The role of cranial MRI in identifying patients suffering from child abuse and presenting with unexplained neurological findings

Neonatal Abusive Head Trauma without External Injuries: Suspicion Improves Diagnosis

The term “shaken baby syndrome” has been replaced by “abusive head trauma (AHT)” based on the mechanism of injury. The reported mortality rate of AHT ranges from 10% to 30%. Up to two-thirds of survivors suffer from serious long-term disabilities. Thus, an expeditious and accurate diagnosis is crucial to prevent further abuse that might result in death or serious disabilities. It remains a challenge for physicians to diagnose AHT when parents do not give a history of trauma in preverbal infants without any external signs. Here, we report a case of a 14-day-old boy who presented with a febrile convulsion without evident external injuries nor history of trauma according to his parents. He was diagnosed with AHT based on MRI findings of subacute subdural hemorrhage, multiple cortical hemorrhages, cerebral edema, and diffuse axonal injury. In conclusion, health care providers should keep in mind that the history of trauma provided by the parents or caregivers might not always be true and that reasonable suspicion of abuse is the most important in the diagnosis of AHT, although neuroimaging plays a pivotal role. Reasonable suspicion of AHT in combination with a thorough physical examination, neuroimaging, and skilled neuroradiologist can improve diagnosis and help victims in a timely manner.

Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT)

Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological “triad”, a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216–223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44–48% when all the spinal cord levels are analysed as opposed to just 0–18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.

Insufficient evidence for 'shaken baby syndrome' - a systematic review

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).

Serial neuroimaging in infants with abusive head trauma: timing abusive injuries

OBJECT

The appearance and evolution of neuroimaging abnormalities following abusive head trauma (AHT) is important for establishing the time frame over which these injuries might have occurred. From a legal perspective this frames the timing of the abuse and therefore identifies and excludes potential perpetrators. A previous pilot study involving 33 infants with AHT helped to refine the timing of these injuries but was limited by its small sample size. In the present study, the authors analyzed a larger group of 210 cases involving infants with AHT to chronicle the first appearance and evolution of radiological (CT, MRI) abnormalities.

METHODS

All children younger than 24 months admitted to the Penn State Hershey Medical Center with AHT over a 10-year period were identified from a medical record review; the time of injury was determined through an evaluation of the clinical records. All imaging studies were analyzed, and the appearance and evolution of abnormalities were chronicled on serial neuroimaging studies obtained in the days and weeks after injury.

RESULTS

One hundred five infants with specific injury dates and available imaging studies were identified; a subset of 43 children additionally had documented times of injury. In infants with homogeneously hyperdense subdural hematomas (SDHs) on initial CT scans, the first hypodense component appeared within the SDH between 0.3 and 16 days after injury, and the last hyperdense subdural component disappeared between 2 and 40 days after injury. In infants with mixed-density SDHs on initial scans, the last hyperdense component disappeared between 1 and 181 days. Parenchymal hypodensities appeared on CT scans performed as early as 1.2 hours, and all were visible within 27 hours after the injury. Rebleeding into SDHs was documented in 17 cases (16%) and was always asymptomatic. Magnetic resonance imaging of the brain was performed in 49 infants. Among those with SDH, 5 patterns were observed. Patterns I and II reflected homogeneous SDH; Pattern I (T1 hyperintensity and T2/FLAIR hypointensity, "early subacute") more commonly appeared on scans performed earlier after injury compared with Pattern II (T1 hyperintensity and T2/FLAIR hyperintensity, "late subacute"), although there was considerable overlap. Patterns III and IV reflected heterogeneous SDH; Pattern III contained relatively equal mixtures having different intensities, whereas Pattern IV had fluid that was predominantly T1 hypointense and T2/FLAIR hyperintense. Again, Pattern III more commonly appeared on scans performed earlier after injury compared with Pattern IV, although there was significant overlap.

CONCLUSIONS

These data extend the preliminary data reported by Dias and colleagues and provide a framework upon which injuries in AHT can be timed as well as the limitations on such timing estimates.

Predictive value of early radiological findings in inflicted traumatic brain injury

AIM

The aim of this study was to evaluate the value of early radiological investigations in predicting the long-term neurodevelopmental outcome of patients with inflicted traumatic brain injury (ITBI).

METHODS

In 28 patients with ITBI, radiological investigations were performed during the acute phase of injury (0-3 days) and during the early post-injury phase (4 days to 1 month). The clinical outcome in survivors (n = 24) was based on the Glasgow Outcome Score.

