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Lin K, Khan SS, Truong T, Parsikia A, Mbekeani JN. Characteristics and associations of ocular and non-ocular manifestations of shaken baby syndrome. Childs Nerv Syst 2024:10.1007/s00381-024-06441-5. [PMID: 38709256 DOI: 10.1007/s00381-024-06441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS. METHODS We retrospectively surveyed the National Trauma Data Bank 2008-2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05. RESULTS Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality. CONCLUSIONS Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages.
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Affiliation(s)
- Kira Lin
- Medical School Program, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabine S Khan
- Department of Surgery (Ophthalmology), Jacobi Medical Center,1400, 1400 Pelham Parkway, Bronx, NY, 10461, USA
- Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy Truong
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
| | - Afshin Parsikia
- Department of Research Services, University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce N Mbekeani
- Department of Surgery (Ophthalmology), Jacobi Medical Center,1400, 1400 Pelham Parkway, Bronx, NY, 10461, USA.
- Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine, Bronx, NY, USA.
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Khosravi P, Huck NA, Shahraki K, Hunter SC, Danza CN, Kim SY, Forbes BJ, Dai S, Levin AV, Binenbaum G, Chang PD, Suh DW. Deep Learning Approach for Differentiating Etiologies of Pediatric Retinal Hemorrhages: A Multicenter Study. Int J Mol Sci 2023; 24:15105. [PMID: 37894785 PMCID: PMC10606803 DOI: 10.3390/ijms242015105] [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: 08/25/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Retinal hemorrhages in pediatric patients can be a diagnostic challenge for ophthalmologists. These hemorrhages can occur due to various underlying etiologies, including abusive head trauma, accidental trauma, and medical conditions. Accurate identification of the etiology is crucial for appropriate management and legal considerations. In recent years, deep learning techniques have shown promise in assisting healthcare professionals in making more accurate and timely diagnosis of a variety of disorders. We explore the potential of deep learning approaches for differentiating etiologies of pediatric retinal hemorrhages. Our study, which spanned multiple centers, analyzed 898 images, resulting in a final dataset of 597 retinal hemorrhage fundus photos categorized into medical (49.9%) and trauma (50.1%) etiologies. Deep learning models, specifically those based on ResNet and transformer architectures, were applied; FastViT-SA12, a hybrid transformer model, achieved the highest accuracy (90.55%) and area under the receiver operating characteristic curve (AUC) of 90.55%, while ResNet18 secured the highest sensitivity value (96.77%) on an independent test dataset. The study highlighted areas for optimization in artificial intelligence (AI) models specifically for pediatric retinal hemorrhages. While AI proves valuable in diagnosing these hemorrhages, the expertise of medical professionals remains irreplaceable. Collaborative efforts between AI specialists and pediatric ophthalmologists are crucial to fully harness AI's potential in diagnosing etiologies of pediatric retinal hemorrhages.
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Affiliation(s)
- Pooya Khosravi
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA 92697, USA;
| | - Nolan A. Huck
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
| | - Kourosh Shahraki
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
| | - Stephen C. Hunter
- School of Medicine, University of California, 900 University Ave, Riverside, CA 92521, USA;
| | - Clifford Neil Danza
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
| | - So Young Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan 31151, Chungcheongnam-do, Republic of Korea;
| | - Brian J. Forbes
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (B.J.F.); (G.B.)
| | - Shuan Dai
- Department of Ophthalmology, Queensland Children’s Hospital, South Brisbane, QLD 4101, Australia;
| | - Alex V. Levin
- Department of Ophthalmology, Flaum Eye Institute, Golisano Children’s Hospital, Rochester, NY 14642, USA;
| | - Gil Binenbaum
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (B.J.F.); (G.B.)
| | - Peter D. Chang
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA 92697, USA;
- Department of Radiological Sciences, School of Medicine, University of California, Irvine, CA 92697, USA
| | - Donny W. Suh
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
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Raissaki M, Adamsbaum C, Argyropoulou MI, Choudhary AK, Jeanes A, Mankad K, Mannes I, Van Rijn RR, Offiah AC. Benign enlargement of the subarachnoid spaces and subdural collections-when to evaluate for abuse. Pediatr Radiol 2023; 53:752-767. [PMID: 36856756 PMCID: PMC10027800 DOI: 10.1007/s00247-023-05611-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 03/02/2023]
Abstract
In infants without a history of trauma, subdural haemorrhages should raise the concern for an abusive head injury, particularly when they are associated with bridging vein clotting/rupture or with septations. However, non-haemorrhagic, fluid-appearing subdural collections (also called hygromas) may also be the result of abuse. Subdural collections have also been uncommonly observed in patients with benign enlargement of the subarachnoid spaces (BESS) and a few large-scale studies accurately investigate the incidence and the significance. Currently, there is a wide variation of practices in children with BESS and subdural collections. Due to the social risks associated with abuse evaluation and the perceived risk of radiation exposure, there might be a reluctance to fully evaluate these children in some centres. The diagnosis of physical abuse cannot be substantiated nor safely excluded in infants with BESS and subdural collection(s), without investigation for concomitant traumatic findings. The exact prevalence of occult injuries and abuse in these infants is unknown. In macrocephalic infants with subdural collections and imaging features of BESS, thorough investigations for abuse are warranted and paediatricians should consider performing full skeletal surveys even when fundoscopy, social work consult, and detailed clinical evaluation are unremarkable.
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Affiliation(s)
- Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece.
| | - Catherine Adamsbaum
- Emeritus Pediatric Radiologist, Faculty of Medicine, Paris-Saclay University, 63 Rue Gabriel Péri, 94270, Le Kremlin Bicêtre, France
| | - Maria I Argyropoulou
- Department of Clinical Radiology and Imaging, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | - Arabinda K Choudhary
- Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Inès Mannes
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin‑Bicêtre, France
| | - Rick R Van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Amaka C Offiah
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
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Primalani NK, Chan YH, Ng ZM, Chong SL, Seow WT, Loh LE, Mok YH, Low SYY. Abusive head injury in the very young: outcomes from a Singapore children's hospital. Childs Nerv Syst 2022; 38:2397-2407. [PMID: 35851614 DOI: 10.1007/s00381-022-05572-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is a serious problem in children. The aims of this study are to identify risk factors that correlate with outcomes for those requiring neurosurgical intervention for very young children with AHT, assessment of variables associated with outcomes, and corroboration of our results with literature. METHODS This is an ethics-approved, retrospective study. Inclusion criteria consisted of patients aged 2 years old or less with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. Logistic regression was applied to statistically significant variables for the risk prediction model. RESULTS From 2000 to 2020, 24 patients required surgery for AHT. Timepoint was set at 12 months post-diagnosis. Univariate analyses demonstrated that patients with mild TBI were likely to have a favourable GOS-E Peds (p = 0.01), whereas radiological presence of cerebral oedema (p < .001), development of scar epilepsy (p = 0.021), and progression to cerebral palsy (p = 0.001) were associated with unfavourable GOS-E Peds. CONCLUSION This is the first study focused on neurosurgical outcomes for very young children with AHT in Singapore. We advocate multidisciplinary efforts to improve outcomes for this devastating condition.
