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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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2
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Doswell A, Killough E, Zinkus TP, Sherman A, Anderst J. Examining diagnostic variability among pediatric subspecialists using case examples of infant head injury. CHILD ABUSE & NEGLECT 2023; 144:106371. [PMID: 37536244 DOI: 10.1016/j.chiabu.2023.106371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists. OBJECTIVES To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs). PARTICIPANTS AND SETTING Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career. METHODS This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons. RESULTS There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example. CONCLUSIONS Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.
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Affiliation(s)
- Angela Doswell
- Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
| | - Emily Killough
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Timothy P Zinkus
- Division of Pediatric Radiology, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, University of Kansas School of Medicine, Saint Louis University School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Ashley Sherman
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - James Anderst
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
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3
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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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4
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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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5
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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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6
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Patterns of retinal hemorrhage associated with cardiac arrest and cardiopulmonary resuscitation. J AAPOS 2021; 25:324.e1-324.e4. [PMID: 34728383 DOI: 10.1016/j.jaapos.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/28/2021] [Accepted: 06/06/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypoxia and cardiopulmonary resuscitation (CPR) have been proposed as causes of retinal hemorrhage (RH) in children evaluated for abusive head trauma (AHT). We sought to determine the prevalence and characteristics of RH in children who underwent CPR after cardiac arrest. METHODS This was a prospective, single-center, consecutive observational study of 38 children (<18 years of age). Indirect ophthalmoscopic examination was completed by an ophthalmologist within 48 hours of CPR. Extensive medical records data were collected to assess for potential confounding factors. Outcomes included the presence and pattern of RH. RESULTS Of the 38 children, 20 had in-hospital arrest; 18 had out-of-hospital arrest. The median duration of CPR was 10 minutes. Seven children had RH, of whom 6 had an RH pattern consistent with coexistent medical conditions: 4 AHT diagnosable with nonocular findings, including subdural and subarachnoid hemorrhage, rib fractures, abdominal injury (RH pattern: diffuse, numerous, intraretinal and/or multilayered RH); 1 septic shock (RH pattern: 1-2 posterior pole RH); 1 ruptured arteriovenous malformation (RH pattern: 4-8 peripapillary RH). The seventh child had unwitnessed cardiac arrest due to nonfatal drowning and a single superficial intraretinal peripapillary hemorrhage. CONCLUSIONS CPR for cardiac arrest is rarely associated with RH, which, absent coexisting conditions causing retinal hemorrhage, are intraretinal, few in number, and located in the posterior pole. In children who have undergone CPR, when RH are multilayered, or are more than a few in number, or extend outside the posterior pole, another etiology for the RH should be sought.
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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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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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Suh DW, Song HH, Mozafari H, Thoreson WB. Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma. Am J Ophthalmol 2021; 223:396-404. [PMID: 32663454 DOI: 10.1016/j.ajo.2020.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is the leading cause of infant death and long-term morbidity from injury. The ocular consequences of AHT are controversial, and the pathophysiology of retinal research findings is still not clearly understood. It has been postulated that vitreoretinal traction plays a major role in the retinal findings. A computer simulation model was developed to evaluate the vitreoretinal traction and determine whether the distribution of forces in different layers and locations of the retina can explain the patterns of retinal hemorrhage (RH) seen in AHT. DESIGN Computer simulation model study. METHODS A computer simulation model of the pediatric eye was developed to evaluate preretinal, intraretinal, and subretinal stresses during repetitive shaking. This model was also used to examine the forces applied to various segments along blood vessels. RESULTS Calculated stress values from the computer simulation ranged from 3-16 kPa at the vitreoretinal interface through a cycle of shaking. Maximal stress was observed at the periphery of the retina, corresponding to areas of multiple vessel bifurcations, followed by the posterior pole of the retina. Stress values were similar throughout all 3 layers of the retina (preretinal, intraretinal, and subretinal layers). CONCLUSIONS Ocular manifestations from AHT revealed unique retinal characteristics. The model predicted stress patterns consistent with the diffuse retinal hemorrhages (RH) typically found in the posterior pole and around the peripheral retina in AHT. This computer model demonstrated that similar stress forces were produced in different layers of the retina, consistent with the finding that retinal hemorrhages are often found in multiple layers of the retina. These data can help explain the RH patterns commonly found in AHT.