RESULTS

Four of 28 infants died and five were severely disabled. Six infants had moderate disability. Detection of changes in the basal ganglia (p < 0.000005) or brainstem (p < 0.01), diffuse oedema (p < 0.005), transtentorial herniation (p < 0.01), subarachnoid haemorrhage (p < 0.05) or parenchymal injury (p < 0.05) by neuroimaging during the first 3 days, and detection of changes in the basal ganglia (p < 0.0005) or brainstem (p < 0.05) or parenchymal injury (p < 0.01) during 1 month were significantly associated with poor long-term outcome.

CONCLUSION

Radiological findings during the first month were significantly associated with the long-term outcome. Especially, basal ganglia lesions were associated with a poor outcome.

ACR Appropriateness Criteria(®) on suspected physical abuse-child

The appropriate imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and whether the injuries are discrepant with the clinical history. The clinical presentations reviewed consider these factors and provide evidence-based consensus recommendations by the ACR Appropriateness Criteria(®) Expert Panel on Pediatric Imaging.

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.

Diagnostic imaging of child abuse

The role of imaging in cases of child abuse is to identify the extent of physical injury when abuse is present and to elucidate all imaging findings that point to alternative diagnoses. Effective diagnostic imaging of child abuse rests on high-quality technology as well as a full appreciation of the clinical and pathologic alterations occurring in abused children. This statement is a revision of the previous policy published in 2000.

What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review

AIMS

To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI).

MATERIALS AND METHODS

A systematic review of studies published between 1970-2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI.

RESULTS

Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3-33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI.

CONCLUSIONS

In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.

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.

[Main temporal aspects of the MRI signal of subdural hematomas and practical contribution to dating head injury]

BACKGROUND AND PURPOSE

MRI signal of a subdural hematoma (SDH) is often regarded as similar to that of an intracerebral hematoma but no precise study has analyzed the evolution of the signal of subdural hematomas. Their dating is however significant, in particular in the child, within the context of the diagnosis of child abuse. The objective of this study is to compare with MRI a group of adult patients having a subdural and/or intracerebral, in order to study the evolution of the signals of these two types of hematomas.

MATERIAL AND METHODS

This prospective study included patients hospitalized for post-traumatic acute subdural or intracerebral hematoma. The protocol included an emergency brain CT and 4 MRI at fixed times: in emergency (early phase), between the third and the seventh day (early subacute phase), during the third week (late subacute phase), and after four months after the hemorrhage. The protocol included T1-weighted sequences before and after injection of gadolinium, T2-weighted, fluid-attenuated inversion-recovery (FLAIR), gradient echo and diffusion.

RESULTS

Eighteen patients were included and all 72 MRI were interpretable. The time course of the cerebral hematomas was similar to that described in the literature, whereas that of subdural hematomas was different in 15 patients. This distinction was significant in the early phase for subdural hematomas, which displayed hypersignal in T2 and FLAIR, whereas cerebral hematomas showed a hyposignal in the same sequences. The variation was also notable in the early subacute period during which subdural hematomas displayed hypersignal in T1, FLAIR and diffusion, and isosignal in T2, whereas cerebral hematomas showed isosignal in T1, and hyposignal in T2, FLAIR and diffusion.

CONCLUSION

The time course of MRI signal of subdural hematomas is different from that of cerebral hematomas. This difference is significant in T2 sequence and FLAIR, especially in the early subacute period. These radiographic observations in adults can be useful for the MRI dating of subdural hematomas in shaken-baby syndrome.

Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography

OBJECTIVE

Mixed-density convexity subdural hematoma and interhemispheric subdural hematoma suggest nonaccidental head injury. The purpose of this retrospective observational study is to investigate subdural hematoma on noncontrast computed tomography in infants with nonaccidental head injury and to compare these findings in infants with accidental head trauma for whom the date of injury was known.

PATIENTS AND METHODS

Two blinded, independent observers retrospectively reviewed computed tomography scans with subdural hematoma performed on the day of presentation on 9 infant victims of nonaccidental head injury (mean age: 6.8 months; range: 1-25 months) and on 38 infants (mean age: 4.8 months; range: newborn to 34 months) with accidental head trauma (birth-related: 19; short fall: 17; motor vehicle accident: 2).

RESULTS

Homogeneous hyperdense subdural hematoma was significantly more common in children with accidental head trauma (28 of 38 [74%]; nonaccidental head trauma: 3 of 9 [33%]), whereas mixed-density subdural hematoma was significantly more common in cases of nonaccidental head injury (6 of 9 [67%]; accidental head trauma: 7 of 38 [18%]). Twenty-two (79%) subdural hematomas were homogeneously hyperdense on noncontrast computed tomography performed within two days of accidental head trauma, one (4%) was homogeneous and isodense compared to brain tissue, one (4%) was homogeneous and hypodense, and four (14%) were mixed-density. There was no statistically significant difference in the proportion of interhemispheric subdural hematoma, epidural hematoma, calvarial fracture, brain contusion, or subarachnoid hemorrhage.

