1
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Yin J, Peng J, Zhang X, Yang Y, Gu VY, Zhang W, Liu H, Xiao H, Xu Y, Zhao P. A retrospective study of ophthalmologic presentation, management, and outcomes in pediatric patients admitted with abusive head trauma. Front Med (Lausanne) 2024; 11:1416626. [PMID: 39211342 PMCID: PMC11357973 DOI: 10.3389/fmed.2024.1416626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 08/05/2024] [Indexed: 09/04/2024] Open
Abstract
Background Abusive head trauma (AHT) is a severe form of physical abuse leading to significant morbidity and mortality in children, often presenting with complex brain injuries. Among the varied manifestations, ophthalmologic presentations are critical yet underexplored, which may provide essential clues for early diagnosis and management, improving long-term visual and neurological outcomes. Objective This study aims to explore the manifestation, management, and outcomes of AHT cases within a single center in China over a five-year period, with a focus on the importance of ophthalmologic evaluation in enhancing the diagnosis, management, and outcome predictions of AHT. Methods A retrospective case series was conducted at a single institution, involving infants diagnosed with AHT from 2019 to 2023. Data on demographics, medical histories, and clinical management were collected. Ophthalmologic examinations including fundus photography, ocular B-scan ultrasound and fundus fluorescein angiography (FFA), were performed to evaluate retinal vasculature and identify peripheral ischemic retina (PIR). Statistical analyses were performed using SPSS ver. 26.0. Results Eight AHT patients (16 eyes) were included in the study. Bilateral ocular involvement was observed in all patients, with 81.25% exhibiting retinal hemorrhages (RH). Other manifestations included retinal detachment (31.25%) and optic nerve atrophy (18.75%). Clinical interventions varied, with 68.75% of patients undergoing treatments such as laser photocoagulation and anti-vascular endothelial growth factor (VEGF) injections. Among all eyes, 75% showed resolution of RH. Despite treatment, some patients progressed to severe conditions such as retinal detachment (RD) and iris neovascularization (INV). Conclusion This study emphasizes the importance of a multidisciplinary approach in the diagnosis and management of AHT, particularly by integrating ophthalmological perspectives into patient care. These findings contribute to the understanding of ophthalmologic presentations in AHT.
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Affiliation(s)
- Jiawei Yin
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Peng
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuerui Zhang
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Yang
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Victoria Y. Gu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Wenting Zhang
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huanyu Liu
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haodong Xiao
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Xu
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peiquan Zhao
- Department of Ophthalmology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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2
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Jain D, Le L, Kissoon N. Ophthalmologic findings in abusive head trauma. Semin Pediatr Neurol 2024; 50:101141. [PMID: 38964817 DOI: 10.1016/j.spen.2024.101141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/20/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma.
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Affiliation(s)
- Disha Jain
- Baylor College of Medicine, 6701 Fannin St., 17th Floor, Houston, TX 77030, United States.
| | - Lien Le
- Baylor College of Medicine, 6701 Fannin St., 17th Floor, Houston, TX 77030, United States
| | - Natalie Kissoon
- University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7821, San Antonio, TX 78229, United States
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3
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Cho N, Koti AS. Identifying inflicted injuries in infants and young children. Semin Pediatr Neurol 2024; 50:101138. [PMID: 38964814 DOI: 10.1016/j.spen.2024.101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/04/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.
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Affiliation(s)
- Nara Cho
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205, United States; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States.
| | - Ajay S Koti
- Safe Child and Adolescent Network, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, United States; University of Washington School of Medicine, Seattle, WA, United States
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4
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Shahraki K, Suh DW. An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse. CHILDREN (BASEL, SWITZERLAND) 2024; 11:586. [PMID: 38790581 PMCID: PMC11119297 DOI: 10.3390/children11050586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024]
Abstract
Abusive head trauma (AHT) is an extreme form of physical child abuse, a subset of which is shaken baby syndrome (SBS). While traumatic injury in children is most readily observed as marks of contusion on the body, AHT/SBS may result in internal injuries that can put the life of the child in danger. One pivotal sign associated with AHT/SBS that cannot be spotted with the naked eye is retinal injury (RI), an early sign of which is retinal hemorrhage (RH) in cases with rupture of the retinal vasculature. If not addressed, RI can lead to irreversible outcomes, such as visual loss. It is widely assumed that the major cause of RI is acceleration-deceleration forces that are repeatedly imposed on the patient during abusive shaking. Still, due to the controversial nature of this type of injury, few investigations have ever sought to delve into its biomechanical and/or biochemical features using realistic models. As such, our knowledge regarding AHT-/SBS-induced RI is significantly lacking. In this mini-review, we aim to provide an up-to-date account of the traumatology of AHT-/SBS-induced RI, as well as its biomechanical and biochemical features, while focusing on some of the experimental models that have been developed in recent years for studying retinal hemorrhage in the context of AHT/SBS.
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Affiliation(s)
| | - Donny W. Suh
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine School of Medicine, Irvine, CA 92697, USA;
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5
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Espinosa Dice AL, Lawn RB, Ratanatharathorn A, Roberts AL, Denckla CA, Kim AH, de la Rosa PA, Zhu Y, VanderWeele TJ, Koenen KC. Childhood maltreatment and health in the UK Biobank: triangulation of outcome-wide and polygenic risk score analyses. BMC Med 2024; 22:135. [PMID: 38523269 PMCID: PMC10962116 DOI: 10.1186/s12916-024-03360-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 03/15/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Childhood maltreatment is common globally and impacts morbidity, mortality, and well-being. Our understanding of its impact is constrained by key substantive and methodological limitations of extant research, including understudied physical health outcomes and bias due to unmeasured confounding. We address these limitations through a large-scale outcome-wide triangulation study. METHODS We performed two outcome-wide analyses (OWAs) in the UK Biobank. First, we examined the relationship between self-reported maltreatment exposure (number of maltreatment types, via Childhood Trauma Screener) and 414 outcomes in a sub-sample of 157,316 individuals using generalized linear models ("observational OWA"). Outcomes covered a broad range of health themes including health behaviors, cardiovascular disease, digestive health, socioeconomic status, and pain. Second, we examined the relationship between a polygenic risk score for maltreatment and 298 outcomes in a non-overlapping sample of 243,006 individuals ("genetic OWA"). We triangulated results across OWAs based on differing sources of bias. RESULTS Overall, 23.8% of the analytic sample for the observational OWA reported at least one maltreatment type. Of 298 outcomes examined in both OWAs, 25% were significant in both OWAs and concordant in the direction of association. Most of these were considered robust in the observational OWA according to sensitivity analyses and included outcomes such as marital separation (OR from observational OWA, ORo = 1.25 (95% CI: 1.21, 1.29); OR from genetic OWA, ORg = 1.06 (1.03, 1.08)), major diet changes due to illness (ORo = 1.27 (1.24, 1.29); ORg = 1.01 (1.00, 1.03)), certain intestinal diseases (ORo = 1.14 (1.10, 1.18); ORg = 1.03 (1.01, 1.06)), hearing difficulty with background noise (ORo = 1.11 (1.11, 1.12); ORg = 1.01 (1.00, 1.01)), knee arthrosis (ORo = 1.13 (1.09, 1.18); ORg = 1.03 (1.01, 1.05)), frequent sleeplessness (ORo = 1.21 (1.20, 1.23); ORg = 1.02 (1.01, 1.03)), and low household income (ORo = 1.28 (1.26, 1.31); ORg = 1.02 (1.01, 1.03)). Approximately 62% of results were significant in the observational OWA but not the genetic OWA, including numerous cardiovascular outcomes. Only 6 outcomes were significant in the genetic OWA and null in the observational OWA; these included diastolic blood pressure and glaucoma. No outcomes were statistically significant in opposite directions in the two analyses, and 11% were not significant in either OWA. CONCLUSIONS Our findings underscore the far-reaching negative effects of childhood maltreatment in later life and the utility of an outcome-wide triangulation design with sensitivity analyses for improving causal inference.
