The eye in child abuse: key points on retinal hemorrhages and abusive head trauma

Ophthalmologic findings in abusive head trauma

A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma.

Identifying inflicted injuries in infants and young children

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.

Ocular findings in the evaluation of abusive head trauma in children

PURPOSE

Abusive head trauma (AHT) is a form of child physical abuse that can result in major ocular injuries. This study describes the clinical presentation and ocular manifestations of infants diagnosed with AHT in a tertiary care center in Saudi Arabia.

METHODS

This is an observational, retrospective, cross-sectional study from 2015 to 2022 conducted at King Abdullah Specialized Children's Hospital (KASCH) in Riyadh, Saudi Arabia. Inclusion criteria include infants <2 years of age, diagnosed with AHT that had an eye examination as part of the evaluation.

RESULTS

A total of 25 (50 eyes) cases of AHT had an eye examination documented in the electronic patients' records. The majority were males 19 (76%), and <6 months of age 10 (40%). About half of the children were healthy 13 (52%), and 12 (48%) had underlying physical illness. All patients had computed tomography scans. Subdural bleeding was noted in 22 (88%), 1 (4%) had epidural, and 4 (16%) had subarachnoid bleed. External ocular signs were noted in 8 (32%) patients only, including raccoon eyes, periorbital bruises, subconjunctival hemorrhage, and nonfixating eyes. Fundus findings were bilateral in 18 (72%), unilateral in 2 (8%), and normal in 5 (20%). In those with findings, the majority of 34 (68%) eyes had multiple retinal hemorrhages, 4 (8%) had vitreous hemorrhages, 2 (4%) retinal detachments, and 1 (2%) retinoschisis.

CONCLUSION

Fundus examination is an important part of the comprehensive examination of children with suspected AHT; the majority of patients had an abnormal fundus examination with the tendency of bilateral findings.

The eye in forensic practice: In the dead

Post-mortem examination of the eye provides valuable forensic information yet is often overlooked. This brief review focuses on determining the cause/manner of death and post-mortem interval. External eye findings like corneal haziness and tache noire, combined with post-mortem changes in the iris, lens, retina and vitreous humour, can help estimate time since death. Ocular biometrics (iris/retinal scans) may facilitate identification. Age-related ocular changes can provide insights. The eye offers clues into personality (corneal tattooing, trichotillomania) and cause of death (petechiae in strangulation, retinal haemorrhages in abusive head trauma). Ocular trauma and underlying eye disease may be evident. Toxicology of vitreous humour can detect drugs/poisons. As a window into systemic disease and age-related changes, the eye aids pathology interpretations and, accordingly, post-mortem examinations have value. Ocular findings should not be overlooked in forensic examinations as they provide distinct information in determining cause/manner of death and post-mortem interval.

Retinal hemorrhages due to intracranial hypertension, is it possible to differentiate them from those associated with abuse?

BACKGROUND

Retinal hemorrhages (RHs) are suggestive of abusive head trauma (AHT). Even so, controversy persists about other possible causes, a fact that hinders the diagnosis of abuse.

OBJECTIVE

To determine the prevalence and patterns of RHs associated with increased intracranial pressure (ICP) in young children.

PARTICIPANTS AND METHODS

Prospective, single center study of children aged 29 days-3 years undergoing a lumbar puncture with opening pressure (OP) measured during routine clinical care in the emergency department, over a 4-year period. Children with known causes of RHs were excluded. All the children underwent a detailed ophthalmological examination within 72 h of admission. For children with RHs, an in-depth investigation was carried out to rule out AHT.

RESULTS

Thirty-four patients were included: 20(58.8 %) were boys, median age 11.7 months (range 1-33 months). Overall, 29(85.3 %) had clinical findings of increased ICP. The duration of symptoms was ≤4 days in all patients except one, in whom it was 1.5 months. The median OP was 27cmH2O (range 20-60cmH2O). One of the children was found to have RHs, with evaluation resulting in a diagnosis of AHT. No RHs were found in any of the others studied. Using the Wilson method, we can be confident to an upper limit of 95 % that the probability of RHs occurring secondary to increased ICP alone is at most 0.1.

CONCLUSIONS

RHs were not detected in patients with isolated nontraumatic increased ICP, measured via OP and diagnosed in the ED. Therefore, if RHs are detected, investigation into the possibility of AHT is warranted.

