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Harris CK, Stagner AM. The Eyes Have It: How Critical are Ophthalmic Findings to the Diagnosis of Pediatric Abusive Head Trauma? Semin Ophthalmol 2023; 38:3-8. [PMID: 36524752 DOI: 10.1080/08820538.2022.2152712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pediatric abusive head trauma (AHT), still colloquially known as shaken baby syndrome, is a leading cause of morbidity and mortality among infants. Controversy has grown surrounding this diagnosis, and the specificity of the clinical findings-subdural hemorrhage, cerebral edema, and retinal hemorrhages-has been challenged. A literature search of peer reviewed publications on PubMed pertaining to the history, clinical, and pathologic features of AHT was conducted using the terms "shaken baby syndrome," "non-accidental trauma," "abusive head trauma," "inflicted traumatic brain injury," "shaken impact syndrome," and "whiplash shaken infant syndrome." Focus was placed on articles discussing ophthalmic findings in AHT. Retinal hemorrhages-particularly those that are too numerous to count, occurring in all layers of the retina (preretinal, intraretinal, subretinal), covering the peripheral pole and extending to the ora serrata, and accompanied by retinoschisis and other ocular/periocular hemorrhages-are highly suggestive of AHT, particularly in the absence of otherwise explained massive accidental trauma. Although the diagnosis has grown in controversy in recent years, AHT has well-documented clinical and pathologic findings across a large number of studies.
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Affiliation(s)
- Cynthia K Harris
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Anna M Stagner
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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Cheshire EC, Malcomson RDG, Sun P, Mirkes EM, Amoroso JM, Rutty GN. A systematic autopsy survey of human infant bridging veins. Int J Legal Med 2018; 132:449-461. [PMID: 29075919 PMCID: PMC5807502 DOI: 10.1007/s00414-017-1714-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/11/2017] [Indexed: 11/06/2022]
Abstract
In the first years of life, subdural haemorrhage (SDH) within the cranial cavity can occur through accidental and non-accidental mechanisms as well as from birth-related injury. This type of bleeding is the most common finding in victims of abusive head trauma (AHT). Historically, the most frequent cause of SDHs in infancy is suggested to be traumatic damage to bridging veins traversing from the brain to the dural membrane. However, several alternative hypotheses have been suggested for the cause and origin of subdural bleeding. It has also been suggested by some that bridging veins are too large to rupture through the forces associated with AHT. To date, there have been no systematic anatomical studies on infant bridging veins. During 43 neonatal, infant and young child post-mortem examinations, we have mapped the locations and numbers of bridging veins onto a 3D model of the surface of a representative infant brain. We have also recorded the in situ diameter of 79 bridging veins from two neonatal, one infant and two young children at post-mortem examination. Large numbers of veins, both distant from and directly entering the dural venous sinuses, were discovered travelling between the brain and dural membrane, with the mean number of veins per brain being 54.1 and the largest number recorded as 94. The mean diameter of the bridging veins was 0.93 mm, with measurements ranging from 0.05 to 3.07 mm. These data demonstrate that some veins are extremely small and subjectively, and they appear to be delicate. Characterisation of infant bridging veins will contribute to the current understanding of potential vascular sources of subdural bleeding and could also be used to further develop computational models of infant head injury.
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Affiliation(s)
- Emma C Cheshire
- East Midlands Forensic Pathology Unit, Robert Kilpatrick Building, Level 3 Leicester Royal Infirmary, University of Leicester, Leicester, LE2 7LX, UK.