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Affiliation(s)
- Ana Lucia Espinosa Dice
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
| | - Rebecca B Lawn
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Andrew Ratanatharathorn
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York City, NY, USA
| | - Andrea L Roberts
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christy A Denckla
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ariel H Kim
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA
| | - Pedro A de la Rosa
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Institute for Culture and Society, University of Navarra, Pamplona, Spain
| | - Yiwen Zhu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Tyler J VanderWeele
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Karestan C Koenen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Psychiatric Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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6
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Stellungnahme zur augenärztlichen Untersuchung bei Verdacht auf ein Schütteltrauma-Syndrom (STS). Klin Monbl Augenheilkd 2023; 240:1421-1426. [PMID: 38092005 DOI: 10.1055/a-2191-7019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
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7
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Barth T, Stahl A, Herrmann B, Tost F, Bertram B. [Statement on ophthalmological examination for suspected shaken baby syndrome (SBS). : Statement of the German Society of Ophthalmology (DOG), the German Retina Society (RG), the German Professional Association of Ophthalmologists (BVA) in cooperation with German Society for Child Protection in Medicine (DGKiM). Status: June 2023]. DIE OPHTHALMOLOGIE 2023; 120:1233-1237. [PMID: 37773527 DOI: 10.1007/s00347-023-01921-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
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8
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Sacco MA, Gualtieri S, Tarda L, Ricci P, Aquila I. Clinical and Forensic Investigation Protocols for Diagnosing Abusive Head Trauma: A Literature Review. Diagnostics (Basel) 2023; 13:3093. [PMID: 37835835 PMCID: PMC10572508 DOI: 10.3390/diagnostics13193093] [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: 08/27/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Abusive head trauma (AHT) represents a very serious global public health problem. Prevention of these episodes is essential to reduce the morbidity and mortality of this phenomenon. All healthcare professionals should be able to recognize the signs of abuse. However, diagnosis is very complex as the signs are often blurred and cannot be recognized with certainty without carrying out adequate instrumental investigations. It has been calculated that approximately one-third of AHT cases remain undetected and require more than one medical visit to be correctly interpreted and diagnosed. On the other hand, the literature has recently also emphasized the problems related to possible false diagnoses of abuse and the numerous family and personal repercussions that follow from this issue. For these reasons, correct and timely recognition is essential to avoid the risk of recurrence of AHT and to start proper forensic investigations, in order to identify the offender or exonerate a suspect. The present work explores the most recent evidence of recent years in the field of AHT diagnostics through a literature review. The purpose of this article is to provide forensic pathologists with clear tools for diagnosis based on the literature. To this end, the review suggests clinical and forensic protocols aimed at the timely diagnosis of AHT in order to prevent abuse from remaining undetected.
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Affiliation(s)
| | | | | | | | - Isabella Aquila
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (L.T.); (P.R.)
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9
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Mullen JE. Recognizing Child Abuse. AACN Adv Crit Care 2023; 34:240-245. [PMID: 37644630 DOI: 10.4037/aacnacc2023779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Jodi E Mullen
- Jodi E. Mullen is Senior Quality Improvement Specialist, Department of Clinical Quality and Patient Safety, UF Health Shands Hospital, 3300 SW Williston Rd, Gainesville, FL 32608
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10
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Geoghegan AR, Shouldice M, Mireskandari K, Smith JN. Subdural hemorrhages and severe retinal hemorrhages in a short fall with a rotational component. J AAPOS 2023; 27:222-224. [PMID: 37307907 DOI: 10.1016/j.jaapos.2023.04.011] [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] [Received: 12/29/2022] [Revised: 04/09/2023] [Accepted: 04/19/2023] [Indexed: 06/14/2023]
Abstract
We present the case of a 5-month-old referred for child abuse investigation with subdural hemorrhages and extensive retinal hemorrhages following a short fall from a swivel chair seen on video footage. Subdural hemorrhages with extensive retinal hemorrhages are not typically seen as the result of short household falls. Reviewing the footage, contributing factors may have included increased rotational and deceleration forces.
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Affiliation(s)
- Aisling R Geoghegan
- Department of Pediatrics, University of Toronto, Toronto, Canada; The Hospital for Sick Children, Toronto, Canada
| | - Michelle Shouldice
- Department of Pediatrics, University of Toronto, Toronto, Canada; The Hospital for Sick Children, Toronto, Canada
| | - Kamiar Mireskandari
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer N Smith
- Department of Pediatrics, University of Toronto, Toronto, Canada; The Hospital for Sick Children, Toronto, Canada.
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11
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Di Fazio N, Delogu G, Morena D, Cipolloni L, Scopetti M, Mazzilli S, Frati P, Fineschi V. New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2023; 13:1722. [PMID: 37238204 PMCID: PMC10217069 DOI: 10.3390/diagnostics13101722] [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: 04/14/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Luigi Cipolloni
- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, 71100 Foggia, Italy;
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Sara Mazzilli
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
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12
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Macher J, Porter RS, Levin AV. Ophthalmic imaging in abusive head trauma. CHILD ABUSE & NEGLECT 2023; 139:106106. [PMID: 36867971 DOI: 10.1016/j.chiabu.2023.106106] [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: 12/19/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Ophthalmic imaging plays an increasingly important role the evaluation of abusive head trauma, however these imaging modalities may be unfamiliar to non-ophthalmologists. OBJECTIVE To provide pediatricians and child abuse pediatric professionals with background on ophthalmic imaging techniques in the context of suspected abuse, as well as information on commercial options and costs for those interested in augmenting their ophthalmic imaging capabilities. METHODS We performed a review of the ophthalmic imaging literature for fundus photography, ocular coherence tomography, fluorescein angiography, ocular ultrasound, computed tomography, magnetic resonance imaging and postmortem imaging. We also contacted individual vendors for equipment pricing information. RESULTS For each ophthalmic imaging modality, we demonstrate its role in the evaluation of abusive head trauma including indications, potential findings, sensitivity and specificity of findings for abuse, and commercial options. CONCLUSIONS Ophthalmic imaging is an important supportive component of the evaluation for abusive head trauma. When used in conjunction with clinical examination, ophthalmic imaging can improve diagnostic accuracy, support documentation, and possibly improve communication in medicolegal contexts.
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Affiliation(s)
- Jared Macher
- University of Rochester School of Medicine, Rochester, NY, USA.
| | - Randall S Porter
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Alex V Levin
- University of Rochester School of Medicine, Rochester, NY, USA; Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Rochester, NY, USA; Clinical Genetics, Golisano Children's Hospital, Rochester, NY, USA.
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13
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Biswas A, Krishnan P, Albalkhi I, Mankad K, Shroff M. Imaging of Abusive Head Trauma in Children. Neuroimaging Clin N Am 2023; 33:357-373. [PMID: 36965952 DOI: 10.1016/j.nic.2023.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
In this article, we describe relevant anatomy, mechanisms of injury, and imaging findings of abusive head trauma (AHT). We also briefly address certain mimics of AHT, controversies, pearls, and pitfalls. Concepts of injury, its evolution, and complex nature of certain cases are highlighted with the help of case vignettes.
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Affiliation(s)
- Asthik Biswas
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada; Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK.
| | - Pradeep Krishnan
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Ibrahem Albalkhi
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; College of Medicine, Alfaisal University, Al Takhassousi، Al Zahrawi Street interconnecting with, Riyadh 11533, Saudi Arabia
| | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; UCL GOS Institute of Child Health
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
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14
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Simon CL, Ude I, Levin MR, Alexander JL. Retinal hemorrhages in abusive head trauma with atraumatic neuroimaging. J AAPOS 2023; 27:39-42. [PMID: 36516943 PMCID: PMC9975066 DOI: 10.1016/j.jaapos.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022]
Abstract
We report 3 cases of suspected abusive head trauma with retinal hemorrhages on fundus examination and neuroimaging findings not necessarily suggestive of shaking injury. Previous studies have suggested that retinal hemorrhages are rare in patients without neuroimaging abnormalities. These cases demonstrate some common features (rib fractures, developmental delay, and history of abuse) that may increase suspicion for abusive head trauma. Our findings suggest a potential role for ophthalmic consultation in scenarios with high clinical suspicion for abusive head trauma without definitive neuroimaging evidence of head injury. The nonspecific neuroimaging features of these 3 cases highlight the importance of interpreting cases with global clinical context.