New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review

(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.

MR Protocols for Paediatric Neurosurgical Common Conditions: An Update Guide for Neurosurgeons

The biggest challenge for clinicians and surgeons when it comes to radiological examinations is the ability to request the right modalities and to understand the strengths and limitations of each modality. This is particularly important in paediatric neurosciences where despite magnetic resonance imaging (MRI) being the main imaging modality, there are several protocols, technical limitations of specific scanners and issues related to sedation that need to be taken into account. In this chapter, we describe a simple approach for six common neurosurgical conditions to guide the paediatric neurosurgeons in requesting the right MR protocol and understanding the rationale of it.Paediatric neuro-oncology, epilepsy and neck/skull base protocols are discussed elsewhere in this book and therefore will not be a focus in this chapter (Bernasconi et al., Epilepsia 60:1054-68, 2019; D'Arco et al., Neuroradiology 64:1081-100; 2022; Avula et al., Childs Nerv Syst 37:2497-508; 2021).

The eye in child abuse

Child physical abuse may result in a range of injuries to the globe and surrounding tissues. These injuries have varying degrees of specificity for abuse, and no pattern of injury is unique to abuse. Easily overlooked eye injuries in non-ambulatory infants often portend more severe abuse and require careful evaluation for occult injury when they are unexplained. Retinal hemorrhages are most often a sign of significant trauma and the severity of the hemorrhages generally parallels the severity of neurological trauma. Ophthalmologists contribute important data that more easily distinguish medical disease from trauma, but caution is needed in differentiating accidental from inflicted trauma. This distinction requires careful consideration of the complete clinical data and occasionally on additional law enforcement or child welfare investigation.

Nonaccidental trauma: bilateral corneal abrasions as only initial presentation

We report a case of nonaccidental trauma in a child who presented emergently with bilateral corneal abrasions of unclear etiology. It was later discovered that these lesions were actually caused by the newborn's father, who had forcefully pressed his thumbs against the child's orbits. Although uncommon, such types of anterior segment pathology should raise suspicion of nonaccidental trauma.

Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

BACKGROUND

Criteria for diagnosing abusive head trauma (AHT) or "shaken baby syndrome" are not well defined; consequently, these conditions might be diagnosed on failing premises.

METHODS

The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)-mean age 5.1 month, without age difference between genders.

RESULTS

Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH).

CONCLUSIONS

BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors' experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

Ophthalmological lesions in shaken baby syndrome: a retrospective analysis of 133 consecutive cases (1992-2018)

INTRODUCTION

Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data.

PATIENTS AND METHODS

This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992 - 2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded.

RESULTS

Mean age at diagnosis was 131 days (range, 14 days - 10 months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6 months: 80%.

CONCLUSION

This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.

Patterns of retinal hemorrhage associated with cardiac arrest and cardiopulmonary resuscitation

BACKGROUND

Hypoxia and cardiopulmonary resuscitation (CPR) have been proposed as causes of retinal hemorrhage (RH) in children evaluated for abusive head trauma (AHT). We sought to determine the prevalence and characteristics of RH in children who underwent CPR after cardiac arrest.

METHODS

This was a prospective, single-center, consecutive observational study of 38 children (<18 years of age). Indirect ophthalmoscopic examination was completed by an ophthalmologist within 48 hours of CPR. Extensive medical records data were collected to assess for potential confounding factors. Outcomes included the presence and pattern of RH.

RESULTS

Of the 38 children, 20 had in-hospital arrest; 18 had out-of-hospital arrest. The median duration of CPR was 10 minutes. Seven children had RH, of whom 6 had an RH pattern consistent with coexistent medical conditions: 4 AHT diagnosable with nonocular findings, including subdural and subarachnoid hemorrhage, rib fractures, abdominal injury (RH pattern: diffuse, numerous, intraretinal and/or multilayered RH); 1 septic shock (RH pattern: 1-2 posterior pole RH); 1 ruptured arteriovenous malformation (RH pattern: 4-8 peripapillary RH). The seventh child had unwitnessed cardiac arrest due to nonfatal drowning and a single superficial intraretinal peripapillary hemorrhage.

