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Colleran GC, Fossmark M, Rosendahl K, Argyropoulou M, Mankad K, Offiah AC. ESR Essentials: imaging of suspected child abuse-practice recommendations by the European Society of Paediatric Radiology. Eur Radiol 2024:10.1007/s00330-024-11052-4. [PMID: 39289300 DOI: 10.1007/s00330-024-11052-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 09/19/2024]
Abstract
The goal of this paper is to provide a useful desktop reference for the imaging of suspected child abuse with clear, age-specific pathways for appropriate evidence-based imaging and follow-up. We aim to provide a road map for the imaging evaluation and follow-up of this important and vulnerable cohort of patients presenting with signs and symptoms concerning for inflicted injury. As the imaging recommendations differ for children of different ages, we provide a flowchart of the appropriate imaging pathway for infants, toddlers, and older children, which allows ease of selection of which children should undergo skeletal survey, non-contrast computed tomography (CT) brain with 3-dimensional (D) reformats, and magnetic resonance imaging (MRI) of the brain and whole spine. For ease of review, we include a table of the common intracranial and spinal patterns of injury in abusive head trauma. We summarise search patterns, areas of review, and key findings to include in the report. To exclude skeletal injury, infants and children under 2 years of age should undergo a full skeletal survey in accordance with national guidelines, with a limited follow-up skeletal survey performed 11-14 days later. For children over 2 years of age, the need for skeletal imaging should be decided on a case-by-case basis. All infants should undergo a non-contrast-enhanced CT brain with 3-D reformats. If this is normal with no abnormal neurology, then no further neuroimaging is required. If this is abnormal, then they should proceed to MRI brain and whole spine within 2-5 days. Children older than 1 year of age who have abnormal neurology and/or findings on skeletal survey that are suggestive of inflicted injury should undergo non-contrast CT brain with 3-D reformats and, depending on the findings, may also require MRI of the brain and whole spine. We hope that this will be a helpful contribution to the radiology literature, particularly for the general radiologist with low volumes of paediatrics in their practice, supporting them with managing these important cases when they arise in daily practice. KEY POINTS: The choice of initial imaging (skeletal survey and/or brain CT) depends on the age of the child in whom abuse is suspected. A follow-up skeletal survey is mandatory 11-14 days after the initial survey. If an MRI of the brain is performed, then an MRI of the whole spine should be performed concurrently.
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Affiliation(s)
| | - Maria Fossmark
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Karen Rosendahl
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Maria Argyropoulou
- Department of Clinical Radiology and Imaging, Medical School, University of Ioannina, Ioannina, Greece
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Amaka C Offiah
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK.
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Popescu CM, Marina V, Avram G, Cristescu Budala CL. Spectrum of Magnetic Resonance Imaging Findings in Acute Pediatric Traumatic Brain Injury - A Pictorial Essay. J Multidiscip Healthc 2024; 17:2921-2934. [PMID: 38911614 PMCID: PMC11193985 DOI: 10.2147/jmdh.s466044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/26/2024] [Indexed: 06/25/2024] Open
Abstract
Head trauma (HT) in pediatric patients is the number one cause of mortality and morbidity in children. Although computer tomography (CT) imaging provides ample information in assessing acute traumatic brain injuries (TBIs), there are instances when magnetic resonance imaging (MRI) is needed. Due to its high sensitivity in diagnosing small bleeds, MRI offers a well-documented evaluation of primary acute TBIs. Our pictorial essay aims to present some of the latest imaging protocols employed in head trauma and review some practical considerations. Injury mechanisms in accidental HT, lesions' topography, and hematoma signal variability over time are also discussed. Acute primary intra- and extra-axial lesions and their MRI aspect are showcased using images from patients in our hospital. This pictorial essay has an educational purpose. It is intended to guide young emergency and intensive care unit doctors, neurologists, and neurosurgeons in diagnosing acute primary TBIs on MRI while waiting for the official radiologist's report. The presentation focuses on the most frequent traumatic lesions encountered in acute pediatric head trauma.
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Affiliation(s)
- Cristina-Mihaela Popescu
- Dental-Medicine Department, Faculty of Medicine and Pharmacy, “dunărea de Jos” University, Galați, 800201, Romania
| | - Virginia Marina
- Medical Department of Occupational Health, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galați, 800201, Romania
| | - Georgiana Avram
- “sf. Ioan” Clinical Emergency Children’s Hospital, Galați, 800487, Romania
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Sokoloff M, Feldman KW, Levin AV, Rockter A, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Hymel KP. Retinal hemorrhage variation in inertial versus contact head injuries. CHILD ABUSE & NEGLECT 2024; 149:106606. [PMID: 38134727 DOI: 10.1016/j.chiabu.2023.106606] [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: 07/23/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) is frequently accompanied by dense/extensive retinal hemorrhages to the periphery with or without retinoschisis (complex retinal hemorrhages, cRH). cRH are uncommon without AHT or major trauma. OBJECTIVE The study objectives were to determine whether cRH are associated with inertial vs. contact mechanisms and are primary vs. secondary injuries. PARTICIPANTS AND SETTING This retrospective study utilized a de-identified PediBIRN database of 701 children <3-years-old presenting to intensive care for head trauma. Children with motor vehicle related trauma and preexisting brain abnormalities were excluded. All had imaging showing head injury and a dedicated ophthalmology examination. METHODS Contact injuries included craniofacial soft tissue injuries, skull fractures and epidural hematoma. Inertial injuries included acute impairment or loss of consciousness and/or bilateral and/or interhemispheric subdural hemorrhage. Abuse was defined in two ways, by 1) predetermined criteria and 2) caretaking physicians/multidisciplinary team's diagnostic consensus. RESULTS PediBIRN subjects with cRH frequently experienced inertial injury (99.4 % (308/310, OR = 53.74 (16.91-170.77)) but infrequently isolated contact trauma (0.6 % (2/310), OR = 0.02 (0.0004-0.06)). Inertial injuries predominated over contact trauma among children with cRH sorted AHT by predetermined criteria (99.1 % (237/239), OR = 20.20 (6.09-67.01) vs 0.5 % (2/339), OR = 0.04 (0.01-0.17)). Fifty-nine percent of patients with cRH, <24 h altered consciousness, and inertial injuries lacked imaging evidence of brain hypoxia, ischemia, or swelling. CONCLUSIONS cRH are significantly associated with inertial angular acceleration forces. They can occur without brain hypoxia, ischemia or swelling suggesting they are not secondary injuries.