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Affiliation(s)
| | - Ifeoma Ude
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Moran R Levin
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet L Alexander
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland.
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Kato M, Nonaka M, Akutsu N, Narisawa A, Harada A, Park YS. Correlations of intracranial pathology and cause of head injury with retinal hemorrhage in infants and toddlers: A multicenter, retrospective study by the J-HITs (Japanese Head injury of Infants and Toddlers study) group. PLoS One 2023; 18:e0283297. [PMID: 36930676 PMCID: PMC10022784 DOI: 10.1371/journal.pone.0283297] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/05/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION In infants who have suffered head trauma there are two possible explanations for retinal hemorrhage (RH): direct vitreous shaking and occurrence in association with intracranial lesions. Which possibility is more plausible was examined. MATERIAL AND METHODS This multicenter, retrospective study reviewed the clinical records of children younger than four years with head trauma who had been diagnosed with any findings on head computed tomography (CT) and/or magnetic resonance imaging (MRI). Of 452 cases, 239 underwent an ophthalmological examination and were included in this study. The relationships of RH with intracranial findings and the cause of injury were examined. RESULT Odds ratios for RH were significant for subdural hematoma (OR 23.41, p = 0.0004), brain edema (OR 5.46, p = 0.0095), nonaccidental (OR 11.26, p<0.0001), and self-inflicted falls (OR 6.22, p = 0.0041). CONCLUSION Although nonaccidental, brain edema and self-inflicted falls were associated with RH, subdural hematoma was most strongly associated with RH.
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Affiliation(s)
- Mihoko Kato
- Department of Neurosurgery, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
- * E-mail:
| | - Nobuyuki Akutsu
- Department of Neurosurgery, Hyogo Prefectural Kobe Children’s Hospital, Hyogo, Japan
| | - Ayumi Narisawa
- Department of Neurosurgery, Sendai City Hospital, Miyagi, Japan
| | - Atsuko Harada
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Osaka, Japan
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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Harris CK, Stagner AM. The Eyes Have It: How Critical are Ophthalmic Findings to the Diagnosis of Pediatric Abusive Head Trauma? Semin Ophthalmol 2023; 38:3-8. [PMID: 36524752 DOI: 10.1080/08820538.2022.2152712] [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] [Indexed: 12/23/2022]
Abstract
Pediatric abusive head trauma (AHT), still colloquially known as shaken baby syndrome, is a leading cause of morbidity and mortality among infants. Controversy has grown surrounding this diagnosis, and the specificity of the clinical findings-subdural hemorrhage, cerebral edema, and retinal hemorrhages-has been challenged. A literature search of peer reviewed publications on PubMed pertaining to the history, clinical, and pathologic features of AHT was conducted using the terms "shaken baby syndrome," "non-accidental trauma," "abusive head trauma," "inflicted traumatic brain injury," "shaken impact syndrome," and "whiplash shaken infant syndrome." Focus was placed on articles discussing ophthalmic findings in AHT. Retinal hemorrhages-particularly those that are too numerous to count, occurring in all layers of the retina (preretinal, intraretinal, subretinal), covering the peripheral pole and extending to the ora serrata, and accompanied by retinoschisis and other ocular/periocular hemorrhages-are highly suggestive of AHT, particularly in the absence of otherwise explained massive accidental trauma. Although the diagnosis has grown in controversy in recent years, AHT has well-documented clinical and pathologic findings across a large number of studies.
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Affiliation(s)
- Cynthia K Harris
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Anna M Stagner
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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17
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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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18
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Abusive head trauma: current practice of investigation and management in Taiwan. Childs Nerv Syst 2022; 38:2425-2428. [PMID: 36289092 DOI: 10.1007/s00381-022-05714-1] [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: 10/06/2022] [Accepted: 10/19/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Abusive head trauma (AHT) is a worldwide leading cause of fatal head injuries in children under 2 years. This study aims to present the development of child protection medical service in Taiwan in the past decade. MATERIALS AND METHODS This study reviews the evolution of the pediatric protection network and the cross-system professional training in Taiwan from 2013 to 2022. The recommendations of Taiwan Pediatric Association on the prevention and management of AHT and the Medical Professionals Manual of Child Abuse and Neglect proposed by the Ministry of Health and Welfare were reviewed. RESULTS Considering the impact of the high incidence of severe sequelae and the mortality caused by of AHT, 10 regional centers for child protection medical service were founded in Taiwan to identify, recognize, and properly manage cases of AHT, which is easily overlooked by the healthcare providers. The child protection network across the healthcare, social welfare administration, and judicial systems facilitate the early detection, management, and proper disposition of the children with AHT. CONCLUSION An increasing of the incidence of AHT is expected after the setting up of the child protection network and the continuing cross-system professional trainings. There is more consensus of the diagnosis and management of AHT than before in Taiwan. However, there is no end to protecting children from AHT.
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19
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Kratchman DM, Vaughn P, Silverman LB, Campbell KA, Lindberg DM, Anderst JD, Bachim AN, Berger RP, Hymel KP, Letson M, Melville JD, Wood JN. The CAPNET multi-center data set for child physical abuse: Rationale, methods and scope. CHILD ABUSE & NEGLECT 2022; 131:105653. [PMID: 35779985 PMCID: PMC9332134 DOI: 10.1016/j.chiabu.2022.105653] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/17/2022] [Accepted: 04/20/2022] [Indexed: 05/27/2023]
Abstract
BACKGROUND The pediatric subspecialty of Child Abuse Pediatrics (CAP) was certified by the American Board of Medical Subspecialties in 2006. Relative to its impact on pediatric health, CAP-focused research has been relatively under-funded. Multi-center networks related to CAP-focused research have made important advances, but have been limited in scope and duration. CAPNET is multi-center network whose mission is to support CAP-focused research. OBJECTIVE To describe the rationale, development, and scope of the CAPNET research network infrastructure, the CAPNET data registry and associated data resources. METHODS Based on existing priorities for CAP-focused research, we used consensus building and iterative testing to establish inclusion criteria, common data elements, data quality assurance, and data sharing processes for children with concerns of physical abuse. RESULTS We describe the rationale, methods and intended scope for the development of the CAPNET research network and data registry. CAPNET is currently abstracting data for children <10 years (120 months) old who undergo sub-specialty evaluation for physical abuse at 10 US pediatric centers (approximately 4000 evaluations/year total) using an online data capture form. Data domains include: demographics; visit timing and providers, medical/social history, presentation, examination findings, laboratory and radiographic testing, diagnoses, outcomes, and data for contact children. We describe the methods and criteria for collecting and validating data which are broadly available to CAP investigators. CONCLUSIONS CAPNET represents a new data resource for the CAP research community and will increase the quantity and quality of CAP-focused research.