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Affiliation(s)
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, Clinical Research Centre, #02-03 (c/o CBmE Office), 10 Medical Drive, Singapore, 117597, Singapore
| | - Zhi Min Ng
- Neurology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore. .,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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Ho MC, Wu AL, Wang NK, Chen KJ, Hwang YS, Lai CC, Wu WC. SURGICAL OUTCOME AND PROGNOSTIC FACTORS AFTER OPHTHALMIC SURGERY IN ABUSIVE HEAD TRAUMA. Retina 2022; 42:967-972. [PMID: 35125478 DOI: 10.1097/iae.0000000000003421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To analyze the clinical characteristics, surgical outcomes, and risk factors associated with visual outcomes in patients with abusive head trauma (AHT). METHODS We retrospectively reviewed surgical outcomes of patients with AHT who underwent vitrectomy from 2001 to 2019. The patients' demographics, comprehensive preoperative and postoperative ocular findings, surgical treatments, visual outcomes, and postoperative complications in the medical records were reviewed. Univariable and multivariable analyses were performed to identify the prognostic factors associated with visual outcomes. RESULTS Fourteen children (18 eyes) diagnosed with AHT who underwent vitrectomy were evaluated. The most common surgical indication was vitreous hemorrhage (n = 6, 33%). Retinal attachment at the final visit was noted in 17 eyes (94%). Thirteen eyes (72%) had a best-corrected visual acuity less than 20/200 after vitrectomy. In the multivariable analysis, optic nerve atrophy (n = 9, 50%) was significantly associated with a poor visual prognosis (final best-corrected visual acuity worse than 20/200) after vitrectomy in children with AHT (95% confidence interval, 1.041-517.963, P = 0.0471). CONCLUSION The general visual prognosis was poor for patients with AHT needing vitrectomy, although a high rate of retinal attachment was observed. Optic nerve atrophy is a prognostic factor for poor visual outcomes in patients with AHT who received ophthalmic surgery.
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Affiliation(s)
- Ming-Chih Ho
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - An-Lun Wu
- Department of Ophthalmology, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan; and
| | - Nan-Kai Wang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Jen Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yih-Shiou Hwang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Ophthalmology, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan; and
| | - Chi-Chun Lai
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Cho IH, Kim MS, Heo NH, Kim SY. Birth-related retinal hemorrhages: The Soonchunhyang University Cheonan Hospital universal newborn eye screening (SUCH-NES) study. PLoS One 2021; 16:e0259378. [PMID: 34752467 PMCID: PMC8577753 DOI: 10.1371/journal.pone.0259378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To report the prevalence, related factors, and characteristics of birth-related retinal hemorrhages (RHs) according to their severity in healthy newborns using a telemedicine network and wide-field digital retinal imaging (WFDRI). Methods Newborns who underwent WFDRI at 61 obstetrics/gynecology hospitals between January 2017 and December 2019 were enrolled. Demographics and related factors were compared among newborns with and without RHs. The newborns’ eyes were divided into the minimal, mild, moderate, and severe groups according to the number of RHs, and characteristics like bilaterality, laterality, involved retinal layer, involved zone, macular and/or optic nerve (ON) involvement were compared. Results Among 56247 newborns, 13026 had birth-related RHs (23.2%). Normal spontaneous vaginal delivery (NSVD) showed the highest association with RHs (odds ratio, 19.774; 95% confidence interval, 18.277–21.393; P < 0.001) on multivariate analysis. Bilateral RHs (8414/13026; 64.59%) were more common than unilateral RHs (4612/13026; 35.41%); however, unilateral RHs (2383/4217; 56.51%) were more common than bilateral RHs (1834/4217; 43.49%) in the minimal group. RHs showed no laterality differences between the two eyes (P = 0.493). Most RHs were intraretinal (18678/21440; 87.12%), and 2328 (31.65%) eyes with preretinal hemorrhage were observed in the severe group. Zone I RHs were common in the minimal (7072/7090; 99.75%), mild (4953/4960; 99.86%), and moderate (2013/2035; 98.92%) groups; zone I and II RHs were common in the severe group (4843/7355; 65.85%); and RHs in zone III were rare (7/21440; 0.03%). Most RHs showed no macular and/or ON involvement in the minimal and mild group; however, this was common in the severe group (7111/7355; 96.68%). Conclusions Birth-related RHs were common in healthy newborns and were significantly associated with NSVD. RHs were usually bilateral, intraretinal, and distributed posterior to the retina, but severe RHs had unique characteristics. Future long-term and longitudinal studies are required to elucidate the prognosis of severe RHs.
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Affiliation(s)
- In Hwan Cho
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Min Seong Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Nam Hun Heo
- Clinical Trial Center, Soonchunhyang University, Cheonan, Korea
| | - So Young Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
- * E-mail:
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Zhao D, Wang Q, Cao Z. Forensic examination of abusive head trauma in child abuse cases. JOURNAL OF FORENSIC SCIENCE AND MEDICINE 2021. [DOI: 10.4103/jfsm.jfsm_44_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lee WJ, Lim YC, Yoon SH. Abusive Head Traumas in 4 Infants. Korean J Neurotrauma 2020; 16:246-253. [PMID: 33163433 PMCID: PMC7607025 DOI: 10.13004/kjnt.2020.16.e30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 12/19/2022] Open
Abstract
Pediatric abusive head trauma (AHT) is a serious, repeated child abuse that causes grave brain damage. In Korea, AHT cases have been reported rarely, especially infants. We present 4 cases of AHT in infants diagnosed in our institution during last 2 years. We collected the demographic data, ophthalmologic examination, imaging study, and outcomes. The mean age was 7.2 months, and 2 infants were girls and the others were boys. All four were admitted with no history of head trauma, and among them 2 patients presented with an episode of seizure and respiratory arrest with no history of head trauma. The initial mental status was semi-coma in 3 cases, and stupor in 1 case. There were multiple retinal hemorrhages in both eyes in 2 cases; one had multiple old fractures on the extremities and another child showed multiple skull fractures. All patients underwent emergent surgery for acute bilateral subdural hemorrhages; 3 had craniotomy and another had burr-hole drainage. Two children expired and the other 2 are in vegetative status. The AHT has recently become more frequent in Korea so that neurosurgeons must alert AHT even in infants with head trauma.