CONCLUSIONS

CPR for cardiac arrest is rarely associated with RH, which, absent coexisting conditions causing retinal hemorrhage, are intraretinal, few in number, and located in the posterior pole. In children who have undergone CPR, when RH are multilayered, or are more than a few in number, or extend outside the posterior pole, another etiology for the RH should be sought.

Unusual eye injury related to abusive head trauma

Ophthalmological examination is an essential component in clinically diagnosing abusive head trauma (AHT). Typical of AHT injuries is retinal bleeding, with other parts of the eye sometimes also being affected. Visual impairment and blindness are long-term complications in this context. We present a case with unusual eye injuries after a diagnostically confirmed AHT.

The ophthalmological findings on admission day showed a massive subhyaloid hemorrhage at the posterior pole and extensive flame-shaped intraretinal hemorrhages accented on the right side., A centrally localized vitreous hemorrhage appeared on both sides 3 weeks later, obscuring the optic disc and macula most probably due to a breakthrough of a sub-internal limiting membrane (ILM) hemorrhage into the vitreous cavity. Follow-up 4 weeks later revealed a dense and organized vitreous hemorrhage occupying the optic disc and macula so that a pars plana vitrectomy was performed on both eyes.

The bilateral bleeding in different retinal layers, the vitreous hemorrhage and the proliferative vitreoretinal reaction (PVR) indicated massive damage caused by a significant acceleration-deceleration trauma. A two-phase vitreous hemorrhage in a child with AHT does not yet appear to have been described in the literature.

The Eye in Forensic Medicine: A Narrative Review

ABSTRACT

The eye, with its distinctive anatomy, not only reflects a wide variety of diseases in life but also undergoes a myriad of post-mortem changes. Consequently, the eye has long been an area of interest in forensic science, primarily for the estimation of post-mortem interval and therefore the time of death and also for assistance in ascertaining the cause of death. There has been significant progress in the knowledge of ophthalmic forensic science using new technologies which have allowed further possibilities to arise where understanding of this field can assist the forensic pathologist. This review aims to highlight the current knowledge which exists in this field and also to identify important avenues for further investigation. Post-mortem changes of the eye along with its current applications and challenges will be discussed. These include the important areas of post-mortem iris biometrics, pupil size correlation with post-mortem interval, use of point-of-care technology on vitreous humor, and the use of ophthalmic imaging in pediatric abusive head trauma.

Catching the red eye: A retrospective review of factors associated with retinal hemorrhage in child physical abuse

BACKGROUND/PURPOSE

Accurate identification of child physical abuse is crucial during the evaluation of injured children. Retinal hemorrhages (RH) are used for diagnosis, but clear criteria for screening with direct fundoscopic exam are lacking. We sought to identify key factors associated with RH to guide evaluations.

METHODS

Electronic medical records for patients <1 year of age presenting to a Level I Pediatric Trauma Center with unwitnessed head injury from January 2015 to December 2018 were retrospectively reviewed. Multivariable logistic regression was used to identify factors associated with RH.

RESULTS

Two hundred and seventy-six patients were included; 63% underwent direct fundoscopic examination, of which 23% were positive and 77% were negative for RH. Unscreened patients tended to be older and have isolated skull fractures. Multivariable regression analysis revealed that abnormal GCS and subdural hemorrhage were positively associated with a diagnosis of retinal hemorrhage, while isolated skull fracture was negatively associated.

CONCLUSIONS

Children under 1 year of age with subdural hemorrhage have a greater risk of associated RH and should undergo routine screening with direct fundoscopic examination. Conversely, those with isolated skull fractures may not require an ophthalmology consultation. Standardized screening protocols may help reduce the risk of missing child physical abuse.

LEVEL OF EVIDENCE

III (Diagnostic Test).

Neuroimaging of retinal hemorrhage utilizing adjunct orbital susceptibility-weighted imaging

Retinal hemorrhages are an integral part of the evaluation of abusive head trauma (AHT). Timely detection of retinal hemorrhage not only facilitates the diagnosis of AHT, but has the potential to prevent further abuse to the child and the siblings and to identify the abuser. The gold standard for diagnosing retinal hemorrhage is a dilated fundoscopy exam, which requires pharmacological dilation. As such, there is a small percentage of patients for whom the dilated fundoscopy exam might be delayed. Evolving literature suggests that MRI, specifically susceptibility-weighted imaging (SWI), of the orbits might provide an alternative diagnostic tool for noninvasively detecting retinal hemorrhages, particularly when there is a delay in administering the dilated fundoscopy exam. In this paper we review the utility of SWI for detecting retinal hemorrhages in abusive head trauma, including discussion of diagnostic limitations and future research.

