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Sokoloff M, Feldman KW, Levin AV, Rockter A, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Hymel KP. Retinal hemorrhage variation in inertial versus contact head injuries. CHILD ABUSE & NEGLECT 2024; 149:106606. [PMID: 38134727 DOI: 10.1016/j.chiabu.2023.106606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) is frequently accompanied by dense/extensive retinal hemorrhages to the periphery with or without retinoschisis (complex retinal hemorrhages, cRH). cRH are uncommon without AHT or major trauma. OBJECTIVE The study objectives were to determine whether cRH are associated with inertial vs. contact mechanisms and are primary vs. secondary injuries. PARTICIPANTS AND SETTING This retrospective study utilized a de-identified PediBIRN database of 701 children <3-years-old presenting to intensive care for head trauma. Children with motor vehicle related trauma and preexisting brain abnormalities were excluded. All had imaging showing head injury and a dedicated ophthalmology examination. METHODS Contact injuries included craniofacial soft tissue injuries, skull fractures and epidural hematoma. Inertial injuries included acute impairment or loss of consciousness and/or bilateral and/or interhemispheric subdural hemorrhage. Abuse was defined in two ways, by 1) predetermined criteria and 2) caretaking physicians/multidisciplinary team's diagnostic consensus. RESULTS PediBIRN subjects with cRH frequently experienced inertial injury (99.4 % (308/310, OR = 53.74 (16.91-170.77)) but infrequently isolated contact trauma (0.6 % (2/310), OR = 0.02 (0.0004-0.06)). Inertial injuries predominated over contact trauma among children with cRH sorted AHT by predetermined criteria (99.1 % (237/239), OR = 20.20 (6.09-67.01) vs 0.5 % (2/339), OR = 0.04 (0.01-0.17)). Fifty-nine percent of patients with cRH, <24 h altered consciousness, and inertial injuries lacked imaging evidence of brain hypoxia, ischemia, or swelling. CONCLUSIONS cRH are significantly associated with inertial angular acceleration forces. They can occur without brain hypoxia, ischemia or swelling suggesting they are not secondary injuries.
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Affiliation(s)
- Michael Sokoloff
- Department of Pediatrics, Pediatric Intensive Care, Sacred Heart Children's Hospital, Spokane, WA, United States of America.
| | - Kenneth W Feldman
- Department of Pediatrics, Seattle Children's, University of Washington's Harborview Medical Center, Seattle, WA, United States of America; Department of Pediatrics, Safe Child and Adolescent Network, Seattle Children's, Seattle, WA, United States of America.
| | - Alex V Levin
- Department of Ophthalmology, Flaum Eye Institute, University of Rochester, Rochester, NY, United States of America.
| | - Adam Rockter
- University of Rochester School of Medicine, Rochester, NY, United States of America.
| | - Veronica Armijo-Garcia
- Department of Pediatrics, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, United States of America.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, KS, United States of America.
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA, United States of America.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, United States of America.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States of America.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, United States of America.
| | - Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, United States of America
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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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Christian CW, Binenbaum G. The eye in child abuse. Childs Nerv Syst 2022; 38:2335-2344. [PMID: 35871261 DOI: 10.1007/s00381-022-05610-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
Child physical abuse may result in a range of injuries to the globe and surrounding tissues. These injuries have varying degrees of specificity for abuse, and no pattern of injury is unique to abuse. Easily overlooked eye injuries in non-ambulatory infants often portend more severe abuse and require careful evaluation for occult injury when they are unexplained. Retinal hemorrhages are most often a sign of significant trauma and the severity of the hemorrhages generally parallels the severity of neurological trauma. Ophthalmologists contribute important data that more easily distinguish medical disease from trauma, but caution is needed in differentiating accidental from inflicted trauma. This distinction requires careful consideration of the complete clinical data and occasionally on additional law enforcement or child welfare investigation.
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Affiliation(s)
- Cindy W Christian
- The Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, USA.
| | - Gil Binenbaum
- The Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Ophthalmology, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, USA
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Maia GLDS, Vieira IKF, Fortes CHF, Silva PHDN, Cunha CEXD, Oliveira AIPD, Ribeiro MVMR. Aspectos médico-legais do olho. REVISTA BRASILEIRA DE OFTALMOLOGIA 2022. [DOI: 10.37039/1982.8551.20220068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Su M, Taylor K, Stoutin J, Shaver C, Recko M. Evidence-Based Screening to Optimize the Yield of Positive Ophthalmologic Examinations in Children Evaluated for Suspected Child Abuse. J Pediatr Ophthalmol Strabismus 2022; 59:310-319. [PMID: 35446193 DOI: 10.3928/01913913-20220216-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine nonocular findings associated with significant retinal hemorrhage on dilated fundus examination in cases of suspected child abuse. METHODS This was a retrospective chart review from May 2014 to August 2021 at a level-1 trauma center. Two hundred seventy-four patients met the following inclusion criteria: (1) children 36 months and younger; (2) concern for child abuse; and (3) had an ophthalmology consultation. Through univariate and multivariate logistic regression, the study produced a screening algorithm for ophthalmic work-up in child abuse. RESULTS One or more abnormal neuroimaging findings had a statistically significant association with retinal hemorrhages and produced the strongest association with a univariate odds ratio of 170 (confidence interval: 10.245 to > 999.999). The multivariate model (P < .0001 with a c-statistic of 0.980) proposes using the following variables for predicting retinal hemorrhage on examination: abnormal neuroimaging, Glasgow Coma Scale score less than 15, altered mental status on examination, seizure activity, vomiting, bruising, scalp hematoma/swelling, and skull fractures. CONCLUSIONS This study elucidates clinical and imaging factors that correlate to retinal findings, validating previously studied variables and introducing new variables to be considered. The authors propose an evidence-based screening algorithm to increase the yield of positive dilated examinations and decrease the burden of potentially unnecessary child abuse ophthalmologic examinations. [J Pediatr Ophthalmol Strabismus. 2022;59(5):310-319.].