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Affiliation(s)
- Michael Sokoloff
- Department of Pediatrics, Pediatric Intensive Care, Sacred Heart Children's Hospital, Spokane, WA, United States of America.
| | - Kenneth W Feldman
- Department of Pediatrics, Seattle Children's, University of Washington's Harborview Medical Center, Seattle, WA, United States of America; Department of Pediatrics, Safe Child and Adolescent Network, Seattle Children's, Seattle, WA, United States of America.
| | - Alex V Levin
- Department of Ophthalmology, Flaum Eye Institute, University of Rochester, Rochester, NY, United States of America.
| | - Adam Rockter
- University of Rochester School of Medicine, Rochester, NY, United States of America.
| | - Veronica Armijo-Garcia
- Department of Pediatrics, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, United States of America.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, KS, United States of America.
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA, United States of America.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, United States of America.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States of America.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, United States of America.
| | - Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, United States of America
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Raghupathi R, Prasad R, Fox D, Huh JW. Repeated mild closed head injury in neonatal rats results in sustained cognitive deficits associated with chronic microglial activation and neurodegeneration. J Neuropathol Exp Neurol 2023; 82:707-721. [PMID: 37390808 PMCID: PMC10357947 DOI: 10.1093/jnen/nlad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023] Open
Abstract
Abusive head trauma in infants is a consequence of multiple episodes of abuse and results in axonal injury, brain atrophy, and chronic cognitive deficits. Anesthetized 11-day-old rats, neurologically equivalent to infants, were subjected to 1 impact/day to the intact skull for 3 successive days. Repeated, but not single impact(s) resulted in spatial learning deficits (p < 0.05 compared to sham-injured animals) up to 5 weeks postinjury. In the first week following single or repetitive brain injury, axonal and neuronal degeneration, and microglial activation were observed in the cortex, white matter, thalamus, and subiculum; the extent of the histopathologic damage was significantly greater in the repetitive-injured animals compared to single-injured animals. At 40 days postinjury, loss of cortical, white matter and hippocampal tissue was evident only in the repetitive-injured animals, along with evidence of microglial activation in the white matter tracts and thalamus. Axonal injury and neurodegeneration were evident in the thalamus up to 40 days postinjury in the repetitive-injured rats. These data demonstrate that while single closed head injury in the neonate rat is associated with pathologic alterations in the acute post-traumatic period, repetitive closed head injury results in sustained behavioral and pathologic deficits reminiscent of infants with abusive head trauma.
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Affiliation(s)
- Ramesh Raghupathi
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Rupal Prasad
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Douglas Fox
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Mankad K, Sidpra J, Mirsky DM, Oates AJ, Colleran GC, Lucato LT, Kan E, Kilborn T, Agrawal N, Teeuw AH, Kelly P, Zeitlin D, Carter J, Debelle GD, Berger RP, Christian CW, Lindberg DM, Raissaki M, Argyropoulou M, Adamsbaum C, Cain T, van Rijn RR, Silvera VM, Rossi A, Kemp AM, Choudhary AK, Offiah AC. International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse. JAMA Pediatr 2023; 177:526-533. [PMID: 36877504 DOI: 10.1001/jamapediatrics.2022.6184] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Importance Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse. Objective To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse. Evidence Review This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021. Findings Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child. Conclusions and Relevance This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.
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Affiliation(s)
- Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jai Sidpra
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - David M Mirsky
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Gabrielle C Colleran
- Department Radiology, Children's Health Ireland and The National Maternity Hospital, Dublin, Ireland
| | - Leandro T Lucato
- Department of Radiology, Universidade de São Paulo, Faculdade de Medicina, São Paulo, Brazil
| | - Elaine Kan
- Department of Radiology, Hong Kong Children's Hospital, Hong Kong
| | - Tracy Kilborn
- Department of Radiology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Nina Agrawal
- City University of New York Graduate School of Public Health and Health Policy, New York
| | - Arianne H Teeuw
- Department of Pediatrics, Emma Children's Hospital-Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Patrick Kelly
- Te Puaruruhau, Starship Children's Health, Auckland, New Zealand
- Department of Pediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Deborah Zeitlin
- Department of Pediatrics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jamieson Carter
- Department of Pediatrics, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Geoff D Debelle
- Department of Pediatrics, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cindy W Christian
- Department of Pediatrics, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Maria Raissaki
- Department of Radiology and Imaging, University Hospital of Heraklion, Medical School, University of Crete, Rethymno, Greece
| | - Maria Argyropoulou
- Department of Clinical Radiology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Catherine Adamsbaum
- Paris Saclay University, Faculty of Medicine, AP-HP, Bicêtre Hospital, Department of Paediatric Radiology, Le Kremlin Bicêtre, France
| | - Timothy Cain
- Department of Medical Imaging, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital-Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, the Netherlands
| | | | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Alison M Kemp
- Division of Population Medicine, Department of Child Health, University of Cardiff, Cardiff, United Kingdom
| | - Arabinda K Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock
| | - Amaka C Offiah
- Department of Radiology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, United Kingdom
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
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Nikam RM, Kecskemethy HH, Kandula VVR, Averill LW, Langhans SA, Yue X. Abusive Head Trauma Animal Models: Focus on Biomarkers. Int J Mol Sci 2023; 24:4463. [PMID: 36901893 PMCID: PMC10003453 DOI: 10.3390/ijms24054463] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023] Open
Abstract
Abusive head trauma (AHT) is a serious traumatic brain injury and the leading cause of death in children younger than 2 years. The development of experimental animal models to simulate clinical AHT cases is challenging. Several animal models have been designed to mimic the pathophysiological and behavioral changes in pediatric AHT, ranging from lissencephalic rodents to gyrencephalic piglets, lambs, and non-human primates. These models can provide helpful information for AHT, but many studies utilizing them lack consistent and rigorous characterization of brain changes and have low reproducibility of the inflicted trauma. Clinical translatability of animal models is also limited due to significant structural differences between developing infant human brains and the brains of animals, and an insufficient ability to mimic the effects of long-term degenerative diseases and to model how secondary injuries impact the development of the brain in children. Nevertheless, animal models can provide clues on biochemical effectors that mediate secondary brain injury after AHT including neuroinflammation, excitotoxicity, reactive oxygen toxicity, axonal damage, and neuronal death. They also allow for investigation of the interdependency of injured neurons and analysis of the cell types involved in neuronal degeneration and malfunction. This review first focuses on the clinical challenges in diagnosing AHT and describes various biomarkers in clinical AHT cases. Then typical preclinical biomarkers such as microglia and astrocytes, reactive oxygen species, and activated N-methyl-D-aspartate receptors in AHT are described, and the value and limitations of animal models in preclinical drug discovery for AHT are discussed.