Charting the Globe: How Technologies Have Affected Our Understanding of Retinal Findings in Abusive Head Trauma/Shaken Baby Syndrome

Purpose: Ocular findings such as retinal hemorrhages are common in abusive head trauma (AHT). Binocular indirect ophthalmoscopy has been the standard for assessing the eyes of children who are victims of AHT. However, technological advances have changed our understanding of retinal findings in AHT.Methods: Literature review on AHT - retinal findings, imaging technologies, models of representation, and telemedicine applications.Results: Many studies suggest vitreoretinal traction from repetitive acceleration-deceleration shearing forces during shaking plays an important role in the development of retinal findings in AHT. This is further supported by different imaging modalities [optical coherence tomography (OCT); magnetic resonance imaging (MRI); fluorescein angiography (FA)] and models of representation (animal and mechanical models; finite element analysis).Conclusion: Emerging technologies have augmented our diagnostic abilities, enhanced our understanding regarding the pathophysiology of retinal findings, and strengthened the link between vitreoretinal traction and ocular pathology in AHT. Telemedicine is also starting to play an important role in AHT.

Timely recognition of retinal hemorrhage in pediatric abusive head trauma evaluation

BACKGROUND

Distinct patterns of retinal hemorrhages (RHs) are suggestive of abusive head trauma in the context of unexplained intracranial injury. Current recommendations encourage an eye examination within 48 hours of admission due to the rapid resolution of RH. The purpose of this study was to identify clinical factors associated with a delay in funduscopic examination outside the recommended 48 hours.

METHODS

Retrospective chart review was completed on all inpatient consultations by the Child Protection Team with evidence of intracranial injury on computed tomography or magnetic resonance imaging over 3 years at a large children's hospital. Extracted data included demographic characteristics, history of intubation, pediatric intensive care unit (PICU) admission, extraventricular drain placement, seizures, use of vasopressor support, and presence of other injuries. Descriptive statistics were used to describe the patient population, clinical characteristics, and outcomes. Multivariate logistic regression was used to identify factors associated with delayed eye examinations.

RESULTS

A total of 203 patients met inclusion criteria. Of those, 39 (19.2%) had a delay in initial funduscopic examination. Multivariate analyses revealed that PICU admission, surgical intervention, and seizure activity were significant predictors of delayed examination after controlling for multiple clinical factors. Neurosurgical consultation was shown to be protective against a delayed examination.

CONCLUSIONS

Rapid resolution of RH may occur in child abuse. Prompt ophthalmology examinations and neurosurgery consultation when child abuse is suspected help avoid a delay in diagnosis.

Bilateral Parietal Skull Fractures in Infants Attributable to Accidental Falls

INTRODUCTION

Multiple skull fractures, including bilateral parietal skull fractures (BPSFs) in infants are considered to be suspicious for abusive head trauma (AHT). The aim of this report is to describe a series of BPSF cases in infants which occurred due to accidental falls.

METHODS

We searched our neuroradiology database for BPSF in infants (<1 year old) diagnosed between 2006 and 2019; we reviewed initial presentation, mechanisms of injury, clinical course, head imaging, skeletal survey X-rays, ophthalmology, social work and child abuse physicians (CAP) assessments, and long-term follow-up. "Confirmed accidental BPSF" were strictly defined as having negative skeletal survey and ophthalmology evaluation and a CAP conclusion of accidental injury.

RESULTS

Twelve cases of BPSF were found; 3 were confirmed to be accidental, with a mean age at presentation of 3 months. Two infants had single-impact falls, and 1 had a compression injury; all 3 had small intracranial hemorrhages. None had bruises or other injuries, and all remained clinically well. A literature search found 10 similar cases and further biomechanical evidence that these fractures can occur from accidental falls.

CONCLUSION

While AHT should be kept in the differential diagnosis whenever BPSFs are seen, these injuries can occur as a result of accidental falls.

Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination

Republished with written permission granted from the American Optometric Association, October 2, 2020.

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.