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Affiliation(s)
- Devon M Kratchman
- Safe Place: The Center for Child Protection and Health, PolicyLab, Center for Pediatric Effectiveness and Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Porcia Vaughn
- Department of Pediatrics, Division of Child Protection and Family Health, University of Utah, Salt Lake City, UT 84115, United States; The Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, UT 84115, United States
| | - Ligia Batista Silverman
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, The University of Colorado Anschutz Medical Campus, 12631 E. 17(th) Ave - C326, Aurora, CO, United States
| | - Kristine A Campbell
- Department of Pediatrics, Division of Child Protection and Family Health, University of Utah, Salt Lake City, UT 84115, United States; The Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, UT 84115, United States
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, The University of Colorado Anschutz Medical Campus, 12631 E. 17(th) Ave - C326, Aurora, CO, United States
| | - James D Anderst
- Children's Mercy Kansas City, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, TX, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, United States
| | - Kent P Hymel
- Penn State College of Medicine, Hershey, PA, United States
| | - Megan Letson
- Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John D Melville
- Division of Child Abuse Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Joanne N Wood
- Safe Place: The Center for Child Protection and Health, PolicyLab, Center for Pediatric Effectiveness and Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
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20
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Salisbury T, Qurashi N, Mansoor Q. Change in Incidence and Severity of Abusive Head Trauma in the Paediatric Age Group Pre- and During COVID-19 Lockdown in the North East of England. BRITISH AND IRISH ORTHOPTIC JOURNAL 2022; 18:101-110. [PMID: 36117555 PMCID: PMC9414736 DOI: 10.22599/bioj.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/17/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Abusive head trauma (AHT) is currently the accepted terminology that encompasses previously used terms such as non-accidental injury (NAI) or non-accidental head injury (NAHI) and shaken baby syndrome (SBS). It is AHT and its ocular manifestations that ophthalmologists are vital in identifying and reporting. Objectives: To investigate whether there is a change in the incidence or severity of AHT pre- and during COVID-19 lockdown. Participants and Settings: AHT cases reported between March–June 2019 and March–June 2020. Data will be collected from ***** **** ********* NHS Foundation Trust. Methods: A retrospective comparative study. Main Outcome Measures: Results: Of the pre-lockdown safeguarding referrals, 5/61 (8.19%) had confirmed AHT, and 4/40 (10%) of the during lockdown group were confirmed AHT. The absence of teachers was evident, as in the pre-lockdown group 40% (2) of referrals originated from schools compared to none during the lockdown period. Ophthalmic involvement was not present in any of the pre-lockdown cases and only 50% (2) of the during lockdown cases, with the appropriate proforma only used in one of these cases. Unfortunately, no further statistical testing was meaningful in light of the small sample size. Conclusions: The loss of the early warning detection mechanism provided by schools and health visitors may have contributed to both the change in presentation and severity of cases during the lockdown. There is also a need for ophthalmology and paediatrics to collaborate to ensure AHT cases are thoroughly investigated and documented.
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21
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Manan MR, Rahman S, Komer L, Manan H, Iftikhar S. A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children. Cureus 2022; 14:e27276. [PMID: 36039273 PMCID: PMC9404682 DOI: 10.7759/cureus.27276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/23/2022] [Indexed: 11/05/2022] Open
Abstract
Child abuse is a preventable phenomenon of considerable concern resulting in significant child mortality and morbidity. We analyze various abuse lesions such as radiological (visceral and skeletal lesions and those associated with head trauma) and cutaneous (burns, bruises, bites, etc.) to enhance streamlined identification of injuries in cases of physical child abuse. For effective results, it is essential to remain mindful of all background factors, such as the caregiver setting and the prevalence of child maltreatment in the concerned community while acknowledging the possibility of natural causes (genetic diseases such as osteogenesis imperfecta and hemophilia, or acquired abnormalities) that can mimic NAT and cause confusion in diagnosis and treatment. The margin of error in cases of abuse is negligible, therefore, making its diagnosis a momentous as well as challenging clinical task. An ineffective diagnosis can have detrimental emotional consequences for the family and may even expose the child to future potentially fatal episodes of abuse. Hence, there is a need to direct special focus on the importance of accurate history taking and immediate, responsible reporting to authorities, as well as to child protective services. Therefore, considering the multifactorial approach this subject requires, this review aims to delve into prevalence statistics, various risk factors, and their effect on psychological health to offer a near-complete regulation to ensure an effective understanding of NAT on part of doctors, social workers, and other relevant authorities.
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Affiliation(s)
| | - Sara Rahman
- Basic Sciences, Services Institute of Medical Sciences, Lahore, PAK
| | - Leah Komer
- Psychiatry, University of Toronto, Toronto, CAN
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22
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Lam MR, Dong P, Shokrollahi Y, Gu L, Suh DW. Finite Element Analysis of Soccer Ball-Related Ocular and Retinal Trauma and Comparison with Abusive Head Trauma. OPHTHALMOLOGY SCIENCE 2022; 2:100129. [PMID: 36249696 PMCID: PMC9560646 DOI: 10.1016/j.xops.2022.100129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/11/2022] [Accepted: 02/14/2022] [Indexed: 11/19/2022]
Abstract
Purpose Design Participants Methods Main Outcome Measures Results Conclusions
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Affiliation(s)
- Matthew R. Lam
- Creighton University School of Medicine, Omaha, Nebraska
- Correspondence: Matthew R. Lam, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178.
| | - Pengfei Dong
- Florida Institute of Technology, Department of Biomedical and Chemical Engineering & Department of Mechanical Engineering, Melbourne, Florida
| | - Yasin Shokrollahi
- Florida Institute of Technology, Department of Biomedical and Chemical Engineering & Department of Mechanical Engineering, Melbourne, Florida
| | - Linxia Gu
- Florida Institute of Technology, Department of Biomedical and Chemical Engineering & Department of Mechanical Engineering, Melbourne, Florida
| | - Donny W. Suh
- Gavin Herbert Eye Institute, University of California at Irvine, Department of Ophthalmology and Visual Sciences, Irvine, California
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23
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Nonaka M, Asai A. Abusive Head Trauma in Infants and Children in Japan. J Korean Neurosurg Soc 2022; 65:380-384. [PMID: 35483020 PMCID: PMC9082133 DOI: 10.3340/jkns.2021.0285] [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: 12/01/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022] Open
Abstract
Subdural hematoma in infants can be caused by abuse, and is thought to be more likely if subdural hematoma is associated with retinal hemorrhage and cerebral edema. In Japan, few doctors disagree that cases of subdural hematoma with retinal hemorrhage and cerebral edema with multiple findings on the body are more likely to have been caused by abuse rather than by household accident. On the other hand, in cases where there are no other significant physical findings, only subdural hematoma and retinal hemorrhage, there is a difference of opinion as to whether the injury was caused by an accident or abuse. The reason for this is that neurosurgeons in Japan promoted the concept that infants can develop subdural hematomas and retinal hemorrages due to minor trauma at home before the concept of abusive head trauma became known. In addition, the age distribution of subdural hematomas in Japan differs from that in other countries, with peaks at around 8 months, and the reason for this remains unclear. Therefore, the etiology of infant subdural hematoma in Japan needs to be investigated in greater detail.
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Affiliation(s)
- Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
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24
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Kwak YH. Diagnosis of Abusive Head Trauma : Neurosurgical Perspective. J Korean Neurosurg Soc 2022; 65:370-379. [PMID: 35468707 PMCID: PMC9082129 DOI: 10.3340/jkns.2021.0284] [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: 11/30/2021] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.
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Affiliation(s)
- Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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25
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Thiblin I, Andersson J, Wester K, Högberg G, Högberg U. Retinal haemorrhage in infants investigated for suspected maltreatment is strongly correlated with intracranial pathology. Acta Paediatr 2022; 111:800-808. [PMID: 34617346 DOI: 10.1111/apa.16139] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 01/14/2023]
Abstract
AIM To test the two prevailing hypotheses regarding the aetiology of infant retinal haemorrhage: (a) traction forces exerted by the lens and/or corpus vitreum on the retina during infant shaking or (b) retinal vessel leakage secondary to intracranial pathology and raised intracranial pressure. METHODS Comparison of medical findings and reported type of trauma in infants investigated for suspected physical abuse with presence (n = 29) or non-presence of retinal haemorrhage (RH) (n = 119). RESULTS Intracranial pathology was recorded in 15 (13%) of the non-RH cases and in 27 (97%) of the RH cases (p < 0.0001). All 18 infants with bilateral RH had intracranial pathology. Of 27 infants subjected to witnessed or admitted shaking, two were in the group with RH. One had a single unilateral RH and no intracranial pathology. The other had bilateral RH and intracranial pathology with non-specific white matter changes, acute subdural and subarachnoid haemorrhages, and suspected cortical venous thrombosis. In 15 RH cases, there was no trauma reported and no findings other than RH and intracranial pathology. Accidental blunt head trauma was reported in 7 RH cases. CONCLUSION The present study indicates that RH in infants is secondary to intracranial pathology of non-specific aetiology.
