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Treves B, Sonnini E, La Russa R, Del Duca F, Ghamlouch A, De Matteis A, Trignano C, Marchal JA, Carrillo E, Napoletano G, Maiese A. Can Hemorrhagic Stroke Genetics Help Forensic Diagnosis in Pediatric Age (<5 Years Old)? Genes (Basel) 2024; 15:618. [PMID: 38790247 PMCID: PMC11120992 DOI: 10.3390/genes15050618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
When stroke occurs in pediatric age, it might be mistakenly interpreted as non-accidental head injury (NAHI). In these situations, a multidisciplinary approach is fundamental, including a thorough personal and familial history, along with accurate physical examination and additional investigations. Especially when the clinical picture is uncertain, it is important to remember that certain genetic conditions can cause bleeding inside the brain, which may resemble NAHI. Pediatric strokes occurring around the time of birth can also be an initial sign of undiagnosed genetic disorders. Hence, it is crucial to conduct a thorough evaluation, including genetic testing, when there is a suspicion of NAHI but the symptoms are unclear. In these cases, a characteristic set of symptoms is often observed. This study aims to summarize some of the genetic causes of hemorrhagic stroke in the pediatric population, thus mimicking non-accidental head injury, considering elements that can be useful in characterizing pathologies. A systematic review of genetic disorders that may cause ICH in children was carried out according to the Preferred Reporting Item for Systematic Review (PRISMA) standards. We selected 10 articles regarding the main genetic diseases in stroke; we additionally selected 11 papers concerning patients with pediatric stroke and genetic diseases, or studies outlining the characteristics of stroke in these patients. The disorders we identified were Moyamoya disease (MMD), COL4A1, COL4A2 pathogenic variant, Ehlers-Danlos syndrome (E-D), neurofibromatosis type 1 (Nf1), sickle cell disease (SCD), cerebral cavernous malformations (CCM), hereditary hemorrhagic telangiectasia (HHT) and Marfan syndrome. In conclusion, this paper provides a comprehensive overview of the genetic disorders that could be tested in children when there is a suspicion of NAHI but an unclear picture.
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Affiliation(s)
- Biancamaria Treves
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (B.T.); (F.D.D.); (A.G.); (A.D.M.); (G.N.)
| | - Elena Sonnini
- Dipartimento Scienze della Vita e Sanità Pubblica, Medicina Genomica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Raffaele La Russa
- Department of Clinical Medicine, Public Health, Life Sciences, and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Fabio Del Duca
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (B.T.); (F.D.D.); (A.G.); (A.D.M.); (G.N.)
| | - Alessandro Ghamlouch
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (B.T.); (F.D.D.); (A.G.); (A.D.M.); (G.N.)
| | - Alessandra De Matteis
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (B.T.); (F.D.D.); (A.G.); (A.D.M.); (G.N.)
| | - Claudia Trignano
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43c, 07100 Sassari, Italy;
| | - Juan Antonio Marchal
- Centre for Biomedical Research (CIBM), Biopathology and Regenerative Medicine Institute (IBIMER), University of Granada, 18016 Granada, Spain; (J.A.M.); (E.C.)
- Instituto de Investigación Biosanitaria ibs. GRANADA, University of Granada, 18071 Granada, Spain
- Excellence Research Unit “Modeling Nature” (MNat), University of Granada, 18016 Granada, Spain
- Department of Human Anatomy and Embryology, Faculty of Medicine, University of Granada, 18016 Granada, Spain
| | - Esmeralda Carrillo
- Centre for Biomedical Research (CIBM), Biopathology and Regenerative Medicine Institute (IBIMER), University of Granada, 18016 Granada, Spain; (J.A.M.); (E.C.)
