In response to a very public reprimand by the General Medical Council of two child abuse pediatricians, which was felt by many to be unwarranted, the UK government re-emphasized its commitment to the protection of children. In the US, this well-publicized set of events has renewed the medical community's commitment to the recognition of child abuse pediatrics as a formal subspecialty. Several authors detail the short-term and long-term outcome of varying forms of abuse for children as they grow into adults, reinforcing the importance of community efforts to prevent abuse and support families during times of heightened stress such as the current war in Iraq.

SUMMARY

The short-term and long-term impact of child maltreatment is significant not only for individuals, but for families and communities where abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children.