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10
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Thau A, Saffren B, Zakrzewski H, Anderst JD, Carpenter SL, Levin A. Retinal hemorrhage and bleeding disorders in children: A review. CHILD ABUSE & NEGLECT 2021; 112:104901. [PMID: 33401159 DOI: 10.1016/j.chiabu.2020.104901] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/16/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Retinal hemorrhages (RH) are a common manifestation of abusive head trauma (AHT) resulting from acceleration-deceleration injury with or without blunt impact. Evaluation of a child with RH requires careful consideration of these differential diagnoses. The extent to which coagulopathy alone can cause RH would be useful to understand as coagulopathy may accompany AHT. OBJECTIVE In this systematic review, we sought to identify whether coagulopathies have been reported with RH similar to those of AHT. METHODS We performed a literature search for ocular manifestations of bleeding disorders in children less than 18 years old. We included clotting factor deficiencies, vitamin K deficiency, platelet function abnormalities, thrombocytopenia, disseminated intravascular coagulation (DIC), and trauma induced coagulopathy (TIC). We included only pediatric reports of intraocular bleeding or documented eye examinations that indicated no hemorrhages. We then re-examined cases for ocular and systemic findings that could potentially mimic abuse. RESULTS Our initial search yielded 816 results. Sixty-one articles met our inclusion criteria. Of these, there were 32 children within the AHT age range (less than 5 years old) who had RH and concomitant coagulopathy. Only 5 cases might potentially be confused for abuse. Of these, no classic characteristics of RH from abuse such as retinoschisis or retinal folds were found. Systemic features were inconsistent with AHT. CONCLUSIONS The presence of coagulopathy alone does not rule out the possibility that the child has been abused. Coagulopathy alone has not been reported as an etiology of RH that are consistent with AHT, especially when other findings are present.
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Affiliation(s)
- Avrey Thau
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Brooke Saffren
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Helena Zakrzewski
- Department of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - James D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shannon L Carpenter
- Department of Hematology, Oncology, and Bone Marrow Transplantation, Children's Mercy Hospital, Kansas City, MO, USA
| | - Alex Levin
- Flaum Eye Institute and Golisano Children's Hospital, University of Rochester, New York, USA.
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Kazmir S, Rosado N. Abusive Head Trauma: A Review of Current Knowledge. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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13
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Abstract
Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.
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Shi A, Kulkarni A, Feldman KW, Weiss A, McCourt EA, Schloff S, Partington M, Forbes B, Geddie BE, Bierbrauer K, Phillips PH, Rogers DL, Abed Alnabi W, Binenbaum G, Levin AV. Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes. Pediatrics 2019; 143:peds.2018-1182. [PMID: 30630868 PMCID: PMC6361344 DOI: 10.1542/peds.2018-1182] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP. METHODS We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded. RESULTS Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions. CONCLUSIONS Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.
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Affiliation(s)
- Angell Shi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Abhaya Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Avery Weiss
- Ophthalmology, Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Emily A. McCourt
- Department of Ophthalmology, Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Susan Schloff
- Associated Eye Care, St Paul, Minnesota;,Department of Ophthalmology and Visual Neurosciences, Children’s Minnesota St Paul Hospital, St Paul, Minnesota
| | - Michael Partington
- Department of Neurosurgery, Gillette Children’s Specialty Healthcare, St Paul, Minnesota
| | - Brian Forbes
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brooke E. Geddie
- Division of Pediatric Ophthalmology, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - Karin Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Paul H. Phillips
- Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas;,Department of Ophthalmology, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - David L. Rogers
- Department of Ophthalmology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Waleed Abed Alnabi
- Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and,Médecins Sans Frontieres, Amman, Jordan
| | - Gil Binenbaum
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alex V. Levin
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania;,Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and
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Elinder G, Eriksson A, Hallberg B, Lynøe N, Sundgren PM, Rosén M, Engström I, Erlandsson BE. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr 2018; 107 Suppl 472:3-23. [PMID: 30146789 PMCID: PMC6585638 DOI: 10.1111/apa.14473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/30/2022]
Abstract
The Swedish Agency for Health Technology Assessment and Assesment of Social Services (SBU) is an independent national authority, tasked by the government with assessing methods used in health, medical and dental services and social service interventions from a broad perspective, covering medical, economic, ethical and social aspects. The language in SBU's reports are adjusted to a wide audience. SBU's Board of Directors has approved the conclusions in this report. The systematic review showed the following graded results: There is limited scientific evidence that the triad (Three components of a whole. The triad associated with SBS usually comprises subdural haematoma, retinal haemorrhages and encephalopathy.) and therefore, its components can be associated with traumatic shaking (low-quality evidence). There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). Limited scientific evidence (low-quality evidence) represents a combined assessment of studies of high or moderate quality which disclose factors that markedly weaken the evidence. It is important to note that limited scientific evidence for the reliability of a method or an effect does not imply complete lack of scientific support. Insufficient scientific evidence (very low-quality evidence) represents either a lack of studies or situations when available studies are of low quality or show contradictory results. Evaluation of the evidence was not based on formal grading of the evidence according to GRADE but on an evaluation of the total scientific basis.