| | - Roger D G Malcomson
- Histopathology Department, Leicester Royal Infirmary, Infirmary Close, Leicester, LE1 5WW, UK
| | - Peng Sun
- Mathematics Department, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Evgeny M Mirkes
- Mathematics Department, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Jasmin M Amoroso
- East Midlands Forensic Pathology Unit, Robert Kilpatrick Building, Level 3 Leicester Royal Infirmary, University of Leicester, Leicester, LE2 7LX, UK
| | - Guy N Rutty
- East Midlands Forensic Pathology Unit, Robert Kilpatrick Building, Level 3 Leicester Royal Infirmary, University of Leicester, Leicester, LE2 7LX, UK
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Arterial spin-labeling perfusion imaging of children with subdural hemorrhage: Perfusion abnormalities in abusive head trauma. J Neuroradiol 2017; 44:281-287. [DOI: 10.1016/j.neurad.2017.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/09/2016] [Accepted: 02/12/2017] [Indexed: 11/17/2022]
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Statistical significance does not imply (forensic medical) relevance. Pediatr Radiol 2017; 47:628-629. [PMID: 28255688 DOI: 10.1007/s00247-017-3803-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/10/2017] [Indexed: 10/20/2022]
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Pasquesi SA, Margulies SS. Failure and Fatigue Properties of Immature Human and Porcine Parasagittal Bridging Veins. Ann Biomed Eng 2017; 45:1877-1889. [PMID: 28405773 DOI: 10.1007/s10439-017-1833-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/05/2017] [Indexed: 11/28/2022]
Abstract
Tearing of the parasagittal bridging veins (BVs) is thought to be a source of extra-axial hemorrhage (EAH) associated with abusive traumatic brain injuries (TBIs) in children. However, the pediatric BV mechanical properties are unknown. We subjected porcine adult, porcine newborn, and human infant BVs to either a low rate pull to failure, a high rate pull to failure, or 30 s of cyclic loading followed by a pull to failure. An additional subset of human infant BVs was examined for viscoelastic recovery between two cycling episodes. We found that human infant BVs are stronger than porcine BVs, and BV mechanical properties are rate dependent, but not age dependent. Successive cyclic loading to a uniform level of stretch softened BVs with decaying peak stresses, and shifted their stress-stretch relationship. These data are critical in understanding BV tissue behavior in accidental and abusive trauma scenarios, which in turn may clarify circumstances that may be injurious to young children.
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Affiliation(s)
- Stephanie A Pasquesi
- Department of Bioengineering, University of Pennsylvania, 240 Skirkanich Hall, 210 South 33rd Street, Philadelphia, PA, 19104-6321, USA
| | - Susan S Margulies
- Department of Bioengineering, University of Pennsylvania, 240 Skirkanich Hall, 210 South 33rd Street, Philadelphia, PA, 19104-6321, USA.
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Stoodley N, Williams M. The importance of neuroimaging in abusive head trauma. IMAGING 2014. [DOI: 10.1259/img.20110067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Acres MJ, Morris JA. The pathogenesis of retinal and subdural haemorrhage in non-accidental head injury in infancy: Assessment using Bradford Hill criteria. Med Hypotheses 2014; 82:1-5. [DOI: 10.1016/j.mehy.2013.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 07/28/2013] [Accepted: 09/08/2013] [Indexed: 11/26/2022]
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Thomas AG, Hegde SV, Dineen RA, Jaspan T. Patterns of accidental craniocerebral injury occurring in early childhood. Arch Dis Child 2013; 98:787-92. [PMID: 23922057 DOI: 10.1136/archdischild-2013-304267] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the range of intracranial injuries encountered in 0-2-year-olds in cases of accidental head injury where the mechanism of trauma was well characterised and to assess the clinical consequences. DESIGN A retrospective review of imaging and clinical data. SETTING Two tertiary paediatric referral centres. PATIENTS All children aged 0-2 undergoing cranial CT as indicated by National Institute for Health and Clinical Excellence guidance for head injury from 2006 to 2011. After exclusion criteria, 149 patients were included. MAIN OUTCOME MEASURES Rates of skull fracture, intracranial haemorrhage, parenchymal injuries and ischaemic change per type of mechanism of injury. Rates of neurological sequelae on follow-up. RESULTS Skull fractures were demonstrated in 54 (36%) patients of whom 17 (11%) had thin underlying subdural haemorrhage (SDH). Extradural haemorrhage complicated one fracture and two cases of isolated subdural haematomas were seen without skull fracture. Radiologically evident brain parenchymal injuries were present in three patients, all with mechanisms of injury involving high levels of force; severe neurological sequelae were only seen in one patient, who had diffuse hypoxic-ischaemic damage at presentation and whose (accidental) mechanism of injury involved extensive acceleration/deceleration/translational forces. CONCLUSIONS Skull fractures and focal SDH are relatively common following minor trauma in this age group but in the vast majority of cases there are no long-term neurological sequelae. Conversely, diffuse brain injury with severe subsequent neurological impairment was only seen in patients with a correspondingly severe mechanism of injury.
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Affiliation(s)
- A G Thomas
- Radiology Department, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, , Leicester, UK
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Imaging of Neonatal Child Abuse with an Emphasis on Abusive Head Trauma. Magn Reson Imaging Clin N Am 2011; 19:791-812; viii. [DOI: 10.1016/j.mric.2011.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Barnes PD. Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine. Radiol Clin North Am 2011; 49:205-29. [PMID: 21111136 DOI: 10.1016/j.rcl.2010.08.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Because of the controversy involving the determination of child abuse, or nonaccidental injury (NAI), radiologists must be familiar with the issues, literature, and principles of evidence-based medicine to understand the role of imaging. Children with suspected NAI must receive protective evaluation along with a timely and complete clinical and imaging work-up. Imaging findings cannot stand alone and must be correlated with clinical findings, laboratory testing, and pathologic and forensic examinations. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive clinical, imaging, biomechanical, or pathology findings.
