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Semenova ZB, Mamatkulov AZ, Erofeev EV, Dmitrienko DM, Melnikov IA, Nalbandyan RT, Zaitseva ES. [Brain injury following child maltreatment syndrome in newborns and young children. Shaken baby syndrome]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:5-12. [PMID: 39169576 DOI: 10.17116/neiro2024880415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
BACKGROUND Shaken baby syndrome is widely discussed in the literature. This syndrome is considered as a variant of child maltreatment syndrome. In the English-language literature, there are data on high incidence of this syndrome and difficult diagnosis. There are no such diagnosis in the Russian and reports devoted to this issue. OBJECTIVE To assess the incidence and nature of injuries following child maltreatment/shaken baby syndrome in infants and young children. MATERIAL AND METHODS We analyzed case records of 3668 patients aged 1-36 month between 2017 and 2021 with injury/suspected traumatic brain injury (TBI). Mild TBI was in 47.2% of patients, moderate and severe - in 56.8% of patients. Twenty-eight children admitted with GCS score 3-8. CT was performed in case of risk factors for intracranial injuries (1703 patients). Abnormalities were found in 71.6% of cases. Sixty-four children required surgical treatment. Overall mortality rate was 0.7%. RESULTS Accidental trauma was found in 3664 cases. We verified child maltreatment/shaken baby syndrome in only 4 (0.1%) cases. At the alleged moment of injury, there were male persons (cohabitant or guardian) with the child that is consistent with literature data. In all 4 cases, we observed severe combined TBI. In one case, brain damage was regarded as a result of chronic trauma. Indeed, MRI diagnosed thrombosis of bridging veins along convexital parts of the frontal, parietal and occipital lobes. There were GOS grade I in 2 patients (death), grade III in 1 patient (severe disability) and grade IV in 1 patient (recovery). CONCLUSION Child maltreatment/shaken baby syndrome is less common among infants and young children in the Russian Federation. This may be due to national, cultural and religious traditions. Indeed, infants and children under 3 years of age are cared for by female persons. The mechanism of injury (shaking) leads to typical multiple injuries involving various organs and systems. These damages require multidisciplinary approach to diagnosis and treatment. MRI-confirmed thrombosis of bridging veins may be an additional diagnostic sign indicating the mechanism of injury.
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Affiliation(s)
- Zh B Semenova
- Research Institute for Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - A Z Mamatkulov
- Research Institute for Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - E V Erofeev
- Research Institute for Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - D M Dmitrienko
- Research Institute for Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - I A Melnikov
- Research Institute for Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - R T Nalbandyan
- Research Institute for Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - E S Zaitseva
- Research Institute for Emergency Pediatric Surgery and Traumatology, Moscow, Russia
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Curcoy AI, Serra A, Morales M, Luaces C, Trenchs V. Retinal hemorrhages due to intracranial hypertension, is it possible to differentiate them from those associated with abuse? CHILD ABUSE & NEGLECT 2023; 144:106387. [PMID: 37549636 DOI: 10.1016/j.chiabu.2023.106387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
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.
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Affiliation(s)
- Ana I Curcoy
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Alicia Serra
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Marta Morales
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Carles Luaces
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Victoria Trenchs
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain.
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Metcalf RM, Comstock JM, Coats B. High-Rate Anisotropic Properties in Human Infant Parietal and Occipital Bone. J Biomech Eng 2021; 143:061010. [PMID: 33564856 DOI: 10.1115/1.4050127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Indexed: 11/08/2022]
Abstract
Computational models of infant head impact are limited by the paucity of infant cranial bone material property data, particularly with regard to the anisotropic relationships created by the trabecular fibers in infant bone. We previously reported high-rate material property data for human infant cranial bone tested perpendicular to trabeculae fiber orientation. In this study, we measure the anisotropic properties of human infant cranial bone by analyzing bending modulus parallel to the trabeculae fibers. We tested human bone specimens from nine donors ranging in age from 32 weeks gestational age to 10 months at strain rates of 12.3-30.1 s-1. Bending modulus significantly increased with donor age (p=0.008) and was 13.4 times greater along the fiber direction compared to perpendicular to the fibers. Ultimate stress was greater by 5.1 times when tested parallel to the fibers compared to perpendicular (p=0.067). Parietal bone had a higher modulus and ultimate stress compared to occipital bone, but this trend was not significant, as previously shown perpendicular to fiber orientation. Combined, these data suggest that the pediatric skull is highly age-dependent, anisotropic, and regionally dependent. The incorporation of these characteristics in finite element models of infant head impact will be necessary to advance pediatric head injury research and further our understanding of the mechanisms of head injury in children.