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Affiliation(s)
- Rahul M. Nikam
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Heidi H. Kecskemethy
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Vinay V. R. Kandula
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Lauren W. Averill
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Sigrid A. Langhans
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Nemours Biomedical Research, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Xuyi Yue
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
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Lee SG, Whang K, Cho SM, Jang YG, Kim J, Choi J. Factors Associated With Subdural Hygroma Following Mild Traumatic Brain Injury. Korean J Neurotrauma 2022; 18:230-237. [PMCID: PMC9634298 DOI: 10.13004/kjnt.2022.18.e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Subdural hygroma (SDG) is a complication of traumatic brain injury (TBI). In particular, the outcome and outpatient treatment period may vary depending on the occurrence of SDG. However, the pathogenesis of SDG has not been fully elucidated. Therefore, this study aimed to identify the risk factors associated with the occurrence of SDG after mild TBI. Methods We retrospectively analyzed 250 patients with mild TBI admitted to a single institution between January 2021 and December 2021. The SDG occurrence and control groups were analyzed according to the risk factors of SDG, such as age, history, initial computed tomography (CT) findings, and initial laboratory findings. Results The overall occurrence rate of SDG was 31.6% (n=79). A statistically significant association was found between preoperative diagnoses and the occurrence of SDG, such as subarachnoid hemorrhage (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.26–4.39) and basal skull fracture (OR, 0.32; 95% CI, 0.12–0.83). Additionally, age ≥70 years (OR, 3.20; 95% CI, 1.74–5.87) and the use of tranexamic acid (OR, 2.12; 95% CI, 1.05–4.54) were statistically significant factors. The prognostic evaluation of patients using the Glasgow Outcome Scale (GOS) did not show any statistical differences between patients with and without SDG. Conclusion SDG was not associated with the prognosis of patients assessed using the GOS. However, depending on the occurrence of SDG, differences in patient symptoms may occur after mild TBI. Therefore, the early evaluation of patients with mild TBI and determination of the probability of developing SDG are important.
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Affiliation(s)
- Sang-Geun Lee
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Min Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeon Gyu Jang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongwook Choi
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Cheon JE, Kim JH. Imaging of Abusive Head Trauma : A Radiologists' Perspective. J Korean Neurosurg Soc 2022; 65:397-407. [PMID: 35483021 PMCID: PMC9082130 DOI: 10.3340/jkns.2021.0297] [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: 12/07/2021] [Accepted: 02/16/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most common and serious form of child abuse and a leading cause of traumatic death in infants and young children. The biomechanics of head injuries include violent shaking, blunt impact, or a combination of both. Neuroimaging plays an important role in recognizing and distinguishing abusive injuries from lesions from accidental trauma or other causes, because clinical presentation and medical history are often nonspecific and ambiguous in this age group. Understanding common imaging features of AHT can increase recognition with high specificity for AHT. In this review, we discuss the biomechanics of AHT, imaging features of AHT, and other conditions that mimic AHT.
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Affiliation(s)
- Jung-Eun Cheon
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Ji Hye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 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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10
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Feld K, Ricken T, Feld D, Helmus J, Hahnemann M, Schenkl S, Muggenthaler H, Pfeiffer H, Banaschak S, Karger B, Wittschieber D. Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study. Int J Legal Med 2022; 136:591-601. [PMID: 34862583 PMCID: PMC8847172 DOI: 10.1007/s00414-021-02751-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.
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Affiliation(s)
- Katharina Feld
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Tim Ricken
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Dustin Feld
- adiutaByte GmbH, Business Campus, Sankt Augustin, Germany
| | - Janine Helmus
- Institute of Legal Medicine, University Hospital Essen, Essen, Germany
| | | | - Sebastian Schenkl
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Holger Muggenthaler
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
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11
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Blangis F, Allali S, Cohen JF, Vabres N, Adamsbaum C, Rey-Salmon C, Werner A, Refes Y, Adnot P, Gras-Le Guen C, Launay E, Chalumeau M. Variations in Guidelines for Diagnosis of Child Physical Abuse in High-Income Countries: A Systematic Review. JAMA Netw Open 2021; 4:e2129068. [PMID: 34787659 PMCID: PMC8600386 DOI: 10.1001/jamanetworkopen.2021.29068] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/04/2021] [Indexed: 01/08/2023] Open
Abstract
Importance The highly variable practices observed regarding the early detection and diagnostic workup of suspected child physical abuse contribute to suboptimal care and could be partially related to discrepancies in clinical guidelines. Objective To systematically evaluate the completeness, clarity, and consistency of guidelines for child physical abuse in high-income countries. Evidence Review For this systematic review, national or regional guidelines that were disseminated from 2010 to 2020 related to the early detection and diagnostic workup of child physical abuse in infants aged 2 years or younger by academic societies or health agencies in high-income countries were retrieved. The definitions of sentinel injuries and the recommended diagnostic workup (imaging and laboratory tests) for child physical abuse were compared. Data were analyzed from July 2020 to February 2021. Findings Within the 20 included guidelines issued in 15 countries, 168 of 408 expected statements (41%) were missing and 10 statements (4%) were unclear. Among 16 guidelines characterizing sentinel injuries, all of them included skin injuries, such as bruises, hematoma, or burns, but only 8 guidelines (50%) included intraoral injuries and fractures. All 20 guidelines agreed on the indication for radiological skeletal survey, head computed tomography, and head magnetic resonance imaging but differed for those of bone scintigraphy, follow-up skeletal survey, spinal magnetic resonance imaging, cranial ultrasonography, chest computed tomography, and abdominal ultrasonography and computed tomography. Additionally, 16 guidelines agreed on exploring primary hemostasis and coagulation but not on the tests to perform, and 8 guidelines (50%) mentioned the need to investigate bone metabolism. Conclusions and Relevance These findings suggest that guidelines for the diagnosis of child physical abuse in infants were often clear but lacked completeness and were discrepant on major issues. These results may help identify priorities for well-designed original diagnostic accuracy studies, systematic reviews, or an international consensus process to produce clear and standardized guidelines to optimize practices and infant outcomes.
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Affiliation(s)
- Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Slimane Allali
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Jérémie F. Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Nathalie Vabres
- Unité d’Accueil des Enfants en Danger, Nantes University Hospital, F-44000, Nantes, France
| | - Catherine Adamsbaum
- Department of Pediatric Radiology, AP-HP, Bicêtre Hospital, F-94270, Le Kremlin Bicêtre, France
| | - Caroline Rey-Salmon
- Pediatrics and Forensic Unit, AP-HP, Hôtel-Dieu Hospital, F-75004, Paris, France
| | - Andreas Werner
- AFPA, Association Française de Pédiatrie Ambulatoire, F-30400, Villeneuve les Avignons, France
| | - Yacine Refes
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
| | - Pauline Adnot
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Christèle Gras-Le Guen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Elise Launay
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
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12
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Mankad K, Sidpra J, Oates AJ, Calder A, Offiah AC, Choudhary A. Sibling screening in suspected abusive head trauma: a proposed guideline. Pediatr Radiol 2021; 51:872-875. [PMID: 33999232 PMCID: PMC8126595 DOI: 10.1007/s00247-020-04917-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/29/2020] [Accepted: 11/16/2020] [Indexed: 11/15/2022]
Abstract
Abusive head trauma (AHT) is the leading cause of death from child abuse in children younger than 5 years. It is well documented that the infant contacts of children presenting with suspected AHT are at an increased risk of abuse when compared to the general infant population. Despite this association, a paucity of literature stratifies this risk and translates it to the clinic such that this high-risk group is stringently screened for abusive injuries. In this light, the authors propose a standardised screening method for all contact children of the index case and call for further consensus on the subject.