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Affiliation(s)
- Göran Elinder
- Department of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation, Forensic Medicine, Umeå University, Umeå, Sweden
- The National Board of Forensic Medicine, Sweden
| | - Boubou Hallberg
- Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Niels Lynøe
- Medical Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Pia Maly Sundgren
- Diagnostic Radiology, Lund University, Lund, Sweden
- Department of Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Måns Rosén
- Health Technology Assessment, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Engström
- Child and Adolecent Psychiatry, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Abstract
Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.
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Christian CW, Levin AV, Flaherty EG, Sirotnak AP, Budzak AE, Gavril AR, Haney SB, Idzerda SM, Laskey A, Legano LA, Messner SA, Moles RL, Palusci VJ, Karr DJ, Bradford GE, Nischal K, Roarty JD, Rubin SE, Suh DW. The Eye Examination in the Evaluation of Child Abuse. Pediatrics 2018; 142:peds.2018-1411. [PMID: 30037976 DOI: 10.1542/peds.2018-1411] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.
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Affiliation(s)
- Cindy W. Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Alex V. Levin
- Departments of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital and Departments of Ophthalmology and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018; 48:1048-1065. [PMID: 29796797 DOI: 10.1007/s00247-018-4149-1] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/22/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
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Affiliation(s)
- Arabinda Kumar Choudhary
- Department of Radiology, Nemours AI duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas L Slovis
- Department of Radiology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Gary L Hedlund
- Department of Medical Imaging, Primary Children's Hospital, Intermountain Healthcare, Department of Radiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sandeep K Narang
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Cindy W Christian
- Department of Pediatrics, Child Abuse and Neglect Prevention, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Marvin D Nelson
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - Susan Palasis
- Pediatric Neuroradiology, Children's Healthcare of Atlanta, Scottish Rite Campus, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Andrea Rossi
- Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Amaka C Offiah
- Paediatric Musculoskeletal Imaging, Academic Unit of Child Health, Sheffield Children's NHS Foundation Trust, Western Bank, University of Sheffield, Sheffield, UK
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19
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The analysis of posterior segment findings in term and premature infants using RetCam images. Int Ophthalmol 2017; 38:1879-1886. [DOI: 10.1007/s10792-017-0670-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/01/2017] [Indexed: 12/18/2022]
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20
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Oshima T, Yoshikawa H, Koda Y, Ohtani M, Tsukamoto S, Mimasaka S. Four intracranial injury cases with peripapillary scleral hemorrhage—Reconsidering the mechanism of hemorrhage. Leg Med (Tokyo) 2017; 27:5-9. [DOI: 10.1016/j.legalmed.2017.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/25/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
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21
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Küppers L, Hartung B, Karenfort M, Ritz-Timme S. Schütteltrauma vs. Impfkomplikation. Rechtsmedizin (Berl) 2017. [DOI: 10.1007/s00194-017-0170-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Binenbaum G, Reid JE, Rogers DL, Jensen AK, Billinghurst LL, Forbes BJ. Patterns of retinal hemorrhage associated with pediatric cerebral sinovenous thrombosis. J AAPOS 2017; 21:23-27. [PMID: 28087346 DOI: 10.1016/j.jaapos.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 10/01/2016] [Accepted: 10/06/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cerebral sinovenous thrombosis (CSVT) has been proposed as an alternative cause of retinal hemorrhage (RH) in children being evaluated for abusive head trauma. This study investigated the prevalence and characteristics of RH in children with CSVT. METHODS The medical records of children >6 weeks of age with newly diagnosed CSVT and fundus examination by an ophthalmologist were examined retrospectively. Primary outcomes were presence and patterns of RH. RESULTS A total of 29 children (median age, 9 years; range, 7 weeks to 17 years) were studied. Of these, 5 (17%) had RH, in 4 of whom RH were peripapillary, superficial, intraretinal, and adjacent to a swollen optic disk. In the fifth child, who had meningitis, sepsis, and multiple cerebral infarcts, there were a moderate number of posterior pole intraretinal hemorrhages. Eighteen children (62%) had optic disk swelling. In 13 children, cerebrospinal fluid opening pressure was recorded (range, 27-59 cm H2O). CSVT risk factors included meningitis, mastoiditis, and hypercoagulability. CONCLUSIONS RH in pediatric CSVT was uncommon. When RHs were present, the appearance matched RH patterns known to be caused by medical conditions, such as raised intracranial pressure and sepsis, also present in these children. These findings suggest that the RHs are due to these other causes and not directly to CSVT itself. In children with CSVT, if RHs are multilayered, extend beyond the peripapillary region into the rest of the posterior pole or retinal periphery, or occur in the absence of optic disk swelling, another etiology for the RH should be sought.