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Scheller J, Wester K. Is external hydrocephalus a possible differential diagnosis when child abuse is suspected? Acta Neurochir (Wien) 2022; 164:1161-1172. [PMID: 33710381 PMCID: PMC8967805 DOI: 10.1007/s00701-021-04786-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/22/2021] [Indexed: 11/07/2022]
Abstract
Background Criteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; consequently, these conditions might be diagnosed on failing premises. Methods The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)—mean age 5.1 month, without age difference between genders. Results Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH). Conclusions BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors’ experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.
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Moskwa R, Todeschi J, Wiedemann-Fode A, Stella I, Joud A, Klein O. Ophthalmological lesions in shaken baby syndrome: a retrospective analysis of 133 consecutive cases (1992-2018). Neurochirurgie 2022; 68:367-372. [PMID: 35150727 DOI: 10.1016/j.neuchi.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data. PATIENTS AND METHODS This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992 - 2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded. RESULTS Mean age at diagnosis was 131 days (range, 14 days - 10 months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6 months: 80%. CONCLUSION This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.
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Affiliation(s)
- Rémy Moskwa
- Department of Ophthalmology, Mercy Regional Hospital, Ars-Laquenexy, France; Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Julien Todeschi
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Arnaud Wiedemann-Fode
- Pediatric Intensive Care Unit, Children's Hospital, Nancy University Hospital, INSERM Unit 1256 N-GERE, Université de Lorraine, France
| | - Irene Stella
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Anthony Joud
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Olivier Klein
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France.
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Weiss R, He CH, Khan S, Parsikia A, Mbekeani JN. Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma. Pediatr Neurol 2022; 127:11-18. [PMID: 34922138 DOI: 10.1016/j.pediatrneurol.2021.11.004] [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: 05/12/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.
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Affiliation(s)
- Rebecca Weiss
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | | | - Sabine Khan
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York; Research Services, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce N Mbekeani
- Albert Einstein College of Medicine, Bronx, New York; Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York.
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Unusual eye injury related to abusive head trauma. Rechtsmedizin (Berl) 2021. [DOI: 10.1007/s00194-021-00460-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AbstractOphthalmological examination is an essential component in clinically diagnosing abusive head trauma (AHT). Typical of AHT injuries is retinal bleeding, with other parts of the eye sometimes also being affected. Visual impairment and blindness are long-term complications in this context. We present a case with unusual eye injuries after a diagnostically confirmed AHT.The ophthalmological findings on admission day showed a massive subhyaloid hemorrhage at the posterior pole and extensive flame-shaped intraretinal hemorrhages accented on the right side., A centrally localized vitreous hemorrhage appeared on both sides 3 weeks later, obscuring the optic disc and macula most probably due to a breakthrough of a sub-internal limiting membrane (ILM) hemorrhage into the vitreous cavity. Follow-up 4 weeks later revealed a dense and organized vitreous hemorrhage occupying the optic disc and macula so that a pars plana vitrectomy was performed on both eyes.The bilateral bleeding in different retinal layers, the vitreous hemorrhage and the proliferative vitreoretinal reaction (PVR) indicated massive damage caused by a significant acceleration-deceleration trauma. A two-phase vitreous hemorrhage in a child with AHT does not yet appear to have been described in the literature.
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Ang JL, Collis S, Dhillon B, Cackett P. The Eye in Forensic Medicine: A Narrative Review. Asia Pac J Ophthalmol (Phila) 2021; 10:486-494. [PMID: 34524140 DOI: 10.1097/apo.0000000000000426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
ABSTRACT The eye, with its distinctive anatomy, not only reflects a wide variety of diseases in life but also undergoes a myriad of post-mortem changes. Consequently, the eye has long been an area of interest in forensic science, primarily for the estimation of post-mortem interval and therefore the time of death and also for assistance in ascertaining the cause of death. There has been significant progress in the knowledge of ophthalmic forensic science using new technologies which have allowed further possibilities to arise where understanding of this field can assist the forensic pathologist. This review aims to highlight the current knowledge which exists in this field and also to identify important avenues for further investigation. Post-mortem changes of the eye along with its current applications and challenges will be discussed. These include the important areas of post-mortem iris biometrics, pupil size correlation with post-mortem interval, use of point-of-care technology on vitreous humor, and the use of ophthalmic imaging in pediatric abusive head trauma.
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Affiliation(s)
- Juan Lyn Ang
- Princess Alexandra Eye Pavilion, Edinburgh, United Kingdom
| | - SallyAnne Collis
- Department of Forensic Pathology, The University of Edinburgh, Edinburgh, United Kingdom
| | - Baljean Dhillon
- Princess Alexandra Eye Pavilion, Edinburgh, United Kingdom
- The University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Cackett
- Princess Alexandra Eye Pavilion, Edinburgh, United Kingdom
- The University of Edinburgh, Edinburgh, United Kingdom
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11
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Ferreira Furtado LM, Da Costa Val Filho JA, Moura de Sousa C, Dantas F, Costa JDS. Neuroendoscopic Approach of a Massive Bilateral Chronic Subdural Hematoma in a Child Using a Single Burr Hole. Cureus 2021; 13:e12755. [PMID: 33489638 PMCID: PMC7813954 DOI: 10.7759/cureus.12755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
There are several treatment modalities for the management of subdural fluid collection in infants, such as fontanelle puncture and drainage, burr hole irrigation, and subduroperitoneal shunt. This report describes the case of a girl born with congenital neurological impairment due to severe injury of the brain with unknown etiology. At five months of age, she suffered from head trauma and developed somnolence after three days and was diagnosed with a bilateral massive chronic subdural hematoma. Normal fundoscopy did not confirm the non-accidental head trauma. Neuroendoscopy using a single burr hole was performed and complete drainage was achieved. Arachnoid tearing was observed during the procedure. Postoperatively, the patient showed clinical improvement, and brain expansion was observed after one month. The main advantages of neuroendoscopy for bilateral massive chronic subdural hematoma are accurate visualization of the space, minimal invasiveness, and treatment of both sides with reliable drainage control.