CONCLUSIONS

Homogeneous hyperdense subdural hematoma is more frequent in cases of accidental head trauma; mixed-density subdural hematoma is more frequent in cases of nonaccidental head injury but may be observed within 48 hours of accidental head trauma. Interhemispheric subdural hematoma is not specific for inflicted head injury.

When a funduscopic examination is the clue of maltreatment diagnostic

OBJECTIVE

: To report a case of unexpected shaken baby syndrome, the diagnosis of which was possible after an incidental funduscopic examination.

METHODS

: Observational case report. An infant was to be sent back home with an apparent unprovoked seizure diagnosis when a funduscopic examination was made because of an incidental research study changing the diagnostic orientation.

RESULTS

: Extensive bilateral subretinal hemorrhages in the funduscopic examination allowed shaken baby syndrome unexpected diagnosis. A funduscopic examination is not usually included in the first seizure diagnosis management, even when a retinal bleeding could be present and be the clue for its causative diagnosis.

CONCLUSION

: We recommend having in mind the practice of a funduscopic examination in all children with a first apparently unprovoked seizure.

Case Analysis of Brain-Injured Admittedly Shaken Infants

The English-language medical case literature was searched for cases of apparent or alleged child abuse between the years 1969 and 2001. Three-hundred and twenty-four cases that contained detailed individual case information were analyzed yielding 54 cases in which someone was recorded as having admitted, in some fashion, to have shaken the injured baby. Individual case findings were tabulated and analyzed with respect to shaking as being the cause for the injuries reported. For all 54 admittedly-shaken-infant cases, the provided details regarding the shaking incidents and other events are reported. Data in the case reports varied widely with respect to important details. Only 11 cases of admittedly shaken babies showed no sign of cranial impact (apparently free-shaken). This small number of cases does not permit valid statistical analysis or support for many of the commonly stated aspects of the so-called shaken baby syndrome.

Diagnosing pediatric head trauma

The accurate diagnosis and successful management of pediatric abusive head trauma present pediatricians with many unique challenges. To overcome these challenges requires a high index of clinical suspicion; a willingness to report any suspicion of abuse; knowledge of the relevant medical literature; a direct, nonaccusatory, and supportive approach with parents; thorough history taking; meticulous physical examination; and most important, professional objectivity and integrity. Your patients deserve no less.

Neuroimaging in non-accidental head injury: if, when, why and how

Non-accidental head injury (NAHI) in infants is an important but difficult topic. To miss or misdiagnose NAHI potentially has important consequences. The evidence base upon which to base decisions is limited but growing. This article aims to summarise current literature and thinking in this difficult area.

Shaken baby syndrome without intracranial hemorrhage on initial computed tomography

OBJECTIVE

We sought to describe the unique characteristics of children diagnosed with shaken baby syndrome (SBS) despite the absence of intracranial hemorrhage on cranial computerized tomography (CT) on hospital admission.

METHODS

Using an international e-mail-based listserv for professionals with an interest in child abuse, we identified and reviewed the charts of children hospitalized in different medical centers who were diagnosed with SBS although CT disclosed no signs of intracranial bleeding. Children with normal imaging were not included.

RESULTS

Eight cases were identified. All children had cerebral edema in CT, which was severe on 7/8 cases (88%). All of these children had extensive retinal hemorrhage. The prognosis was poor; 5/8 infants died (63% mortality), and the rest had permanent neurologic damage.

CONCLUSION

The diagnosis of SBS can be established even when CT at presentation does not demonstrate intracranial hemorrhage. We hypothesize that rapidly developing cerebral edema may cause increased intracranial pressure and tamponade that prevents the accumulation of intracranial blood. The prognosis in these cases is grave.

Normal computerized tomography of brain in children with shaken baby syndrome

OBJECTIVE

To characterize the clinical presentation and clinical course of shaken baby syndrome (SBS) with normal cranial computerized tomography (CT) on admission and to suggest further diagnostic procedures in such circumstances.

METHODS

Using a worldwide listserv designed to facilitate discussion in the field of child abuse and neglect, we solicited case information for children hospitalized in different medical centers, who were diagnosed with SBS and had a normal CT scan on admission.