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Affiliation(s)
- Gil Binenbaum
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Julia E Reid
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Anne K Jensen
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lori L Billinghurst
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian J Forbes
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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23
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Levin AV. Retinal hemorrhage: science versus speculation. J AAPOS 2016; 20:93-5. [PMID: 27079586 DOI: 10.1016/j.jaapos.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 03/05/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Alex V Levin
- Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.
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24
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Levinson JD, Pasquale MA, Lambert SR. Diffuse bilateral retinal hemorrhages in an infant with a coagulopathy and prolonged cardiopulmonary resuscitation. J AAPOS 2016; 20:166-8. [PMID: 26988775 PMCID: PMC4833622 DOI: 10.1016/j.jaapos.2015.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/28/2015] [Accepted: 11/01/2015] [Indexed: 10/22/2022]
Abstract
We report a case of diffuse bilateral retinal and optic nerve sheath hemorrhages in an 8-week-old boy who was found unresponsive. The child underwent prolonged cardiopulmonary resuscitation and was noted on admission to have a coagulopathy. An autopsy determined the cause of death to be a myocardial infarct in the distribution of an anomalous coronary artery. This case demonstrates the difficulty that may occur in establishing whether child abuse caused death in the setting of another potential cause of mortality.
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Affiliation(s)
| | | | - Scott R Lambert
- Department of Ophthalmology, Emory University, Atlanta, Georgia.
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25
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Bais B, Kubat B, Motazedi E, Verdijk RM. β-Amyloid Precursor Protein and Ubiquitin Immunohistochemistry Aid in the Evaluation of Infant Autopsy Eyes With Abusive Head Trauma. Am J Ophthalmol 2015; 160:1285-1295.e6. [PMID: 26384166 DOI: 10.1016/j.ajo.2015.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate β-amyloid precursor protein (β-APP), ubiquitin, and glial fibrillary acid protein (GFAP) immunostaining as a diagnostic tool to aid in the discrimination between abusive head trauma and nonabusive head trauma in postmortem ocular histopathologic investigation. DESIGN Retrospective cross-sectional study. METHODS Seventy-four eyes of 37 infants were studied for hemorrhage and immunohistochemical expression of β-APP, ubiquitin, and GFAP in the retina and optic nerve. Infants were assigned to abusive head trauma or control groups, according to published criteria. RESULTS In the abusive head trauma group, positive β-APP and ubiquitin immunostaining of the retina was significantly more likely to be found than in the control group, odds ratio (OR) 11.4, confidence interval (CI) 2.9-44.3; P < .001 and OR 8.8, CI 2.2-34.5; P = .002, respectively. Positive correlations were found between retinal expression of β-APP and ubiquitin immunostaining and retinal hemorrhage. Vitreal hemorrhages, orbital fat hemorrhages, and macular folds could only be identified in abusive head trauma cases. Retinal hemorrhages were significantly more severe, occupied a larger proportion of the retina, and involved more retinal layers in abusive head trauma compared to controls (OR 2.7, CI 1.7-4.4; P < .001). CONCLUSIONS This study shows correlations between positive retinal β-APP and ubiquitin immunostaining as a sign of axonal injury in abusive head trauma. Axonal injury is a useful pathologic feature that can be demonstrated in postmortem ocular investigation of deceased children using immunohistochemical staining for β-APP and ubiquitin with a high OR for abusive head trauma when compared to controls.