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Affiliation(s)
- Patrick D Barnes
- Department of Radiology, Lucile Packard Children's Hospital, Stanford University Medical Center, 725 Welch Road, Palo Alto, CA 94304, USA.
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Barnes PD, Galaznik J, Gardner H, Shuman M. Infant acute life-threatening event--dysphagic choking versus nonaccidental injury. Semin Pediatr Neurol 2010; 17:7-11. [PMID: 20434683 DOI: 10.1016/j.spen.2010.01.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 4-month-old male infant presented to the emergency room with a history of choking while bottle feeding at home, and was found by emergency medical services (EMS) to be apneic and pulseless. He subsequently developed disseminated intravascular coagulopathy and died. Computed tomography (CT) and magnetic resonance imaging (MRI) showed subdural hemorrhages (SDHs), subarachnoid hemorrhage (SAH), and retinal hemorrhages (RHs), along with findings of hypoxic-ischemic encephalopathy (HIE). The caretaker account appeared to be inconsistent with the clinical and imaging features, and a diagnosis of nonaccidental injury with "shaken baby syndrome" was made. The autopsy revealed diffuse anoxic central nervous system (CNS) changes with marked edema, SAH, and SDH, but no evidence of "CNS trauma." Although NAI could not be ruled out, the autopsy findings provided further evidence that the child's injury could result from a dysphagic choking type of acute life threatening event (ALTE) as consistently described by the caretaker.
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Affiliation(s)
- Patrick D Barnes
- Department of Radiology, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, CA 94304, USA.
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Tang PH, Lim CCT. Imaging of accidental paediatric head trauma. Pediatr Radiol 2009; 39:438-46. [PMID: 19125244 DOI: 10.1007/s00247-008-1083-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 09/21/2008] [Indexed: 10/24/2022]
Abstract
Head trauma is the most common form of injury sustained in serious childhood trauma and remains one of the top three causes of death despite improved road planning and safety laws. CT remains the first-line investigation for paediatric head trauma, although MRI may be more sensitive at picking up the full extent of injuries and may be useful for prognosis. Follow-up imaging should be tailored to answer the specific clinical question and to look for possible complications.
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Affiliation(s)
- Phua Hwee Tang
- Department of Diagnostic Imaging, KK Women's and Children's Hospital, Singapore, Singapore.
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Offiah A, van Rijn RR, Perez-Rossello JM, Kleinman PK. Skeletal imaging of child abuse (non-accidental injury). Pediatr Radiol 2009; 39:461-70. [PMID: 19238374 DOI: 10.1007/s00247-009-1157-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 12/23/2008] [Accepted: 01/04/2009] [Indexed: 11/30/2022]
Abstract
In recent years there has been a worldwide increased awareness that children are physically abused by their carers. Radiologists play a vital role in the detection of inflicted injuries. This article reviews the skeletal imaging findings seen in child abuse.
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Affiliation(s)
- Amaka Offiah
- Radiology Department, Great Ormond Street Hospital, London, UK
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Abstract
Child physical abuse that results in injury to the head or brain has been described using many terms, including battered child syndrome, whiplash injuries, shaken infant or shaken impact syndrome, and nonmechanistic terms such as abusive head trauma or nonaccidental trauma. These injuries sustained by child abuse victims are discussed in detail in this article, including information about diagnosis, management and outcomes. The use of forensics, the use imaging studies, and associated injuries are also detailed.
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Affiliation(s)
- Antonia Chiesa
- Department of Pediatrics, Kempe Child Protection Team, The Children's Hospital, 13123 E. 16th Avenue, Box 138, Denver, CO 80045, USA.