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Affiliation(s)
- Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK.
| | - Jai Sidpra
- University College London Medical School, London, UK
| | - Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, UK
| | - Alistair Calder
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - Amaka C Offiah
- Academic Unit of Child Health, University of Sheffield, Western Bank, Sheffield, UK
| | - Arabinda Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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13
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Venous injury in pediatric abusive head trauma: a pictorial review. Pediatr Radiol 2021; 51:918-926. [PMID: 33884464 DOI: 10.1007/s00247-021-05016-9] [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: 08/09/2020] [Revised: 11/21/2020] [Accepted: 02/11/2021] [Indexed: 10/21/2022]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. An intracranial pathology can exist even in the setting of a normal physical exam. A delay in the diagnosis of AHT can have serious life-threatening consequences for the child and increases the potential the child will be abused again. In this article, we review the traumatic subdural hematoma as well as various morpho-structural patterns of shearing injuries and thrombosis of intracranial bridging veins. This work serves as a summary of patterns of imaging features of intracranial venous injury in AHT, as described in the literature, to facilitate familiarity and early detection of abusive head trauma in the pediatric population. Essentially, in AHT there is a traumatic injury to the bridging vein with either partial or complete tear. This can secondarily result in thrombosis at the terminal end of the bridging vein with blood clots adjacent to the bridging vein.
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14
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Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatr Radiol 2021; 51:853-860. [PMID: 33999229 DOI: 10.1007/s00247-020-04864-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.
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Affiliation(s)
- Colleen E Bennett
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Cindy W Christian
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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15
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Vilanilam GK, Jayappa S, Desai S, Zuccoli G, Ramakrishnaiah RH, Choudhary AK. Venous injury in pediatric abusive head trauma: a pictorial review. Pediatr Radiol 2021. [PMID: 33884464 DOI: 10.1007/s00247-021-050f16-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. An intracranial pathology can exist even in the setting of a normal physical exam. A delay in the diagnosis of AHT can have serious life-threatening consequences for the child and increases the potential the child will be abused again. In this article, we review the traumatic subdural hematoma as well as various morpho-structural patterns of shearing injuries and thrombosis of intracranial bridging veins. This work serves as a summary of patterns of imaging features of intracranial venous injury in AHT, as described in the literature, to facilitate familiarity and early detection of abusive head trauma in the pediatric population. Essentially, in AHT there is a traumatic injury to the bridging vein with either partial or complete tear. This can secondarily result in thrombosis at the terminal end of the bridging vein with blood clots adjacent to the bridging vein.
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Affiliation(s)
- George Koshy Vilanilam
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA.
| | - Sateesh Jayappa
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Shivang Desai
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Giulio Zuccoli
- The NDRD (Program for the Study in Neurodevelopment in Rare Disorders), University of Pittsburgh, Pittsburgh, PA, USA
| | - Raghu H Ramakrishnaiah
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Arabinda K Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
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16
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Aromatario M, Torsello A, D’Errico S, Bertozzi G, Sessa F, Cipolloni L, Baldari B. Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020125. [PMID: 33535407 PMCID: PMC7912597 DOI: 10.3390/medicina57020125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 04/09/2023]
Abstract
Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.
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Affiliation(s)
| | - Alessandra Torsello
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Giuseppe Bertozzi
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
- Correspondence:
| | - Francesco Sessa
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Luigi Cipolloni
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Benedetta Baldari
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00186 Rome, Italy;
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18
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Kazmir S, Rosado N. Abusive Head Trauma: A Review of Current Knowledge. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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19
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Ryan ME, Pruthi S, Desai NK, Falcone RA, Glenn OA, Joseph MM, Maheshwari M, Marin JR, Mazzola C, Milla SS, Mirsky DM, Myseros JS, Niogi SN, Partap S, Radhakrishnan R, Robertson RL, Soares BP, Udayasankar UK, Whitehead MT, Wright JN, Karmazyn B. ACR Appropriateness Criteria® Head Trauma-Child. J Am Coll Radiol 2020; 17:S125-S137. [PMID: 32370957 DOI: 10.1016/j.jacr.2020.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
Head trauma is a frequent indication for cranial imaging in children. The majority of accidental pediatric head trauma is minor and sustained without intracranial injury. Well-validated pediatric-specific clinical decision guidelines should be used to identify very low-risk children who can safely forgo imaging. In those who require acute imaging, CT is considered the first-line imaging modality for suspected intracranial injury because of the short duration of the examination and its high sensitivity for acute hemorrhage. MRI can accurately detect traumatic complications, but often necessitates sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment. There is a paucity of literature regarding vascular injuries in pediatric blunt head trauma and imaging is typically guided by clinical suspicion. Advanced imaging techniques have the potential to identify changes that are not seen by standard imaging, but data are currently insufficient to support routine clinical use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Maura E Ryan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Orit A Glenn
- University of California San Francisco, San Francisco, California
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | | | - Jennifer R Marin
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Society for Academic Emergency Medicine
| | - Catherine Mazzola
- Rutgers, New Jersey Medical School, Newark, New Jersey; Neurosurgery expert
| | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery Expert
| | | | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | | | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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20
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Berger RP, Furtado AD, Flom LL, Fromkin JB, Panigrahy A. Implementation of a brain injury screen MRI for infants at risk for abusive head trauma. Pediatr Radiol 2020; 50:75-82. [PMID: 31901990 DOI: 10.1007/s00247-019-04506-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/19/2019] [Accepted: 08/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Head computed tomography (CT) is the current standard of care for evaluating infants at high risk of abusive head trauma. OBJECTIVE To both assess the feasibility of using a previously developed magnetic resonance imaging (MRI) brain injury screen (MRBRscreen) in the acute care setting in place of head CT to identify intracranial hemorrhage in high-risk infants and to compare the accuracy of a rapid imaging pulse sequence (single-shot T2 fast spin echo [ssT2FSE]) to a conventional pulse sequence (conventional T2 fast spin echo [conT2FSE]). MATERIALS AND METHODS This was a quality improvement initiative to evaluate infants <12 months of age who were screened for intracranial hemorrhage using an MRBRscreen as part of clinical care. The MRBRscreen included axial conT2FSE, axial gradient recalled echo, coronal T1-weighted inversion recovery, axial diffusion-weighted image and an axial ssT2FSE. A comparison of ssT2FSE to conT2FSE with respect to lesion detection was also performed. RESULTS Of 158 subjects, the MRBRscreen was able to be completed in 155 (98%); 9% (14/155) were abnormal. Ninety-four percent (137/145) of subjects underwent only an MRBRscreen and avoided both radiation from head CT and sedation from MRI. The axial ssT2FSE and conT2FSE results were congruent 99% of the time. CONCLUSION An MRBRscreen in place of a head CT is feasible and potentially could decrease head CT use by more than 90% in this population. Using a rapid ssT2FSE in place of a conT2FSE can reduce total scan time without losing lesion detection. If an MRBRscreen is readily available, physicians' threshold to perform neuroimaging may be lowered and lead to earlier detection of abusive head trauma.