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26
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Leeuw MD, Beuls E, Jorens PG, Parizel P, Jacobs W. The optic nerve sheath hemorrhage is a non-specific finding in cases of suspected child abuse. J Forensic Leg Med 2015; 36:43-8. [PMID: 26386200 DOI: 10.1016/j.jflm.2015.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 05/12/2015] [Accepted: 08/24/2015] [Indexed: 11/27/2022]
Abstract
In young infants, the triad consisting of acute encephalopathy, retinal hemorrhages, and a subdural hematoma is a nonspecific finding. It has traumatic and non-traumatic etiologies. The triad may be found among a vast spectrum of natural diseases. Optic nerve sheath hemorrhage in infants is typically detected at autopsy. It is a nonspecific finding that can be found in traumatic and non-traumatic etiologies. Neither the triad nor the ONSH are pathognomonic for an abusive head injury. Opposite to the triad, the spectrum of non-traumatic etiologies of ONSH is limited. In infants ONSH rarely occurs in spontaneous subarachnoidal hemorrhage or in infectious conditions. Our results show that the clinical significance of the optic nerve sheath hemorrhage in the forensic work-up of fatal cases of alleged abusive head injury is its limited differential diagnosis. Only after careful differential diagnosis ONSH may contribute to the diagnosis of AHT. However, the main limitation of our study is the sampling bias, as the eyes are usually removed when abusive head trauma is suspected.
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Affiliation(s)
- Marc De Leeuw
- Department of Forensic Medicine and Pathology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium; Community Hospital Aalst, Merestraat 80, B-9300 Aalst, Belgium; Decanaat University of Gent, De pintelaan, 185, 9000 Gent, Belgium
| | - Emile Beuls
- Department of Forensic Medicine and Pathology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.
| | - Philippe G Jorens
- Department of Intensive Care Medicine, Antwerp University Hospital, University of Antwerp Wilrijkstraat 10, B-2650 Edegem, Belgium
| | - Paul Parizel
- Department of Radiology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium
| | - Werner Jacobs
- Department of Forensic Medicine and Pathology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium
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27
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Beavers AJ, Stagner AM, Allbery SM, Lyden ER, Hejkal TW, Haney SB. MR detection of retinal hemorrhages: correlation with graded ophthalmologic exam. Pediatr Radiol 2015; 45:1363-71. [PMID: 25737098 DOI: 10.1007/s00247-015-3312-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 12/21/2014] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Dilated fundoscopic exam is considered the gold standard for detecting retinal hemorrhage, but expertise in obtaining this exam is not always immediately available. MRI can detect retinal hemorrhages, but correlation of the grade or severity of retinal hemorrhage on dilated fundoscopic exam with retinal hemorrhage visibility on MRI has not been described. OBJECTIVE To determine the value of standard brain protocol MRI in detecting retinal hemorrhage and to determine whether there is any correlation with MR detection of retinal hemorrhage and the dilated fundoscopic exam grade of hemorrhage. MATERIALS AND METHODS We conducted a retrospective chart review of 77 children <2 years old who were seen for head trauma from April 2007 to July 2013 and had both brain MRI and dilated fundoscopic exam or retinal camera images. A staff pediatric radiologist and radiology resident reviewed the MR images. Retinal hemorrhages were graded by a chief ophthalmology resident on a 12-point scale based on the retinal hemorrhage type, size, location and extent as seen on review of retinal camera images and detailed reports by ophthalmologists. Higher scores indicated increased severity of retinal hemorrhages. RESULTS There was a statistically significant difference in the median grade of retinal hemorrhage examination between children who had retinal hemorrhage detected on MRI and children who did not have retinal hemorrhage detected on MRI (P = 0.02). When examination grade was categorized as low-grade (1-4), moderate-grade (5-8) or high-grade (>8) hemorrhage, there was a statistically significant association between exam grade and diagnosis based on MRI (P = 0.008). For example, only 14% of children with low-grade retinal hemorrhages were identified on MRI compared to 76% of children with high-grade hemorrhages. MR detection of retinal hemorrhage demonstrated a sensitivity of 61%, specificity of 100%, positive predictive value of 100% and negative predictive value of 63%. Retinal hemorrhage was best seen on the gradient recalled echo (GRE) sequences. CONCLUSION MRI using routine brain protocol demonstrated 61% sensitivity and 100% specificity in detecting retinal hemorrhage. High-grade hemorrhage was more often detected on MRI than low-grade hemorrhage, 76% vs. 14%. GRE images were the most sensitive for detection of retinal hemorrhages. A dilated fundoscopic exam can be difficult to obtain in infancy, especially in critically ill or non-sedated children. MRI is a useful modality for added documentation of retinal hemorrhage and can be used as an alternative exam when ophthalmologic expertise or retinal camera images are unavailable. Additionally, identification of retinal hemorrhage on MRI can raise the possibility of abuse in children presenting with nonspecific findings.