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Affiliation(s)
- Won Jae Lee
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Soo Han Yoon
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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Kozner P, Stepankova J, Dotrelova D. Long-term evaluation of pars plana vitrectomy in children with Abusive head trauma. Eur J Ophthalmol 2020; 32:553-558. [PMID: 33118379 DOI: 10.1177/1120672120968760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine the efficacy of pars plana vitrectomy (PPV) in children with intraocular hemorrhage (IOH) secondary to Abusive head trauma (AHT). METHODS A long-term retrospective analysis evaluating epidemiology, management, safety, anatomical and functional results of PPV for IOH in children with AHT at tertiary referral center for children in the Czech Republic from 2004 to 2017. RESULTS 18 children were identified with IOH due to AHT during observation period of 14 years. Overall incidence of IOH related to AHT was 29.6/100 000, in children under 1 year 22.2/100 000, in children 1 to 5 years 7.4/100 000. Mean age at the time of diagnosis was 13.7 (SD±20.53) months, median 5 months. IOH resolved in 56% of children, 64% eyes, spontaneously. 44% children, 36% eyes, underwent PPV. PPV was performed 30.5 (SD±16.98) days after established diagnosis on average. Postoperatively, 80% of eyes had anatomical improvement, 20% eyes had preexisting irreversible changes in the posterior pole. Vision of 50% eyes improved after surgery, vision of 20% eyes remained poor, 30% of eyes was not possible to test due to severe neurological impairment. Mean observational period was 33.4 (SD±38.21) months. Mortality rate of AHT in our group was 17%, all victims were younger 4 months. CONCLUSIONS PPV is a safe and effective procedure to clear IOH in children with AHT. Ophthalmology outcomes are strongly associated with degree of neurological impairment. Best outcomes were achieved with PPV performed between 2 and 5 weeks after trauma. Opportunity to plan surgery within this time frame indicates a good neurological prospect and prevents deprivation amblyopia.
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Affiliation(s)
- Pavel Kozner
- Department of Ophthalmology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jana Stepankova
- Department of Ophthalmology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Dagmar Dotrelova
- Department of Ophthalmology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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Gencturk M, Cam I, Koksel Y, McKinney AM. Role of Susceptibility-Weighted Imaging in Detecting Retinal Hemorrhages in Children with Head Trauma. Clin Neuroradiol 2020; 31:611-617. [DOI: 10.1007/s00062-020-00939-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/09/2020] [Indexed: 11/25/2022]
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Modeling Hypertension as a Contributor to Retinal Hemorrhaging from Abusive Head Trauma. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:4714927. [PMID: 32566113 PMCID: PMC7256766 DOI: 10.1155/2020/4714927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 12/31/2019] [Accepted: 01/20/2020] [Indexed: 12/05/2022]
Abstract
Retinal hemorrhaging (RH) is indicative and prevalent in abusive head trauma (AHT)—yet the direct cause of the RH from AHT is unknown. Our hypothesis is that RH in AHT is the combination of shaking forces and hypertension. This combination of effects explains why RH is not normally observed in common childhood accidents but is nearly exclusively observed in AHT. An experimental model using porcine eyes was designed to ascertain the required pressure change for sudden RH and, via a computer model, the subsequent stress increase in blood vessels. The porcine eyes were cannulated via the maxillary artery and pressurized until perfusion and RH were observed. Fluid was injected into the head with a computer-controlled continuous flow syringe pump; video of the fundus was recorded during perfusion; and the pressure of the fluid entering the eye was recorded as well. A computer model was created in COMSOL to simulate loading from hypertension, shaking, and the combination of the forces. This model was validated via experimental data collected from the porcine model. It was found that hypertension or shaking alone did not cause an increase in stress required to cause RH. But when the loading of shaking and hypertension was combined, as would occur in AHT, the stress increases were greater than those extrapolated from the porcine model and would cause RH.
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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13
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Gimaldinova NE, Ignatyeva EN, Lubovceva LA, Vorobyeva OV. [Pathomorphological features of baby shaking syndrome]. Sud Med Ekspert 2020; 63:19-22. [PMID: 32597606 DOI: 10.17116/sudmed20206303119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The aim of study is to identify pathomorphological changes of the Central nervous system in childhood with rarely diagnosed of «baby shaking» syndrome on the example of sectional case. The analysis of medical documentation (medical history and outpatient card of the child) was done. The standard method of opening the skull cavity of infants was used. Histological cuts of autopsy material were treated with hematoxilin-eosin coloring. The relationship of clinical and morphological manifestations of this pathology with anatomical and physiological features of the structure of the Central nervous system and its blood supply in children was stated. We describe in details the characteristic pathomorphological changes in the brain in childhood that occur with this syndrome. Dark red «flattened» blood coagulations of subtentorial localization and in the left convexital region were visualized in the cranial cavity. We paid attention to the presence of numerous bridge veins of the brain, flowing into the sagittal sinus (frontal and parietal) and the transverse sinus.
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Affiliation(s)
- N E Gimaldinova
- Chuvash State University named after I.N. Ulyanov, Cheboksary, Russia
| | - E N Ignatyeva
- Chuvash State University named after I.N. Ulyanov, Cheboksary, Russia
| | - L A Lubovceva
- Chuvash State University named after I.N. Ulyanov, Cheboksary, Russia
| | - O V Vorobyeva
- Chuvash State University named after I.N. Ulyanov, Cheboksary, Russia
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Shouldice M, Al-Khattabi F, Thau A, McIntyre S, Ng WKY, Levin AV. Traumatic macular retinoschisis in infants and children. J AAPOS 2018; 22:433-437.e2. [PMID: 30394342 DOI: 10.1016/j.jaapos.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide detailed description of pediatric traumatic retinoschisis. METHODS The medical records of children with either abusive head trauma and traumatic macular retinoschisis seen at a single center from 1993 to 2006 were reviewed retrospectively. Clinical details were extracted from the record and photographic documentation. Evaluation regarding abuse excluded ophthalmology findings to avoid circular reasoning. RESULTS Of 134 patients with suspected abusive head trauma, 31 had retinoschisis. Mean age was 9 months. Of the 31, 22 (71%) offered a history of injury, and 9 (29%) were found unresponsive without history of injury; 6 were reportedly shaken. All patients had seizures, vomiting, and/or altered responsiveness. All had subdural hemorrhage, with cerebral edema in 17 (55%). In 10 (32%), there were findings of blunt force head injuries; in 4 of these there was no impact history. Retinal hemorrhages were present in all cases. Agreement between sidedness of retinoschisis and subdural hemorrhage was poor. Eleven patients had retinal folds, 3 of which had a hemorrhagic edge to the schisis. Nine patients had extracranial manifestations of abuse. Multidisciplinary team adjudications were as follows: of the 31 cases, 18 were suspicious for abuse, 11 were indeterminate, and 2 were possibly accounted for by accidental severe crush injury. Three children died, and 11 suffered neurological sequelae. CONCLUSIONS Traumatic retinoschisis in children is highly associated with subdural hemorrhage, neurologic symptoms, and poor outcomes. Even with a conservative approach to opinion formulation, traumatic retinoschisis was associated with likely abuse.