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Abstract
PURPOSE OF REVIEW The authors explore the literature published in the past year addressing child maltreatment issues, including sexual abuse, physical child abuse, inflicted head trauma, and child abuse prevention. RECENT FINDINGS The body of knowledge about child abuse and its mimics continues to expand. Evident in this year's literature is the challenge which the diagnosis of child abuse creates for clinicians. Although further strides are being made toward universal education of providers, it is clear that there is still a reluctance to report abuse to child welfare agencies. The legal repercussions of diagnosing abuse can be extensive, and there has been a proliferation of medical defense experts who disagree with the commonly accepted tenets of abusive injury and who are vocal in the literature. SUMMARY It remains the responsibility of pediatric providers to consider child maltreatment in the differential diagnosis of any unexplained injury or medical problem. Several studies document the high rate of spanking, slapping or shaking children, and primary care clinicians may be the first professionals in a position to begin the evaluation for possible child maltreatment. Despite the natural hesitancy to diagnose abuse, clinicians have an ethical and moral obligation to address this issue both in their practice and in their communities. The short-term and long-term costs to individuals who experience family violence have been well demonstrated and include not only emotional repercussions, but also chronic health conditions, which result in significant cost to society.
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Squier W, Mack J. The neuropathology of infant subdural haemorrhage. Forensic Sci Int 2009; 187:6-13. [PMID: 19303229 DOI: 10.1016/j.forsciint.2009.02.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 02/03/2009] [Accepted: 02/09/2009] [Indexed: 10/21/2022]
Abstract
Subdural haemorrhage (SDH) in the infant has a different pattern from that seen in the older child and adult. It is usually a widespread, bilateral, thin film, unlike the thick, space-occupying and often unilateral clot seen in older children and adults after trauma. Whether both arise by the same mechanism is unknown, but it seems unlikely. Most SDH is said to be due to trauma but in infants there are other, atraumatic causes. Birth is also important; recent MRI studies show an incidence of almost 50% in asymptomatic neonates. Traumatic SDH is said to result from rupture of bridging veins but new insights into the anatomy of infant dura suggest a dural origin for thin film subdural bleeding in young babies. Acute SDH usually rapidly resolves, but sometimes develops into a chronic fluid collection. Healing of SDH is by formation of a granulating membrane which may confer vulnerability to rebleeding, either spontaneously or after an otherwise innocuous event. SDH has a particular significance as one of the features of the triad (together with retinal haemorrhage and encephalopathy) associated with non-accidental injury. As the possibility of non-accidental injury is often first raised by a radiologic report of subdural bleeding, it becomes critically important in the interpretation of the scan appearances to understand the unique physiology and anatomy of the infant dura.
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Affiliation(s)
- Waney Squier
- Department of Neuropathology, Level 1, West Wing, John Radcliffe Hospital, Oxford OX39DU, United Kingdom.
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Anatomy and development of the meninges: implications for subdural collections and CSF circulation. Pediatr Radiol 2009; 39:200-10. [PMID: 19165479 DOI: 10.1007/s00247-008-1084-6] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 11/04/2008] [Accepted: 11/17/2008] [Indexed: 10/21/2022]
Abstract
The dura is traditionally viewed as a supportive fibrous covering of the brain containing the dural venous sinuses but otherwise devoid of vessels and lacking any specific function. However, review of the embryology and anatomy reveals the dura to be a complex, vascularized and innervated structure, not a simple fibrous covering. The dura contains an inner vascular plexus that is larger in the infant than in the adult, and this plexus likely plays a role in CSF absorption. This role could be particularly important in the infant whose arachnoid granulations are not completely developed. Although subdural hemorrhage is frequently traumatic, there are nontraumatic conditions associated with subdural hemorrhage, and the inner dural plexus is a likely source of bleeding in these nontraumatic circumstances. This review outlines the development and age-specific vascularity of the dura and offers an alternative perspective on the role of the dura in homeostasis of the central nervous system.
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Barnes PD, Krasnokutsky MV, Monson KL, Ophoven J. Traumatic spinal cord injury: accidental versus nonaccidental injury. Semin Pediatr Neurol 2008; 15:178-84; discussion 185. [PMID: 19073323 DOI: 10.1016/j.spen.2008.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 21-month-old boy with steroid-dependent asthma presented to the emergency room with Glascow Coma Score (GCS) 3 and retinal hemorrhages. He was found to have subdural and subarachnoid hemorrhage on computed tomography plus findings of hypoxic-ischemic encephalopathy (HIE). The caretaker history was thought to be inconsistent with the clinical and imaging features, and the patient was diagnosed with nonaccidental injury (NAI) and "shaken baby syndrome." The autopsy revealed a cranial impact site and fatal injury to the cervicomedullary junction. Biomechanical analysis provided further objective support that, although NAI could not be ruled out, the injuries could result from an accidental fall as consistently described by the caretaker.
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Affiliation(s)
- Patrick D Barnes
- Department of Radiology, Lucile Packard Children's Hospital, Palo Alto, CA 94304, USA.
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