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Affiliation(s)
- Angela J Beavers
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE, 68198-1045, USA,
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28
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Abstract
OBJECTIVE The purpose of this article is to review the constellation of findings of abusive head trauma, which may be accompanied by injuries to the appendicular and axial skeleton, brain and spinal cord, and retina. Additional common features include skin and soft-tissue injury, visceral findings, and evidence of oral trauma. CONCLUSION The evidence base for abusive head trauma encompasses diverse disciplines, including diagnostic imaging, pathology, pediatrics, biomechanics, ophthalmology, epidemiology, and orthopedics. When the varied sources of evidence are pieced together and taken in toto, abusive head trauma is often readily differentiated from alternative explanations of an infant's injuries.
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29
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Abstract
PURPOSES OF REVIEW This article provides an update on abusive head trauma (AHT), focusing on new developments most salient to the emergency medicine clinician, including epidemiology, clinical recognition, diagnostic work-up, management of neurologic injury, and public health implications. RECENT FINDINGS The recent literature has focused on honing the clinician's ability to recognize AHT and its immediate sequelae, to more accurately distinguish between abusive and accidental head injuries by patterns of neuroimaging and retinal hemorrhages, and to appreciate the long-term impacts. Specifically, both a clinical prediction rule and biomarker show promise, and new research advocates for the early identification of subclinical seizures as well as cervical spine injuries. SUMMARY The emergency medicine provider must be able to recognize and manage children who may have AHT and to appreciate when the diagnostic findings warrant consultation with a child protection team. These authors summarize the recent and notable advances in our understanding of AHT.
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30
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Abstract
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
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31
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Salvatori MC, Lantz PE. Retinal haemorrhages associated with fatal paediatric infections. MEDICINE, SCIENCE, AND THE LAW 2015; 55:121-128. [PMID: 24644226 DOI: 10.1177/0025802414527077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
For many physicians, retinal haemorrhages (RHs) in infants and young children remain highly diagnostic of non-accidental (abusive) head trauma. Because clinicians have applied indirect ophthalmoscopy selectively to cases of suspected child abuse, the association between RH and other conditions such as infection, coagulopathy and accidental trauma has encountered habitual bias, creating the potential for iatrogenic misdiagnosis of child abuse. We present an autopsy case series of four children, aged three years old or younger, in whom RHs were detected by post-mortem monocular indirect ophthalmoscopy after the patients had died from infections. We discuss the laterality, number, type and location of RHs in these cases, and summarize proposed mechanisms of RH formation in fatalities from paediatric infection. We demonstrate that many of the ophthalmological findings that have been considered diagnostic of abusive head trauma can also occur in association with infective processes.
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Affiliation(s)
| | - Patrick E Lantz
- Department of Pathology, Wake Forest University School of Medicine, USA
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32
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Abstract
Abusive head trauma has a robust and interesting scientific history. Recently, the American Academy of Pediatrics has endorsed a change in terminology to a term that is more general in describing the vast array of abusive mechanisms that can result in pediatric head injury. Simply defined, abusive head trauma is "child physical abuse that results in injury to the head or brain." Abusive head trauma is a relatively common cause of childhood neurotrauma, with an estimated incidence of 16 to 33 cases per 100,000 children per year in the first 2 years of life. Clinical findings are variable; AHT should be considered in all children with neurologic signs and symptoms, especially if no or only mild trauma is described. Subdural and retinal hemorrhages are the most common findings. The current best evidence-based literature has identified some features--apnea and severe retinal hemorrhages--that reliably discriminate abusive from accidental injury. Longitudinal studies of outcomes in abusive head trauma patients demonstrate that approximately one-third of the children are severely disabled, one third of them are moderately disabled, and one third have no or only mild symptoms. Abusive head trauma cases are complex cases that require a rigorous, multidisciplinary team approach. The clinician can establish this diagnosis with confidence if he/she maintains a high index of suspicion for the diagnosis, has knowledge of the signs, symptoms, and risk factors of abusive head trauma, and reasonably excludes other etiologies on the differential diagnosis.
