Retinal hemorrhage and pediatric brain injury: etiology and review of the literature

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

Oxygen care and treatment of retinopathy of prematurity in ocular and neurological prognosis

This retrospective cohort study aimed to investigate the effects of neonatal oxygen care and retinopathy of prematurity (ROP) treatment on ROP-related ocular and neurological prognoses. We included premature infants treated for ROP at a tertiary referral center between January 2006 and December 2019. Demographic and clinical data were collected from electronic medical records. Odds ratios (ORs) of oxygen care- and ROP treatment-related factors were calculated for ocular and neurological comorbidities 3 years after ROP treatment, after adjusting for potential confounders. ROP requiring treatment was detected in 171 eyes (88 infants). Laser treatment for ROP (OR = 4.73, 95% confidence interval [CI] 1.64–13.63) and duration of invasive ventilation (OR = 1.02, 95% CI 1.00–1.03) were associated with an increase in ocular comorbidities, along with a history of neonatal seizure (OR = 28.29, 95% CI 5.80–137.95) and chorioamnionitis (OR = 32.13, 95% CI 5.47–188.74). No oxygen care- or ROP treatment-related factors showed significant odds for neurological comorbidities. Shorter duration of invasive oxygen supply during neonatal care (less than 49 days) and anti-vascular endothelial growth factor injection as the primary treatment for ROP are less likely to cause ocular comorbidities. No association was identified between ROP treatment modalities and the risk of neurological comorbidities.

Magnetic resonance imaging of optic nerve and optic sheath hemorrhages in child abuse

In abusive head trauma victims, optic nerves and optic sheath hemorrhages are commonly associated with retinal hemorrhages. Until now, optic nerve and optic nerve sheath hemorrhages related to abusive head trauma have been identified by exenteration and soft-tissue sectioning during postmortem examination. In 2013, we proposed the use of tailored high-resolution susceptibility-weighted imaging (SWI) MRI sequences to depict retinal hemorrhages in lieu of the gold standard dilated fundus exam, in select patients, and in 2017 we showed how the same high-resolution sequences used in the coronal plane can depict ruptured bridging veins in abusive head trauma. This paper describes the new potential diagnostic application of high-resolution axial and coronal SWI in the diagnosis of optic nerve and optic sheath hemorrhages.

Shock wave propagation along the central retinal blood vessels

Retinal haemorrhage is often observed following brain injury. The retinal circulation is supplied (drained) by the central retinal artery (vein) which enters (leaves) the eye through the optic nerve at the optic disc; these vessels penetrate the nerve immediately after passing through a region of cerebrospinal fluid (CSF). We consider a theoretical model for the blood flow in the central retinal vessels, treating each as multi-region collapsible tubes, where we examine how a sudden change in CSF pressure (mimicking an injury) drives a large amplitude pressure perturbation towards the eye. In some cases, this wave can steepen to form a shock. We show that the region immediately proximal to the eye (within the optic nerve where the vessels are strongly confined by the nerve fibres) can significantly reduce the amplitude of the pressure wave transmitted into the eye. When the length of this region is consistent with clinical measurements, the CSF pressure perturbation generates a wave of significantly lower amplitude than the input, protecting the eye from damage. We construct an analytical framework to explain this observation, showing that repeated rapid propagation and reflection of waves along the confined section of the vessel distributes the perturbation over a longer lengthscale.

Diagnostic Imaging for Physical Abuse in Children

신체적 학대로 인한 손상은 소아에서 이환율과 사망률의 중요한 원인이 된다. 특히, 1세 이하의 영아가 신체적 학대의 위험이 높다. 신체적 학대가 의심되는 경우 영상의학과 의사의 역할은 매우 중요한데 학대가 의심되는 영상의학적 소견을 찾고 다른 질환과의 감별을 통해 신속하고 정확한 진단을 내려야 한다. 본 논문에서는 신체적 학대를 받은 아동에서 흔히 보일 수 있는 특징적인 손상인 골절, 머리 손상, 척추 손상, 흉부와 복부의 손상 등의 여러 영상의학적 소견을 설명하고 이러한 손상이 유발되는 생체 역학적 힘의 기전에 대해 알아보고자 한다.