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Affiliation(s)
- Robert M Metcalf
- Department of Mechanical Engineering, University of Utah, 1495 E 100 S (1550 MEK), Salt Lake City, UT 84112
| | - Jessica M Comstock
- Pediatric Pathology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah 84112
| | - Brittany Coats
- Department of Mechanical Engineering, University of Utah, 1495 E 100 S (1550 MEK), Salt Lake City, UT 84112
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Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018; 48:1048-1065. [PMID: 29796797 DOI: 10.1007/s00247-018-4149-1] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/22/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
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Affiliation(s)
- Arabinda Kumar Choudhary
- Department of Radiology, Nemours AI duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas L Slovis
- Department of Radiology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Gary L Hedlund
- Department of Medical Imaging, Primary Children's Hospital, Intermountain Healthcare, Department of Radiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sandeep K Narang
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Cindy W Christian
- Department of Pediatrics, Child Abuse and Neglect Prevention, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Marvin D Nelson
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - Susan Palasis
- Pediatric Neuroradiology, Children's Healthcare of Atlanta, Scottish Rite Campus, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Andrea Rossi
- Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Amaka C Offiah
- Paediatric Musculoskeletal Imaging, Academic Unit of Child Health, Sheffield Children's NHS Foundation Trust, Western Bank, University of Sheffield, Sheffield, UK
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Fingarson AK, Ryan ME, McLone SG, Bregman C, Flaherty EG. Enlarged subarachnoid spaces and intracranial hemorrhage in children with accidental head trauma. J Neurosurg Pediatr 2017; 19:254-258. [PMID: 27885942 DOI: 10.3171/2016.8.peds16146] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Benign external hydrocephalus (BEH) is an enlargement of the subarachnoid spaces (SASs) that can be seen in young children. It is controversial whether children with BEH are predisposed to developing subdural hemorrhage (SDH) with or without trauma. This issue is clinically relevant as a finding of unexplained SDH raises concerns about child abuse and often prompts child protection and law enforcement investigations. METHODS This retrospective study included children (1-24 months of age) who underwent head CT scanning after an accidental fall of less than 6 feet. Head CT scans were reviewed, cranial findings were documented, and the SAS was measured and qualitatively evaluated. Enlarged SAS was defined as an extraaxial space (EAS) greater than 4 mm on CT scans. Clinical measurements of head circumference (HC) were noted, and the head circumference percentile was calculated. The relationship between enlarged SAS and HC percentile, and enlarged SAS and intracranial hemorrhage (ICH), were investigated using bivariate analysis. RESULTS Of the 110 children included in this sample, 23 had EASs greater than 4 mm. The mean patient age was 6.8 months (median 6.0 months). Thirty-four patients (30.9%) had ICHs, including subarachnoid/subpial (6.2%), subdural (6.2%), epidural (5.0%), and unspecified extraaxial hemorrhage (16.5%). Enlarged SAS was positively associated with subarachnoid/subpial hemorrhage; there was no association between enlarged SASs and either SDH or epidural hemorrhage. A larger SAS was positively associated with larger HC percentile; however, HC percentile was not independently associated with ICH. CONCLUSIONS Enlarged SAS was not associated with SDH, but was associated with other ICHs. The authors' findings do not support the theory that BEH predisposes children to SDH with minor accidental trauma.
