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Curcoy AI, Serra A, Morales M, Luaces C, Trenchs V. Retinal hemorrhages due to intracranial hypertension, is it possible to differentiate them from those associated with abuse? CHILD ABUSE & NEGLECT 2023; 144:106387. [PMID: 37549636 DOI: 10.1016/j.chiabu.2023.106387] [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: 03/16/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Retinal hemorrhages (RHs) are suggestive of abusive head trauma (AHT). Even so, controversy persists about other possible causes, a fact that hinders the diagnosis of abuse. OBJECTIVE To determine the prevalence and patterns of RHs associated with increased intracranial pressure (ICP) in young children. PARTICIPANTS AND METHODS Prospective, single center study of children aged 29 days-3 years undergoing a lumbar puncture with opening pressure (OP) measured during routine clinical care in the emergency department, over a 4-year period. Children with known causes of RHs were excluded. All the children underwent a detailed ophthalmological examination within 72 h of admission. For children with RHs, an in-depth investigation was carried out to rule out AHT. RESULTS Thirty-four patients were included: 20(58.8 %) were boys, median age 11.7 months (range 1-33 months). Overall, 29(85.3 %) had clinical findings of increased ICP. The duration of symptoms was ≤4 days in all patients except one, in whom it was 1.5 months. The median OP was 27cmH2O (range 20-60cmH2O). One of the children was found to have RHs, with evaluation resulting in a diagnosis of AHT. No RHs were found in any of the others studied. Using the Wilson method, we can be confident to an upper limit of 95 % that the probability of RHs occurring secondary to increased ICP alone is at most 0.1. CONCLUSIONS RHs were not detected in patients with isolated nontraumatic increased ICP, measured via OP and diagnosed in the ED. Therefore, if RHs are detected, investigation into the possibility of AHT is warranted.
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Affiliation(s)
- Ana I Curcoy
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Alicia Serra
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Marta Morales
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Carles Luaces
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Victoria Trenchs
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain.
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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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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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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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Abusive head trauma: Canadian and global perspectives. Pediatr Radiol 2021; 51:876-882. [PMID: 33999233 DOI: 10.1007/s00247-020-04844-5] [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: 04/22/2020] [Revised: 07/28/2020] [Accepted: 09/08/2020] [Indexed: 10/21/2022]
Abstract
Canada has come a long way since Dr. C. Henry Kempe first described battered-child syndrome in 1962. The year 1999 was crucial in Canada's battle against shaken baby syndrome/abusive head trauma (SBS/AHT), when the first national conference on the topic was held in Saskatoon. This was followed by the issuance of a national statement and multidisciplinary guidelines, recently updated in 2020. Incidence of AHT in Canada is similar to that found in population-based studies from Switzerland and New Zealand. The mainstay of prevention of AHT in Canada is education of parents and caregivers with respect to their response to infant crying. Population-based data for global incidence of AHT are lacking, largely because of social and cultural differences contributing to poor understanding of AHT as a medico-legal entity. India faces a distinct challenge in the battle against female feticide and infanticide.
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Skull fractures in abusive head trauma: a single centre experience and review of the literature. Childs Nerv Syst 2021; 37:919-929. [PMID: 32935234 DOI: 10.1007/s00381-020-04870-6] [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] [Received: 03/06/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The authors provide a comprehensive framework with which to approach paediatric calvarial injury sustained as a result of suspected abusive head trauma (AHT). This is achieved through the presentation of a case series set in the context of the unique morphology of the infant skull and the possible diagnostic pitfalls which may arise due to the presence of variant anatomy or other mimicking conditions. METHODS A retrospective analysis of sixty-three patients referred to our institution with suspected AHT was carried out. Seventeen patients with skull fractures were identified and their fractures were described in terms of anatomical location, type and course. Our data was then interpreted in the light of known anatomical fracture mimics and the available literature on the subject. RESULTS Forty-two skull fractures were identified and described in our cohort, most of which were simple linear fractures of the parietal bones (33%). There were also a substantial number of complex stellate fractures, namely of the parietal (29%) and occipital (10%) bones. Eleven fracture mimics including accessory sutures and wormian bones were also identified in this cohort. CONCLUSIONS Our study supports and builds on the existing literature, thereby offering a more complete view of the spectrum of calvarial damage sustained as a result of AHT in the context of its diagnostic pitfalls.