- Instituto de Investigación Biosanitaria ibs. GRANADA, University of Granada, 18071 Granada, Spain
- Excellence Research Unit “Modeling Nature” (MNat), University of Granada, 18016 Granada, Spain
- Department of Human Anatomy and Embryology, Faculty of Medicine, University of Granada, 18016 Granada, Spain
| | - Gabriele Napoletano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (B.T.); (F.D.D.); (A.G.); (A.D.M.); (G.N.)
| | - Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy
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Biswas A, Krishnan P, Albalkhi I, Mankad K, Shroff M. Imaging of Abusive Head Trauma in Children. Neuroimaging Clin N Am 2023; 33:357-373. [PMID: 36965952 DOI: 10.1016/j.nic.2023.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
In this article, we describe relevant anatomy, mechanisms of injury, and imaging findings of abusive head trauma (AHT). We also briefly address certain mimics of AHT, controversies, pearls, and pitfalls. Concepts of injury, its evolution, and complex nature of certain cases are highlighted with the help of case vignettes.
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Affiliation(s)
- Asthik Biswas
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada; Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK.
| | - Pradeep Krishnan
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Ibrahem Albalkhi
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; College of Medicine, Alfaisal University, Al Takhassousi، Al Zahrawi Street interconnecting with, Riyadh 11533, Saudi Arabia
| | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; UCL GOS Institute of Child Health
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
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Kwak YH. Diagnosis of Abusive Head Trauma : Neurosurgical Perspective. J Korean Neurosurg Soc 2022; 65:370-379. [PMID: 35468707 PMCID: PMC9082129 DOI: 10.3340/jkns.2021.0284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.
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Affiliation(s)
- Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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Caré MM. Parenchymal Insults in Abuse—A Potential Key to Diagnosis. Diagnostics (Basel) 2022; 12:diagnostics12040955. [PMID: 35454003 PMCID: PMC9029348 DOI: 10.3390/diagnostics12040955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Subdural hemorrhage is a key imaging finding in cases of abusive head trauma and one that many radiologists and radiology trainees become familiar with during their years of training. Although it may prove to be a marker of trauma in a young child or infant that presents without a history of injury, the parenchymal insults in these young patients more often lead to the debilitating and sometimes devastating outcomes observed in this young population. It is important to recognize these patterns of parenchymal injuries and how they may differ from the imaging findings in other cases of traumatic injury in young children. In addition, these parenchymal insults may serve as another significant, distinguishing feature when making the medical diagnosis of abusive head injury while still considering alternative diagnoses, including accidental injury. Therefore, as radiologists, we must strive to look beyond the potential cranial injury or subdural hemorrhage for the sometimes more subtle but significant parenchymal insults in abuse.
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Affiliation(s)
- Marguerite M. Caré
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Radiology and Medical Imaging, University of Cincinnati, Cincinnati, OH 45267, USA
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Wester K, Stridbeck U, Syse A, Wikström J. Re-evaluation of medical findings in alleged shaken baby syndrome and abusive head trauma in Norwegian courts fails to support abuse diagnoses. Acta Paediatr 2022; 111:779-792. [PMID: 34041784 DOI: 10.1111/apa.15956] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 12/24/2022]
Abstract
AIM The criteria for diagnosing abusive head trauma (AHT) are not well defined and this condition might be diagnosed on failing premises. Our aim was to review criminal AHT cases in Norwegian courts by scrutinising the underlying medical documentation. METHODS Cases were identified in the data registry for Norwegian courts from 2004 to 2015. Documentation was obtained from relevant health institutions. The medical co-authors first made independent evaluations of the documentation for each child, followed by a consensus evaluation. RESULTS A total of 17 children (11 boys) were identified, all diagnosed as AHT by court appointed experts, 15 were infants (mean age 2.6 months). A high proportion (41.2%) was born to immigrant parents and 31.3% were premature. The medical findings could be explained by alternative diagnoses in 16 of the 17 children; 8 boys (7 infants - mean age 2.9 months) had clinical and radiological characteristics compatible with external hydrocephalus complicated by chronic subdural haematoma. Six children (five infants with mean age 2.1 months) had a female preponderance and findings compatible with hypoxic ischaemic insults. CONCLUSION The medical condition in most children had not necessarily been caused by shaking or direct impact, as was originally concluded by the court experts.