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Affiliation(s)
| | - Jennifer Clarke
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
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33
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Alternate theories of causation in abusive head trauma: what the science tells us. Pediatr Radiol 2014; 44 Suppl 4:S543-7. [PMID: 25501725 DOI: 10.1007/s00247-014-3106-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
When cases of suspected abusive head trauma are adjudicated in courts of law, several alternative theories of causation are frequently presented. This paper reviews common theories and examines their scientific basis.
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Longmuir SQ, McConnell L, Oral R, Dumitrescu A, Kamath S, Erkonen G. Retinal hemorrhages in intubated pediatric intensive care patients. J AAPOS 2014; 18:129-33. [PMID: 24698608 DOI: 10.1016/j.jaapos.2013.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/14/2013] [Accepted: 12/22/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE To define the diagnoses associated with the presence of retinal hemorrhages, to clarify the association between retinal hemorrhages, cardiopulmonary resuscitation (CPR), and coagulopathy, and to describe the type of retinal hemorrhages found in intubated critically ill patients <4 years of age. METHODS This was a prospective observational study of intubated patients <4 years of age admitted to the pediatric intensive care unit of a tertiary care center from March 2010 to May 2012. The presence and description of retinal hemorrhages was recorded along with diagnoses, international normalized ratio (INR), CPR (in minutes), and mortality. RESULTS A total of 85 intubated, critically ill patients (37 females) were included; average patient age was 8.2 months (range, 0.1-46.8 months). Of the 85 patients, 6 (7%) had retinal hemorrhages (95% CI, 0.029-0.153). Of the 6 patients with RH, abusive head trauma (AHT) was diagnosed in 4 patients, 1 patient had direct head trauma, and 1 had CPR. There were 8 patients with CPR out of the 85. AHT was highly associated with severe multilayered retinal hemorrhages (P = 0.0001) but coagulopathy (P = 0.2671) and CPR (P = 0.5342) were not. CONCLUSIONS Severe multilayered retinal hemorrhages were associated with AHT in this cohort of patients. Without a history of trauma, retinal hemorrhages occurred in only 1 of 85 patients; in this case the hemorrhages were mild, confined to the posterior pole, and found only in the retinal layer.
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Affiliation(s)
- Susannah Q Longmuir
- Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
| | | | - Resmiye Oral
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Alina Dumitrescu
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Sameer Kamath
- Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gwen Erkonen
- Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Binenbaum G, Christian CW, Ichord RN, Ying GS, Simon MA, Romero K, Pollock AN, Forbes BJ. Retinal hemorrhage and brain injury patterns on diffusion-weighted magnetic resonance imaging in children with head trauma. J AAPOS 2013; 17:603-8. [PMID: 24215807 PMCID: PMC3859722 DOI: 10.1016/j.jaapos.2013.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 06/01/2013] [Accepted: 09/02/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate associations between retinal hemorrhage severity and hypoxic-ischemic brain injury (HII) patterns by diffusion-weighted magnetic resonance imaging (DW-MRI) in young children with head trauma. METHODS DW-MRI images of a consecutive cohort study of children under age 3 years with inflicted or accidental head trauma who had eye examinations were analyzed by two independent masked examiners for type, severity, and location of primary lesions attributable to trauma, HII secondary to trauma, and mixed injury patterns. Retinal hemorrhage was graded retrospectively on a scale from 1 (none) to 5 (severe). RESULTS Retinal hemorrhage score was 3-5 in 6 of 7 patients with predominantly post-traumatic HII pattern and 4 of 32 who had traumatic injury without HII (P < 0.001) on DW-MRI imaging. Severe retinal hemorrhage was observed in absence of HII but only in inflicted injury. Retinal hemorrhage severity was correlated with HII severity (ρ = 0.53, P < 0.001) but not traumatic injury severity (ρ = -0.10, P = 0.50). HII severity was associated with retinal hemorrhage score 3-5 (P = 0.01), but traumatic injury severity was not (P = 0.37). CONCLUSIONS During inflicted head injury, a distinct type of trauma occurs causing more global brain injury with HII and more severe retinal hemorrhages. HII is not a necessary factor for severe retinal hemorrhage to develop from inflicted trauma.
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Affiliation(s)
- Gil Binenbaum
- Division of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Ophthalmology, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, Pennsylvania.
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Greiner MV, Berger RP, Thackeray JD, Lindberg DM. Dedicated retinal examination in children evaluated for physical abuse without radiographically identified traumatic brain injury. J Pediatr 2013; 163:527-31. [PMID: 23498157 DOI: 10.1016/j.jpeds.2013.01.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 12/21/2012] [Accepted: 01/29/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging. STUDY DESIGN This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI. RESULTS The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification. CONCLUSIONS Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination.