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Affiliation(s)
| | | | - Camila Moura de Sousa
- Neurological Surgery, Federal University of Vales do Jequitinhonha e Mucuri, Diamantina, BRA
| | - François Dantas
- Neurological Surgery, Biocor Instituto, Belo Horizonte, BRA.,Neurological Surgery, Hospital Vila da Serra, Belo Horizonte, BRA
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12
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Ajmera S, Motiwala M, Weeks M, Oravec CS, Hersh DS, Fraser BD, Vaughn B, Klimo P. What Variables Correlate With Different Clinical Outcomes of Abusive Head Injury? Neurosurgery 2020; 87:803-810. [PMID: 32243538 DOI: 10.1093/neuros/nyaa058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/29/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The spectrum of injury severity for abusive head trauma (AHT) severity is broad, but outcomes are unequivocally worse than accidental trauma. There are few publications that analyze different outcomes of AHT. OBJECTIVE To determine variables associated with different outcomes of AHT. METHODS Patients were identified using our AHT database. Three different, but not mutually exclusive, outcomes of AHT were modeled: (1) death or hemispheric stroke (diffuse loss of grey-white differentiation); (2) stroke(s) of any size; and (3) need for a neurosurgical operation. Demographic and clinical variables were collected and correlations to the 3 outcomes of interest were identified using bivariate and multivariable analysis. RESULTS From January 2009 to December 2017, 305 children were identified through a prospectively maintained AHT database. These children were typically male (60%), African American (54%), and had public or no insurance (90%). A total of 29 children (9.5%) died or suffered a massive hemispheric stroke, 57 (18.7%) required a neurosurgical operation, and 91 (29.8%) sustained 1 or more stroke. Death or hemispheric stroke was statistically associated with the pupillary exam (odds ratio [OR] = 45.7) and admission international normalized ratio (INR) (OR = 17.3); stroke was associated with the pupillary exam (OR = 13.2), seizures (OR = 14.8), admission hematocrit (OR = 0.92), and INR (9.4), and need for surgery was associated with seizures (OR = 8.6). CONCLUSION We have identified several demographic and clinical variables that correlate with 3 clinically applicable outcomes of abusive head injury.
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Affiliation(s)
- Sonia Ajmera
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Chesney S Oravec
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David S Hersh
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey Clinic, Memphis, Tennessee
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13
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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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14
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Wester K. Two Infant Boys Misdiagnosed as "Shaken Baby" and Their Twin Sisters: A Cautionary Tale. Pediatr Neurol 2019; 97:3-11. [PMID: 31147228 DOI: 10.1016/j.pediatrneurol.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/06/2019] [Accepted: 02/27/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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15
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Jones PA, Minns RA, Tandon A, Fleck B, Mulvihill A. Resolution patterns and duration of retinal haemorrhages measured by two-dimensional retinal area pixel counts from sequential retinal imaging in childhood encephalopathies: a morphometric study. BMJ Open Ophthalmol 2019; 4:e000275. [PMID: 31321309 PMCID: PMC6597619 DOI: 10.1136/bmjophth-2019-000275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 05/02/2019] [Accepted: 05/22/2019] [Indexed: 12/02/2022] Open
Abstract
Objective To determine the time to resolution of different-layered retinal haemorrhages (RHs), and to describe the main patterns of their resolution in a group of children with encephalopathies. Methods and analysis From a prospective study of 114 children with traumatic and non-traumatic encephalopathies, 429 selected individual RHs (iRHs) from 18 children were serially imaged from admission using a RetCam. Photoshop and Scion Imaging software allowed calculation of RH area in pixels. Results Two patterns of the resolution were recognised on the basis of area measurements: a progressive decrease (pattern A, 60% of iRHs), and a form of asymmetrical decay in which iRHs first increased in size before then progressively decreasing (pattern B, 35% of iRHs). Within the pattern A group, the Kaplan-Meier median survival time (MST) (95% CI) was 10 (9.3 to 10.7) days for intra-RHs (IRHs) and 38 (10.8 to 65.2) days for pre-RHs (PRHs), log rank (Mantel-Cox) p=0.001. The mean percentage reduction in area per day was 12.5% for all iRHs, 14.5% for IRHs and 6.3% for PRHs. Conclusion Serial area measurements of iRHs revealed that 35% haemorrhages became temporarily larger before decreasing to resolution. Serially imaged selected RHs showed a longer MST for PRHs than for IRHs.
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Affiliation(s)
| | - Robert A Minns
- Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK
| | - Anamika Tandon
- Paediatric Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Brian Fleck
- Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK.,Paediatric Ophthalmology, Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK
| | - Alan Mulvihill
- Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK.,Paediatric Ophthalmology, Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK
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16
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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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17
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18
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19
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SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations. Int J Legal Med 2018; 132:1719-1727. [PMID: 29982863 DOI: 10.1007/s00414-018-1889-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.
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20
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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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21
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Mattheij M, Venstermans C, de Veuster I, Vanderstraete I, Menovsky T, Jorens P, Ceulemans B. Retinal haemorrhages in a university hospital: not always abusive head injury. Acta Neurol Belg 2017; 117:515-522. [PMID: 28160241 DOI: 10.1007/s13760-017-0748-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/13/2017] [Indexed: 11/26/2022]
Abstract
Retinal haemorrhages (RH) and subdural haematomas (SDH) are frequently seen in abusive head trauma (AHT). The aim of our study is to show that they are suggestive, but not pathognomonic for AHT. We performed an observational retrospective study on children, aged 1-18 months old, admitted to the Antwerp University Hospital with RH. History, physical examination, medical course, coagulation and metabolic tests, skeletal survey, head circumference, retinal findings, cerebral imaging, and evaluation reports by social services or civil/criminal courts were collected. Twenty-nine children with RH were included. Twenty three of them were found suspect of AHT. Three children of this group showed intraparenchymal haematomas/infarctions, 5 interhemispheric blood, 6 cerebral oedema, 7 ventricle compression, and 4 papilloedema. Seven of the 16 children with diffusion-weighted MRI images showed diffuse lesions. In 2 of the 6 children not suspect for AHT, an aetiology was found. None of the 4 remaining children showed the above-mentioned abnormalities. Three of these 4 cases showed an accelerated growth of the head circumference months before presentation. The majority of the children in all groups showed 'too numerous to count' (>20) RH (12 of the 23 'suspect' children, and 4 of the 6 'non-suspect' children). Results showed no differences between the groups concerning the location, distribution, or size of the RH. Infants with RH and/or SDH are not necessarily victims of AHT. Cerebral imaging and retinal findings can help differentiate suspect from non-suspect cases. Infants with a large head circumference could be predisposed to RH or SDH.