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Affiliation(s)
| | - Fadiah Al-Khattabi
- College of Medicine at Alfaisal University, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Avrey Thau
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan McIntyre
- Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Wendy K Y Ng
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Alex V Levin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania.
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Elinder G, Eriksson A, Hallberg B, Lynøe N, Sundgren PM, Rosén M, Engström I, Erlandsson BE. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr 2018; 107 Suppl 472:3-23. [PMID: 30146789 PMCID: PMC6585638 DOI: 10.1111/apa.14473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/30/2022]
Abstract
The Swedish Agency for Health Technology Assessment and Assesment of Social Services (SBU) is an independent national authority, tasked by the government with assessing methods used in health, medical and dental services and social service interventions from a broad perspective, covering medical, economic, ethical and social aspects. The language in SBU's reports are adjusted to a wide audience. SBU's Board of Directors has approved the conclusions in this report. The systematic review showed the following graded results: There is limited scientific evidence that the triad (Three components of a whole. The triad associated with SBS usually comprises subdural haematoma, retinal haemorrhages and encephalopathy.) and therefore, its components can be associated with traumatic shaking (low-quality evidence). There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). Limited scientific evidence (low-quality evidence) represents a combined assessment of studies of high or moderate quality which disclose factors that markedly weaken the evidence. It is important to note that limited scientific evidence for the reliability of a method or an effect does not imply complete lack of scientific support. Insufficient scientific evidence (very low-quality evidence) represents either a lack of studies or situations when available studies are of low quality or show contradictory results. Evaluation of the evidence was not based on formal grading of the evidence according to GRADE but on an evaluation of the total scientific basis.
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Affiliation(s)
- Göran Elinder
- Department of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation, Forensic Medicine, Umeå University, Umeå, Sweden
- The National Board of Forensic Medicine, Sweden
| | - Boubou Hallberg
- Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Niels Lynøe
- Medical Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Pia Maly Sundgren
- Diagnostic Radiology, Lund University, Lund, Sweden
- Department of Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Måns Rosén
- Health Technology Assessment, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Engström
- Child and Adolecent Psychiatry, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Impact of positive end expiratory pressure on cerebral hemodynamic in paediatric patients with post-traumatic brain swelling treated by surgical decompression. PLoS One 2018; 13:e0196980. [PMID: 29746600 PMCID: PMC5944965 DOI: 10.1371/journal.pone.0196980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 04/24/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction The objective of our present study is to evaluate the impact of different PEEP levels on cerebral hemodynamic, gas exchanges and respiratory system mechanics in paediatric patients with post-traumatic brain swelling treated with decompressive craniectomy (DC). Materials and methods A prospective physiologic study was carried out on 14 paediatric patients presenting with severe traumatic brain swelling treated with DC. Transcranial Doppler ultrasonography was performed on the middle cerebral artery bilaterally after DC. After assessment at ZEEP, intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), central venous pressure (CVP) and gas exchanges were recorded at PEEP 4 and PEEP 8. Results From ZEEP to PEEP 8, the compliance of respiratory system indexed to the weight of the patient significantly increased (P = 0.02) without ICP modifications. No significant variation of the MAP, CPP, Vmed, the total resistance of respiratory system and ohmic resistance of the respiratory system indexed to the weight of the patients was observed. CVP significantly increased between ZEEP and PEEP 8 (P = 0.005), and between PEEP 4 and PEEP 8 (P = 0.05). Conclusions PEEP values up to 8 cmH20 seem to be safe in paediatric patients with a severe post-traumatic brain swelling treated with DC.
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Levin AV. The SBU report: a different view. Acta Paediatr 2017; 106:1037-1039. [PMID: 28301061 DOI: 10.1111/apa.13834] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/13/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Alex V. Levin
- Pediatric Ophthalmology and Ocular Genetics; Wills Eye Hospital; Thomas Jefferson University; Philadelphia PA USA
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Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A. Insufficient evidence for 'shaken baby syndrome' - a systematic review. Acta Paediatr 2017; 106:1021-1027. [PMID: 28130787 DOI: 10.1111/apa.13760] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/24/2017] [Indexed: 01/08/2023]
Abstract
Shaken baby syndrome has typically been associated with findings of subdural haematoma, retinal haemorrhages and encephalopathy, which are referred to as the triad. During the last decade, however, the certainty with which the triad can indicate that an infant has been violently shaken has been increasingly questioned. The aim of this study was to determine the diagnostic accuracy of the triad in detecting that an infant had been shaken. The literature search was performed using PubMed, Embase and the Cochrane Library up to October 15, 2015. Relevant publications were assessed for the risk of bias using the QUADAS tool and were classified as having a low, moderate or high risk of bias according to predefined criteria. The reference standards were confessions or witnessed cases of shaking or accidents. The search generated 3773 abstracts, 1064 were assessed as possibly relevant and read as full texts, and 30 studies were ultimately included. Of these, 28 were assessed as having a high risk of bias, which was associated with methodological shortcomings as well as circular reasoning when classifying shaken baby cases and controls. The two studies with a moderate risk of bias used confessions and convictions when classifying shaken baby cases, but their different designs made a meta-analysis impossible. None of the studies had a low risk of bias. CONCLUSION The systematic review indicates that there is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). It was also demonstrated that there is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low-quality evidence).