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Affiliation(s)
- Knut Wester
- Department of Clinical Medicine K1 University of Bergen Bergen Norway
| | - Ulf Stridbeck
- Department of Public and International Law Faculty of Law University of Oslo Oslo Norway
| | - Aslak Syse
- Department of Public and International Law Faculty of Law University of Oslo Oslo Norway
| | - Johan Wikström
- Department of Radiology Uppsala University Uppsala Sweden
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Shah YS, Iftikhar M, Justin GA, Canner JK, Woreta FA. A National Analysis of Ophthalmic Features and Mortality in Abusive Head Trauma. JAMA Ophthalmol 2022; 140:227-234. [PMID: 35050347 PMCID: PMC8778601 DOI: 10.1001/jamaophthalmol.2021.5907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE It is important to recognize presenting features and factors associated with mortality in abusive head trauma (AHT) owing to the severity of the diagnosis and the necessity for prompt action. OBJECTIVE To describe the prevalence and economic burden of AHT and identify factors associated with mortality. DESIGN, SETTING, AND PARTICIPANTS This retrospective, cross-sectional study used the Nationwide Emergency Department Sample database to identify all emergency department visits in the US for patients younger than 5 years with a primary diagnosis of abusive head trauma between January 1, 2006, and December 31, 2018. This study was conducted in 2021. MAIN OUTCOMES AND MEASURES Prevalence, demographic characteristics, clinical characteristics, mortality, and economic burden associated with AHT. Weighted national estimates were calculated using sampling weights provided in the Nationwide Emergency Department Sample database. RESULTS From 2006 to 2018, there were an estimated 12 287 cases of emergency department visits in the US for patients younger than 5 years with a primary diagnosis of AHT. The estimated number of AHT cases decreased by 672 (95% CI, 403-940; P < .001) from 2006 to 2018. The incidence decreased by 6.7% each year (incidence rate ratio, 0.93; 95% CI, 0.93-0.94; P < .001) between 2006 and 2018. During the course of a hospital visit, 646 patients (5.3%) died. The majority of patients with a diagnosis of AHT were younger than 1 year (n = 7046; 57.3%), were male (n = 7268; 59.2%) and had Medicaid insurance (n = 8585; 70.0%). After controlling for demographic characteristics, factors associated with increased mortality were age greater than 1 year (odds ratio [OR], 2.45; 95% CI, 1.50-3.99; P < .001), first or second income quartile (OR, 1.78; 95% CI, 1.08-2.91; P = .02), midwestern United States (OR, 2.04; 95% CI, 1.04-4.00; P = .04), level 1 trauma center (OR, 2.69; 95% CI, 1.07-6.75; P = .04), orbital fracture (OR, 15.38; 95% CI, 2.41-98.18; P = .004), cerebral edema (OR, 8.49; 95% CI, 5.57-12.93; P < .001), intracranial hemorrhage (OR, 4.27; 95% CI, 1.71-10.67; P = .002), hypoxic ischemic brain injury (OR, 4.16; 95% CI, 2.13-8.10; P < .001), skull fractures (OR, 3.20; 95% CI, 1.76-5.82; P < .001), subarachnoid hemorrhage (OR, 2.43; 95% CI, 1.22-4.83; P = .01), retinal hemorrhage (OR, 2.17; 95% CI, 1.40-3.38; P < .001), and subdural hemorrhage (OR, 2.05; 95% CI, 1.05-3.98; P = .04). CONCLUSIONS AND RELEVANCE This study's findings suggest that health care disparities may be present in the treatment of AHT. Recognizing factors suggested in this investigation to be associated with higher mortality, public health efforts should be targeted toward low-income areas and in the midwestern United States.