Retinal haemorrhage in a child with optic neuritis and acute disseminated encephalomyelitis

A 2-year-old presented with lethargy, acute visual loss, fixed dilated pupils and severe bilateral retinal haemorrhages. The retinal findings raised concerns about abusive head trauma, but subsequent investigations confirmed the diagnosis of bilateral optic neuritis associated with acute disseminated encephalomyelitis.

[Complementary exams in child abuse: A French national study in 2015]

INTRODUCTION

Even if there are HAS (French National Health Authority) guidelines on shaken baby syndrome, many other child abuse situations are not included in these recommendations. The aim of this study was to invent the complementary exams in cases of child abuse in France and compare the practice to existing guidelines.

MATERIAL AND METHODS

This was a multicenter study by email to 128 French hospitals (35 university hospitals and 93 general hospitals) that receives children in emergency and hospitalization settings. Three child abuse clinical situations were included in a clinical case multiple-choice format concerning the further explorations. We described the main results and evaluated their adherence to the HAS protocol for case 1.

RESULTS

Of 128 hospitals surveyed, 104 responded, for an 81 % response rate, which corresponded to 274 doctors. Analysis of the results showed great heterogeneity in practices. The majority of physicians (99 %) performed systematic explorations in the situation of physical abuse, while only 27 % undertook such exams in situations of serious neglect. The situation of sexual abuse was the most consensual in terms of diagnostic tests for the detection of sexually transmitted diseases, but other types of associated abuse were not sought. In the first case, the HAS guidelines were respected in less than half of the cases for all complementary exams except the eye fundus exam. Abdominal imaging was insufficiently performed (40 % of cases). Examinations that were not indicated were still prescribed. Moreover, siblings under 2 years of age were examined in only one-third of cases (n=88/274; 32 %). Practices were not influenced by the age of the child.

CONCLUSION

This study illustrates the heterogeneity in the use of complementary exams in cases of child abuse in France. Common protocols throughout the country would be useful, standardizing the most relevant exams for potential medical-legal issues, and facilitating exchanges concerning practices between different centers.

Revisiting neuroimaging of abusive head trauma in infants and young children

OBJECTIVE

The purpose of this article is to use a mechanism-based approach to review the neuroimaging findings of abusive head trauma to infants. Advanced neuroimaging provides insights into not only the underlying mechanisms of craniocerebral injuries but also the long-term prognosis of brain injury for children on whom these injuries have been inflicted.

CONCLUSION

Knowledge of the traumatic mechanisms, the key neuroimaging findings, and the implications of functional imaging findings should help radiologists characterize the underlying causes of the injuries inflicted, thereby facilitating effective treatment.

History of an abusive head trauma including a lucid interval and a retinal hemorrhage is most likely false

A lucid interval (LI) is the period of time between regaining consciousness after a short period of unconsciousness, resulting from a head injury and deteriorating after the onset of neurologic signs and symptoms caused by that injury. The incentive for this study was the case of a father who left his 14-week-old infant with the nanny in whose custody the infant had collapsed. The nanny denied involvement in the injury, and the father became a suspect. Of 47 abusive head trauma (AHT) cases, 8 were found to have an LI in the past. The history of the cases were thoroughly analyzed and compared with evidence in the literature. An LI is not compatible with an inertial brain injury. Shaking has either an immediate effect or no effect, which means that an LI occurs only in pure impact or blunt injuries. When "shaking lesions" are found including a retinal hemorrhage while the history mentions an LI, the story most likely is false, regardless of whether the perpetrator confesses. The finding of an LI may change the assessment of an AHT case. Lucid interval is a valuable variable in the diagnostic accuracy of an AHT.

Presumed non-accidental injury with retinal haemorrhages--findings from a tertiary referral centre in the United Kingdom

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.

Prevalence of retinal hemorrhages in critically ill children

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.