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Affiliation(s)
- Mary V Greiner
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Adams GGW, Agrawal S, Sekhri R, Peters MJ, Pierce CM. Appearance and location of retinal haemorrhages in critically ill children. Br J Ophthalmol 2013; 97:1138-42. [PMID: 23645820 DOI: 10.1136/bjophthalmol-2012-302429] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are few high-quality studies describing the appearance and location of retinal haemorrhages in critically ill children not due to birth or abusive head trauma. METHODS Prospective study from February 2008 to December 2009 of emergency admissions to a paediatric intensive care unit aged over 6 weeks. Children with a penetrating eye injury or suspected or proven abusive head injury were excluded. The children underwent either dilated funduscopy performed by a paediatric ophthalmologist or RetCam imaging. RESULTS Retinal haemorrhages were identified in 24/159 (15%) patients. 50% of the haemorrhages were bilateral. The severity was mild (<5 retinal haemorrhages) or moderate (5-20 retinal haemorrhages) in 75%. The location was in zone 1 in 45.8%, zones 1 and 2 in 33.3%, zone 2 alone in 8.3% and not described in 8.3%. Schisis cavities and perimacular folds were identified in two patients with one having a pseudohypopyon appearance; a further one patient had bilateral haemorrhagic retinal detachments. Three patients had exudates or scarring consistent with cytomegalovirus infection. CONCLUSIONS Retinal haemorrhages are seen in a proportion of critically ill children, however most retinal bleeding is not extensive as indicated by location within the retina or layer of bleeding. Higher numbers and extent of retinal haemorrhages were only observed in the presence of severe coagulopathy, leukaemia, one victim of a road traffic accident, and one child who sustained a fatal witnessed fall down the stairs; all circumstances that would be readily distinguished by history and laboratory testing from abusive head injury.
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Affiliation(s)
- G G W Adams
- Department of Strabismus and Paediatrics, Moorfields Eye Hospital, London, UK.
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Li LH, Li N, Zhao JY, Fei P, Zhang GM, Mao JB, Rychwalski PJ. Findings of perinatal ocular examination performed on 3573, healthy full-term newborns. Br J Ophthalmol 2013; 97:588-91. [PMID: 23426739 PMCID: PMC3632968 DOI: 10.1136/bjophthalmol-2012-302539] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective To document the findings of a newborn eye examination programme for detecting ocular pathology in the healthy full-term newborn. Methods This is a cross-sectional study of the majority of newborns born in the Kunming Maternal and Child Healthcare Hospital, China, between May 2010 and June 2011. Infants underwent ocular examination within 42 days after birth using a flashlight, retinoscope, hand-held slit lamp microscope and wide-angle digital retinal image acquisition system. The retinal fundus examination utilised the RetCam wide-field digital imaging system (Clarity Medical Systems, Pleasanton, California, USA). The external eye, pupillary light reflex, red reflex, opacity of refractive media, anterior chamber and posterior segments were also examined. Results A total of 3573 healthy full-term newborns were enrolled and examined in the programme. There was detection of 871 abnormal cases (24.4%). The majority of abnormal exams were 769 (21.52%) retinal haemorrhages. Of these, there were 215 cases of significant retinal haemorrhage, possible sight threatening or amblyogenic, representing 6.02% of the total. In addition, 67 cases (1.88%) involved macular haemorrhage. The other 107 cases (2.99%) with abnormal ocular findings included subconjunctival haemorrhage, congenital microphthalmos, congenital corneal leukoma, posterior synechia, persistent pupillary membrane, congenital cataract, enlarged C/D ratio, retinal hamartoma versus retinoblastoma, optic nerve defects, macular pigment disorder and non-specific peripheral retinopathy. Conclusion Ocular examination of healthy newborns leads to the detection of a significant number of ocular pathologies. The most commonly discovered ocular abnormality during examination of the newborns in this study is retinal haemorrhage. The long-term impact of these findings is unknown. Although presumed by some to benign, neonatal retinal haemorrhages due to birth trauma could be involved in altering visual development. Further work, including prospective examination of newborns with long-term follow-up, is needed and supported by our findings.
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Affiliation(s)
- Li-Hong Li
- Maternal and Children’s Hospital, Kunming, Yunnan, China
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