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Affiliation(s)
- Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4117 Penn Ave., Pittsburgh, PA, 15224, USA.
| | - Andre D Furtado
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lynda L Flom
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Janet B Fromkin
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4117 Penn Ave., Pittsburgh, PA, 15224, USA
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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21
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Fingarson A, Fortin K. Yield of Neuroimaging in Infant Physical Abuse Evaluations: Do Infant Age and Injury Type Matter? J Emerg Med 2019; 57:195-202. [DOI: 10.1016/j.jemermed.2019.03.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/22/2019] [Accepted: 03/27/2019] [Indexed: 10/26/2022]
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Compliance With Skeletal Surveys for Child Abuse in General Hospitals: A Statewide Quality Improvement Process. AJR Am J Roentgenol 2019; 212:976-981. [PMID: 30860887 DOI: 10.2214/ajr.18.20701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE. The purpose of this study is to perform a statewide quality improvement process to improve compliance with the American College of Radiology (ACR) guidelines in performing skeletal surveys for suspected child abuse. SUBJECTS AND METHODS. We prospectively identified all outside hospital skeletal surveys for suspected child abuse in children younger than 3 years referred to our tertiary children's hospital in 2016-2017. We included a 3-month baseline and 21-month intervention period. The quality improvement process was based on sending educational material to all ACR member radiologists in the state and making telephone calls to radiology technologist team leaders whenever the surveys were not compliant, followed by e-mails with guidance on performing skeletal surveys. We documented the views obtained and compared them with the ACR guidelines. The percentage of compliance with each individual view was assessed with the chi-square test. The total number of compliant views per survey was evaluated with ANOVA. RESULTS. Two hundred twenty-seven patients (105 female) with a mean age of 0.8 year (SD, 0.67 year; range, 0.01-3 years) were evaluated. These 227 surveys (baseline, n = 27; postintervention, n = 200) were performed at 69 different outside hospitals. Compliance significantly (p = 0.006) improved from 25.9% (7/27) during baseline to 54.0% (108/200) after intervention. There was a nonsignificant trend of improved compliance between the first (51.9%; 41/79) and last 7-month (62.3%; 33/53) periods of intervention. Among individual views, only rib oblique views showed significantly (p = 0.02) improved compliance after the intervention, from 51.9% (14/27) to 73.5% (147/200). CONCLUSION. The compliance rate with ACR guidelines for skeletal surveys in suspected child abuse at outside general hospitals significantly increased after implementation of a quality improvement process.
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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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A descriptive study of accidental skeletal injuries and non-accidental skeletal injuries of child maltreatment. J Forensic Leg Med 2017; 54:14-22. [PMID: 29291497 DOI: 10.1016/j.jflm.2017.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 11/09/2017] [Accepted: 12/18/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Lack of awareness and recognition of child maltreatment is the major reason behind underreporting. All victims often interact with the health care system for routine or emergency care. In several research works, non-accidental fractures are the second most common injury in maltreated children and it is represented up to one-third of cases. AIM OF THE STUDY To determine the incidence of different types of accidental and non-accidental skeletal injuries among children, estimate the severity of injuries according to the modified injury severity score and to determine the degree of fractures either closed or opened (Gustiloe-Anderson open fracture classification). Moreover, identifying fractures resulting from child abuse and neglect. This aimed for early recognition of non-accidental nature of fractures in child maltreatment that can prevent further morbidity and mortality. PATIENTS AND METHOD A descriptive study was carried out on all children (109) with skeletal injuries who were admitted to both Main Alexandria and El-Hadara Orthopedic and Traumatology University Hospitals during six months. History, physical examination and investigations were done for the patients. A detailed questionnaire was taken to diagnose child abuse and neglect. Gustiloe-Anderson open fracture classification was used to estimate the degree of open fractures. RESULTS Out of 109 children, twelve cases (11%) were categorized as child maltreatment. One case was physical abuse, eight cases (7.3%) were child neglect and three cases (2.8%) were labour exploitation. Road traffic accidents (RTA) was the commonest cause of skeletal injuries followed by falling from height. Regarding falls, they included 4 cases of stair falls in neglected children and another four cases of falling from height (balcony/window). The remaining 36 cases of falls were accidental. The skeletal injuries were in the form of fractures in 99 cases, dislocation in two cases, both fracture and/or dislocation in three cases, and bone deformity from brachial plexus injury in five cases. Fractures of the lower limb (42.2%) and both bones of the forearm (35%) represented the highest incidence of skeletal injuries in children. 54.5% of fractures due to neglect were lower limb fractures due to falling from height. Ninety-nine cases were diagnosed as long bone fractures and classified as the following; eighty patients as closed fractures, six patients as open grade I fractures, three patients as open grade II fractures, three patients as open grade IIIA fractures, four patients as open grade IIIB fractures and three patients as open grade IIIC fractures. CONCLUSION AND RECOMMENDATION Cases of neglect and child abuse represented 11% of all the studied cases, where neglect was the main cause. RTA and falling from height represented the most common cause of skeletal injury in children. Most fractures due to neglect were lower limb fractures resulting from falling from height. This demonstrates the need for early detection of neglect and child maltreatment aiming for early initiation of parental educational programs about child care and safety. Misinterpretation of skeletal injuries due to neglect or abuse can be avoided by proper training of orthopedic and traumatology staff on signs of child neglect and abuse.
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Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria ® Suspected Physical Abuse—Child. J Am Coll Radiol 2017; 14:S338-S349. [DOI: 10.1016/j.jacr.2017.01.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
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Elliott CA, Ramaswamy V, Jacob FD, Sankar T, Mehta V. Early diffusion restriction of white matter in infants with small subdural hematomas is associated with delayed atrophy. Childs Nerv Syst 2017; 33:289-295. [PMID: 27766468 DOI: 10.1007/s00381-016-3271-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/05/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of infant morbidity and mortality. In these patients, magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) is the test of choice to describe the extent of microstructural injury. CASE PRESENTATION AND DISCUSSION In this case series, we describe novel acute and chronic MRI findings in four infants (6-19 months) with small, unilateral subdural hematomas in whom the etiology of head injury was suspicious for non-accidental trauma (NAT). Acute (<1-week post-injury) DWI revealed extensive areas of restricted diffusion isolated to the cerebral white matter predominantly ipsilateral to the subdural hematoma. After prolonged pediatric intensive care treatment including subdural evacuation (n = 2) or decompressive craniectomy (n = 1), all patients survived albeit with significant motor and cognitive deficits. Delayed structural MRI (6-9-year post-injury) demonstrated cortical and subcortical atrophy well-correlated with areas of acute restricted diffusion. CONCLUSION These four cases highlight that relatively small subdural hematomas can be associated with extensive white matter injury-detectable only by early DWI-which have long-term structural and functional consequences.