Ophthalmology referral as part of a multidisciplinary approach to suspected abusive head trauma

OBJECTIVE

To determine the use of ophthalmology consultation as part of investigation of children with suspected abusive head trauma (AHT).

METHODS

Retrospective chart review of children under age 3 years evaluated at McMaster Children's Hospital for suspected AHT from January 2011 to December 2017.

RESULTS

Fifty-seven children were investigated, and 29 (50.9%) of these were determined to have likely AHT. Eleven (19.3%) had other nonaccidental injuries. A mean of 3.6 consulting services were involved. Neuroimaging was performed for 52 patients (91.2%), including all patients in the AHT group. Intracranial hemorrhage (ICH) was present in 21 of the 29 AHT children (72.4%). All 57 patients had a dilated fundus examination, and retinal hemorrhages (RH) were seen in 23 patients (40.4%), including 16 (55.2%) in the AHT group. All patients with RH in AHT also had ICH. In the AHT group, there were more cases of hemorrhages too numerous to count (68.8% vs 28.6%), multilayered hemorrhages (75.0% vs 57.1%), and hemorrhages in the posterior pole and periphery (87.5% vs 42.9%) when compared with patients with RH from other etiologies. Retinoschisis was seen in the AHT group only in 3 patients (18.8%).

CONCLUSIONS

A multidisciplinary approach is important when investigating suspected AHT. Not every child with RH had suffered AHT; however, children with AHT showed more widespread and more multilayered RH. The only finding specific to AHT was retinoschisis.

Susceptibility-weighted imaging of retinal hemorrhages in abusive head trauma

BACKGROUND

Retinal hemorrhages are one of the most important supportive evidences for abusive head trauma (AHT). Susceptibility-weighted imaging (SWI) is highly suited to identify various forms of intracranial hemorrhage in AHT. However its utility in imaging retinal hemorrhage is not well established.

OBJECTIVE

SWI is a sensitive sequence for identifying retinal hemorrhage on MRI.

MATERIALS AND METHODS

In this retrospective analysis, 26 consecutive infants and young children with a suspected admission diagnosis of AHT underwent indirect ophthalmoscopy and brain MRI protocol for AHT along with SWI. Brain susceptibility-weighted images of 14 age-matched children were used as controls. For detecting retinal hemorrhage, susceptibility-weighted images of patients and controls were reviewed randomly and independently by two neuroradiologists who were blinded to the history and ophthalmology findings. A pediatric ophthalmologist graded the indirect ophthalmoscopy images.

RESULTS

A diagnosis of AHT was confirmed in all 26 cases from a multidisciplinary meeting. Indirect ophthalmoscopy images were available in 21 cases. Ophthalmoscopy was positive for retinal hemorrhage in the right eye in 18 cases (85.7%) and in the left eye in 16 cases (76.2%). On SWI, retinal hemorrhage was identified in the right eye in 9/21 cases (42.8%) and in the left eye in 8/21 cases (38.1%) of AHT. Analysis of SWI in 21 cases of AHT demonstrated a sensitivity of 50%, specificity of 100%, positive predictive value of 100% and negative predictive value of 32% for detecting retinal hemorrhage.

CONCLUSION

SWI is moderately sensitive and highly specific for identifying retinal hemorrhage in AHT. Further studies are needed to identify steps to improve the efficiency of SWI in detecting retinal hemorrhage.

Retinal Hemorrhages: Abusive Head Trauma or Not?

Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.

SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations

Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.

The Anesthesiologist's Role in Treating Abusive Head Trauma

Abusive head trauma (AHT) is the most common cause of severe traumatic brain injury (TBI) in infants and the leading cause of child abuse-related deaths. For reasons that remain unclear, mortality rates after moderate AHT rival those of severe nonintentional TBI. The vulnerability of the developing brain to injury may be partially responsible for the poor outcomes observed after AHT. AHT is mechanistically more complex than nonintentional TBI. The acute-on-chronic nature of the trauma along with synergistic injury mechanisms that include rapid rotation of the brain, diffuse axonal injury, blunt force trauma, and hypoxia-ischemia make AHT challenging to treat. The anesthesiologist must understand the complex injury mechanisms inherent to AHT, as well as the pediatric TBI treatment guidelines, to decrease the risk of persistent neurologic disability and death. In this review, we discuss the epidemiology of AHT, differences between AHT and nonintentional TBI, the severe pediatric TBI treatment guidelines in the context of AHT, anesthetic considerations, and ethical and legal reporting requirements.