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Affiliation(s)
- Ingemar Thiblin
- Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Jacob Andersson
- Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Knut Wester
- Department of Clinical Medicine K1 University of Bergen Bergen Norway
| | | | - Ulf Högberg
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
- Department of Epidemiology and Global Health Umeå University Umeå Sweden
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Akutsu N, Nonaka M, Narisawa A, Kato M, Harada A, Park YS. Infantile subdural hematoma in Japan: A multicenter, retrospective study by the J-HITs (Japanese head injury of infants and toddlers study) group. PLoS One 2022; 17:e0264396. [PMID: 35213611 PMCID: PMC8880432 DOI: 10.1371/journal.pone.0264396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
Objective
Subdural hematoma in infants or toddlers has often been linked to abuse, but it is not clear how many cases actually occur and how many are suspected of abuse. The purpose of this study was to investigate subdural hematoma in infants and toddlers in Japan.
Methods
This multicenter, retrospective study reviewed the clinical records of children younger than 4 years with head trauma who were diagnosed with any finding on head computed tomography (CT) and/or magnetic resonance imaging (MRI), such as skull fracture and/or intracranial injury. A total of 452 children were included. The group suspected to have been abused was classified as nonaccidental, and the group considered to have been caused by an accident was classified as accidental. Subdural hematoma and other factors were examined on multivariate analysis to identify which factors increase the risk of nonaccidental injuries.
Results
Of the 452 patients, 158 were diagnosed with subdural hematoma. Subdural hematoma was the most common finding intracranial finding in head trauma in infants and toddlers. A total of 51 patients were classified into the nonaccidental group, and 107 patients were classified into the accidental group. The age of patients with subdural hematoma showed a bimodal pattern. The mean age of the accidental group with subdural hematoma was significantly older than that in the nonaccidental group (10.2 months vs 5.9 months, respectively. p < 0.001). Multivariate analysis showed that patients under 5 months old, retinal hemorrhage, and seizure were significant risk factors for nonaccidental injury (odds ratio (OR) 3.86, p = 0.0011; OR 7.63, p < 0.001; OR 2.49, p = 0.03; respectively). On the other hand, the odds ratio for subdural hematoma was 1.96, and no significant difference was observed (p = 0.34).
Conclusions
At least in Japanese children, infantile subdural hematoma was frequently observed not only in nonaccidental but also in accidental injuries. In infants with head trauma, age, the presence of retinal hemorrhage, and the presence of seizures should be considered when determining whether they were abused. Subdural hematoma is also a powerful finding to detect abuse, but care should be taken because, in some ethnic groups, such as the Japanese, there are many accidental cases.
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Affiliation(s)
- Nobuyuki Akutsu
- Department of Neurosurgery, Hyogo Prefectural Kobe Children’s Hospital, Hyogo, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
- * E-mail:
| | - Ayumi Narisawa
- Department of Neurosurgery, Sendai City Hospital, Miyagi, Japan
| | - Mihoko Kato
- Department of Neurosurgery, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Atsuko Harada
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Osaka, Japan
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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27
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Depallens S, Favrod C, Maeder P, San Millan D, Cheseaux JJ. Early Diagnosis of Abusive Head Trauma to Avoid Repetitive Shaking Events. Glob Pediatr Health 2022; 9:2333794X211067037. [PMID: 35224142 PMCID: PMC8864258 DOI: 10.1177/2333794x211067037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/28/2021] [Indexed: 11/17/2022] Open
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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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30
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Vaslow DF. Chronic subdural hemorrhage predisposes to development of cerebral venous thrombosis and associated retinal hemorrhages and subdural rebleeds in infants. Neuroradiol J 2022; 35:53-66. [PMID: 34167377 PMCID: PMC8826291 DOI: 10.1177/19714009211026904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson's syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.
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Affiliation(s)
- Dale F Vaslow
- Department of Radiology, Harry S.
Truman Veterans Administration Hospital, Columbia, MO, USA,Dale F Vaslow, 2504 Lenox Place, Columbia,
MO 65203, USA.
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31
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Oliva A, Grassi S, Cazzato F, Jabbehdari S, Mensi L, Amorelli G, Orazi L, Arena V, Lepore D. The role of retinal imaging in the management of abusive head trauma cases. Int J Legal Med 2022; 136:1009-1016. [DOI: 10.1007/s00414-021-02750-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
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32
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Burns J, Rohl S, Marth D, Proctor D, Amin R, Sekhon C. Which Clinical Features of Children on Initial Presentation to the Emergency Department With Head Injury Are Associated With Clinically Important Traumatic Brain Injury, Classification as Abuse, and Poor Prognosis? Pediatr Emerg Care 2022; 38:e254-e258. [PMID: 32925700 DOI: 10.1097/pec.0000000000002239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are leading causes of morbidity and mortality. Clinicians may not be aware of AHT at presentation to the emergency department (ED). OBJECTIVE The objective of this study was to determine which clinical features associated with head injury in children on initial presentation to the ED trauma bay predict 3 outcomes including clinically important TBI (CiTBI), classification as confirmed abuse by Child Protection Team (CPT), and poor neurologic status on hospital discharge. PARTICIPANTS AND SETTING Inclusion for this study were children 3 years or younger, presenting to the ED with significant TBI. In addition, presentations where the mechanism of injury was not verifiable such as with falls, being struck by object, or no mechanism of injury reported by caregiver were included. METHODS Researchers used 3 sources of information for this analysis: a regional trauma registry, hospital records, and the CPT database. Clinical features included demographics, mechanisms of injury, physical, radiological findings, and CPT classification. RESULTS On pairwise analysis, seizures, apnea, and no mechanism of injury reported by caregiver were the only clinical features related to all 3 outcomes (P < 0.001). Rib fractures (relative risk [RR], 3.3; P < 0.001), long bone fractures (RR, 3.1; P < 0.001), retinal hemorrhages (RR, 3.0; P < 0.001), seizures (RR, 3.6; P < 0.001), apnea (RR, 4.4; P < 0.001), and younger than 6 months (RR, 1.8; P < 0.001) were related to AHT. On multivariable logistic regression, no mechanism of injury reported by caregiver and seizures remained significantly related to CiTBI; seizures and retinal hemorrhage remained significantly related to classification as abuse by CPT, and no mechanism of injury by the caregiver, apnea, and seizures were significantly related to poor outcome on hospital discharge. CONCLUSIONS No mechanism of injury reported by the caregiver, seizures, and apnea at the time of presentation to the ED are important features associated with CiTBI, classification as AHT, and poor prognosis. In addition, younger age, retinal hemorrhage, rib, and long bone fractures were found to be important clinical features associated with AHT.
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Affiliation(s)
- James Burns
- From the Pediatric Trauma Research Team, Studer Family Children's Hospital at Ascension Sacred Heart
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33
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Cohrs G, Winter SM, Siska W, Thomale UW. Underestimating isolated bilateral hygroma as non-accidental head injury with dramatic consequences: a case presentation. Childs Nerv Syst 2022; 38:2429-2435. [PMID: 36323956 PMCID: PMC9630064 DOI: 10.1007/s00381-022-05720-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Abusive head injury (AHI) in infancy is associated with significantly worse outcomes compared to accidental traumatic brain injury. The decision-making of the diagnosis of AHI is challenging especially if the clinical signs are not presenting as a multifactorial pattern. METHOD We present a case of isolated bilateral hygroma in which this differential diagnosis of AHI was evaluated but primarily not seen as such leading subsequently to extensive secondary AHI with fatal brain injury. RESULTS The case of an 8-week-old infant with apparently isolated bilateral hygroma without any external signs of abuse and no retinal hemorrhages was interpreted in causative correlation to the perinatal complex course of delivery. At a second readmission of the case, severe brain injury with bilateral cortical hypoxia, subarachnoid and subdural hemorrhages, and skull and extremity fractures led to severe disability of the affected infant. CONCLUSION Any early suspicion of AHI with at least one factor possibly being associated with abusive trauma should be discussed in multidisciplinary team conferences to find the best strategy to protect the child. Beside clinical factors, social factors within the family household may additionally be evaluated to determine stress-related risk for traumatic child abuse. In general, prevention programs will be essential in future perspective.