RESULTS

Nine cases were identified. While all children had an abnormal neurologic examination on admission, eight had a normal CT, and one had "widening of cranial sutures." In four cases, subdural hemorrhage was diagnosed on magnetic resonance imaging (MRI) 3 to 7 days after admission. Five children had bone fractures. The neurological outcome was normal in four of nine cases. Five children had long-term neurologic damage. The diagnosis of SBS was supported by either perpetrator confession, characteristic evolution of brain abnormalities on CT or MRI, inconsistent or absent explanatory history, and/or other social risk factors.

CONCLUSION

The diagnosis of SBS can be established even when brain CT is normal on admission. The documentation of retinal hemorrhages is of primary importance in establishing the diagnosis of SBS in these cases.

Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome

OBJECTIVE

Studies of long-term outcome on nonaccidental head injury (NAHI) in young children have shown severe neurodevelopmental sequelae in most cases. For improving the knowledge of outcome and for identifying prognostic factors, additional clinical and cerebral imaging data are needed. The aim of this study was to describe clinical and imaging features over time and to consider their value for predicting neurodevelopmental outcome.

METHODS

A retrospective medical record review was conducted of 23 children with confirmed NAHI, for whom an extended follow-up of 2.5 to 13 years (mean: 6 years) was contemplated. Glasgow Coma Scale scores, severity of retinal hemorrhages, presence of skull fractures, cranial growth deceleration, and sequential neuroimaging data (computed tomography and/or magnetic resonance imaging) were compared with patterns of clinical evolution assessed by the Glasgow Outcome Scale.

RESULTS

Clinical outcome showed that 14 (61%) children had severe disabilities, 8 (35%) had moderate disabilities, and 1 (4%) was normal. A low initial Glasgow Coma Scale score, severe retinal hemorrhages, presence of skull fracture, and cranial growth deceleration were significantly associated with poor developmental outcome. Eighteen of the 23 patients had abnormal magnetic resonance imaging scans. This examination disclosed atrophy when performed beyond 15 days of injury. Atrophy seemingly resulted from various brain lesions, namely, contusions, infarcts, and other lesions within the white matter. Presence of intraparenchymal brain lesions within the first 3 months was significantly associated with neurodevelopmental impairment. Severity of motor and cognitive dysfunctions was related to the extent of intraparenchymal lesions.

CONCLUSIONS

Early clinical and radiologic findings in NAHI are of prognostic value for neurodevelopmental outcome.

Shaken baby syndrome

Shaken baby syndrome is the most common cause of death or serious neurological injury resulting from child abuse. It is specific to infancy, when children have unique anatomic features. Subdural and retinal haemorrhages are markers of shaking injury. An American radiologist, John Caffey, coined the name whiplash shaken infant syndrome in 1974. It was, however, a British neurosurgeon, Guthkelch who first described shaking as the cause of subdural haemorrhage in infants. Impact was later thought to play a major part in the causation of brain damage. Recently improved neuropathology and imaging techniques have established the cause of brain injury as hypoxic ischaemic encephalopathy. Diffusion weighted magnetic resonance imaging is the most sensitive and specific method of confirming a shaking injury. Families of children with subdural haemorrhages should be thoroughly investigated by social welfare agencies.

Child abuse in the pediatric intensive care unit

Critically ill and injured children due to abusive or inflicted injury represent a growing challenge for pediatric intensive care unit personnel in terms of the number of patients seen each year in the United States and the intellectual and emotional response required to deal with this tragic problem. We present a distillation of the current knowledge of childhood physical abuse with a focus on the child with inflicted injury who is admitted to the pediatric intensive care unit. In addition to a discussion of the epidemiology, clinical presentation, an approach to diagnosis, and treatment strategies, we also explore the legal issues that confront pediatric intensive care unit physicians in relation to determination of brain death, suitability of victims for organ donation, and the physician's role in the criminal investigation of child abuse and as a witness for court proceedings.

Ethical issues in imaging nonaccidental injury: child abuse

One of the most controversial areas of nonaccidental injury is the medical diagnosis of inflicted central nervous system injury and its impact on medical, social, and legal outcomes for children and families. This review addresses the role of the neuroradiologist in the clinical care of the pediatric patient and as an expert medical witness in the area of nonaccidental injury.

Investigating subdural haemorrhage in infants

When an infant or young child presents with subdural haemorrhage, the diagnostic priority is to exclude physical child abuse. A team approach should be adopted for the clinical child protection investigation. The diagnostic process is inevitably one of detective work; appropriate radiological, ophthalmological, haematological, biochemical, and postmortem investigations are discussed.