Sequential cranial computed tomography in infants with retinal hemorrhages

Abusive head trauma in infants and young children: a unique contributor to developmental disabilities

Abusive head trauma in infants and young children is the leading cause of death and disability from child abuse. This article discusses the history, epidemiology, clinical aspects, developmental outcomes, and associated injuries of this unique contributor to developmental disabilities. Prevention of abusive injuries and prevention of child abuse and neglect are also discussed.

EARLY HYPODENSITY ON COMPUTED TOMOGRAPHIC SCAN OF THE BRAIN IN AN ACCIDENTAL PEDIATRIC HEAD INJURY

OBJECTIVE

Hypodensities on computed tomographic (CT) brain scans are thought to take at least 6 hours to become apparent after blunt head trauma. This finding, in conjunction with the later evolution of the hypodensities, is used in timing the injury in children with suspected non-accidental brain injury, in whom the history may be inaccurate. The purpose of this study is to report the occurrence of diffuse cerebral parenchymal hypodensities on CT scans performed within 5 hours of a well-defined accidental head injury.

METHODS

A retrospective review was performed of five patients admitted to British Columbia Children's Hospital who had accidental head injury and who were identified as having diffuse cerebral hemispheric hypodensities on early CT scans.

RESULTS

We present five patients (age range, 4 mo-14 yr) with well-documented accidental head injuries who demonstrated obvious and extensive CT brain scan cerebral hemispheric hypodensity from 60 minutes to 4.5 hours after trauma. All five patients presented with severe head injuries and immediate, unremitting coma, and all five progressed rapidly to brain death within 48 hours.

CONCLUSION

It is unusual, but possible, to develop CT hypodensities as early as 1 hour after accidental head injury. In our small series of cerebral hemispheric hypodensity occurring less than 5 hours after trauma, all five patients had a uniformly fatal outcome. These observations may be important medicolegally in the assessment of the timing of head injury when the history of the trauma is not clear, as in children with suspected non-accidentally inflicted injury. It is inappropriate to generalize these findings to patients who are not unconscious immediately after a head injury, who regain consciousness after an injury before deteriorating, or who do not progress rapidly to brain death.

Case Analysis of Brain-Injured Admittedly Shaken Infants

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

Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Retinal hemorrhage asymmetry in inflicted head injury: a clue to pathogenesis?

OBJECTIVE

To determine whether regional cerebral parenchymal injury patterns correlate with the distribution of retinal hemorrhages after inflicted head injury.

STUDY DESIGN

Retrospective case series of funduscopic photographs and serial computerized tomographic imaging of 14 children with confirmed inflicted head injury.

MAIN OUTCOME MEASURES

Retinal Hemorrhage Score per eye and per subject, visual field examination, regional patterns of parenchymal injury on computerized tomographic scans and necropsy, and retinal/optic nerve sheath hemorrhage distribution at necropsy.

RESULTS

Ten of 14 children had retinal hemorrhages (71%); 90% were asymmetric (mean retinal score, 4.89 vs 2.56; P=.006). Retinal hemorrhages were maximal on the side of greatest cerebral injury in seven of 10 children initially. Subsequent imaging asymmetry predicted retinal hemorrhage distribution in all eight survivors. Children's Coma Scores, apnea or cardiorespiratory arrest, initial hemoglobin, and plasma glucose concentration did not predict laterality. Asymmetry was greatest if dilated ophthalmoscopy was performed during the first 24 hours (P=.03). Visual outcome was poor; three had homonymous hemianopia and four had cortical visual loss, all correlating with parenchymal atrophy patterns.

CONCLUSION

The distribution of retinal hemorrhages after inflicted head injury correlates with acute and evolving regional cerebral parenchymal injury patterns.

Ophthalmologic findings in suspected child abuse victims with subdural hematomas

PURPOSE

Shaken baby syndrome consists of intracranial and intraocular hemorrhages in young children in the absence of signs of direct head trauma. Because it has major medicolegal implications, it must be distinguished from accidental trauma. This study aimed to determine the ophthalmologic manifestations and their natural course in child abuse victims and whether ophthalmologic examination can help to distinguish shaken babies from children with accidental impact head trauma.

DESIGN

Prospective comparative observational case series.

METHODS

A prospective study was conducted from January 1996 to September 2001 on 241 consecutive infants hospitalized for a subdural hematoma to determine the frequency and the type of ocular abnormalities encountered. At admission, 186 children were highly presumed to have been shaken (group 1), 38 children had signs of direct head trauma without any relevant history of trauma (group 2), some of them having been possibly shaken, whereas 7 children had proven severe accidental head trauma (group 3).

RESULTS

Intraocular hemorrhages were the main finding. Their shape, laterality, and size were not significantly different in groups 1 and 2. However they were significantly more frequent in nonaccidental head trauma than in infants with head impact (77.5% versus 20%). None of the group 3 children had intraocular hemorrhage. Eighty-two percent of intraocular hemorrhages resolved within 4 weeks.