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Affiliation(s)
- Cameron A Elliott
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Vijay Ramaswamy
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Francois D Jacob
- Division of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Tejas Sankar
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Vivek Mehta
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada.
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Young JY, Duhaime AC, Caruso PA, Rincon SP. Comparison of non-sedated brain MRI and CT for the detection of acute traumatic injury in children 6 years of age or less. Emerg Radiol 2016; 23:325-31. [DOI: 10.1007/s10140-016-1392-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 03/18/2016] [Indexed: 11/25/2022]
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Delgado Álvarez I, de la Torre IBM, Vázquez Méndez É. The radiologist's role in child abuse: imaging protocol and differential diagnosis. RADIOLOGIA 2016; 58 Suppl 2:119-28. [PMID: 27091551 DOI: 10.1016/j.rx.2016.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 11/19/2022]
Abstract
Child abuse or nonaccidental trauma is a major problem worldwide; in Spain, there are about 12,000 victims per year. The detection of specific lesions or findings that are incongruent with the reported mechanism of trauma mean that radiologists are often the physician responsible for sounding the alarm in cases of abuse. The triad consisting of subdural hematoma, metaphyseal fracture, and posterior rib fractures is very characteristic of the battered child syndrome. The finding of acute and chronic lesions in the same patient is highly specific for nonaccidental trauma. Fractures of long bones in patients who have yet begun to walk should also alert to possible child abuse. Lesions that are highly specific for abuse, such as classic metaphyseal fractures or posterior rib fractures, can be difficult to demonstrate radiographically and are usually clinically occult. The American College of Radiology (ACR) protocols recommend obtaining three separate X-rays of each upper and lower limb. It is important to use X-ray systems that give high resolution images with low kilovoltage (50-70 kvp) and appropriate milliamperage. A skeletal survey consisting of a series of images collimated to each body region is recommended for all children under the age of two years in whom abuse is suspected. A follow-up skeletal survey about two weeks after the initial survey is useful for detecting new fractures and for assessing the consolidation of others, which helps in dating the lesions. Head injuries are the leading cause of death in abused children. Although computed tomography is the first neuroimaging technique in nonaccidental trauma, magnetic resonance imaging of the head can better characterize the lesions seen on computed tomography and can help to estimate the age of the lesions.
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Affiliation(s)
- I Delgado Álvarez
- Departamento de Radiología Pediátrica, Hospital Universitario Materno Infantil Vall d'Hebron, Barcelona, España.
| | | | - É Vázquez Méndez
- Departamento de Radiología Pediátrica, Hospital Universitario Materno Infantil Vall d'Hebron, Barcelona, España
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Rapid MRI evaluation of acute intracranial hemorrhage in pediatric head trauma. Neuroradiology 2016; 58:793-9. [DOI: 10.1007/s00234-016-1686-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/04/2016] [Indexed: 11/24/2022]
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Flom L, Fromkin J, Panigrahy A, Tyler-Kabara E, Berger RP. Development of a screening MRI for infants at risk for abusive head trauma. Pediatr Radiol 2016; 46:519-26. [PMID: 26589303 PMCID: PMC4814308 DOI: 10.1007/s00247-015-3500-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is an important cause of morbidity in infants. Identifying which well-appearing infants are at risk for AHT and need neuroimaging is challenging, and concern about radiation exposure limits the use of head CT. Availability of an MRI protocol that is highly sensitive for intracranial hemorrhage would allow for AHT screening of well-appearing infants without exposing them to radiation. OBJECTIVE To develop a screening MRI protocol to identify intracranial hemorrhage in well-appearing infants at risk for AHT. MATERIALS AND METHODS Infants enrolled in a parent study of well-appearing infants at increased risk for AHT were eligible for the current study if they underwent both head CT and conventional brain MRI. A derivation cohort of nine infants with AHT was used to identify sequences that provided the highest sensitivity for intracranial hemorrhage. A validation cohort of 78 infants including both controls with normal neuroimaging and cases with AHT was used to evaluate the accuracy of the selected sequences. RESULTS Three pulse sequences - axial T2, axial gradient recalled echo (GRE) and coronal T1-W inversion recovery - were 100% sensitive for intracranial hemorrhage in the derivation cohort. The same sequences were 100% sensitive (25/25) and 83% specific (44/53) for intracranial hemorrhage in the validation cohort. CONCLUSION A screening MRI protocol including axial T2, axial GRE and coronal T1-W inversion recovery sequences is highly sensitive for intracranial hemorrhage and may be useful as a screening tool to differentiate well-appearing infants at risk for AHT who should undergo head CT from those who can safely be discharged without head CT. Additional research is needed to evaluate the feasibility of this approach in clinical practice.
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Affiliation(s)
- Lynda Flom
- Department of Radiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Janet Fromkin
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Ashok Panigrahy
- Department of Radiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Elizabeth Tyler-Kabara
- Department of Neurosurgery, Children’s Hospital of Pittsburgh of UPMC, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rachel P. Berger
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, USA,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
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Slovis TL, Strouse PJ, Strauss KJ. Radiation Exposure in Imaging of Suspected Child Abuse: Benefits versus Risks. J Pediatr 2015; 167:963-8. [PMID: 26354874 DOI: 10.1016/j.jpeds.2015.07.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 05/29/2015] [Accepted: 07/30/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas L Slovis
- Department of Radiology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI
| | - Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Department of Radiology, University of Michigan Health System, Ann Arbor, MI.
| | - Keith J Strauss
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Buttram SDW, Garcia-Filion P, Miller J, Youssfi M, Brown SD, Dalton HJ, Adelson PD. Computed tomography vs magnetic resonance imaging for identifying acute lesions in pediatric traumatic brain injury. Hosp Pediatr 2015; 5:79-84. [PMID: 25646200 DOI: 10.1542/hpeds.2014-0094] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Pediatric traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Computed tomography (CT) is the modality of choice to screen for brain injuries. MRI may provide more clinically relevant information. The purpose of this study was to compare lesion detection between CT and MRI after TBI. METHODS Retrospective cohort of children (0-21 years) with TBI between 2008 and 2010 at a Level 1 pediatric trauma center with a head CT scan on day of injury and a brain MRI scan within 2 weeks of injury. Agreement between CT and MRI was determined by κ statistic and stratified by injury mechanism. RESULTS One hundred five children were studied. Of these, 78% had mild TBI. The MRI scan was obtained a median of 1 day (interquartile range, 1-2) after CT. Overall, CT and MRI demonstrated poor agreement (κ=-0.083; P=.18). MRI detected a greater number of intraparenchymal lesions (n=36; 34%) compared with CT (n=16; 15%) (P<.001). Among patients with abusive head trauma, MRI detected intraparenchymal lesions in 16 (43%), compared with only 4 (11%) lesions with CT (P=.03). Of 8 subjects with a normal CT scan, 6 out of 8 had abnormal lesions on MRI. CONCLUSIONS Compared with CT, MRI identified significantly more intraparenchymal lesions in pediatric TBI, particularly in children with abusive head trauma. The prognostic value of identification of intraparenchymal lesions by MRI is unknown but warrants additional inquiry. Risks and benefits from early MRI (including sedation, time, and lack of radiation exposure) compared with CT should be weighed by clinicians.