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Affiliation(s)
- M Mattheij
- Department of Neurology - Paediatric Neurology, Antwerp University Hospital, University of Antwerp, Wijlrijkstraat 10, 2610, Edegem, Belgium.
| | - C Venstermans
- Department of Radiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - I de Veuster
- Department of Ophthalmology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - I Vanderstraete
- Vertrouwenscentrum Kindermishandeling (Confidentiality center), Prof. Claraplein 1, 2018, Antwerp, Belgium
| | - T Menovsky
- Department of Neurosurgery, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - P Jorens
- Intensive Care Unit, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - B Ceulemans
- Department of Neurology - Paediatric Neurology, Antwerp University Hospital, University of Antwerp, Wijlrijkstraat 10, 2610, Edegem, Belgium
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22
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Bhardwaj G, Jacobs MB, Martin FJ, Moran KT, Prelog K, Donaldson C, Vollmer-Conna U, Coroneo MT. Photographic assessment of retinal hemorrhages in infant head injury: the Childhood Hemorrhagic Retinopathy Study. J AAPOS 2017; 21:28-33.e2. [PMID: 28104500 DOI: 10.1016/j.jaapos.2016.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 11/09/2016] [Accepted: 11/19/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Retinal hemorrhages (RH) in babies in the absence of severe trauma or a medical cause have been strongly associated with abusive head trauma (AHT). We examined the pattern of RH in accidental head injury and AHT objectively using widefield retinal imaging. METHODS A total of 118 infants and children 1-36 months of age admitted with head injuries at two centers were included in this prospective, consecutive, comparative cohort study. Dilated fundus examination was performed with indirect ophthalmoscopy and widefield imaging. Designation of AHT was made using predetermined criteria independent of retinal findings. Retinal images were graded by two independent observers. RESULTS There were 21 cases of AHT. RH were present in 14 cases (66%); macular retinoschisis or retinal folds, in 8 (38%). There were 86 cases of accidental head injuries, with RH present in 2 (2%); there were none with retinal folds or retinoschisis. In cases of head injury with intracranial hemorrhage, the positive likelihood ratio of AHT with RH was 5.7 (95% CI, 2.6-12.00) and negative likelihood ratio was 0.26 (95% CI, 0.11-0.62). A severe, panretinal pattern with multilayered hemorrhages was the most specific for AHT. CONCLUSIONS Our imaging study confirmed that RH in infants with head injury have a high positive likelihood ratio for AHT. A severe hemorrhagic retinopathy, particularly in association with perimacular folds or macular retinoschisis, has the highest positive predictive value for AHT.
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Affiliation(s)
- Gaurav Bhardwaj
- Faculty of Medicine, University of New South Wales (UNSW), Sydney NSW, Australia.
| | - Mark B Jacobs
- Faculty of Medicine, University of New South Wales (UNSW), Sydney NSW, Australia; Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW, Australia
| | - Frank J Martin
- Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW, Australia; Department of Ophthalmology, The Children's Hospital at Westmead, Westmead, NSW, Australia; Faculty of Medicine, University of Sydney, NSW, Australia
| | - Kieran T Moran
- Faculty of Medicine, University of New South Wales (UNSW), Sydney NSW, Australia; Child Protection Unit, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Kristina Prelog
- Department of Radiology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Craig Donaldson
- Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW, Australia; Department of Ophthalmology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Ute Vollmer-Conna
- School of Psychiatry, Faculty of Medicine, University of New South Wales (UNSW), Randwick, NSW, Australia
| | - Minas T Coroneo
- Faculty of Medicine, University of New South Wales (UNSW), Sydney NSW, Australia; Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW, Australia
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23
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Saunders D, Raissaki M, Servaes S, Adamsbaum C, Choudhary AK, Moreno JA, van Rijn RR, Offiah AC. Throwing the baby out with the bath water - response to the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) report on traumatic shaking. Pediatr Radiol 2017; 47:1386-1389. [PMID: 28785782 PMCID: PMC5608779 DOI: 10.1007/s00247-017-3932-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/15/2017] [Indexed: 11/23/2022]
Affiliation(s)
- Dawn Saunders
- 0000000121901201grid.83440.3bGreat Ormond Street Hospital NHS Trust for Children, Institute of Child Health, WC1N 3JH, London, UK
| | - Maria Raissaki
- grid.412481.aDepartment of Radiology, University Hospital of Heraklion, Iraklio, Greece ,0000 0004 0576 3437grid.8127.cUniversity of Crete, Heraklion, Crete, Greece
| | - Sabah Servaes
- 0000 0004 1936 8972grid.25879.31The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA USA
| | - Catherine Adamsbaum
- 0000 0001 2171 2558grid.5842.bAP-HP, Bicêtre Hospital, Pediatric Imaging Department, Paris Sud University, Bicêtre, France
| | - Arabinda Kumar Choudhary
- 0000 0004 0458 9676grid.239281.3Department of Medical Imaging, Alfred I. duPont Hospital for Children, Wilmington, DE USA
| | | | - Rick R. van Rijn
- 0000000404654431grid.5650.6Department of Radiology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Amaka C. Offiah
- 0000 0004 1936 9262grid.11835.3eAcademic Unit of Child Health, Sheffield Childrens NHS Foundation Trust, University of Sheffield, Sheffield, UK
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24
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Child Abuse and Neglect. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Kim YH, Choi SY, Lee JS, Yoon SH, Chung SA. Smartphone Fundus Photography in an Infant with Abusive Head Trauma. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2017. [DOI: 10.3341/jkos.2017.58.11.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Yong Hyun Kim
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Shin Young Choi
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Sook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Soo Han Yoon
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Seung Ah Chung
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
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26
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Payne BS, Kutz TJ, Di Maio A, Gerard JM. Prevalence of Retinal Hemorrhages in Infants Presenting with Isolated Long Bone Fractures and Evaluation for Abuse. J Emerg Med 2016; 51:365-369. [DOI: 10.1016/j.jemermed.2016.05.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/23/2016] [Accepted: 05/17/2016] [Indexed: 11/29/2022]
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27
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Sato A, Kikuchi N, Yokota S. Inadequate sociomedical evaluation of possible abusive head trauma in Yokohama. Pediatr Int 2016; 58:445-9. [PMID: 26513132 DOI: 10.1111/ped.12840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 09/11/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND There have been no previous studies on the adequacy of combined evaluation of possible abusive head trauma cases by frontline medical personnel, hospital-based child protection teams, and child protective services in local districts of Japan. METHODS We conducted a questionnaire survey of hospitalized patients under 24 months old with a diagnosis of intracranial hemorrhage (ICH) from January 2011 to December 2013. Eleven large-scale general hospitals in Yokohama, Japan were surveyed, which provide centralized inpatient care to moderately-severely ill children. RESULTS A total of 51 ICH patients were listed from eight hospitals. Median patient age was 7 months, and 84% were younger than 12 months. The most common diagnosis on computed tomography was subdural hematoma (n = 26; 51%). Of a total of 51 cases, 31 (61%) occurred inside the home; the injury scene was unknown in six cases (12%). We reviewed these 37 cases from the viewpoint of evaluation with concern for suspected child abuse. Three out of 37 patients (8%) were not examined for inflicted skin lesions, and skeletal surveys and funduscopy were not conducted in 14 (38%) and 15 (41%), respectively. Thirteen out of 37 cases (35%) were not reported to hospital-based child protection teams and 22 (59%) were not reported to regional child protective services. CONCLUSION The sociomedical evaluation of possible child abuse appears to be systematically inadequate in Yokohama.