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Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healthcare Ethics; Karolinska Institutet; Stockholm Sweden
| | - Göran Elinder
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; and Karolinska University Hospital; Stockholm Sweden
| | - Måns Rosén
- Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Pia Sundgren
- Department of Diagnostic Radiology, Clinical Sciences; Lund University; Lund Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation; Forensic Medicine; Umeå University Umeå Sweden
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Callaway NF, Ludwig CA, Blumenkranz MS, Jones JM, Fredrick DR, Moshfeghi DM. Retinal and Optic Nerve Hemorrhages in the Newborn Infant: One-Year Results of the Newborn Eye Screen Test Study. Ophthalmology 2016; 123:1043-52. [PMID: 26875004 DOI: 10.1016/j.ophtha.2016.01.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/01/2016] [Accepted: 01/05/2016] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To report the birth prevalence, risk factors, characteristics, and location of fundus hemorrhages (FHs) of the retina and optic nerve present in newborns at birth. DESIGN Prospective cohort study at Stanford University School of Medicine. PARTICIPANTS All infants who were 37 weeks postmenstrual age or older and stable were eligible for screening. Infants with known or suspected infectious conjunctivitis were excluded. METHODS Infants born at Lucile Packard Children's Hospital (LPCH) from July 25, 2013, through July 25, 2014, were offered universal newborn screening via wide-angle digital retinal photography in the Newborn Eye Screen Test study. Maternal, obstetric, and neonatal factors were obtained from hospital records. The location, retinal layer, and laterality of FH were recorded by 1 pediatric vitreoretinal specialist. MAIN OUTCOME MEASURES Birth prevalence of FH. Secondary outcomes included rate of adverse events, risk factors for FH, hemorrhage characteristics, and adverse events. RESULTS The birth prevalence of FH in this study was 20.3% (41/202 infants). Ninety-five percent of FHs involved the periphery, 83% involved the macula, and 71% involved multiple layers of the retina. The fovea was involved in 15% of FH cases (birth prevalence, 3.0%). No cases of bilateral foveal hemorrhage were found. Fundus hemorrhages were more common in the left eye than the right. Fundus hemorrhages were most commonly optic nerve flame hemorrhages (48%) and white-centered retinal hemorrhages (30%). Retinal hemorrhages were found most frequently in all 4 quadrants (35%) and more often were multiple than solitary. Macular hemorrhages most often were intraretinal (40%). Among the risk factors examined in this study, vaginal delivery compared with cesarean section (odds ratio [OR], 9.34; 95% confidence interval [CI], 2.57-33.97) showed the greatest level of association with FH. Self-identified ethnicity as Hispanic or Latino showed a protective effect (OR, 0.43; 95% CI, 0.20-0.94). Other study factors were not significant. CONCLUSIONS Fundus hemorrhages are common among newborns. They often involve multiple areas and layers of the retina. Vaginal delivery was associated with a significantly increased risk of FH, whereas self-identified Hispanic or Latino ethnicity was protective against FH in this study. The long-term consequences of FH on visual development remain unknown.
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Affiliation(s)
- Natalia F Callaway
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Cassie A Ludwig
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Mark S Blumenkranz
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Michelle Jones
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Douglas R Fredrick
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Darius M Moshfeghi
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California.
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Beavers AJ, Stagner AM, Allbery SM, Lyden ER, Hejkal TW, Haney SB. MR detection of retinal hemorrhages: correlation with graded ophthalmologic exam. Pediatr Radiol 2015; 45:1363-71. [PMID: 25737098 DOI: 10.1007/s00247-015-3312-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 12/21/2014] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Dilated fundoscopic exam is considered the gold standard for detecting retinal hemorrhage, but expertise in obtaining this exam is not always immediately available. MRI can detect retinal hemorrhages, but correlation of the grade or severity of retinal hemorrhage on dilated fundoscopic exam with retinal hemorrhage visibility on MRI has not been described. OBJECTIVE To determine the value of standard brain protocol MRI in detecting retinal hemorrhage and to determine whether there is any correlation with MR detection of retinal hemorrhage and the dilated fundoscopic exam grade of hemorrhage. MATERIALS AND METHODS We conducted a retrospective chart review of 77 children <2 years old who were seen for head trauma from April 2007 to July 2013 and had both brain MRI and dilated fundoscopic exam or retinal camera images. A staff pediatric radiologist and radiology resident reviewed the MR images. Retinal hemorrhages were graded by a chief ophthalmology resident on a 12-point scale based on the retinal hemorrhage type, size, location and extent as seen on review of retinal camera images and detailed reports by ophthalmologists. Higher scores indicated increased severity of retinal hemorrhages. RESULTS There was a statistically significant difference in the median grade of retinal hemorrhage examination between children who had retinal hemorrhage detected on MRI and children who did not have retinal hemorrhage detected on MRI (P = 0.02). When examination grade was categorized as low-grade (1-4), moderate-grade (5-8) or high-grade (>8) hemorrhage, there was a statistically significant association between exam grade and diagnosis based on MRI (P = 0.008). For example, only 14% of children with low-grade retinal hemorrhages were identified on MRI compared to 76% of children with high-grade hemorrhages. MR detection of retinal hemorrhage demonstrated a sensitivity of 61%, specificity of 100%, positive predictive value of 100% and negative predictive value of 63%. Retinal hemorrhage was best seen on the gradient recalled echo (GRE) sequences. CONCLUSION MRI using routine brain protocol demonstrated 61% sensitivity and 100% specificity in detecting retinal hemorrhage. High-grade hemorrhage was more often detected on MRI than low-grade hemorrhage, 76% vs. 14%. GRE images were the most sensitive for detection of retinal hemorrhages. A dilated fundoscopic exam can be difficult to obtain in infancy, especially in critically ill or non-sedated children. MRI is a useful modality for added documentation of retinal hemorrhage and can be used as an alternative exam when ophthalmologic expertise or retinal camera images are unavailable. Additionally, identification of retinal hemorrhage on MRI can raise the possibility of abuse in children presenting with nonspecific findings.
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Affiliation(s)
- Angela J Beavers
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE, 68198-1045, USA,
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Abstract
Shaken Baby Syndrome occurs in infants as a result of the brain pushing against the skull due to severe acceleration-deceleration forces. Symptoms of Shaken Baby Syndrome include subdural, subarachnoid, and retinal hemorrhages. MRI and ocular examinations are used to determine the extent of mental and visual damage and β-amyloid precursor protein immunohistochemical staining is used to detect axonal injuries. Surgeries such as Subdural hemorrhage (SDH) evacuation surgery and the Burr hole craniotomy are used to treat Shaken Baby Syndrome; however, the prognosis is poor in many cases. Because of the severity of Shaken Baby Syndrome and its traumatic and sometimes fatal effects, it is important to educate new parents, nurses, and doctors on the syndrome in order to prevent incidents.
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Affiliation(s)
- Maha Mian
- 1SUNY Stony Brook, Physiology and Biophysics, Stony Brook , New York , USA
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Salvatori MC, Lantz PE. Retinal haemorrhages associated with fatal paediatric infections. MEDICINE, SCIENCE, AND THE LAW 2015; 55:121-128. [PMID: 24644226 DOI: 10.1177/0025802414527077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
For many physicians, retinal haemorrhages (RHs) in infants and young children remain highly diagnostic of non-accidental (abusive) head trauma. Because clinicians have applied indirect ophthalmoscopy selectively to cases of suspected child abuse, the association between RH and other conditions such as infection, coagulopathy and accidental trauma has encountered habitual bias, creating the potential for iatrogenic misdiagnosis of child abuse. We present an autopsy case series of four children, aged three years old or younger, in whom RHs were detected by post-mortem monocular indirect ophthalmoscopy after the patients had died from infections. We discuss the laterality, number, type and location of RHs in these cases, and summarize proposed mechanisms of RH formation in fatalities from paediatric infection. We demonstrate that many of the ophthalmological findings that have been considered diagnostic of abusive head trauma can also occur in association with infective processes.