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Affiliation(s)
- Yesha S. Shah
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mustafa Iftikhar
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Grant A. Justin
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joseph K. Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Fasika A. Woreta
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
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Oates AJ, Sidpra J, Mankad K. Parenchymal brain injuries in abusive head trauma. Pediatr Radiol 2021; 51:898-910. [PMID: 33638693 DOI: 10.1007/s00247-021-04981-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/23/2020] [Accepted: 12/16/2020] [Indexed: 11/30/2022]
Abstract
The consequences of abusive head trauma (AHT) can be devastating for both the individual child and for wider society. Death is undoubtedly a very real possibility, but even for those children who survive, there is often very significant morbidity with the potential for gross motor and cognitive impairment, behavioural problems, blindness and epilepsy, which can greatly affect their quality of life. Caring for such children places a vast financial and infrastructural burden on society that frequently extends well into adulthood. While few struggle to have any sympathy for the perpetrator, frequently the infant's father, it should be noted that a single solitary and momentary loss of complete control can have horrific and unforeseen consequences. A number of papers within this edition describe features of AHT and include descriptions of skull fractures and extra-axial haemorrhage, along with mimics of such phenomena. However, in this review we concentrate our attention on the myriad of parenchymal findings that can occur. Such parenchymal injuries include hypoxic-ischaemic damage, clefts, contusion and focal haemorrhage. We offer our perspectives on current thinking on these entities and put them in the context of the immensely important question - how do we recognise abusive head trauma?
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Affiliation(s)
- Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, UK
| | - Jai Sidpra
- University College London Medical School, London, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK.
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Cartocci G, Fineschi V, Padovano M, Scopetti M, Rossi-Espagnet MC, Giannì C. Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma. Brain Sci 2021; 11:179. [PMID: 33535601 PMCID: PMC7912837 DOI: 10.3390/brainsci11020179] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/10/2023] Open
Abstract
In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration-deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice.
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Affiliation(s)
- Gaia Cartocci
- Emergency Radiology Unit, Department of Radiological, Oncological and Pathological Sciences, Umberto I University Hospital, Sapienza University of Rome, 00198 Rome, Italy;
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Maria Camilla Rossi-Espagnet
- Neuroradiology Unit, NESMOS Department, Sapienza University, 00185 Rome, Italy;
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Costanza Giannì
- Department of Human Neurosciences, Sapienza University of Rome, 00198 Rome, Italy;
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Blackwell LS, Martinez M, Fournier-Goodnight A, Figueroa J, Appert A, Vats A, Wali B, Sayeed I, Reisner A. Patterns of Osteopontin Expression in Abusive Head Trauma Compared with Other Causes of Pediatric Traumatic Brain Injury. J Pediatr 2020; 227:170-175. [PMID: 32622673 PMCID: PMC7686267 DOI: 10.1016/j.jpeds.2020.06.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To examine levels of plasma osteopontin (OPN), a recently described neuroinflammatory biomarker, in children with abusive head trauma (AHT) compared with children with other types of traumatic brain injury (TBI). STUDY DESIGN The study cohort comprised children aged <4 years diagnosed with TBI and seen in the intensive care unit in a tertiary children's hospital. Patients were classified as having confirmed or suspected AHT or TBI by other mechanisms (eg, motor vehicle accidents), as identified by a Child Protection Team clinician. Serial blood samples were collected at admission and at 24, 48, and 72 hours after admission. Levels of OPN were compared across groups. RESULTS Of 77 patients identified, 24 had confirmed AHT, 12 had suspected AHT, and 41 had TBI. There were no differences in the Glasgow Coma Scale score between the patients with confirmed AHT and those with suspected AHT and those with TBI (median score, 4.5 vs 4 and 7; P = .39). At admission to the emergency department, OPN levels were significantly higher in children with confirmed AHT compared with the other 2 groups (mean confirmed AHT, 471.5 ng/mL; median suspected AHT, 322.3 ng/mL; mean TBI, 278.0 ng/mL; P = .03). Furthermore, the adjusted mean trajectory levels of OPN were significantly higher in the confirmed AHT group compared with the other 2 groups across all subsequent time points (P = <.01). CONCLUSIONS OPN is significantly elevated in children with confirmed AHT compared with those with suspected AHT and those with other types of TBI. OPN expression may help identify children with suspected AHT to aid resource stratification and triage of appropriate interventions for children who are potential victims of abuse.