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Affiliation(s)
| | - Maura E Ryan
- Medical Imaging, Division of Neuroradiology; and
| | - Suzanne G McLone
- Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | | | - Emalee G Flaherty
- Departments of 1 Pediatrics, Division of Child Abuse Pediatrics, and
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Coats B, Binenbaum G, Smith C, Peiffer RL, Christian CW, Duhaime AC, Margulies SS. Cyclic Head Rotations Produce Modest Brain Injury in Infant Piglets. J Neurotrauma 2016; 34:235-247. [PMID: 26953505 DOI: 10.1089/neu.2015.4352] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Repetitive back-and-forth head rotation from vigorous shaking is purported to be a central mechanism responsible for diffuse white matter injury, subdural hemorrhage, and retinal hemorrhage in some cases of abusive head trauma (AHT) in young children. Although animal studies have identified mechanisms of traumatic brain injury (TBI) associated with single rapid head acceleration-decelerations at levels experienced in a motor vehicle crash, few experimental studies have investigated TBI from repetitive head rotations. The objective of this study was to systematically investigate the post-injury pathological time-course after cyclic, low-velocity head rotations in the piglet and compare them with single head rotations. Injury metrics were the occurrence and extent of axonal injury (AI), extra-axial hemorrhage (EAH), red cell neuronal/axonal change (RCNAC), and ocular injury (OI). Hyperflexion/extension of the neck were purposefully avoided in the study, resulting in unscaled angular accelerations at the lower end of reported infant surrogate shaking kinematics. All findings were at the mild end of the injury spectrum, with no significant findings at 6 h post-injury. Cyclic head rotations, however, produced modest AI that significantly increased with time post-injury (p < 0.035) and had significantly greater amounts of RCNAC and EAH than noncyclic head rotations after 24 h post-injury (p < 0.05). No OI was observed. Future studies should investigate the contributions of additional physiological and mechanical features associated with AHT (e.g., hyperflexion/extension, increased intracranial pressure from crying or thoracic compression, and more than two cyclic episodes) to enhance our understanding of the causality between proposed mechanistic factors and AHT in infants.
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Affiliation(s)
- Brittany Coats
- 1 Department of Mechanical Engineering, University of Utah , Salt Lake City, Utah
| | - Gil Binenbaum
- 2 Department of Ophthalmology, Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.,3 Department of Ophthalmology, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Colin Smith
- 4 Department Pathology, Edinburgh University , Edinburgh, Scotland
| | - Robert L Peiffer
- 3 Department of Ophthalmology, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Cindy W Christian
- 5 Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Ann-Christine Duhaime
- 6 Department of Neurosurgery, Massachusetts General Hospital and Harvard University , Boston, Massachusetts
| | - Susan S Margulies
- 7 Department of Bioengineering, University of Pennsylvania , Philadelphia, Pennsylvania
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Scheller J, Huisman TAGM. Moderate Bilateral Retinal Hemorrhages in an Infant Following a Short Fall. Clin Pediatr (Phila) 2015; 54:999-1002. [PMID: 25316220 DOI: 10.1177/0009922814554501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Joseph Scheller
- Johns Hopkins Hospital, Department of Radiology, Baltimore, MD, USA
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Diagnosing abusive head trauma: the challenges faced by clinicians. Pediatr Radiol 2014; 44 Suppl 4:S537-42. [PMID: 25501724 DOI: 10.1007/s00247-014-3074-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 05/28/2014] [Indexed: 10/24/2022]
Abstract
This article highlights five important aspects of the clinical problem of evaluating young children who are suspected of having abusive head trauma: 1) the clinical questions to be addressed, 2) challenges when evaluating young children with suspected abuse, 3) key aspects of clinical practice and data collection, 4) a framework for decision-making and 5) key articles in the literature that can help inform a sound clinical decision about the likelihood of abuse.
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Yamazaki J, Yoshida M, Mizunuma H. Experimental analyses of the retinal and subretinal haemorrhages accompanied by shaken baby syndrome/abusive head trauma using a dummy doll. Injury 2014; 45:1196-206. [PMID: 24810668 DOI: 10.1016/j.injury.2014.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/11/2014] [Accepted: 04/05/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We explored several modes of violent shaking using a dummy doll with an eyeball model to reproduce abusive events that lead to retinal haemorrhages (RH) seen in shaken baby syndrome or abusive head trauma (SBS/AHT). MATERIALS AND METHODS A dummy doll equipped with an eyeball model was prepared. The eyeball model was filled with a model of vitreous body, i.e. agar gel or water, and was with a pressure sensor to measure normal stress. RESULTS The modes of shaking were classified into three patterns, i.e. fast shaking with the fore arms, fast shaking with the whole arms and synchronized shaking with the whole arms. The frequency of the cyclic acceleration-deceleration history experienced by the head of the dummy doll was 5.0, 4.0 and 2.2 Hz, respectively, with the maximum acceleration of 20, 20 and 60 m/s(2), respectively. We considered the last of these three modes of shaking as possibly corresponding to the worst case of violent shaking. This mode of shaking could be instructed to volunteers who acted as imitate perpetrators, and resulted in both increased peak intensities of the acceleration experienced by the head of the dummy doll and increased stresses on the retina at the posterior pole of the eyeball model. DISCUSSION The time integral of the stress through a single cycle of shaking was 107 Pa·s, much larger than that of a single event of fall, which resulted in 60-73 Pa·s. Taking into account that abusive shaking is likely to include multiple cycles, the time integral of the stress due to abusive shaking can be even larger. This clear difference may explain why RH in SBS/AHT is frequent, while RH in accidental falls is rare.