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Affiliation(s)
- Gesa Cohrs
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sibylle Maria Winter
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany ,Child Protection Team, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wiebke Siska
- Child Protection Team, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Watanabe Y, Shiga K, Kikuchi N, Kurihara Y, Sato A. A regional multidisciplinary network enhances child abuse case management. Pediatr Int 2022; 64:e15240. [PMID: 35859263 DOI: 10.1111/ped.15240] [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: 01/28/2022] [Revised: 04/01/2022] [Accepted: 05/12/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND We previously reported an inadequate response to intracranial hemorrhage (ICH) cases under 24 months of age in Yokohama from 2011 to 2013. Hence, it is very important to evaluate how the establishment of a regional multidisciplinary network for child abuse affects the response to ICH cases in medical institutions. METHODS We conducted a questionnaire survey of ICH cases under 24 months of age from 2014 to 2016 using a regional multidisciplinary network for child abuse established in Yokohama in September 2013. We investigated the patients' characteristics, examinations to identify inflicted injury, and reports made to the hospital-based child protection team (CPT) or regional child protective service (CPS), and compared the results of a previous study and the current study, which corresponds to before and after the establishment of the regional network, respectively. RESULTS The total number of ICH cases was 50 in 3 years. The number of cases surveyed for covert fracture and fundus hemorrhage increased significantly after the establishment of the regional network (P = 0.0001 and P = 0.0182, respectively). The number of cases reported as suspected child abuse was 41 (82%) to the hospital-based CPTs and 27 (54%) to the regional CPSs. There were significant differences between before and after the establishment of the regional network regarding CPT (P = 0.0062) and CPS (P = 0.0215) reports. CONCLUSIONS A regional multidisciplinary network can enhance response and cooperation to address child abuse. It deepens our understanding of such care and improves awareness by hospital personnel of child abuse.
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Affiliation(s)
- Yoshihiro Watanabe
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kentaro Shiga
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Nobuyuki Kikuchi
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Yachiyo Kurihara
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, St. Marianna University Yokohama City Seibu Hospital, Yokohama, Japan
| | - Atsuo Sato
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, Yokohama Rosai Hospital, Yokohama, Japan
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35
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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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36
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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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37
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Boruah AP, Potter TO, Shammassian BH, Hills BB, Dingeldein MW, Tomei KL. Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review. J Neurosurg Pediatr 2021; 28:268-277. [PMID: 34171842 DOI: 10.3171/2021.2.peds20872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk. METHODS A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk. RESULTS A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup). CONCLUSIONS Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.
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Affiliation(s)
| | | | - Berje H Shammassian
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Byron B Hills
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Michael W Dingeldein
- 1Case Western Reserve University School of Medicine
- 3Surgery, University Hospitals Cleveland Medical Center
- and Divisions of4Pediatric Surgery and
| | - Krystal L Tomei
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
- 5Pediatric Neurosurgery, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
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38
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Franchina M, Blaszkowska M, Lewis J, Johnson A, Clark A, Lam G, Mackey DA. Paediatric eye injuries during a COVID-19 pandemic lockdown. Clin Exp Optom 2021; 105:637-641. [PMID: 34402757 DOI: 10.1080/08164622.2021.1964921] [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: 12/09/2022] Open
Abstract
CLINICAL RELEVANCE Eye injuries, both accidental and non-accidental, are a significant cause of long-term visual impairment in children. An understanding of when and how such injuries occur is key to development of adequate prevention strategies. BACKGROUND To evaluate accidental and non-accidental eye injuries in children presenting to the major tertiary emergency department and outpatient ophthalmology clinic in Western Australia during the nationwide COVID-19 lockdown and to determine whether the frequency or nature of these injuries differed from pre-pandemic presentations. METHODS Retrospective review of the medical records of paediatric patients presenting to the emergency department and specialist ophthalmology clinic with an ocular injury and those presenting to the hospital Child Protection Unit with physical injuries during March-August 2020 and the same period in 2019. RESULTS There was no significant difference in the total number of accidental eye injury presentations during the lockdown period despite a significant decrease in emergency department attendance overall. Closed-globe injuries were the most common accidental eye injury presentation during lockdown (70/110, 64%), followed by adnexal injuries (39/110, 35%) and open-globe injuries (1/110, 1%). In contrast, referrals to the hospital Child Protection Unit for suspicious injuries declined during lockdown. Although eye injury presentations have changed in other parts of the world since the start of the pandemic, during COVID-19 lockdown in Western Australia, accidental paediatric ocular and adnexal trauma sustained at home continues to be a significant cause for hospital attendance. Public education regarding in-home eye injury prevention must be ongoing.
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Affiliation(s)
- Maria Franchina
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
| | - Magda Blaszkowska
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
| | - Joel Lewis
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Alice Johnson
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Antony Clark
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Geoffrey Lam
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - David A Mackey
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
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Unuma K, Makino Y, Yamamoto K, Hattori S, Arai N, Sakai K, Kitagawa M, Uemura K, Kanegane H. Fatal intracranial hemorrhage due to infantile acute lymphoblastic leukemia mimicking abusive head trauma. J Forensic Sci 2021; 66:2504-2510. [PMID: 34296766 DOI: 10.1111/1556-4029.14815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/29/2021] [Accepted: 07/13/2021] [Indexed: 11/27/2022]
Abstract
We report the case of a 2-month-old infant who was found moribund in her crib. Postmortem computed tomography (PMCT) was performed before autopsy. As the baby had a severe subdural hematoma, retinal hemorrhage, and encephalopathy on PMCT, abusive head trauma (AHT) was tentatively diagnosed. At autopsy, no scalp hemorrhages or skull fractures were found; however, the classic triad of AHT was present, mainly on the right side. Additionally, there was dark red discoloration around the heart, and the liver, spleen, and pancreas were enlarged. Peripheral blood was macroscopically cloudy with marked leukocytosis. After careful histological examination, B-cell precursor acute lymphoblastic leukemia (ALL) was diagnosed. All the macroscopic lesions could be attributed to ALL. The manner of death was natural. To the best of our knowledge, this is the first report of infantile ALL mimicking AHT on PMCT images. This case demonstrates the importance of a comprehensive systematic approach to considering differential diagnosis when PMCT shows multiple intracranial hemorrhages suggestive of AHT in an infant.
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Affiliation(s)
- Kana Unuma
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
| | - Shinya Hattori
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Nobutaka Arai
- Laboratory of Neuropathology, Tokyo Metropolitan Institute of Medical Science, Setagaya-ku, Tokyo, Japan
| | - Kentaro Sakai
- Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, Bunkyo-ku, Tokyo, Japan
| | - Masanobu Kitagawa
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Koichi Uemura
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
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40
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Wright J, Painter S, Kodagali SS, Jones NR, Roalfe A, Jayawant S, Elston J, Anand G. Disability and visual outcomes following suspected abusive head trauma in children under 2 years. Arch Dis Child 2021; 106:590-593. [PMID: 32665266 DOI: 10.1136/archdischild-2019-318638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To report disability and visual outcomes following suspected abusive head trauma (AHT) in children under 2 years. METHODS We present a retrospective case series (1995-2017) of children with suspected AHT aged ≤24 months. King's Outcome Score of Childhood Head Injury (KOSCHI) was used to assess disability outcomes at hospital discharge and at follow-up. The study used a retinal haemorrhage score (RHS) to record findings at presentation and a visual outcome score at follow-up. RESULTS We included 44 children (median age 16 weeks). At presentation, 98% had a subdural haemorrhage and 93% had a retinal haemorrhage. At discharge, 61% had moderate-to-severe disability, and 34% a good recovery. A higher RHS was observed in those with more disability (r=-0.54, p=0.0002). At follow-up, 14% had a worse KOSCHI score (p=0.055). 35% children had visual impairment, including 9% with no functional vision. Those with poorer visual function had a higher RHS (r=0.53, p=0.003). 28% attended mainstream school without support; 50% were in foster care or had been adopted, 32% lived with birth mother and 18% with extended family. CONCLUSION It is known that injuries from suspected AHT result in high levels of morbidity; our cohort showed significant rates of disability and visual impairment. Those with higher disability at discharge and poorer visual function showed more significant retinal changes. The extent of disability was not always apparent at hospital discharge, impacting on provision of prognostic information and targeted follow-up.