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Kanya Iyer A, Lemos NP. Are we looking for retinal haemorrhages? MEDICINE, SCIENCE, AND THE LAW 2019; 59:70-71. [PMID: 30852984 DOI: 10.1177/0025802419828922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
| | - Nikolas P Lemos
- William Harvey Institute, Queen Mary University of London, UK
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Teixeira SR, Gonçalves FG, Servin CA, Mankad K, Zuccoli G. Ocular and Intracranial MR Imaging Findings in Abusive Head Trauma. Top Magn Reson Imaging 2018; 27:503-514. [PMID: 30516697 DOI: 10.1097/rmr.0000000000000169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Abusive head trauma (AHT) is a form of inflicted head injury. AHT is more frequent in 2-year-old or younger children. It is an important cause of neurological impairment and the major cause of death from head trauma in this age group. Brain magnetic resonance imaging allows the depiction of retinal hemorrhages, injured bridging veins, and identifying and localizing extra- and intra-axial bleeds, contusions, lacerations, and strokes. The diagnosis of AHT is a multidisciplinary team effort which includes a careful evaluation of social, clinical, laboratory, and radiological findings. Notwithstanding, the introduction in the current clinical practice of high-resolution techniques is adding forensic evidence to the recognition of AHT.
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Affiliation(s)
- Sara Reis Teixeira
- Division of Radiology, Clinical Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto
| | | | - Carolina A Servin
- Centro Medico La Costa - Centro de Diagnóstico, Av General José Gervasio Artigas, Asunción, Paraguay
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Giulio Zuccoli
- Professor of Radiology, University of Pittsburgh School of Medicine, Director of Pediatric Neuroradiology, Children Hospital of Pittsburgh, Pittsburgh, PA
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Morgan LA, Fouzdar Jain S, Svec A, Svec C, Haney SB, Allbery S, High R, Suh DW. Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma. Clin Ophthalmol 2018; 12:1505-1510. [PMID: 30174411 PMCID: PMC6110291 DOI: 10.2147/opth.s163734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose Child abuse is a leading cause of death in infants, which is often associated with abusive head trauma (AHT). The purpose of this retrospective analysis was to identify ocular and systemic findings in confirmed cases of AHT and compare them to a group of non-abusive head trauma (NAHT) patients. Patients and methods A retrospective chart review of 165 patients with accidental and non-accidental trauma admitted between 2013 and 2015 to Children’s Hospital and Medical Center in Omaha, NE, USA, was performed. Diagnosis of AHT was made after the analysis of ocular and systemic findings by various subspecialists. The NAHT group consisted of accidental trauma, abusive trauma without significant apparent head involvement on initial evaluation and unconfirmed AHT cases. Results Of the 165 presenting cases, 30 patients were diagnosed with AHT and 127 were diagnosed with NAHT. Ocular findings in AHT patients were significant for retinal hemorrhages (63%) and vitreous hemorrhages (37%), while NAHT patients had no ocular findings (p<0.001). Neuroimaging revealed subdural hemorrhages (SDHs) in 29 out of 30 AHT patients (97%) and in 27 out of 127 NAHT patients (21%). Seizures were present in 43% of AHT patients (n=13) and only in 8% of NAHT patients (n=10). Conclusion AHT has statistically significant findings of retinal and vitreous hemorrhages. The absence of diffuse retinal hemorrhages, however, does not preclude the AHT diagnosis as more than one-third of AHT patients lacked retinal hemorrhages. SDHs, loss of consciousness and history of seizures also have high correlation with a diagnosis of AHT.
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Affiliation(s)
| | | | - Austin Svec
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Claire Svec
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Robin High
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Donny W Suh
- Children's Hospital and Medical Center, Omaha, NE, USA, .,University of Nebraska Medical Center, Omaha, NE, USA
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Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Room 3-231,Department of Radiology, University of Michigan Health System, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4252, USA.
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Gurney SP, Makanjuola T, Kutubi M, Parulekar M, Abbott J. How to use…the direct ophthalmoscope. Arch Dis Child Educ Pract Ed 2018; 103:102-109. [PMID: 28935833 DOI: 10.1136/archdischild-2016-312378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2017] [Indexed: 01/16/2023]
Abstract
Ophthalmoscopy and red reflex examination are core medical skills required to identify sight-threatening and life-threatening disease. We discuss the predictive utility and limitations of findings with an ophthalmoscope and tips as to how to optimise these. We outline important considerations in three clinical scenarios: an abnormal red reflex, an abnormal optic disc and retinal haemorrhages in the context of child protection concerns.
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Affiliation(s)
- Sam P Gurney
- Department of Paediatric Ophthalmology, Birmingham Children's Hospital, Birmingham, UK
| | - Taiwo Makanjuola
- Department of Paediatric Ophthalmology, Birmingham Children's Hospital, Birmingham, UK
| | - Muhammad Kutubi
- Department of Paediatric Ophthalmology, Birmingham Children's Hospital, Birmingham, UK
| | - Manoj Parulekar
- Department of Paediatric Ophthalmology, Birmingham Children's Hospital, Birmingham, UK.,Department of Ophthalmology, John Radcliffe Hospital, Oxford, UK
| | - Joseph Abbott
- Department of Paediatric Ophthalmology, Birmingham Children's Hospital, Birmingham, UK
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