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Affiliation(s)
- Atsuo Sato
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Kanagawa, Japan.,Department of Pediatrics, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Nobuyuki Kikuchi
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Kanagawa, Japan.,Department of Pediatrics, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Shumpei Yokota
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Kanagawa, Japan.,Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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28
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Fieß A, Dithmar S, Kölb-Keerl R, Kunze A, Riße M, Knuf M, Bauer J. [Retinal bleeding and venous stasis in a 10-month-old infant after a fall?]. Ophthalmologe 2015; 113:694-8. [PMID: 26676641 DOI: 10.1007/s00347-015-0188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This report describes the case of a 10-month-old infant, who was delivered to our hospital by the emergency physician intubated and in an unclear unconscious state. The father reported that the child had fallen from the couch to the ground. The consulted ophthalmologist reported venous stasis in both eyes including intraretinal and preretinal bleeding in all four quadrants, a diffuse vitreous hemorrhage in the right eye and temporal retinal wrinkling in both eyes. Based on these particular clinical findings a shaken baby syndrome was suspected. This report demonstrates the importance of recognizing and correctly interpreting the typical ophthalmological signs of physical child abuse in order to detect and prevent further mistreatment of children; moreover, the increasing importance of photographic documentation and histological work-up of the findings for forensic reasons are emphasized.
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Affiliation(s)
- A Fieß
- Klinik für Augenheilkunde, Helios Dr. Horst-Schmidt-Kliniken, Ludwig-Erhard-Straße 100, 65199, Wiesbaden, Deutschland.
| | - S Dithmar
- Klinik für Augenheilkunde, Helios Dr. Horst-Schmidt-Kliniken, Ludwig-Erhard-Straße 100, 65199, Wiesbaden, Deutschland
| | - R Kölb-Keerl
- Klinik für Augenheilkunde, Helios Dr. Horst-Schmidt-Kliniken, Ludwig-Erhard-Straße 100, 65199, Wiesbaden, Deutschland
| | - A Kunze
- Klinik für Kinder und Jugendliche, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Deutschland
| | - M Riße
- Institut für Rechtsmedizin, Universitätsklinikum Gießen und Marburg, Gießen, Deutschland
| | - M Knuf
- Klinik für Kinder und Jugendliche, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Deutschland
| | - J Bauer
- Klinik für Kinder und Jugendliche, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Deutschland
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29
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Graff A. Child Abuse and Neglect. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_27-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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The eye in child abuse: key points on retinal hemorrhages and abusive head trauma. Pediatr Radiol 2014; 44 Suppl 4:S571-7. [PMID: 25501729 DOI: 10.1007/s00247-014-3107-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
This review presents an up-to-date overview of ocular injuries resulting from child abuse, with a spotlight on abusive head trauma. Retinal hemorrhage is a principle finding of inflicted head trauma. The specific pattern of hemorrhages holds valuable diagnostic information, which can help to guide multidisciplinary assessments of the likelihood of abuse. Indirect ophthalmoscopy through dilated pupils by an ophthalmologist is necessary for adequate examination and documentation of retinal findings. Initial pediatrician evaluation of the eye and indications for ophthalmological consultation are reviewed. Focus is then placed upon understanding retinal hemorrhage patterns, their diagnostic significance and likely pathophysiological mechanisms. The differential diagnosis of retinal hemorrhage in young children is discussed, highlighting key distinctions among retinal hemorrhage patterns, severity and frequencies, as well as other ocular findings. The most common cause of retinal hemorrhage in an infant is trauma, and most other causes can be identified by considering the hemorrhage pattern, ocular or systemic signs and the results of laboratory and imaging tests, when indicated.
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31
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Adamsbaum C, Morel B, Ducot B, Antoni G, Rey-Salmon C. Dating the abusive head trauma episode and perpetrator statements: key points for imaging. Pediatr Radiol 2014; 44 Suppl 4:S578-88. [PMID: 25501730 DOI: 10.1007/s00247-014-3171-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 05/30/2014] [Accepted: 08/20/2014] [Indexed: 11/24/2022]
Abstract
Shaken baby syndrome/abusive head trauma is a leading cause of morbidity and mortality in infants. The presence of a diffuse subdural hematoma without evidence of accident is a key diagnostic clue. The hematoma is typically attributed to rupture of the cerebral bridging veins due to violent shaking, with or without impact. Dating the incident, however, remains controversial. The aim of this article is to review the most reliable features used for dating the incident, based on both legal statements by perpetrators and medical documentation. The key points are: 1) The high (yet likely underestimated) frequency of repeated shaking is around 50%, 2) Children do not behave normally immediately after shaking, and the time of onset of even mild symptoms appears to be the best clue for dating the incident and 3) Brain imaging provides strong indicators of "age-different" injuries but the ranges for dating the causal event are wide. The density pattern in a single subdural hematoma location provides no reliable clues for assessing repeated violence. Only the finding of different density in two distant subdural hematomas argues in favor of "age-different" injuries, i.e. repeated violence. MRI is difficult to interpret in terms of dating subdural hemorrhages and must be analyzed in conjunction with CT. Most importantly, all of the child's previous clinical and radiological data must be carefully studied and correlated to provide accurate information on the date and repetition of the trauma.