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Affiliation(s)
- Juliana Wright
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Painter
- Paediatric Ophthalmology, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | | | - Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, Oxford, Oxfordshire, UK
| | - Andrea Roalfe
- Nuffield Department of Primary Care Health Sciences, Oxford, Oxfordshire, UK
| | - Sandeep Jayawant
- Paediatric Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - John Elston
- Paediatric Ophthalmology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Geetha Anand
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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41
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Sidpra J, Chhabda S, Oates AJ, Bhatia A, Blaser SI, Mankad K. Abusive head trauma: neuroimaging mimics and diagnostic complexities. Pediatr Radiol 2021; 51:947-965. [PMID: 33999237 DOI: 10.1007/s00247-020-04940-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/13/2020] [Accepted: 12/16/2020] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury is responsible for approximately half of all childhood deaths from infancy to puberty, the majority of which are attributable to abusive head trauma (AHT). Due to the broad way patients present and the lack of a clear mechanism of injury in some cases, neuroimaging plays an integral role in the diagnostic pathway of these children. However, this nonspecific nature also presages the existence of numerous conditions that mimic both the clinical and neuroimaging findings seen in AHT. This propensity for misdiagnosis is compounded by the lack of pathognomonic patterns and clear diagnostic criteria. The repercussions of this are severe and have a profound stigmatic effect. The authors present an exhaustive review of the literature complemented by illustrative cases from their institutions with the aim of providing a framework with which to approach the neuroimaging and diagnosis of AHT.
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Affiliation(s)
- Jai Sidpra
- University College London Medical School, London, UK
| | - Sahil Chhabda
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, UK
| | - Aashim Bhatia
- Department of Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susan I Blaser
- Department of Radiology, Hospital for Sick Children, Toronto, ON, Canada
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK.
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Casar Berazaluce AM, Moody S, Jenkins T, Farooqui Z, Shebesta K, Kotagal M, Falcone RA. Catching the red eye: A retrospective review of factors associated with retinal hemorrhage in child physical abuse. J Pediatr Surg 2021; 56:1009-1012. [PMID: 32888720 DOI: 10.1016/j.jpedsurg.2020.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/22/2020] [Accepted: 07/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE Accurate identification of child physical abuse is crucial during the evaluation of injured children. Retinal hemorrhages (RH) are used for diagnosis, but clear criteria for screening with direct fundoscopic exam are lacking. We sought to identify key factors associated with RH to guide evaluations. METHODS Electronic medical records for patients <1 year of age presenting to a Level I Pediatric Trauma Center with unwitnessed head injury from January 2015 to December 2018 were retrospectively reviewed. Multivariable logistic regression was used to identify factors associated with RH. RESULTS Two hundred and seventy-six patients were included; 63% underwent direct fundoscopic examination, of which 23% were positive and 77% were negative for RH. Unscreened patients tended to be older and have isolated skull fractures. Multivariable regression analysis revealed that abnormal GCS and subdural hemorrhage were positively associated with a diagnosis of retinal hemorrhage, while isolated skull fracture was negatively associated. CONCLUSIONS Children under 1 year of age with subdural hemorrhage have a greater risk of associated RH and should undergo routine screening with direct fundoscopic examination. Conversely, those with isolated skull fractures may not require an ophthalmology consultation. Standardized screening protocols may help reduce the risk of missing child physical abuse. LEVEL OF EVIDENCE III (Diagnostic Test).
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Affiliation(s)
- Alejandra M Casar Berazaluce
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Suzanne Moody
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Todd Jenkins
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Zishaan Farooqui
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Kaaren Shebesta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Meeta Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Richard A Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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Maiese A, Iannaccone F, Scatena A, Del Fante Z, Oliva A, Frati P, Fineschi V. Pediatric Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11040734. [PMID: 33924220 PMCID: PMC8074611 DOI: 10.3390/diagnostics11040734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023] Open
Abstract
Abusive head trauma (AHT) represents a commonly misdiagnosed condition. In fact, there is no pathognomonic sign that allows the diagnosis in children. Therefore, it is such an important medico-legal challenge to evaluate reliable diagnostic tools. The aim of this review is to evaluate the current scientific evidence to assess what the best practice is in order to diagnose AHT. We have focused particularly on evaluating the importance of circumstantial evidence, clinical history, the use of postmortem radiological examinations (such as CT and MRI), and the performance of the autopsy. After autopsy, histological examination of the eye and brain play an important role, with attention paid to correlation with symptoms found in vivo.
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Affiliation(s)
- Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
| | - Francesca Iannaccone
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Andrea Scatena
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Zoe Del Fante
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Antonio Oliva
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, 00100 Rome, Italy;
| | - Paola Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Vittorio Fineschi
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
- Correspondence: ; Tel.: +39-064-991-2722
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Gjerde H, Mantagos IS. Charting the Globe: How Technologies Have Affected Our Understanding of Retinal Findings in Abusive Head Trauma/Shaken Baby Syndrome. Semin Ophthalmol 2021; 36:205-209. [PMID: 33793387 DOI: 10.1080/08820538.2021.1890150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Purpose: Ocular findings such as retinal hemorrhages are common in abusive head trauma (AHT). Binocular indirect ophthalmoscopy has been the standard for assessing the eyes of children who are victims of AHT. However, technological advances have changed our understanding of retinal findings in AHT.Methods: Literature review on AHT - retinal findings, imaging technologies, models of representation, and telemedicine applications.Results: Many studies suggest vitreoretinal traction from repetitive acceleration-deceleration shearing forces during shaking plays an important role in the development of retinal findings in AHT. This is further supported by different imaging modalities [optical coherence tomography (OCT); magnetic resonance imaging (MRI); fluorescein angiography (FA)] and models of representation (animal and mechanical models; finite element analysis).Conclusion: Emerging technologies have augmented our diagnostic abilities, enhanced our understanding regarding the pathophysiology of retinal findings, and strengthened the link between vitreoretinal traction and ocular pathology in AHT. Telemedicine is also starting to play an important role in AHT.
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Affiliation(s)
- Harald Gjerde
- Department of Ophthalmology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Iason S Mantagos
- Department of Ophthalmology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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AlSahlawi A, Morantz G, Lacroix C, Saint-Martin C, Dudley RWR. Bilateral Parietal Skull Fractures in Infants Attributable to Accidental Falls. Pediatr Neurosurg 2021; 56:424-431. [PMID: 34352782 DOI: 10.1159/000516972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/03/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Multiple skull fractures, including bilateral parietal skull fractures (BPSFs) in infants are considered to be suspicious for abusive head trauma (AHT). The aim of this report is to describe a series of BPSF cases in infants which occurred due to accidental falls. METHODS We searched our neuroradiology database for BPSF in infants (<1 year old) diagnosed between 2006 and 2019; we reviewed initial presentation, mechanisms of injury, clinical course, head imaging, skeletal survey X-rays, ophthalmology, social work and child abuse physicians (CAP) assessments, and long-term follow-up. "Confirmed accidental BPSF" were strictly defined as having negative skeletal survey and ophthalmology evaluation and a CAP conclusion of accidental injury. RESULTS Twelve cases of BPSF were found; 3 were confirmed to be accidental, with a mean age at presentation of 3 months. Two infants had single-impact falls, and 1 had a compression injury; all 3 had small intracranial hemorrhages. None had bruises or other injuries, and all remained clinically well. A literature search found 10 similar cases and further biomechanical evidence that these fractures can occur from accidental falls. CONCLUSION While AHT should be kept in the differential diagnosis whenever BPSFs are seen, these injuries can occur as a result of accidental falls.