CONCLUSIONS

Intraocular hemorrhages are frequent in shaken babies but not specific of this syndrome. When associated with a subdural hematoma, they are strongly suggestive of shaken neglect. They are rare in pediatric accidental head trauma.

Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies

Does an expanded subarachnoid space predispose to subdural bleeding? What does heterogeneity in the appearance of a subdural collection on CT or MRI imaging indicate? Spontaneous rebleeding? Minor re-injury? Major re-injury? In some specific cases, answers to these questions have important forensic implications. To conclude objectively that an infant's intracranial hemorrhage or rebleeding resulted from inflicted injury or re-injury requires an in-depth understanding of the pathogenesis of posttraumatic subdural and subarachnoid collections. The authors present two cases of indoor, accidental, pediatric, closed-head trauma that resulted in intracranial rebleeding. Both accidental cranial impacts occurred in medical settings and were independently witnessed by medical personnel. In addition, the authors summarize the relevant medical literature regarding pediatric intracranial bleeding and rebleeding.

Manifestations of the shaken baby syndrome

Retinal hemorrhages are the most common fundus finding in the shaken baby syndrome. They vary in type and location; no particular type is pathognomonic for the condition. Retinal hemorrhages are not needed to make a diagnosis of shaken baby syndrome. However, in a child under age 3 years, the presence of extensive bilateral retinal hemorrhages raises a very strong possibility of abuse, which must be investigated. The other possible causes for hemorrhages in this age child can be investigated and eliminated. The diagnosis of abuse should be made by someone particularly trained in this area, who can put together the entire picture of inadequate or changing history, fractures of various ages, particularly rib fractures, subdural hematoma of the brain, and retinal hemorrhages. Photographs of retinal hemorrhages are very helpful to child advocacy experts who take these cases to court.

Unilateral retinal hemorrhages and ipsilateral intracranial bleeds in nonaccidental trauma

The classic ophthalmologic finding in nonaccidental traumatic injury is bilateral widespread retinal hemorrhage with or without intracranial hemorrhage. We present 3 cases of unilateral retinal hemorrhage associated with ipsilateral intracranial bleeds to extend the many different presentations of nonaccidental trauma.

Subdural hematomas in children under 2 years. Accidental or inflicted? A 10-year experience

OBJECTIVE

The aim of this study was to determine the relative frequency of child abuse, accidents and disease as a cause of subdural hematomas in children under 2 years of age, and to determine the main clinical features at presentation, that may help to distinguish these groups of patients.

METHOD

A retrospective review was undertaken of the medical records of all children under 2 years of age admitted to the Royal Alexandra Hospital for Children with the diagnosis of subdural hematoma in the 10-year period January 1987 to December 1996.

RESULTS

Thirty eight children were identified with subdural hematomas during the study period. The commonest cause was nonaccidental injury in 55% of cases, accidents in 39% and nontraumatic causes (6%) made up the remainder. The nonaccidental injury cases were significantly younger than the accidentally injured children. The most important clinical features were the significantly higher incidence of retinal hemorrhages and associated long bone and rib fractures in the abuse group. Delay in presentation for medical evaluation was also more commonly seen in the abused children.

CONCLUSION

Nonaccidental injury is the commonest cause of subdural hematomas in children under 2 years of age. The presence of retinal hemorrhages, bone and rib fractures, delay in presentation and the young age of the infants, suggests child abuse is the most likely cause of these injuries.

Electroretinographic findings in infants with the shaken baby syndrome

PURPOSE

To determine if electroretinography is helpful in the work-up of children with the shaken baby syndrome.

METHODS

Six children with retinal hemorrhages and the shaken baby syndrome underwent electroretinography (ERG). The ERGs of these six children were compared with six age-matched controls using the sign-rank test.

RESULTS

Neither the implicit time nor the amplitude of the white scotopic ERG response was significantly different between these patients and age-matched controls. Although the amplitude of the blue scotopic and 30 Hz flicker responses were attenuated (p < 0.05), the implicit times were not significantly different from controls. Three of the patients had serial ERGs recorded. The b-wave implicit time and amplitude improved in two of these patients. The ERG was helpful in distinguishing between a CNS and a retinal cause of visual loss in one child.

CONCLUSIONS

The ERG can be helpful in assessing retinal function in children with the shaken baby syndrome who have persistent visual impairment. In most cases, the ERG is not helpful in the initial assessment of children with the shaken baby syndrome.