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32
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Characteristics of shaken baby syndrome in a regional Japanese children's hospital. Jpn J Ophthalmol 2013; 57:568-72. [PMID: 23881041 DOI: 10.1007/s10384-013-0264-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 06/21/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To report the characteristics of Japanese shaken baby syndrome (SBS) in a regional Japanese children's hospital and verify previously reported idiosyncratic features that differ from those of SBS in Western countries: (1) a considerably higher frequency of mothers as perpetrators, (2) older ages of abusive parents, and (3) a higher rate of premature infant birth. METHODS We reviewed medical charts obtained between 2002 and 2012 at Nagano Children's Hospital, Japan. RESULTS Thirty-seven SBS cases with abusive head trauma were found, among which 11 (30 %) of the perpetrators were mothers, 9 (24 %) fathers, 3 (8 %) brothers, and 14 (37 %) involved both parents. A history of premature birth was present in 2 (5 %) of the cases. The mean age of the mother was 32.4 years and that of the father was 31.3 years. CONCLUSION The clinical characteristics of Japanese SBS in this study are largely comparable to those seen in Western countries. Compared with the previously reported idiosyncratic features, there was a decreased predominance of mothers as perpetrators of SBS, suggestive of an increasing culpability of fathers. We also noticed that the ratio of premature births was more similar to those seen in Western surveys, while the mean ages of abusive Japanese parents remained older. Such varying results warrant a further nationwide survey.
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Nonaccidental head injury. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/b978-0-444-52910-7.00012-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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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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Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond) 2012; 27:28-36. [PMID: 23079748 DOI: 10.1038/eye.2012.213] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
AIM To report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT). METHODS A systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT. RESULTS Of the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined. CONCLUSIONS Our systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.
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Taylor DSI. Educational paper : retinal haemorrhages in abusive head trauma in children. Eur J Pediatr 2012; 171:1007-9. [PMID: 21968906 DOI: 10.1007/s00431-011-1579-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 09/08/2011] [Indexed: 10/17/2022]
Abstract
Retinal haemorrhages are an important component of the clinical effects of non-accidental head injuries which have significant visual morbidity. Their importance extends into the legal investigations of carers of children with subdural haemorrhages and encephalopathy who are suspected of having been non-accidentally injured. The vital precision in diagnosis relies not just on the presence of retinal haemorrhages but on the severity, extent, bilaterality and their location in the retina. Inadequate documentation of ophthalmological clinical findings and too short a follow-up to allow proper assessment of severity each give rise to difficulties for both expert witnesses and the courts.
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Affiliation(s)
- David S I Taylor
- Institute of Child Health, University College London, 30, Guilford Street, London, WC1N 1EH, UK.
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Oluigbo CO, Wilkinson CC, Stence NV, Fenton LZ, McNatt SA, Handler MH. Comparison of outcomes following decompressive craniectomy in children with accidental and nonaccidental blunt cranial trauma. J Neurosurg Pediatr 2012; 9:125-32. [PMID: 22295915 DOI: 10.3171/2011.11.peds09449] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to compare clinical outcomes following decompressive craniectomy performed for intracranial hypertension in children with nonaccidental, blunt cranial trauma with outcomes of decompressive craniectomy in children injured by other mechanisms. METHODS All children in a prospectively acquired database of trauma admissions who underwent decompressive craniectomy over a 9-year span, beginning January 1, 2000, are the basis for this study. Clinical records and neuroimaging studies were systematically reviewed. RESULTS Thirty-seven children met the inclusion criteria. Nonaccidental head trauma was the most common mechanism of injury (38%). The mortality rate in patients with abusive brain injury (35.7%) was significantly higher (p < 0.05) than in patients with other causes of traumatic brain injury (4.3%). Children with inflicted head injuries had a 12-fold increase in the odds of death and 3-fold increase in the odds of a poor outcome (King's Outcome Scale for Closed Head Injury score of 1, 2, or 3). CONCLUSIONS Children with nonaccidental blunt cranial trauma have significantly higher mortality following decompressive craniectomy than do children with other mechanisms of injury. This understanding can be interpreted to mean either that the threshold for decompression should be lower in children with nonaccidental closed head injury or that decompression is unlikely to alter the path to a fatal outcome. If decompressive craniectomy is to be effective in reducing mortality in the setting of nonaccidental blunt cranial trauma, it should be done quite early.
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Affiliation(s)
- Chima O Oluigbo
- Department of Neurosurgery, The Children's Hospital and University of Colorado, Aurora, Colorado 80045, USA
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Laurent-Vannier A, Nathanson M, Quiriau F, Briand-Huchet E, Cook J, Billette de Villemeur T, Chazal J, Christophe C, Defoort-Dhellemmes S, Fortin G, Rambaud C, Raul JS, Rey-Salmon C, Sottet F, Vieux E, Vinchon M, Willinger R. A public hearing. "Shaken baby syndrome: guidelines on establishing a robust diagnosis and the procedures to be adopted by healthcare and social services staff". Scoping report. Ann Phys Rehabil Med 2011; 54:533-99. [PMID: 22118913 DOI: 10.1016/j.rehab.2011.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Laurent-Vannier
- Service de rééducation des pathologies neurologiques acquises de l'enfant, hôpitaux de Saint-Maurice, 14, rue du Val-d'Osne, 94415 Saint-Maurice cedex, France.