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Affiliation(s)
- Aysha AlSahlawi
- Montreal Children Hospital, McGill University, Montreal, Québec, Canada
| | - Gillian Morantz
- Montreal Children Hospital, McGill University, Montreal, Québec, Canada
| | - Caroline Lacroix
- Montreal Children Hospital, McGill University, Montreal, Québec, Canada
| | | | - Roy W R Dudley
- Montreal Children Hospital, McGill University, Montreal, Québec, Canada
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Syed S, Ashwick R, Schlosser M, Gonzalez-Izquierdo A, Li L, Gilbert R. Predictive value of indicators for identifying child maltreatment and intimate partner violence in coded electronic health records: a systematic review and meta-analysis. Arch Dis Child 2021; 106:44-53. [PMID: 32788201 PMCID: PMC7788194 DOI: 10.1136/archdischild-2020-319027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Electronic health records (EHRs) are routinely used to identify family violence, yet reliable evidence of their validity remains limited. We conducted a systematic review and meta-analysis to evaluate the positive predictive values (PPVs) of coded indicators in EHRs for identifying intimate partner violence (IPV) and child maltreatment (CM), including prenatal neglect. METHODS We searched 18 electronic databases between January 1980 and May 2020 for studies comparing any coded indicator of IPV or CM including prenatal neglect defined as neonatal abstinence syndrome (NAS) or fetal alcohol syndrome (FAS), against an independent reference standard. We pooled PPVs for each indicator using random effects meta-analyses. RESULTS We included 88 studies (3 875 183 individuals) involving 15 indicators for identifying CM in the prenatal period and childhood (0-18 years) and five indicators for IPV among women of reproductive age (12-50 years). Based on the International Classification of Disease system, the pooled PPV was over 80% for NAS (16 studies) but lower for FAS (<40%; seven studies). For young children, primary diagnoses of CM, specific injury presentations (eg, rib fractures and retinal haemorrhages) and assaults showed a high PPV for CM (pooled PPVs: 55.9%-87.8%). Indicators of IPV in women had a high PPV, with primary diagnoses correctly identifying IPV in >85% of cases. CONCLUSIONS Coded indicators in EHRs have a high likelihood of correctly classifying types of CM and IPV across the life course, providing a useful tool for assessment, support and monitoring of high-risk groups in health services and research.
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Affiliation(s)
- Shabeer Syed
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
- Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Rachel Ashwick
- Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Marco Schlosser
- Division of Psychiatry, University College London, London, UK
| | | | - Leah Li
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
| | - Ruth Gilbert
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
- Institute of Health Informatics and Health Data Research UK, University College London, London, UK
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Barth T, Altmann M, Batzlsperger C, Jägle H, Helbig H. [Unilateral retinal hemorrhage in infants-two cases of shaken baby syndrome?]. Ophthalmologe 2020; 117:1033-1036. [PMID: 31996999 PMCID: PMC8497311 DOI: 10.1007/s00347-020-01038-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ein 2,5 Monate alter Junge und ein 2 Monate altes Mädchen wurden wegen schwerer Bewusstseinstrübung pädiatrisch behandelt. Bei beiden Kindern fanden sich Subduralhämatome. Bei Verdacht auf nichtakzidentelles Schädel-Hirn-Trauma (NAHI) erfolgte eine Untersuchung des Augenhintergrundes, bei der sich bei beiden Säuglingen unilaterale Netzhautblutungen zeigten. Nach intensiver Differenzialdiagnostik wurde in beiden Fällen der Verdacht auf ein NAHI gestellt und eine rechtsmedizinische Begutachtung initiiert. Wichtig an dieser Fallserie ist, dass die Einseitigkeit von Netzhautblutungen ein NAHI nicht ausschließt.
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Affiliation(s)
- T Barth
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - M Altmann
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - C Batzlsperger
- Klinik für Kinder- und Jugendmedizin, Neonatologie, Neuropädiatrie, DONAUISAR Klinikum Deggendorf, Perlasbergerstr. 41, 94469, Deggendorf, Deutschland
| | - H Jägle
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - H Helbig
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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Gencturk M, Cam I, Koksel Y, McKinney AM. Role of Susceptibility-Weighted Imaging in Detecting Retinal Hemorrhages in Children with Head Trauma. Clin Neuroradiol 2020; 31:611-617. [DOI: 10.1007/s00062-020-00939-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/09/2020] [Indexed: 11/25/2022]
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Nonaccidental trauma in pediatric patients: evidence-based screening criteria for ophthalmologic examination. J AAPOS 2020; 24:226.e1-226.e5. [PMID: 32822853 DOI: 10.1016/j.jaapos.2020.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ophthalmologic examination is included in the work-up for pediatric nonaccidental trauma (NAT) when there is concern for retinal hemorrhage. However, dilated fundus examination entails patient discomfort and prohibition of assessment of pupillary response. Previous studies have suggested that patients without neuroimaging abnormalities are unlikely to have retinal hemorrhage. The purpose of the current study was to analyze the findings in patients who received NAT evaluation with eye examination at our institution, and to propose screening criteria for inclusion of ophthalmologic examination in NAT evaluation. METHODS The medical records of patients who received NAT evaluation with ophthalmologic examination at The Johns Hopkins Children's Center Pediatric Emergency Department from August 2014 to July 2018 were reviewed retrospectively. Data collected included demographics, presenting symptoms, imaging findings, and ophthalmologic examination findings. The main outcome measure was presence of retinal hemorrhage. RESULTS A total of 192 evaluations with ophthalmologic examination were included, representing 190 unique individuals of mean age 8.4 ± 9.5 months at presentation. In approximately half (54%) of the evaluations, there were abnormal findings on neuroimaging. Fifteen children (8%) had retinal hemorrhage, all of whom also had abnormal neuroimaging. Abnormal neuroimaging was associated with presence of retinal hemorrhage, with an odds ratio of 21.0 (95% CI, 3.47-∞; P < 0.001). Of the 15 children with retinal hemorrhage, 14 had subdural hemorrhage. CONCLUSIONS When neuroimaging abnormalities are present, ophthalmologic examination should be performed as part of the pediatric NAT evaluation. When there is no evidence of head injury on neuroimaging, ophthalmologic examination should not be routine.
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Byrne MP, McMillan KR, Coats B. Morphological Analysis of Retinal Microvasculature to Improve Understanding of Retinal Hemorrhage Mechanics in Infants. Invest Ophthalmol Vis Sci 2020; 61:16. [PMID: 32176264 PMCID: PMC7401705 DOI: 10.1167/iovs.61.3.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose In this experimental study, we quantify retinal microvasculature morphological features with depth, region, and age in immature and mature ovine eyes. These data identify morphological vulnerabilities in young eyes to inform the mechanics of retinal hemorrhage in children. Methods Retinal specimens from the equator and posterior pole of preterm (n = 4) and adult (n = 9) sheep were imaged using confocal microscopy. Vessel segment length, diameter, angular asymmetry, tortuosity, and branch points were quantified using a custom image segmentation code. Significant differences were identified through two-way ANOVAs and correlation analyses. Results Vessel segment lengths were significantly shorter in immature eyes compared to adults (P < 0.003) and were significantly shorter at increasing depths in the immature retina (P < 0.04). Tortuosity significantly increased with depth, regardless of age (P < 0.05). These data suggest a potential vulnerability of vasculature in the deeper retinal layers, particularly in immature eyes. Preterm retina had significantly more branch points than adult retina in both the posterior pole and equator, and the number increased significantly with depth (P < 0.001). Conclusions The increased branch points and decreased segment lengths in immature microvasculature suggest that infants will experience greater stress and strain during traumatic loading compared to adults. The increased morphological vulnerability of the immature microvasculature in the deeper layers of the retina suggest that intraretinal hemorrhages have a greater likelihood of occurring from trauma compared to preretinal hemorrhages. The morphological features captured in this study lay the foundation to explore the mechanics of retinal hemorrhage in infants and identify vulnerabilities that explain patterns of retinal hemorrhage in infants.
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