Retinal haemorrhages in a university hospital: not always abusive head injury

Retinal haemorrhages (RH) and subdural haematomas (SDH) are frequently seen in abusive head trauma (AHT). The aim of our study is to show that they are suggestive, but not pathognomonic for AHT. We performed an observational retrospective study on children, aged 1-18 months old, admitted to the Antwerp University Hospital with RH. History, physical examination, medical course, coagulation and metabolic tests, skeletal survey, head circumference, retinal findings, cerebral imaging, and evaluation reports by social services or civil/criminal courts were collected. Twenty-nine children with RH were included. Twenty three of them were found suspect of AHT. Three children of this group showed intraparenchymal haematomas/infarctions, 5 interhemispheric blood, 6 cerebral oedema, 7 ventricle compression, and 4 papilloedema. Seven of the 16 children with diffusion-weighted MRI images showed diffuse lesions. In 2 of the 6 children not suspect for AHT, an aetiology was found. None of the 4 remaining children showed the above-mentioned abnormalities. Three of these 4 cases showed an accelerated growth of the head circumference months before presentation. The majority of the children in all groups showed 'too numerous to count' (>20) RH (12 of the 23 'suspect' children, and 4 of the 6 'non-suspect' children). Results showed no differences between the groups concerning the location, distribution, or size of the RH. Infants with RH and/or SDH are not necessarily victims of AHT. Cerebral imaging and retinal findings can help differentiate suspect from non-suspect cases. Infants with a large head circumference could be predisposed to RH or SDH.

Apparent Diffusion Coefficient (ADC) of the vitreous humor and Susceptibility Weighted Imaging (SWI) of the retina in abused children with retinal hemorrhages

This study speculated that the apparent diffusion coefficient (ADC) of the vitreous humor might be altered in the setting of abusive head trauma (AHT) with retinal hemorrhages (RH). Fourty-four subjects were analyzed (n=20 AHT cases; n=24 controls). There was no statistically significant difference in normalized ADC values between the cases and controls (-0.14 and -0.08 respectively, p=0.46), but analysis of RH by susceptibility weighted imaging (SWI) compared to dilated funduscopic exam demonstrated statistically significant correlation (p=0.003 and 0.012). Our results suggest that SWI serves as a more sensitive diagnostic tool for detection of ocular injury in AHT than ADC.

Patterns of retinal hemorrhage associated with pediatric cerebral sinovenous thrombosis

BACKGROUND

Cerebral sinovenous thrombosis (CSVT) has been proposed as an alternative cause of retinal hemorrhage (RH) in children being evaluated for abusive head trauma. This study investigated the prevalence and characteristics of RH in children with CSVT.

METHODS

The medical records of children >6 weeks of age with newly diagnosed CSVT and fundus examination by an ophthalmologist were examined retrospectively. Primary outcomes were presence and patterns of RH.

RESULTS

A total of 29 children (median age, 9 years; range, 7 weeks to 17 years) were studied. Of these, 5 (17%) had RH, in 4 of whom RH were peripapillary, superficial, intraretinal, and adjacent to a swollen optic disk. In the fifth child, who had meningitis, sepsis, and multiple cerebral infarcts, there were a moderate number of posterior pole intraretinal hemorrhages. Eighteen children (62%) had optic disk swelling. In 13 children, cerebrospinal fluid opening pressure was recorded (range, 27-59 cm H₂O). CSVT risk factors included meningitis, mastoiditis, and hypercoagulability.

CONCLUSIONS

RH in pediatric CSVT was uncommon. When RHs were present, the appearance matched RH patterns known to be caused by medical conditions, such as raised intracranial pressure and sepsis, also present in these children. These findings suggest that the RHs are due to these other causes and not directly to CSVT itself. In children with CSVT, if RHs are multilayered, extend beyond the peripapillary region into the rest of the posterior pole or retinal periphery, or occur in the absence of optic disk swelling, another etiology for the RH should be sought.

Deaths Due to Child Abuse: A 6-Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.