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Affiliation(s)
- Junpei Yamazaki
- Department of Mechanical Engineering, Tokyo Metropolitan University, 1-1 Minami-Osawa, Hachioji, Tokyo 192-0397, Japan.
| | - Makoto Yoshida
- Department of Mechanical Engineering, Tokyo Metropolitan University, 1-1 Minami-Osawa, Hachioji, Tokyo 192-0397, Japan.
| | - Hiroshi Mizunuma
- Department of Mechanical Engineering, Tokyo Metropolitan University, 1-1 Minami-Osawa, Hachioji, Tokyo 192-0397, Japan.
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Melo JRT, Di Rocco F, Bourgeois M, Puget S, Blauwblomme T, Sainte-Rose C, Meyer PG, Zerah M. Surgical options for treatment of traumatic subdural hematomas in children younger than 2 years of age. J Neurosurg Pediatr 2014; 13:456-61. [PMID: 24559279 DOI: 10.3171/2014.1.peds13393] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Subdural hematoma (SDH) is the most common finding on cranial CT in pediatric victims of abusive head trauma (AHT). The hematomas are commonly bilateral and sometimes associated with interhemispheric hyperdensity and/or convexity hemorrhages. There is no consensus regarding the best surgical treatment in such cases nor are there standardized surgical protocols. The authors report their experience and discuss the routine surgical options in the management of traumatic SDH at a Level 1 Pediatric Trauma Center. METHODS In this paper, the authors describe a cross-sectional study with consecutive revision of data described in the medical records of Hôpital Universitaire Necker-Enfants Malades between January 2008 and January 2013. During this period, all children younger than 2 years of age who were admitted with a traumatic SDH identified on CT scans were included in this study. RESULTS One hundred eighty-four children who had SDH and were younger than 2 years of age were included. Their median age was 5.8 months (range 5 days-23 months), and 70% of the children were male. On admission CT scans, the SDH was bilateral in 52% of cases and homogeneously hypodense in 77%. Neurosurgical treatment was undertaken in 111 children (60%) with an admission Glasgow Coma Scale score of 12 or less, bulging fontanels, or other signs suggestive of intracranial hypertension. The first surgical option was craniotomy in 1.8% (2) of these 111 cases, decompressive craniectomy in 1.8% (2), transcutaneous subdural puncture in 15% (17), external subdural drainage in 16% (18), subdural-subgaleal shunt placement in 17% (19), and subdural-peritoneal shunt placement in 48% (53). In 82% of the children initially treated with transcutaneous subdural puncture and in 50% of those treated with external subdural drainage, increase or persistence of the SDH, CSF or skin infection, or shunt system malfunction was observed and further surgical intervention was required. There was a 26% rate of complications in patients initially treated with a subdural-peritoneal shunt. Although 52% of the patients had bilateral SDH, bilateral drainage was only required in 9.4%. CONCLUSIONS The choice of treatment should be determined by the clinical and radiological characteristics of the individual case. Although effective on an emergency basis, subdural puncture and external subdural drainage are frequently insufficient to obtain complete resolution of SDH, and temporary placement of a subdural-peritoneal shunt is needed in most cases.