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Affiliation(s)
| | - Patrick E Lantz
- Department of Pathology, Wake Forest University School of Medicine, USA
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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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Levin AV. Retinal hemorrhages: what are we talking about? J AAPOS 2014; 18:521-2. [PMID: 25498460 DOI: 10.1016/j.jaapos.2014.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 11/06/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Alex V Levin
- Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Abstract
Retinal hemorrhages in children in the absence of risk factors are regarded to be pathognomonic of shaken baby syndrome or other nonaccidental injuries. The physician must decide whether the retinal hemorrhages in children without risk factors are due to abuse or cardiopulmonary resuscitation with chest compression (CPR-CC). The objective of this study was to determine if CPR-CC can lead to retinal hemorrhages in children. Twenty-two patients who received in-hospital CPR-CC between February 15, 1990, and June 15, 1990, were enrolled. Pediatric ophthalmology fellows carried a code beeper and responded to calls for cardiopulmonary arrest situations. At the scene of CPR-CC, an indirect funduscopic examination was conducted for presence of retinal hemorrhages in the posterior pole. Follow-up examinations were performed at 24 and 72 hours. Of the 22 patients, 6 (27%) had retinal hemorrhages at the time of CPR-CC. Of these 6 patients, 5 had risk factors for retinal hemorrhages. The sixth patient had no risk factors and may have represented the only true case of retinal hemorrhages due to CPR-CC. Retinal hemorrhages are uncommon findings after CPR-CC. Retinal hemorrhages that are found after CPR-CC usually occur in the presence of other risk factors for hemorrhage with a mild hemorrhagic retinopathy in the posterior pole.
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Alzahrani M, Ratelle J, Cavel O, Laberge-Malo M, Saliba I. Hearing loss in the shaken baby syndrome. Int J Pediatr Otorhinolaryngol 2014; 78:804-6. [PMID: 24646684 DOI: 10.1016/j.ijporl.2014.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 02/15/2014] [Accepted: 02/17/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate hearing in children diagnosed with shaken baby syndrome. METHODS A retrospective study conducted in a pediatric tertiary care center between 2006 and 2012. Children diagnosed with shaken baby syndrome were included for hearing evaluation by conventional audiometry, distortion product otoacoustic emissions and auditory brainstem responses. RESULTS Twenty-eight children were included (22 boys and 6 girls). The mean age of children at presentation was 8 months (range 1-26 months) and the mean delay before audiometric evaluation was 30 months (range 1-87 months). One child was diagnosed as having a moderate sensorineural hearing loss. The tympanic membrane mobility was normal (type A) for both ears in 22 children, one child had a reduced tympanic mobility in one ear, two children had a negative pressure, one child had a functional trans-tympanic tube and test was not performed in 2 patients. CONCLUSION This is the first study reporting hearing loss as a possible result of shaken baby syndrome. However, further studies with larger number of children would be preferable. We recommend hearing evaluation for these children to rule out hearing loss.
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Affiliation(s)
- Musaed Alzahrani
- Division of Otorhinolaryngology, University of Montreal, Montreal, QC, Canada
| | - Justine Ratelle
- Department of Audiology, Sainte-Justine University Hospital, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC H3T 1C5, Canada
| | - Oren Cavel
- Division of Otorhinolaryngology, University of Montreal, Montreal, QC, Canada
| | - Marie Laberge-Malo
- Department of Pediatrics, Sainte-Justine University Hospital (CHUSJ), 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC H3T 1C5, Canada
| | - Issam Saliba
- Division of Otorhinolaryngology Head & Neck Surgery, University of Montreal, Otology and Neurotology, Sainte-Justine University Hospital Center (CHUSJ) and University of Montreal Hospital Center (CHUM), Montreal, QC, Canada.
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Segev-Becker A, Har-Gil M, Fainmesser P, Assia EL, Watemberg N. Yield and clinical efficacy of funduscopic examinations performed in the pediatric emergency room. Eur J Pediatr 2014; 173:375-9. [PMID: 24146164 DOI: 10.1007/s00431-013-2176-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 10/02/2013] [Indexed: 11/24/2022]
Abstract
UNLABELLED Consultations by ophthalmologists to rule out papilledema are frequently requested by emergency room (ER) physicians. The clinical setting and optimal timing for examination are not well established, and the impact on patient management is unclear. We evaluated the yield of emergency funduscopic examinations, aiming at establishing the optimal timing and efficacy of the consultation. The medical records of all children aged 0-18 years referred for funduscopic examinations from the ER between June 2010 and May 2011 were reviewed. Of 19,772 ER visits, 1,920 (9.7 %) were seen by an ophthalmologist and 479 (2.4 %) to rule out papilledema. Headache (44.5 %) and head trauma (18.4 %) were the most common indications. Sixty percent of the 479 patients had been symptomatic for <24 h, all having normal eye exams. Only 6/479, with diverse etiologies, depicted papilledema. Among these six children, visual complaints associating with headache were statistically significant to suggest the presence of papilledema (p = 0.014). Seventy-one of the 479 children underwent neuroimaging studies despite normal funduscopic examinations. A single tumor case (medulloblastoma), symptomatic for weeks, had normal funduscopy. CONCLUSION The vast majority of ER consultations to rule out papilledema show normal findings, particularly among children with signs and symptoms lasting for <24 h. The yield of funduscopy may be higher if visual disturbances are reported. If neuroimaging studies are considered, emergency room ophthalmological consultation is probably not warranted, except for young infants with neurological signs and symptoms in whom retinal hemorrhages suggestive of physical abuse must be ruled out.
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Affiliation(s)
- Anat Segev-Becker
- Pediatrics Department, Meir Medical Center, Tel Aviv University, Kfar Saba, Israel
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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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Annagür A, Altunhan H, Annagür BB, Ertuğrul S, Örs R. Shaken Baby Syndrome Suggestive of The Diagnosis of Osteogenesis Imperfecta in Newborn. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2013. [DOI: 10.29333/ejgm/82256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Adams GGW, Agrawal S, Sekhri R, Peters MJ, Pierce CM. Appearance and location of retinal haemorrhages in critically ill children. Br J Ophthalmol 2013; 97:1138-42. [PMID: 23645820 DOI: 10.1136/bjophthalmol-2012-302429] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are few high-quality studies describing the appearance and location of retinal haemorrhages in critically ill children not due to birth or abusive head trauma. METHODS Prospective study from February 2008 to December 2009 of emergency admissions to a paediatric intensive care unit aged over 6 weeks. Children with a penetrating eye injury or suspected or proven abusive head injury were excluded. The children underwent either dilated funduscopy performed by a paediatric ophthalmologist or RetCam imaging. RESULTS Retinal haemorrhages were identified in 24/159 (15%) patients. 50% of the haemorrhages were bilateral. The severity was mild (<5 retinal haemorrhages) or moderate (5-20 retinal haemorrhages) in 75%. The location was in zone 1 in 45.8%, zones 1 and 2 in 33.3%, zone 2 alone in 8.3% and not described in 8.3%. Schisis cavities and perimacular folds were identified in two patients with one having a pseudohypopyon appearance; a further one patient had bilateral haemorrhagic retinal detachments. Three patients had exudates or scarring consistent with cytomegalovirus infection. CONCLUSIONS Retinal haemorrhages are seen in a proportion of critically ill children, however most retinal bleeding is not extensive as indicated by location within the retina or layer of bleeding. Higher numbers and extent of retinal haemorrhages were only observed in the presence of severe coagulopathy, leukaemia, one victim of a road traffic accident, and one child who sustained a fatal witnessed fall down the stairs; all circumstances that would be readily distinguished by history and laboratory testing from abusive head injury.