Imaging of Abusive Trauma

"Shaken baby syndrome" is a term often used by the physicians and public to describe abusive trauma inflicted on infants and young children. Advances in the understanding of the mechanisms and the associated clinical spectrum of injury has lead us to modify our terminology and address it as "abusive trauma" (AT). Pediatric abusive head trauma is defined as an injury to the skull or intracranial contents of an infant or a young child (< 5 y age) due to inflicted blunt impact and/or violent shaking. This chapter focuses on the imaging aspects of childhood abusive trauma along with a brief description of the mechanism and pathophysiology of abusive injury. The diagnosis of AT is not always obvious, and abusive injuries in many infants may remain unrecognized. Pediatricians should be cognizant of AT since pediatricians play a crucial role in the diagnosis, management and prevention of AT.

Diffuse bilateral retinal hemorrhages in an infant with a coagulopathy and prolonged cardiopulmonary resuscitation

We report a case of diffuse bilateral retinal and optic nerve sheath hemorrhages in an 8-week-old boy who was found unresponsive. The child underwent prolonged cardiopulmonary resuscitation and was noted on admission to have a coagulopathy. An autopsy determined the cause of death to be a myocardial infarct in the distribution of an anomalous coronary artery. This case demonstrates the difficulty that may occur in establishing whether child abuse caused death in the setting of another potential cause of mortality.

Venous injury in abusive head trauma

BACKGROUND

Abusive head trauma (AHT) is an important cause of serious brain injury in infants and young children who have characteristic clinical and imaging findings that are discordant with the clinical history provided. Recent attention has focused on abnormalities of the cranial venous sinuses and cortical veins, both on MRI and at autopsy. Although many have interpreted these to be secondary to the AHT, some have recently argued that these venous abnormalities represent primary cortical sinus and venous thrombosis that leads secondarily to subdural hemorrhage and secondary brain injury. Direct trauma to the veins and sinuses has been reported at autopsy in AHT, but there has been no systematic study of venous abnormalities in cases of AHT.

OBJECTIVE

The purpose of this study was to define the incidence and characteristics of venous and sinus abnormalities in AHT.

MATERIALS AND METHODS

We included all children <36 months of age who were diagnosed with abusive head trauma between 2001 and 2012 and who had MRI and magnetic resonance (MR) venography as part of their diagnostic workup. We analyzed age, gender and clinical findings. MRI and MR venography were analyzed independently by two neuroradiologists with a focus on abnormalities involving the intracranial veins and venous sinuses.

RESULTS

A total of 45 children were included. The median age was 3 months (range 15 days to 31 months) and 28 were boys (62%). Clinical findings included retinal hemorrhage in 71% and extracranial fractures in 55%. CT or MRI demonstrated subdural hemorrhage in 41 (91%); none had subdural effusions. In 31 cases (69%) MR venography demonstrated mass effect on the venous sinuses or cortical draining veins, with either displacement or partial or complete effacement of the venous structures from an adjacent subdural hematoma or brain swelling. We also describe the lollipop sign, which represents direct trauma to the cortical bridging veins and was present in 20/45 (44%) children.

CONCLUSION

Evidence of displacement or compression of cortical veins and sinuses from subdural hemorrhage or edema on MR venography was present in the majority of children with abusive head trauma. Evidence of direct trauma to the veins (lollipop sign) was identified in nearly half of cases. It is important to understand the superimposed effects of subdural hematoma and brain swelling on the veins and sinuses to differentiate it from cortical sinus and venous thrombosis.

Update on abusive head trauma

PURPOSES OF REVIEW

This article provides an update on abusive head trauma (AHT), focusing on new developments most salient to the emergency medicine clinician, including epidemiology, clinical recognition, diagnostic work-up, management of neurologic injury, and public health implications.

RECENT FINDINGS

The recent literature has focused on honing the clinician's ability to recognize AHT and its immediate sequelae, to more accurately distinguish between abusive and accidental head injuries by patterns of neuroimaging and retinal hemorrhages, and to appreciate the long-term impacts. Specifically, both a clinical prediction rule and biomarker show promise, and new research advocates for the early identification of subclinical seizures as well as cervical spine injuries.

SUMMARY

The emergency medicine provider must be able to recognize and manage children who may have AHT and to appreciate when the diagnostic findings warrant consultation with a child protection team. These authors summarize the recent and notable advances in our understanding of AHT.