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Affiliation(s)
- Sandra D W Buttram
- Divisions of Critical Care Medicine, Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona
| | - Pamela Garcia-Filion
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona Trauma, Phoenix Children's Hospital, Phoenix, Arizona
| | - Jeffrey Miller
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona Radiology and
| | - Mostafa Youssfi
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona Radiology and
| | - S Danielle Brown
- Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona; and
| | - Heidi J Dalton
- Divisions of Critical Care Medicine, Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona
| | - P David Adelson
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona; and
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Nishimoto H. Recent progress and future issues in the management of abusive head trauma. Neurol Med Chir (Tokyo) 2015; 55:296-304. [PMID: 25797781 PMCID: PMC4628176 DOI: 10.2176/nmc.ra.2014-0349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Head trauma is the leading cause of death in child abuse cases and one of the important issues in the care of abused children. Since the Child Abuse Prevention Law was enforced in 2000 in Japan, various measures have been taken to prevent child abuse over the following decade. Accordingly, medical research on abusive head trauma (AHT) has advanced, leading to significant progress in the medical diagnosis of AHT. This progress has been brought about by (1) the widespread establishment of child protection teams (CPTs) at core hospitals, (2) the progress in neuroradiological imaging and ophthalmoscopic technologies, and (3) the introduction of postmortem imaging. However, the pathological condition of patients with AHT, particularly that of the diffuse brain swelling type, still remains poorly understood. As a result, no clear treatment strategies for AHT have been developed and no treatment outcomes have been improved to date. The development of new treatment strategies for AHT and the construction of a comprehensive database that supports clinical studies are required in the future.
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Affiliation(s)
- Hiroshi Nishimoto
- Department of Neurosurgery, Saitama Children's Medical Center, Iwatsuki, 2. Department of Neurosurgery, Kasukabe Municipital Hospital, Kasukabe, Saitama, Japan
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Wittschieber D, Karger B, Niederstadt T, Pfeiffer H, Hahnemann ML. Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications. AJNR Am J Neuroradiol 2015; 36:432-9. [PMID: 24948499 PMCID: PMC8013070 DOI: 10.3174/ajnr.a3989] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Are subdural hygromas the result of abusive head trauma? CT and MR imaging represent important tools for the diagnosis of abusive head trauma in living infants. In addition, in-depth understanding of the pathogenesis of subdural hygromas is increasingly required by neuroradiologists, pediatricians, and forensic physicians. Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. The most important diagnostic pitfalls, benign enlargement of the subarachnoid space, and chronic subdural hematoma, are discussed in detail. Illustrative cases from forensic practice are presented. Literature analysis indicates that subdural hygromas can occur immediately or be delayed. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan.
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Affiliation(s)
- D Wittschieber
- From the Departments of Forensic Medicine (D.W., B.K., H.P.)
| | - B Karger
- From the Departments of Forensic Medicine (D.W., B.K., H.P.)
| | - T Niederstadt
- Clinical Radiology (T.N.), University Hospital Münster, Münster, Germany
| | - H Pfeiffer
- From the Departments of Forensic Medicine (D.W., B.K., H.P.)
| | - M L Hahnemann
- Department of Diagnostic and Interventional Radiology and Neuroradiology (M.L.H.), University Hospital Essen, Essen, Germany
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Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers. Child Adolesc Psychiatr Clin N Am 2015; 24:41-64. [PMID: 25455575 DOI: 10.1016/j.chc.2014.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.
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Vázquez E, Delgado I, Sánchez-Montañez A, Fábrega A, Cano P, Martín N. Imaging abusive head trauma: why use both computed tomography and magnetic resonance imaging? Pediatr Radiol 2014; 44 Suppl 4:S589-603. [PMID: 25501731 DOI: 10.1007/s00247-014-3216-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 09/08/2014] [Accepted: 10/20/2014] [Indexed: 11/25/2022]
Abstract
Abusive head trauma is the leading cause of death in child abuse cases. The majority of victims are infants younger than 1 year old, with the average age between 3 and 8 months, although these injuries can be seen in children up to 5 years old. Many victims have a history of previous abuse and the diagnosis is frequently delayed. Neuroimaging is often crucial for establishing the diagnosis of abusive head trauma as it detects occult injury in 37% of cases. Several imaging patterns are considered to be particularly associated with abusive head trauma. The presence of subdural hematoma, especially in multiple locations, such as the interhemispheric region, over the convexity and in the posterior fossa, is significantly associated with abusive head trauma. Although CT is the recommended first-line imaging modality for suspected abusive head trauma, early MRI is increasingly used alongside CT because it provides a better estimation of shear injuries, hypoxic-ischemic insult and the timing of lesions. This article presents a review of the use and clinical indications of the most pertinent neuroimaging modalities for the diagnosis of abusive head trauma, emphasizing the newer and more sensitive techniques that may be useful to better characterize the nature and evolution of the injury.
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Affiliation(s)
- Elida Vázquez
- Pediatric Radiology Department, Hospital Universitario Vall d'Hebron, UAB, Psg. Vall d'Hebron, 112-119, 08035, Barcelona, Spain,
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Stoodley N, Williams M. The importance of neuroimaging in abusive head trauma. IMAGING 2014. [DOI: 10.1259/img.20110067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Kim H, Kim GD, Yoon BC, Kim K, Kim BJ, Choi YH, Czosnyka M, Oh BM, Kim DJ. Quantitative analysis of computed tomography images and early detection of cerebral edema for pediatric traumatic brain injury patients: retrospective study. BMC Med 2014; 12:186. [PMID: 25339549 PMCID: PMC4219082 DOI: 10.1186/s12916-014-0186-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 09/18/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The purpose of this study was to identify whether the distribution of Hounsfield Unit (HU) values across the intracranial area in computed tomography (CT) images can be used as an effective diagnostic tool for determining the severity of cerebral edema in pediatric traumatic brain injury (TBI) patients. METHODS CT images, medical records and radiology reports on 70 pediatric patients were collected. Based on radiology reports and the Marshall classification, the patients were grouped as mild edema patients (n=37) or severe edema patients (n=33). Automated quantitative analysis using unenhanced CT images was applied to eliminate artifacts and identify the difference in HU value distribution across the intracranial area between these groups. RESULTS The proportion of pixels with HU=17 to 24 was highly correlated with the existence of severe cerebral edema (P<0.01). This proportion was also able to differentiate patients who developed delayed cerebral edema from mild TBI patients. A significant difference between deceased patients and surviving patients in terms of the HU distribution came from the proportion of pixels with HU=19 to HU=23 (P<0.01). CONCLUSIONS The proportion of pixels with an HU value of 17 to 24 in the entire cerebral area of a non-enhanced CT image can be an effective basis for evaluating the severity of cerebral edema. Based on this result, we propose a novel approach for the early detection of severe cerebral edema.