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Minns RA, Jones PA, Tandon A, Fleck BW, Mulvihill AO, Elton RA. Prediction of inflicted brain injury in infants and children using retinal imaging. Pediatrics 2012; 130:e1227-34. [PMID: 23045566 DOI: 10.1542/peds.2011-3274] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Retinal hemorrhages (RHs) occur in inflicted traumatic brain injury (ITBI), accidental traumatic brain injury (ATBI), and some medical conditions, although the reported number, distribution, type, and frequency vary greatly between these different etiologies. We hypothesize that these RH characteristics reliably help to distinguish ITBI from ATBI and nontraumatic etiologies. METHODS A 6-year prospective observational study using wide-field retinal imaging (RetCam) was conducted within 24 hours of admission to PICU, on serially recruited children with traumatic and nontraumatic encephalopathies. "Definite" and "probable" ITBI cases were confirmed by multiagency child protection case conferences. Image analysis used digital color and grayscale images for retinal "zoning" and "layering" of hemorrhages. RESULTS Significant differences were found between the mean numbers of hemorrhages in ATBI/ITBI, and ITBI/nontraumatic etiologies for the 3 retinal zones (range, P = .003-.009) and for the dot-blot hemorrhages (range P = .001-.002). The mean numbers of RHs per ITBI patient in the peripapillary, macula, and peripheral zones were 14, 28, and 31 respectively. RHs in ATBI were near the optic disc and more superficial than in ITBI, where hemorrhages involved deeper layers (range, P = .003-.039) and were more peripheral (P = .03). The positive predictive value for ITBI in children <3 years with >25 dot-blot (intraretinal) hemorrhages was 93%. CONCLUSIONS This prospective study, which included all potential causes of RHs, with objective retinal methodology, has confirmed that a young age and a high dot-blot count are strong predictors of ITBI. This high predictive value may support medicolegal deliberations.
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Affiliation(s)
- Robert A Minns
- Department of Child Life and Health, Princess Alexandra Eye Pavilion, Royal Hospital for Sick Children Edinburgh, Edinburgh, Scotland.
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Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond) 2012; 27:28-36. [PMID: 23079748 DOI: 10.1038/eye.2012.213] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
AIM To report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT). METHODS A systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT. RESULTS Of the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined. CONCLUSIONS Our systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.
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Laurent-Vannier A, Nathanson M, Quiriau F, Briand-Huchet E, Cook J, Billette de Villemeur T, Chazal J, Christophe C, Defoort-Dhellemmes S, Fortin G, Rambaud C, Raul JS, Rey-Salmon C, Sottet F, Vieux E, Vinchon M, Willinger R. A public hearing. "Shaken baby syndrome: guidelines on establishing a robust diagnosis and the procedures to be adopted by healthcare and social services staff". Scoping report. Ann Phys Rehabil Med 2011; 54:533-99. [PMID: 22118913 DOI: 10.1016/j.rehab.2011.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Laurent-Vannier
- Service de rééducation des pathologies neurologiques acquises de l'enfant, hôpitaux de Saint-Maurice, 14, rue du Val-d'Osne, 94415 Saint-Maurice cedex, France.
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Lantz PE, Couture DE. Fatal Acute Intracranial Injury, Subdural Hematoma, and Retinal Hemorrhages Caused by Stairway Fall*. J Forensic Sci 2011; 56:1648-53. [DOI: 10.1111/j.1556-4029.2011.01892.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Patrick E. Lantz
- Department of Pathology, Wake Forest University School of Medicine, Medical Center Blvd., Winston‐Salem, NC 27157
| | - Daniel E. Couture
- Department of Neurosurgery, Wake Forest University School of Medicine, Medical Center Blvd., Winston‐Salem, NC 27157
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Thackeray JD, Scribano PV, Lindberg DM. Yield of retinal examination in suspected physical abuse with normal neuroimaging. Pediatrics 2010; 125:e1066-71. [PMID: 20385633 DOI: 10.1542/peds.2009-2184] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In some centers, dedicated ophthalmologic examination is performed for all children who are evaluated for potential physical abuse. Although retinal hemorrhages have been reported in rare cases of abused children with normal neuroimaging results, the utility of ophthalmologic examination in this group is currently unknown. The objective of this study was to determine the prevalence of retinal hemorrhages in children younger than 2 years who were evaluated for physical abuse and who had no evidence of traumatic brain injury (TBI) on neuroimaging. PATIENTS AND METHODS We performed retrospective analysis of data obtained from 1676 children younger than 5 years who were evaluated for potential physical abuse as a part of the Using Liver Transaminases to Recognize Abuse research network. We reviewed results of dedicated ophthalmologic examination in all children younger than 2 years with no evidence of TBI on neuroimaging. RESULTS Among 282 children who met inclusion criteria, only 2 (0.7% [95% confidence interval: 0.1%-2.5%]) had retinal hemorrhages considered "characteristic" of abuse. Seven other children (2.5% [95% confidence interval: 1.0%-5.1%]) had a nonspecific pattern of retinal hemorrhages. Both children with characteristic retinal hemorrhages in the absence of TBI showed evidence of head or facial injury on physical examination and/or altered mental status. CONCLUSIONS In children younger than 2 years being evaluated for physical abuse without radiographic evidence of brain injury, retinal hemorrhages are rare. Dedicated ophthalmologic examination should not be considered mandatory in this population.