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Affiliation(s)
- Laura S. Blackwell
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA
| | | | | | | | - Andrew Appert
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Atul Vats
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA,Emory University, Atlanta, GA
| | | | | | - Andrew Reisner
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA
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Matschke J, Sperhake JP, Wilke N, Püschel K, Glatzel M. Cerebellar heterotopia of infancy in sudden infant death syndrome: an observational neuropathological study of four cases. Int J Legal Med 2020; 134:2143-2147. [PMID: 32435901 PMCID: PMC7577907 DOI: 10.1007/s00414-020-02316-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/08/2020] [Indexed: 12/31/2022]
Abstract
Sudden infant death syndrome (SIDS) is the sudden unexpected death of an infant < 1 year of age that remains unexplained after comprehensive workup including complete autopsy and investigation of the circumstances of death. The triple risk hypothesis posits that SIDS results as a combination of both intrinsic and extrinsic factors on the background of a predisposing vulnerability. Neuropathological examination in the past has focussed mainly on the brainstem as the major player in respiratory control, where subtle findings have been linked to the chain of events leading to death in SIDS. The cerebellum has received less attention, probably due to an assumed negligible role in central cardiorespiratory control. We report four cases of SIDS in which neuropathological investigation revealed cerebellar heterotopia of infancy, a distinct malformation of the cerebellum, and discuss the potential impact of this condition on the aetiology and pathogenesis of SIDS.
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Affiliation(s)
- Jakob Matschke
- Forensic Neuropathology Unit, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. .,Institute of Neuropathology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Jan-Peter Sperhake
- Institute of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Nadine Wilke
- Institute of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Institute of Legal Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Klaus Püschel
- Institute of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Orman G, Kralik SF, Meoded A, Desai N, Risen S, Huisman TAGM. MRI Findings in Pediatric Abusive Head Trauma: A Review. J Neuroimaging 2019; 30:15-27. [PMID: 31696594 DOI: 10.1111/jon.12670] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Gunes Orman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Avner Meoded
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Nilesh Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Sarah Risen
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, TX
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Benavente-Fernandez I, Ramos-Rodriguez JJ, Infante-Garcia C, Jimenez-Gomez G, Lechuga-Sancho A, Lubian-Lopez S, Garcia-Alloza M. Altered plasma-type gelsolin and amyloid-β in neonates with hypoxic-ischaemic encephalopathy under therapeutic hypothermia. J Cereb Blood Flow Metab 2019; 39:1349-1354. [PMID: 29466895 PMCID: PMC6668521 DOI: 10.1177/0271678x18757419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 01/06/2018] [Accepted: 01/12/2018] [Indexed: 01/08/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a severe neonatal complication responsible for ∼23% of all neonatal deaths. Also, 30-70% of these patients will suffer lifetime disabilities, including learning impairment, epilepsy or cerebral palsy. However, biomarkers for HIE screening, or monitoring disease progression are limited. Herein, we sought to evaluate the clinical usefulness of plasma-type gelsolin (pGSN) and amyloid-beta (Aβ) 40 and 42 as prognostic biomarkers for HIE. pGSN has been previously suggested as a feasible marker in other brain injuries and amyloid-beta 40 and 42 are classically assessed in neurodegenerative diseases. However, to our knowledge, they have not been previously assessed in HIE patients. We have analyzed plasma pGSN and Aβ 40 and 42 levels in 55 newborns (16 controls, 16 mild and 23 moderate-severe HIE) at birth, during 72 h of therapeutic hypothermia, a gold-standard treatment for HIE, and 24 h after hypothermia. Aβ levels were lower in HIE patients, and pGSN levels were progressively reduced in mild and moderate-severe HIE patients. The fact that pGSN reductions could predict the severity of HIE and significantly correlated with the time to undergo hypothermia supports the prognostic value of plasmatic pGSN. Further studies are warranted to investigate the role of pGSN in neonatal HIE.