Suspicious childhood injury: formulation of forensic opinion

Child protection paediatricians have a role as forensic experts in the context of suspicious childhood injury. The task of forensic evaluation of suspicious injury is to reach a conclusion to support legal proceedings. For each injury, one of four conclusions should be reached: 1 The injury has been caused by another person and is considered to have been inflicted. 2 The injury is adequately explained by the circumstances of the injury event provided (by the carer or other witnesses). 3 The injury is self-inflicted - has been caused by the child's own behaviour as a result of normal childhood activity (with no other person actively involved). 4 The mechanism or sequence of events leading to the injury remains indeterminate or unclear. An additional consideration is determining the extent to which an injury incident was foreseeable and therefore preventable, to form an opinion on whether lack of care (neglect) is involved. Opinions reflect a body of knowledge in forensic and medical literature of known mechanisms of injury including biomechanical aspects of tissue injury in trauma scenarios. Limitations in using research documenting injury type and prevalence at different developmental stages is discussed and in particular, the application of such research to support a conclusion that the injury must have been inflicted. Emerging recognition of research documenting injuries that overlap with those found in populations of children thought to have been physically assaulted creates some doubt on previous opinions regarding exclusivity of certain findings in children definitively indicating 'abuse'. Forensic paediatricians should remain objective, limit their opinions to what can be confidently stated and exercise caution where reasonable doubt exists and avoid speculation.

Manifestations of ocular fundus in children with febrile seizures

PURPOSE

To study the potential incidence of retinopathy in children with febrile seizures.

METHODS

Thirty-four children with febrile seizures, aged 3 months to 9 years and admitted from January 2000 to June 2008, were retrospectively analyzed. All cases received fundus examination within 24 hours after admission and the incidence of retinopathy was calculated.

RESULTS

None of the subjects was found to have retinal hemorrhages. Therefore, using Hanley's Rule of Three, the upper limit of 95% confidence interval of retinal hemorrhages following febrile seizures in children is less than 10%.

CONCLUSION

The incidence of retinal hemorrhages in children with febrile seizures is lower than 10%. If retinal hemorrhages are found in children with febrile seizures, other causes need to be considered.

Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine

Because of the controversy involving the determination of child abuse, or nonaccidental injury (NAI), radiologists must be familiar with the issues, literature, and principles of evidence-based medicine to understand the role of imaging. Children with suspected NAI must receive protective evaluation along with a timely and complete clinical and imaging work-up. Imaging findings cannot stand alone and must be correlated with clinical findings, laboratory testing, and pathologic and forensic examinations. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive clinical, imaging, biomechanical, or pathology findings.

Yield of retinal examination in suspected physical abuse with normal neuroimaging

OBJECTIVE

In some centers, dedicated ophthalmologic examination is performed for all children who are evaluated for potential physical abuse. Although retinal hemorrhages have been reported in rare cases of abused children with normal neuroimaging results, the utility of ophthalmologic examination in this group is currently unknown. The objective of this study was to determine the prevalence of retinal hemorrhages in children younger than 2 years who were evaluated for physical abuse and who had no evidence of traumatic brain injury (TBI) on neuroimaging.

PATIENTS AND METHODS

We performed retrospective analysis of data obtained from 1676 children younger than 5 years who were evaluated for potential physical abuse as a part of the Using Liver Transaminases to Recognize Abuse research network. We reviewed results of dedicated ophthalmologic examination in all children younger than 2 years with no evidence of TBI on neuroimaging.

RESULTS

Among 282 children who met inclusion criteria, only 2 (0.7% [95% confidence interval: 0.1%-2.5%]) had retinal hemorrhages considered "characteristic" of abuse. Seven other children (2.5% [95% confidence interval: 1.0%-5.1%]) had a nonspecific pattern of retinal hemorrhages. Both children with characteristic retinal hemorrhages in the absence of TBI showed evidence of head or facial injury on physical examination and/or altered mental status.

CONCLUSIONS

In children younger than 2 years being evaluated for physical abuse without radiographic evidence of brain injury, retinal hemorrhages are rare. Dedicated ophthalmologic examination should not be considered mandatory in this population.

Retinal hemorrhages and apparent life-threatening events

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.

Retinal hemorrhages associated with meningitis in a child with a congenital disorder of glycosylation

A 9-month old infant presented in a state of shock to a district hospital. She was subsequently referred to the regional tertiary hospital. On admission, bruises were noted on the vertex of the skull. Retinal hemorrhages were present on ophthalmological examination. CT scan of the brain showed poor grey-white matter differentiation with apparent frontoparietal fractures of the skull. Her case was subsequently referred to the relevant authorities as it was suspicious for nonaccident injury (NAI). Her condition deteriorated and she died the next day. Postmortem examination showed that the bruises on the vertex were caused by rapid widening of the sutures of the skull, caused by rising intracranial pressure. There was no skull fracture or evidence of trauma. Histological examination of the brain showed meningitis which had extended to the optic nerve sheath. Hemorrhages were noted in the retinas as well as the optic nerve sheath. An incidental congenital disorder of glycosylation (CDG) was diagnosed on brain histology and confirmed by metabolic tests. Retinal hemorrhages are known to occur in head injuries especially in association with NAI. In this case, suspicion of NAI was further augmented by the presence of apparent bruises on the head. The full postmortem examination showed no evidence of injuries and instead showed that the child was suffering from meningitis. Blood culture grew Group A Streptococcus pyogenes. The underlying mechanisms for such a presentation and the association with CDG are discussed.