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Affiliation(s)
- G G W Adams
- Department of Strabismus and Paediatrics, Moorfields Eye Hospital, London, UK.
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Carrim ZI, Arbabi EM, Long VW. Presumed non-accidental injury with retinal haemorrhages--findings from a tertiary referral centre in the United Kingdom. Brain Inj 2013; 26:1716-22. [PMID: 23163252 DOI: 10.3109/02699052.2012.722261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To describe the clinical and demographic features of patients with retinal haemorrhages from presumed non-accidental injury (NAI) at a tertiary referral centre in Leeds over a 2-year period. METHODS All patients with retinal haemorrhages from presumed NAI between 1 January 2007 and 31 December 2008 were retrospectively identified from the hospital RetCam® (Clarity Medical System, Pleasanton, CA, USA) database. Case-notes, fundus photographs and radiological studies were retrieved for all patients and examined. RESULTS Over the study period, 14 infants had retinal haemorrhages secondary to presumed NAI. All were male with a mean age of 18 ± 15 weeks (range 2-47) and came from areas with a mean Index of Multiple Deprivation (IMD 2007) rank of 34 ± 27% (range 0.97-68). Seizure/collapse was the reason for presentation in 71% (10/14). Retinal haemorrhages were bilateral in 64% (9/14) and unilateral in 36% (5/14). They were single-layered in 71% (10/14) and multi-layered in 29% (4/14). Subdural haemorrhages were found in 93% (13/14) and were symmetrical in 77% (10/13). Skeletal survey was positive in 28% (4/14). CONCLUSIONS In the context of presumed NAI, there is a strong association between presence of retinal haemorrhages and the likelihood of underlying subdural haemorrhage. In this region, male infants under 12 months, from deprived areas, appear to constitute a vulnerable group.
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Affiliation(s)
- Zia I Carrim
- Department of Ophthalmology, St James's University Hospital, Leeds, UK.
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Abstract
OBJECTIVE The objectives of this study were to provide population-based incidence estimate of abusive head trauma (AHT) in children aged 0 to 5 years from inpatient and emergency department (ED) and identify risk characteristics for recognizing high-risk children to improve public health surveillance. METHODS This was a retrospective cohort study based on children's first encounter in ED or hospital admission with a diagnosis of head trauma (HT), 2000-2010. The relationship between clinical markers and AHT was examined controlling for covariables in the model using Cox hazards regression. Kaplan-Meier incidence probability was plotted, and the number of weeks elapsing from date of birth to the first encounter with HT established the survival time (T). RESULTS Twenty-six thousand six hundred eighty-one children had HT, 502 (1.8%) resulted from abuse; 42.4% was captured from ED. Incidence varied from 28.9 (95% confidence interval [CI], 27.9-37.4) in infants to 4.1 (95% CI, 2.4-5.7) in 5-year-olds per 100,000 per year. Adjusted hazard ratio was 20.3 (95% CI, 10.9-38.0) for intracranial bleeding and 11.4 (95% CI, 8.57-15.21) for retinal hemorrhage. CONCLUSIONS Incidence estimates of AHT are incomplete without including ED. Intracranial bleeding is a cardinal feature of AHT to be considered in case ascertainment to improve public health surveillance.
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Clinical predictors of outcome following inflicted traumatic brain injury in children. J Trauma Acute Care Surg 2013; 73:S248-53. [PMID: 23026962 DOI: 10.1097/ta.0b013e31826b0062] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The study aimed to determine which acute injury variables were predictors of long-term functional outcome following inflicted traumatic brain injury (iTBI). METHODS A retrospective case review of 35 children with iTBI was performed. After controlling for age at injury and time since injury, the generalized estimation equations method was used to identify acute injury variables that were significantly related to the Glasgow Outcome Scale scores at the initial follow-up assessments. When available, functional sequelae at these and longer-term follow-ups were also examined. RESULTS In bivariate generalized estimation equations analyses, a low Glasgow Coma Scale (GCS) eye component score, a low GCS motor component score, a low GCS verbal component score, need for neurosurgical intervention, seizures in the first week after injury, need for mechanical ventilation for more than 10 days, length of intensive care unit stay of more than 10 days, initial hyperglycemia, and neuroimaging findings of cerebral edema or loss of gray-white matter differentiation were significantly (p ≤ 0.05) related to having a poor outcome, as defined by their Glasgow Outcome Scale score at the initial follow-up. In multivariable analyses, considering the significant predictors while controlling for age at injury and time since injury, the presence of cerebral edema on neuroimaging (odds ratio, 27.21; 95% confidence interval, 4.40-168.22), and length of intensive care unit stay of more than 10 days (odds ratio, 21.57; 95% confidence interval, 3.09-150.48) were significantly related to having a poor outcome. CONCLUSION Early clinical data following iTBI help predict long-term functional outcome. Further research to support these findings may help delineate acutely after injury which children with iTBI are at risk for a poor prognosis and should be more closely followed up over time. LEVEL OF EVIDENCE Prognostic study, level IV.
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Minns RA, Jones PA, Tandon A, Fleck BW, Mulvihill AO, Elton RA. Prediction of inflicted brain injury in infants and children using retinal imaging. Pediatrics 2012; 130:e1227-34. [PMID: 23045566 DOI: 10.1542/peds.2011-3274] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Retinal hemorrhages (RHs) occur in inflicted traumatic brain injury (ITBI), accidental traumatic brain injury (ATBI), and some medical conditions, although the reported number, distribution, type, and frequency vary greatly between these different etiologies. We hypothesize that these RH characteristics reliably help to distinguish ITBI from ATBI and nontraumatic etiologies. METHODS A 6-year prospective observational study using wide-field retinal imaging (RetCam) was conducted within 24 hours of admission to PICU, on serially recruited children with traumatic and nontraumatic encephalopathies. "Definite" and "probable" ITBI cases were confirmed by multiagency child protection case conferences. Image analysis used digital color and grayscale images for retinal "zoning" and "layering" of hemorrhages. RESULTS Significant differences were found between the mean numbers of hemorrhages in ATBI/ITBI, and ITBI/nontraumatic etiologies for the 3 retinal zones (range, P = .003-.009) and for the dot-blot hemorrhages (range P = .001-.002). The mean numbers of RHs per ITBI patient in the peripapillary, macula, and peripheral zones were 14, 28, and 31 respectively. RHs in ATBI were near the optic disc and more superficial than in ITBI, where hemorrhages involved deeper layers (range, P = .003-.039) and were more peripheral (P = .03). The positive predictive value for ITBI in children <3 years with >25 dot-blot (intraretinal) hemorrhages was 93%. CONCLUSIONS This prospective study, which included all potential causes of RHs, with objective retinal methodology, has confirmed that a young age and a high dot-blot count are strong predictors of ITBI. This high predictive value may support medicolegal deliberations.