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Affiliation(s)
| | - Juan J Ramos-Rodriguez
- Division of Physiology, School of Medicine, Instituto de Investigación Biomedica de Cadiz (INIBICA), Universidad de Cadiz, Cadiz, Spain
- Salus Infirmorum, Universidad de Cadiz, Cádiz, Spain
| | - Carmen Infante-Garcia
- Division of Physiology, School of Medicine, Instituto de Investigación Biomedica de Cadiz (INIBICA), Universidad de Cadiz, Cadiz, Spain
| | | | - Alfonso Lechuga-Sancho
- Department of Pediatrics, Neonatology Unit, Puerta del Mar University Hospital, Cadiz, Spain
- Department of Mother and Child Health and Radiology, Universidad de Cadiz, Cadiz, Spain
| | - Simon Lubian-Lopez
- Department of Pediatrics, Neonatology Unit, Puerta del Mar University Hospital, Cadiz, Spain
| | - Monica Garcia-Alloza
- Division of Physiology, School of Medicine, Instituto de Investigación Biomedica de Cadiz (INIBICA), Universidad de Cadiz, Cadiz, Spain
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Landgraf MN, Heinen F, Kammer B, Seubert C, Olivieri M, Schön C, Hoffmann F, Reiter K, Well T, Müller-Felber W. Schütteltrauma bei einem jungen Säugling. Rechtsmedizin (Berl) 2018. [DOI: 10.1007/s00194-018-0281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Orru' E, Huisman TAGM, Izbudak I. Prevalence, Patterns, and Clinical Relevance of Hypoxic-Ischemic Injuries in Children Exposed to Abusive Head Trauma. J Neuroimaging 2018; 28:608-614. [PMID: 30125430 DOI: 10.1111/jon.12555] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/28/2018] [Accepted: 08/30/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Hypoxic-ischemic injuries (HIIs) are a scarcely investigated but important cause of morbidity and mortality in children who suffered abusive head trauma (AHT). The purpose of this study is to determine: (a) prevalence, types, and clinical relevance of cytotoxic edema compatible with HII in nonpenetrating AHT, (b) their relationship to other classic neuroimaging findings of AHT, and (c) their correlation with clinical outcomes. METHODS Diffusion-weighted imaging sequences of magnetic resonance imagings performed on children under 5 years diagnosed with AHT were reviewed to detect the most common patterns of acute parenchymal damage. Patterns of cytotoxic edema were described, and HII-compatible ones divided in subtypes. Correlation between HII, fractures, and subdural hemorrhages (SDHs) and with clinical outcomes was determined using imaging and available follow-up data. RESULTS Out of 57 patients, 36.8% showed lesions compatible with HII. A predominantly asymmetric cortical distribution was observed in 66.7% of cases, while 33.3% had diffused both cortical and deep gray/white matter distribution injury. Traumatic axonal injuries and focal contusions were less common. There was no significant correlation between the presence of SDH (P = .6) or skull fractures (P = .53) and HII. HII was the most severe form of parenchymal damage in terms of in-hospital mortality and morbidity at follow-up. CONCLUSIONS HII is the most common type of parenchymal damage in children victim of AHT, being present in 1/3 of patients with this condition, and correlates with more severe outcomes. Its presence is independent from other classic traumatic findings such as SDH and fractures.
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Affiliation(s)
- Emanuele Orru'
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Izlem Izbudak
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore, MD
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Dingman AL, Stence NV, O'Neill BR, Sillau SH, Chapman KE. Seizure Severity Is Correlated With Severity of Hypoxic-Ischemic Injury in Abusive Head Trauma. Pediatr Neurol 2018; 82:29-35. [PMID: 29625848 DOI: 10.1016/j.pediatrneurol.2017.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The objective of this study was to characterize hypoxic-ischemic injury and seizures in abusive head trauma. METHODS We studied 58 children with moderate or severe traumatic brain injury due to abusive head trauma. Continuous electroencephalograms and magnetic resonance images were scored. RESULTS Electrographic seizures (51.2%) and hypoxic-ischemic injury (77.4%) were common in our cohort. Younger age was associated with electrographic seizures (no seizures: median age 13.5 months, interquartile range five to 25 months, versus seizures: 4.5 months, interquartile range 3 to 9.5 months; P = 0.001). Severity of hypoxic-ischemic injury was also associated with seizures (no seizures: median injury score 1.0, interquartile range 0 to 3, versus seizures: 4.5, interquartile range 3 to 8; P = 0.01), but traumatic injury severity was not associated with seizures (no seizures: mean injury score 3.78 ± 1.68 versus seizures: mean injury score 3.83 ± 0.95, P = 0.89). There was a correlation between hypoxic-ischemic injury severity and seizure burden when controlling for patient age (rs=0.61, P < 0.001). The ratio of restricted diffusion volume to total brain volume (restricted diffusion ratio) was smaller on magnetic resonance imaging done early (median restricted diffusion ratio 0.03, interquartile range 0 to 0.23 on magnetic resonance imaging done within two days versus median restricted diffusion ratio 0.13, interquartile range 0.01 to 0.43 on magnetic resonance imaging done after two days, P = 0.03). CONCLUSIONS Electrographic seizures are common in children with moderate to severe traumatic brain injury from abusive head trauma, and therefore children with suspected abusive head trauma should be monitored with continuous electroencephalogram. Severity of hypoxic-ischemic brain injury is correlated with severity of seizures, and evidence of hypoxic-ischemic injury on magnetic resonance imaging may evolve over time. Therefore children with a high seizure burden should be reimaged to evaluate for evolving hypoxic-ischemic injury.