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Lantz PE, Couture DE. Fatal Acute Intracranial Injury, Subdural Hematoma, and Retinal Hemorrhages Caused by Stairway Fall*. J Forensic Sci 2011; 56:1648-53. [DOI: 10.1111/j.1556-4029.2011.01892.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Patrick E. Lantz
- Department of Pathology, Wake Forest University School of Medicine, Medical Center Blvd., Winston‐Salem, NC 27157
| | - Daniel E. Couture
- Department of Neurosurgery, Wake Forest University School of Medicine, Medical Center Blvd., Winston‐Salem, NC 27157
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Maguire SA, Kemp AM, Lumb RC, Farewell DM. Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics 2011; 128:e550-64. [PMID: 21844052 DOI: 10.1542/peds.2010-2949] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT AND OBJECTIVE To determine which combinations of clinical features assist in distinguishing abusive head trauma (AHT) from nonabusive head trauma. METHODS Individual patient data from 6 comparative studies of children younger than 3 years with intracranial injury were analyzed to determine the association between AHT and combinations of apnea; retinal hemorrhage; rib, skull, and long-bone fractures; seizures; and head and/or neck bruising. An aggregate analysis of data from these studies used multiple imputation of combined clinical features using a bespoke hotdeck imputation strategy, which accounted for uncertainty arising from missing information. RESULTS Analyzing 1053 children (348 had AHT), excluding nonsignificant variables (gender, age, skull fractures), for a child with an intracranial injury and 1 or 2 of the 6 features, the positive predictive value (PPV) of AHT varies from 4% to 97% according to the different combinations. Although rarely recorded, apnea is significantly associated with AHT (odds ratio [OR]: 6.89 [confidence interval: 2.08-22.86]). When rib fracture or retinal hemorrhage was present with any 1 of the other features, the OR for AHT is >100 (PPV > 85%). Any combination of 3 or more of the 6 significant features yielded an OR of >100 (PPV for AHT > 85%). CONCLUSIONS Probabilities of AHT can be estimated on the basis of different combinations of clinical features. The model could be further developed in a prospective large-scale study, with an expanded clinical data set, to contribute to a more refined tool to inform clinical decisions about the likelihood of AHT.
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Affiliation(s)
- Sabine Ann Maguire
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, United Kingdom.
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Faridi OS, Ho LY, Trese MT. Intrauterine injury simulating abusive head trauma. Retin Cases Brief Rep 2011; 5:141-143. [PMID: 25389884 DOI: 10.1097/icb.0b013e3181cc2159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE The purpose of this study was to describe a patient with intrauterine injury simulating abusive head trauma and its management. METHODS A case report of a premature infant born at 35 weeks 2 days through an uncomplicated vaginal delivery was found to have cerebral hemorrhages on magnetic resonance imaging after presenting with respiratory distress. The infant was referred to us for bilateral subconjunctival hemorrhages and periorbital edema. We performed serial ophthalmologic examinations, reviewed all prenatal history with the mother of the infant, and reviewed all relevant hospital notes, laboratory results, and imaging results. RESULTS On ophthalmologic examination, the patient was found to have vitreous and retinal hemorrhages bilaterally. Prenatal history showed intrauterine trauma inflicted by the mother in the setting of an atraumatic delivery. The patient required bilateral vitrectomies to prevent amblyopia. CONCLUSION Intrauterine injury may simulate abusive head trauma, and it is important for clinicians to recognize this presentation to prevent further harm to the infant and prevent devastating visual loss.
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Affiliation(s)
- Omar S Faridi
- From the *Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, Michigan; and †Associated Retinal Consultants, William Beaumont Hospital, Royal Oak, Michigan
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Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical review of the literature. Childs Nerv Syst 2010; 26:1195-205. [PMID: 20195617 DOI: 10.1007/s00381-010-1105-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 01/29/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Subdural hematomas (SDH) in infants often result from nonaccidental head injury (NAHI), which is diagnosed based on the absence of history of trauma and the presence of associated lesions. When these are lacking, the possibility of spontaneous SDH in infant (SSDHI) is raised, but this entity is hotly debated; in particular, the lack of positive diagnostic criteria has hampered its recognition. The role of arachnoidomegaly, idiopathic macrocephaly, and dehydration in the pathogenesis of SSDHI is also much discussed. PURPOSE We decided to analyze apparent cases of SSDHI from our prospective databank. MATERIALS AND METHODS We selected cases of SDH in infants without systemic disease, history of trauma, and suspicion of NAHI. All cases had fundoscopy and were evaluated for possible NAHI. Head growth curves were reconstructed in order to differentiate idiopathic from symptomatic macrocrania. RESULTS Sixteen patients, 14 males and two females, were diagnosed with SSDHI. Twelve patients had idiopathic macrocrania, seven of these being previously diagnosed with arachnoidomegaly on imaging. Five had risk factors for dehydration, including two with severe enteritis. Two patients had mild or moderate retinal hemorrhage, considered not indicative of NAHI. Thirteen patients underwent cerebrospinal fluid drainage. The outcome was favorable in almost all cases; one child has sequels, which were attributable to obstetrical difficulties. CONCLUSION SSDHI exists but is rare and cannot be diagnosed unless NAHI has been questioned thoroughly. The absence of traumatic features is not sufficient, and positive elements like macrocrania, arachnoidomegaly, or severe dehydration are necessary for the diagnosis of SSDHI.
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Abstract
PURPOSE The purpose of this study was to document the hand-held spectral domain optical coherence tomography (HHSD-OCT, Bioptigen, Durham, NC) findings in shaken-baby syndrome (SBS). The nonaccidental trauma in SBS has been associated with retinal findings, including hemorrhages in all layers of the retina and retinoschisis. METHODS Three consecutive patients with presumed SBS underwent complete ocular examination, fundus photography with the RetCam (Clarity Medical Systems, Pleasanton, CA), and imaging with the HHSD-OCT. Acquisition of the HHSD-OCT images required an assistant to stabilize the head of the infant. RESULTS All three patients had clinical findings consistent with SBS, including preretinal and intraretinal hemorrhages. Hand-held spectral domain optical coherence tomography documented focal posterior vitreous separation in four of the five eyes with multilayered retinoschisis in one eye, disruption of the foveal architecture and foveolar detachment in one eye, and disinsertion of the internal limiting membrane or inner retinoschisis in one eye. Hand-held spectral domain optical coherence tomography documented preretinal hemorrhages in all five eyes. CONCLUSION Hand-held spectral domain optical coherence tomography is helpful in the evaluation of patients with SBS. All patients in our series had vitreoretinal abnormalities not detected on clinical examination, including, for example, multilayered retinoschisis. Hand-held spectral domain optical coherence tomography allows high-resolution imaging of the vitreoretinal interface and retina in infants with SBS and has provided insight into the mechanism of various retinal findings.