Neuroimaging evaluation of non-accidental head trauma with correlation to clinical outcomes: a review of 57 cases

OBJECTIVE

To review the clinical presentation and neuroimaging findings in patients with high clinical suspicion for non-accidental trauma (NAT) of the head, to investigate associations between imaging findings and long-term neurologic outcome in abused children.

STUDY DESIGN

A retrospective review of 57 cases of NAT of the head from a single institution was performed. Neuroimaging studies (computed tomography [CT] and magnetic resonance imaging [MRI]) were reviewed by a senior neuroradiologist, a neuroradiology fellow, and a radiology resident. Clinical history and physical findings, including retinal examination, imaging, and follow-up assessment, were reviewed.

RESULTS

The mean time between the patient's arrival at the hospital and CT and MRI imaging was 2.9 hours and 40.6 hours, respectively. The most common clinical presentation was mental status changes, seen in 47% of patients. The most common neuroimaging finding was subdural hematoma, seen in 86% of patients. In the 47 patients who underwent both MRI and CT, 1 case of suspected NAT was missed on head CT. CT detected signs of global ischemia in all 11 patients who died (mean time after arrival at the hospital until undergoing CT, 1.1 hours). MRI detected additional signs of injury in patients who developed mild to moderate developmental delay.

CONCLUSION

CT was able to detect evidence of NAT of the head in 56 of 57 abused children included in our cohort and predicted severe neurologic injury and mortality. MRI was useful in detecting additional evidence of trauma, which can be helpful in risk stratification for neurologic outcomes as well in providing confirming evidence of repeated injury.

Shaken baby syndrome: a common variant of non-accidental head injury in infants

BACKGROUND

Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality.

METHODS

Selective literature review including an overview over national and international recommendations.

RESULTS

Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations.

CONCLUSIONS

The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.

Nonaccidental head trauma in infants

BACKGROUND

Nonaccidental head trauma in infants is the leading cause of infant death from injury.

RESULTS AND DISCUSSION

Clinical features that suggest inflicted head trauma include the triad of the so-called shaken baby syndrome, consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Studies have shown that, in general, the average short fall in the home is extremely unlikely to produce either subdural or retinal hemorrhage, although focal injuries such as skull fractures and epidural hemorrhage may be seen. Acceleration/deceleration, especially of the rotational type, is believed to be the most probable mechanism of injury in cases of nonaccidental head trauma. Damage to the cervicomedullary junction and the respiratory centers, with subsequent hypoxia and intracerebral edema, has also been implicated. After the initial trauma and hemorrhage, loss of cerebral autoregulation, breakdown of the blood-brain barrier, and disruption of ionic homeostasis occur, leading to brain edema and cytotoxicity. Cellular damage can involve large volumes of tissue, without respecting vascular territories.

CONCLUSION

Overall, a satisfactory biomechanical model is lacking, and the criminal nature of abusive injury makes it difficult to perform systematic, controlled studies. Unfortunately, outcomes are poor, and the rate of repeated abusive episodes is high. Future research should focus on the development of a satisfactory research model and on prevention strategies.

Imaging of the central nervous system in suspected or alleged nonaccidental injury, including the mimics

Because of the widely acknowledged controversy in nonaccidental injury, the radiologist involved in such cases must be thoroughly familiar with the imaging, clinical, surgical, pathological, biomechanical, and forensic literature from all perspectives and with the principles of evidence-based medicine. Children with suspected nonaccidental injury versus accidental injury must not only receive protective evaluation but also require a timely and complete clinical and imaging workup to evaluate pattern of injury and timing issues and to consider the mimics of abuse. All imaging findings must be correlated with clinical findings (including current and past medical record) and with laboratory and pathological findings (eg, surgical, autopsy). The medical and imaging evidence, particularly when there is only central nervous system injury, cannot reliably diagnose intentional injury. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive medical, imaging, biomechanical, or pathological findings.