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Affiliation(s)
- Andra L Dingman
- Department of Pediatrics, Division of Child Neurology, University of Colorado Anschuts Medical Campus, Aurora, Colorado.
| | - Nicholas V Stence
- Department of Radiology, Division of Pediatric Radiology, University of Colorado Anschuts Medical Campus, Aurora, Colorado
| | - Brent R O'Neill
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Colorado Anschuts Medical Campus, Aurora, Colorado
| | - Stefan H Sillau
- Department of Neurology, University of Colorado Anschuts Medical Campus, Aurora, Colorado
| | - Kevin E Chapman
- Department of Pediatrics, Division of Child Neurology, University of Colorado Anschuts Medical Campus, Aurora, Colorado
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Various Cranial and Orbital Imaging Findings in Pediatric Abusive and Non-abusive Head trauma, and Relation to Outcomes. Clin Neuroradiol 2018; 29:253-261. [DOI: 10.1007/s00062-018-0663-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
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Abusive Head Trauma and Mortality-An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury. Crit Care Med 2017; 45:1398-1407. [PMID: 28430697 DOI: 10.1097/ccm.0000000000002378] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. DESIGN First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial-a comparative effectiveness study using an observational, cohort study design. SETTING PICUs in tertiary children's hospitals in United States and abroad. PATIENTS Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%). CONCLUSIONS In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.
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Snyder VS, Hansen LA. A Conceptual Overview of Axonopathy in Infants and Children with Allegedly Inflicted Head Trauma. Acad Forensic Pathol 2016; 6:608-621. [PMID: 31239934 PMCID: PMC6474503 DOI: 10.23907/2016.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/14/2016] [Accepted: 11/12/2016] [Indexed: 11/12/2022]
Abstract
Fatal, allegedly inflicted pediatric head trauma remains a controversial topic in forensic pathology. Recommendations for systematic neuropathologic evaluation of the brains of supposedly injured infants and children usually include the assessment of long white matter tracts in search of axonopathy - specifically, diffuse axonal injury. The ability to recognize, document, and interpret injuries to axons has significant academic and medicolegal implications. For example, more than two decades of inconsistent nosology have resulted in confusion about the definition of diffuse axonal injury between various medical disciplines including radiology, neurosurgery, pediatrics, neuropathology, and forensic pathology. Furthermore, in the pediatric setting, acceptance that "pure" shaking can cause axonal shearing in infants and young children is not widespread. Additionally, controversy abounds whether or not axonal trauma can be identified within regions of white matter ischemia - a debate with very significant implications. Immunohistochemistry is often used not only to document axonal injury, but also to estimate the time since injury. As a result, the estimated post-injury interval may then be used by law enforcement officers and prosecutors to narrow "exclusive opportunity" and thus, identify potential suspects. Fundamental to these highly complicated and controversial topics is a philosophical understanding of the diffuse axonal injury spectrum disorders.
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Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma. J Trauma Acute Care Surg 2016; 80:711-6. [DOI: 10.1097/ta.0000000000000954] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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