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Affiliation(s)
- Robert A Minns
- Department of Child Life and Health, Princess Alexandra Eye Pavilion, Royal Hospital for Sick Children Edinburgh, Edinburgh, Scotland.
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Agrawal S, Peters MJ, Adams GGW, Pierce CM. Prevalence of retinal hemorrhages in critically ill children. Pediatrics 2012; 129:e1388-96. [PMID: 22614777 DOI: 10.1542/peds.2011-2772] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Retinal hemorrhages (RHs) with encephalopathy and subdural bleeding are considered suggestive of abusive head trauma (AHT). Existing studies describing RH focus on AHT and have potential selection bias. We undertook a prospective observational study to define the prevalence, distribution, and extent of RH in critically ill children. METHODS From February 2008 to December 2009, emergency intensive care admissions ≥ 6 weeks of age underwent dilated retinal examination by either a pediatric ophthalmologist or RetCam (retinal photograph) imaging after written informed consent. Patients with suspected or proven AHT, penetrating eye trauma, and elective admissions were excluded. RESULTS The prevalence of RH was 15.1% (24/159; 95% confidence interval [CI]: 9.5%-21%); 16/24 (66%) mild, and 2/24 (8%) moderate. Severe multilayered RH were seen in only 6 patients (3.7%), 3 with myeloid leukemia and sepsis, 2 with severe accidental head injury, and 1 with severe coagulopathy secondary to late onset hemorrhagic disease of newborn. There was no detectable impact of age, gender, seizures, coagulopathy or cardiopulmonary resuscitation on prevalence of severe multilayered RH; however, sepsis (odds ratio: 3.2; 95% CI: 1.3-8.0, P = .018) and coagulopathy (odds ratio: 2.8; 95% CI: 1.2-7.0, P = .025) were significantly associated with any RH. Only admission diagnosis was independently associated with severe multilayered RH on logistic regression. CONCLUSIONS RHs were seen in critically ill children with a prevalence of 15.1% (24/159); however, most were mild. Severe multilayered RH resembling those described in AHT were rare (6/24) and were only seen in patients with fatal accidental trauma, severe coagulopathy, sepsis with myeloid leukemia, or a combination of these factors.
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Affiliation(s)
- Shruti Agrawal
- Paediatric and Neonatal Intensive Care Units, Great Ormond Street Hospital for Children, London, United Kingdom.
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Hendrickson DJ, Knisely AS, Coulter K, Telander DG, Quan R, Ruebner BH, Leigh MJ. An inborn error of bile salt transport with features mimicking abusive head trauma. CHILD ABUSE & NEGLECT 2010; 34:472-476. [PMID: 20627390 DOI: 10.1016/j.chiabu.2009.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 11/12/2009] [Accepted: 11/12/2009] [Indexed: 05/29/2023]
Affiliation(s)
- Debra J Hendrickson
- University of California Davis Medical Center, Department of Pediatrics, Sacramento, CA, USA
| | - A S Knisely
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Kevin Coulter
- University of California Davis Medical Center, Department of Pediatrics, Sacramento, CA, USA
| | - David G Telander
- University of California Davis Medical Center, Department of Ophthalmology and Vision Science, Sacramento, CA, USA
| | - Richard Quan
- University of California Davis Medical Center, Department of Pediatrics, Sacramento, CA, USA
| | - Boris H Ruebner
- University of California Davis Medical Center, Department of Pathology, Sacramento, CA, USA
| | - Mary Jacena Leigh
- University of California Davis Medical Center, Department of Pediatrics, Sacramento, CA, USA
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Bhardwaj G, Chowdhury V, Jacobs MB, Moran KT, Martin FJ, Coroneo MT. A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma. Ophthalmology 2010; 117:983-992.e17. [PMID: 20347153 DOI: 10.1016/j.ophtha.2009.09.040] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 09/24/2009] [Accepted: 09/24/2009] [Indexed: 11/20/2022] Open
Abstract
TOPIC To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT). CLINICAL RELEVANCE Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed. METHODS A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy. RESULTS The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions. CONCLUSIONS Prospective, consecutive studies confirm that IOH in infants-particularly bilateral, extensive, and multilayered-are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.
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Affiliation(s)
- Gaurav Bhardwaj
- Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
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Abstract
OBJECTIVE To determine the prevalence of retinal hemorrhages in apparent life-threatening events (ALTEs) with the purpose of facilitating the differential diagnosis of the cases of nonaccidental head trauma. METHODS Prospective study on children aged 15 days to 2 years admitted to our hospital with a diagnosis of an ALTE over a period of 2 years (May 2004-May 2006). All the children underwent detailed ophthalmologic examination within 72 hours of admission. If retinal hemorrhages were detected, further investigation was undertaken to rule out systemic disorder or maltreatment. RESULTS One hundred eight children with an ALTE were examined. No patient was found to have retinal hemorrhages nor was any found to have experienced child abuse. Therefore, using the Hanley rule of 3, we can be confident to an upper limit of 95% that the chance of retinal hemorrhages occurring as a result of an ALTE alone is at the most 0.028. CONCLUSIONS Apparent life-threatening events alone are unlikely to cause retinal hemorrhages in children younger than 2 years. Therefore, if retinal hemorrhages are detected, investigation into the possibility of nonaccidental injury is essential.
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Lopez JP, Roque J, Torres J, Levin AV. Severe retinal hemorrhages in infants with aggressive, fatal Streptococcus pneumoniae meningitis. J AAPOS 2010; 14:97-8. [PMID: 20227631 DOI: 10.1016/j.jaapos.2009.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 11/18/2009] [Accepted: 11/21/2009] [Indexed: 10/19/2022]
Abstract
Retinal hemorrhages in children occasionally accompany bacterial meningitis, usually due to hemophilus or meningococcal organisms. The hemorrhages may be intraretinal, usually in the posterior pole of the eye and few in number, or, more uncommonly, subhyaloid or vitreous. Pathogenesis may include vasculitis, disseminated intravascular coagulation, or intracranial hypertension. We report 2 cases of bilateral severe retinal hemorrhages in fatal Streptococcus pneumoniae meningitis.
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Affiliation(s)
- Juan Pablo Lopez
- Department of Ophthalmology, Clinica Alemana de Santiago and Universidad Del Desarrollo, Santiago, Chile
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