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Affiliation(s)
- Hakseung Kim
- Department of Brain and Cognitive Engineering, Korea University, Anam-dong, Seongbuk-gu, Seoul, 136-713, South Korea.
| | - Gwang-dong Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Byung C Yoon
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
| | - Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Byung-Jo Kim
- Department of Neurology, Korea University College of Medicine, Seoul, South Korea.
| | - Young Hun Choi
- Department of Radiology, Seoul National University Children's Hospital, Seoul, South Korea.
| | - Marek Czosnyka
- Academic Neurosurgical Unit, University of Cambridge Clinical School, Cambridge, UK.
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Dong-Joo Kim
- Department of Brain and Cognitive Engineering, Korea University, Anam-dong, Seongbuk-gu, Seoul, 136-713, South Korea. .,Academic Neurosurgical Unit, University of Cambridge Clinical School, Cambridge, UK.
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ACR Appropriateness Criteria head trauma--child. J Am Coll Radiol 2014; 11:939-47. [PMID: 25164794 DOI: 10.1016/j.jacr.2014.07.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/08/2014] [Indexed: 12/11/2022]
Abstract
Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? AJR Am J Roentgenol 2014; 202:868-71. [PMID: 24660718 DOI: 10.2214/ajr.13.11068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The purpose of our study was to determine whether adding oblique bilateral rib radiography to the skeletal survey for child abuse significantly increases detection of the number of rib fractures. MATERIALS AND METHODS We identified all patients under 2 years old who underwent a skeletal survey for suspected child abuse from January 2003 through July 2011 and who had at least one rib fracture. These patients were age-matched with control subjects without fractures. Two randomized radiographic series of the ribs were performed, one containing two views (anteroposterior and lateral) and another with four views (added right and left oblique). Three fellowship-trained radiologists (two in pediatrics and one in trauma) blinded to original reports independently evaluated the series using a Likert scale of 1 (no fracture) to 5 (definite fracture). We analyzed the following: sensitivity and specificity of the two-view series for detection of any rib fracture and for location (using the four-view series as the reference standard), interobserver variability, and confidence level. RESULTS We identified 212 patients (106 with one or more fractures and 106 without). The sensitivity and specificity of the two-view series were 81% and 91%, respectively. Sensitivity and specificity for detection of posterior rib fractures were 74% and 92%, respectively. There was good agreement between observers for detection of rib fractures in both series (average kappa values of 0.70 and 0.78 for two-views and four-views, respectively). Confidence significantly increased for four-views. CONCLUSION Adding bilateral oblique rib radiographs to the skeletal survey results in increased rib fracture detection and increased confidence of readers.
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Greeley CS. “Shaken baby syndrome” and forensic pathology. Forensic Sci Med Pathol 2014; 10:253-5. [DOI: 10.1007/s12024-014-9540-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2014] [Indexed: 11/28/2022]
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Sieswerda-Hoogendoorn T, Robben SGF, Karst WA, Moesker FM, van Aalderen WM, Laméris JS, van Rijn RR. Abusive head trauma: differentiation between impact and non-impact cases based on neuroimaging findings and skeletal surveys. Eur J Radiol 2013; 83:584-8. [PMID: 24360233 DOI: 10.1016/j.ejrad.2013.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/22/2013] [Accepted: 11/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether imaging findings can be used to differentiate between impact and non-impact head trauma in a group of fatal and non-fatal abusive head trauma (AHT) victims. METHODS We included all AHT cases in the Netherlands in the period 2005-2012 for which a forensic report was written for a court of law, and for which imaging was available for reassessment. Neuroradiological and musculoskeletal findings were scored by an experienced paediatric radiologist. RESULTS We identified 124 AHT cases; data for 104 cases (84%) were available for radiological reassessment. The AHT victims with a skull fracture had fewer hypoxic ischaemic injuries than AHT victims without a skull fracture (p=0.03), but the relative difference was small (33% vs. 57%). There were no significant differences in neuroradiological and musculoskeletal findings between impact and non-impact head trauma cases if the distinction between impact and non-impact head trauma was based on visible head injuries, as determined by clinical examination, as well as on the presence of skull fractures. CONCLUSIONS Neuroradiological and skeletal findings cannot discriminate between impact and non-impact head trauma in abusive head trauma victims.
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Affiliation(s)
- T Sieswerda-Hoogendoorn
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands; Department of Radiology, Academic Medical Center/Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - S G F Robben
- Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - W A Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, P.O. Box 24044, 2490 AA The Hague, The Netherlands.
| | - F M Moesker
- Faculty of Medicine, Academic Medical Center, Amsterdam, The Netherlands.
| | - W M van Aalderen
- Department of Paediatrics, Academic Medical Center/Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - J S Laméris
- Department of Radiology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - R R van Rijn
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands; Department of Radiology, Academic Medical Center/Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Leetch AN, Woolridge D. Emergency Department Evaluation of Child Abuse. Emerg Med Clin North Am 2013; 31:853-73. [DOI: 10.1016/j.emc.2013.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Advanced neuromonitoring and imaging in pediatric traumatic brain injury. Crit Care Res Pract 2012; 2012:361310. [PMID: 22675618 PMCID: PMC3363371 DOI: 10.1155/2012/361310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 03/22/2012] [Indexed: 12/22/2022] Open
Abstract
While the cornerstone of monitoring following severe pediatric traumatic brain injury is serial neurologic examinations, vital signs, and intracranial pressure monitoring, additional techniques may provide useful insight into early detection of evolving brain injury. This paper provides an overview of recent advances in neuromonitoring, neuroimaging, and biomarker analysis of pediatric patients following traumatic brain injury.
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Sieswerda-Hoogendoorn T, Boos S, Spivack B, Bilo RAC, van Rijn RR. Abusive head trauma Part II: radiological aspects. Eur J Pediatr 2012; 171:617-23. [PMID: 22080958 PMCID: PMC3306566 DOI: 10.1007/s00431-011-1611-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 10/11/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis. CONCLUSION The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.
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Affiliation(s)
- Tessa Sieswerda-Hoogendoorn
- Section Forensic Paediatrics, Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands.
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