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Forbes BJ, Rubin SE, Margolin E, Levin AV. Evaluation and management of retinal hemorrhages in infants with and without abusive head trauma. J AAPOS 2010; 14:267-73. [PMID: 20603062 DOI: 10.1016/j.jaapos.2010.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/30/2010] [Accepted: 03/31/2010] [Indexed: 11/18/2022]
Abstract
Extensive intraocular hemorrhage in young infants in the setting of acute brain injury and in the absence of a history of severe accidental trauma or underlying medical cause must be considered to be nonaccidental injury until otherwise proven. In the absence of any obvious explanation, the presence of any retinal hemorrhage should raise the possibility of abusive head trauma in the differential diagnosis and perhaps lead to such testing as skeletal radiography and neuroimaging, consultation with a child abuse specialist, as well as workup for other relevant systemic conditions. Physicians who treat infants and children are mandated to report suspected child abuse to child welfare agencies for investigation, and ophthalmologists who encounter children with ophthalmic manifestations of abuse need to ensure that the proper steps are taken to protect their patients from the potential for further harm. Ascertainment of abusive head trauma is critical to prevent a potentially fatal recurrence.
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Affiliation(s)
- Brian J Forbes
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Overrepresentation of Males in Traumatic Brain Injury of Infancy and in Infants With Macrocephaly. Am J Forensic Med Pathol 2010; 31:165-73. [DOI: 10.1097/paf.0b013e3181d96a8e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological, and ophthalmological data in corroborated cases. Childs Nerv Syst 2010; 26:637-45. [PMID: 19946688 DOI: 10.1007/s00381-009-1048-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The diagnosis of inflicted head injury (IHI) or accidental trauma (AT) in infants is based on clinical, radiological, and/or ophthalmological findings such as subdural hematoma (SDH), encephalopathy, retinal hemorrhage (RH), and signs of impact. As a consequence, the diagnostic value of these criteria is difficult to assess because of a circularity bias. PURPOSE In order to assess the predictive value of these diagnostic criteria avoiding circularity, we studied prospectively corroborated cases of head injuries in infants, comparing IHI with AT. MATERIAL AND METHODS We selected 45 cases of confessed IHI and 39 cases of AT having occurred in public places. Patients were systematically evaluated clinically, with computed tomography scanner and ophthalmological evaluation by a trained ophthalmologist. RH was rated as absent, mild, and severe, according to the depth and extent of the RH. RESULTS Brain ischemia was found in 26.7% of IHI; the most prominent elements in favor of IHI were SDH, severe RH, and absence of signs of impact; the predictive diagnostic values of these three features were 0.685, 0.961, and 0.830, respectively; however, only severe RH in the absence of ocular impact was specific of IHI. When all three features were combined, the specificity was 100%, but the sensitivity was only 24.4%. CONCLUSION Our study confirms the high diagnostic value of RH, SDH, and signs of impact for the differential diagnosis between AT and IHI. The evaluation of head injuries in infants requires a high level of awareness and thorough and systematic examination by a trained multidisciplinary team.
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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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Goldenberg DT, Wu D, Capone A, Drenser KA, Trese MT. Nonaccidental Trauma and Peripheral Retinal Nonperfusion. Ophthalmology 2010; 117:561-6. [DOI: 10.1016/j.ophtha.2009.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 08/06/2009] [Accepted: 08/10/2009] [Indexed: 10/20/2022] Open
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Retinal Hemorrhages and Shaken Baby Syndrome: An Evidence-Based Review. J Emerg Med 2009; 37:98-106. [DOI: 10.1016/j.jemermed.2008.06.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Revised: 04/08/2008] [Accepted: 06/11/2008] [Indexed: 11/21/2022]
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Binenbaum G, Mirza-George N, Christian CW, Forbes BJ. Odds of abuse associated with retinal hemorrhages in children suspected of child abuse. J AAPOS 2009; 13:268-72. [PMID: 19541267 PMCID: PMC2712730 DOI: 10.1016/j.jaapos.2009.03.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 03/02/2009] [Accepted: 03/06/2009] [Indexed: 11/19/2022]
Abstract
PURPOSE To describe the prevalence of retinal hemorrhages in children being evaluated for abusive head trauma and quantify the association between the likelihood of abuse and the presence and severity of retinal hemorrhages. METHODS Retrospective cross-sectional study of 110 children aged 15 months or younger who were evaluated for abusive head trauma and received an ophthalmological examination. The child abuse specialist's diagnosis was categorized as definite accident, probable accident, probable abuse, or definite abuse, according to an algorithm that excluded eye findings. Retinal hemorrhage severity was scored on a 12-point scale (6 points per eye) based on type, size, location, and extent. Higher scores indicated greater severity of eye findings. RESULTS Seventy-four percent of children were younger than 6 months old. Forty-five percent of cases were definite abuse and 37% were definite accident. The prevalence of retinal hemorrhages was 32%. Across all subjects, the presence of retinal hemorrhage was highly associated with definite or probable abuse versus definite or probable accident (age-adjusted odds ratio 5.4 [95% CI, 2.1-13.6]). The odds ratio in children younger than 6 months (n = 81) was 11.7 (95% CI, 2.9-66.8). Retinal hemorrhage severity was higher in abuse versus accident (p < 0.0001) and correlated positively with abuse (Spearman r = 0.406, p < 0.0001). Scores above 8 (n = 13) were only present in abused children. CONCLUSIONS Retinal hemorrhages are highly associated with abusive head trauma, particularly in children younger than 6 months of age. Increasing retinal hemorrhage severity is correlated with increasing likelihood of abuse.
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Affiliation(s)
- Gil Binenbaum
- Division of Pediatric Ophthalmology, Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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