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Affiliation(s)
- Jonathan D Thackeray
- Center for Child and Family Advocacy, Nationwide Children's Hospital, Columbus, OH 43205, USA.
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Coats B, Binenbaum G, Peiffer RL, Forbes BJ, Margulies SS. Ocular hemorrhages in neonatal porcine eyes from single, rapid rotational events. Invest Ophthalmol Vis Sci 2010; 51:4792-7. [PMID: 20435592 DOI: 10.1167/iovs.10-5211] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To characterize ocular hemorrhages from single, rapid head rotations in the neonatal pig. METHODS Three- to 5-day-old anesthetized piglets (n=51) underwent a single, rapid (117-266 rad/s) head rotation in the sagittal (n=13), coronal (n=7), or axial (n=31) planes. Six hours after injury, the animals were euthanatized and perfusion fixed, and the brain and eyes were harvested for gross and histopathologic examination by masked neuro- and ocular pathologists. RESULTS Ocular hemorrhage was found in 73% of animals (51% bilateral). Intraocular hemorrhage was primarily located near the vitreous base (70% of injured animals had ciliary body hemorrhage, and 11% had peripheral retinal hemorrhage). Hemorrhages were also found in the anterior chamber (11%), vitreous (5%), and optic nerve (disc, 8%; nerve sheath, 57%). Rapid axial head rotations resulted in a higher incidence of intraocular hemorrhage than coronal or sagittal head rotations, but the difference did not reach statistical significance (P=0.06). Control eyes had no injuries. CONCLUSIONS Optic nerve sheath and ciliary body hemorrhages were common in piglets that experienced a single, rapid head rotation. Retinal hemorrhage was present in a smaller number of animals. Most intraocular hemorrhages were located in regions of strong vitreous attachment, suggesting that this animal model will be useful in investigating the effect of vitreoretinal adhesion on ocular hemorrhage caused by inertial head rotations. Extrapolation of this model to the human infant should not be made until the effect of anatomic differences between the human and pig on the occurrence and patterns of ocular injuries is further investigated.
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Affiliation(s)
- Brittany Coats
- Department of Bioengineering, Scheie Eye Institute, University of Pennsylvania, and Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Aslam T, Chua P, Richardson M, Patel P, Musadiq M. A system for computerised retinal haemorrhage analysis. BMC Res Notes 2009; 2:196. [PMID: 19785742 PMCID: PMC2760568 DOI: 10.1186/1756-0500-2-196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Accepted: 09/28/2009] [Indexed: 12/04/2022] Open
Abstract
Background Our aim was to develop an objective computerised system for measuring different types of retinal haemorrhages in differing digital images, for use as a research tool. Despite developing various fully automated systems of retinal haemorrhage measurement we ultimately found user interaction to be necessary to achieve satisfactory validity of segmentation, and developed an interactive system of haemorrhage assessment based on this. Findings The Haemorrhage Assessment System (HAS) presented here is an open access interactive program with graphical user interface allowing the ophthalmically trained user to easily delineate different haemorrhage types, optic disc and fovea. The system then automatically calculates a variety of measures, including mean haemorrhage area, total haemorrhage area, centre of mass, distance of centre of mass from disc and fovea, eccentricity and orientation. This paper presents evidence for the validity of HAS by comparison against established software and known results for geometric images. Conclusion The system should be of use to experimenters studying the distribution and topography of vitreoretinal haemorrhages who require a means of accurately quantifying an ophthalmologist's gold standard assessment of a digital image.
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