Outcome and prognosis of whiplash shaken infant syndrome; late consequences after a symptom-free interval

Long-term follow-up five to 13 (mean seven years) of 13 cases of whiplash-shaken-infant syndrome (WSIS) demonstrated long sign-free intervals. Full clinical appearance of neurological deficits takes four months for the interruption of brain growth, six to 12 months for lesions of the central nervous system long pathways, up to two years for epilepsy, and three to six years for behavioural and neuropsychological signs. In our series, WSIS occurred at a mean postnatal age of 5.5 months and caused intracranial, retinal and preretinal haemorrhages, intracranial haematomas, oedema, contusional tears, and developmental disturbances interfering with the growth and differentiation of neural tissue and with synaptic stabilisation. These mechanisms account for the long sign-free interval that makes its impossible to formulate a precise and final neurological prognosis before the age of school entrance. Only one of our patients seems to have remained normal even several years after the shaking.

Evolution of the cranial computed tomography scan in child abuse

Computed tomography (CT) scans obtained at the time of clinical presentation have occasionally been reported to be normal in children with history and findings of significant abusive head injury. We have retrospectively observed abnormalities in "normal" scans of some similar children. We have also seen abnormalities develop on serial scanning. To determine how frequently these situations occur, we reviewed charts of 34 children with a final diagnosis of child abuse who also had cranial CT scans performed. Their CT scans were retrospectively reviewed by a pediatric radiologist. Eleven (11/34) CT scans had initially been interpreted as normal. Four (4/11) of these had been reinterpreted during the hospitalization as abnormal, affecting medical (1) and legal (3) outcome. Repeat scanning in three of the remaining seven resulted in surgical drainage of a subdural effusion (1) and affected legal outcome (2). Four of the seven initial scans felt normal throughout the hospitalizations were judged abnormal on retrospective review. This evaluation was confirmed in the two rescanned. Initial CT interpretation most often failed to appreciate changes in parenchymal density and small amounts of falcine or cortical subdural blood. Subsequent scans also showed evolving effusions and infarcts. Changes were noted in 1 1/2 to 5 days. The CT scan frequently shows subtle changes in the immediate posttrauma period. If the child does not recover promptly, subsequent scans frequently result in significant changes in clinical and legal management.

Ocular and optic nerve hemorrhages in abused infants with intracranial injuries

PURPOSE

To ascertain whether the pathology of the eye and optic nerve might be useful in determining the manner of death in infants who died after sustaining apparent nonaccidental intracranial injury.

METHODS

Complete autopsies were performed on 13 infants who died of acute intracranial injuries after nonaccidental trauma. The infants were divided into two groups: nine with physical evidence of blunt trauma to the head, and four without detectable scalp or skull injury whose intracranial injuries were attributed to violent shaking (shaken baby syndrome). Six infants with no intracranial injuries who died suddenly from unidentifiable causes (the so-called sudden infant death syndrome) served as controls.

RESULTS

Optic nerve sheath hemorrhage, most prominent in the subdural space, was present in all 13 infants with nonaccidental intracranial injury. Multilayered retinal hemorrhage was present in at least one eye of 11 of these 13 infants. The location and quantity of the intraocular and optic nerve sheath hemorrhages did not differ in those with external head trauma and those without scalp or skull lesions. A single control infant had a few erythrocytes in the nerve fiber layer of the anterior optic nerve of one eye. The remainder of the control infants did not have evidence of hemorrhage in the eye or optic nerve sheath.

CONCLUSION

Histopathologic analysis of optic nerve sheath and intraocular hemorrhages may be helpful in distinguishing traumatic from non-traumatic causes of death in infants.

Child abuse intervention in the emergency room

The pediatrician and other emergency room caregivers are often on the frontlines in the identification and treatment of child abuse and neglect. The ability to recognize the possibility of intentional injury is crucial because immediate intervention may be necessary to prevent further harm to the child. The evaluation requires a careful taking of history, thorough physical examination, and detailed documentation. Reporting of suspected abuse or neglect is mandated and must be made to appropriate authorities. Follow-up of medical treatment, services, and available therapy should be emphasized to assure the continued safety of the child.

Ocular findings at autopsy of child abuse victims

The incidence of retinal hemorrhage in child abuse victims was studied in cadavers of children that underwent autopsy in the Los Angeles County Coroner's office. One hundred ninety consecutive cases of childrens' eyes received at Doheny Eye Institute from 1985 to 1989 were included in the study. Retinal hemorrhage is the most common form of eye damage due to child abuse and is more likely to occur in infants who have been shaken than after blunt trauma to the head. Accordingly, retinal involvement is seen more frequently in younger children. The mechanism of retinal hemorrhage is unknown, but the authors' evidence suggests that it is not a direct result of submeningeal hemorrhage. The retinal hemorrhages are found most frequently in the bipolar and nerve fiber layers. They may be severe and widespread or small, scattered foci; both forms are indicative of abuse type injury. Any child who is comatose or who has other unexplained neurologic symptoms should have a thorough eye examination with the pupils dilated with emphasis on studies of the retina.